Ambulatory blood pressure monitoring and target organ damage: effects of age and sex

OBJECTIVE: The objective of the present study was to investigate the effect of age and sex in the ambulatory blood pressure measurements, and target organ damage. METHODS: A total of 1596 patients (50.6% male and 49.4% female), aged 10-87 years, referred to our Hypertension Center for borderline hypertension, underwent 24-h ambulatory blood pressure monitoring, left ventricular echocardiography and measurement of intima-media thickness of carotid arteries. RESULTS: Adolescent girls had higher mean 24-h and clinic systolic and diastolic blood pressure values than adolescent boys. Men aged 20-60 years had higher mean 24-h and clinic systolic and diastolic blood pressure values than women of the same age. Men older than 60 years had higher mean 24-h systolic and diastolic blood pressure values than women of the same age, but women older than 60 years had higher clinic systolic and diastolic blood pressure values. White-coat effect increased with age in both sexes, but the magnitude of the white-coat effect was higher in women than in men at older ages. Men had higher left ventricular mass corrected for body surface area or height than women in all ages and significantly higher differences in ages between 30 and 80 years. In addition, men had greater carotid intima-media thickness than women in all ages and significantly higher differences in ages between 30 and 80 years. CONCLUSIONS: Men have greater ambulatory blood pressure values and target organ damage than women of the same age.     

Impact of gender on 24-h ambulatory blood pressure and target organ damage

Differences between male and female subjects in mean 24 h blood pressure (BP) values and target organ damage such as left ventricular mass (LVMASS) and intima-media thickness (IMT) of carotid arteries were explained. The study population consisted of 1,445 subjects. All subjects underwent 24 h ambulatory BP monitoring, left ventricular echocardiography and measurement of IMT of carotid arteries. Men and women did not differ in age, body mass index (BMI) and clinic BP values. Mean 24 h systolic and diastolic BP were significantly higher in men compared to women. LVMASS corrected for body surface area or height(2.7), IMT of common (MCCA) and internal (MICA) carotid arteries were found to be significantly higher in men compared to women. Analysis of covariance showed that men had significantly higher LVMASS, MCCA and MICA than women, after adjustment for BMI, age, smoking status, mean 24 h systolic and diastolic BPs, fasting serum glucose, total cholesterol and triglycerides. These findings indicate that male sex could be an important predictor of higher mean 24 h BP and target organ damage for subjects of similar BMI and clinic BP values.     

Long-term prognostic role of flow-mediated dilatation of the brachial artery after acute coronary syndromes without ST elevation

Coronary endothelial vasodilator dysfunction is associated with increased cardiac events; the close relation between coronary vasomotor dysfunction and brachial artery vasoreactivity has been previously described. This study assessed the prognostic value of noninvasively assessed brachial artery vasoreactivity in survivors of acute coronary syndromes without ST-segment elevation. We examined 98 men (63.1 +/- 10.8 years) who were referred to our hospital for acute coronary syndromes without ST-segment elevation. Brachial artery endothelium-dependent flow-mediated dilation (FMD) and endothelium-independent nitrate-mediated dilation were examined in all patients using high-resolution echocardiographic Doppler ultrasound within 24 hours of admission. Plasma malondialdehyde, a marker of oxidative stress, and left ventricular ejection fraction were also assessed. Twenty-seven patients underwent coronary revascularization. Patients were followed for 24.8 +/- 5.9 months. Cardiovascular death, myocardial infarction, stroke, and unstable angina were designated as cardiovascular events (CEs). Twenty CEs were recorded. Kaplan-Meyer analysis showed that patients with FMD <1.9% (tertile 1 of FMD values) were more likely to have CEs than those with FMD >1.9% (log rank 5.29, p = 0.021). Multivariate Cox regression analysis showed that FMD <1.9% predicted CEs with an adjusted hazard ratio of 3.035 (95% confidence interval 1.148 to 8.023, p = 0.025) after adjustment for age, risk factors, troponin T, ejection fraction, revascularization procedures, number of diseased vessels, and medication. In conclusion, endothelium-dependent dilation of the brachial artery is a strong independent predictor of adverse outcome in survivors of acute coronary syndromes without ST-segment elevation.     

Ability of ambulatory blood pressure monitoring and myocardial/carotid ultrasound to predict the location and the severity of coronary artery lesions in normotensive patients: a clinical study.

Pulse pressure has been recognized as a marker of cardiovascular disease in normotensives. Moreover, internal carotid artery intima-media thickness (IMT) has been proposed to reflect coronary artery lesions. The aim of the present study was to evaluate the predictive value of other parameters derived from ambulatory blood pressure monitoring (ABPM), myocardial ultrasound, and carotid ultrasound to predict the location and the severity of coronary artery disease in normotensives. One hundred and thirteen patients with suspected coronary artery disease underwent coronary angiography, 24-h ABPM and myocardial/carotid ultrasound. Multivariate analysis was applied and equations were extrapolated based on independent variables derived from ABPM and ultrasound. The Gensini score was independently correlated with male gender, pulse pressure, average heart rate for both 24-h (p=0.001) and night (p=0.006) values, as well as percentage of high systolic blood pressure (BP), average diastolic BP, average mean BP, and heart rate concerning daily mesurements (p=0.001). Moreover, the Gensini score was independently correlated with end-systolic volume, posterior wall thickness during systole and intraventricular septum thickness during diastole, along with male gender and age (p=0.001), as well as mean internal and right common carotid artery IMT (p=0.002). Similar mathematical formulas have been calculated separately for the coronary arteries and their main branches. In conclusion, the location and the severity of coronary disease can be effectively evaluated by ABPM and myocardial/carotid ultrasound in normotensives. This approach could be useful for determining atypical patients at risk and/or for treating patients with suspected coronary disease who refuse coronary angiography.     

Target organ damage in "white coat hypertension" and "masked hypertension"

BACKGROUND: In this study we investigated (i) the prevalence of white coat hypertension (WCH) and masked hypertension (MH) in patients who had never been treated earlier with antihypertensive medication, and (ii) the association of these conditions with target organ damage. METHODS: A total of 1,535 consecutive patients underwent office blood pressure (BP) measurements, 24-h ambulatory BP monitoring (ABPM), echocardiography, and ultrasonography of the carotid arteries. Subjects who showed normotension or hypertension on the basis of both office and ambulatory BP (ABP) measurement were characterized as having confirmed normotension or confirmed hypertension, respectively. WCH was defined as office hypertension with ambulatory normotension, and MH as office normotension with ambulatory hypertension. RESULTS: WCH was found in 17.9% and MH in 14.5% of the subjects. The prevalence of WCH was significantly higher in subjects with obesity, while the prevalence of MH was significantly higher in normal-weight subjects. The confirmed hypertensive subjects as well as the masked hypertensive subjects had significantly higher left ventricular mass (LVM) (corrected for body surface area) and carotid intima media thickness (cIMT) than the confirmed normotensive subjects did (108.9 +/- 30.6, 107.1 +/- 29.1 vs. 101.4 +/- 29.9 g/m(2) and 0.68 +/- 0.16, 0.68 +/- 0.21 vs. 0.63 +/- 0.15 mm, respectively, P < 0.005). White coat hypertensive subjects did not have a significantly higher LVM index than confirmed normotensive subjects (101.5 +/- 25.9 vs. 101.4 +/- 29.9 g/m(2)); they tended to have higher cIMT than the confirmed normotensive subjects, but the difference was not statistically significant (0.67 +/- 0.15 vs. 0.63 +/- 0.15 mm). CONCLUSIONS: WCH and MH are common conditions in patients who visit hypertension outpatient clinics. Confirmed hypertension and MH are accompanied by increased LVM index and cIMT, even after adjusting for other risk factors.     

The androgen receptor gene CAG polymorphism is associated with the severity of coronary artery disease in men

OBJECTIVE: The role of androgens in the pathogenesis of coronary artery disease (CAD) remains controversial. The length of the polyglutamine stretch of the transactivation domain (CAG repeat) of the androgen receptor (AR) inversely affects androgen activity. The aim of this study was to investigate the effect of this polymorphism of the AR gene in the extent of CAD in male patients. DESIGN AND PATIENTS: The relationship of the length of the AR gene CAG repeat on the severity of CAD was examined in 131 men (36-86 years old) undergoing coronary angiography. MEASUREMENTS: The severity of CAD was assessed by the number (0-3) of coronary vessels with > 50% reduction in the luminal diameter. The interaction of the AR gene polymorphism with the intima media thickness (IMT) of peripheral arteries and serum levels of sex steroids, insulin and biochemical parameters were also studied. RESULTS: The upper quartile of CAG length (range 9-30) was > or = 23 repeats (longAR). The mean body mass index (BMI) of patients with shorter repeats (< 23; shortAR) was significantly lower than in men with longAR (26.1 vs. 27.6, respectively; P = 0.043 M-W Rank test). There was no correlation between the AR gene repeat length and serum testosterone. Oestradiol levels were significantly higher in longAR (0.19 +/- 0.08 nmol/l vs. 0.14 +/- 0.07 in shortAR, P = 0.031). This difference was independent of BMI. Men with shortAR had significant CAD (i.e. one to three arteries with stenosis) more frequently (79.5%) than men with longAR (20.5%); of the subjects with stenosis in no arteries, 56.5% had shortAR and 43.5% longAR (chi2 = 4.3, P = 0.038). This association was independent of age and BMI. The IMT of peripheral arteries, lipid parameters, basal insulin resistance, blood pressure and family history for early CAD, did not differ according to AR length. CONCLUSIONS: The shorter CAG repeat of the AR gene is associated with more severe CAD, which suggests a role for the sensitivity to androgens in the increased frequency of CAD in males. In addition, a protective role of endogenous oestrogen, which is higher in the longAR subgroup, can contribute to the observed difference.     

Acute effects of caffeine on blood pressure and wave reflections in healthy subjects: should we consider monitoring central blood pressure?

BACKGROUND: Data concerning blood pressure changes, acutely induced by caffeine consumption, are conflicting. Furthermore, limited data exist regarding central hemodynamic response to caffeine ingestion by healthy young subjects. We investigated the acute effect of coffee (80 mg of caffeine) and decaffeinated coffee on peripheral and central hemodynamics, as well as on wave reflections. SUBJECTS: For this purpose, 16 healthy volunteers (eight females and eight males, mean age 29+/-3.2 years) were investigated. METHODS: Repeated measurements were performed at baseline and 30, 60, 90 and 120 min after oral administration of each beverage in a double-blind crossover design. Aortic blood pressures, augmentation index (AI) and pressure (AP) and timing of reflected waves were evaluated by using applanation tonometry and pulse wave analysis. RESULTS: Regular coffee increased central systolic (SBP) and diastolic pressure (DBP) from 96.2+/-9.9 to 101.1+/-10.1 mmHg, p=0.011 and from 72.6+/-9.4 to 76.5+/-9.0 mmHg, p=0.027, respectively, but no change was observed following consumption of decaffeinated coffee. Peripheral systolic blood pressure did not change significantly after the administration of either coffee. Augmentation index increased significantly following regular coffee consumption. The change in AI was significantly higher following regular compared to decaffeinated coffee consumption as shown by analysis of variance (ANOVA) for repeated measures (p=0.001). CONCLUSIONS: These caffeine effects reveal an unfavourable effect on wave reflections and therefore on left ventricular (LV) pulsatile afterload. It also revealed a significant acute effect of caffeine consumption on central hemodynamics which is not observed at peripheral pressures.     

Circulating androgen levels are associated with subclinical atherosclerosis and arterial stiffness in healthy recently menopausal women

Although increasing evidence supports an association between endogenous sex hormones and cardiovascular disease, the results still remain controversial. This study aims to examine the association between endogenous sex hormones and indices of vascular function and structure. Serum follicle-stimulating hormone, luteinizing hormone, estradiol, testosterone, sex hormone-binding globulin, dehydroepiandrosterone sulfate (DHEAS), and Δ4-androstenedione were measured in 120 healthy postmenopausal women aged 41 to 60 years. Possible associations with surrogate markers of subclinical atherosclerosis, arterial stiffness, and endothelial function were investigated. Indices of arterial structure included carotid and femoral intima-media thickness and atheromatous plaques presence. Indices of arterial function included flow-mediated dilation of the brachial artery, carotid-femoral pulse wave velocity (PWV), and augmentation index. Total testosterone and free androgen index (FAI) were the most important predictors of common carotid artery intima-media thickness (β = 0.376 and β = 0.236, P < .001 and P = .014, respectively). Similarly, FAI was the only significant independent predictor of PWV (β = 0.254, P = .027) after adjusting for age, smoking, body mass index, homeostasis model assessment of insulin resistance, and blood lipids. Free estrogen index showed a positive association with PWV, independently of age, smoking, and body mass index, but not of homeostasis model assessment of insulin resistance and blood lipids. Age-adjusted levels of DHEAS exhibited a significant independent negative association with measures of augmentation index. Follicle-stimulating hormone, luteinizing hormone, estradiol, sex hormone-binding globulin, and Δ4-androstenedione were not associated with any of the vascular parameters independently of traditional cardiovascular risk factors. Higher serum testosterone and FAI are associated with subclinical atherosclerosis in healthy recently menopausal women. This association is independent of traditional cardiovascular risk factors or insulin resistance. On the contrary, serum DHEAS exhibits a negative association with arterial stiffness.