Arterial diseases of surgical importance. Long-term control of diet-related risk factors

From 1980 to 1990 a yearly medical-surgical control was carried out on 950 arteriopathic patients hospitalised in the General and Cardiovascular Surgery Institute, Milan University, during the above mentioned period. The operations for surgical reconstruction were mainly for arteriosclerotic lesions involving the abdominal-peripheral district (750 patients, 79%) and the supra aortic trunks (200 patients, 21%). 84% of the patients were males. Among the patients on follow-up, a relatively modest number (100 patients) did not attend the prescribed diet therapies for several reasons, consequently these patients have been considered as a control group. The comparison, between the patients who attended and those who did not attend the diet, has been made on the basis of the following parameters: cholesterolemia (COL), LDL, HDL, triglyceridemia (TG), VLDL, glycemia (GLI), body mass index (BMI) and arterial pressure (PA). The results have shown a decrease in the absolute normal values of cholesterol, LDL and triglycerides, while they have not shown the same significant variations regarding glycemia and body weight. In accordance with the literature, the diet seems to have obtained satisfactory results, especially regarding the values of lipidemia, with a reduction in the atherogenic risk index. Regarding smoke as a risk factor it has been shown that it is present in 80% of the patients at the beginning: 60% of the patients stop smoking at the moment they are hospitalised and the remaining 20% continue smoking. The hygienic-dietetic intervention is confirmed, also in our experience, as a curative, or even more, a preventive tool against the worsening of an already overt arteriosclerosis as well as a necessary support for drug therapies.     

Effects of valsartan/ hydrochlorothiazide and amlodipine on ambulatory blood pressure and plasma norepinephrine levels in high-risk hypertensive patients

The efficacy and tolerability of the combination of valsartan and hydrochlorothi-azide (HCTZ) were compared with that of amlodipine in reducing ambulatory blood pressure and plasma norepinephrine levels in patients with mild to moderate hypertension and at least 1 cardiovascular risk factor. At the end of a 2-week washout period, 92 outpatients with a sitting diastolic blood pressure ≥95 and <110 mm Hg, associated with at least 1 additional risk factor, were randomly assigned to receive either valsartan 160 mg and HCTZ 12.5 mg once daily (n=46) or amlodipine 10 mg alone once daily (n=46) for 12 weeks, according to a prospective, randomized, open-label, blinded end point, parallel-group design. At the end of the washout period and after 6 and 12 weeks of active treatment, 24-hour ambulatory blood pressure monitoring was performed, and clinical blood pressure and heart rate and plasma norepinephrine levels were assessed (by high-performance liquid chromatography). Both the valsartan/HCTZ combination and amlodipine had a demonstrable antihypertensive effect, but the combination showed an antihypertensive effect significantly greater than that of amlodipine, as demonstrated by the 24-hour (P < .001), daytime (P < .001), and nighttime ambulatory blood pressure values (P < .01) and by the clinical blood pressure values at trough, which were all significantly lower. Although the trough-to-peak ratios were similar in both groups, the smoothness indexes pertaining to both systolic and diastolic pressures were significantly higher (P < .05 andP < .001, respectively) in patients receiving valsartan/HCTZ, suggesting the combination produces a more homogeneous antihypertensive effect. A significant increase in plasma norepinephrine levels was associated with amlodipine (+9% at 6 weeks, +15% at 12 weeks) but not with the valsartan/HCTZ combination. The valsartan/HCTZ combination was better tolerated than amlodipine, which was associated with a higher frequency of ankle edema. These results indicate that the combination of valsartan 160 mg and HCTZ 12.5 mg provides more sustained and homogeneous control of blood pressure than does amlodipine 10 mg in high-risk hypertensive patients, without producing reflex sympathetic activation.     

Hypofunctionality of Gi proteins as aetiopathogenic mechanism for migraine and cluster headache

The involvement of Gi proteins in the modulation of pain perception has been widely established, and mutations in G-proteins have already been identified as the aetiopathological cause of human diseases. The aim of the present study was to determine whether a deficiency or a hypofunctionality of the Gi proteins occurred in primary headache. The functionality and the level of expression of Gi proteins were investigated in lymphocytes from migraine without aura, migraine with aura and cluster headache sufferers. A reduced capability to inhibit forskolin-stimulated adenylyl cyclase activity in headache patients was observed. Migraine patients also showed basal adenosine cAMP levels about four times higher than controls. The reduced activity of Gi proteins seems not to be related to a reduction of protein levels since no significant reduction of the Gialpha subunits was observed. These results indicate Gi protein hypofunctionality as an aetiopathogenic mechanism in migraine and cluster headache.     

Twenty-four-hour blood pressure profile,orthostatic hypotension,and cardiac dysautonomia in elderly type 2 diabetic hypertensive patients

Purpose

The aim of this study was to evaluate the relationship between orthostatic hypotension (OH), defined as a decrease in systolic blood pressure (SBP) ≥20 mmHg and/or a decrease in diastolic blood pressure (DBP) ≥10 mmHg, and 24-h ambulatory BP profile in elderly hypertensive type 2 diabetic patients.

Methods

After a 2-week antihypertensive wash-out period, 200 hypertensive well-controlled diabetic outpatients, aged 65–75 years, underwent a clinical examination, including BP measurements, ECG, 24-h ABP monitoring (ABPM), an orthostatic test, and three tests for cardiovascular autonomic function assessment [deep breathing, heart rate (HR) variability, resting HR].

Results

According to their nighttime BP profile, patients were divided into three groups: dippers (n = 86) (BP fall during nighttime ≥10 %), non-dippers (n = 80) (BP fall during nighttime 0–10 %), and reverse dippers (n = 34) (nighttime BP > daytime BP). Orthostatic test produced a significantly greater orthostatic SBP fall in dippers and even more in reverse dippers. In these latter, a significant fall was observed also in DBP. Prevalence of OH was 9.3 % in dippers, 30 % in non-dippers, and 79.4 % in reverse dippers.

Conclusions

In elderly hypertensive type 2 diabetics, a blunted nocturnal BP fall is associated with OH and autonomic dysfunction. These data suggest that ABPM should be performed in the assessment of hypertensive diabetic patients in whom the cardiovascular dysautonomia is suspected or the signs of it are present (such as OH).

     

Cutaneous pain threshold changes after sympathetic block in reflex dystrophies.

In a group of 30 subjects suffering from sympathetic reflex dystrophies of the limbs, the sympathetic ganglia of the affected side were blocked with a local anesthetic. Using an original method, we measured the cutaneous pain threshold before the block and at prefixed intervals after the block during a period of 2 days. In all subjects the cutaneous pain threshold showed damped oscillations both in the limb ipsilateral to the block and in the contralateral one. The analysis of these oscillations showed: (a) that the sympathetic control of the cutaneous pain threshold may be exerted through a negative feedback loop (skin-afferent input-CNS-sympathetic output-skin); (b) that the afferent discharge of a limb controls the contralateral sympathetic output through central mechanisms.