OBJECTIVE:White-coat hypertension (WCH) displays an increased cardiovascular (CV) risk. Scanty are the data available on the impact of 24-hour average blood pressure (BP) load on the increased CV ...risk in this condition.
DESIGN AND METHOD:2051 subjects randomly selected from the general population of Monza (Italy), aged 25 to 74 years, stratified for sex and decades of age, underwent measurement of systolic (S) and diastolic (D) office BP and average 24-hour ambulatory SBP and DBP. Anthropometric variables, serum cholesterol, blood glucose were also measured. During a median follow-up of 156 months hospital admissions for coronary and stroke events were collected. Fatal events were also collected, among which those related to CV causes (ICD-10 from I-0 to I-99) were identified. In the whole population sample, the subjects with both normal office BP (<140/90 mmHg) and normal 24-hour BP (<125/79 mmHg) were defined as normotensives (NT, n. 1001). Among the 356 subjects with high office BP and normal 24-hour BP (WCH), those with 24-hour SBP above and under the median value (118 mmHg) were classified as WCHH and WCHL, respectively.
RESULTS:The analysis was carried out on the 1001 NT and on the 356 WCH subjects. During the follow-up 112 deaths and 73 fatal and non fatal CV events. Total mortality was 5.7%, 20.8% and 10.1% in NT, WCHH and WCHL, respectively. Incidence of CV events was 3.4%, 14.6% and 7.3%, in NT, WCHH and WCHL, respectively. Adjusting the data for age, sex, hypercholesterolemia, diabetes mellitus, smoking, obesity, previous CV events and antihypertensive therapy, the risk of all cause death and CV events in WCHH was significantly higher than that of NT (HR 1.8, CI 1.2–2.8, and HR 2.7, CI 1.6–4.7, respectively; p < 0.01 for both). No significant difference was found in the CV risk between WCHL and NT.
CONCLUSIONS:Although by definition in the normal range, the level of 24-hour ambulatory SBP load is a relevant factor in determining the enhanced CV risk in WCH. Indeed, when the 24-hour SBP values are low, the CV risk of WCH is not different from that displayed by NT.
OBJECTIVE:We estimated the risk of cardiovascular and all-cause mortality associated with left ventricular (LV) geometric patterns, as defined by a new classification system proposed by the Dallas ...Heart Study, in 1716 representatives of the general population of Monza enrolled in the Pressioni Monitorate e Loro Associazioni (PAMELA) study.
DESIGN AND METHOD:Cut-points for abnormal LV geometric patterns were derived from reference values of the healthy fraction of the PAMELA population by combining LV mass (LVM) index, LV diameter and relative wall thickness. Death certificates were collected over an average 211 months follow-up period.
RESULTS:During follow-up, 89 fatal cardiovascular events and 264 all-cause deaths were recorded. Concentric remodeling (CR) was the most common LV geometric abnormality (9.4%) followed by eccentric non-dilated LVH (6.3%), concentric LVH (4.6%) and dilated LVH (3.5%). Compared to normal LV geometry, concentric LVH (HR = 4.04, 95% CI2.05–7.97, p < 0.0001), dilated LVH (HR = 3.83, 95% CI1.93–7.60, p = 0.0001) and eccentric non-dilated LVH (HR = 2.61, 95% CI1.39–4.92, p = 0.003) predicted the risk of cardiovascular mortality, after adjustment for baseline covariates, including ambulatory blood pressure. Similar findings were observed for all-cause mortality. Only concentric LVH maintained a significant prognostic value for both outcomes after adjustment for baseline differences in LVM index.
CONCLUSIONS:The new classification system of LV geometric patterns, may improve mortality risk stratification in a general population. The risk is markedly dependent on LVM values; only concentric LVH provides a prognostic information beyond that conveyed by cardiac mass.
OBJECTIVE:We have previously shown that in the general population of the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study heart rate (HR) values fail to display a prognostic ...relevance for cardiovascular (CV) events, presumably because of the low risk profile of the overall population. In the present study we restricted the analysis to HR values in subjects affected by an obese state, i.e. a condition in which the detection of elevated HR values and an increased CV risk is common.
DESIGN AND METHOD:In 1944 subjects recruited in the PAMELA study and aged 51 ± 13.6 we measured at the study entry along with clinic, home and 24 hour blood pressure (BP), the corresponding HR values and waist circumference (WC). During the median follow-up period of 212 months we evaluated cardiovascular (CV) and total mortality. Data were analyzed subdividing the population in 3 gender specific tertiles of WC.
RESULTS:Compared to the lowest tertile, subjects in the highest tertile of WC displayed significantly greater clinic, home and 24 hour HR values. Focusing the analysis on subjects in the highest tertile of WC, after adjustment for gender, corresponding systolic BP and age, the risk of CV death was significantly greater with an increase of 1 bpm of home and 24 hour HR (hazard ratio 1.04 and 1.05, respectively, p < 0.05 for both), while no significant impact on CV mortality was found for clinic HR (hazard ratio 1.01, p = NS). The risk of all cause death was statistically significant for an increase of 1 bpm of clinic, home and 24 hour HR, after adjustment for confounders (hazard ratio 1.01, 1.023 and 1.039, p < 0.01 for all).
CONCLUSIONS:HR, particularly when evaluated at home and during the 24 hours, represents an independent long-term predictor of fatal cardiovascular and non-cardiovascular events in patients with central obesity. For cardiovascular mortality, however, clinic HR does not appear to retain a prognostic value.
Abstract Background and aims Elevated values of body mass index (BMI) and waist circumference (WC) are associated with an augmented cardiovascular (CV) risk. It is debated, however, whether and to ...what extent this depends on the body fat increase ‘ per se ’ or on the related cardiometabolic alterations. Methods and results In 2005 subjects randomly selected from the general population of Monza (Italy), we assessed BMI, WC, office, home and 24 h blood pressure (BP), heart rate and metabolic variables. The impact of BMI and WC on the incidence of CV events, CV and all-cause mortality was estimated during a 148-month follow-up. Progressively higher values of BMI and WC were associated with a progressive increase in office, home and 24 h BP and in erratic BP variability ( P < 0.0001 for trend). Metabolic variables were directly and significantly ( P < 0.0001) related to BMI and WC, while an inverse significant relationship was detected with high-density lipoprotein (HDL)-cholesterol. The incidence of CV events, CV and all-cause deaths increased progressively from the lowest to the highest quintile of BMI and WC ( P for trend always <0.005). Baseline BMI and WC higher by respectively 1 kg m−2 and 1 cm were associated with an increased risk of CV events, CV and all-cause death by 8%, 12% and 7% (for baseline BMI) and 4%, 5% and 4% (for baseline WC), respectively. After adjustment for confounders, only the increased risk of CV death related to higher baseline BMI remained significant (hazard ratio (HR) 1.062, confidence interval (CI) 95% 1.003–1.126, P < 0.05). Conclusion The adverse prognostic impact of the accumulation of body fat is mediated by the associated haemodynamic and metabolic alterations. Baseline values of BMI, however, are an independent predictor of CV mortality.
Objectives
The prognostic utility of lifestyle risk factors and job-related conditions (LS&JRC) for cardiovascular disease (CVD) risk stratification remains to be clarified.
Methods
We investigated ...discrimination and clinical utility of LS&JRC among 2532 workers, 35–64 years old, CVD-free at the time of recruitment (1989–1996) in four prospective cohorts in Northern Italy, and followed up (median 14 years) until first major coronary event or ischemic stroke, fatal or non-fatal. From a Cox model including cigarette smoking, alcohol intake, occupational and sport physical activity and job strain, we estimated 10-year discrimination as the area under the ROC curve (AUC), and clinical utility as the Net Benefit.
Results
N
= 162 events occurred during follow-up (10-year risk: 4.3%). The LS&JRC model showed the same discrimination (AUC = 0.753, 95% CI 0.700–0.780) as blood lipids, blood pressure, smoking and diabetes (AUC = 0.753), consistently across occupational classes. Among workers at low CVD risk (
n
= 1832, 91 CVD events), 687 were at increased LS&JRC risk; of these, 1 every 15 was a case, resulting in a positive Net Benefit (1.27; 95% CI 0.68–2.16).
Conclusions
LS&JRC are as accurate as clinical risk factors in identifying future cardiovascular events among working males. Our results support initiatives to improve total health at work as strategies to prevent cardiovascular disease.
OBJECTIVE:We estimated the risk of cardiovascular mortality associated with echocardiographic (ECHO) sub-types of left ventricular hypertrophy (LVH), as defined by an up-dated classification, in ...subjects with and without electrocardiographic (ECG) LVH. To this purpose 1,691 representatives of the general population of Monza, enrolled in the Pressioni Monitorate e Loro Associazioni (PAMELA) study, were included in the present analysis.
DESIGN AND METHOD:Cut-points for ECHO-LVH and abnormal LV geometry were derived from reference values of the healthy fraction of the PAMELA population by combining LV mass index, LV diameter and relative wall thickness, ECG-LVH was defined according to Cornell voltage index. Death certificates were collected over an average 211 months follow-up period.
RESULTS:A total of 89 fatal cardiovascular events were recorded during follow-up. Compared to individuals with neither ECHO-LVH nor ECG-LVH, fully adjusted risk of cardiovascular mortality increased (HR 3.36, 95% CI1.51-7.47, p = 0.003) in subjects with both ECHO- and ECG-LVH, whereas the risk entailed by ECHO-LVH alone was of borderline statistical significance (p = 0.04). Combined concentric LVH and ECG-LVH, but not concentric LVH alone, predicted the long-term incidence and risk of fatal cardiovascular events (HR = 3.78, 95% CI1.25–11.38, p = 0.01). Similar findings were observed for eccentric non dilated LVH.
CONCLUSIONS:The present analysis underlines the value of combining ECG and ECHO in the assessment of cardiovascular prognosis related to LVH. The advantage of combining both noninvasive techniques in refining risk prediction persists also when echo-LVH is categorized according to concentric or eccentric LV patterns.
OBJECTIVE:Stratification of cardiovascular (CV) risk is of fundamental importance in white coat hypertension (WCH) to identify individuals in need of closer follow up and perhaps antihypertensive ...drug treatment.
DESIGN AND METHOD:In subjects representative of the general population of Monza (Italy), the risk of CV and all-cause mortality was assessed over 16 years in stable and unstable WCH individuals, i.e, those in whom ambulatory BP normality was associated with a persistent or non persistent office BP elevation at two consecutive visits, respectively. Data were compared with those from an entire normotensive group, i.e ambulatory and persistent office BP normality.
RESULTS:Compared to the normotensive group, the risk of CV and all cause death was not significantly different in unstable WCH, whereas in stable WCH the risk was increased also when data were adjusted for baseline confounders, including ambulatory BP(hazard ratio 12.39 p = 0.0021 for CV, and 1.91 p = 0.0178 for all cause death). At a multivariable analysis, office BP was among the factors indipendently predicting death, and results were superimposable with use of Monza population-and guidelines-derived cutoff values for ambulatory BP normality (125/79 and 130/80 mmHg, respectively).
CONCLUSIONS:Thus, only when office BP is persistently elevated does WCH reflect the existence of an abnormal long term mortality risk. This means that in WCH office BP is prognostically relevant and that repeated collection of office BP values should be regarded as necessary.
OBJECTIVE:The relation between blood pressure (BP) and cognitive function has received growing interest in recent years. Some cross-sectional studies have shown an inverse association between BP and ...cognitive dysfunction, while longitudinal studies yield mixed results.
DESIGN AND METHOD:In the PAMELA study cognitive function was assessed via minimental test at the evaluation performed in 2001–2002, taking as reference clinic data collected at the 1st PAMELA examination carried out 10 yrs before. 471 subjects participated at this substudy. Measurements included clinic and 24-hour BP (Spacelabs 90207). BP variability was obtained by calculating 1) the SD of 24-hour, day, and night mean values, 2) the day/night BP difference and (3) the residual or erratic BP variability (Fourier spectral analysis).
RESULTS:Mean age of the subjects enrolled was 63.0 ± 5.7 yrs (mean ± SD) at the 1St examination. At the 2nd evaluation performed 10 yrs later 26 subjects had a minimental score < 23, indicative of a cognitive dysfunction (CD), the remaining 445 showing normal scores (C, 24–30). For similar heart rate, office and home systolic (but not diastolic) BP were, although not significantly, greater in CD than in C (148.0 ± 22.5 vs 143.5 ± 19.9 and 139.5 ± 15.14 vs 133.3 ± 17.9 mmHg, P = NS). 24hour BP was similar in CD and C, this being the case also for 24 hour BP variability, expressed as SD systolic (15.3 ± 4.1 vs 14.8 ± 3.7 mmHg, P = NS) and diastolic (12.9 ± 3.47 vs 12.2 ± 2.9 mmHg, P = NS) or day/night BP difference. In contrast, residual BP variability was significantly greater in CD than in C for both systolic (11.2 ± 2.2 vs 10.6 ± 2.5 mmHg, P < 0.05) and diastolic (9.3 ± 2.1 vs 8.7 ± 2.3 mmHg, P < 0.05), the difference between groups being greater when the grading of minimental responses was based on 3 score categories (0–20,21–24 and >24). This was particularly the case in males.
CONCLUSIONS:Our data show that the most sensitive prognostic variable for the development of cognitive alterations does not appear to be absolute BP load or absolute BP variability but rather its short-term erratic component, which has been previously shown to represent the part of BP variability with major impact on cardiovascular mortality.
OBJECTIVE:According to the 2013 ESH/ESC guidelines combination drug treatment is recommended in the treatment of isolated systolic hypertension (ISH) to improve blood pressure (BP) control. The ...present study was aimed at comparing the antihypertensive effects, tolerability and side effects profile of nebivolol/hydrochlorothiazide vs irbesartan/hydrochlorothiazide combination in elderly patients with ISH.
DESIGN AND METHOD:124 ISH patients aged 69.1 ± 3.1 (mean ± SEM) followed by 13 general practictioners in Netherlands and Belgium were enrolled and randomized in a double blind fashion to Nebivolol 5 mg/Hydrochlorothiazide 12.5 mg (NH, n = 62) or Irbesartan 150 mg/Hydrochlorothaizide 12.5 (IH,N = 62) once daily for a 12 week period on sitting office BP, ambulatory BP, 24 hour BP variability, pulse pressure, tolerability and safety profile.
RESULTS:9 pts were withdrawn after randomization. After 12 weeks NH caused a significant greater reduction than IH in sitting SBP (-25.8 ± 1.6 vs -20.6 ± 1.7 mmHg, P < 0.03) and heart rate (HR, -7.0 ± 1.0 vs 2.5 ± 1 b/min, P < 0.01), while the decrease in diastolic and pulse BP showed a non significant tendency to be greater in NH than in IH (-7.4 ± 1.0 and -18.3 ± 1.5 vs -5.0 ± 0.09 and -15.7 ± 1.7 mmHg, P = NS for both). The magnitude of the 24-h, day-time and night-time SBP reduction was almost superimposable in the 2 groups, while HR reduction induced by NH was significantly (P < 0.001) greater during the 24-h, the daytime as well as the nighttime period than that induced by IH. NH caused a significantly greater reduction than IH in 24-h SBP variability, both when expressed as standard deviation (-4.4 ± 2.7 ± vs -2.2 ± 5.1 mmHg, P < 0.02) or as coefficient of variation (-2.0 ± 2.6 vs -0.3 ± 3.4, P < 0.01). This was the case also for pulse pressure and mean BP. Both the 2 drug combinations were well tolerated.
CONCLUSIONS:These data provide evidence that NH induces an office BP reduction greater than IN but similar effects throughout the 24 hours. NH, however, reduces, at variance from IH, 24-h systolic, mean and pulse BP variability, suggesting a greater protection against a variable known to adversely affect morbidity and mortality in hypertensive patients.
In the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, office, home, and ambulatory blood pressure (BP) values were measured contemporaneously between 1990 and 1993 in a large ...population sample (n=2051). Cardiovascular (CV) and non-CV death certificates were collected over the next 148 months, which allowed us to assess the prognostic value of selective and combined elevation in these 3 BPs over a long follow-up. There were 69 CV and 233 all-cause deaths. Compared with subjects with normal office and 24-hour BP, the hazard ratio for CV death showed a progressive increase in those with a selective office BP elevation (white-coat hypertension), a selective 24-hour BP elevation (masked hypertension), and elevation in both office and 24-hour BP. This was the case also when the above conditions were identified by office versus home BP values. Selective elevation in home versus ambulatory BP or vice versa also carried an increased risk. There was indeed a progressive increase in both CV and all-cause mortality risk from subjects in whom office, home, and ambulatory BP were all normal to those in whom 1, 2, or all 3 BPs were elevated, regardless of which BP was considered. The trends remained significant after adjustment for age and gender, as well as, in most instances, after further adjustment for other cardiovascular risk factors. Thus, white-coat hypertension and masked hypertension, both when identified by office and ambulatory or by office and home BPs, are not prognostically innocent. Indeed, each BP elevation (office, home, or ambulatory) carries an increase in risk mortality that adds to that of the other BP elevations.
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