To determine the prognostic significance of ambulatory blood pressure, we prospectively followed for up to 7.5 years (mean, 3.2) 1187 subjects with essential hypertension and 205 healthy normotensive ...control subjects who had baseline off-therapy 24-hour noninvasive ambulatory blood pressure monitoring. Prevalence of white coat hypertension, defined by an average daytime ambulatory blood pressure lower than 131/86 mm Hg in women and 136/87 mm Hg in men in clinically hypertensive subjects, was 19.2%. Cardiovascular morbidity, expressed as the number of combined fatal and nonfatal cardiovascular events per 100 patient-years, was 0.47 in the normotensive group, 0.49 in the white coat hypertension group, 1.79 in dippers with ambulatory hypertension, and 4.99 in nondippers with ambulatory hypertension. After adjustment for traditional risk markers for cardiovascular disease, morbidity did not differ between the normotensive and white coat hypertension groups (P=.83). Compared with the white coat hypertension group, cardiovascular morbidity increased in ambulatory hypertension in dippers (relative risk, 3.70; 95% confidence interval, 1.13 to 12.5), with a further increase of morbidity in nondippers (relative risk, 6.26; 95% confidence interval, 1.92 to 20.32). After adjustment for age, sex, diabetes, and echocardiographic left ventricular hypertrophy (relative risk versus subjects with normal left ventricular mass, 1.82; 95% confidence interval, 1.02 to 3.22), cardiovascular morbidity in ambulatory hypertension was higher (P=.0002) in nondippers than in dippers in women (relative risk, 6.79; 95% confidence interval, 2.45 to 18.82) but not in men (P=.91). Our findings suggest that ambulatory blood pressure stratifies cardiovascular risk in essential hypertension independent of clinic blood pressure and other traditional risk markers including echocardiographic left ventricular hypertrophy. Cardiovascular morbidity is low in white coat hypertension and exceedingly high in women with ambulatory hypertension and absent or blunted blood pressure reduction from day to night.
With excessive weight being the second-most-important, preventable cause of premature disease and death in America, a new way to reduce weight could provide important benefits to overweight or obese ...individuals who find exercising or dieting difficult. To determine if thermoregulation, in conjunction with the consumption of a well-balanced Mediterranean diet, can increase calorie burning and weight loss. This 8-week pilot study examined the effects of thermal-wrap technique on weight, percentage of fat composition, body mass index (BMI), basal metabolic rate (BMR), circumference of waist and hip, and water loss. The study took place between November 2004 and January 2005 at the Vivinlinea Clinic in Great Neck, New York. The study included 70 subjects who were either overweight or obese as determined by BMI. The study was nonrandomized, with the researchers assigning subjects to one of two groups based on the services the participants selected while attending the clinic-50 to the Thermal Group (TG) and 20 to the Control Group (CG). The distribution of subjects was self-selected in that those who requested the thermal-wrap technique received it plus nutritional planning and those who did not received only the nutritional planning. The researchers recorded baseline morphologic measurements and personal data, including height, weight, age, and menstrual status. The groups were not matched but did not differ on baseline measures. Researchers also calculated the baseline BMI and BMR (using the Sterling-Passmore equation14). In the TG, 4 participants stopped the program due to claustrophobia and 3 stopped due to lack of compliance with the nutritional plan. In the CG there were no dropouts All participants who remained active through the 4-week point completed the study. Intervention consisted of two, 50-minute sessions each week for eight weeks, consisting of thermal-wrap technique. The thermal wrap uses electromagnetic energy to create heat, directing it to specific tissue areas. A trained professional applied the thermal wrap. Intervention for the TG and mock intervention for the CG both employed a thermal wrap; the wrap for the TG group was heated to a temperature of 44°C, while the wrap for the CG was not. The study used the thermal wrap in 2 configurations, depending on the participant's BMI. Members of both groups also received a series of dietary counseling sessions providing guidance on individualized eating programs based on a well-balanced Mediterranean diet of between 1600 and 2000 kCal. The researchers examined cumulative weight loss over eight weeks as the primary outcome. Secondary outcomes included changes in percentage of fat composition, BMI, basal metabolic rate (BMR), circumference of waist and hip, and water loss. At the end of the 8-week study, the CG had lost an average of 1.0 (0.7) kg while the TG had lost an average of 5.2 (1.3) kg (95% CI (Δ): 3.7-4.7, P < .0001). During the 8-week treatment, the CG lost a mean (sd) of 758.6 (558) kcal/week while the TG lost 5105.2 (1191) kcal/week (95% CI (Δ): 3928-4765, P < 0.0001). The average BMI in the CG declined 0.4 (0.4) kg/m^sup 2^ and the TG 2.0 (0.5) kg/m^sup 2^ (95% CI (Δ): 1.4-1.8, P<0001). The mean BMR of the CG decreased 18.5 (17.8) compared with 34.3 (23.8) in the TG (95% CI (Δ): 19.9-29.6, P < .01). Mean percentage of body fat decreased 0.5% (1.0) and 3.7% (1.1) in the CG and TG respectively (95% CI (Δ): 2.7%-3.8%, P < .0001). Waist circumference declined an average of 0.7 (0.6) cm in the CG and 5.8 (1.9) cm in the TG (95% CI (Δ): 4.5-5.6,P < .0001), while the hip circumference declined an average of 1.0 (0.8) cm in the CG and 6.3 (2.0) cm in the TG (95% CI (Δ): 5.2-4.6, P < .0001). Water decreased 0.2% (0.9%) in the CG and increased 3.1% (0.6%) in the TG (95% CI (Δ): -3.8 to -2.9, P < .0001). No adverse events were observed or reported. Although preliminary, this pilot study suggests that thermal-wrap technique may provide a safe and effective mechanism for inducing weight loss in overweight and obese women. Further research is needed to confirm this finding.
Twenty-four-hour noninvasive ambulatory blood pressure (BP) monitoring and echocardiography were performed in 165 consecutive untreated hypertensive patients and in 92 healthy subjects. In the ...hypertensive group, left ventricular (LV) mass index showed closer correlations (all p less than 0.01 in the comparisons between the r coefficients) with average 24-hour ambulatory systolic (r = 0.47) and diastolic (r = 0.33) BP than with casual systolic (r = 0.35) and diastolic (r = 0.28) BP. Hypertensive patients were classified according to the difference between their observed and predicted levels of ambulatory BP (the latter assessed by regressing the observed ambulatory BP on the casual BP). When compared to those with lower than predicted ambulatory BP (less than or equal to 10 mm Hg systolic, less than or equal to 6 mm Hg diastolic), patients with higher than predicted ambulatory BP (greater than or equal to 10 mm Hg systolic and greater than or equal to 6mm Hg diastolic) had higher values of LV mass index and other indexes of LV hypertrophy (all p less than 0.01) but had similar values of casual BP. Prevalence of LV hypertrophy was 6 to 10% in the former and 35 to 39% in the latter (p less than 0.001). None of the indexes of LV structure differed between the group with low ambulatory BP and the normotensive group. It is concluded that hypertensive patients whose ambulatory BP readings are notably higher than one would predict from clinical BP readings are at highest risk of LV hypertrophy, an independent prognostic marker.
The effects of circadian blood pressure (BP) changes on the echocardiographic parameters of left ventricular (LV) hypertrophy were investigated in 235 consecutive subjects (137 unselected untreated ...patients with essential hypertension and 98 healthy normotensive subjects) who underwent 24-hour noninvasive ambulatory blood pressure monitoring (ABPM) and cross-sectional and M-mode echocardiography. In the hypertensive group, LV mass index correlated with nighttime (8:00 PM to 6:00 AM) systolic (r = 0.51) and diastolic (r = 0.35) blood pressure more closely than with daytime (6:00 AM to 8:00 PM) systolic (r = 0.38) and diastolic (r = 0.20) BP, or with casual systolic (r = 0.33) and diastolic (r = 0.27) BP. Hypertensive patients were divided into two groups by presence (group 1) and absence (group 2) of a reduction of both systolic and diastolic BP during the night by an average of more than 10% of the daytime pressure. Casual BP, ambulatory daytime systolic and diastolic BP, sex, body surface area, duration of hypertension, prevalence of diabetes, quantity of sleep during monitoring, funduscopic changes, and serum creatinine did not differ between the two groups. LV mass index, after adjustment for the age, the sex, the height, and the daytime BP differences between the two groups (analysis of covariance) was 82.4 g/m2 in the normotensive patient group, 83.5 g/m2 in hypertensive patients of group 1 and 98.3 g/m2 in hypertensive patients of group 2 (normotensive patients vs. group 1, p = NS; group 1 vs. group 2, p = 0.002).
This study was aimed at improving the performance of standard electrocardiographic criteria of left ventricular hypertrophy (LVH) in essential hypertension using echocardiographic left ventricular ...mass as reference. In 923 white, untreated hypertensive subjects (mean age 51, prevalence of echocardiographic LVH 34%), sensitivity of electrocardiographic criteria of LVH varied between 9% and 33% and specificity was generally > or = 90%. The sum of Sv3 + RaVL (Cornell voltage) showed the closest association with echocardiographic left ventricular mass (r = 0.48, p < 0.001), and its performance was superior to that of Sokolow-Lyon voltage in a receiver-operating characteristic curve analysis. A modified partition value of the Cornell voltage was tested (> 2.4 mV in men and > 2.0 mV in women), that yielded a good combination between sensitivity (26% in men and 19% in women, overall 22%) and specificity (96% in men and 95% in women, overall 95%). When LVH at electrocardiography was defined as the positivity of at least 1 of the following 3 criteria--Sv3 + RaVL > 2.4 mV in men or > 2.0 mV in women, a typical strain pattern, or a Romhilt-Estes point score > or = 5--sensitivity increased to 39% in men and 29% in women (overall 34%) and specificity decreased to 94% in men and 93% in women (overall 93%). Sensitivity of electrocardiography progressively increased from the first to the fourth quartile of left ventricular mass in subjects with echocardiographic LVH.
The finding of increased left ventricular (LV) mass in hypertensive subjects with blunted nocturnal fall in blood pressure (BP) might be an artifact of matching patients for daytime BP, with ...resulting higher 24-h BP in nondippers. Therefore, we compared a large number (n = 1048) of hypertensive dippers and nondippers in their LV mass at echocardiography before and after adjustment for 24-h, daytime, and nighttime ambulatory BP. In men, the difference between dippers and nondippers was not significant before and after adjustment for 24-h BP, but after adjustment for nighttime BP LV mass was greater in dippers (more properly "peakers"). In women, LV mass was greater in nondippers than in dippers both before and after adjustment for 24-h BP, while the difference between the two groups disappeared after adjustment for nighttime BP. Thus, for any given level of mean 24-h BP, a flattened diurnal BP profile is associated with a greater LV mass in hypertensive women. Daytime hypertension, either associated or not with a blunted nocturnal fall in BP, may be a sufficient determinant of LV wall thickening in men.
To test the hypothesis of a difference between men and women in the left ventricular hypertrophic response to diurnal variations of ambulatory blood pressure in essential hypertension.
Non-invasive ...ambulatory blood pressure monitoring and echocardiography in untreated hypertensive patients and healthy normotensive subjects.
Community-based ambulatory population in tertiary care centers.
Two hundred and sixty hypertensive patients and sixty-three healthy normotensive subjects.
Patients with average daytime systolic blood pressure (SBP) and diastolic blood pressure (DBP) falling by less than 10% during the night were defined as non-dippers, the others as dippers.
In the hypertensive group, dippers and non-dippers did not differ, in either gender, in several covariates possibly affecting left ventricular structure, including daytime ambulatory blood pressure, prevalence of white coat hypertension, age, body mass index, family history and known duration of hypertension, funduscopic changes, diabetes, alcohol consumption and renal function. Left ventricular mass (LVM) did not differ between dippers and non-dippers in hypertensive men whilst in hypertensive women it was significantly lower in dippers than in non-dippers. This sex difference held for all quartiles of the distribution of mean daytime blood pressure. In hypertensive women there was an inverse correlation between LVM and the per cent reduction of SBP and DBP from day to night, but this relationship was absent in hypertensive men. Other indices of left ventricular structure differed between dippers and non-dippers in both genders, as did LVM.
For any level of daytime ambulatory blood pressure, a reduction of SBP and DBP by less than 10% from day to night identifies a subset of hypertensive patients at increased risk of left ventricular hypertrophy only in the female gender. These data suggest that, compared with men, hypertensive women require a longer duration of exposure to high blood pressure levels during the 24 h to develop left ventricular hypertrophy.
Ambulatory blood pressure (ABP) monitoring shows that pulse pressure (PP) changes from day to night, but correlates and prognostic relevance of such phenomenon are unknown. In the setting of the ...PIUMA study, 3617 initially untreated subjects with essential hypertension (age 50, 55% men, 25% current smokers, 6.4% with type II diabetes) underwent 24-hour non-invasive ABP monitoring. Office BP was 153/95 mmHg, 24-hour BP 135/85 mmHg, daytime BP 144/92 mmHg and nighttime BP 118/74 mmHg. PP decreased from 50 to 48 mmHg from day (10:00 a.m.- 8:00 p.m.) to night (0:00 to 5:00 a.m.). The night/day ratio in PP was 0.97 (±0.12); it showed a direct association with nighttime systolic BP (r=0.28, p=0.001) and PP (r=0.29, p=0.001), and an inverse association with daytime systolic BP (r=−0.19, p=0.001) and PP (r=−0.15, p=0.001). Subsequent treatment was tailored to the single subject. Over a mean follow-up of 5.9 years (range:0-16) there were 175 major cardiac events. Event rate (x 100 person-years) was 1.20 in the upper tertile of the night/day ratio in PP (>1.011) and 0.90 in the remaining subjects (log-rank test: p = 0.04). In a Cox model, after adjustment for average daytime PP (p=0.005), the upper tertile of the night/day ratio in PP was associated with a 54% higher risk of cardiac events (95% CI: 13-109). However, after adjustment for the average 24-hour PP (p=0001) or nighttime PP (p=0.001) the night/day ratio in PP lost its independent significance. Inclusion in the model of other independent determinants of cardiac events (age, gender, diabetes, smoking, left ventricular hypertrophy) did not affect results. In conclusion, for any level of daytime PP, a blunted reduction in PP from day to night identifies hypertensive subjects at increased risk for cardiac events. A comparable prognostic information is provided by the average 24-hour PP see Figure.
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