OBJECTIVE:The PAMELA is an epidemiological study performed on a population sample, including office, home and 24 h ambulatory blood pressure (BP) measurements. Measurements were made at baseline, ...after 11 years, and repeated in a 3rd survey 26 years later.
DESIGN AND METHOD:3200 subjects were randomly selected to represent the population of Monza (North Italy) aged 25–74 years. In each subject body mass index (BMI), office (sphygmomanometer), home (semiautomatic validated device), 24 h (validated automatic oscillometric device) systolic (S) and diastolic (D) BP measurements, heart rate (HR) and biochemical variables were obtained. All values were measured at baseline (1st survey, 1990–91), 11 years later (2nd survey, 2001–02) and after further 15 years (3rd survey, 2016–17).
RESULTS:562 subjects (279/283 males/females, mean age 41 ± 10 yrs) participated at the 3 surveys. Baseline average office, home and 24 h SBP/DBP were respectively 122/81 ± 14/9, 116/73 ± 15/10, 116/73 ± 9/7 mmHg and increased respectively of 5/1 ± 14/9, 4/1 ± 14/9 and 4/2 ± 10/7 mmHg at the 2nd survey. At the 3rd survey a further increase of 11/2 ± 7/11, 8/3 ± 16/10 and 13/2 ± 15/9 mmHg was observed in office, home and 24 h BP respectively. The baseline-3rd survey office, home and 24 h SBP difference was unrelated to age, while the DBP increase was inversely related to age (r = −0.32, −0.39 and −0.38, respectively, P < 0.0001). The baseline-3rd survey increase in office, home and 24 h DBP was significantly directly related to the concomitant BMI increase (r = 0.23, 0.17 and 0.14, respectively, P < 0.005). Office and home HR was similar in the 3 surveys. A reduction in 24 h HR was detected between the 1st and 3rd survey (−4.0 ± 8.2 b/min). At baseline hypertensive subjects were 22.2% (office BP), 19.3% (home BP) and 20.7% (24 h BP), and increased to 37.7%, 33.8% and 43.5% at the 2nd survey and to 68.7%, 65.8% and 80.8% at the 3rd survey respectively.
CONCLUSIONS:The PAMELA 26-year follow-up represents the longest survey ever done describing the long-term changes of BP measurements in general population. It shows a long-term increase in office, home and 24 h BP only partially accompanied by HR changes, and an increase in the prevalence of hypertension, particularly pronounced when defined with 24 h measurements.
OBJECTIVE:Limited information is available on the association between serum uric acid (SUA) and metabolic syndrome, diabetes mellitus, renal failure, blood pressure (BP) control and cardiovascular ...(CV) risk profile in treated hypertensives of eastern European countries.
DESIGN AND METHOD:The BP-CARE study examined BP control and CV risk profile in about 8000 treated hypertensive patients followed by non-specialist or specialist physicians in Albania, Belarus, Bosnia, Czech Republic, Latvia, Romania, Serbia, Slovakia and Ukraine. In 3220 of them measurements included, along with clinic BP, 24-hour BP, metabolic and renal function variables, SUA values.
RESULTS:51% were males, while mean age (±SD) was 60.0 ± 10.9 yrs, clinic BP 147.3 ± 18/87.8 ± 10 mmHg, 24 hour BP 137.3 ± 19/81.3 ± 10 mmHg and SUA values 5.68 ± 1.9 mg/dl, with a normal distribution in the population. SUA was significantly higher in males than females (5.99 ± 1.9 vs 5.34 ± 1.9 mg/dl, P < 0.0001) and progressively and significantly greater from the low to the medium, high and very high risk patients (4.87 ± 1.38 vs 5.85 ± 2.00, P < 0.0001, ESH CV risk categories). Significant differences were also found between diabetic and non-diabetic patients (5.92 ± 2.2 vs 5.58 ± 1.8, P < 0.0001), patients with and without metabolic syndrome (5.92 ± 2.1 vs 5.43 ± 1.7, P < 0.0001) and from stage 1 to stage 5 renal insufficiency (from 5.87 ± 2.0 to 10.48 ± 3.4, P < 0.0001). No significant difference in SUA was found between patients treated and non-treated with diuretic or angiotensin II blockers or in those under antihypertensive drug combination vs monotherapy. No difference in SUA was also found when analyzing the data in relation to clinic or 24-hour BP control.
CONCLUSIONS:These data provide evidence that similarly to what described in western Europe, in central and eastern European countries SUA values are closely related to metabolic alterations, including diabetes mellitus, to renal insufficiency and CV risk profile. At variance from other studies, however, no relationship was found with BP control.
Blood pressure is a determinant of the risk of stroke among both hypertensive and non-hypertensive individuals with cerebrovascular disease. However, there is uncertainty about the efficacy and ...safety of blood-pressure-lowering treatments for many such patients. The perindopril protection against recurrent stroke study (PROGRESS) was designed to determine the effects of a blood-pressure-lowering regimen in hypertensive and non-hypertensive patients with a history of stroke or transient ischaemic attack.
6105 individuals from 172 centres in Asia, Australasia, and Europe were randomly assigned active treatment (n=3051) or placebo (n=3054). Active treatment comprised a flexible regimen based on the angiotensin-converting-enzyme inhibitor perindopril (4 mg daily), with the addition of the diuretic indapamide at the discretion of treating physicians. The primary outcome was total stroke (fatal or non-fatal). Analysis was by intention to treat.
Over 4 years of follow up, active treatment reduced blood pressure by 9/4 mm Hg. 307 (10%) individuals assigned active treatment suffered a stroke, compared with 420 (14%) assigned placebo (relative risk reduction 28% 95% Cl 17–38, p<0·0001). Active treatment also reduced the risk of total major vascular events (26% 16–34). There were similar reductions in the risk of stroke in hypertensive and non-hypertensive subgroups (all p<0·01). Combination therapy with perindopril plus indapamide reduced blood pressure by 12/5 mm Hg and stroke risk by 43% (30–54). Single-drug therapy reduced blood pressure by 5/3 mm Hg and produced no discernable reduction in the risk of stroke.
This blood-pressure-lowering regimen reduced the risk of stroke among both hypertensive and non-hypertensive individuals with a history of stroke or transient ischaemic attack. Combination therapy with perindopril and indapamide produced larger blood pressure reductions and larger risk reductions than did single drug therapy with perindopril alone. Treatment with these two agents should now be considered routinely for patients with a history of stroke or transient ischaemic attack, irrespective of their blood pressure.
OBJECTIVE:Neurogenic mechanims have been shown to regulate not only absolute blood pressure levels but also blood pressure variability during the short-term 24 hour period. No information are ...available on whether visit-to-visit blood pressure variability is related to sympathetic and baroreflex function.
DESIGN AND METHOD:61 untreated essential hypertensive patients aged 56.1 ± 2.5 years (mean ± SEM) underwent 3 clinic BP measurements on 3 occasions during a 6 weeks period. In each patient we assessed muscle sympathetic nerve traffic (MSNA, microneurography), spontaneous MSNA-baroreflex sensitivity according to Kienbaum method, and blood pressure variability of systolic and diastolic BP, quantified as coefficient of variation (CV) and as standard deviation (SD) of the BP values.
RESULTS:Patients were subdivided into CV and SD quartiles. Quartiles were matched for age and gender. For each quartile a relationship was sought with MSNA and baroreflex sensitivity. Compared with the patients in the lowest systolic BP CV quartile, patients in the highest quartile showed significantly greater MSNA (62.5 ± 4 vs 48.2 ± 3 bursts/100 heart beats, P < 0.02) and significantly lower baroreflex sensitivity values (1.23 ± 0.2 vs 2.09 ± 0.2 a.u., P < 0.03). This was the case also when BP variability was expressed as SD. When diastolic BP data were analyzed no significant difference between quartiles was found.
CONCLUSIONS:These data provide the first demonstration that in hypertension a greater visit-to-visit blood pressure variability is associated with greater levels of sympathetic activation and more pronounced baroreflex dysfunction. The relationship appears to be valid particularly for the systolic BP component. Thus sympathetic and reflex mechanisms contribute not only to the short-term but also to the long-term BP variability phenomenon.
OBJECTIVE:Office and 24-h ambulatory (A) blood pressure (BP) measurement are the main techniques to quantify the BP effects of treatment in clinical trials and practice. Several clinical trials have ...made it clear that the BP reduction as evaluated by the two techniques differs. We performed a meta-analysis to quantify the magnitude of this difference in patients given a variety of drug treatments. Moreover, we stratified the analysis for antihypertensive class.
DESIGN AND METHOD:A MEDLINE research based on the following inclusion criteria was performedi) randomized clinical trials published from the 1st of January 1960 to the 9th of July 2015; ii) patients treated with any antihypertensive drug either in monotherapy or in combination; iii) treatment-induced office and 24-h mean BP reduction in the same patients; iv) availability of variability measures of BP reduction or sufficient raw data to calculate it. Fixed and random effect models were fitted to estimate the pooled BP reductions for both techniques on condition that the corresponding estimates were reported by at least three studies. Between study heterogeneity was tested using Q statistics and measured with the I2 index. Publication bias was evaluated using funnel plot and Eggerʼs regression asymmetry test.
RESULTS:41 studies satisfying inclusion criteria and including 8,171 patients were analyzed. The main results are showed in Table 1. Compared to office 24-h mean BP reduction was always less. The ratio between office and 24-h BP reduction was similar for the different treatments (range 1.4–1.9), its value being somewhat lower for patients under combination treatment and markedly higher and more variable for placebo.(Figure is included in full-text article.)
CONCLUSIONS:The effect of antihypertensive treatment is systematically greater for office than for ABP. The difference is marked and visible for all major antihypertensive drugs as well as for combination treatment as compared to monotherapy.
Abstract Objective The aim of this study is to assess whether family history of coronary heart disease (CHD) and education as proxy of social status improve long-term cardiovascular disease risk ...prediction in a low-incidence European population. Methods The 20-year risk of first coronary or ischemic stroke events was estimated using sex-specific Cox models in 3956 participants of three population-based surveys in northern Italy, aged 35–69 years and free of cardiovascular disease at enrollment. The additional contribution of education and positive family history of CHD was defined as change in discrimination and Net Reclassification Improvement (NRI) over the model including 7 traditional risk factors. Results Kaplan–Meier 20-year risk was 16.8% in men (254 events) and 6.4% in women (102 events). Low education (hazard ratio = 1.35, 95%CI 0.98–1.85) and family history of CHD (1.55; 1.19–2.03) were associated with the endpoint in men, but not in women. In men, the addition of education and family history significantly improved discrimination by 1%; NRI was 6% (95%CI: 0.2%–15.2%), raising to 20% (0.5%–44%) in those at intermediate risk. NRI in women at intermediate risk was 7%. Conclusion In low-incidence populations, family history of CHD and education, easily assessed in clinical practice, should be included in long-term cardiovascular disease risk scores, at least in men.
OBJECTIVE:Activity of the sympathetic nervous system (SNS) is increased in hypertensive patients with chronic kidney disease (CKD). We tested the hypothesis that hypertensive patients with CKD ...enrolled in the Global Symplicity Registry (GSR) show different patterns in blood pressure (BP) outcomes in the short-term (6 months), as well as long-term follow-up (3 years).
DESIGN AND METHOD:The GSR (NCT 01534299) is a prospective, open-label, international, multicentre observational study for assessment of safety and effectiveness of renal denervation (RDN) among real-world patients treated with the Symplicity™ RDN system (Medtronic, Santa Rosa, CA, USA). Inclusion criteria are age > = 18 years and eligibility for RDN. 24-h ambulatory BP was assessed at pre-specified time-points (6, 12, 24 and 36 months). For the current analyses, enrolled patients (N = 1600) were stratified based on baseline estimated glomerular filtration rate (eGFR) in <60 ml/min/1.73 m versus > = 60 ml/min/1.73 m (according to MDRD formula) into with (N = 383) and without (N = 1217) CKD groups.
RESULTS:Patients with CKD were significantly older (65.3 ± 11 versus 59.9 ± 12 yrs, p < 0.0001) and were treated with more antihypertensive medications (4.78 ± 1.3 versus 4.48 ± 1.4, p < 0.0001) compared to patients without CKD. There was no difference in baseline 24-h ambulatory systolic BP, whereas 24-h ambulatory diastolic BP was lower in patients with compared to without CKD (152.9 ± 19/81.3 ± 13 versus 153.2 ± 18/87.2 ± 14 mmHg, p = 0.6380/ < 0.0001), resulting in an increased pulse pressure. In patients with and without CKD, 24-h ambulatory BP was significantly reduced after RDN compared to baseline values at all time-points (all p < 0.01). There was no difference in 24-h ambulatory systolic and diastolic BP reduction after RDN in favor of patients with compared to without CKD (Table).(Figure is included in full-text article.)
CONCLUSIONS:Hypertensive patients with CKD did not show a greater short-term or long-term decrease in 24-hour ambulatory BP. Changes in pulse pressure and eGFR over the 3 years follow-up will be also presented.
OBJECTIVE:We explored if differences in blood pressure profiles can explain the differences in risks of cardiovascular events and death among patients treated with valsartan or amlodipine in the ...Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial.
DESIGN AND METHOD:The VALUE trial was a randomised, double-masked trial of valsartan versus amlodipine in patients with hypertension. Mean follow-up was 4.2 years. We calculated mean systolic blood pressure as a time-dependent variable and blood pressure variability as the standard deviation (SD) of systolic blood pressure during follow-up in patients with 3 or more visits, and compared blood pressure profiles in the treatment groups. We performed multiple Cox regression analyses to assess the importance of mean blood pressure, blood pressure variability and clinical risk factors for the effects of valsartan versus amlodipine on myocardial infarction, stroke, congestive heart failure, and death.
RESULTS:14,996 patients were eligible for analysis. Mean systolic blood pressure and blood pressure variability was higher in the valsartan group (mean difference 2.2 mm Hg and 1.4 mm Hg, p < 0.0001 and p < 0.0001, respectively). For myocardial infarction, adjustment for mean blood pressure and blood pressure variability attenuated the risk increase for valsartan towards the null (from HR 1.19 to 1.12), mainly attributable to blood pressure variability. For stroke, adjustment for mean pressure and blood pressure variability both attenuated the risk increase for valsartan (from HR 1.12 to 1.01). For congestive heart failure the risk reduction for valsartan became even more pronounced (from HR 0.89 to 0.77). No clear effect was seen on death (from HR 1.01 to 1.00). The effects were the same if we excluded measurements from the first 6 months.
CONCLUSIONS:Differences in mean systolic blood pressure and pressure variability during follow-up explained most of the effects of valsartan versus amlodipine on risk of myocardial infarction and stroke. Differences in variability seem to be particularly important for the effect on myocardial infarction. For congestive heart failure, there seems to be a beneficial effect of valsartan versus amlodipine, independent of blood pressure. These data deserve further investigation.
1 Polo Tecnologico, Fondazione Don Carlo Gnocchi, ONLUS, Milano, Italy; 2 Dipartimento di Medicina Interna, Universita' di Roma "Tor Vergata," and IRCCS San Raffaele Pisana, Roma, Italy; 3 IRCCS San ...Raffaele Pisana, Roma, Italy; 4 Centro di Terapia Neurovegetativa, Polo L. Sacco-Universita di Milano, Milano, Italy; 5 Department of Clinical Medicine and Prevention, University of Milano-Bicocca, and Department of Cardiology, San Luca Hospital, IRCCS, Istituto Auxologico Italiano Milan, Italy; and 6 Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Submitted 9 May 2008
; accepted in final form 13 August 2008
This study explored the process of arterial baroreflex adaptation to microgravity, starting from the first day of flight, during the 16-day STS-107 Columbia Space Shuttle mission. Continuous blood pressure (BP), ECG, and respiratory frequency were collected in four astronauts on ground (baseline) and during flight at days 0–1 , 6–7, and 12–13 , both at rest and during moderate exercise (75 W) on a cycle ergometer. Sensitivity of the baroreflex heart rate control (BRS) was assessed by sequence and spectral alpha methods. Baroreflex effectiveness index (BEI); low-frequency (LF) power and high-frequency (HF) power of systolic BP (SBP), diastolic BP (DBP), and R-R interval (RRI); the RRI LF/HF ratio; and the RRI root mean square of successive differences (RMSSD) index were also estimated. We found that, at rest, BRS increased in early flight phase, compared with baseline (means ± SE: 18.3 ± 3.4 vs. 10.4 ± 1.2 ms/mmHg; P < 0.05), and it tended to return to baseline in subsequent days. During exercise, BRS was lower than at rest, without differences between preflight and in-flight values. At rest, in the early flight phase, RMSSD and RRI HF power increased ( P < 0.05) compared with baseline, whereas LF powers of SBP and DBP decreased. No statistical difference was found in these parameters during exercise before vs. during flight. These findings demonstrate that heart rate baroreflex sensitivity and markers of cardiac vagal modulation are enhanced during early exposure to microgravity, likely because of the blood centralization, and return to baseline values in subsequent flight phases, possibly because of the fluid loss. No deconditioning seems to occur in the baroreflex control of the heart.
arterial baroreflex; heart rate variability; blood pressure monitoring
Address for reprint requests and other correspondence: M. Di Rienzo, Polo Tecnologico, Fondazione Don Carlo Gnocchi, ONLUS Via Capecelatro 66, 20133 Milano, Italy (e-mail: mdirienzo{at}dongnocchi.it )
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