Cardiovascular diseases still represent the leading cause of mortality and hospitalization, worldwide. As a consequence of the marked demographic changes observed in the general population, the ...improved survival rate after an acute cardiovascular event and the progressive rise of costs (mostly due to technological and pharmacological innovations), the estimated burden of cardiovascular diseases will be soon become insurmountable for national healthcare systems. In this view, an integrated approach aimed at improving strategies for cardiovascular disease prevention and, thus, limiting the negative outcomes, would probably be successful. Such an approach may not only achieve long-term benefits, but even significant advantages in the short to medium term, mostly in asymptomatic high-risk individuals. Indeed, this latter population of asymptomatic high-risk individuals would mostly benefit from extensive application and improvement of strategies for cardiovascular disease prevention with a favourable cost-benefit ratio.The Italian Society for Cardiovascular Disease Prevention — Società Italiana per la Prevenzione Cardiovascolare (SIPREC) — has recognized this strategic aim, focusing a significant part of its institutional actions on the effort for providing educational supports and consensus documents, which represent an overview of the scientific knowledge and personal clinical expertise by national and international key opinion leaders. Expert committees periodically generate ‘state-of-the-art’ documents on specific scientific topics with relevant socioeconomic implications and large clinical impact. The present article is dedicated to healthcare professionals, is based on the available evidence, and provides information on diagnostic algorithms and therapeutic options on abnormal glucose regulation (or dysglycaemia).The relationship between abnormalities in glucose metabolism and cardiovascular complications represents an important and relatively early target for cardiovascular disease prevention. SIPREC identified, even in this clinical setting, a group of scientific experts in order to form a multidisciplinary ‘task force’. This group has been asked to explain in a short, simple and effective fashion the epidemiological impact and the pathophysiological nature of the problem, its clinical features, potential diagnostic algorithms and therapeutic options, and its influence on the clinical practice of both specialist physicians and general practitioners.This work provides the background for discussing novel future strategies for cardiovascular prevention. It is also aimed at highlighting the importance of an emerging marker of cardiovascular risk, which is often not recognized and underestimated.
Arterial Hypertension and Cardiac Damage Rosei, Enrico Agabiti; de Simone, Giovanni; Mureddu, Gianfrancesco ...
High blood pressure & cardiovascular prevention,
07/2008, Letnik:
15, Številka:
3
Journal Article
Recenzirano
Arterial hypertension still represents the most common preventable cause of morbidity and mortality, worldwide, and the WHO states that high blood pressure levels are responsible for 62% of ...cerebrovascular events and 49% of ischaemic heart diseases globally. Effective antihypertensive treatment significantly reduces individual total cardiovascular risk.Both cardiac and vascular consequences of arterial hypertension derive from structural and functional abnormalities of peripheral arteries, and these clinical conditions strongly predispose to developing major hypertension-related cardiovascular events.Due to the asymptomatic or oligo-symptomatic course, before being clinically evident, of hypertensive cardiopathy (e.g. hypertensive disease), the appropriate and periodic evaluation of structural and functional cardiac damage represents an important diagnostic and prognostic outcome for driving therapeutic strategy in the clinical management of hypertension.The present guidelines, endorsed by the Joint Committee of the Italian Society of Hypertension, the Italian Society of Cardiology, and the Associazione Nazionale Medici Cardiologi Ospedalieri, are aimed to help physicians to choose the best diagnostic and therapeutic approach in the clinical management of any individual hypertensive patient.
To provide model-based estimates of all cancers patient survival in Italy and in Italian large geographical areas (North-West, North-East, Center, South), where only partial coverage of cancer ...registries data is available, and to describe them in terms of time trends. Moreover, to measure the degree of representativeness of cancer patient survival obtained from Italian cancer registries data.
Relative survival in the four main Italian geographical areas was estimated by a parametric mixture model belonging to the class of "cure" survival models. Data used are from Italian cancer registries, stratified by sex, period of diagnosis and age. The Italian national survival was obtained as a weighted average of these area-specific estimates, with weights proportional to the number of estimated incident cases in every area. The model takes into account also differences in survival temporal trends between the areas.
Relative survival for all cancers combined in Italian patients diagnosed in 1990-1994 was estimated to be higher in women (53%) than in men (38%) at 5 years from the diagnosis. The survival trend is increasing by period and decreasing by age, both for men and women. The greatest gain in terms of survival was obtained by the elderly, with annual mean growth rates in the period 1978-1994 equal to 3.5% and 3.2% for men and women, respectively. More than 50% of the youngest cancer patients were "cured", whereas for the elderly this proportion dropped to 15% and 25% for men and women, respectively. The South of Italy had the lowest survival and the North the most pronounced increase.
The obtained national survival estimates are similar, but not identical, to previously published estimates, in which Italian registries' data were pooled without any adjustment for geographical representativeness. The four Italian areas have different survival levels and trends, showing variability within the country. The differences in survival between men and women may be explained by the different proportion of lethal cancers. Among males, most cases had a poor prognosis (lung and stomach cancers), whereas among females the largest proportion was made up of curable and less lethal cancers (breast cancer).
Although electrocardiography (ECG) is recommended in all subjects with hypertension, no information is available on the influence exerted by random changes in the placement of electrodes on the ...day-to-day variability of ECG criteria for diagnosis of left ventricular hypertrophy (LVH).
In a multicentre, randomized study, two standard 12-lead ECG were recorded, 24 h apart, from 276 consecutive hypertensive patients (mean age 65 +/- 12 years, 49.6% men). Overall, 142 patients were randomized to ECG with the position of electrodes marked on the skin using a dermographic pen and 134 to traditional ECG without marking the position of electrodes. Day-to-day variability of ECG criteria for LVH was compared between the two groups.
Coefficients of variation (SD of the difference between paired voltage measurements divided by the mean value) varied consistently among subjects randomized to ECG without dermographic pen, ranging from 30% (R wave in lead I) to 81% (R wave in lead V5). Dermographic pen led to a lesser variability of ECG voltages with consequent reduction in the coefficients of variation, which ranged from 26% (R-wave amplitude in lead I) to 43% (R-wave amplitude in lead V5). The proportion of subjects who changed classification status for LVH ('reclassification rate') from the first to the second ECG session (LVH present in session 1 and absent in session 2, or vice versa) decreased for effect of dermographic pen from 11 to 4% (P = 0.040) with the Cornell voltage, from 19 to 11% (P = 0.029) with the Sokolow-Lyon voltage, and from 18 to 7% with the Romhilt-Estes criterion (P = 0.018), but not with other criteria. In particular, the typical strain and the Cornell strain were associated with the lowest reclassification rates regardless of dermographic pen.
Random changes in the position of ECG electrodes strongly impair the day-to-day reproducibility of Cornell voltage, Sokolow-Lyon and Romhilt-Estes criteria for LVH. The typical strain and Cornell strain criteria showed a lesser spontaneous day-to-day variability.
Early identification of left ventricular (LV) structural changes may have an impact on the outlook of patients with essential hypertension. Of 669 untreated hypertensive subjects, 496 (74%) with ...normal LV mass at echocardiography (< 125 g/m2) were grouped according to normal LV geometry (n = 303; 61%), asymmetric LV remodeling due to isolated septal thickening (n = 111; 22%), asymmetric LV remodeling due to isolated posterior wall thickening (n = 5; 1%), or concentric LV remodeling due to septal and posterior wall thickening (n = 77; 16%). Remodeling was defined as twice the thickness of septum or posterior wall divided by the internal diameter at end diastole > 0.45. Twenty-four-hour noninvasive ambulatory blood pressure (BP) monitoring was performed in all subjects. Compared with subjects with normal LV geometry, those with asymmetric LV remodeling due to isolated septal thickening showed increased clinic BP (158/100 vs 153/97 mm Hg, both p < 0.05), mean daytime ambulatory BP (144/95 vs 138/90 mm Hg, both p < 0.01), mean nighttime ambulatory BP (128/80 vs 122/76 mm Hg, both p < 0.01), LV mass (99 vs 89 g/m2, p < 0.001), total peripheral resistance (1,881 vs 1,562 dynes s cm-5, p < 0.01) and known duration of hypertension (5.5 vs 3.6 years, p < 0.01) and decreased stroke index (39 vs 47 ml/m2, p < 0.01).
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.
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.
Arterial Hypertension and Cardiac Damage Rosei, Enrico Agabiti; de Simone, Giovanni; Mureddu, Gianfrancesco ...
High blood pressure & cardiovascular prevention,
2008/7, Letnik:
15, Številka:
3
Journal Article
Recenzirano
Arterial hypertension still represents the most common preventable cause of morbidity and mortality, worldwide, and the WHO states that high blood pressure levels are responsible for 62% of ...cerebrovascular events and 49% of ischaemic heart diseases globally. Effective antihypertensive treatment significantly reduces individual total cardiovascular risk.
Both cardiac and vascular consequences of arterial hypertension derive from structural and functional abnormalities of peripheral arteries, and these clinical conditions strongly predispose to developing major hypertension-related cardiovascular events.
Due to the asymptomatic or oligo-symptomatic course, before being clinically evident, of hypertensive cardiopathy (e.g. hypertensive disease), the appropriate and periodic evaluation of structural and functional cardiac damage represents an important diagnostic and prognostic outcome for driving therapeutic strategy in the clinical management of hypertension.
The present guidelines, endorsed by the Joint Committee of the Italian Society of Hypertension, the Italian Society of Cardiology, and the
Associazione Nazionale Medici Cardiologi Ospedalieri
, are aimed to help physicians to choose the best diagnostic and therapeutic approach in the clinical management of any individual hypertensive patient.
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