Abstract
Aims
To evaluate the long-term reproducibility of masked (MUCH) and white-coat uncontrolled hypertension (WUCH), an information crucial for determining the long-term prognostic impact of ...these conditions.
Methods and results
Reproducibility of MUCH and WUCH was assessed in 1664 hypertensive patients recruited for the European Lacidipine Study on Atherosclerosis and treated with atenolol or lacidipine (±additional drugs) during a 4-year period. Office and 24 h blood pressure (BP) was measured at baseline and every year during treatment, allowing repeated classification of either condition. After 1 year of treatment 21.1% and 17.8% of the patients were classified as MUCH and WUCH, respectively. For both conditions the prevalence was similar in the following years, although with a large change in patients composition because only about 1/3 of patients classified as MUCH or WUCH at one set of office and ambulatory BP measurements maintained the same classification at a subsequent set of measurements. In only 4.5% and 6.2% MUCH and WUCH persisted throughout the treatment period. MUCH and WUCH reproducibility was worse than that of patients showing control or lack of control of both office and ambulatory BP, i.e. controlled and uncontrolled hypertension, respectively.
Conclusion
Both MUCH and WUCH display poor reproducibility over time. This should be taken into account in studies assessing the long-term prognostic value of these conditions based on only one set of BP measurements.
Stratification of cardiovascular risk is of fundamental importance in white coat hypertension (WCH) to identify individuals in need of closer follow-up and perhaps antihypertensive drug treatment. In ...subjects representative of the general population of Monza (Italy), the risk of cardiovascular and all-cause mortality was assessed >16 years in stable and unstable WCH individuals, that is, those in whom ambulatory blood pressure (BP) normality was associated with a persistent or nonpersistent office BP elevation at 2 consecutive visits, respectively. Data were compared with those from an entirely normotensive group, that is, ambulatory and persistent office BP normality. Compared with the normotensive group, the risk of cardiovascular 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, 16; P=0.001 for cardiovascular death and 1.92; P=0.02 for all-cause death). At a multivariable analysis, office BP was among the factors independently predicting death, and results were superimposable with use of Monza population-derived and guidelines-derived cutoff values for ambulatory BP normality (125/79 and 130/80 mm Hg, respectively). 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 its values is clinically important to better define patient risk.
It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e ...Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. The condition of WCHT was identified as office BP >140/90 mm Hg and 24-hour BP mean <125/79 mm Hg or home BP <132/82 mm Hg. Corresponding values for MHT diagnosis were office BP <140/90 mm Hg, 24-hour BP > or =125/79 mm Hg, and home BP >or =132/82 mm Hg. SHT was identified when both office and 24-hour BP means or home BP were over threshold values and normotension was under the threshold value. Subjects were reassessed 10 years later to evaluate the BP status of the various conditions defined previously. At the first examination, 758 (54.1%), 225 (16.1%), 124 (8.9%), and 293 (20.9%) subjects were normotensive, WCHT, MHT, and SHT subjects, respectively. At the second examination, 136 normotensives (18.2%), 95 WCHT (42.6%), and 56 MHT (47.1%) subjects became SHT. As compared with normotensives, adjusting for age and sex, the risk of becoming SHT was significantly higher for WCHT and MHT subjects (odds ratio: 2.51 and 1.78, respectively; P<0.0001). Similar results were obtained when the definition of the various conditions was based on home BP. Independent contributors of worsening of hypertension status were not only baseline BP, but also, although to a lesser extent, metabolic variables and age. Subjects with WCHT and MHT are at increased risk of developing SHT. This may contribute to their prognosis that appears to be worse as compared with that of normotensive subjects.
The Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension conceived and designed an ad-hoc study aimed at searching for prognostic cut-off values of serum uric ...acid (SUA) in predicting fatal myocardial infaction (MI) in women and men.
The URic acid Right for heArt Health study is a nationwide, multicentre, observational cohort study involving data on individuals aged 18-95 years recruited on a regional community basis from all the territory of Italy under the patronage of the Italian Society of Hypertension with a mean follow-up period of 122.3 ± 66.9 months.
A total of 23 467 individuals were included in the analysis. Cut-off values of SUA able to discriminate MI status were identified by mean of receiver operating characteristic curves in the whole database (>5.70 mg/dl), in women (>5.26 mg/dl) and in men (>5.49 mg/dl). Multivariate Cox regression analyses adjusted for confounders (age, arterial hypertension, diabetes, chronic kidney disease, smoking habit, ethanol intake, BMI, haematocrit, LDL cholesterol and use of diuretics) identified an independent association between SUA and fatal MI in the whole database (hazard ratio 1.381, 95% confidence intervals, 1.096-1.758, P = 0.006) and in women (hazard ratio 1.514, confidence intervals 1.105-2.075, P < 0.01), but not in men.
The results of the current study confirm that SUA is an independent risk factor for fatal MI after adjusting for potential confounding variables, and demonstrate that a prognostic cut-off value associated to fatal MI can be identified at least in women.
We sought to investigate left ventricular (LV) mechanics in the recently diagnosed hypertensive patients with different 24-h blood pressure (BP) patterns (dipping, nondipping, extreme dipping and ...reverse dipping).
The current cross-sectional study included 209 hypertensive patients who underwent 24-h ambulatory BP monitoring and comprehensive two-dimensional echocardiographic examination including multilayer strain analysis.
There was no difference in 24-h and daytime BP values between four groups. Night-time BP significantly and gradually increased from extreme dippers, across dippers and nondippers, to reverse dippers. LV global longitudinal and circumferential strains were greater in dippers and extreme dippers than in nondippers and reverse dippers. This was also found for endocardial and epicardial LV longitudinal and circumferential strains. Multivariate logistic regression analysis demonstrated that nondipping and reverse dipping patterns were associated with reduced LV longitudinal strain odds ratio (OR) 1.71 (95% confidence interval (CI): 1.10-5.61) and OR 2.50 (95% CI: 1.31-6.82), respectively independently of age, sex, 24-h SBP, LV mass index and E/è. Only the reverse dipping BP pattern was independently of clinical and echocardiographic parameters related with reduced LV circumferential strain OR 1.90 (95% CI: 1.10-4.80).
Nondipping and reverse dipping BP patterns had stronger impact on LV mechanics compared with patients with dipping and extreme dipping BP patterns in hypertensive population. LV functional and mechanical remodeling deteriorated from extreme dippers and dippers, to nondippers and reverse dippers.
To assess the prognostic cut-off values of serum uric acid (SUA) in predicting fatal and morbid heart failure in a large Italian cohort in the frame of the Working Group on Uric Acid and ...Cardiovascular Risk of the Italian Society of Hypertension.
The URic acid Right for heArt Health (URRAH) study is a nationwide, multicentre, cohort study involving data on individuals aged 18-95 years, recruited on a community basis from all regions of Italy under the patronage of the Italian Society of Hypertension with a mean follow-up period of 128 ± 65 months. Incident heart failure was defined on the basis of International Classification of Diseases Tenth Revision codes and double-checked with general practitioners and hospital files. Multivariate Cox regression models having fatal and morbid heart failure as dependent variables, adjusted for sex, age, SBP, diabetes, estimated glomerular filtration rate, smoking habit, ethanol intake, BMI, haematocrit, LDL cholesterol, previous diagnosis of heart failure and use of diuretics as possible confounders, were used to search for an association between SUA as a continuous variable and heart failure. By means of receiver operating characteristic curves, two prognostic cut-off values (one for all heart failure and one for fatal heart failure) were identified as able to discriminate between individuals doomed to develop the event. These cut-off values were used as independent predictors to divide individuals according to prognostic cut-off values in a multivariate Cox models, adjusted for confounders.
A total of 21 386 individuals were included in the analysis. In Cox analyses, SUA as a continuous variable was a significant predictor of all hazard ratio 1.29 (1.23-1.359), P < 0.0001 and fatal hazard ratio 1.268 (1.121-1.35), P < 0.0001 incident heart failure. Cut-off values of SUA able to discriminate all and fatal heart failure status were identified by mean of receiver operating characteristic curves in the whole database: SUA more than 5.34 mg/dl (confidence interval 4.37-5.6, sensitivity 52.32, specificity 63.96, P < 0.0001) was the univariate prognostic cut-off value for all heart failure, whereas SUA more than 4.89 mg/dl (confidence interval 4.78-5.78, sensitivity 68.29, specificity 49.11, P < 0.0001) for fatal heart failure. The cut-off for all heart failure and the cut-off value for fatal heart failure were accepted as independent predictors in the Cox analysis models, the hazard ratios being 1.645 (1.284-2.109, P < 0.0001) for all heart failure and 1.645 (1.284-2.109, P < 0.0001) for fatal heart failure, respectively.
The results of the current study confirm that SUA is an independent risk factor for all heart failure and fatal heart failure, after adjusting for potential confounding variables and demonstrate that a prognostic cut-off value can be identified for all heart failure (>5.34 mg/dl) and for fatal heart failure (>4.89 mg/dl).
Cardiovascular events have their greatest prevalence in the early morning period. Whether this is attributable to an arousal-dependent blood pressure (BP) increase is far from being clear. It is also ...not clear to what extent this phenomenon reflects overall 24-hour BP variability. In 2051 subjects (aged 25-74 years) representative of the population of Monza (Italy), we measured 24-hour ambulatory systolic BP (SBP) and calculated the difference between the 2-hour average values after morning arousal and the lowest 3 or average 2-hour values before arousal (morning BP surge 1 and 2, respectively). For either measure, we sought the relationship with a variety of indices of 24-hour SBP variability and collected information on (1) the occurrence of cardiovascular and all cause deaths during a follow-up of ≈16 years and (2) the appearance of echocardiographic left ventricular hypertrophy after 10 years from the baseline visit. Morning SBP surge 1 was directly related to indices of 24-hour SBP variability, including those made independent on the magnitude of the day-night SBP difference. There was a weak positive relationship between morning SBP surge 1 and the risk of cardiovascular and all-cause death, which disappeared after adjustment for confounders. This was the case also for development of left ventricular hypertrophy. Morning SBP surge 2 was smaller, inconsistently related to 24-hour SBP variability and not at all related to fatal events or new-onset left ventricular hypertrophy. In a white population, morning BP surge was not found to be an independent predictor of cardiovascular death, all-cause death, or development of high cardiovascular risk (as documented by new-onset cardiac damage) even when appropriately assessed by measures that reflect its association with 24-hour BP variability.
We aimed to evaluate right ventricular (RV) deformation in recently diagnosed untreated hypertensive patients with different 24-h blood pressure (BP) patterns (dipping, nondipping, extreme dipping ...and reverse dipping). This cross-sectional study involved 190 untreated hypertensive patients who underwent 24-h ambulatory BP monitoring and a detailed two-dimensional echocardiographic examination, including the assessment of layer-specific strain. We found that 24-h and daytime BP values did not differ between the four groups. Nighttime BP significantly and gradually increased from extreme dippers across dippers and nondippers to reverse dippers. RV structure and systolic and diastolic function did not significantly differ among the four groups. However, RV global and RV free wall longitudinal strains were significantly lower in nondippers and reverse dippers than in dippers and extreme dippers. The endocardial and epicardial RV longitudinal strains of the whole RV and free wall RV were the lowest in reverse dippers and highest in extreme dippers. Multivariate logistic regression analysis demonstrated that only reverse dipping patterns were associated with reduced RV global longitudinal strain OR 2.9 (95% CI: 1.5-8.2), independent of age, sex, 24-h systolic BP, LV mass index, RV wall thickness and E/e'
. Similarly, the reverse dipping pattern was associated with reduced RV free wall longitudinal strain, independently of the mentioned parameters OR 3.8 (95% CI: 1.8-8.5). In conclusion, in the hypertensive population, the reverse dipping BP pattern had an adverse effect on RV deformation. RV remodeling progressively deteriorated from extreme dippers to reverse dippers, but only the reverse dipping BP pattern was independently associated with the reduction in RV longitudinal strain.
We assessed the value of 3 electrocardiographic (EKG) voltage criteria in detecting variations of left ventricular mass (LVM) over time, taking echocardiographic (ECHO) LVM as reference, in the ...Pressioni Arteriose Monitorate E Loro Associazioni study. In 927 subjects (age 47 ± 13 years on entry, 49.9% men) an ECHO evaluation of LVM and EKG suitable for measurement of EKG‐LVH criteria (Sokolow‐Lyon voltage, Cornell voltage and R‐wave voltage in aVL) were available at baseline and at a 2nd evaluation performed 10 years later. Δ (delta) LVM, Δ LVMI, and Δ EKG parameters values were calculated from 2nd evaluation to baseline. The sensitivity of the EKG criteria in the diagnosis of LVH, poor at baseline, becomes even worse after 10 years, reaching very low values. Only the sensitivity of R‐wave amplitude exhibited slight increase over time but with unsatisfactory absolute values. Despite the prevalence of ECHO‐LVH at the 2nd evaluation was threefold increased compared to baseline (29.3% and 33.7% for LVM indexed to BSA and height2.7, respectively), the prevalence of EKG‐LVH was unchanged when evaluated by Sokolow‐Lyon criteria, significantly reduced when assessed by Cornell voltage index, while significantly increased using R‐wave voltage in aVL criteria. Despite an ECHO‐LVM increase over the time, mean EKG changes were of opposite sign, except for R‐wave amplitude in aVL. Our study highlights the discrepancy between ECHO and EKG in monitoring LVM changes over the time, especially for Sokolow‐Lyon and Cornell voltage. Thus, EKG is an unsuitable method for the longitudinal evaluation of LVM variations.
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