How common is isolated nocturnal hypertension?

The growing use of methods to measure blood pressure (BP) under everyday life conditions in ‘out-of-office’ settings, through either 24-h ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM), for defining BP status has led to identification of four specific hypertension phenotypes, characterized by variable agreement or disagreement between office BP (OBP) and out-of-office BP: true normotension (normal office and out-of-office BP), sustained hypertension (both elevated office and out-of-office BP), masked hypertension (normal office BP and out-of-office BP), and white-coat hypertension (WCH), when OBP is elevated, but out-of-office BP levels are within normal limits. The term ‘white-coat hypertension’ is probably a misnomer and a misconception, because it does not necessarily reflect, or at most partially, an alerting reaction or white-coat effect. However, the suggestion to use the term ‘isolated office hypertension’ instead of the more appealing ‘white coat hypertension’ has not gained popularity in clinical practice

The referral centers for the diagnosis and treatment of hypertension in adolescents

Primary hypertension in adolescence was felt to be quite rare. However, the worldwide childhood obesity epidemic has had a profound impact on the frequency of high blood pressure (BP) with the result that primary hypertension should now be viewed as one of the most common health conditions in the young (estimated prevalence 1–5%). Therefore, current guidelines recommend that all children and adolescents seen in a medical setting should have their BP measured. The availability of BP tables with normal BP percentiles for age, sex and height has improved BP values classification. Studies conducted at referral clinics for evaluation of hypertension have indicated that as many as 30 to 40% of adolescents may actually have in a clinical setting white-coat hypertension. This may lead to a misdiagnosis of “true” hypertension in a considerable number of cases. The usefulness of out-of-office BP evaluation using ambulatory or home monitoring is well established. These measurements allow the detection of the white-coat and masked hypertension, the opposite of white-coat hypertension, and are more closely associated with organ damage and cardiovascular risk than office measurements. A thorough familial and personal history is of primary importance as well as the physical examination that should be focused on the search for signs suggestive for an underlying cause and/or for the severity of hypertension. Following investigations must be tailored to the child’s age, anamnesis and clinical examination and to the severity of BP elevation, in order to investigate not only the possible cause of hypertension, but also associated diseases and target organs damage. Therapeutic approach should firstly include non-pharmacological measures, and the use of medications when indicated. A key role in the management of the adolescents with hypertension may be attributed to the hypertension referral center

Electrocardiography for Assessment of Hypertensive Heart Disease: A New Role for an Old Tool

Left ventricular (LV) hypertrophy (LVH), detected either by electrocardiography (ECG) or echocardiography (ECHO), has long been recognized as a powerful predictor of serious cardiovascular (CV) sequelae.A very large and highly consistent body of evidence indicates that LVH is not only an adaptation to increased hemodynamic load in hypertension, but is also independently associated with an enhanced risk for myocardial infarction, cardiac sudden death, congestive heart failure, and stroke in the general population, as well as in patients with systemic hypertension, coronary heart disease, chronic kidney disease, and atrial fibrillation. Intriguingly, the cumulative incidence of cardiovascular events increases progressively with increasing LV mass (LVM), without evidence of any threshold separating the postulated “compensatory” from “pathological” LVH. In other words, patients with LVM in the upper-normal range already have increased risk for CV events

INVERSE RELATIONSHIP BETWEEN AORTIC ROOT DIAMETER AND RENAL FUNCTION IN HYPERTENSIVE SUBJECTS

Recent studies suggest that enlarged aortic root diameter (ARD) may predict cardiovascular events in absence of aneurysmatic alterations. Little is known about the influence of renal function on ARD. Our study was aimed to assess the relationships between glomerular filtration rate (GFR) and ARD in hypertensive subjects

Short and middle term effects of hypocaloric low carbohydrate diet vs hypocaloric Mediterranean diet on endothelial function in obese subjects

Adequate nutritional treatment is required to address the problem of increasing prevalence of obesity in Western countries. The Mediterranean diet style is now acknowledged to have large scientific evidences in terms of cardiovascular prevention. However, many popular diets are diffusing also as self-prescribed treatments. Among those, the efficacy of low-carbohydrate diets (also known as Atkins’ diet in its most popular variety) has been addressed by some investigations. It is generally concluded that the low-carbohydrate diet is able to induce a greater weight loss, at least in the middle term, and a better serum lipid profile than the conventional diet. In this longitudinal, randomised, open study we compared the effects on endothelial function of a hypocaloric low-carbohydrate diet (according to the Atkins’ diet; AD) versus a similarly hypocaloric Mediterranean diet (MD). Overweight-obese (range of BMI: 27-34.9 Kg/m2; range of age: 30-50 years) otherwise healthy, normal glucose tolerant women were enrolled and randomly assigned to one of the two dietary treatments until reaching the final number of 10 women for each group of treatment. So, twenty-five women were enrolled and five of them (3 in the MD group and 2 in the AD group) were subsequently excluded from the study due to intercurrent diseases (1 subject) or declaration of inadequate compliance (2 subjects) or f voluntary drop out (2 subjects). Measurements were performed before (T0), 5-7 days (T5) and 2 months (T60) after starting the diet treatment. Endothelial function was investigated at each time of the study by measuring the brachial artery flow-mediated dilation (FMD). Serum concentrations of insulin, adiponectin, interleukin 6 (IL-6), tumor necrosis factor α (TNF-α) and 8-iso-prostaglandin (8-iso-PG) F2α were also assessed at each time of the study. Urinary ketone bodies were observed at T5 only in AD group. Briefly, body weight was not significantly decreased at T5 in both groups; as expected, a higher body weight reduction was observed at T60 in AD group (change in body weight T60 – T0, mean ± sem, MD -4.9 ± 0.6 Kg vs AD -7.6 ± 0.8 Kg, p= 0.014). The FMD was significantly reduced at T5 in the AD group and increased at T60 until reaching the T0 values (T0: 12.2 ± 2.9; T5: 5.2 ± 0.8; T60: 11.0 ± 1.2 %; p< 0.05 T5 vs T0 and T60). On the contrary, the FMD increased significantly at T5 in the MD group and decreased until reaching values comparable to those of T0 at T60 (T0: 10.3 ± 2.3; T5: 14.5 ± 2.8; T60: 10.6 ± 1.9 %; p< 0.05 T5 vs T0 and T60). This trend of FMD change was observed in each subject. Insulin concentrations and HOMA-I decreased significantly at T5 and at T60 in both groups. Adiponectin and TNF-α concentrations remained unchanged in both groups throughout the study. Both IL-6 and 8-iso-PGF2α increased significantly at T5 in the AD group and decreased at T60 to values comparable to T0 (IL-6: T0 57.5 ± 9.0, T5 78.1 ± 10.9, T60 56.6 ± 6.8 pg/ml; T5 vs T0 p< 0,005, T5 vs T60 p< 0,02; 8-iso-PGF2α: T0 171.5 ± 30.6, T5 222.6 ± 35.1, T60 178.7 ± 25.8 pg/ml; T5 vs T0 p< 0,005, T5 vs T60 p< 0,02); no significant change was observed in the MD group. This study suggests that the hypocaloric low-carbohydrate diet induces a significant endothelial dysfunction in the short term (5-7 days) that is reverted in the middle term (2 months) as suggested by both the brachial artery FMD and serum markers of inflammation (IL-6) and oxidative stress (8-iso-PGF2α). On the contrary, the hypocaloric Mediterranean diet is able to improve the endothelial function at least in the short term. These effects are independent of body weight loss. Therefore, this study points out also the potential disadvantages of low-carbohydrate diets when prescribed (or self-prescribed) especially in subjects at high cardiovascular risk

Intrarenal hemodynamics and carotid intima-media thickness in the metabolic syndrome

Aims: Metabolic syndrome (MetS) is associated with increased cardiovascular risk. We hypothesize that early vascular changes are already present at the time of diagnosis of MetS. The relationship of different measures of early vascular impairment with body fat distribution and the natural progression of MetS was examined in newly diagnosed subjects non-pharmacologically treated. Methods: 246 consecutively enrolled subjects were categorized according to the presence of MetS and type 2 diabetes (T2D). Intra-renal Doppler flow was used to ascertain resistive (RI) and pulsatility (PI) indices as markers of vascular resistance. Carotid intima-media thick- ness (IMT), cutis-rectis (CR) and rectis-aorta (RA) thicknesses were measured by ultrasono- graphy; RA/CR ratio was used as measure of body fat distribution. Pro-inflammatory cytokines, C-reactive protein, oxidative markers insulin and adiponectin blood concentra- tions were also measured. Results: Baseline characteristics demonstrated increasing trends in biochemical, inflam- matory, and oxidative parameters from MetS??, MetS+, to MetS+/T2D (p&lt;0.001). After adjusting for age, the same increasing trends across the groups were observed in both sexes in IMT (p &lt; 0.001), RI (p &lt; 0.001) and PI (p &lt; 0.001). IMT correlated with RI (r = 0.25; p &lt; 0.001), PI (r = 0.26; p &lt; 0.001), and RA/CR ratio (r = 0.43; p &lt; 0.001). Conclusions: Carotid IMT and intra-renal resistances are elevated at an early stage in MetS and are associated with a dysregulated production of fat-derived hormones and cytokines

Relationship between albumin excretion rate and aortic stiffness in untreated essential hypertensive patients

OBJECTIVES: To evaluate, in a group of nondiabetic essential hypertensive patients with normal renal function, the relationship between albumin excretion rate (AER) and carotid-femoral pulse wave velocity (PWV), as an index of aortic stiffness. DESIGN: Cross-sectional study. SETTING: Outpatient hypertension clinic. SUBJECTS: Seventy patients with mild-to-moderate essential hypertension, aged 42 +/- 8 years, never pharmacologically treated. All subjects underwent routine laboratory tests, 24-h ambulatory blood pressure (BP) monitoring, measurement of carotid-femoral PWV, by means of a computerized method, and AER. RESULTS: Microalbuminuric patients (AER > or = 20 microg min(-1); n = 19), when compared with normoalbuminuric subjects, showed more elevated 24-h BP (136/88 +/- 10/10 vs. 128/83 +/- 7/6 mmHg; P < 0.001 and P = 0.013, for systolic and diastolic BP respectively) and higher values of carotid-femoral PWV (10.4 +/- 2 m s(-1) vs. 9.2 +/- 1.3; P = 0.006). This latter difference remained statistically significant, even after correction by ancova for 24-h systolic and diastolic BP, and body mass index (BMI, P = 0.016). Univariate regression analysis disclosed a tight correlation between AER and carotid-femoral PWV (r = 0.42; P = 0.0003). This association was confirmed in a multiple regression model (beta = 0.35; P = 0.009) in which, as independent variables, besides PWV, 24-h BP, age, serum glucose values, smoking status, gender and BMI, were added. CONCLUSIONS: Our results seem to confirm that microalbuminuria may represent the early renal manifestation of a widespread vascular dysfunction, and therefore it is an integrated marker of cardiovascular risk

Relationship Between Short-Term Blood Pressure Variability and Subclinical Renal Damage in Essential Hypertensive Patients

The authors aimed to analyze the relationship between subclinical renal damage, defined as the presence of microalbuminuria or an estimated glomerular filtration rate (eGFR) between 30&nbsp;mL/min/1.73&nbsp;m(2) and 60&nbsp;mL/min/1.73&nbsp;m(2) and short-term blood pressure (BP) variability, assessed as average real variability (ARV), weighted standard deviation (SD) of 24-hour BP, and SD of daytime and nighttime BP. A total of 328 hypertensive patients underwent 24-hour ambulatory BP monitoring, 24-hour albumin excretion rate determination, and eGFR calculation using the Chronic Kidney Disease Epidemiology Collaboration equation. ARV of 24-hour systolic BP (SBP) was significantly higher in patients with subclinical renal damage (P=.001). This association held (P=.04) after adjustment for potential confounders. In patients with microalbuminuria, ARV of 24-hour SBP, weighted SD of 24-hour SBP, and SD of daytime SBP were also independently and inversely related to eGFR. These results seem to suggest that in essential hypertension, short-term BP variability is independently associated with early renal abnormalities

Influence of metabolic syndrome on hypertension-related target organ damage

OBJECTIVES: The aim of our study was to analyse, in a wide group of essential hypertensive patients without diabetes mellitus, the influence of metabolic syndrome (MS) (defined according to the criteria laid down in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults) on markers of preclinical cardiac, renal and retinal damage. DESIGN: Cross-sectional study. SETTING: Outpatient hypertension clinic. SUBJECTS AND METHODS: A total of 353 young and middle-aged hypertensives, free from cardiovascular and renal diseases (and 37% of whom had MS), underwent echocardiographic examination, microalbuminuria determination and non-mydriatic retinography. RESULTS: When compared with subjects without MS, hypertensive patients with MS exhibited more elevated left ventricular (LV) mass (either normalized by body surface area or by height elevated by a power of 2.7), higher myocardial relative wall thickness, albumin excretion rate (AER) and a greater prevalence of LV hypertrophy (57.7% vs. 25.1%; P < 0.00001), of microalbuminuria (36.2% vs. 19.3%; P = 0.002) and of hypertensive retinopathy (87.7% vs. 48.4%; P < 0.00001). These results held even after correction for age, 24-h blood pressures, duration of hypertension, previous antihypertensive therapy, and gender distribution. The independent relationships between LV mass and MS, and between AER and MS, were confirmed in multivariate regression models including MS together with its individual components. CONCLUSIONS: MS may amplify hypertension-related cardiac and renal changes, over and above the potential contribution of each single component of this syndrome. As these markers of target organ damage are well-known predictors of cardiovascular events, our results may partly explain the enhanced cardiovascular risk associated with MS

[OP.7B.08] INFLUENCE OF GENDER ON THE RELATIONSHIPS BETWEEN NEW INDICES OF ADIPOSITY AND LEFT VENTRICULAR MASS AND HYPERTROPHY IN HYPERTENSIVE PATIENTS

OBJECTIVE: The unfavourable effects of the association of obesity with hypertension on cardiac structure and function have been extensively studied. However, controversy still exists about the influence of gender on the relationship between obesity and left ventricular mass (LVM) and hypertrophy (LVH). Even if body mass index (BMI) and waist circumference (WC) are widely used as anthropometric predictors for cardiovascular diseases (CVD), their validity has been questioned. Recently, Body Shape Index (ABSI) and Body Roundness Index (BRI) were proposed as alternative measures of adiposity that may better reflect health status (1-2).Our study was aimed to assess the ability of ABSI and BRI in identifying LVH and to determine whether they are superior to BMI and WC. Moreover, the influence of gender on the relationships between all these indices of adiposity and LVM was also evaluated. DESIGN AND METHOD: We enrolled 724 subjects with EH (mean age 45 ± 12 years, 63 % men) without cardiovascular complications.In all subjects the anthropometric indices (weight, height and waist circumference) and the routine biochemical parameters were determined. BMI, ABSI and BRI were calculated. Furthermore, all patients underwent a 24-h blood pressure monitoring and an echocardiogram. LVM was indexed for body surface area (LVMI) and for height2.7 (LVMH2.7). RESULTS: The univariate correlations of LVMI and LVMH2.7 with the measures of adiposity evaluated are shown in the table 1.ROC curves analysis revealed that in overall population (table 2) and in men BRI has a greater ability to identify LVH defined as LVMH2.7 > 51 g/m2.7.(Figure is included in full-text article.) CONCLUSIONS: : Our results seems to suggest that in men, but not in women, the BRI has a greater sensitivity to detect LVH than ABSI and the traditional measures of adiposity