Nocturnal non-dipping pattern in untreated hypertensives at different cardiovascular risk according to the 2003 ESH/ESC guidelines.

To evaluate in a large population of untreated, uncomplicated essential hypertensives the relationship between alterations in nocturnal blood pressure (BP) profile, i.e. non-dipping pattern, and total cardiovascular risk.A total of 580 consecutive patients with grade 1 or 2 hypertension, referred to our outpatient clinic, underwent the following procedures: (i) clinical and routine laboratory examinations; (ii) 24-h ambulatory BP monitoring; (iii) 24-h collection for microalbuminuria; (iv) echocardiography; and (v) carotid ultrasonography. Cardiovascular risk was assessed according to the stratification scheme suggested by the 2003 ESH/ESC guidelines.According to this classification, 16.2% of the 580 patients were considered at low added risk, 42.4% at medium added risk and 41.4% at high added risk; 38.5% of the overall population was classified in the high-risk stratum because of at least one manifestation of target organ damage (TOD) and 6.3% for the presence of three or more risk factors. The prevalence rates of a non-dipping pattern (decrease in BP at nightor = 10% compared with the average daytime values) were 28.5% in low-risk, 32.6% in medium-risk and 42.2% in high-risk patients, respectively. CONCLUSIONS. Our findings show that the prevalence of a non-dipping profile is significantly greater in patients stratified at high compared with those at low and medium added risk

Influencia de la edición de los valores de presión arterial (PA) en la interpretación de la monitorización ambulatoria de la PA (MAPA)

En este trabajo se recogieron 115 MAPAs realizados a pacientes hipertensos, y se investigó la influencia que la edición de los valores de PA en el periodo que rodea al inicio del sueño y la vigilia podía tener en la interpretación de la prueba. Se observó que el porcentaje de pacientes con PA controlada con o sin la edición de valores fue similar. Sin embargo, la edición de la MAPA condicionó cambios en la clasificación del perfil circadiano, observándose una disminución de perfiles reductores, reclasificados hacia perfiles menos fisiológicos como no-reductor y reductor extremo, ambos asociados a un peor pronóstico cardiovascular.En aquest treball es van recollir 115 MAPAs realitzats a pacients hipertensos, i es va investigar la influencia que la edició dels valors de PA en el període que envolta l'inici de la son i la vigília podia tenir en la interpretació de la prova. Es va observar que el percentatge de pacients amb PA controlada amb o sense la edició dels valors va ser similar. Però, la edició de la MAPA va condicionar canvis en la classificació del perfil circadiari, observant-se una disminució de perfils reductors, reclassificats cap a perfils menys fisiològics com no-reductor o reductor extrem, ambdós associats a un pitjor pronòstic cardiovascular

Relationships between 24-Hour Blood Pressures, Subcortical Ischemic Lesions, and Cognitive Impairment

Background and Purpose The most important treatment for subcortical vascular dementia (SVaD) is controlling the blood pressure (BP). However, the few studies that have investigated the relationships between diurnal BP rhythm and subcortical ischemic vascular cognitive impairment have produced inconclusive results. In the study presented here, the 24-hour BP values of three groups of subjects-patients with subcortical vascular mild cognitive impairment (SvMCI), patients with SVaD, and normal controls-were compared using working criteria and 24-hour ambulatory BP (ABP) monitoring. Methods The subjects (42 patients with SVaD, 37 patients with SvMCI, and 30 controls) were selected according to the Study`s inclusion/exclusion criteria. All subjects underwent brain magnetic resonance (MR) imaging and MR angiography, detailed neuropsychological testing, and 24-hour ABP monitoring. Results The prevalence of nondippers differed markedly between the control group and both the SVaD and SvMCI groups. Loss of nocturnal dipping was significantly associated with SVaD [odds ratio (OR), 4.827; 95% confidence interval (CI), 1.07-12.05]. Conclusions It was found that SVaD is associated with loss of nocturnal BP dipping combined with increased pulse pressure and systolic BP (SBP) variability. Correction of these factors could therefore be important in the prevention of SVaD, independent of measures used to reduce BP. J Clin Neurol 2009;5:139-145Ohmine T, 2008, HYPERTENS RES, V31, P75van Boxtel MPJ, 2006, J HUM HYPERTENS, V20, P5, DOI 10.1038/sj.jhh.1001934van der Flier WM, 2005, STROKE, V36, P2116Birns J, 2005, STROKE, V36, P1308, DOI 10.1161/01.STR.0000165901.38039.5fYamamoto Y, 2005, CEREBROVASC DIS, V19, P302, DOI 10.1159/000084498BOWLER JV, 2005, J NEUROL NEUROSUR S5, V76, P35KU HM, 2004, J KOREAN NEUROPSYCHI, V43, P189O`Brien E, 2003, J HYPERTENS, V21, P821, DOI 10.1097/01.hjh.0000059016.82022.caKANG Y, 2003, INCHEON HUMAN BRAINOhkubo T, 2002, J HYPERTENS, V20, P2183de Leeuw FE, 2002, BRAIN, V125, P765O`Brien JT, 2002, ANN NY ACAD SCI, V977, P436Kario K, 2001, HYPERTENSION, V38, P852Wahlund LO, 2001, STROKE, V32, P1318Dufouil C, 2001, NEUROLOGY, V56, P921Puisieux F, 2001, EUR NEUROL, V46, P115Staessen JA, 1999, JAMA-J AM MED ASSOC, V282, P539Swan GE, 1998, NEUROLOGY, V51, P986Blacher J, 1998, HYPERTENSION, V32, P570Cummings JL, 1998, J PSYCHOSOM RES, V44, P627Kilander L, 1998, HYPERTENSION, V31, P780Guo ZC, 1997, AM J EPIDEMIOL, V145, P1106Liao DP, 1996, STROKE, V27, P2262LAUNER LJ, 1995, JAMA-J AM MED ASSOC, V274, P1846YAMAMOTO Y, 1995, STROKE, V26, P829VERDECCHIA P, 1994, HYPERTENSION, V24, P793KUUSISTO J, 1993, HYPERTENSION, V22, P771SHIMADA K, 1992, J HYPERTENS, V10, P875SCHERR PA, 1991, AM J EPIDEMIOL, V134, P1303TOHGI H, 1991, STROKE, V22, P603OBRIEN E, 1988, LANCET, V2, P397PARATI G, 1987, J HYPERTENS, V5, P93HACHINSKI VC, 1975, ARCH NEUROL-CHICAGO, V32, P632

Diurnal blood pressure pattern and development of prehypertension or hypertension in young adults: the CARDIA study

Nondippers (people whose sleep systolic blood pressure [SBP] fails to decrease >10% from daytime SBP) have increased risk of cardiovascular disease. The prevalence of nondipping in younger adults has not been well studied, nor has its value for predicting hypertension. We examined the prevalence of nondipping in a substudy of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. We used Cox regression to estimate the hazard ratio (HR) conferred by nondipping for incident prehypertension or hypertension (preHTN/HTN) over 15 years. Of the 264 nonhypertensive participants at baseline, 118 (45%) were nondippers. Blacks were more likely than whites to be nondippers (52% versus 33%, P = .004). The incidence rate of preHTN/HTN was 29.2/1000 person-years among dippers and 36.2/1000 person-years among nondippers. Compared with those in the lowest quartile of nighttime to daytime SBP, those in the highest quartile were more likely to develop preHTN/HTN (HR 1.61; P = .06), but this relationship was attenuated after adjustment (HR 1.34; P = .27). Our results demonstrate that nondipping is common in young, nonhypertensive adults, and is more common in blacks than whites. Nondipping might predate a meaningful clinically detected increase in BP in some people, but more research in larger study samples is needed

Elderly hypertensive patients: Silent white matter lesions, blood pressure variability, baroreflex impairment and cognitive deterioration

Introduction: Hypertension may increase the risk for stroke and is frequently associated with subcortical and periventricular white matter lesions (WML). This is considered a prognostic factor for the development of stroke and cognitive impairment, particularly in attention processes. Additionally, in elderly subjects, it is known the implications of alterations in the neural cardiovascular regulation and the cardiovascular risk. Aims: To evaluate, in asymptomatic elderly hypertensives, the association of ambulatory blood pressure values and autonomic activity with neurocognitive impairment and WML. In addition, we also evaluated the role of the autonomic nervous system particularly the vagal component, in the pathogenesis of white matter lesions. Methods: We studied 22 elderly essential hypertensive patients (69±1.1y) and as control group, 16 normotensive elderly subjects (age 67±3.2y) were also enrolled. To each one of them, a cerebral MRI was performed to classify them, by a neuro-radiologist blinded of the subject clinical status, using a 0 to 9 scale where 0 denoted no WML and 9 the most severe lesions. Twenty four hours arterial blood pressure monitoring was performed to each one of the subjects under study. Office blood pressure was measured 3 times and the mean value reported. Beat to beat finger arterial pressure monitoring (Finapres) was performed for a 2h period. During the first hour the patient remained lying supine in a quiet darkened room and during the second hour four manoeuvres: stand-up, cold pressor test, handgrip and quiet activity were randomly performed. Mean blood pressure and pulse interval values, from the two periods, and their respective variabilities, baroreflex sensitivity and power spectral analysis were calculated. Regarding neuropsychological assessment: Minimental test, attention evaluation, RAVLT, visual memory, language and executive function, geriatric depression scale, cognitive deficit rate tests were performed in all subject. Results: We found a closer correlation of WML with 24hs ABPM than with office BP readings being more evident with systolic blood pressure during the night time period. WML failed to show any correlation with SBP average values derived from the Finapres recordings in either the supine or the upright position, while it was positively and significantly related to PP in both conditions. However, beat to beat SBP variability, either in the supine or in the upright position, showed a positive and significant correlation with WML. During the resting period, BRS calculated through the sequence method (Time Domain) was similar in HT and NT subjects. However when BRS was assessed in the frequency domain a significant reduction was observed in HT compared with NT. In addition, At the time of laboratory manoeuvres implying sympathetic activation, BRS was significantly reduced as compared to the resting values being particularly evident for the HF values. In hypertensive subjects, only semantic fluency showed a significant difference (p=0.01), when compared to normotensives. When the patients were divided in older and younger than 75 years, a significant difference was observed in the delayed analysis of words, and in the phonological fluency showing a significant higher rate of pathological results in the group of patients older than 75 years. Conclusions: As previously shown, incidental WML, suggestive of silent cerebrovascular disease, is a frequent finding in elderly hypertensives. Night-time BP mean values and SBP variability in upright position seems to be the best predictor on silent cerebral WML. The vagal component of the autonomic nervous system seems to be involved in the pathogenesis of these lesions. Finally, the neurocognitive alterations are multifactorial in origin where the aging process seems to be the principal component.Fil: Ramírez, Agustín José. Fundación Favaloro; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Parati, Gianfranco. San Gerardo Hospital; Italia. University of Milan-Bicocca; ItaliaFil: Castiglioni, Paolo. Fondazione Don Gnocchi; ItaliaFil: Consalvo, Damian. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; ArgentinaFil: Solis, Patricia Cristina Lourdes. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; ArgentinaFil: Risk, Marcelo. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Departamento de Computación; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Waissman, Paola. Fundación Favaloro; ArgentinaFil: di Rienzo, Marco. Fondazione Don Gnocchi; ItaliaFil: Mancia, Giusepe. San Gerardo Hospital; Italia. University of Milan-Bicocca; ItaliaFil: Sanchez, Ramiro A.. Fundación Favaloro; Argentin

organ damage in hiv positive patients with high blood pressure

Our objective has been the investigation of possible cardiovascular or renal organ damage in HIV patients with confirmed high blood pressure by means of instrumental cardiovascular investigation and renal function evaluation. A total of 265 consecutive patients accessing our outpatient facility were enrolled in the study. Patients with confirmed pathological pressure values or high normal values were submitted to clinical and instrumental monitoring by 24-hour ambulatory blood pressure monitoring (ABPM), to derivation of 12-lead ECG registration, to echocardiography and to epi-aortic vessel echo-color-Doppler. The ECG and echocardiographic data were compared to a control group of 40 hypertensive HIV-negative subjects. Renal damage was evaluated by means of the microalbuminuria/creatininuria ratio on a spot urine sample, plus 24-hour albuminuria and proteinuria measurements. 61 (23.0%) of the subjects examined were hypertensive: 24 (39.3%) had a previous hypertensive diagnosis but had never been treated for this condition, and 37 (60.7%) had a new diagnosis; In 100% of cases, 24-hour ABPM confirmed the hypertension and 27.8% of the patients resulted non-dippers. The ECG showed left ventricle overload, V4-V6 strain, or left ventricular hypertrophy in 64.3% of cases compared to 35.7% in the control group. Echocardiography demonstrated increasing in left ventricle parietal thickness with concentric remodeling and hypertrophy in 85.2% of patients. HIV-positive patients showed a statistically significant tendency to concentric remodeling and concentric hypertrophy, even in presence of mild hypertension. Echocolor-Doppler examination detected intima-media thickness > and/or carotid plaques in 72.1% of patients. Renal function seems spared in these subjects. Our data highlights the importance of investigating arterial hypertension among our patients as it is a frequently undiagnosed condition, and illustrates the utility of 24- hr ABPM to confirm hypertension and to identify the non-dipper subject. Moreover, the ECG, echocardiography and echocolor-Doppler examinations evidenced a premature tendency to organ damage in these patients that showed altered cardiac remodeling compared to those without HIV. This stresses the need for an early diagnosis, including a complete instrumental evaluation to properly identify organ damage even at a subclinical level

Morning surge of blood pressure : clinical relevance, review of definitions

Wzrost ciśnienia tętniczego po przebudzeniu i podjęciu dziennej aktywności życiowej jest zjawiskiem fizjologicznym, jednak nadmierny i nagły skok ciśnienia w godzinach porannych (tzw. morning surge) uznaje się za czynnik sprzyjający uszkodzeniu narządów i jeden z elementów odpowiedzialnych za wystąpienie niekorzystnych epizodów sercowo-naczyniowych w tym okresie. Celem niniejszego opracowania było przybliżenie zagadnienia porannego wzrostu ciśnienia — patomechanizmu, implikacji klinicznych oraz sposobu jego rozpoznawania. Sformułowane ostatnio definicje porannego wzrostu ciśnienia tętniczego różnią się między sobą w istotny sposób. Niektóre definiują poranny przyrost ciśnienia jako różnicę między wartościami ciśnienia bezpośrednio po obudzeniu w stosunku do zarejestrowanych w godzinie poprzedzającej pobudkę. Inne z kolei odnoszą go do najniższych wartości ciśnienia tętniczego odnotowanych podczas snu. W większości definicji za nadmierny wzrost ciśnienia w godzinach porannych przyjmuje się wartości wyliczonej różnicy powyżej 90. percentyla. Klinicznie istotnym aspektem rozważań nad zagadnieniem morning surge jest zapobieganie incydentom sercowo-naczyniowym, między innymi poprzez zapewnienie właściwej kontroli farmakologicznej ciśnienia w ciągu całej doby.The morning rise of blood pressure, especially after morning physical activity, is a physiological reaction. On the other hand excessive and rapid morning peak of BP (morning surge) is a risk factor for organ damage and probably causes high prevalence of cardiovascular incidents in the morning. This paper discusses pathomechanism, clinician aspects and type of defining of blood pressure morning surge. So far definitions of morning surge of blood pressure differ from one another. Some of them defined morning surge of blood pressure as the difference between blood pressure after waking up and one hour before. Others, define the morning rise of BP according to the lowest BP value during nighttime. Most of the authors recognize excessive morning peak of blood pressure as BP values which reflect 90th percentile of the morning-night difference. Important clinical aspect of the morning surge is prevention of cardiovascular incidents by effective, pharmacological 24 hour control of blood pressure

Morning surge of blood pressure - clinical relevance, review of definitions

Wzrost ciśnienia tętniczego po przebudzeniu i podjęciu dziennej aktywności życiowej jest zjawiskiem fizjologicznym, jednak nadmierny i nagły skok ciśnienia w godzinach porannych (tzw. morning surge) uznaje się za czynnik sprzyjający uszkodzeniu narządów i jeden z elementów odpowiedzialnych za wystąpienie niekorzystnych epizodów sercowo-naczyniowych w tym okresie. Celem niniejszego opracowania było przybliżenie zagadnienia porannego wzrostu ciśnienia - patomechanizmu, implikacji klinicznych oraz sposobu jego rozpoznawania. Sformułowane ostatnio definicje porannego wzrostu ciśnienia tętniczego różnią się między sobą w istotny sposób. Niektóre definiują poranny przyrost ciśnienia jako różnicę między wartościami ciśnienia bezpośrednio po obudzeniu w stosunku do zarejestrowanych w godzinie poprzedzającej pobudkę. Inne z kolei odnoszą go do najniższych wartości ciśnienia tętniczego odnotowanych podczas snu. W większości definicji za nadmierny wzrost ciśnienia w godzinach porannych przyjmuje się wartości wyliczonej różnicy powyżej 90. percentyla. Klinicznie istotnym aspektem rozważań nad zagadnieniem morning surge jest zapobieganie incydentom sercowo-naczyniowym, między innymi poprzez zapewnienie właściwej kontroli farmakologicznej ciśnienia w ciągu całej doby.The morning rise of blood pressure, especially after morning physical activity, is a physiological reaction. On the other hand excessive and rapid morning peak of BP (morning surge) is a risk factor for organ damage and probably causes high prevalence of cardiovascular incidents in the morning. This paper discusses pathomechanism, clinician aspects and type of defining of blood pressure morning surge. So far definitions of morning surge of blood pressure differ from one another. Some of them defined morning surge of blood pressure as the difference between blood pressure after waking up and one hour before. Others, define the morning rise of BP according to the lowest BP value during nighttime. Most of the authors recognize excessive morning peak of blood pressure as BP values which reflect 90th percentile of the morning-night difference. Important clinical aspect of the morning surge is prevention of cardiovascular incidents by effective, pharmacological 24 hour control of blood pressure

Cerebral microbleeds are associated with nocturnal reverse dipping in hypertensive patients with ischemic stroke

Background Abnormalities in nocturnal blood pressure dipping are well known for its relationship to cardiovascular diseases. Cerebral microbleeds are frequently observed in patients with hypertension and are known to be potent risk factors for stroke. However, there are scanty reports about the relationship between nocturnal dipping and cerebral microbleeds. Methods We recruited consecutive patients with both hypertension and ischemic stroke within 7 days after symptom onset, and those with cardioembolism were excluded. We applied 24-hour ambulatory blood pressure monitoring two weeks after stroke onset, and we used brain MRI to detect cerebral microbleeds. Various blood pressure parameters such as mean 24-hour blood pressure, awake/sleep blood pressure, and morning surge were compared between cerebral microbleeds (+) vs. (-) groups. Subjects were further classified according to nocturnal dipping status and were analyzed by logistic regression to determine its association with cerebral microbleeds with adjustment for age, gender, and cardiovascular risk factors. Results A total of 162 patients (100 males, age 65.33 ± 10.32 years) were included. Cerebral microbleeds were detected in 65 patients (40.1%). Most ambulatory blood pressure parameters except morning surge were significantly higher in those who had cerebral microbleeds. After adjusting for the confounding factors, the reverse dippers were prone to have cerebral microbleeds (odds ratio, 3.81; 95% confidential interval, 1.36-10.65; p-value = 0.01). Conclusion Cerebral microbleeds are independently associated with reverse dipping on ambulatory blood pressure monitoring in hypertensive stroke patients.This study was supported by a grant from the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea. (A101311)Peer Reviewe