A.G. Marinakis

Impact of abnormal nocturnal blood pressure fall on vascular function

BACKGROUND It is well known that nondipping pattern of arterial hypertension has a harmful effect on target organs such as the brain, heart, and kidneys. However, it remains uncertain whether abnormal dipping patterns of nocturnal blood pressure (BP), such as extreme and reverse dipping, influence vascular function. METHODS This study comprised consecutive 2800 individuals (1554 men and 1246 women). All were nondiabetic and had uncomplicated, untreated essential sustained hypertension based on office measurements. After a 2-week wash-out period, 24-h ambulatory BP recordings were obtained and patients were classified by their nocturnal systolic BP fall (132 extreme dippers with >20% nocturnal systolic BP fall; 1235 dippers with >10% but <20% fall; 1146 nondippers with >0% but <10% fall; and 287 reverse dippers with <0% fall). Microalbumin, ACR (albumin/creatinine ratio), and microglobulin values were measured in all groups. RESULTS Extreme dippers did not differ from dippers with regard to microalbumin, microglobulin excretion, or ACR. On the contrary, reverse dippers had significantly (P <.0001) higher values, compared with nondippers, for microalbumin (49.5 v 37.2 mg/dL), microglobulin (10.33 v 8.71 mg/dL), ACR (104.9 v 65.2), and percentages of abnormal values for these parameters. CONCLUSIONS Microalbuminuria, an index of vascular function, differentiates reverse dippers from nondippers, but not extreme dippers from dippers among hypertensive patients.

Left ventricular (LV) geometry and dipping state are determinants of LV mass reduction with angiotensin-converting enzyme inhibitor antihypertensive treatment.

ObjectivesLeft ventricular hypertrophy is a major risk predictor in hypertensive patients and its regression is beneficial in terms of prognosis. The aim of this observational, open-labeled study was to investigate the effect of left ventricular geometry and dipping pattern on left ventricular mass reduction after chronic treatment with angiotensin-converting enzyme inhibitors, in a large population of hypertensive patients. MethodsWe evaluated untreated patients with mild to moderate essential hypertension, before and 6 months after treatment with angiotensin-converting enzyme inhibitor monotherapy or angiotensin-converting enzyme inhibitor–low-dose thiazide combination. Left ventricular mass index, relative wall thickness and geometry pattern were derived from echocardiography. Dipping state was determined with 24-h ambulatory blood pressure monitoring at enrollment. ResultsOverall, left ventricular mass index decrease in the 1400 patients (mean age 52.5 years) who completed the study was 12.9% of baseline value (P<0.00001). After adjusting for pretreatment value, left ventricular mass index reduction was similar with all angiotensin-converting enzyme inhibitors used [P= NS (not significant)], but it was higher in nondippers than dippers (14.1 vs. 12.3%, P<0.0001) and in patients with than without baseline left ventricular hypertrophy (14.6 vs. 11.3%, P<0.0001). We observed a stepwise augmentation of left ventricular mass index decrease with worsening left ventricular geometry (P<0.001). In multivariable analysis, impaired left ventricular geometry and blunted nocturnal blood pressure fall before treatment were independent predictors of a high left ventricular mass index reduction after treatment, independent of blood pressure fall, pretreatment left ventricular mass index, and other potential confounders. ConclusionIn essential hypertension, left ventricular geometry and dipping state are independent determinants of left ventricular mass reduction with angiotensin-converting enzyme inhibitor treatment. All angiotensin-converting enzyme inhibitors are efficient in decreasing left ventricular mass.

ВЛИЯНИЕ АНТИГИПЕРТЕНЗИВНОЙ ТЕРАПИИ БЕТА-БЛОКАТОРАМИ ТРЕТЬЕГО ПОКОЛЕНИЯ НА ФУНКЦИЮ ЭНДОТЕЛИЯ И ПРОТРОМБОТИЧЕСКИЙ СТАТУС. ЭФФЕКТЫ КУРЕНИЯ

The significance of β-blockers in the treatment of cardiovascular diseases is well established. The effect of vasodilating β-blockers on endothelial function and prothrombotic state has not been investigated. The study comprised 550 consecutive patients with uncomplicated essential hypertension. They were treated with celiprolol, carvedilol or nebivolol monotherapy (171, 179, and 200 patients, respectively), achieving comparable blood pressure reduction. Plasma levels of fibrinogen and homocysteine and serum levels of plasminogen activator inhibitor-1 (PAI-1) were obtained before and 6 months after initiation of treatment. The three drugs differentiated in regard to homocysteine (p<0,00001) and fibrinogen level changes (p=0,00003), but not (p=NS) in PAI-1 change. In smokers, differentiation was found in all three parameters (p=0,0002, p=0,001, and p=0,006 for fibrinogen, PAI-1, and homocysteine, respectively), but in non-smokers differentiation was found only in homocysteine change (p=0,00003). In smokers, fibrinogen, PAI-1, and homocysteine were reduced more (p=0,002, p=0,0009, and p<0,0001, respectively) than in non-smokers in the whole study cohort. The effect of nebivolol was more prominent in smokers than non-smokers in reducing all three parameters (p=0,0001, p=0,003, and p=0,003, respectively), whereas in celiprolol and carvedilol-treated groups, differentiation between smokers and non-smokers was significant (p=0,00003 and p=0,01, respectively) only in homocysteine level change. In hypertensive smokers, nebivolol resulted in a significant decrease of plasma PAI-1, fibrinogen, and homocysteine. Celiprolol also significantly affected these parameters but to a lesser degree, whereas carvedilol had no significant favourable action. In non-smokers, homocysteine was reduced significantly by nebivolol. We conclude that smoking status should be a determinant of antihypertensive treatment choice.

OR-10: Left atrial dimension depends on 24 hour ambulatory blood pressure dipping pattern and left ventricular geometry in arterial hypertension

Left ventricle hypertrophy (LVH) is a common and powerful risk factor in arterial hypertension, while concentric LVH is considered the most dangerous. It is well known that LV geometry and the dipping status according to 24h ambulatory blood pressure provide independent prognostic informations in hypertensive patients. On the other hand left atrial dilation is associated with increased cardiovascular risk in arterial hypertension. The aim of this study was to evaluate the possible relationship between LA enlargement and LVH, LV, geometry and dipping status. We studied 5175 consecutive untreated patients with essential hypertension. Dippers were 2976 and LVH had 2907 (1087 patients with eccentric and 1820 with concentric LVH), while 1236 patients had concentric remodeling. LA was measured from 2D derived M-mode tracings and LA index was calculated after correction with body surface area. The LA/aortic root ratio was obtained as well. Non-dippers had larger LA in comparison to dippers (35 vs 32 mm, p 0.00001), as did patients with LVH compared to those without LVH (35 vs 31 mm, p 0.00001). LV geometry differentiated LA size (normal geometry 31mm, concentric remodeling 32mm, eccentric LVH 36 mm, concentric LVH 34 mm, F 294, p 0.00001). Dippers without LVH had smaller LA compared to non dippers with LVH 34 mm, F 294, p 0.00001). Dippers without LVH had smaller LA compared to non dippers with LVH (31 vs 36 mm, p 0.00001). Overall, dippers with normal geometry had the smallest LA (30.7 mm) and the non dippers with eccentric LVH had the largest LA (37.4 mm). These findings held true after correcting LA dimension for body surface area or aortic root diameter. It is concluded that LA dimension is related to LV hypertrophy and geometry while 24 h ambulatory blood pressure dipping pattern adds to prognosis.