Barbara Bonino

Changes in albuminuria and cardiovascular risk under antihypertensive treatment: a systematic review and meta-regression analysis

Background: Increased urine albumin excretion (UAE) is a well known predictor of cardiovascular events in patients with primary hypertension. Whether a reduction in UAE is associated to an improvement in cardiovascular risk is at present unclear. We performed a systematic review and meta-regression analysis of available trials to investigate whether treatment-induced changes in UAE are related to cardiovascular outcome. Methods: We searched MEDLINE, ISIWeb of Science, Cochrane Database and Scopus for studies including hypertensive patients, which reported cardiovascular events and UAE at baseline and at end of follow-up. Results: In trials reporting pairwise comparisons between antihypertensive treatment for cardiovascular outcome (16 randomized controlled trials and 48 580 patients, mean follow-up 45 months, 5867 cardiovascular events) after adjustment for differences in achieved blood pressure, a relationship between changes in albuminuria and risk was evident in the presence of a relevant between-arms difference in albuminuria [relative risks (RR) pooled 0.45, confidence interval (CI) 0.23–0.85] but not when no improvement in UAE was found between randomized arms (RR pooled 1.04, 95% CI 0.86–1.26, P for difference between subgroups <0.001). Meta-regression analysis showed a relationship between changes in albuminuria and risk after adjustment for blood pressure variation under treatment (adj. coeff. 0.005, 95% CI 0.0005–0.0096, P = 0.033, R2 34.8%). In studies reporting changes in cardiovascular events on the basis of UAE variations (six trials and 36 325 patients, mean follow-up 60 months, 3741 cardiovascular events), the overall adjusted RR of total cardiovascular events was 0.51 (95% CI 0.38–0.59, P = 0.000) for albuminuria regression/stable vs increase. Conclusion: Reduction in UAE under antihypertensive treatment is associated with reduced risk of clinical cardiovascular events. Our findings suggest that UAE changes may represent a valuable intermediate end point for cardiovascular events in primary hypertension.

Left ventricular dilatation and subclinical renal damage in primary hypertension

Objective: A new classification of left ventricular geometry based on left ventricular dilatation and concentricity has recently been developed. This classification identifies subgroups differing with regard to systemic haemodynamics, left ventricular function and cardiovascular prognosis. We investigated the relationship between the new classification of left ventricular geometry and subclinical renal damage, namely urine albumin excretion and early intrarenal vascular changes in primary hypertensive patients. Methods: A total of 449 untreated hypertensive patients were studied. Four different patterns of left ventricular hypertrophy (eccentric nondilated, eccentric dilated, concentric nondilated and concentric dilated hypertrophy) were identified by echocardiography. Albuminuria was measured as the albumin-to-creatinine ratio. Early intrarenal vascular changes, expressed as the renal volume to resistive index ratio, were evaluated by ultrasound and Doppler scan. Results: Patients with concentric dilated left ventricular hypertrophy had higher albumin excretion rates (P = 0.0258) and prevalence of microalbuminuria (P < 0.0001) and lower renal volume to resistive index ratio than patients with concentric nondilated hypertrophy (P = 0.0093). Patients with eccentric dilated hypertrophy showed a higher prevalence of microalbuminuria than patients with eccentric nondilated hypertrophy (P < 0.0001). Moreover, patients with chamber dilatation showed a higher prevalence of microalbuminuria (P = 0.0002) and lower renal volume to resistive index ratio (P = 0.0107) than patients without chamber dilatation. After adjusting for potentially confounding variables, left ventricular chamber dilatation was an independent predictor of subclinical renal damage. Conclusion: Left ventricular dilatation is associated with subclinical renal damage in hypertension. These findings extend previous reports and provide a pathophysiological rationale for the observed unfavourable prognosis in patients with left ventricular dilatation.

Early Renal Abnormalities as an Indicator of Cardiovascular Risk in Type 2 Diabetes

Accurate assessment of cardiovascular (CV) risk is a prerequisite for devising effective therapeutic strategies in patients with type 2 diabetes (T2DM) as it allows to refine prognosis and treatment targets as well as the cost-benefit ratio for specific pharmacological interventions. The presence of subclinical vascular organ damage plays a well known role in determining overall risk and a wider use of low cost, easy to perform diagnostic tools to stratify CV risk is very much needed. Besides their well known prognostic value for progression to end stage renal disease (ESRD), subclinical renal abnormalities such as microalbuminuria and/or a slight reduction in estimation of glomerular filtration rate (eGFR), have been shown to be powerful, independent predictors of CV diseases in patients with T2DM. Through the combined evaluation of these two biomarkers of chronic kidney disease (CKD), clinicians can usefully and reliably get a perspective on global and CV outcome of their diabetic patients.

Chronic kidney disease as a predictor of clinical risk in the elderly

Facing the needs of an increasingly ageing population is rapidly becoming a major public health issue in western countries.[1],[2] Chronic kidney disease (CKD), whose current prevalence is estimated around 10%−15% in the general population, with considerably higher figures in at-risk groups, is widely known to increase with age.[3] In the elderly, renal impairment is often concomitant or secondary to several other systemic disorders such as hypertension, atherosclerosis, diabetes and cardiovascular (CV) diseases. As accurate clinical risk assessment is a prerequisite for devising effective preventive and therapeutic strategies, identifying and enhancing the presence of renal abnormalities is an important step to effectively deal with the frail patient with comorbidities. Glomerular filtration rate (GFR) and albuminuria, the two main components of CKD, have been shown to be independent and strong predictors of CV morbidity and mortality and all-cause mortality in the general population as well as in the elderly.[3] We will briefly review data from the literature supporting the role of renal parameters as practical, low cost and efficient tools for a comprehensive risk assessment in the elderly and will argue in favor of a wider use of these tests in different clinical settings from general practice to specialized hospital centres.

7A.09: METABOLIC SYNDROME IS ASSOCIATED WITH LEFT VENTRICULAR DILATATION IN PRIMARY HYPERTENSION.

Objective: Metabolic syndrome (MS) has been shown to predict cardiovascular events in patients with hypertension. Recently, a new four-group left ventricular (LV) hypertrophy classification based on both LV dilatation and concentricity was proposed. This classification has been shown to provide a more accurate prediction of cardiovascular events, suggesting that the presence of LV dilatation may add prognostic information. We investigated the relationship between MS and the new classification of LV geometry in patients with primary hypertension. Design and method: A total of 372 untreated hypertensive patients were studied. Four different patterns of LV hypertrophy (eccentric non-dilated, eccentric dilated, concentric non-dilated, and concentric dilated hypertrophy) were identified by echocardiography. A modified National Cholesterol Education Program definition for MS was used, with body mass index replacing waist circumference. Results: The overall prevalence of MS and LV hypertrophy was 29% and 61% respectively. Patients with metabolic syndrome showed higher prevalence of LVH (P = 0.0281) and dilated LV geometries, namely eccentric dilated and concentric dilated hypertrophy (P = 0.0075). Moreover, patients with MS showed higher LV end diastolic volume (P = 0.0005) and prevalence of increased LV end diastolic volume (P = 0.0068). The prevalence of LV chamber dilatation increased progressively with the number of components of metabolic syndrome (P = 0.0191). Logistic regression analysis showed that the presence of MS entails a three time higher risk of having LV chamber dilatation even after adjusting for several potential confounding factors. Conclusions: MS is associated with LV dilatation in hypertension. These findings may, in part, explain the unfavorable prognosis observed in patients with MS.