Claudio Fania

Rectangular cuffs may overestimate blood pressure in individuals with large conical arms

Objectives: Although the upper arm has the shape of a truncated cone, cylindrical cuffs and bladders are currently used for blood pressure (BP) measurement. The aim of this study was to ascertain whether cylindrical and tronco-conical cuffs provide different readings according to arm size and shape. Design: We studied 220 individuals with arm circumference ranging from 22 to 42.5 cm. Four different cylindrical and four different tronco-conical bladders of appropriate size were used. Sequential same-arm measurements were performed in triplicate by two observers using the two cuffs in a random order. In 100 individuals, the actual pressure transmitted to the arm surface by the two cuffs at the central point was also measured. Results: Upper arm shape was tronco-conical in all of the individuals. In a multiple regression, conicity was related to arm circumference (P < 0.001) and length (P = 0.001). Arm conicity and size were independently related to the between-cuff SBP (P = 0.001 and 0.002, respectively) and DBP (P = 0.001 and <0.001, respectively) discrepancies. In the group with arm circumference of 37.5–42.5 cm, the cylindrical cuff overestimated BP measured with the tronco-conical cuff by 2.0 ± 0.4/1.8 ± 0.3 mmHg (P = 0.001 and <0.001). In this group, 15% of individuals found hypertensive with the cylindrical cuff were normotensive when assessed with the conical cuff. Differences as great as 9.7/7.8 mmHg were found in individuals with large arms and slant angle equal to or less than 83°. Conclusion: In obese people, the upper arm may have a pronounced tronco-conical shape and cylindrical cuffs may overestimate BP. Tronco-conical cuffs should be used for BP measurement in individuals with large arms.

Coffee consumption and risk of cardiovascular events in hypertensive patients. Results from the HARVEST

BACKGROUND Controversy still exists about the long-term cardiovascular effects of coffee consumption in hypertension. METHODS The predictive capacity of coffee use for cardiovascular events (CVEs) was investigated in 1204 participants from the HARVEST, a prospective cohort study of non-diabetic subjects aged 18-45years, screened for stage 1 hypertension. Subjects were grouped into three categories of coffee drinking, non-drinkers (none), moderate drinkers (1 to 3cups/day) and heavy drinkers (4or more cups/day). Multivariate Cox proportional hazards models were developed adjusting for possible confounding variables and risk factors. RESULTS During a median follow-up of 12.6years, CVEs were developed by 60 participants. CVEs were more common among coffee drinkers than abstainers (abstainers, 2.2%; moderate drinkers, 7.0%; heavy drinkers, 14.0%; p for trend=0.0003). In a multivariable Cox regression model, coffee use was a significant predictor of CVE in both coffee categories, with a hazard ratio of 2.8 (95% CI, 1.0-7.9) in moderate coffee drinkers and of 4.5 (1.4-14.2) in heavy drinkers compared to abstainers. After inclusion of change in body weight (p=ns), incident hypertension (p=0.027) and presence of diabetes/prediabetes (p=ns) at follow-up end, the association with CVE was attenuated but remained significant in heavy coffee drinkers (HR, 95% CI, 3.4, 1.04-11.3). CONCLUSIONS These data show that coffee consumption increases the risk of CVE in a linear fashion in hypertension. This association may be explained in part by the association between coffee and development of hypertension. Hypertensive patients should be discouraged from drinking coffee.

Effects of smoking on central blood pressure and pressure amplification in hypertension of the young

The aim of this study was to investigate the effect of cigarette smoking on peripheral and central blood pressure (BP) in a group of young stage I hypertensives. A total of 344 untreated subjects from the HARVEST study were examined (mean age 37±10 years). Patients were divided into three groups based on smoking status: non-smokers, light smokers (⩽5 cigarettes/day) and moderate-to-heavy smokers (>5 cigarettes/day); and into three groups by age: 18–29, 30–39 and ⩾40 years. Central BP measurements and augmentation index (AIx) were calculated from brachial pressure waveform, with applanation tonometry, by means of the Specaway DAT System plus a Millar tonometer. The central waveform was derived from peripheral BP using the same software system of the SphygmoCor System pulse wave analysis. In addition, two indirect measurements of arterial stiffness were calculated: pulse pressure (PP) and systolic BP amplification. Central systolic BP and PP were higher in smokers than in non-smokers (systolic BP: 121.9±13.1 mmHg in non-smokers, 127.2±16.5 mmHg in light smokers, 126.7±15.3 mmHg in those who smoked >5 cigarettes/day, p=0.009; PP: 37.7±9.8 mmHg, 41.5±13.1 mmHg, 41.9±10.5 mmHg, respectively, p=0.005). Lower systolic BP amplification (p<0.001) and PP amplification (p=0.001) were observed in smokers compared to non-smokers. In a two-way ANCOVA analysis, systolic BP amplification markedly declined across the three age groups (p=0.0002) and from non-smokers to smokers (p=0.0001), with a significant interaction between smoking and age group (p=0.05). The AIx was higher in smokers compared to non-smokers (p=0.024). In young hypertensives, smoking has a detrimental effect on central BP, accelerating the age-related decline in BP amplification.

Office Pulse Pressure Is a Predictor of Favorable Outcome in Young- to Middle-Aged Subjects With Stage 1 Hypertension

The role of pulse pressure in young individuals remains controversial. The aim of the present study was to investigate the clinical significance of elevated pulse pressure in young- to middle-aged subjects screened for stage 1 hypertension. We examined 1241 subjects (mean age, 33.1±8.4 years) from the HARVEST (Hypertension Ambulatory Recording Venetia Study), during a median follow-up of 12.1 years. To evaluate the predictive value of pulse pressure and mean blood pressure for future hypertension needing treatment and for cardiovascular events, participants were grouped into pressure tertiles. Significant determinants of pulse pressure were male sex (P=0.029), younger age (P<0.001), physical activity (P=0.003), heart rate (P<0.001), systolic white-coat effect (P<0.001), and stroke volume (n=829; P<0.001). During follow-up, 65.1% of participants developed hypertension requiring pharmacological treatment and 5.1% experienced a cardiovascular event. Participants in the highest pulse pressure tertile had a reduced risk of incident hypertension compared with those of the bottom tertile (hazard ratio, 0.75; 95% confidence interval, 0.62–0.91; P=0.003). In contrast, participants in the top mean blood pressure tertile had an increase in risk (1.91; 1.57–2.33; P<0.001). In addition, participants in the highest pulse pressure tertile had a reduced risk of cardiovascular events (0.35; 0.17–0.73; P=0.005) and those in the top mean blood pressure tertile had an increase in risk (3.06; 1.32–7.09; P=0.009). Our data show that in subjects <45 years, only mean blood pressure is a predictor of adverse outcome whereas high pulse pressure even carries a reduced risk.

Validation of the A&D BP UB-542 wrist device for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The objective of this study was to determine the accuracy of the A&D BP UA-651 device for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension. Device evaluation was carried out in 33 patients. The mean age of the patients was 48.3±15.5 years, the mean systolic BP was 138.3±24.9 mmHg (range 90–180), the mean diastolic BP was 88.3±13.8 mmHg (range 60–108), and the mean arm circumference was 28.6±3.4 cm (range 23–36). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device underestimated the systolic BP by 0.4±4.4 mmHg and diastolic BP by 1.3±3.5 mmHg. The device–observer discrepancies were unrelated to patients’ clinical characteristics. These data show that the A&D BP UA-651 device fulfilled the requirements for validation by the International Protocol and can be recommended for clinical use in the adult population.

Validation of the A&D BP UA-651 device with a wide-range cuff for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The aim of this study was to determine the accuracy of the A&D BP UA-651 device coupled to a wide-range cuff for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension. The device was evaluated in 33 patients. The mean age of the patients was 56.5±15.1 years. The mean systolic BP was 144.3±23.8 mmHg (range 88 : 196), the mean diastolic BP was 87.5±15.8 mmHg (range 38 : 132), and the mean arm circumference was 29.0±3.4 cm (range 22 : 36). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device overestimated the systolic BP by 0.7±3.4 mmHg and underestimated the diastolic BP by 0.8±3.6 mmHg. The measurement error was unrelated to the patient’s arm circumference. These data show that the A&D BP UA-651 device coupled to a wide-range cuff fulfilled the requirements for validation by the International Protocol over a wide range of arm circumferences and can be recommended for clinical use in the adult population.

Regular physical activity prevents development of hypertension in young people with hyperuricemia

Objective: The association of serum uric acid (SUA) with risk of hypertension is controversial and may be modulated by lifestyle factors. We did a prospective study to investigate whether SUA was an independent predictor of hypertension in the young and whether physical activity influences this association. Methods: The study was conducted in a cohort of 1156 young to middle-age participants screened for stage 1 hypertension and followed for a median of 11.4 years. In multivariable Cox analyses, participants were stratified by tertiles of uric acid and physical activity habits. Results: At follow-up end, 63.3% of the study participants developed hypertension needing treatment. In the whole group, SUA was an independent predictor of future hypertension (P = 0.005). Participants with SUA more than 5.60 mg/dl (top tertile) had a 31% increase in risk compared with those of the bottom tertile. However, the risk of hypertension related to SUA was increased only among the sedentary participants with a hazard ratio of 1.44 (95% confidence interval, 1.11–1.88) for the participants of the top SUA tertile. In contrast, among the active participants no association was found between SUA and risk of hypertension. Alcohol intake was another modulator of the SUA-hypertension relationship (hazard ratio, 95% confidence interval: 1.38, 1.02–1.87). Plasma renin activity, office and ambulatory heart rates, and metabolic variables were proportional to SUA level and were lower in active than sedentary participants. Conclusion: These data confirm that SUA is a predictor of hypertension and suggest that exercise may counteract the pathophysiological mechanisms involved in the association between hyperuricemia and future hypertension.

Intima-media thickness remodelling in hypertensive subjects with long-term well-controlled blood pressure levels

Abstract Aim of this study was to evaluate in a long follow-up the carotid artery remodelling in a cohort of young hypertensive subjects having good blood pressure (BP) control. We studied 20 grade I hypertensives (HT) by assessing the B-mode ultrasound of mean carotid intima-media thickness (mean-IMT) and maximum IMT (M-MAX) in each carotid artery segment (common, bulb, internal), bilaterally. We compared their ultrasound measurements with those recorded 5 and 10 years earlier. While the first 5-year follow-up was observational, in the second 5-year follow-up, lifestyle modifications and/or pharmacological therapy were started to obtain well-controlled BP levels. Office BP was measured at the time of the ultrasound studies and every 6 months during the follow-up. BP levels were: 10 years 144/91 mmHg, 5 years 143/90 mmHg and 129 ± 79 mmHg at the time of the study. In the first 5-year observational follow-up, both mean-IMT and M-MAX increased (Δ 0.116 and Δ 0.165 mm, respectively, p < 0.0005). In the 5-year intervention follow-up, characterized by well-controlled BP, mean-IMT slightly but significantly increased (Δ 0.084 mm, p = 0.004), whereas M-MAX remained stable (Δ 0.026 mm). In our HT, well-controlled BP levels were able to prevent pro-atherogenic remodelling (expressed by M-MAX). Conversely, good BP control slightly decreased but did not stop the progression in mean-IMT, which is likely to reflect some hypertrophy of the arterial media layer.

Validation of the Thermor BIOS BD215 device for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The objective of this study was to determine the accuracy of the Thermor BIOS BD215 device for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension (ESH). Device evaluation was carried out in 33 patients. The mean age of the patients was 57.0±15.0 years, the mean systolic BP was 142.0±20.3 mmHg (range 100–177 mmHg), the mean diastolic BP was 88.0±14.6 mmHg (range 48–123 mmHg), and the mean arm circumference was 28.0±3.0 cm (range 24–33 cm). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device overestimated the systolic BP by 0.6±4.2 mmHg and underestimated diastolic BP by −0.5±3.2 mmHg. The device–observer discrepancies were unrelated to patients’ clinical characteristics. These data show that the Thermor BIOS BD215 device fulfilled the requirements for validation by the International Protocol and can be recommended for clinical use in the adult population.

3A.07: NIGHT-TIME HEART RATE IS A LONG-TERM PREDICTOR OF MICROALBUMINURIA IN SUBJECTS SCREENED FOR STAGE 1 HYPERTENSION

Objective: Heart rate (HR) has been found to be associated with target organ damage in hypertension but the predictive capacity of resting HR vs ambulatory HR in longitudinal studies is not well known. We did a prospective study to investigate whether clinic HR and ambulatory HR assessed at baseline were independent predictors of albumin excretion rate (AER) and microalbuminuria (MA) in the early stage of hypertension. Design and method: The study was conducted in a cohort of 621 white stage 1 hypertensive subjects from the HARVEST never treated for hypertension (mean age 33.8 ± 8.4 years, 449 men). Clinic HR was the average of 6 readings. Clinic HR, daytime HR and night-time HR were included separately in linear (for AER) and logistic (for MA) regressions and were adjusted for baseline logAER, age, gender, body mass index, blood pressure, physical activity, smoking, alcohol consumption, and follow-up time. Results: During a median follow-up of 8.5 years AER increased from a median value of 5.7 mg/24 h to 7.2 mg/24 h (p < 0.001 for log-transformed data), and 42 subjects developed MA (AER >  = 30 mg/24 h). In both linear and logistic regressions average night-time HR was an independent predictor of final AER (p = 0.014) and MA (p = 0.007), whereas clinic HR and daytime HR were not associated with these outcomes (p = NS for both). Night-time HR was 62.6 ± 8.3 bpm in the 579 subjects who did not develop MA and was 66.6 ± 7.7 bpm in the 42 subjects who developed MA (p = 0.002). Baseline BMI was another independent predictor of final AER (p = 0.007) and final MA (p = 0.001) and its inclusion into the models slightly attenuated the association of night-time HR with AER (p = 0.029) and MA (p = 0.016). Conclusions: HR is an independent predictor of microalbuminuria in young persons screened for stage 1 hypertension suggesting that the chronic hemodynamic stress related to tachycardia may play a role in the development of renal damage in hypertension. In agreement with previous results, HR measured during sleep seems to be more representative of the overall hemodynamic load on the arteries than HR measured during waking hours or in the doctors office.