D. Stassaldi

Pulsatile Hemodynamics and Microcirculation Evidence for a Close Relationship in Hypertensive Patients

The possible relationships between indicators of small resistance artery structure and of arterial stiffness and central hemodynamics have not yet been evaluated. Aim of this study was to assess the relationship between indicators of large arteries stiffness, including carotido-femoral pulse wave velocity and of vascular alterations in small resistance arteries (media/lumen ratio, M/L) in patients with primary and secondary hypertension. In 73 patients (mean age, 53±14 years, 34 females, 25 with type 2 diabetes mellitus, 18 never treated) with essential (n=37) and secondary (n=36) hypertension, carotido-femoral pulse wave velocity was measured. In all patients, small resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, for the measurement of the M/L. Pulse wave analysis was performed in 67 patients. M/L ratio was significantly related to brachial systolic blood pressure and pulse pressure (r=0.36 and 0.31, P<0.001, respectively) and to central systolic and pulse pressure (r=0.44 and 0.42, P<0.001, respectively). A positive correlation was observed between M/L ratio and carotido-femoral pulse wave velocity (r=0.45; P<0.001); this correlation remained statistically significant after adjustment for age and mean blood pressure. M/L ratio was also associated to aortic augmentation index (r=0.33; P=0.008), and this correlations remained statistically significant after adjustment for potential confounders. In hypertensive patients, the presence of structural alterations of small resistance arteries may be associated with the increase in large arteries stiffness and possibly contribute to an increase in central pressure by increasing the magnitude of wave reflections.The possible relationships between indicators of small resistance artery structure and of arterial stiffness and central hemodynamics have not yet been evaluated. Aim of this study was to assess the relationship between indicators of large arteries stiffness, including carotido-femoral pulse wave velocity and of vascular alterations in small resistance arteries (media/lumen ratio, M/L) in patients with primary and secondary hypertension. In 73 patients (mean age, 53±14 years, 34 females, 25 with type 2 diabetes mellitus, 18 never treated) with essential (n=37) and secondary (n=36) hypertension, carotido-femoral pulse wave velocity was measured. In all patients, small resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, for the measurement of the M/L. Pulse wave analysis was performed in 67 patients. M/L ratio was significantly related to brachial systolic blood pressure and pulse pressure ( r =0.36 and 0.31, P <0.001, respectively) and to central systolic and pulse pressure ( r =0.44 and 0.42, P <0.001, respectively). A positive correlation was observed between M/L ratio and carotido-femoral pulse wave velocity ( r =0.45; P <0.001); this correlation remained statistically significant after adjustment for age and mean blood pressure. M/L ratio was also associated to aortic augmentation index ( r =0.33; P =0.008), and this correlations remained statistically significant after adjustment for potential confounders. In hypertensive patients, the presence of structural alterations of small resistance arteries may be associated with the increase in large arteries stiffness and possibly contribute to an increase in central pressure by increasing the magnitude of wave reflections. # Novelty and Significance {#article-title-38}

Pulsatile Hemodynamics and MicrocirculationNovelty and Significance: Evidence for a Close Relationship in Hypertensive Patients

The possible relationships between indicators of small resistance artery structure and of arterial stiffness and central hemodynamics have not yet been evaluated. Aim of this study was to assess the relationship between indicators of large arteries stiffness, including carotido-femoral pulse wave velocity and of vascular alterations in small resistance arteries (media/lumen ratio, M/L) in patients with primary and secondary hypertension. In 73 patients (mean age, 53±14 years, 34 females, 25 with type 2 diabetes mellitus, 18 never treated) with essential (n=37) and secondary (n=36) hypertension, carotido-femoral pulse wave velocity was measured. In all patients, small resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, for the measurement of the M/L. Pulse wave analysis was performed in 67 patients. M/L ratio was significantly related to brachial systolic blood pressure and pulse pressure (r=0.36 and 0.31, P<0.001, respectively) and to central systolic and pulse pressure (r=0.44 and 0.42, P<0.001, respectively). A positive correlation was observed between M/L ratio and carotido-femoral pulse wave velocity (r=0.45; P<0.001); this correlation remained statistically significant after adjustment for age and mean blood pressure. M/L ratio was also associated to aortic augmentation index (r=0.33; P=0.008), and this correlations remained statistically significant after adjustment for potential confounders. In hypertensive patients, the presence of structural alterations of small resistance arteries may be associated with the increase in large arteries stiffness and possibly contribute to an increase in central pressure by increasing the magnitude of wave reflections.The possible relationships between indicators of small resistance artery structure and of arterial stiffness and central hemodynamics have not yet been evaluated. Aim of this study was to assess the relationship between indicators of large arteries stiffness, including carotido-femoral pulse wave velocity and of vascular alterations in small resistance arteries (media/lumen ratio, M/L) in patients with primary and secondary hypertension. In 73 patients (mean age, 53±14 years, 34 females, 25 with type 2 diabetes mellitus, 18 never treated) with essential (n=37) and secondary (n=36) hypertension, carotido-femoral pulse wave velocity was measured. In all patients, small resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, for the measurement of the M/L. Pulse wave analysis was performed in 67 patients. M/L ratio was significantly related to brachial systolic blood pressure and pulse pressure ( r =0.36 and 0.31, P <0.001, respectively) and to central systolic and pulse pressure ( r =0.44 and 0.42, P <0.001, respectively). A positive correlation was observed between M/L ratio and carotido-femoral pulse wave velocity ( r =0.45; P <0.001); this correlation remained statistically significant after adjustment for age and mean blood pressure. M/L ratio was also associated to aortic augmentation index ( r =0.33; P =0.008), and this correlations remained statistically significant after adjustment for potential confounders. In hypertensive patients, the presence of structural alterations of small resistance arteries may be associated with the increase in large arteries stiffness and possibly contribute to an increase in central pressure by increasing the magnitude of wave reflections. # Novelty and Significance {#article-title-38}

Pulse wave velocity and cardiovascular risk stratification in a general population: the Vobarno study.

Background Hypertension guidelines underline the importance of quantification of total cardiovascular risk; an extensive evaluation of target organ damage (TOD) may increase the number of patients classified at high-added cardiovascular risk. Objective To assess the effect of the evaluation of different forms of TOD, in addition to ‘routine’ workup, on cardiovascular risk stratification in a general population sample in Northern Italy. Methods In 385 patients (age 57 ± 10 years, 44% men, 64% hypertensives, 32% treated), left ventricular and carotid artery structure and carotid–femoral pulse wave velocity (PWV) were measured. All patients underwent laboratory examinations. Patients were divided into risk categories according to European Society of Hypertension/European Society of Cardiology guidelines before and after TOD evaluation. Results After routine workup, patients were classified as follows: 6% at average cardiovascular risk, 35% at low cardiovascular risk, 25% at moderate cardiovascular risk, 33% at high cardiovascular risk and 1% at very high cardiovascular risk. The proportion of patients at low or moderate cardiovascular risk reclassified at high cardiovascular risk were 5, 14, 30 and 14% after echocardiography, measurement of albuminuria and estimated glomerular filtration rate, carotid ultrasound and PWV, respectively (χ2 P < 0.001 for all vs. routine). Assessment of PWV in addition to echocardiography led to an increase of the proportion of patients at high risk (from 5 to 15%, P < 0.001), as for PWV in addition to albuminuria, estimated glomerular filtration rate or both (from 14 to 31%, P < 0.01), but did not affect risk stratification in addition to carotid ultrasound (from 30 to 34%, P = NS). Conclusion Our data suggest that measurement of PWV may significantly change cardiovascular risk stratification in addition to echocardiography and to detection of albuminuria and/or of a reduction of estimated glomerular filtration rate, but not after carotid ultrasound. Our results confirm that evaluation of different forms of TOD is useful for a more accurate assessment of global cardiovascular risk.

Left ventricular hypertrophy and renal dysfunction during antihypertensive treatment adversely affect cardiovascular prognosis in hypertensive patients.

Objectives: Renal dysfunction is associated with an increased risk of cardiovascular events in hypertensive patients. Chronic kidney disease (CKD) and left ventricular hypertrophy (LVH) are both independent prognostic factors for cardiovascular events. The relation between changes in renal function and/or cardiac structure with subsequent prognosis has not yet been definitely assessed, and the aim of this study was to evaluate the relationships between renal and cardiac target-organ damage not only at baseline but also during treatment, and their influence on cardiovascular prognosis in hypertensive patients. Methods: Among 436 uncomplicated hypertensive individuals, 246 with a baseline and follow-up (last examination 68 ± 34 months apart) echocardiogram and creatinine measurements were followed for an additional 55 ± 29 months. All patients received treatment by their family doctor. After the last follow-up echocardiogram, a first major cardiovascular event occurred in 54 patients. Results: By multivariate Cox regression analysis, persistence and development of LVH from baseline to follow-up [adjusted hazard ratio 2.36, 95% confidence interval (CI) 1.03–3.68, P = 0.041] and persistence/development of CKD (estimated glomerular filtration rate according to the Modification of Diet in Renal Disease formula <60 ml/min) (adjusted hazard ratio 1.94, 95% CI 1.12–3.87, P = 0.021) from baseline to follow-up were identified as independent predictors of cardiovascular events. Conclusion: This study indicates that in hypertensive patients free of cardiovascular disease, both persistence or development of a reduced renal function and of LVH represent independent prognostic factors of cardiovascular events.

Acute blood pressure elevation: Therapeutic approach

&NA; International guidelines have suggested to avoid the term “hypertensive crisis” for the description of an acute and severe increase in blood pressure (BP) and to consider the definition of ‘hypertensive emergencies’ or ‘hypertensive urgencies’. These two clinical presentations are characterized by the presence of high BP values but imply a different diagnostic and therapeutic approach. Hypertension awareness, treatment and control are slightly increased in the last years mostly in the United States and in some European nations. Nevertheless the prevalence of hypertensive emergencies is still high and remains associated to a higher mortality. International Guidelines have also given some recommendations regarding the target BP during treatment and the use of antihypertensive drugs in hypertensive emergencies, although the adherence to these indications is frequently suboptimal. The present paper is aimed to update the currently available data on the treatment of hypertensive emergencies.

Changes in left ventricular geometry during antihypertensive treatment

&NA; The reduction of echocardiographic left ventricular (LV) mass and the change toward a less concentric geometry during antihypertensive treatment are independently associated with a better prognosis. Blood pressure–lowering treatment may reduce cardiac hypertrophy, although different effect on changes of LV mass have been reported among antihypertensive drug classes, while changes in echocardiographic evaluated LV geometry have not been systemically evaluated. It is not yet clear whether antihypertensive drugs may influence LV geometry. Our aim was to compare the effects of diuretics (D), beta‐blockers (BB), calcium channel blockers (CCB), angiotensin‐converting enzyme inhibitors (ACE‐I), and angiotensin receptor blockers (ARBS) on relative wall thickness (RWT) in patients with hypertension on the basis of prospective, randomized comparative studies. Methods: MEDLINE, and the ISI Web of Sciences were searched for randomized clinical trials evaluating LV mass and geometry at baseline and end follow‐up. We have performed a pooled pairwise comparisons of the effect of the 5 major drug classes on relative wall thickness changes, and of each drug class versus other classes statistically combined. Results: We selected 53 publications involving 7684 patients. A significant correlation was observed between percent changes from baseline to end of treatment in LV mass and those in systolic BP (r = 0.44, p < 0.001). Reduction of LV mass was significantly greater with CCB than with BB (P < 0.02) without other significant differences between drug classes. Percent changes in RWT were related to percent changes in LV mass/LVmass index (r = 0.68, p = 0.016) and of SBP (r = 0.64 p < 0.033). RWT decreased during treatment with all classes of drugs, except the combination of BB and D; the decrease of RWT was less with diuretics and sympatholytic drugs. Conclusions: In studies evaluating the effect of different classes of antihypertensive drugs on LV mass, the reduction of relative wall thickness seems to be less during treatment with diuretics.

Current Pharmacological Therapies in Heart Failure Patients

Heart failure (HF) is a major problem of public health. More than 23 million patients worldwide are affected by heart failure. Despite incidence and prevalence of heart failure may vary according to real world or randomized trials database, advancing age is a major determinant of heart failure. Heart failure is also characterized by an elevated rate of morbidity and mortality and represents one of the leading causes of hospitalization. A major consequence of heart failure is the frequent hospital admissions and related costs. Guidelines have clearly indicated evidence-based treatments in patients with heart failure, and the adherence to these indications has translated in an improvement of patient’s prognosis. Nevertheless, the use of recommended treatments at the recommended dosages is still lower than expected. In the last year in Europe new guidelines on the diagnosis and treatment of heart failure and in USA an update on pharmacological treatment of heart failure were published, pointing the attention on the use of new available pharmacological and non-pharmacological treatments. HF syndrome reflects the interaction between hemodynamic dysregulation (alterations in myocardial preload, afterload, and contractility and a neurohormonal disarray those results in the development of symptoms and in the progression of the disease. Current treatment approaches target both hemodynamic alterations and the neurohumoral elements to slow disease progression as well as to improve symptoms and outcomes.

Pulsatile Hemodynamics and Microcirculation

The possible relationships between indicators of small resistance artery structure and of arterial stiffness and central hemodynamics have not yet been evaluated. Aim of this study was to assess the relationship between indicators of large arteries stiffness, including carotido-femoral pulse wave velocity and of vascular alterations in small resistance arteries (media/lumen ratio, M/L) in patients with primary and secondary hypertension. In 73 patients (mean age, 53±14 years, 34 females, 25 with type 2 diabetes mellitus, 18 never treated) with essential (n=37) and secondary (n=36) hypertension, carotido-femoral pulse wave velocity was measured. In all patients, small resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, for the measurement of the M/L. Pulse wave analysis was performed in 67 patients. M/L ratio was significantly related to brachial systolic blood pressure and pulse pressure (r=0.36 and 0.31, P<0.001, respectively) and to central systolic and pulse pressure (r=0.44 and 0.42, P<0.001, respectively). A positive correlation was observed between M/L ratio and carotido-femoral pulse wave velocity (r=0.45; P<0.001); this correlation remained statistically significant after adjustment for age and mean blood pressure. M/L ratio was also associated to aortic augmentation index (r=0.33; P=0.008), and this correlations remained statistically significant after adjustment for potential confounders. In hypertensive patients, the presence of structural alterations of small resistance arteries may be associated with the increase in large arteries stiffness and possibly contribute to an increase in central pressure by increasing the magnitude of wave reflections.The possible relationships between indicators of small resistance artery structure and of arterial stiffness and central hemodynamics have not yet been evaluated. Aim of this study was to assess the relationship between indicators of large arteries stiffness, including carotido-femoral pulse wave velocity and of vascular alterations in small resistance arteries (media/lumen ratio, M/L) in patients with primary and secondary hypertension. In 73 patients (mean age, 53±14 years, 34 females, 25 with type 2 diabetes mellitus, 18 never treated) with essential (n=37) and secondary (n=36) hypertension, carotido-femoral pulse wave velocity was measured. In all patients, small resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, for the measurement of the M/L. Pulse wave analysis was performed in 67 patients. M/L ratio was significantly related to brachial systolic blood pressure and pulse pressure ( r =0.36 and 0.31, P <0.001, respectively) and to central systolic and pulse pressure ( r =0.44 and 0.42, P <0.001, respectively). A positive correlation was observed between M/L ratio and carotido-femoral pulse wave velocity ( r =0.45; P <0.001); this correlation remained statistically significant after adjustment for age and mean blood pressure. M/L ratio was also associated to aortic augmentation index ( r =0.33; P =0.008), and this correlations remained statistically significant after adjustment for potential confounders. In hypertensive patients, the presence of structural alterations of small resistance arteries may be associated with the increase in large arteries stiffness and possibly contribute to an increase in central pressure by increasing the magnitude of wave reflections. # Novelty and Significance {#article-title-38}

UNATTENDED VS ATTENDED BP MEASUREMENT: MEAN VALUES AND DETERMINANTS OF THE DIFFERENCE

Objective: The results of the SPRINT study have called attention on the possible differences between blood pressure (BP) values obtained by health-care professionals in the office, during the visit (“attended BP”) as compared to those obtained in the office leaving the patient alone (“automated office BP” or “unattended BP”). Only few studies have compared the two techniques and none of them implemented the approach for unattended BP measurement used in SPRINT by the use of completely automated device for both attended and unattended BP and by the measurement of 3 values after 5 minutes of rest,. Design and method: In 261 consecutive outpatients attending the outpatient clinic at an ESH Excellence Centre, BP values were measured by the physician with an automated oscillometric device (Omron HEM 9000Ai, mean of 3 measurements), after 5 minutes of rest. After the measurement of BP by the physician, the patient was left alone in the room, and the device was programmed to automatically perform 3 BP measurements after 5 minutes. Results: Mean age was 61 ± 16 yrs, 60% F, BMI 26.1 ± 4.2, 88 % with a previous diagnosis of hypertension (64 % treated). Unattended systolic BP (SBP) and diastolic BP (DBP) were both lower as compared to attended SBP (130.1 ± 15.7vs138.6 ± 17.2 mmHg) and DBP (77.1 ± 11.7vs78.9 ± 12.2 mmHg). The differences (Delta) between the values obtained using the two techniques were 8.5 ± 7.9 mmHg for SBP and 1.8 ± 5.6 mmHg for DBP. Delta SBP was directly correlated with age (r = 0.235 p < 0001) and with attended BP values (r = 0.407 p < 0.0001); Delta SBP was significantly lower in males than in females. At multivariate analysis Delta SBP remained independently correlated with age and attended SBP. Delta DBP was directly correlated with attended DBP (r = 0,322 p < 0.001) and was lower in males. Conclusions: Our findings indicate that “unattended BP” measurement provides values significantly lower as compared to measurements obtained in the presence of the physician. Interestingly, the difference between the values obtained by the two approaches is not constant for all patients, being significantly affected by age, gender and BP values

RELATIONSHIP BETWEEN UNATTENDED AND ATTENDED BP VALUES AND PRECLINICAL ORGAN DAMAGE

Objective: It has been suggested that measurement of “unattended” or “automated oscillatory (AOBP)” blood pressure values may provide advantages over conventional BP measurement; some hypertension guidelines now suggest this approach as the preferred one for measuring office BP. Data on the relationship between AOBP and cardiovascular events are much less solid as compared to those obtained with the standard BP measurement; on the other hand, some study suggested that AOBP might be more strictly correlated with hypertensive target organ damage than “attended” BP. The aim of our study was to evaluate the relationship between “attended” or “unattended” BP values and target organ damage in 261 subjects attending the outpatient clinic of an ESH Excellence Centre. Design and method: BP values were measured by the physician with an automated oscillometric device (Omron HEM 9000Ai, mean of 3 measurements), after 5 minutes of rest; thereafter, the patient was left alone and unattended BP was measured automatically after 5 minutes (3 measurements at 1 minute interval). Results: Patients mean age was 61 ± 16 yrs, mean BMI 26.1 ± 4.2, 60% were female, 88 % had a previous diagnosis of hypertension (64% treated). Systolic unattended BP was lower as compared to attended SBP (130.1 ± 15.7vs138.6 ± 17.2 mmHg). Left ventricular mass index (LVMI) was similarly correlated with unattended and attended SBP (r = 0.132 and r = 0.133, p < 0.05, respectively). LVMI was similarly correlated with unattended and attended pulse pressure (PP) (r = 0.277 and r = 0.299, p < 0.05, respectively). Carotid IMT was significantly and similarly correlated with both attended and unattended BP values (CBMaxIMT: r = 0.172 and r = 0.153 for attended and unattended SBP, p < 0.05 and: r = 0.459 and r = 0.436 for attended and unattended PP, p < 0.001). The differences between correlations were not statistically significant. Conclusions: Measurement of BP “unattended” or “unattended” provides different values, being unattended BP lower as compared to attended BP. Our results suggest that attended and unattended BP values are similarly related with cardiac and vascular hypertensive target organ damage.