E. A. Karpanou

Effect of Age on Interdependence and Hierarchy of Cardiovascular Risk Factors in Hypertensive Patients

The prognostic significance, interdependence, and hierarchy of cardiovascular risk factors could evolve with advancing age. Our study reports on the interdependence among blood pressure (BP), other metabolic syndrome components, and high-sensitivity C-reactive protein according to age in hypertensive subjects. A total of 5,712 nondiabetic patients (50.1% men, age range 40 to 95 years) evaluated in outpatient hypertension clinics were included and divided into 5 age groups (age 40 to 49, 50 to 59, 60 to 69, 70 to 79, and >80 years). BP, evaluated by both office and 24-hour ambulatory BP monitoring, and the metabolic and inflammation parameters were determined after a ≥2-week drug washout period. The prevalence of the metabolic syndrome (Adult Treatment Panel III definition) remained stable across the age groups. We observed a stable or increased association between waist circumference and insulin resistance (Homeostasis Model of Assessment-Insulin Resistance index) and fasting plasma glucose. However, the association between waist circumference and ambulatory BP monitoring systolic BP (r(2) decrease from 9.9% to 1.0%, p <0.001), high-density lipoprotein cholesterol (r(2) decreased from 21% to 4.9%, p = 0.002), and triglyceride levels (r(2) decreased from 17.5% to 1.9%, p <0.001) decreased with age. High-sensitivity C-reactive protein correlated with all metabolic syndrome components in all age groups (p <0.001 for all). It became the strongest determinant of ambulatory BP monitoring systolic BP (p <0.001) and high-density lipoprotein cholesterol (p <0.05) in patients >80 years old. In contrast, its association with waist circumference markedly decreased. In conclusion, hypertension and dyslipidemia, but not fasting plasma glucose, dissociate from central obesity with advancing age. They are increasingly determined by low-grade inflammation, independently of central obesity. These changing associations might underlie the weakening of obesity as a cardiovascular risk factor in older persons.

A prospective angiographic study of the coronary collateral circulation in coronary arterial disease

A prospective angiographic study of the coronary collateral circulation was performed in 600 consecutive patients found to have significant coronary arterial disease at cardiac catheterization. As the number of diseased coronary vessels increased the evidence of collaterals rose significantly (P = 0.00002) and the intensity of the collateral circulation increased (P = 0.05). For totally occluded lesions the collateral incidence was 70.4%, independent of the particular vessel involved. For stenoses greater than 90% collateral frequency and intensity were significantly greater for lesions of the right coronary artery than of the left anterior descending and the left circumflex arteries. The distribution of the coronary collateral circulation is described quantitatively according to the site of the lesion. Finally, a coronary collateral circulation occurred more frequently (P less than 0.000 001) and excepting Grade I, the intensity of the coronary collateral circulation was significantly greater in patients with a history of acute myocardial infarction.

Ambulatory blood pressure profile in anemic hypertensive patients

The purpose of the present study was to investigate whether there is a relationship between anemia and day-night blood pressure variations in essential hypertensive patients. We found that anemic hypertensives had significantly elevated nocturnal BP, and decreased mean 24-h BP and daytime BP.

Renal and Heart Function in Essential Hypertension

Background: The relationship between heart and renal function is a precarious matter that has been investigated through the years. Lately many studies suggest that renal injury is associated with early stage heart dysfunction. The aim of the present study is to investigate the grade of renal deterioration according to heart function in non diabetic essential, never treated, hypertensive patients. Methods: We studied 7970 consecutive patients (4419 males, mean age 53 years) with uncomplicated essential hypertension and the correlation between cardiac function using the Tei index (defined as the sum of the isovolumetric relaxation and contraction time divided by the ejection time), transmitral blood flow velocities ratio (E/A), ejection fraction (EF) and kidney injury [eGFR( ml/min), ACR (urine albumin-creatinine ratio)]. Patients were grouped by ACR (ACR>30 and ACR90, eGFR 90-60, eGFR 60-40). Results: The model was adjusted for age, gender, blood pressure, lipid profile and smoking habit. EF was decreased with renal function deterioration as did the E/A ratio, while the Tei index increased (Table). Furthermore EF has higher normal levels in patients with ACR <30 as did the E/A ratio while Tei index present lower levels. Conclusions: We found that the Tei index and E/A was correlated with eGFR, and ACR. It seems that systolic and diastolic heart function indices can be used not only for the evaluation of the global myocardial performance of hypertensive patients but also for the assessment of the risk of kidney damage.

AMBULATORY BLOOD PRESSURE PROFILE IN HYPERTENSIVE PATIENTS WITH Â-THALASSEMIA MINOR: PP.14.05

Objective: â-thalassemia trait (â-TT) is a genetic blood disorder, more common in Mediterranean countries, including Greece. Previous studies have indicated a protective effect of â-TT on myocardial infarction due to lower cholesterol or lower blood pressure levels. However, the ambulatory blood pressure profile of such patients has not been investigated yet. Moreover, it has been reported that anemic hypertensive patients usually have significantly elevated nocturnal BP, and decreased mean 24-h BP and daytime BP. Thus, the purpose of the present study was to investigate the ABPM profile of hypertensives with â-TT, in comparison to all cause anemic and non-anemic essential hypertensive patients. Design and Methods: The study comprised 8861 essential hypertensive, non-diabetic patients who were divided in three groups: groups I (n = 191, with â-TT), group II (n = 655, anemic), and group III (n = 8015, non-anemic). All patients underwent full laboratory workout and were subjected to ABPM. Anemia was defined as hemoglobin < 12 g/dl for women and < 13 g/dl for men, while patients with â-TT were self-referred. Results: The distribution of dipping pattern among the three groups was (61.3 vs 41.2 vs 45.8 %, p < 0.001), while for non-dipping (20.4 vs 31.5 vs 27.7 %, p < 0.001), for extreme-dipping (15.7 vs 15.0 vs 17.5%, p < 0.001) and for reverse dipping (2.6 vs 12.4 vs 9.0%, p < 0.001). Furthermore, mean daytime-SBP among the three groups was (140 ± 7 vs 142 ± 11 vs 141 ± 9 mmHg, p = 0.03) and mean nighttime SBP (125 ± 10 vs 131 ± 15 vs 129 ± 13 mmHg, p < 0.001). In multiple regression analysis after adjustments for age, body mass index and lipid levels, the differences among daytime and nighttime SBP remained significant [(140 ± 9 vs 142 ± 9 vs 141 ± 9 mmHg, p = 0.04), (125 ± 13 vs 131 ± 13 vs 129 ± 13 mmHg, p < 0.001), respectively]. Conclusions: Hypertensive patients with â-TT present with a better 24-h BP profile in comparison with anemic and non-anemic hypertensives. Thus â-TT may act protectively in their total cardiovascular risk profile.

THYROID FUNCTION AND LARGE ARTERY STIFFNESS WITH ESSENTIAL HYPERTENSION AND ISOLATED OFFICE HYPERTENSION: PP.31.217

Objective: The association between hypothyroidism and increased vascular resistance, arterial wall thickening and endothelial dysfunction is well recognized. The aim of this study was to assess possible associations between thyroid hormones within normal levels and arterial stiffness in essential hypertensive patients versus patients with isolated office hypertension and healthy controls. Design and Methods: The study comprised 1445 patients with essential hypertension (n = 880), isolated office hypertension (n = 388) and healthy controls (n = 177), all with normal thyroid function. The study participants underwent full clinical and biochemical evaluation. Thyroid function was evaluated with the measurement of serum T3, T4, TSH, FT3 and FT4. Aortic stiffness and arterial wave reflection assessment were evaluated with carotid femoral (PWVc-f) and carotid radial (PWVc-r) pulse wave velocity and aortic augmentation index corrected for heart rate (Aix75). Results: In patients with arterial hypertension, regression analysis revealed that TSH, FT3, FT4 levels are determinants of PWVc-r [(beta (SE) = -0.079 (0.038), p = 0.039), (beta (SE) = 0.281 (0.101), p = 0.005), (beta (SE) = 0.595 (0.209), p = 0.005), respectively] and additionally all thyroid hormones T3[beta (SE) = 0.399 (0.197), p = 0.0043], T4 [beta (SE) = 0.071 (0.032), p = 0.027], TSH [beta (SE) = -0.8 (0.041), p = 0.049], FT3 [beta (SE) = 0.253 (0.107) p = 0.018] and FT4 [beta (SE) = 1.277 (0.222) p < 0.001] are predictive for PWVc-f. Furthermore, T4 [beta (SE) = 0.812 (0.253) p = 0.001] and TSH [beta (SE) = -0.751 (0.32) p = 0.019] determined AIx75. Finally in patients with isolated office hypertension only FT4 [beta (SE) = 0.71(0.295) p = 0.017] was independently predictive of PWVc-f. Conclusions: There seems to be an independent association between thyroid hormones, within normal values, and arterial stiffness indices in essential hypertensive patients. Thus, even mild changes in thyroid hormone levels may affect large artery properties.

SERUM PHOSPHATE IN WHITE COAT HYPERTENSIVE PATIENTS: FOCUS ON DIPPING STATUS AND METABOLIC SYNDROME: 5B.05

Objective: Recent studies indicate an association of serum phosphate levels with blood pressure in hypertensive patients. A growing body of evidence suggests that white coat hypertension (WCH) is associated with target organ damage. Furthermore, metabolic syndrome (MS) and non-dipping pattern are also associated with increased cardiovascular risk. The purpose of this study was to explore the nocturnal blood pressure fall in WCH patients according to their serum phosphate, calcium levels and MS components. Design and Methods: The study comprised 2600 patients with WCH who attended our outpatient clinics. All patients underwent repeated office blood pressure measurements, 24-h ambulatory blood pressure monitoring, full clinical and laboratory evaluation. The diagnosis of MS was made according to the Adult Treatment Panel III criteria. Dipping pattern was defined as ‘dippers’ with nocturnal systolic blood pressure (NSBP) fall greater than or equal to 10% but less than 20%,‘non-dippers’ with NSBP fall greater than or equal to 0% but less than 10%, ‘extreme dippers’ with NSBP fall greater than or equal to 20%, and ‘reverse dippers’ with NSBP increase. Results: ‘Extreme dippers’ were 413, ‘dippers’ 1337, ‘non-dippers’ 734 and ‘reverse dippers’ 116. ‘Reverse dippers’ presented with significantly lower levels of serum phosphate, while ‘extreme dippers’ had significantly higher levels (3.39 ± 3.29 vs 3.58 ± 3.52 mg/dl, p < 0.0001). Grouping the patients according to the number of MS components, the main observation was the inverse relationship of serum phosphate to MS components (3.53 ± 0.36 to 3.50 ± 0.38 to 3.49 ± 0.38 to 3.44 ± 0.36 to 3.35 ± 0.31 mg/dl, p = 0.003). Conclusions: WCH patients with low phosphate levels appear to have impaired metabolic profile and higher incidence of non dipping profile. This observation may be important for the stratification of cardiovascular risk in WCH patients.

PROSTATE SPECIFIC ANTIGEN LEVELS WITHIN NORMAL RANGE ARE ASSOCIATED WITH ARTERIAL STIFFNESS IN ESSENTIAL HYPERTENSIVE PATIENTS: PP.31.234

Objective: Prostate specific antigen (PSA) is an established marker for prostate hypertrophy and cancer. PSA within normal limits reflects both gland hypertrophy and specific inflammation. The aim of the present study was to investigate whether PSA values, within normal levels, are associated with arterial stiffness independently of subclinical inflammation in patients with essential hypertension. Design and Methods: The study comprised 150 consecutive male patients (mean age 60 years) with uncomplicated never-treated essential hypertension. All patients underwent a complete clinical and laboratory evaluation, including PSA levels. Aortic stiffness and arterial wave reflection assessment was made by using carotid femoral (PWVc-f) pulse wave velocity and aortic augmentation index corrected for heart rate (Aix75). Patients with prostate cancer or benign prostate hyperplasia (PSA>4ng/ml) were excluded from the study. Results: PSA levels were positively associated to PWVc-f (r = 0.426, p < 0.001), AIx75 (r = 0.264, p=0.001) and hsCRP (r = 0.376, p < 0.001). When PSA values were grouped in quartiles, patients in the higher quartile presented with higher PWVc-f (p < 0.00001), AIx75 (p < 0.001) and hsCRP (p < 0.001) values. In multivariate analysis after adjustment for the factors affecting arterial stiffness, PSA remained significant determinant of PWVc-f values (R2 = 0.405, p<0.001), while hsCRP was non-significant (p = 0.09). Conclusions: The present study points to an association of PSA levels to aortic stiffness in untreated essential hypertensive males. Potential causal relationships between PSA and arterial stiffness remain to be further explored.

NIGHT-TIME HYPERTENSION AND TARGET ORGAN DAMAGE IN NEVER TREATED PATIENTS: PP.3.111

Objective: Essential hypertensive patients with non-dipping blood pressure profile are at higher risk of cardiac and all-cause mortality. Several studies involving subjects with uncomplicated essential hypertension have revealed an association between a non-dipper BP profile and an increased risk of target organ damage (TOD). The purpose of the present study was to assess possible differences in TOD status of patients presenting with isolated nocturnal hypertension (INO), isolated daytime hypertension (IDH) and day-night hypertension (DNH). Design and Methods: The study comprised 1045 essential, non-diabetic, hypertensive patients who refereed to our outpatient clinic for BP management. Patients underwent full clinical, anthropometric, laboratory and echocardiographic evaluation, while BP was assessed by a 24 h ambulatory blood pressure monitoring (ABPM). Furthermore, in all patients the levels of C-reactive protein (hsCRP) were measured and arterial stiffness was assessed by pulse wave velocity (PWV) using the Complior device. Finally, all patients underwent a 24-h urine collection and microalbumin levels were measured. Results: Based on ABPM results patients were divided in three groups: group I, INO, (n = 192), group II IDH (n = 109) and group III DNH (n = 744). Microalbumin(>20 mg/dl) and LV mass index were mostly present in patients with DNH in comparison to patients with IDH and INO [(30.3 vs 22.9 vs 18.7%, p = 0.003), (37.3 vs 15.6 vs 16.6%, p < 0.001). PWV (>8m/s) and CRP (>1.2 mg/L) were higher in DNH than in IDH and INO [(42.7 vs 33.9 vs 23.4%, p < 0.001), (46.6 vs 42.2 vs 33.8%, p = 0.006). In multivariate analysis, patients with INO in comparison to DNH had lower possibility to present with high microalbuminuria [OR = 0.58, p = 0.009, 95%CI], LV hypertrophy [OR = 0.30, p < 0.0001, 95% CI], elevated hsCRP [OR = 0.66, p = 0.018, 95%CI], and high PWV [OR = 0.52, p = 0.001, 95%CI]. Conclusions: The present study points to the burden posed by day-night BP in TOD in essential hypertensive patients, which is clearly higher than that of isolated nocturnal and daytime hypertension.