Elisabetta Benetti

Premenopausal Women Have Increased Risk of Hypertensive Target Organ Damage Compared with Men of Similar Age

BACKGROUND The impact of high blood pressure (BP) on target organs (TO) in premenopausal women is not well known. The purpose of this study was to describe gender differences in TO involvement in a cohort of young-to-middle-aged subjects screened for stage 1 hypertension and followed for 8.2 years. METHODS Participants were 175 women and 451 men with similar age (range 18-45 years). Ambulatory BP at entry was 127.5±12.5/83.7±7.2 mm Hg in women and 131.9±10.3/81.0±7.9 mm Hg in men. Ambulatory BP, albumin excretion rate (AER), and echocardiographic data (n=489) were obtained at entry, every 5 years, and before starting antihypertensive treatment. RESULTS Female gender was an independent predictor of final AER (p=0.01) and left ventricular mass index (LVMI) (p<0.001). At follow-up end, both microalbuminuria (13.7% vs. 6.2%, p=0.002) and left ventricular hypertrophy (LVH) (26.4% vs. 8.8%, p<0.0001) were more common among women than men. In a multivariable Cox analysis, after adjusting for age, lifestyle factors, body mass, ambulatory BP, heart rate, and parental hypertension, female gender was a significant predictor of time to development of microalbuminuria (p=0.002), with a hazard ratio (HR) of 3.06, (95% confidence interval [CI] 1.48-6.34) and of LVH (p=0.004), with an HR of 2.50 (1.33-4.70). Inclusion of systolic and diastolic BP changes over time in the models only marginally affected these associations, with HRs of 3.13 (1.50-6.55) and 3.43 (1.75-6.70), respectively. CONCLUSIONS These data indicate that premenopausal women have an increased risk of hypertensive TO damage (TOD) and raise the question about whether early antihypertensive treatment should be considered in these patients.

Isolated systolic hypertension of young-to-middle-age individuals implies a relatively low risk of developing hypertension needing treatment when central blood pressure is low.

Objectives The clinical significance of isolated systolic hypertension (ISH) in the young is still controversial. Aim of the present study was to investigate whether prognosis of ISH in young-to-middle-age individuals differs according to central blood pressure (BP). Design We studied 354 participants screened for stage 1 hypertension and 34 normotensive controls to determine which individuals developed hypertension needing drug therapy. Among the hypertensive patients, 67 had ISH and were divided according to whether their central SBP, measured with applanation tonometry, was above (ISH-high) or below (ISH-low) the median (120.5 mmHg). Large artery (C1) and small artery (C2) compliance were also measured. Results Compared to normotensive individuals, ISH-high had decreased C1 (P = 0.02) and C2 (P = 0.01), and higher peripheral resistance (P = 0.01). In contrast, in ISH-low, all these variables were similar to those in normotensive individuals. During 9.5 years of follow-up, incident hypertension was more common among participants with systolic-diastolic hypertension (SDH) and ISH-high than the other two groups [odds ratio (OR) = 6.2, 95% confidence interval (CI) = 1.8–21.1, P = 0.003 for SDH; OR = 6.0, 95% CI = 1.5–24.0, P = 0.01 for ISH-high, versus normotensive individuals]. Among ISH-low, incidence of hypertension was only slightly higher than that in normotensive individuals (OR = 1.1, 95% CI 0.2–5.3, P = 0.90) and lower than that in ISH-high (P = 0.03). These associations remained significant when ambulatory BP was included in the models or when the 125 mmHg cut-off for central BP was used to identify ISH subgroups. Conclusion These data show that young-to-middle-age ISH individuals with low central BP have a lower risk of hypertension needing treatment than those with high central BP. These results are applicable mainly to male individuals.

Accuracy of a single rigid conical cuff with standard-size bladder coupled to an automatic oscillometric device over a wide range of arm circumferences

Although the upper arm has the shape of a truncated cone, cylindrical cuffs and bladders are currently used for blood pressure (BP) measurement. The aims of this study were to describe upper arm characteristics and to test the accuracy of a standard adult-size conical cuff coupled to an oscillometric device over a wide range of arm circumferences. Arm characteristics were studied in 142 subjects with arm circumferences ranging from 22 to 45 cm (study 1). In a subset of 33 subjects with the same range of arm circumferences, a rigid conical cuff with standard-size bladder (12.6 × 24.0 cm) and a rigid cylindrical cuff (13.3 × 24.0 cm), both coupled to a Microlife BP A100 device, were tested according to the requirements of the protocol of the European Society of Hypertension (ESH; study 2). Study 1. In all subjects, upper-arm shape was tronco-conical with slant angles ranging from 89.5° to 82.2°. In a multiple linear regression analysis, only arm circumference was an independent predictor of conicity (P<0.001). Study 2. The rigid conical cuff passed all three phases of the ESH protocol for systolic and diastolic BPs. Mean device-observer BP differences obtained with the conical cuff were unrelated to arm circumference. When the rigid cylindrical cuff was used, ESH criteria were not satisfied, and the cuff overestimated systolic BPs in subjects with large arms. BP can be measured accurately with the use of a standard-size rigid conical cuff coupled to a BP A100 device for a wide range of arm circumferences.

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.

Cystatin C as predictor of microalbuminuria in the early stage of hypertension.

Background/Aims: Predictors of microalbuminuria in the early stage of hypertension are not well known. We did a prospective study to investigate whether glomerular hyperfiltration assessed from serum cystatin C predicts development of microalbuminuria in hypertension. Methods: We assessed 101 treatment-naive subjects screened for stage 1 hypertension and followed-up for a median 3.1 years. Cystatin C was measured at entry and glomerular filtration rate was estimated using the Hoek formula (CystGFR). Urinary albumin and ambulatory blood pressure were measured at entry and during the follow-up. Results: Subjects in the top CystGFR tertile (>115 ml/min/1.73m2) were leaner (p = 0.002) and developed microalbuminuria more frequently (p = 0.02) than the rest of the group. In univariate Cox regression, CystGFR was associated with future microalbuminuria (hazard ratio, 1.06, 95% confidence interval (CI), 1.02–1.10, p = 0.001). After controlling for baseline albumin excretion rate and several confounders, CystGFR remained a significant predictor of microalbuminuria development (hazard ratio, 1.19, 95% CI, 1.03–1.37, p = 0.019). The association between future microalbuminuria and creatinine clearance or glomerular filtration rate estimated with the Cockroft-Gault or the Modification of Diet in Renal Disease formula did not attain the level of statistical significance in this sample. Conclusions: The present findings indicate that CystGFR is more sensitive than creatinine clearance or estimated glomerular filtration rate for predicting microalbuminuria development in the early stage of hypertension and confirm that hyperfiltration precedes microalbuminuria in this clinical entity.

Accuracy of Microlife WatchBP Office ABI monitor assessed according to the 2002 European Society of Hypertension protocol and the British Hypertension Society protocol.

ObjectiveTo determine the accuracy of the WatchBP Office ABI monitor for blood pressure measurement developed by the Microlife Company. MethodsThe device accuracy was tested in 85 subjects with a mean age of 54±19 years. Their systolic and diastolic blood pressure (SBP/DBP) at entry was 141±30/86±19 mmHg, and upper arm circumference was 28±5 cm. Initially, the data from 33 participants were examined according to the 2002 version of the European Society of Hypertension (ESH) protocol. An additional 52 subjects were then enrolled to fulfill the requirements of the British Hypertension Society (BHS) protocol. In all participants, sequential same arm measurements were performed by two trained observers. ResultsThe device passed all three phases of the ESH protocol for SBP and DBP. For the BHS protocol the device was graded A for both SBP and DBP. The A/A grade was achieved in the low blood pressure category (<130/80 mmHg), the B/A grade in the medium category (130–160/80-100 mmHg) and the A/A grade in the high category (>160/100 mmHg). Mean blood pressure difference between device and observers in the first 33 subjects was −0.9±5.5 mmHg for SBP and −2.2±4.5 mmHg for DBP and in the 85 participants it was −1.2±6.5 mmHg and −2.3±5.1, respectively. ConclusionThese data show that the Microlife WatchBP Office ABI monitor satisfied the recommended ESH accuracy levels and achieved A/A grade of the BHS protocol across a wide range of BP.

BP reactivity to public speaking in stage 1 hypertension: Influence of different task scenarios.

Abstract Aim. To investigate the blood pressure (BP) reaction to public speaking performed according to different emotionally distressing scenarios in stage 1 hypertension. Methods. We assessed 64 hypertensive and 30 normotensive subjects. They performed three speech tasks with neutral, anger and anxiety scenarios. BP was assessed with the Finometer beat-to-beat non-invasive recording system throughout the test procedure. Results. For all types of speech, the systolic BP response was greater in the hypertensive than the normotensive subjects (all p < 0.001). At repeated-measures analysis of covariate (R-M ANCOVA), a significant group-by-time interaction was found for all scenarios (p ≤ 0.001). For the diastolic BP response, the between-group difference was significant for the task with anxiety scenario (p < 0.05). At R-M ANCOVA, a group-by-time interaction of borderline statistical significance was found for the speech with anxiety content (p = 0.053) but not for the speeches with neutral or anger content. Within the hypertensive group, the diastolic BP increments during the speeches with anxiety and anger scenarios were greater than those during the speech with neutral scenario (both p < 0.001). Conclusions. These data indicate that reactivity to public speaking is increased in stage 1 hypertension. A speech with anxiety or anger scenario elicits a greater diastolic BP reaction than tasks with neutral content.

Accuracy of the Microlife large–extra large-sized cuff (32–52 cm) coupled to an automatic oscillometric device

To determine the accuracy of the large–extra large-sized (L–XL) cuff (32–52 cm) coupled to a Microlife WatchBP Office ABI blood pressure measuring device tested according to the requirements of the International Protocol of the European Society of Hypertension. The L–XL cuff tested in this study is designed to provide accurate blood pressure measurements in patients with large arms (arm circumference≥32 cm) over a wide range of arm circumferences using a single 145±1×320±1 mm bladder. The evaluation was made in 33 patients with a mean±standard deviation age of 53±17 years (range: 30–96 years). Their systolic blood pressure (SBP) was 142±21 mmHg (range: 110–180 mmHg), diastolic blood pressure (DBP) was 87±14 mmHg (range: 62–106 mmHg) and arm circumference was 36±5 cm (range: 32–50 cm). Blood pressure measurements were made in the sitting position. The L–XL cuff coupled to the WatchBP Office ABI passed all three phases of the European Society of Hypertension protocol for SBP and DBP. Mean blood pressure differences between device and observer were −1.3±5.1 mmHg for SBP and −1.8±5.8 mmHg for DBP. Similar device–observer differences were observed in patients divided into two subgroups according to whether their arm circumference was above or below the median in the group. These results indicate that the L–XL cuff coupled to the WatchBP Office ABI monitor provides accurate blood pressure readings in patients with large arms over a wide range of arm circumferences.

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.

Does home blood pressure allow for a better assessment of the white-coat effect than ambulatory blood pressure?

Background: The difference between clinic and ambulatory blood pressure (BP) is a poor estimate of the true white-coat effect (WCE) measured with beat-to-beat recording. Method: We investigated whether the difference between clinic and home BP (home WCE) was a better estimate of true WCE than ambulatory WCE. In 73 young hypertensives, ambulatory WCE was calculated as the difference between clinic BP and the mean of two 24-h BP recordings, and home WCE as the difference between clinic and home BP (HBP) measured over 6 months. All individuals underwent beat-to-beat BP monitoring with the Finometer. During the recording, a white-coat test (true WCE) and a public speaking test were performed. Results: Ambulatory WCE correlated with home WCE (P < 0.001 for systolic and diastolic BPs). However, both surrogate WCEs were unrelated to true WCE (P = 0.93/0.36 and P = 0.11/0.36, respectively). True WCE correlated with the BP reaction to public speaking (P < 0.001/P < 0.001), whereas both surrogate WCEs were unrelated to the BP response to this test (all P > 0.21). Individuals were divided into two groups according to whether BP response to the doctors visit was above (WCH+) or below (WCH−) the median. WCH+ patients had similar clinic and ambulatory BPs to WCH− but showed a higher BP response to public speaking. Conclusion: As previously observed for ambulatory WCE, home WCE does not reflect the true BP reaction to doctors visit. BP response to psychosocial stressors is increased in individuals with hyperreactivity to doctors measurement but not in individuals with white-coat hypertension identified with either ambulatory or HBP measurement.