Eugenia Marchesi

Cardiovascular autonomic modulation in essential hypertension. Effect of tilting.

To better understand the role played by the autonomic nervous system in essential hypertension, we used autoregressive power spectrum analysis to study the noncasual oscillations in RR interval, blood pressure, and skin blood flow in 40 subjects with mild to moderate hypertension and in 25 age-matched control subjects at low frequency (index of sympathetic activity to the heart and the peripheral circulation) and high frequency, respiratory related (index of vagal tone to the heart). RR interval, respiration, noninvasive systolic blood pressure, and skin arteriolar blood flow were simultaneously and continuously recorded with subjects in the supine position and immediately after tilting. The low-frequency component was not significantly different in the two groups either at the cardiac level (control versus hypertensive subjects: 39.1 +/- 4.3 versus 39.9 +/- 3.7 normalized units [NU]) or at the vascular level (1.52 +/- 0.17 versus 1.69 +/- 0.13 ln mm Hg2). After head-up tilting, the RR interval fluctuations were less in hypertensive subjects (low-frequency components from 39.9 +/- 3.7 to 48.4 +/- 4.1 NU, P < .05; high-frequency components from 53.9 +/- 3.7 to 44 +/- 4 NU, P < .05) than in control subjects (low-frequency components from 39.1 +/- 4.3 to 64.4 +/- 4.9 NU, P < .001; high-frequency components from 56.0 +/- 4.5 to 31.2 +/- 4.6 NU, P < .001); the low-frequency components in systolic blood pressure increased similarly in hypertensive subjects (to 2.43 +/- 0.17 ln mm Hg2, P < .0001) and in control subjects (to 2.44 +/- 0.21 ln mm Hg2, P < .01), but the low-frequency components in skin blood flow increased only in control subjects (from 5.34 +/- 0.45 to 6.55 +/- 0.53 mm Hg2, P < .01), not in hypertensive subjects (from 5.55 +/- 0.34 to 5.60 +/- 0.35 ln mm Hg2). In hypertensive subjects with left ventricular hypertrophy, the low-frequency components in systolic blood pressure did not increase after tilting (from 1.75 +/- 0.33 to 2.05 +/- 0.41 ln mm Hg2). Baroreflex sensitivity, as assessed by spectrum analysis, was significantly lower in hypertensive than in control subjects (5.17 +/- 0.49 versus 13.18 +/- 2.44 ms/mm Hg, P < .001. Power spectrum analysis did not reveal an increased sympathetic activity or reactivity either at the cardiac or at the vascular level. The decreased baroreceptor sensitivity in hypertensive subjects could explain the reduced change in sympathovagal balance in the tilt position at the cardiac level. In hypertensive subjects without left ventricular hypertrophy, cardiopulmonary reflex deactivation induced by tilting and/or amplification of sympathetic nervous tone by arteriolar structural change could have preserved the sympathetic activation at the vascular level.

Effect of enalapril on left ventricular mass and performance in essential hypertension

The effect of enalapril on left ventricular (LV) morphology and function was studied in 12 hypertensive patients. The subjects were evaluated after 2 weeks of placebo and after 4 months of treatment with enalapril (20 or 40 mg once daily), using M-mode digitized echocardiograms. The drug reduced arterial blood pressure in all patients. Systemic vascular resistance decreased significantly without changes in cardiac output and heart rate. No patient had significant side effects. After treatment LV mass decreased significantly (233 +/- 46 to 204 +/- 37 g, p less than 0.01); the reduction was due to a decrease in septal and posterior wall thickness, without changes in LV diameter. LV systolic function remained unchanged, whereas peak lengthening rate of LV dimension, an index of LV diastolic function, increased significantly (4.05 +/- 1.8 to 5.11 +/- 1.8 s-1, p less than 0.01). After treatment the basal inverse correlation between peak shortening rate and wall stress did not change, the inverse correlation between peak lengthening rate and wall stress became closer and the basal inverse correlation between peak lengthening rate and LV mass disappeared. In conclusion, antihypertensive treatment with enalapril led to a significant regression of LV hypertrophy associated with improvement in LV diastolic performance and no deterioration of LV systolic function.

Plasminogen activator inhibitor-1 and carotid intima-media thickening in patients with newly detected primary hypertension.

Objective To investigate the correlation between ultrasonographically evaluated intima-media thickness (IMT) of common carotid artery (CCA) and cardiovascular risk factors for subjects with newly detected, uncomplicated and untreated primary hypertension. Methods The study population consisted of 200 subjects (123 men and 77 women, aged 46±7.5 years). Blood pressure was measured in the clinical setting and by 24 h noninvasive ambulatory monitoring. Fasting levels of blood glucose, plasma lipids and lipoproteins, fibrinogen and plasminogen activator inhibitor (PAI)-1 were measured. Ultrasound examination included measurement of far-wall intima-media complex of CCA and morphologic evaluation of occurrence of plaques in carotid and femoral bifurcations. Results The prevalence of greater than normal IMT (mean IMT ≥ 0.80 mm) was 22%. Significant univariate correlations to the dichotomy between normal and greater than normal mean IMT were detected for age, smoking, level of LDL cholesterol, level of PAI-1 and total ultrasonographic score. Multivariate logistic regression analysis confirmed the associations between greater than normal mean IMT and plasma concentrations of LDL cholesterol and PAI-1 as well as total ultrasonographic score. Conclusion Greater than normal IMT of CCA was more strictly related to other cardiovascular risk factors than it was to blood pressure and was strongly associated with the occurrence of atherosclerotic plaques in carotid and femoral arteries. The role of PAI-1 in intima-media thickening that is emerging suggests that fibrinolytic balance is an important determinant of vessel-wall homeostasis in hypertensive patients.

Metabolic effects of the combination of captopril and hydrochlorothiazide in hypertensive subjects

The medium‐term (16 weeks) effects of the combination of captopril and hydrochlorothiazide (HCTZ) on some metabolic indexes, particularly on plasma lipoproteins, were evaluated in 20 mild to moderate hypertensive outpatients.

Caso clinico: cuore d’atleta o cardiopatia?

Cardiomyopathies represent a heterogeneous group of diseases, with significant mortality, which often lead to progressive heart failure. Cardiomyopathies may be primary (hypertrophic cardiomyopathy or infiltrative cardiomyopathies) or secondary (for example: hypertension or athletic heart syndrome). The athlete’s heart is a condition in which a systematic training in a person determines physiological adaptation of heart, generally represented by a benign increase of cardiac mass with specific alteration of heart morphology. There are two types of exercise: endurance-training requires oxygen for performance and it leads to a reduction of systemic arterial resistance and an increased of the cardiac output; strength-training is mostly anaerobic, meaning that the body does not require oxygen for performance and it increases peripheral resistance. Both endurance-training and strength-training lead to alterations of the left ventricle: scientific studies show that when athletes stop training, the heart returns normal. We describe a case of a black man of 31 years old with left ventricular hypertrophy.

Acido urico e rischio cardiovascolare

Un legame fra iperuricemia e disordini cardiovascolari e stato ipotizzato da decenni. Non e mai stato chiarito comunque se l’acido urico (AU) rappresenti solo un marcatore di rischio o sia un vero fattore di rischio. Questo studio si e proposto di verificare, in soggetti ipertesi di prima diagnosi, l’esistenza di una correlazione tra uricemia e parametri classici di rischio cardiovascolare (RCV) nonche tra uricemia e presenza di danno d’organo subclinico, sia cardiaco che renale. Sono stati arruolati 534 soggetti (166 donne e 368 uomini, eta media 47 anni) affetti da ipertensione arteriosa primaria, esenti da complicanze. La prevalenza di soggetti iperuricemici e risultata del 15 %. Indice di massa corporea (BMI) e circonferenza addominale (CA) sono significativamente piu elevati nei soggetti appartenenti al terzo rispetto al primo terzile di distribuzione di AU (p<0.001), cosi come gli score di RCV (Framingham e progetto cuore italiano), nonche glicemia (p<0.001), trigliceridemia (p<0.001), omocisteinemia (p<0.001), mentre i valori di C-HDL sono significativamente inferiori (p<0.001). L’uricemia e risultata significativamente piu elevata nei soggetti con sindrome metabolica (SM) (p<0.001). Alla analisi multivariata i parametri della SM si correlano in modo indipendente con l’uricemia nel sesso maschile, mentre nel sesso femminile l’uricemia si correla significativamente solo con la CA elevata. I soggetti con ipertrofia ventricolare sinistra, rispetto a quelli senza, presentano valori di uricemia significativamente piu elevati (p<0.01) cosi come quelli con microalbuminuria (p=0.01). I risultati ottenuti confermano l’utilita clinica della determinazione dell’uricemia nell’inquadramento del rischio cardiometabolico in pazienti ipertesi di prima diagnosi, in particolare nell’ottica di identificare i soggetti a maggior rischio di sviluppare danno d’organo.

Sindrome metabolica e rischio cardiovascolare in soggetti ipertesi: differenze tra maschi e femmine

Nell’ambito di una popolazione di soggetti ipertesi di prima diagnosi, senza comorbidita, senza danni d’organo clinicamente manifesti, mai trattati in precedenza, abbiamo valutato le differenze fra i soggetti di sesso femminile e quelli di sesso maschile per quanto riguarda il livello di rischio cardiovascolare globale e la presenza di sindrome metabolica (SM) definita secondo i criteri ATP III, allo scopo di evidenziare quali sono i principali parametri di rischio che distinguono i due sessi. I 523 soggetti, 165 di sesso femminile e 358 di sesso maschile, sono stati sottoposti a: anamnesi, rilevazione dei principali indici antropometrici, misurazione della pressione arteriosa (PA) sia clinica che monitorata, dosaggio ematico dei principali parametri metabolici, dosaggio della microalbuminuria, calcolo dello score di rischio cardiovascolare utilizzando lo score di Framingham e quello della carta del rischio italiana. Sono state ottenute statistiche descrittive per tutte le variabili. Media e deviazione standard sono state usate per le variabili quantitative, mentre per le variabili qualitative sono stati utilizzati conteggi e percentuali. Le differenze di genere sono state analizzate utilizzando modelli uni- e multivariati di regressione logistica condizionale. La percentuale di soggetti affetti da SM e analoga nei 2 sessi (M 25%, F 24%), mentre diversa risulta la distribuzione dei parametri diagnostici per la SM tra i maschi e le femmine. Infatti piu maschi presentano alti valori di trigliceridemia e glicemia, mentre piu donne, in modo statisticamente significativo, presentano circonferenza addominale (CA) elevata. Analizzando la correlazione fra lo score di rischio ed alcuni dei parametri esaminati ma che non rientrano nel computo dello score, si evidenzia una differenza fra maschi e femmine per quanto riguarda trigliceridemia, CA e BMI: per queste variabili il coefficiente di correlazione con lo score di Framingham risulta statisticamente significativo nelle femmine ma non nei maschi (rispettivamente Tg r=0.524, BMI r=0.276, CA r=0.274 nelle femmine). Le donne, anche se aventi un livello di rischio CV globale inferiore rispetto agli uomini coetanei, sembrano piu sensibili al rischio derivato dall’obesita viscerale e dalla ipertrigliceridemia. Nella donna ipertesa alcuni parametri che caratterizzano la SM quali l’obesita viscerale e la ipertrigliceridemia possono rivestire un ruolo particolarmente importante nel determinismo del rischio cardiovascolare e particolare attenzione richiedono quindi il controllo del peso corporeo ed il livello di attivita fisica.

Impatto della sindrome metabolica sul danno d’organo subclinico nella donna ipertesa

Nel nostro studio abbiamo confrontato, in soggetti ipertesi di prima diagnosi, il diverso impatto, nei due sessi, della presenza di Sindrome Metabolica (SM) sulle alterazioni ecocardiografiche del ventricolo sinistro (VS) come espressione di danno d’organo subclinico. In 354 ipertesi di prima diagnosi (108 di sesso femminile e 246 di sesso maschile), mai trattati, abbiamo riscontrato uguale prevalenza di SM tra i due sessi, ma diversa prevalenza dei singoli fattori: glicemia e trigliceridi sono piu frequentemente elevati negli uomini, mentre la circonferenza addominale (CA) e piu frequentemente elevata nelle donne. Dal confronto fra donne e uomini senza SM emerge che i maschi, a parita di eta, hanno glicemia (p=0.001), uricemia (p=0.001) e creatininemia (p=0.001) piu elevati, invece valori di pressione arteriosa (PA) sostanzialmente sovrapponibili. Confrontando donne e uomini, entrambi con SM, emergono nei maschi valori piu elevati di PA diastolica (p<0.001), di uricemia (p=0.001) e di creatininemia (p=0.001). Soggetti con SM, sia maschi che femmine, non presentano parametri ecocardiografici diversi da quelli senza SM. La presenza di ipertrofia ventricolare sinistra (IVS) si correla significativamente in modo lineare con l’eta e la glicemia nelle donne e con i valori di pressione arteriosa negli uomini. La regressione logistica multivariata fra parametri della Sindrome Metabolica e presenza di Ipertrofia Ventricolare sinistra, rispettivamente nel gruppo dei maschi e nel gruppo delle femmine, evidenzia come il parametro che mantiene significativita statistica nell’analisi, e il valore della pressione sistolica (p=0.001 nei maschi, p=0.05 nelle femmine). In conclusione, non emerge dal nostro studio un’influenza esercitata dalla presenza di SM sulle caratteristiche ecocardiografiche del VS ed in particolare non emerge un maggior impatto prognostico negativo della presenza di SM nel sesso femminile rispetto a quello maschile.

Rilevanza di alcuni parametri metabolici nella stratificazione del rischio cardiovascolare nel paziente iperteso. Gamma-glutamiltransferasi: nuova visione di un vecchio enzima

Very high serum levels of GGT represented a proved index of alcohol hepatotoxicity and hepatosteatosis. However still in normal range GGT was found as an independent marker of metabolic syndrome and an important predictor of cardiovascular disease. In our study was enrolled 339 subject, 94 female 245 male, affected by hypertension never treated, without diabetes or cardiovasculare desease. We evaluated anthropometric parameters, ECG, venous sample, cardiac ultrasound, EBPM of each subject, and we had also calculated the Framingham score. Our study confirmed the correlation of serum level of GGT with metabolic syndrome makers; moreover we found a correlation between serum level of GGT and markers of subclinical organ damage as left hypertrophy ventricular, suggesting that increased serum levels of GGT, still in range of normality, may constitute a early and sensitive marker of cardiovasculare desease.

Il contributo di criteri elettrocardiografici alla diagnosi differenziale fra cardiopatia ipertensiva ed amiloidosi cardiaca

Hypertensive heart disease and cardiac amyloidosis are similar for the increasing of left ventricular mass (LVM) but differ from electrocardiographic aspects. Although in amyloidosis it was observed an increased wall thick-ness, ECG doesn’t show any left ventricular hypertrophy (LVH) signs, in particular high QRS voltages. Low spread voltages are often detected, especially in inferior leads due to the composition of electrically inert mate-rial of amyloid fibrils. In patients with hypertension, although rarely, reversion to normal values of pressure, not associated with LVM regression detected by ECG can be sometimes a symptom of cardiac amyloidosis onset. The aim of our study relies on a comparison between a group of 176 first diagnosed patients with hypertension and 137 patients with AL amyloidosis and cardiac involvement. Furthermore, we evaluate the usefulness of simple electrocardiographic criteria (Sokolow-Lyon, peripheral leads QRS score Cornell criteria) by themselves or index linked for LVM, integrated with ecocardiographic data, in order to achieve an earlier identification of a rare disease such as cardiac amyloidosis. Four considered parameters compared through ROC curves have been found useful to discriminate between LVH and cardiac amyloidosis. The less accurate parameter is Cornell criteria related to voltage and voltage- duration (AUC: 0.613 e 0.743; criterion: > 11 e <4.943; sensibility: 45.16% e 55.7%; specificity: 75% e 89.4%, p<0.001). Relating to Sokolow-Lyon criteria we found: AUC of 0.809; criterion <0.0615, sensibility of 74.04%, specificity of 80%, p<0.001; the peripheral QRS score index linked to MVS has been the most accurate diagnos-tic measure (AUC 0.989). We identify a cut-off of 0.17 (sensibility 96% and specificity 97% p<0.001) , likely this value allows to identify patients with cardiac amyloidosis.