G. Schirosi

Effect of clustering of metabolic syndrome factors on capillary and cerebrovascular impairment

BACKGROUND Hypertension and metabolic disorders, attended by impaired microcirculation, represent major risk factors for cerebrovascular impairment, as well as being individual components of the metabolic syndrome (MetS). Aim of the study was to establish whether mild hypertensives, aged ≤65years, may be affected by progressive microvascular damage impairing cerebrovascular perfusion, related to a progressive clustering of MetS components. METHODS Twenty-two normotensives with no MetS component (NTN-0), 29 hypertensives with no (HTN-0), 30 with one (HTN-1), 29 with two (HTN-2), 27 with three (HTN-3), 25 with all four (HTN-4) MetS components, were recruited. The study required office and twenty-four hour ambulatory blood pressure monitoring and video capillaroscopy. Functional (fCD), anatomical (aCD) and recruited (RECR) phalangeal skin capillarity were assessed. Cerebral vasodilatory reserve was measured by the breath-holding index (BHI), using transcranial Doppler, in HTN-1 and HTN-2 with MetS. RESULTS The fCD and aCD were reduced in hypertensives and progressively reduced in those with MetS, while RECR was also impaired. BHI was lower in HTN-2 than in HTN-1 (p<0.001). BHI was correlated with fCD in HTN-1 (.396, p: .046), HNT-2 (.497, p: .011), and with aCD in HTN-2 (.494, p: .012), by partial Pearson test. DISCUSSION The findings show that hypertensives exhibit an increasing microvascular rarefaction with MetS progression and that an impaired cerebral perfusion occurs when the MetS is established. The data underline the importance of preventing MetS in mild hypertensives, as it causes microvascular damage and impairs cerebral arterial perfusion.

Impaired cognitive executive dysfunction in adult treated hypertensives with a confirmed diagnosis of poorly controlled blood pressure.

Background. High blood pressure (BP) poses a major risk for cognitive decline. Aim of the study was to highlight the relationship between cognitive assessment scores and an effective therapeutic BP control. Methods. By medical visit and ambulatory BP monitoring (ABPM), we studied 302 treated hypertensives, subdivided according to office/daytime BP values into 120 with good (GC) and 98 poor (PC) BP control, 40 with “white coat hypertension” (WCH) and 44 a “masked-hypertension” phenomenon (MH). Patients underwent neuropsychological assessment to evaluate global cognitive scores at the Mini Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) and attention/executive functions (Delayed Recall, Digit Span Forwards, Digit Span Backwards, Selective Attention, Verbal Fluency, Stroop Test and Clock Drawing). Carotid intima-media thickness (IMT) served as the index of vascular damage. Results. There were no differences among the groups in terms of gender, age, education, metabolic assessment, clinical history and hypertension treatment. GC presented lower office and ambulatory BP values and IMT. PC performed worse than GC on global executive and attention functions, especially executive functions. In PC, office systolic BP (SBP) was significantly associated to the MMSE and FAB scores and, in particular, to Verbal Fluency, Stroop Errors and Clock Drawing tests. Office diastolic BP (DBP) was associated to Selective attention, nocturnal SBP to Digit Span backwards and Verbal Fluency. Worse cognitive assessment scores were obtained in WCH than GC. Conclusions. The findings showed that in adult treated hypertensives, a poor BP control, as both doctors office and daytime scores, is associated to impaired global cognitive and especially executive/attention functions.

Stress-induced hemodynamic responses are associated with insulin resistance in mild hypertensives

BACKGROUND High blood pressure (BP) and pulse pressure (PP) are recognized as independent risk factors for cardiovascular diseases, whereas insulin resistance (IR) is often associated with hypertension. The purpose of the study was to verify whether PP, taken at the doctors office and during laboratory stimuli, might be predictive of IR. METHODS Homeostasis model assessment insulin resistance index (HOMA) was calculated in 75 grade 1 hypertensives (148 +/- 2/92 +/- 1 mm Hg). Then, patients underwent hemodynamic reactivity study, induced by color word stroop, cold pressor, and handgrip tests. Stress response was calculated as total area (value x time) - baseline area (baseline value x time). RESULTS Patients with similar age, history of hypertension, blood lipids and office blood pressure, but different HOMA (IR-low: 36.3 +/- 1.7 v IR-medium: 62.6 +/- 1.6, P <.001; IR-high: 123.1 +/- 12.8, P <.001 v IR-low and IR-medium), were divided in tertiles. They demonstrated a significant reactivity of systolic BP (IR-low: 225 +/- 58 v IR-medium: 448 +/- 43, P <.01; IR-high: 625 +/- 55, P <.001 v IR-low and P <.01 v IR-medium), PP (IR-low: -8 +/- 19 v IR-medium: 83 +/- 13, P <.001; IR-high: 201 +/- 19, P <.001 v IR-low and IR-medium), and stroke volume (SV) (IR-low: -138 +/- 43 v IR-medium: 1 +/- 27, P <.01; IR-high: 28 +/- 24, P <.001 v IR-low), but similar arterial stiffness (PP/SV) response. Partial correlation between IR and hemodynamic measurements showed a significant association only for systolic BP (0.54, P <.001), PP (0.686, P <.001), and SV (0.384, P <.001) reactivity, but not for office and baseline values. Stepwise multiple regression showed that only PP (beta: 0.634, P <.001) and, among hemodynamic determinants, SV (beta: 0.401, P <.001) response entered into the equation. CONCLUSIONS The findings demonstrate that increased stress-induced PP, maintained by SV response, is the most predictive hemodynamic variable of reduced insulin sensitivity in mild hypertensives.

A FAST AND SIMPLE NEW QUESTIONNAIRE TO HIGHLIGHT THE COGNITIVE IMPAIRMENT IN HYPERTENSIVES: THE ASSOCIATION WITH ARTERIAL STIFFNESS

Objective: The critical incidence of cognitive impairment in hypertensives leads into the need to adopt tools easy to use and able to precociously discern the neuropsychological deficit. Aim of the study was to verify, in relatively well-treated hypertensive patients, the discriminative ability of a brief questionnaire to discern the quality and the grade of a mild cognitive impairment and their association with the preclinical vascular damage. Design and method: Following a pilot study performed in healthy and hypertensive subjects, an 18-item (NPI) questionnaire, with a good internal coherency (alpha:0.87) and graded answers (never-very often: 1–4), exploring diverse neuropsychological abilities ascribable to different cerebral cortical areas, was administered to 375 grade1–2 hypertensives treated with ACEi or ARBs as monotherapy. In the patients, subdivided in tertiles, in order of the total score for cognitive impairment (CIStot), 196 with lower (LCIS), 120 with intermediate (ICIS) and 59 with higher (HCIS), but with similar education, metabolic assessment, history and hypertensive state (BPoff and ABPM), the preclinical vascular damage, structural as carotid intima-media thickness (IMT) and functional, as carotid-femoral pulse wave velocity (PWVcf), was determined. Results: Results. The analysis showed significant characteristics. (m ± s.d.; *:p < .05, **:p < .01, ***:p < .001 vs LCIS; °:p < .05, °°:p < .01, °°°:p < .001 vs ICIS) Figure. No caption available. In particular, psychophysical attitude (NPI1), brief-term memory (NPI3, NPI7) and problem solving (NPI6, NPI10) deficits are impaired in HCIS hypertensives. Pearson analysis pointed out the association between PWV and brief-term memory (.649***), and problem solving (.618**), attentive-cognitive functions under the control of frontal cortical areas. Conclusions: The findings show that between relatively well-treated hypertensives, the mild impairment of attentive-executive capabilities are associate with the arterial stiffness, before the onset of a preclinical structural vascular damage, as IMT, and are detectable by a new rapid and easy-to-use screening tool.

THE BLOOD PRESSURE MEASUREMENTS TAKEN BY BOTH DOCTORS AND NURSES IN THE SAME ENVIRONMENT: DIFFERENCES AND INFORMATION

Objective: Blood pressure (BP) surge during medical visit represents a phenomenon associated to vascular damage but little is known on implication of BP change measured by nurse and doctor in the same medical setting. Aim of the study was to discern the association of different indices of vascular damage and cognitive impairment with the different BP measures in hypertensives treated with ARBs or ACEi as monotherapy. Design and method: In the same day, hours (08.00–11.30 a.m.) and medical controlled environment, by the same sphygmomanmeter (Microlife Afib), 226 grade 1–2 hypertensives with similar age, education, metabolic and hypertensive state, were visited. After ambulatory blood pressure monitoring (day/night), they underwent to BP measurement by the nurse (lab) and the doctor (doc), general cognitive impairment (COGtot) by 18-items (NPI) and, by carotid intima-media thickness (IMT) and carotid-femoral pulse wave velocity (PWVcf), assessment of preclinical, structural and functional, vascular damage. Results : Patients, subdivided in tertiles by the SBPdoc-lab difference, reduced (R), intermediate (M) and elevated (E), showed significant differences (m ± s.d.; *:p < .05, **:p < .01, ***:p < .001 vs SBPdoc-labR; °:p < .05, °°:p < .01, °°°:p < .001 vs SBPdoc-labM). Figure. No caption available. SBPdoc-labE patients demonstrated a higher total cognitive deficit score, particularly, brief-term memory (NPI3) and phrontal cortex activity (NPI4, NPI5) impairment. Pearson analysis, adjusted for age and history of hypertension, showed the association between SBPdoc-lab and PWV (.193*), NPI3 (.148*) and COGtot (.137*). The BP surge during the medical examination, mostly due to the doctor visit, seems to be associated to the onset to functional preclinical vascular damage in patients with similar circadian profile. Conclusions: The findings showed that brief-term BP changes, ascertained in a controlled environment by standardized methods, particularly the changes ascribable to the “white-coat effect”, might be predictive of preclinical vascular damage and, then, of cardiovascular prognosis.

[PP.12.16] THE BLOOD PRESSURE TARGET, THE MACRO- AND MICRO-VASCULAR DAMAGE IN HYPERTENSIVES TREATED WITH INHIBITING RENIN-ANGIOTENSIN-SYSTEM AGENTS

Objective: Recent findings suggest that a lower therapeutic BP goals (<120/80 mmHg: HRBP) than those recommended by the actual guidelines (<140–135/85–90mmHg: GLBP) are associated to a more favorable cardiovascular prognosis. Aim of the study was to highlight the association between micro- and macro-vascular damage and BP values in adult hypertensives treated with ACEi or ARBs. Design and method: By medical visit (SBP/DBPoff), estimated history (HISThtn, months) and BP values at the diagnosis (HISTsbp/dbp), metabolic syndrome factors (nATPIII) and glomerular filtration rate (CKDepi), we studied 190 grade1–2 hypertensives, 55 HRBP, 92 GLBP and 43 with scarce BP control (SCBP) who underwent measurement of arterial stiffness (PWVcf), carotid intima-media thickness (IMT), preclinical indices, functional and structural, of arterial damage. Then, by videocapillaroscopy, the capillary density of the medial and distal phalanx of the 2nd, 3rd and 4th finger of the non-dominant hand at rest (CAP), venous congestion (CVC) and secondary capillary recruitment (REC), indices of structural and functional rarefaction, were determined. Results: ABPM confirmed the diagnosis. The study demonstrated similar metabolic characteristics but different vascular features (m ± s:d.*:p < .05, **:p < .01, ***:p < .001 vs HRBP; ^:p < .05,^^:p < .01, ^^^:p < .001 vs GLBP) Figure. No caption available. Pearson analysis showed that the therapeutic SBP values are associated to the microvascular damage (CAP:−192*; CVC:−268***; REC: −225**). Conclusions: The findings suggest that a scarce BP control is associated to preclinical macro- and micro-vascular damage. The macrovascular subclinical damage is restrained by a satisfactorily BP control but a lower therapeutic target seems to restrain the microvascular rarefaction, often misrecognized. The findings, if confirmed in further proper studies, might explain, at least in part, the improved cardiovascular prognosis in hypertensives with a more aggressive BP target.

7D.09: REDUCED VIT D AND ELEVATED URICEMIA INDUCE CAPILLARY RAREFACTION BEFORE MACROVASCULAR DAMAGE IN PATIENTS WITH METABOLIC SYNDROME AT THE VERY EARLY STAGES OF HYPERTENSION.

Objective: Reduced (L) Vit D (D) and high (H) uric acid (U) levels have been associate with increased cardiovascular risk. Aim of the study was to highlight their association with the subclinical vascular damage in untreated recently diagnosed very mild hypertensives with a similar number of metabolic syndrome factors (nATPIII). Design and method: By medical visit and identification of the metabolic syndrome factors, 238 very mild hypertensives (136 ± 15/84 ± 9 mmHg), 62 controls with normal (N) D and U, 96 with LD, 40 with HU and 40 with both the conditions (LDHU) with similar metabolic assessment, underwent measures of carotid-femoral pulse wave velocity (PWV), ankle-brachial index (ABI), carotid intima-media thickness (IMT), as indices of functional and structural arterial damage, and videocapillaroscopy of the middle and distal phalangeal skin of the 2nd, 3rd and 4th finger of the non-dominant hand during baseline (CAP) and venous congestion (CVC) obtaining capillary recruitment (REC) as indices of functional and structural microcirculatory damage. Results: Patients showed a similar hypertensive state during the medical visit and ABPM but different capillary indices. (m ± s:d.*:p<.05, **:p < .01, ***:p < .001 vs NDNU; °:p < .05, °°:p < .01, °°°:p < .001 vs LDNU;^p < .05, ^^:p < .01, ^^^:p < .001 vs NDHU). Figure. No caption available. Pearson analysis showed the association between Vit D and CVC (.440*) and REC (.335***) in LDNU and with CVC (631***) and REC (.666*) in LDHU as well as between U and CAP (-.470*) in NDHU and (-606*) in LDHU. Conclusions: The results suggest that, in very mild hypertensives with metabolic syndrome, reduced Vit D is associate to structural microvascular damage before the onset of structural or functional macrovascular impairment. Hyperuricemia show a lower microcirculatory damage but this is amplified in patients with both the disorders (LDHU),