Giuseppe Mancia

1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization.

The present Guidelines were prepared by the Guidelines Sub-Committee of the World Health Organization-International Society of Hypertension (WHO-ISH) Mild Hypertension Liaison Committee, the members of which are listed at the end of the text. These guidelines represent the fourth revision of the WHO-ISH Guidelines and were finalised after presentation and discussion at the 7th WHO-ISH Meeting on Hypertension, Fukuoka, Japan, 29th Sept-1st Oct, 1998. Previous versions of the Guidelines were published in Bull WHO 1993, 71:503-517 and J Hypertens 1993, 11:905-918.

Feasibility of ambulatory, continuous 24-hour finger arterial pressure recording.

We tested Portapres, an innovative portable, battery-operated device for the continuous, noninvasive, 24-hour ambulatory measurement of blood pressure in the finger. Portapres is based on Finapres, a stationary device for the measurement of finger arterial pressure. Systems were added to record signals on tape, to alternate measurements between fingers automatically each 30 minutes, and to correct for the hydrostatic height of the hand. We compared the pressure as measured by Portapres with contralateral intrabrachial pressure measured with an Oxford device. Results were obtained in eight volunteers and 16 hypertensive patients. Time lost due to artifact was about 10% for each device. In two patients a full 24-hour Oxford profile was not obtained. In the remaining 22 subjects finger systolic, diastolic, and mean pressures differed +1 (SD 9), -8 (6), and -10 (6) mm Hg, respectively, from intrabrachial pressure. These diastolic and mean pressure underestimations are similar to what was found earlier for Finapres, are typical for the technique, and are systematic. Avoiding brisk hand movements resulted in fewer waveform artifacts. The hand had to be kept covered to continue recording at low outside temperatures. Sleep was not disturbed by Portapres, and arterial pressure showed a marked fall during siesta and nighttime. There were no major limitations in behavior, and no discomfort that originated from continuous monitoring was reported. Measurements continued normally during physical exercise. Portapres provides for the first time continuous 24-hour, noninvasive ambulatory blood pressure waveform monitoring and offers real and obvious advantages over current noninvasive and invasive devices.

Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial

Aims/hypothesisThe relationship between cognitive function, cardiovascular disease and premature death is not well established in patients with type 2 diabetes. We assessed the effects of cognitive function in 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Furthermore, we tested whether level of cognitive function altered the beneficial effects of the BP-lowering and glycaemic-control regimens in the trial.MethodsCognitive function was assessed using the Mini Mental State Examination at baseline, and defined by scores 28-30 (‘normal’, nu2009=u20098,689), 24-27 (‘mild dysfunction’, nu2009=u20092,231) and <24 (‘severe dysfunction’, nu2009=u2009212). Risks of major cardiovascular events, death and hypoglycaemia and interactions with treatment were assessed using Cox proportional hazards analysis.ResultsRelative to normal function, both mild and severe cognitive dysfunction significantly increased the multiple-adjusted risks of major cardiovascular events (HR 1.27, 95% CI 1.11–1.46 and 1.42, 95% CI 1.01–1.99; both pu2009<u20090.05), cardiovascular death (1.41, 95% CI 1.16–1.71 and 1.56, 95% CI 0.99–2.46; both pu2009≤u20090.05) and all-cause death (1.33, 95% CI 1.16–1.54 and 1.50, 95% CI 1.06–2.12; both pu2009<u20090.03). Severe, but not mild, cognitive dysfunction increased the risk of severe hypoglycaemia (HR 2.10, 95% CI 1.14–3.87; pu2009=u20090.018). There was no evidence of heterogeneity of treatment effects on cardiovascular outcomes in subgroups defined by cognitive function at baseline.Conclusions/interpretationCognitive dysfunction is an independent predictor of clinical outcomes in patients with type 2 diabetes, but does not modify the effects of BP lowering or glucose control on the risks of major cardiovascular events.Trial registration:ClinicalTrials.gov NCT00145925Funding:Supported by grants from Servier and from the National Health and Medical Research Council of Australia.

Blood pressure monitoring: theory and practice. European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability Teaching Course Proceedings

The European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring and Cardiovascular Variability organized a Teaching Course on Blood Pressure Monitoring: Theory and Practice during the 2017 ESH Meeting in Milan, Italy. This course performed by 11 international BP monitoring experts covered key topics of BP monitoring, including office BP measurement, ambulatory BP monitoring, home BP monitoring, ambulatory versus home BP, white-coat and masked hypertension, cuff use, and BP variability. This article presents a summary of the proceedings of the ESH BP Monitoring Teaching Course, including essential information, practical issues, and recommendations on the clinical application of BP monitoring methods, aiming to the optimal management of patients with suspected or diagnosed hypertension.

White coat hypertension: An unresolved diagnostic and therapeutic problem

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HYPERTENSION AND OBSTRUCTIVE SLEEP APNEA: IS THE BERLIN QUESTIONNAIRE A VALID SCREENING TOOL?: PP.32.273

Obstructive sleep Apnea Syndrome (OSA) increases the risk of cardiovascular diseases, in particular hypertension. The gold standard for the diagnosis of OSA is polysomnography (PSG). Berlin questionnaire (BQ) is a validated approach to indirectly quantify the risk of OSA in a general population. Aim of our study was to explore the actual prevalence of OSA in a group of unselected hypertensive patients and to evaluate sensitivity and specificity of BQ in determining the risk of OSA in this population vs PSG. Methods. 151 subjects referred to the Hypertension Center of our Institute, were also administered the BQ; 66 of these also performed a cardiorespiratory PSG (Embletta device). 17 subjects were excluded because inconsistency or lack of questionnaire responses or technical problems during PSG. Results: BQ suggested a high risk of OSA in 96% of cases. PSG showed that 59.2% of subjects presented an apnea-hypopnea index (AHI) > 5, and 40.8% an AHI <5. The two groups were comparable by gender and age and subjective daytime sleepiness. BMI was significantly higher in patients with OSA (OSA 30.3 kg/m2, non-OSA 27.1 kg/m2, p < 0.05). Application of BQ as compared to PSG showed an high sensitivity (0.94) but an extremely low specificity (0), if the BQ is interpreted according to standard guidelines (use of 3 categories of questions, international criteria). If we exclude from the analysis the 3th category (not appropriate in this population because specifically asking for presence of hypertension or BMI >30), the sensibility is 0.88 and the specificity increases significantly until to 0.39. Conclusions: Our data confirm the high prevalence of OSA in patients with hypertension. For the first time we compare BQ and PSG data in hypertensive patients. Our data suggest that caution is needed when applying BQ in this population because of inappropriate questions in patients with known hypertension. A specific version of BQ applicable to hypertensive subjects is thus needed for a reliable screening of OSA in this population.

Isolated systolic hypertension in the young

&NA; Whether isolated systolic hypertension in the young (ISHY) implies a worse outcome and needs antihypertensive treatment is still a matter for dispute. ISHY is thought to have different mechanisms than systolic hypertension in the elderly. However, findings from previous studies have provided inconsistent results. From the analysis of the literature, two main lines of research and conceptualization have emerged. Simultaneous assessment of peripheral and central blood pressure led to the identification of a condition called pseudo or spurious hypertension, which was considered an innocent condition. However, an increase in pulse wave velocity has been found by some authors in about 20% of the individuals with ISHY. In addition, obesity and metabolic disturbances have often been documented to be associated with ISHY both in children and young adults. The first aspect to consider whenever evaluating a person with ISHY is the possible presence of white-coat hypertension, which has been frequently found in this condition. In addition, assessment of central blood pressure is useful for identifying ISHY patients whose central blood pressure is normal. ISHY is infrequently mentioned in the guidelines on diagnosis and treatment of hypertension. According to the 2013 European Guidelines on the management of hypertension, people with ISHY should be followed carefully, modifying risk factors by lifestyle changes and avoiding antihypertensive drugs. Only future clinical trials will elucidate if a benefit can be achieved with pharmacological treatment in some subgroups of ISHY patients with associated risk factors and/or high central blood pressure.

Arterial Alterations in Hypertension

Several metabolic, humoral, local, and neural influences contribute to the homeostatic control of the cardiovascular system. All these factors physiologically interact with each other and participate in the regulation of cardiac as well as vascular function. Both endothelial and sympathetic functions seem to be the main important regulatory mechanisms involved in maintaining the homeostatic balance and participating in the cardiovascular responses to environmental needs. The alterations of these mechanisms represent the key factor for the cardiovascular modifications typical of several clinical conditions, such as heart, kidney, lung, and liver diseases as well as obesity and diabetes and represent the target for non-pharmacologic and pharmacologic interventions.

Effects of somatostatin analogues on muscle sympathetic nerve activity in acromegaly

muscle sympathetic nerve activity (MSNA), in spite of insulin resistance (Seravalle et al., Clin Endocrinol 77:262, 2012). Our data pointed to a phenomenon mediated by hypoleptinaemia rather than a direct action of the GH-IGF-I system. Aim: It has been shown that centrally administered somatostatin (SS) inhibits peripheral sympathetic outflow in rodents (Rettig et al., Am J Physiol 257:R588, 1989). Based on the above, we elected to study MSNA in acromegalic patients before and during treatment with SS analogues (SSA)

RELATIONSHIP BETWEEN NOCTURNAL BLOOD PRESSURE PATTERNS AND DAYTIME BLOOD PRESSURE VARIABILITY IN THE SPANISH AMBULATORY BLOOD PRESSURE MONITORING REGISTRY: 8C.05

Objective: Different abnormal patterns of nocturnal blood pressure (BP) including nocturnal hypertension, absent or excessive night-time BP fall, as well as increased short-term BP variability have been reported to be associated with an increased risk of cardiovascular events. However, it is not clear whether any relationship exists between different nocturnal BP patterns and daytime BP variability. The aim of the present study was to address this issue taking advantage of the large number of subjects included in the Spanish Ambulatory Blood Pressure Monitoring Registry. Methods: We studied 18405 subjects (mean age: 52.7 ± 14.3 years, male 54%) not on antihypertensive medication for at least 2 weeks. Ambulatory BP monitoring was performed with Spacelabs 90207 devices. BP variability was quantified as standard deviation (SD) of daytime (10 a.m.-10 p.m.) values. Data were analyzed by different models, subdividing subjects into: 1) categories of day/night systolic(S) BP pattern [risers (R): < 0% nocturnal SBP fall, nondippers: 0–5% (ND1) and 5–10% (ND2), dippers (D): 10–20%, extreme dippers (ED): >20%] and 2) quintiles of mean night-time (midnight-6 a.m.) SBP. The differences between categories were assessed by means of an ANCOVA model adjusted for age, BMI, gender, smoking, diabetes, dyslipidemia, previous cardiovascular disease, renal insufficiency and mean 24 h SBP (Model 1) or mean awake SBP (Model 2). Post hoc analysis with Bonferroni correction was used for multiple comparisons. Results: Significant differences in daytime SBP SD were found between day/night SBP fall categories (p < 0.0001) and between night-time SBP quintiles (p < 0.0001) (see Figure). Conclusions: Untreated subjects with very high or very low nocturnal BP, as well as with “riser” and “extreme-dipper” SBP profile show increased short-term BP variability during the awake period even after adjustment for major confounders. This relationship may reflect an increased sympathetic activity in these subjects. Studies on the clinical relevance of these ambulatory BP patterns should thus not disregard such an association. Figure 1. No caption available.