Lorella Lambertucci

Low Diastolic Ambulatory Blood Pressure Is Associated with Greater All-Cause Mortality in Older Patients with Hypertension

OBJECTIVES: To assess the relationship between office and ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) and total mortality in elderly patients with hypertension.

Pulse pressure and mortality in hypertensive type 2 diabetic patients. A cohort study.

Hypertension is a well‐known cardiovascular risk factor in type 2 diabetic patients. It has been suggested that pulse pressure (PP) could be an independent cardiovascular risk factor in the general population, particularly in the elderly. An association between office PP and cardiovascular mortality has been previously reported in diabetic patients, while the relationship between ambulatory measurements of PP and all‐cause mortality has not been assessed so far.

Isolated ambulatory hypertension is common in outpatients referred to a hypertension centre

The present investigation was aimed at determining the prevalence and the blood pressure (BP) profile of isolated ambulatory hypertension, defined as an elevated ambulatory BP with normal office blood pressure, in a series of 1488 consecutive outpatients referred for routine clinical evaluation of suspected or established arterial hypertension. All patients underwent both office BP (OBP) measurement by a physician and 24-h ambulatory blood pressure monitoring (ABPM). Using OBP values (cutoff for diagnosis of hypertension ⩾140/90 mmHg) and daytime ABPM (cutoff for diagnosis of hypertension ⩾135/85 mmHg), patients were classified into eight subgroups. In the whole series we found that, independent of treatment status, the prevalence of isolated ambulatory hypertension exceeded 10%. More importantly, 45.3% of individuals who presented with normal OBP values, showed elevated BP at ABPM. Night-time BP, 24-h pulse pressure, and BP variability were significantly higher in isolated ambulatory hypertensives than in normotensive or in white-coat hypertensive individuals. Therefore, isolated ambulatory hypertension is characterized by a blood pressure profile that is similar to that observed in sustained hypertension. These findings suggest that isolated ambulatory hypertension is very common and probably the indications for ABPM should be more extensive in outpatients referred to hypertensive centre.

Are comorbidity indices useful in predicting all-cause mortality in Type 2 diabetic patients? Comparison between Charlson index and disease count

Background and aims: Several studies have shown that comorbidity is important in predicting morbidity and mortality in the general population. However, few studies have assessed the validity of comorbidity indices in diabetic patients. The aim of the present study was to compare the predictive value of disease count and Charlson’s Comorbidity Index (CCI) for 3-year mortality in type 2 diabetic (T2D) patients. Methods: The study was performed on a consecutive series of 1667 T2D outpatients. Comorbidity was assessed using Charlson’s index, whereas the diseases used to calculate Charlson’s score were taken into account for disease count. Information on all-cause mortality over the 3-year follow-up period was obtained from the City of Florence Registry Office. Results: Mean duration of follow-up (±SD) was 31A±10.6 months. One hundred and ninety-nine (11.9%) patients died during follow-up, with a yearly mortality rate of 4.7%. At multivariate analysis, after adjustment for sex and age, each additional disease was associated with a 54 [37–77]% increase in all-cause mortality. Mortality increased by 31 [21–41]% for each incremental point of Charlson’s comorbidity score. Conclusions: A simple disease count is as predictive of mortality in T2D patients as the more complex Charlson’s index. The possible usefulness of specific comorbidity indices in predicting incident disability in diabetic subjects needs to be further investigated.

Trandolapril, but not Verapamil nor their association, restores the physiological renal hemodynamic response to adrenergic activation in essential hypertension

The purpose of this study was to evaluate the effects of antihypertensive drugs on renal hemodynamics in hypertensive patients during an adrenergic activation by mental stress (MS), which induces renal vasoconstriction in healthy subjects. Renal hemodynamics was assessed twice in 30 middle-aged essential hypertensive patients (57±6 years)-after 15 days of pharmacological wash-out and after 15 days of treatment with Trandolapril (T, 4 mg, n=10), Verapamil (V, 240 mg, n=10), or both (T 2 mg+V 180 mg, n=10). Each experiment consisted of 4 30-min periods (baseline, MS, recovery I and II). Renal hemodynamics was evaluated with effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) from plasminogen activator inhibitor and inulin clearance, respectively. MS increased blood pressure (BP) to a similar extent before and after each treatment. Before treatment, the increasing BP was not associated with any modification of ERPF in the 3 groups. Renal vascular resistances (RVR) markedly increased during MS (+23% in the T group, +21.6% in the V group, and +32.9% in the T+V group); GFR remained constant during the whole experiment. After treatment, ERPF decreased significantly during MS in the T group (-15%, P<0.05) and in the V group (-11.7%, p<0.01); in the T+V group, ERPF modifications were not statistically significant (P=0.07). In the T group, ERPF reverted to baseline values at the end of the stimulus, whereas in the V group, renal vasoconstriction was more prolonged. Only in hypertensive patients treated with 4 mg of T, RVR reverted to baseline during the recovery I, whereas in the V group, RVR remained elevated for the whole experiment. No modifications of GFR were observed in all groups. The kidney of hypertensive patients cannot react to a sympathetic stimulus with the physiological vasoconstriction. A short-term antihypertensive treatment with 4 mg of T restores the physiological renal response to adrenergic activation.

Hypertension and reduced renal function in an 83-year-old patient

Dr. Andrea Ungar, Dr. Lorella Lambertucci: An 83-year-old woman was admitted to our department for a hypertensive crisis. Essential hypertension was diagnosed 30 years ago and was treated with different drugs. At the age of 79 years, the patient had symptomatic atrial fibrillation and was treated with DC-shock. On that occasion hypercholesterolaemia was diagnosed (total cholesterol 290 mg/dl) and mild, not haemodynamically significant, atherosclerosis of carotid and femoral arteries so that treatment with statin was started. One month before admission, she started complaining of mild dyspnoea and palpitations during the night associated with elevated blood pressure (BP) values (170/100 mmHg). Diuretic was added to current treatment without any significant BP reduction. Due to a new hypertensive crisis complicated by pulmonary oedema, she was referred to our department in emergency. At referral, the patient was under treatment with felodipine (10 mg), enalapril (20 mg), hydrochlorothiazide (12.5 mg) and propafenone (75 mg twice daily). On admission, the patient was alert, oriented, dyspnoic. BP was 190/110 mmHg at both arms, the pulse was rhythmic (75 bpm). Body weight was 67 kg with 167 cm height. Bilateral basal rales were present at pulmonary auscultation with third sound at cardiac auscultation. On abdominal examination, the liver and spleen were normal and no abdominal bruit was found. Mild peripheral oedema and moderate jugular venous distension were also present. All peripheral pulses were symmetrically present and no carotid or femoral bruits were found. The electrocardiogram revealed only a left anterior fascicular block (Fig. 1). A chest X-ray revealed mild pulmonary congestion (Fig. 2). Echocardiography revealed a large left atrium (25 mm/m2), normal dimensions and function of the left ventricle (ejection fraction 50%), an increased posterior wall thickness and ventricular mass, a mild mitral regurgitation and a decreased ventricular compliance. Serum creatinine was 1.3 mg/dl with a creatinine clearance of 34.7 ml/min (calculated with the Cockroft & Gault formula). Other routine laboratory tests were within the normal range.