M. Alloni

Blood Pressure Control in Italian Essential Hypertensives Treated by General Practitioners

BACKGROUND Adequate control of blood pressure (BP) is limited worldwide. This has serious consequences for public health because in hypertensive patients, uncontrolled BP is associated with a higher incidence of cardiovascular events, particularly stroke. The aim of this study was to investigate BP control in a cohort of treated patients with diagnosed hypertension, who were under general practitioner care in Italy. METHODS Data were collected by 2,643 physicians on 8,572 individual Italian patients. Office BP was measured 5 min after seating each patient and then 3-5 min later. For each patient, data such as medical history of patients, physical examination data, antihypertensive drug usage, and self-BP measurement frequency were obtained. RESULTS Male prevalence was 48.4%, and mean age was 64.3 ± 10.5 years. Based on the second measurement, BP control (<140/90 mm Hg) was observed in 33.5% of all patients (34.2% in men and 33.4% in women). BP control was much lower for systolic BP than for diastolic BP (35.9 vs. 61.3%, P < 0.0001); moreover, BP control was much more common in patients who were engaged in self-BP measurement (61.2 vs. 38.8%, P < 0.0001). A stricter BP control recommended by the guidelines of the European Society of Hypertension (ESH) and European Society of Cardiology (ESC) (<130/80 mm Hg) was observed in only 5.5% of diabetic patients. CONCLUSIONS In treated Italian hypertensives effective BP control remains uncommon largely due to the failure to appropriately reduce the systolic BP. The stricter values recommended by the ESH/ESC guidelines for diabetic patients are achieved only by a small fraction of hypertensive diabetic population.

Persistence of arterial functional abnormalities after successful coronary revascularization.

Background In patients with myocardial ischemia and coronary atherosclerosis, arterial stiffness and endothelial function are impaired. Whether these alterations can be favorably affected by successful coronary revascularization is debated. Methods We studied 39 hospitalized patients 59.3 ± 3.2 years old (mean ± SEM). In 21 patients with angiographic evidence of significant coronary artery stenosis, revascularization procedures were performed (stenting n = 11 and bypass surgery n = 10). The remaining patients had no significant stenosis and thus served as controls. Prerevascularization measurements included carotido-femoral pulse wave velocity (PWV), radial artery flow-mediated vasodilatation and a complete echocardiographic examination. The same measurements were performed 6 months later. Pharmacological treatment consisted of different cardiovascular drugs and remained substantially unchanged over the 6-month follow-up period. Results With the exception of an increased left ventricular mass index (LVMI; 130 ± 5.3 versus 105.8 ± 7.2 g/m2, P < 0.05) and a lower Em/Am (0.6 ± 0.01 and 0.8 ± 0.01 respectively, P < 0.05) observed in patients with coronary stenosis, all other hemodynamic, cardiac and vascular variables were similar in the two groups. Following the 6-month follow-up period, all variables remained substantially unchanged, with the exception, in revascularized patients, of a significant reduction in LVMI (−12%, P < 0.05) and an improvement in Tissue Doppler Imaging-measured diastolic function (Em/Am + 30%, P < 0.05). This was not associated, however, with any significant change in PWV and in flow-mediated vasodilatation. Conclusion Cardiac revascularization has no effect on arterial function, assessed either as arterial stiffness or as flow-mediated vasodilatation. On the contrary, the improvement in coronary blood flow triggers local cardiac changes, namely, a reduction in LVMI and an improvement in diastolic function.

Impact of blood glucose variability on carotid artery intima media thickness and distensibility in type 1 diabetes mellitus

Abstract Aims. Diabetes mellitus is characterized by structural and functional alterations of the large- and medium-size arteries. Whether blood glucose variability, i.e. the glycemic oscillations occurring during the 24-h period, represents a risk factor for vascular alterations additional to and independent on HbA1c in type 1 diabetes mellitus is still undefined. The present study was carried out with the aim at investigating the impact of different measures of blood glucose variability on arterial structure and function. We studied 17 non-complicated type 1 diabetic patients (11 males, six females) with an age of 40.8 ± 7.6 years (mean ± SD). In each patient, 24-h glucose profile was obtained by continuous glucose monitoring system and glucose variability was expressed as mean ± SD of 24-h blood glucose levels, mean amplitude of glycemic excursions and postprandial hyperglycemic spikes. Arterial structure and function was measured as carotid IMT and stiffness. Major findings. The different approaches to assessing blood glucose variability well correlated between and with HbA1c. Carotid IMT and stiffness showed significant correlations with age, blood pressure, heart rate and daily insulin intake but a non- significant correlation with blood glucose variability. Principal conclusion. Thus, in type 1 diabetes mellitus, measures of glycemic variability are useful in predicting both actual and long-lasting glycemic control. In absence of diabetes-related complications and of any intima-media thickness alterations, the major predictors of arterial distensibility are represented by traditional risk factors beside glycemic 24-h control.

Early alterations in left ventricular diastolic function in normotensive diabetic patients

Abstract In diabetes mellitus, structural and functional alterations of the heart can be already present at the time of first diagnosis. However, how early these alterations may occur has never been fully clarified. The present study aimed at investigating cardiac functional abnormalities in uncomplicated hypertensive or normotensive patients with a recent diagnosis of diabetes mellitus. We studied 40 diabetics (24 normotensives and 16 hypertensives) by means of routine echocardiography plus pulse tissue Doppler analysis. Data were compared with those obtained in healthy age- and sex-matched controls. Left ventricular remodelling was more evident in hypertensive diabetics than in normotensive diabetics vs controls. Diastolic function was altered in diabetic patients only when detected by pulse tissue Doppler analysis and not by conventional transmitral Doppler evaluation. Normotensive patients with type 2 diabetes with little or no evidence at standard echocardiography of alterations in cardiac structure and function, already displayed an alteration in diastolic function when the evaluation was based on the tissue Doppler approach. Patients with type 2 diabetes combined to hypertension showed more evident functional cardiac alterations at echocardiography. These findings support the conclusion that cardiac abnormalities are very early phenomena in type 2 diabetes.

[BP.07.05] ASSOCIATION BETWEEN URIC ACID AND CARDIAC, VASCULAR AND RENAL TARGET ORGAN DAMAGE IN HYPERTENSIVES SUBJECTS.

Objective: To date no definitive results exist about the relationship of Serum Uric Acid (SUA) and Target Organ Damage (TOD) in hypertensives subjects (HT). We sought to determine if such an association exist between SUA and subclinical cardiac, vascular and renal alterations in HT. Design and method: We enrolled 632 consecutive outpatients, followed by the Hypertension Unit of S. Gerardo Hospital (Monza, Italy) affected by essential HT. We evaluated anamnestic data, clinical Blood Pressure (BP) and laboratory data as well as TOD with cardiac echocardiography (both as Left Ventricular Mass Index – LMVI and diastolic function – E/A), carotid ultrasound (Intima Media Thickness – IMT), arterial stiffness (Pulse Wave Velocity – PWV) and renal function analysis (creatinine and microalbumiuria). Results: Mean age was 53.4 ± 12.7 years, Systolic and Diastolic BP (SBP/DBP) were 140.5 ± 18.8 and 85.1 ± 13.1 mmHg and SUA was 5.2 ± 1.4 mg/dL. Regarding TOD mean LVMI was 109.6 ± 31.4 g/m2, IMT 0.71 ± 0.1 mm, PWV 8.5 ± 2.2 m/s, while creatinine and microalbuminuria were 0.8 ± 0.2 mg/dL and 25.4 ± 126.1 mg/24 h respectively. When subjects were divided into high and low SUA group (depending on the median SUA of 5.2 mg/dL), with similar age and BP values the first group showed significantly higher values of metabolic index (BMI: 27.9 ± 4.1 vs 25.7 ± 4.1 kg/m2; HDL chol: 49.8 ± 13.1 vs 56.8 ± 14.1 mg/dL; triglicerides: 136.1 ± 81.9 vs 104.2 ± 58.1 mg/dL; glucose: 95.4 ± 27.4 vs 86.4 ± 18.2 mg/dL, p < 0.01 for all), LVMI (117.1 ± 32.8 vs 102.1 ± 28.1 g/m2, p < 0.01), IMT (0.73 ± 0.1 vs 0.70 ± 0.1, p = 0.04), PWV (8.8 ± 2.4 vs 8.3 ± 2.1 m/s, p = 0.01) and creatinine (0.9 ± 0.2 vs 0.7 ± 0.1 mg/dL, p < 0.01) and lower E/A (1,0 ± 0.3 vs 1.1 ± 0.3, p < 0.01). SUA showed significant correlation with sex (r = -0.41, p < 0.01), age (r = 0.12, p = 0.01), BMI (r = 0.33, p < 0.01), SBP (r = 0.10, p < 0.01), HDL chol (r = -0.29, p < 0.01), triglicerides (r = 0.34, p < 0.01), glucose (r = 0.21, p < 0.01), creatinine (r = 0.42, p < 0.01), IMT (r = 0.12, p < 0.01), LVMI (r = 0.24, p < 0.01) and E/A (r = -0.15, p < 0.01). Regarding TOD only creatinine presents SUA as as significant determinant in logistic regression analysis with age, sex, BMI, HDL chol, triglicerides and glucose as covariates. Conclusions: In HT, SUA values correlate with metabolic derangements and with cardiac, vascular and renal TOD. The most significant correlation is with renal damage.

Renal artery stenosis as the cause of resistant arterial hypertension: an unusual technique for revascularization.

To the Editor: A 45-year-old Caucasian man in hypertensive crisis was referred to our hospital with general malaise, cephalalgia, and chest pain (blood pressure [BP], 210/ 100 mm Hg). The patient’s medical history included never-treated hypertension, dyslipidemia, and smoking. At admission, the patient was oriented and alert. Results from physical examination were normal and the patient was in hemodynamic balance. The abdomen auscultation revealed a periumbilical bruit. Findings from resting electrocardiography showed signs of left ventricular hypertrophy and negative T-wave changes in V4–V6. Laboratory findings showed a modest increase in troponin Ths (56 ng/L) and no other significant alterations. Findings from 2-dimensional echocardiography showed concentric hypertrophy of the left ventricle, with no decrease of left ventricular contraction and with a conserved ejection fraction (0.50). Color Doppler analysis showed normal function of all heart valves. To correctly study the renin-angiotensin-aldosterone axis and noradrenergic system and to exclude secondary hypertension, the patient was initially treated with a-blockers only. All bioassay results were in the high-normal range according to the presence of high BP. Therapy was later modified and implemented with calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors, furosemide, and aand b-blockers without reaching adequate BP control (160/90 mm Hg). Subsequent findings from computed tomography angiography of the abdomen showed a significant hemodynamic stenosis at the origin of the left kidney artery of 10 mm, normal contralateral renal artery, and no evidence of adrenal or renal parenchyma tumefactions (Figure 1). After case assessment by the radiologists and collegial discussion, it was decided to treat the renal artery stenosis (RAS). Findings from angiography of the renal arteries confirmed the stenosis very tightened to the origin of the left renal artery. The attempt of crossing the stenosis via intraluminal procedure using a 0.014-inch guidewire and a microcatheter failed. Following multiple subintimal passages, the renal artery dissection at the end of the stenotic occlusion was reported, and the procedure was stopped. The patient was discharged, and, after 2 months, a new right transfemoral arteriography and an aortoiliac angiography were performed. The evidence was a revascularizated left kidney from the left spermatic artery, which was hypertrophic and with inverted flow. After several failed attempts of crossing the obstruction, it was decided to perform the procedure with retrograde access: the occlusion was crossed using a 0.035-inch guidewire that was rescued in the aorta and via anterograde procedure and, after predilation, the premounted stent on a 6918 mm balloon was positioned (Figure 2). Following the procedure, the patient underwent treatment with 5 antihypertensive agents, ie, ACE inhibitors, diuretics, calcium antagonists, and aand b-blockers, and aspirin 100 mg/d was added to obtain good BP control (130/80 mm Hg). Hypertension induced by RAS is a form of secondary hypertension caused by renin overproduction, and atherosclerotic disease is the most common cause. It is known that RAS affects 1% to 5% of hypertensive patients. Furthermore, many studies have shown an elevated prevalence of RAS in patients with coronary artery disease diagnosed by cardiac catheterization. Angiography is the gold standard for the diagnosis of RAS, and the most common technique uses a reverse-curve catheter that advances cephalic from below the renal artery until it engages the renal artery ostium. The specificity of this case was the unusual angiographic approach, ie, a retrograde access from the spermatic artery, due to the unavailability of the standard access. According to our knowledge, this approach is rarely used; therefore, information about the results is limited. In our patient, the results produced a complete resolution of RAS, as well as optimal BP control, with no procedural complications. doi: 10.1111/jch.12331 FIGURE 1. Computed tomographic angiography revealing a significant hemodynamic stenosis at the origin of the left kidney artery.

INAPPROPRIATE LEFT VENTRICULAR MASS IS ASSOCIATED WITH VASCULAR ORGAN DAMAGE INDEPENDENTLY ON LEFT VENTRICULAR HYPERTROPHY IN HYPERTENSION: 3B.05

C. Giannattasio, F. Cesana, F. Soriano, M. Alloni, M. Cairo, G. Colombo, M. Pozzi, C. Menni, G. Trocino, A. Fontana, A. Capra, P. Canova, G. Grassi, G. Mancia. Div Internal Med, Milano-Bicocca University, Osp. San Gerardo and Istituo Auxologico Italiano, Monza-Italy, Division of Internal Medicine, Milano-Bicocca University and Osp. San Gerardo, Monza-Italy, Department of Statistics, Milano-Bicocca University, Milano-Italy, Division of Cardiology, Osp. S. Gerardo, Monza-Italy

PREVALENCE OF LEFT VENTRICULAR HYPERTROPHY ACCORDING TO ESC AND ACC CRITERIA IN ESSENTIAL HYPERTENSION: PP.22.381

Aims and Methods: Aim of our study was to define in a large number of treated EH patients the impact of different echocardiographic criteria (ACC 2006 versus ESH ESC guidelines) on the prevalence of LVH. An additional aim was to see how closely LVH, as defined by the two criteria, reflected diastolic dysfunction. Results: Data were obtained in 827 patients (age 53 ± 13.7 year, means ± SE) 50 percent of which were male. Systolic(S) blood pressure (BP) and diastolic (D) BP were142.3 ± 18.6/86.7 ± 10.6mmHg, respectively. Left ventricular mass index (LVMI) was 111.36 ± 32.7 g/m2 when indexed by the body surface area(BSA) and 50.6 ± 15.4 g/m 2.7 when indexed by height(h)2.7. The prevalence of LVH was significantly and markedly greater (49.4 vs. 36.0%, p < 0.05) when calculated with ACC vs. ESH-ESC criteria. This was the case also when prevalence of cardiac remodelling was compared (14.6% vs. 13.6%, p < 0.05) although the difference was much less pronounced. LVMI showed a correlation with diastole (E/A ratio, r = 0.3) but not with systolic function. Conclusion: Prevalence of LVH is much greater with the ACC than with ESH ESC criteria; therefore, following the ACC criteria we may overestimate cardiac damage, with thus an excessive labelling of hypertensive patients as at high risk