Renata Giudice

Insufficient control of blood pressure and incident diabetes

OBJECTIVE Incidence of type 2 diabetes might be associated with preexisting hypertension. There is no information on whether incident diabetes is predicted by blood pressure control. We evaluated the hazard of diabetes in relation to blood pressure control in treated hypertensive patients. RESEARCH DESIGN AND METHODS Nondiabetic, otherwise healthy, hypertensive patients (N = 1,754, mean ± SD age 52 ± 11 years, 43% women) participated in a network over 3.4 ± 1 years of follow-up. Blood pressure was considered uncontrolled if systolic was ≥140 mmHg and/or diastolic was ≥90 mmHg at the last outpatient visit. Diabetes was defined according to American Diabetes Association guidelines. RESULTS Uncontrolled blood pressure despite antihypertensive treatment was found in 712 patients (41%). At baseline, patients with uncontrolled blood pressure were slightly younger than patients with controlled blood pressure (51 ± 11 vs. 53 ± 12 years, P < 0.001), with no differences in sex distribution, BMI, duration of hypertension, baseline blood pressure, fasting glucose, serum creatinine and potassium, lipid profile, or prevalence of metabolic syndrome. During follow-up, 109 subjects developed diabetes. Incidence of diabetes was significantly higher in patients with uncontrolled (8%) than in those with controlled blood pressure (4%, odds ratio 2.08, P < 0.0001). In Cox regression analysis controlling for baseline systolic blood pressure and BMI, family history of diabetes, and physical activity, uncontrolled blood pressure doubled the risk of incident diabetes (hazard ratio [HR] 2.10, P < 0.001), independently of significant effects of age (HR 1.02 per year, P = 0.03) and baseline fasting glucose (HR 1.10 per mg/dl, P < 0.001). CONCLUSIONS In a large sample of treated nondiabetic hypertensive subjects, uncontrolled blood pressure is associated with twofold increased risk of incident diabetes independently of age, BMI, baseline blood pressure, or fasting glucose.

Hypertensive target organ damage predicts incident diabetes mellitus

Aims Whether patients with hypertensive preclinical cardiovascular disease (CVD) are at higher risk of incident diabetes has never been studied. Methods and results We assessed incident diabetes in 4176 hypertensive non-diabetic patients (age 58.7 ± 8.9 years, 58% male) with ≥1 year follow-up (median: 3.57 years; inter-quartile range: 2.04–7.25). Left ventricular (LV) hypertrophy (LVH) was defined as LV mass index (LVMi) ≥51 g/m2.7. Carotid atherosclerosis (CA) was defined as intima-media thickness >1.5 mm. During follow-up, diabetes developed in 393 patients (9.4%), more frequently in those with than without initial LVH or CA (odds ratio = 1.97 and 1.67, respectively; both P < 0.0001). In the Cox regression, the presence of either initial LVH or CA was associated with higher hazard of diabetes [hazards ratio (HR) = 1.30 and 1.38, respectively; both P = 0.03], independently of the type and number of anti-hypertensive medications, initial systolic blood pressure (P < 0.001), body mass index, fasting glucose, family history of diabetes (all P < 0.0001), and therapy with β-blockers. The presence of one of the, or both, markers of preclinical CVD increased the chance of incident diabetes by 63 or 64%, respectively (both P < 0.002), independently of significant confounders, a result that was confirmed (HR = 1.70 or 1.93, respectively; both P < 0.0001) using ATPIII metabolic syndrome (HR = 2.73; P < 0.0001) in the Cox model. Conclusion Initial LVH and CA are significant predictors of new onset diabetes in a large population of treated hypertensive patients, independently of initial metabolic profile, anti-hypertensive therapy, and other significant covariates. This sequence may be attributable to risk factors common to preclinical CVD and diabetes, but a vascular origin of diabetes cannot be excluded.

Effects of nutraceuticals on prevalence of metabolic syndrome and on calculated Framingham Risk Score in individuals with dyslipidemia

Background Nutraceuticals (NUTs) are forms of compounds with biological activity and are used to improve health in dosage largely exceeding those obtainable in food. Objectives To investigate whether addition of NUTs to lifestyle management including diet counseling improves lipid profile and reduces cardiovascular risk and prevalence of metabolic syndrome (MetS). Methods One thousand, three hundred and eighty, 18–80-year-old nondiabetic participants with dyslipidemia, with or without MetS not requiring pharmacological therapy were assigned to diet; after 2 weeks, 690 patients were also given NUT combination over other 8 weeks. Fasting plasma glucose and lipid compounds were measured by standard methods. Waist circumference, systolic and diastolic blood pressure (BP) were measured at each visit. MetS was defined according to ATPIII guidelines. Ten-year risk of coronary heart disease was calculated using the Framingham Risk Score (FRS). Results At baseline, NUT patients were older and more dyslipidemic than placebo, with no difference in other cardiovascular risk factors and prevalence of MetS. After 8 weeks, high-density lipoprotein (HDL) cholesterol was increased and diastolic BP, waist girth, triglycerides, total and non-HDL cholesterol were significantly reduced in NUT than in the placebo group, whereas systolic BP and fasting glucose did not change. Prevalence of MetS was also significantly lower in the NUT (36.1%) than in placebo (48.1%, P < 0.05) and reduction in the FRS greater (73.3 vs. 52%, respectively; P < 0.0001). Conclusion In a large clinical sample of patients with moderate cardiovascular risk, combination of NUT with dietary counseling reduces central obesity, improves lipid profile, diastolic BP and FRS, and decreases prevalence of MetS.

Arterial Stiffness Is Associated With Carotid Atherosclerosis in Hypertensive Patients (The Campania Salute Network)

BACKGROUND Pulse pressure/stroke volume indexed to height(2.04) (PP/SVi) is a validated measure of arterial stiffness, but its relation to carotid atherosclerosis is unknown. METHODS Clinical, echocardiographic, and carotid ultrasound data from 6,209 hypertensive patients without prevalent cardiovascular (CV) disease in the Campania Salute Network were analyzed. The population was grouped into tertiles of PP/SVi. From carotid ultrasound, peak and mean intima-media thickness (IMT) and presence of carotid plaques in the common and internal carotid arteries were reported. RESULTS Increasing PP/SVi tertile was associated with a parallel increase in age, blood pressure, total serum cholesterol and the number of antihypertensive drugs used (all P < 0.01). Higher PP/SVi was also associated with greater peak and mean IMT (all P < 0.01), also when adjusting for age, gender, blood pressure, lipid profile, and diabetes mellitus (all P < 0.01). Similarly, compared to the lower PP/SVi tertile, the multiple adjusted prevalence ratio of carotid plaque was 7 (95% confidence interval (CI) 1-13, P < 0.03) in the middle tertile and 21 (95% CI 15-28, P < 0.0001) in the upper tertile, independently of confounders. CONCLUSION In treated hypertensive patients participating in the Campania Salute Network, higher PP/SVi is associated with carotid atherosclerosis independent of well-known clinical confounders.

Persistence and adherence to antihypertensive treatment in relation to initial prescription: diuretics versus other classes of antihypertensive drugs.

Background: The use of thiazide diuretics in the treatment of hypertension is widely considered as a first-line treatment, given the efficacy and low cost of this class of drugs. This indication is not unanimous, because thiazides can cause metabolic alterations, and other side effects that reduce compliance and persistence on treatment. Objectives: In a multicentre, open-label randomized study we compared adherence and persistence to therapy of chlortalidone versus other treatments, as a first-line antihypertensive therapy. Methods: Ninety-two general practitioners (GPs) recruited 2409 hypertensive patients with indication to antihypertensive therapy, who were randomized in two arms to start treatment with chlortalidone (12.5–25 mg daily) or any other single medications (excluding thiazides). The patients have been followed for at least 2 years. Result: Patients receiving diuretic therapy as first-line antihypertensive treatment, modified antihypertensive treatment regimen more often than the others (79.1 versus 43.9%; &khgr;2 < 0.0001). Patients starting with diuretics received greater number of drugs, compared to patients starting with different antihypertensive therapy (1.55 versus 1.4 antihypertensive drugs; P < 0.0001), but achieved the same blood pressure (BP) control during the follow-up. No differences were observed in persistence and adherence to treatment between the two groups. Conclusion: Our results demonstrate that the recommendation to start antihypertensive therapy with diuretics, when no compelling indications are present, is not supported by the evidence that this strategy produces more rapid and better control of BP.

Smoking Selectively Accelerates Carotid Atherosclerosis in Hypertensive Patients

AbstractBackground and objectives: Left ventricular hypertrophy, carotid atherosclerosis and renal dysfunction are indicators of target organ damage in hypertension, and independent risk factors for both fatal and non-fatal cardio- and cerebrovascular events. In the general population, smoking is associated with increases in left ventricular mass and carotid intima-media thickness (IMT), and impaired renal function. The aim of the present study was to evaluate whether smoking affects the development of target organ damage in patients with arterial hypertension. Methods: 3192 hypertensive patients referred to the Hypertension Clinic of the “Federico II” University of Naples from January 2000 to July 2006 were retrospectively analysed. Subjects were aged from 18 to 75 years. Among these patients, 1391 were smokers and 1801 non-smokers. Results: The duration and severity of hypertension was significantly shorter in smokers when compared with non-smokers. The maximum arterial IMT was significantly higher in smokers compared with non-smokers (1.7 ± 0.1 mm vs 1.5 ± 0.1, p < 0.0001), while left ventricular mass index was comparable between the two groups. In contrast, glomerular filtration rate was observed to be higher in smokers compared with non-smokers. Logistic regression analysis showed that smoking, age, sex, duration of hypertension, systolic blood pressure and diastolic blood pressure were significantly correlated with IMT. Furthermore, a strong correlation was found between the number of cigarettes smoked per day and IMT. Conclusions: Together, these data indicate that in hypertensive patients who have a high risk of developing atherosclerosis, smoking could potentiate the development of atherosclerotic plaques.

LEFT VENTRICULAR MASS IS A PREDICTOR OF FOLLOW-UP UNCONTROLLED BLOOD PRESSURE IN HYPERTENSIVE PATIENTS: 4B.04

Background: Left ventricular (LV) hypertrophy (LVH) is considered as a target organ response to chronic arterial hypertension and is used to stratify cardiovascular (CV) risk. LV mass (LVM) is also increased in subjects developing subsequent hypertension. Whether initial LVM also influences effective therapeutic control of blood pressure (BP) is unknown. Methods: We estimated risk of suboptimal BP control in relation to baseline LVM index (LVMi) in 4693 hypertensive outpatients from the Campaniasalute Network, with at least 1 yr follow-up (mean 4 ± 3yrs) and without prevalent CV disease (age 53 ± 11 yrs, 43% women, 5% diabetic). BP was defined uncontrolled when systolic BP> = 140mmHg or/and diastolic BP>=90mmHg (or BP>=130 or/and 80 mmHg in diabetic patients) at the last available outpatient visit. Results: Poor BP control was detected in 2240 patients (48%), despite treatment with 2 or more antihypertensive drugs. Patients with uncontrolled BP were older, more often obese (28% versus 21%) and diabetic (9% versus 1.6%), with a longer duration of hypertension and higher baseline BP, heart rate, LVMi, and prevalence of LVH (36% versus 26%, all p < 0.0001), with no difference in sex distribution. Of 1440 patients with baseline LVH, 803 (or 56%) had uncontrolled BP at follow-up, compared to 44% of those without LVH (p < 0.0001). In multivariate analyses, odds of uncontrolled BP increased significantly with higher baseline systolic BP, heart rate, BMI, duration of hypertension, diabetes (all p < 0.0001) and greater baseline LVMi (OR = 1.10/10 g/m2.7, 1.04–1.20, p = 0.002) independent of age, gender and number of medications. When specific classes of medications were added to the previous model, only use of anti-Renin-Angiotensin System reduced the risk of uncontrolled BP (OR = 0.83, 0.71–0.95, p = 0.01), with no impact for other classes of drugs (diuretics, β-blockers, Ca++-channel blockers and α-blockers). Conclusions: We conclude that in a large population of treated hypertensive patients, higher baseline left ventricular mass is significantly associated with risk of uncontrolled BP independently of age, gender, body max index, diabetes and antihypertensive therapy.