Riccardo Pini

Parallel cardiac and vascular adaptation in hypertension.

BackgroundAlthough vascular damage in the noncoronary circulation is a major cause of complica-tions in hypertension, relatively little is known of the in vivo geometry and function of the arterial circulation in patients with uncomplicated hypertension or of their relation to left ventricular hypertro-phy, a marker of enhanced risk of cardiovascular complications. Methods and ResultsWall thickness and internal diameter of the common carotid artery and the presence of atherosclerosis within the extracranial carotid arteries were determined by ultrasound in 43 asymptomatic hypertensive patients and 43 normotensive subjects matched for sex, age, and body size. Vascular stiffness was estimated from simultaneous superimposed carotid pressure waveforms obtained with an external solid-state transducer. Left ventricular size and function were determined echocardio-graphically. Compared with normal subjects, hypertensive patients had greater left ventricular absolute and relative wall thicknesses, left ventricular mass, and carotid absolute and relative wall thicknesses (p < O.O05). Carotid intimal-medial thickness exceeded the 95th percentile of normal values in 28% of hypertensive patients (p < O.Ol). Carotid atherosclerosis was equally prevalent within the two blood pressure groups and was associated with older age, larger left ventricular and carotid wall thicknesses, and carotid diameter. Despite similar carotid pulse pressures, vascular stiffness was significantly increased in the hypertensive patients. Among the population as a whole, significant relations existed between cardiac and vascular wall thicknesses and internal dimensions. In multivariate analyses, these relations were statistically independent of age and blood pressure. ConclusionsThe present study documents the presence of geometric and functional changes within the common carotid artery in uncomplicated hypertension that parallel findings within the left ventricle. The potential contribution of these changes to the cardiovascular complications of hypertension, particularly in the setting of left ventricular hypertrophy, is unknown.

Central but not brachial blood pressure predicts cardiovascular events in an unselected geriatric population: the ICARe Dicomano Study.

OBJECTIVES The present study investigated whether central blood pressure (BP) predicts cardiovascular (CV) events better than brachial BP in a cohort of normotensive and untreated hypertensive elderly individuals. BACKGROUND Limited and conflicting data have been reported on the prognostic relevance of central BP compared with brachial BP. METHODS Community-dwelling individuals > or =65 years of age, living in Dicomano, Italy, underwent an extensive clinical assessment in 1995 including echocardiography and carotid ultrasonography and applanation tonometry. In 2003, vital status and CV events were assessed, reviewing the electronic database of the Regional Ministry of Health. Only normotensive (n = 173) and untreated hypertensive subjects (95 diastolic and 130 isolated systolic) were included in the present analysis. RESULTS During 8 years, 106 deaths, 45 of which were cardiovascular, and 122 CV events occurred. In univariate analyses, both central and brachial systolic blood pressure (SBP) and pulse pressure (PP) predicted CV events (all p < 0.005); however, in multivariate analyses, adjusting for age and gender, higher carotid SBP and PP (hazard ratios 1.19/10 and 1.23/10 mm Hg, respectively; both p < 0.0001) but neither brachial SBP nor PP independently predicted CV events. Similarly, higher carotid SBP but not brachial pressures independently predicted CV mortality (hazard ratio 1.37/10 mm Hg; p < 0.0001). CONCLUSIONS Our prospective study in an unselected geriatric population demonstrates superior prognostic utility of central compared with brachial BP.

Relation of arterial pressure waveform to left ventricular and carotid anatomy in normotensive subjects.

OBJECTIVES The purpose of this study was to examine the relation of the central arterial pressure waveform to left ventricular and carotid structure. BACKGROUND The pressure waveform in the central arteries is affected by reflection of the pressure wave from the periphery. When reflected waves merge with the incident wave during systole, a late systolic peak and increment in systolic blood pressure are observed. The consequent increase in hemodynamic load may stimulate left ventricular and vascular adaptive changes. METHODS Sixty-seven normotensive adults were studied by noninvasive techniques. Anatomy and function of the left ventricle and carotid artery were investigated by ultrasonography. Pressure waveforms were recorded by an external tonometer applied to the carotid artery, and waveform shape was expressed by the augmentation index, calculated from the difference between the maximal systolic pressure and that at the inflection between early and late systolic pressure peaks divided by the pulse pressure. Subjects were assigned to groups with a dominant early (group 1, augmentation index < or = 0) or dominant late systolic peak (group 2, augmentation index > 0). RESULTS Left ventricular mass index was significantly higher in group 2 than in group 1, a difference that persisted after controlling for the confounding effects of gender, age and blood pressure. Carotid wall thickness and regional arterial stiffness were significantly increased in group 2, but differences disappeared in the analysis of covariance for age. CONCLUSIONS Left ventricular and carotid artery structure are related to the shape of the central pressure waveform. Although the increase in left ventricular mass seen in subjects with a dominant late systolic peak pressure appears to be directly related to the shape of the pressure waveform, changes in the structural and physical properties of the carotid artery appear to be more closely related to the aging process.

Association of carotid atherosclerosis and left ventricular hypertrophy

OBJECTIVES This study was undertaken to determine the prevalence of carotid atherosclerosis in a large group of asymptomatic hypertensive and normotensive adults and to examine its relation to the presence of left ventricular hypertrophy. BACKGROUND Both electrocardiographic and echocardiographic left ventricular hypertrophy predict an increased risk of cardiovascular events and mortality, including cerebrovascular disease, but the mechanism of association is unknown. METHODS Four hundred eighty-six (277 normotensive and 209 untreated hypertensive) adults, free of clinical evidence of cardiovascular disease, were studied prospectively with echocardiography to determine left ventricular mass and carotid ultrasound to detect atherosclerosis and to measure common carotid artery dimensions. RESULTS Carotid atherosclerosis was present in 16% of normotensive and 23% of hypertensive participants (p < 0.05) and was associated with older age, higher systolic and pulse pressures and larger left ventricular mass index ([mean +/- SD] 91 +/- 19 vs. 82 +/- 18 g/m2, p < 0.0001). The difference in mass persisted after adjustment for baseline differences in age and blood pressure. Subjects with left ventricular hypertrophy were twice as likely to have carotid atheromas (35% vs. 18%, p < 0.01). Logistic regression analyses, including standard risk factors, indicated that only age and left ventricular mass index independently predicted the presence of carotid plaque, both in the entire study group and when normotensive and hypertensive subjects were considered separately. CONCLUSIONS We believe that the present study provides the first evidence that higher left ventricular mass as detected by echocardiography is associated with the presence of carotid plaque. The association between cardiac hypertrophy and systemic atherosclerosis may contribute to the pathogenesis of the high incidence of vascular events that is well documented in patients with left ventricular hypertrophy.

Impact of Arterial Stiffening on Left Ventricular Structure

Aging of the vasculature results in arterial stiffening and an increase in systolic and pulse pressures. Although pressure load is a stimulus for left ventricular hypertrophy, the extent to which vascular stiffening per se, independent of blood pressure, influences left ventricular structure is uncertain. Two hundred seventy-six subjects (79 normotensive and 197 otherwise healthy hypertensive individuals) underwent echocardiography to assess left ventricular structure. Arterial stiffness was estimated by the pressure-independent stiffness index, &bgr;, and the pressure-dependent elastic modulus derived from simultaneous carotid ultrasound and applanation tonometry. Systemic arterial compliance (the inverse of stiffness) was estimated by the arterial compliance index. In multivariate analysis, &bgr; was related to age (P <0.001) and smoking history (P <0.01) but not mean pressure, whereas elastic modulus was related to age and mean pressure (both P <0.001). The arterial compliance index was only related to age. Whereas systolic and diastolic pressures and the elastic modulus were positively associated with left ventricular mass (all P <0.001), primarily because of increases in wall thicknesses, &bgr; and the arterial compliance index bore no relation to left ventricular mass. &bgr; was inversely related to chamber diameter and directly related to left ventricular relative wall thickness, the ratio of wall thickness to chamber radius. Younger and older hypertensive subjects had comparable left ventricular mass, despite higher systolic and pulse pressures in the older group, whereas older hypertensives had higher mean relative wall thickness, associated with a significant increase in arterial stiffness (&bgr;, 7.06 versus 5.17; elastic modulus, 595 versus 437 dyne/cm2 ×10−6) and reduction in the arterial compliance index (0.87 versus 1.05 mL/mm Hg per square meter) (all P <0.001). Thus, the extent to which arterial stiffness relates to left ventricular hypertrophy is dependent on the method by which arterial stiffness is estimated. Pressure-dependent methods show an association with left ventricular hypertrophy, whereas the pressure-independent stiffness index, &bgr;, and the arterial compliance index are most strongly associated with aging and left ventricular concentric remodeling but not hypertrophy.

Relation of arterial structure and function to left ventricular geometric patterns in hypertensive adults

OBJECTIVES The present study sought to determine whether conduit artery structure and function vary according to the pattern of left ventricular adaptation to hypertension. BACKGROUND Although left ventricular geometric pattern has been shown to predict cardiovascular events in hypertension, the arterial status in patients with the different patterns is unknown. METHODS We evaluated arterial structure and function by carotid ultrasound and applanation tonometry in 271 unmedicated hypertensive patients classified by echocardiography as having normal ventricular geometry (n = 176), concentric remodeling (n = 54), concentric hypertrophy (n = 16) or eccentric hypertrophy (n = 25). RESULTS All groups were similar in age, gender distribution and body size. Patients with concentric and eccentric hypertrophy had similar blood pressures (mean 173/100 and 171/99 mm Hg, respectively) and left ventricular mass, but compared with patients with normal left ventricular geometry and concentric remodeling, only those with concentric hypertrophy had increased arterial wall thickness (0.96 +/- 0.20 vs. 0.80 +/- 0.18 mm, p < 0.05), end-diastolic diameter (6.38 +/- 0.97 vs. 5.76 +/- 0.87 mm, p < 0.05), cross-sectional area (22.1 +/- 5.71 vs. 16.6 +/- 5.4 mm(1)2 p < 0.05) and elastic modulus (713 +/- 265 vs. 471 +/- 241 dynes/cm2 x 10(-5), p < 0.05). Patients with concentric remodeling and eccentric hypertrophy had similar values for these measures (0.85 +/- 0.22 and 0.89 +/- 0.21 mm, 5.67 +/- 0.77 and 6.04 +/- 0.44 mm, 17.2 +/- 5.4 and 19.7 +/- 5.9 mm2, 558 +/- 263 and 614 +/- 257 dynes/cm2 x 10(-6), respectively), despite lower systolic blood pressures in the former group (156/94 mm Hg, p < 0.001). The prevalence of plaque was comparable in patients with concentric (56%) and eccentric (42%) hypertrophy and significantly greater than that in patients [corrected] with normal geometry (21%). CONCLUSIONS Among patients with generally mild, uncomplicated systemic hypertension, arterial structure and function are most abnormal when concentric left ventricular hypertrophy is present and may contribute to the more adverse outcome associated with this geometric pattern.

Diagnosis and classification of severity of mitral valve prolapse: Methodologic, biologic, and prognostic considerations

In the quarter century since it was recognized that Although the development of auscultatory,‘, z 4, 5 midsystolic clicks and late systolic murmurs were of angiographic,“, 7 echocardiographic,8-12 and pathologmitral valve origin,‘, 2 a considerable body of inforic13,14 methods of recognizing MVP has facilitated mation has accumulated about the condition that is clinical diagnosis and investigation of this condition, now generally known as mitral valve prolapse the resultant multiplicity of diagnostic methods and (MVP).3 The central feature of MVP is posterior criteria has alrio engendered confusion. The frequent and superior systolic displacement of the mitral discordances between the presence or absence of leaflets in relation to the mitral am&s, due to MVP by different techniques~*5 has raised the possistructural enlargement or abnormal distensibility of bility that patients identified by different methods the mitral valve. MVP occurs most often in a may not have the same condition.16 Particular conprimary or “idiopathic form”-commonly associcern exists about whether MVP diagnosed either by ated with alterations of body habitus and blood auscultatory or laboratory methods or by the prespressure and evidence of heritibility-or as a sece.nce of the symptom complex known commonly as ondary feature of several connective tissue diseases, the “mitral prolapse. syndrome”15* *‘, I* accurately whereas the same abnormal motion pattern may be identifies anatomic MVP as documented by anaproduced without intrinsic valvular abnormality by tomic, pathology or MVP that is clinically “pathologconditions that alter left ventricular size or geomeic” because of a significant risk of important complitry. cations.‘9

Is White Coat Hypertension Associated With Arterial Disease or Left Ventricular Hypertrophy

Although white coat hypertension may be present in 20% or more of hypertensive individuals, its prognostic significance is unknown. We compared prognostically relevant measures of target-organ damage among 24 individuals with white coat hypertension and age- and sex-matched groups of sustained hypertensive and normotensive subjects classified by clinical and 24-hour ambulatory blood pressures. Left ventricular and carotid artery structure and function were evaluated by ultrasonography. Left ventricular mass index was similar in white coat hypertensive (82 +/- 17 g/m2) and normotensive (78 +/- 15 g/m2) subjects but was higher in sustained hypertensive subjects (97 +/- 19 g/m2, P < .02 and P < .002, respectively). Similarly, carotid artery intimal-medial thickness was greater in the sustained hypertensive group (0.98 +/- 0.21 mm) than in the white coat hypertensive (0.84 +/- 0.16 mm, P < .05) and normotensive (0.76 +/- 0.18 mm, P < .001) groups. The prevalence of discrete atherosclerotic plaques was higher in the sustained hypertensive group (58%) than in the white coat hypertensive (25%, P < .05) and normotensive (21%, P < .02) groups. Cardiac and carotid structure in individuals with white coat hypertension resemble findings in normotensive subjects and differ significantly from those in age- and sex-matched sustained hypertensive subjects. These findings suggest that white coat hypertension may be a benign condition for which pharmacological intervention may not be necessary, a hypothesis that needs to be tested in longitudinal studies with clinical end points.

Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial

Background— Observational studies suggest that open visiting policies are preferred by most patients and visitors in intensive care units (ICUs), but no randomized trial has compared the safety and health outcomes of unrestrictive (UVP) and restrictive (RVP) visiting policies. The aim of this pilot, randomized trial was to compare the complications associated with UVP (single visitor with frequency and duration chosen by patient) and RVP (single visitor for 30 minutes twice a day). Methods and Results— Two-month sequences of the 2 visiting policies were randomly alternated for 2 years in a 6-bed ICU, with 226 patients enrolled (RVP/UVP, n=115/111). Environmental microbial contamination, septic and cardiovascular complications, emotional profile, and stress hormones response were systematically assessed. Patients admitted during the randomly scheduled periods of UVP received more frequent (3.2±0.2 versus 2.0±0.0 visits per day, mean±SEM) and longer (2.6±0.2 versus 1.0±0.0 h/d) visits (P<0.001 for both comparisons). Despite significantly higher environmental microbial contamination during the UVP periods, septic complications were similar in the 2 periods. The risk of cardiocirculatory complications was 2-fold (odds ratio 2.0; 95% CI, 1.1 to 3.5; P=0.03) in the RVP periods, which were also associated with a nonsignificantly higher mortality rate (5.2% versus 1.8%; P=0.28). The UVP was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. Conclusions— Despite greater environmental microbial contamination, liberalizing visiting hours in ICUs does not increase septic complications, whereas it might reduce cardiovascular complications, possibly through reduced anxiety and more favorable hormonal profile.

Prevalence and Determinants of Cardiac and Vascular Hypertrophy in Hypertension

Hypertrophy of the capacitance arteries has recently been documented in hypertensive patients by noninvasive ultrasound techniques. To better define the prevalence and determinants of vascular hypertrophy and its potential association with ventricular hypertrophy in hypertension, we compared carotid and cardiac ultrasound findings in 172 normotensive and 172 unmedicated hypertensive subjects matched for age and sex. Despite similar body size, hypertension was associated with increased left ventricular wall thicknesses, mass, and mass index (89 versus 80 g/m2, P < .0001 for all comparisons) and increased carotid wall thickness (0.82 versus 0.77 mm) and cross-section area (17.1 versus 15.3 mm2, P < .005 for both comparisons). Among the 172 normotensive subjects, left ventricular hypertrophy was noted in 9 (5.2%) and arterial hypertrophy was found in 9 (5.2%), whereas ventricular hypertrophy was found in 21 (12.2%) and arterial hypertrophy in 19 (11%) hypertensive subjects. Arterial hypertrophy was found in 9% of hypertensive subjects with normal ventricular mass and in 24% with left ventricular hypertrophy (P < .05). Among hypertensive subjects carotid wall thickness and cross-sectional area were most strongly related to age and systolic pressure (P < .0001 for all comparisons), with little contribution form body size. Carotid relative wall thickness was only related to increasing age (P < .01). In contrast, left ventricular wall thickness and mass were strongly related to body size and systolic pressure (P < .0001 for comparisons) but not to age (P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)