Does the reduction in systolic blood pressure alone explain the regression of left ventricular hypertrophy?

Systolic blood pressure (SBP) is an important determinant of the development and regression of left ventricular hypertrophy (LVH) in hypertensive humans. However, comparative assessments with other BP components are scarce and generally limited in size. As part of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA), 743 hypertensive subjects underwent echocardiography and 24-h ambulatory BP monitoring before and after an average of 3.9 years of treatment. The changes in left ventricular mass showed a significant direct association with the changes in 24-h SBP (r=0.40), diastolic blood pressure (DBP) (r=0.33) and pulse pressure (PP) (r=0.35). Weaker associations were found with the changes in clinic BP (r=0.32, 0.31 and 0.16, respectively). In a multivariate linear regression analysis, the changes in 24-h SBP were the sole independent determinants of the changes in left ventricular mass (LVM) according to the following equation: percentage changes in LVM=0.73 x (percentage changes in 24-h SBP) -0.48 (P<0.0001). For any given reduction in 24-h SBP, the reduction in LVM did not show any association with the changes in DBP and PP, either clinic or ambulatory. These data indicate that SBP is the principal determinant of LVH regression in hypertensive humans.

Long-term effects of losartan and enalapril, alone or with a diuretic, on ambulatory blood pressure and cardiac performance in hypertension: a case-control study.

BACKGROUND: The long-term effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on ambulatory blood pressure and cardiac performance have never been examined comparatively. OBJECTIVE: We compared losartan and enalapril in their long-term effects on office and ambulatory blood pressure, cardiac structure and function, and routine biochemical tests. DESIGN: In the setting of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study, 22 hypertensive subjects were studied with ambulatory blood pressure monitoring and echocardiography before and after an average of 3.3 years of treatment with losartan 50mg daily. These subjects were matched in a 1:3 ratio with a group of 66 subjects treated with enalapril 20mg daily. Case-control sampling was based on age (+/-5years), sex, pre-treatment office blood pressure (+/-5mmHg) and ambulatory blood pressure (+/-5mmHg), and duration of treatment (+/-6months). An additional group of subjects who interrupted their treatment with enalapril (n=18) or losartan (n =2) because of unwanted effects before execution of the follow-up study was not included in the analysis. RESULTS: Hydrochlorothiazide was added during follow-up in order to optimize blood pressure control (office blood pressure <140mmHg systolic and 90mmHg diastolic) in 10 subjects (45%) in the losartan group and 34 subjects (52%) in the enalapril group. Office and ambulatory blood pressures were lowered to a similar extent by losartan and enalapril. Left ventricular mass decreased from 98 to 87g/m(2) with losartan (P <0.01) and from 98 to 89 g/m(2) with enalapril (P <0.01). The change in left ventricular mass over time was more closely associated with the change in ambulatory blood pressure than with office blood pressure in both groups. Left ventricular internal diameter did not change with either drug. The endocardial shortening fraction, mid-wall shortening fraction and Doppler indexes of active diastolic relaxation did not change with either drug. None of the biochemical parameters showed a significant change. Serum uric acid showed a slight and non-significant reduction only in the losartan group. CONCLUSION: In this case-control study in uncomplicated subjects with essential hypertension, losartan and enalapril, alone or combined with a diuretic, effectively and equally lowered office and ambulatory blood pressure and induced a significant reduction in left ventricular mass during long-term treatment. Left ventricular systolic and diastolic function remained unchanged with either regimen.

Persistence of increased left ventricular mass despite optimal blood pressure control in hypertension.

BACKGROUND: Left ventricular hypertrophy is an adverse risk marker in essential hypertension and its regression has a favorable effect on prognosis. It is unclear whether blood pressure normalization induced by long-term therapy is able to normalize left ventricular mass completely. METHODS: In the setting of a prospective cohort study, 107 consecutive hypertensive patients who achieved blood pressure normalization (clinic blood pressure < 140/90 mmHg on > or = 3 consecutive visits) under long-term (1-10 years, average 2.9) drug treatment were individually matched with 107 healthy normotensive controls by gender, age (+/- 5 years), body mass index (+/- 3 kg/m2), and clinic systolic blood pressure (+/- 5 mmHg) in a case-control design. All subjects underwent 24-hour blood pressure monitoring and M-mode echocardiography. RESULTS: Treated hypertensive patients and normotensive controls did not differ by age, body mass index, clinic blood pressure (128/82 vs 128/81 mmHg), and 24-hour blood pressure (120/77 vs 120/76 mmHg). Left ventricular mass and relative wall thickness were greater in the hypertensive than in the normotensive group (97 +/- 24 vs 86 +/- 17 g/m2 and 0.40 +/- 0.08 vs 0.37 +/- 0.08, both p < 0.001). CONCLUSIONS: Left ventricular mass is greater in well-controlled hypertensive patients than in normotensive controls matched by age, obesity, gender, and clinic and 24-hour blood pressure. This finding is consistent with the lower than epidemiologically expected reduction in coronary heart disease risk during antihypertensive therapy and might reflect the persistent effect on left ventricular mass of hemodynamic and/or non-hemodynamic factors other than blood pressure in treated patients with essential hypertension.

Clinical relevance of office underestimation of usual blood pressure in treated hypertension.

Average 24-h blood pressure (BP) is more representative of usual BP than office BP. However, the clinical relevance of 24-h BP in treated hypertensive subjects is incompletely known. Thus, we studied 395 uncomplicated hypertensive subjects (209 men, 53+/-10 years) who were receiving antihypertensive drug therapy from >1 year. All subjects underwent 24-h ambulatory BP monitoring and M-mode echocardiography. Subjects were classified by tertile of the difference between observed and predicted 24-h systolic BP (the latter determined by regressing 24-h systolic BP on office systolic BP): higher-than-predicted (III tertile), around the regression line (II tertile), and lower-that-predicted (I tertile) 24-h BP. Despite similar office BP (144/89, 141/88, and 144/89 mm Hg in the III, II, and I tertile, P = not significant), age, body mass index, and duration of hypertension, left ventricular mass was greater in the subjects with higher-than-predicted 24-h systolic BP (50+/-14 g x m(-2.7)) than in the other two groups (46+/-13 g x m(-2.7) and 42+/-10 g x m(-2.7), both P < .05). The III tertile also showed a more concentric left ventricular geometric pattern (relative wall thickness was 0.42+/-0.08, 0.40+/-0.07, and 0.38+/-0.07 in the III, II, and I tertile, P < .001) and a reduced systolic function at the midwall level (16.8+/-3, 17.7+/-3, and 18.2+/-3, P < .001). In conclusion, treated hypertensive subjects whose 24-h BP is notably higher than one would predict from office BP are more likely to develop left ventricular hypertrophy, a strong adverse prognostic marker. In a sizable subset of treated hypertensive subjects, BP measured in the physician's office underestimates usual BP and its impact on left ventricular structure.

Influence of cigarette smoking on the electrocardiographic diagnosis of left ventricular hypertrophy in arterial hypertension.

Electrocardiography (ECG) has a lower sensitivity for the diagnosis of left ventricular (LV) hypertrophy in smokers than in non-smokers, but the explanation for this finding is not known. In the setting of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study, all subjects smoking > or = 15 cigarettes/day (n = 121, 89 men, age 48 +/- 11 years) were selected from 1443 untreated hypertensive subjects undergoing ECG and M-mode echocardiography, and matched with 484 hypertensive non-smokers by gender (same sex), age (+/- 5 years), and systolic and diastolic blood pressure (both +/- 5 mmHg) in a case-to-control design with a 1:4 matching ratio. Smokers and non-smokers did not differ by age, gender, body mass index, and blood pressure. The voltage of SV1 + RV5 or V6 and RI (p < 0.05), but not of SV3 + RaVL, was lower in smokers. Sensitivity of ECG was lower in smokers when using peripheral or left precordial voltage criteria (e.g. 11 vs 26% for Sokolow-Lyon voltage). When using definitions based on different criteria (voltage of S wave in V3, LV axis, LV strain), sensitivity was not dissimilar in smokers and non-smokers (e.g. 19 vs 18% for Romhilt-Estes score, 40 vs 34% for Perugia criterion). Thus, in hypertensive smokers, sensitivity of ECG is lower than in non-smokers when using peripheral or left precordial voltage criteria, probably due to increased chest size in smokers resulting from increased lung compliance. For LV hypertrophy detection, Sokolow-Lyon voltage should be avoided in hypertensive smokers and replaced by other criteria (Cornell voltage, Romhilt-Estes score, Perugia criterion), which are not influenced by cigarette smoking.

Ambulatory blood pressure is superior to clinic blood pressure in predicting treatment-induced regression of left ventricular hypertrophy. SAMPLE Study Group. Study on Ambulatory Monitoring of Blood Pressure and Lisinopril Evaluation.

BACKGROUND: In cross-sectional studies, ambulatory blood pressure (ABP) correlates more closely than clinic BP with the organ damage of hypertension. Whether ABP predicts development or regression of organ damage over time better than clinic BP, however, is unknown. METHODS AND RESULTS: In 206 essential hypertensive subjects with left ventricular hypertrophy (LVH), we measured clinic supine BP, 24-hour ABP, and left ventricular mass index (LVMI, echocardiography) before and after 12 months of treatment with lisinopril (20 mg UID) without or with hydrochlorothiazide (12.5 or 25 mg UID). Measurements included random-zero, clinic orthostatic, and home BP. In all, 184 subjects completed the 12-month treatment period. Before treatment, clinic supine BP was 165 +/- 15/105 +/- 5 mm Hg (systolic/diastolic), 24-hour average BP was 149 +/- 16/95 +/- 11 mm Hg, and LVMI was 158 +/- 32 g/m2. At the end of treatment, they were 139 +/- 12/87 +/- 7 mm Hg, 131 +/- 12/83 +/- 10 mm Hg, and 133 +/- 26 g/m2, respectively (P < .01 for all). Before treatment, LVMI did not correlate with clinic BP, but it showed a correlation with systolic and diastolic 24-hour average BP (r = .34/.27, P < .01). The LVMI reduction was not related to the reduction in clinic BP, but it was related to the reduction in 24-hour average BP (r = .42/.38, P < .01). Treatment-induced changes in average daytime and nighttime BPs correlated with LVMI changes as strongly as 24-hour BP changes. No substantial advantage over clinic supine BP was shown by clinic orthostatic, random-zero, and home BP. CONCLUSIONS: In hypertensive subjects with LVH, regression of LVH was predicted much more closely by treatment-induced changes in ABP than in the clinic BP. This provides the first longitudinally controlled evidence that ABP may be clinically superior to traditional BP measurements.

Altered circadian blood pressure profile and prognosis.

BACKGROUND: In a previous analysis of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale we found a higher rate of cardiovascular morbid events among hypertensive nondippers than we did among dippers (5.86 versus 1.18 events per 100 person-years, P = 0.0002) for women, whereas the difference between the two groups was smaller and not statistically significant for men (4.15 versus 2.48 events per 100 person-years). These differences held in a multivariate analysis after adjustment for several confounders including average 24 h ambulatory blood pressure. In another analysis, the rate of occurrence of cardiovascular end-points was higher among nondippers than it was among dippers regardless of the definition of day and night (0600-2200 h and 2200-0600 h, awake and asleep, and 1000-2000 h and 2400-0600 h) and of the dividing line between dippers and nondippers (10 versus 0% day-night difference in blood pressure). OBJECTIVE: To test in a subsequent analysis based on a larger sample and a longer follow-up period, for both sexes, the prognostic value of a blunted diurnal rhythm of blood pressure. METHOD: We used the night: day ratio of ambulatory blood pressure, a continuous and normally distributed variable. RESULTS: A night: day systolic blood pressure ratio > 0.899 for men and > 0.909 for women (upper tertiles of distributions) identified a subset of subjects with greater than normal cardiovascular risk for any level of concomitant risk factors, wherease the hight:day diastolic blood pressure ratio was not statistically significant as an independent predictor. The excess risk for subjects in the upper tertile of the night: day systolic blood pressure ratio held after adjustment for several risk markers, including average 24 h ambulatory blood pressure. CONCLUSION: These data suggest that a blunted reduction in blood pressure from day to night predicts an increased cardiovascular morbidity at any level of concomitant risk factors including average 24 h ambulatory blood pressure. Nondippers can be defined in terms of a night: day ambulatory systolic blood pressure ratio > 0.899 for men and > 0.909 for women, regardless of the diastolic blood pressure profile.

Predictors of diurnal blood pressure changes in 2042 subjects with essential hypertension.

OBJECTIVE: To determine the independent predictors of day-night blood pressure changes in a large population of subjects with essential hypertension. METHODS: We studied 2042 white untreated subjects with essential hypertension (mean age 52 years, range 17-93, 1052 men) who underwent 24 h ambulatory blood pressure monitoring on an outpatient basis. Night-time workers were excluded from analysis. RESULTS: For both sexes, the changes in systolic and diastolic blood pressures from day to night decreased progressively with age and increased with the reported duration of sleep. The 1207 employed subjects who underwent ambulatory blood pressure monitoring during a usual working day had greater day-night blood pressure differences than did those who did not work (16.2 versus 14.0%). By using multiple regression analysis we assessed the independent association of several variables with the diurnal blood pressure changes. Age and diabetes for both sexes, and clinic blood pressure in men, were inversely associated with the nocturnal fall in blood pressure. The duration of sleep and the occurrence of blood pressure monitoring during a normal work day predicted a greater day-night blood pressure difference for both sexes; smoking predicted a greater nocturnal fall in blood pressure for women. CONCLUSIONS: Age is associated with an important and progressive attenuation of the day-night blood pressure difference in untreated and unrestricted subjects with essential hypertension. Other factors influencing diurnal blood pressure variations include clinic blood pressure, diabetes, the reported duration of sleep, smoking habits and working activity during blood pressure monitoring. These factors should be treated as potential confounders in the analysis of the relationship between diurnal blood pressure changes and target organ damage or prognosis.

[The irrelevance of the clinical arterial pressure with respect to outpatient pressure in defining the risk of left ventricular hypertrophy in essential arterial hypertension]. / Irrilevanza della pressione arteriosa clinica, rispetto a quella ambulatoriale, nella definizione del rischio di ipertrofia ventricolare sinistra nell'ipertensione arteriosa essenziale.

To investigate whether the level of clinical blood pressure (BP) may serve to stratify the risk of left ventricular (LV) hypertrophy in essential hypertension regardless of the level of ambulatory BP, we performed 24-hour noninvasive ambulatory BP monitoring and echocardiography in 115 consecutive hypertensive patients who had never been treated before and in 92 normotensive subjects. Hypertensive patients were grouped according to the difference between the observed clinical BP and the predicted value of clinical BP, defined by regressing the observed clinical BP on the 24-hour average of the ambulatory BP: "low" clinical BP group (clinical systolic BP less than = 10 mmHg, diastolic BP less than = 6 mmHg than predicted values), "high" clinical BP group (systolic greater than = 10 mmHg, diastolic greater than = 6 mmHg than predicted values), "intermediate" clinical BP group (values within the above mentioned limits). Ambulatory BP did not show any statistically significant differences between the three groups. LV mass index was higher in hypertensive patients in each of the three groups (including the "low" clinical BP group) as compared with the normotensive group (all p less than 0.01), but did not show any statistically significant difference among the three groups of hypertensive patients, either defined by systolic BP or by diastolic BP. Other indexes of LV anatomy (relative wall thickness, cross-sectional area) showed a similar pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

[Noninvasive ambulatory monitoring of arterial pressure in hypertensive patients: inside or outside the hospital?]. / Monitoraggio ambulatoriale non invasivo della pressione arteriosa in pazienti ipertesi: fuori o dentro l'ospedale?

To investigate whether hospitalization may influence the circadian rhythm of blood pressure (BP), 15 untreated patients with essential hypertension underwent noninvasive ambulatory blood pressure monitoring twice, at home and in the hospital, in a random order, 11 days apart. During the hospital session, which took place on the ninth day of hospitalization, patients were allowed to move freely in the hospital area, to receive visits by friends and relatives and to engage in social activities with other inpatients. Home sessions were performed during a usual working day in 14 of 15 patients. Average 24-hour systolic/diastolic BP was 151/93 mmHg (DS 19/10) at home and 154/93 mmHg (DS 21/7) in the hospital; average daytime (6am-10pm) values were 155/97 mmHg (DS 19/10) at home and 157/96 mmHg (DS 20/5) in the hospital; average night-time (10pm-6am) values were 146/88 mmHg (DS 21/12) at home and 150/89 mmHg (DS 23/10). These values did not show any statistical differences (analysis of variance) due to status (home vs hospital), period or sequence. The hourly BP averages of the hospital recording did not differ significantly from the corresponding averages of the home recording. The correlation between hospital and home 24-hour averages of systolic and diastolic BP was close (r = 0.87 and r = 0.78, respectively; p less than 0.01). The chronobiological analysis (single cosinor) showed a statistically significant circadian rhythm of systolic BP in 10/15 patients at home and in 8/15 patients in the hospital (p = NS), and a statistically significant rhythm of diastolic BP in 9/15 patients at home and in 10/15 patients in the hospital (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Sex differences in echocardiographic indices of left ventricular hypertrophy in arterial hypertension. Influence of age and pressure levels over 24 hours]. / Differenze tra i sessi negli indici ecocardiografici di ipertrofia ventricolare sinistra nell'ipertensione arteriosa. Influenza dell'età e dei livelli pressori nelle 24 ore.

To evaluate the difference between the sexes in the echocardiographic indices of left ventricular hypertrophy in essential hypertension, we analysed the results of 24-hour non invasive ambulatory blood pressure monitoring and echocardiography in 195 consecutive untreated hypertensive patients (101 males, 94 females). Patients were divided into 3 age groups: up to 40 years, 41-60 years, and greater than 60 years of age. Clinical blood pressure did not differ between sexes in any of the three groups, while average 24-hour ambulatory systolic and diastolic blood pressure levels were higher in males than in females up to 40 years of age (140/93 vs 129/87 mmHg, p less than 0.01), but not between 41 and 60 years (142/93 vs 141/90 mmHg) nor in those over 60 years of age (151/92 vs 145/91 mmHg). LV mass index was higher in males than in females up to 40 years (93 vs 68 g/m2, p less than 0.01), and between 41 and 60 years (115 vs 90 g/m2, p less than 0.01), but not dissimilar between the sexes over 60 years of age (102 vs 107 g/m2, p = n.s.). In females, LV mass index increased with age (r = 0.33) and body weight (r = 0.38; both p less than 0.01), but none of these relationships was significant in males (r = 0.01 and r = 0.19, respectively). Moreover, all the relations of LV mass to either clinical or ambulatory BP were closer in females than in males. None of the echocardiographic indices of left ventricular systolic function showed statistically significant differences between the sexes in any of the three age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk stratification of left ventricular hypertrophy in systemic hypertension using noninvasive ambulatory blood pressure monitoring.

Twenty-four-hour noninvasive ambulatory blood pressure (BP) monitoring and echocardiography were performed in 165 consecutive untreated hypertensive patients and in 92 healthy subjects. In the hypertensive group, left ventricular (LV) mass index showed closer correlations (all p less than 0.01 in the comparisons between the r coefficients) with average 24-hour ambulatory systolic (r = 0.47) and diastolic (r = 0.33) BP than with casual systolic (r = 0.35) and diastolic (r = 0.28) BP. Hypertensive patients were classified according to the difference between their observed and predicted levels of ambulatory BP (the latter assessed by regressing the observed ambulatory BP on the casual BP). When compared to those with lower than predicted ambulatory BP (less than or equal to 10 mm Hg systolic, less than or equal to 6 mm Hg diastolic), patients with higher than predicted ambulatory BP (greater than or equal to 10 mm Hg systolic and greater than or equal to 6mm Hg diastolic) had higher values of LV mass index and other indexes of LV hypertrophy (all p less than 0.01) but had similar values of casual BP. Prevalence of LV hypertrophy was 6 to 10% in the former and 35 to 39% in the latter (p less than 0.001). None of the indexes of LV structure differed between the group with low ambulatory BP and the normotensive group. It is concluded that hypertensive patients whose ambulatory BP readings are notably higher than one would predict from clinical BP readings are at highest risk of LV hypertrophy, an independent prognostic marker.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and determinants of left ventricular diastolic filling abnormalities in an unselected hypertensive population.

The independent contribution of age, sex, duration of hypertension, heart rate, clinic and ambulatory blood pressure and echocardiographic left ventricular mass to left ventricular diastolic filling abnormalities in essential hypertension was investigated in 250 subjects (145 untreated and unselected hypertensives and 105 healthy normotensive controls) undergoing Doppler and standard echocardiography and non-invasive 24-h ambulatory blood pressure monitoring. Late and early diastolic transmitral peak flow velocities and their ratio (all P less than 0.01), the rate of deceleration of early diastolic mitral flow (P less than 0.01) and the time of deceleration of early diastolic mitral flow (P = 0.018) were abnormal in the hypertensive group vs controls. None of these parameters significantly varied in the presence vs absence of LV hypertrophy. In the hypertensive group, the prevalence of abnormal age-corrected Doppler values varied up to 46% (up to 45.4% and 50% in the absence and presence of left ventricular hypertrophy, respectively; P = n.s.). In a stepwise multivariate regression analysis, age and average daytime or night-time ambulatory blood pressure showed a significant independent relationship with each of these Doppler indexes of left ventricular diastolic filling. Late transmitral peak flow velocity and the ratio of late to early peak flow velocity were also independently affected by the heart rate. Sex, duration of hypertension, clinic systolic and diastolic blood pressure and left ventricular mass index did not show any independent relationship to these Doppler parameters of left ventricular filling. In conclusion, Doppler abnormalities of diastolic transmitral blood flow were detected in up to 46% of patients in an unselected hypertensive population with a low prevalence (14.5%) of left ventricular hypertrophy. Age and ambulatory blood pressure, but not sex, duration of hypertension, clinic blood pressure and left ventricular mass itself, were the major independent determinants of these abnormalities.

Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension.

The effects of circadian blood pressure (BP) changes on the echocardiographic parameters of left ventricular (LV) hypertrophy were investigated in 235 consecutive subjects (137 unselected untreated patients with essential hypertension and 98 healthy normotensive subjects) who underwent 24-hour noninvasive ambulatory blood pressure monitoring (ABPM) and cross-sectional and M-mode echocardiography. In the hypertensive group, LV mass index correlated with nighttime (8:00 PM to 6:00 AM) systolic (r = 0.51) and diastolic (r = 0.35) blood pressure more closely than with daytime (6:00 AM to 8:00 PM) systolic (r = 0.38) and diastolic (r = 0.20) BP, or with casual systolic (r = 0.33) and diastolic (r = 0.27) BP. Hypertensive patients were divided into two groups by presence (group 1) and absence (group 2) of a reduction of both systolic and diastolic BP during the night by an average of more than 10% of the daytime pressure. Casual BP, ambulatory daytime systolic and diastolic BP, sex, body surface area, duration of hypertension, prevalence of diabetes, quantity of sleep during monitoring, funduscopic changes, and serum creatinine did not differ between the two groups. LV mass index, after adjustment for the age, the sex, the height, and the daytime BP differences between the two groups (analysis of covariance) was 82.4 g/m2 in the normotensive patient group, 83.5 g/m2 in hypertensive patients of group 1 and 98.3 g/m2 in hypertensive patients of group 2 (normotensive patients vs. group 1, p = NS; group 1 vs. group 2, p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic analysis of the left ventricle in patients with type II diabetes mellitus]. / Analisi ecocardiografica del ventricolo sinistro in pazienti con diabete mellito di tipo II.

Left ventricular involvement in type II diabetes mellitus is poorly understood. We performed a cross-sectional, M-mode and pulsed Doppler echocardiographic study on 27 diabetic patients and 27 controls accurately matched for age, sex, weight and height. All subjects also underwent 24-hour non-invasive ambulatory blood pressure monitoring. Left ventricular wall thicknesses and dimensions in diastole and systole, left ventricular mass index (82.7 g/m2 vs 78.4 g/m2) and the echocardiographic indices of left ventricular contractility did not show any statistical differences between diabetics and controls. Clinic and 24-hour ambulatory blood pressure did not show important differences between diabetics and controls. Doppler parameters for transmitral flow velocity (including peak A and peak E velocity and their ratio, pressure half time and pressure half slope) were the same in diabetics and controls. A stepwise multivariate regression analysis showed a significant positive independent relationship of peak A/peak E ratio with age (peak A/peak E = 0.0087 + 0.20 x age; F = 18.7; p = 0.0001), but not with diabetes or glycosylated haemoglobin (Hb 1 AC). Compared with non-diabetics, diabetics showed a slight increase in aortic peak flow velocity (0.83 m/sec vs. 0.70 m/sec; p = 0.011) and a very slight increase in peak aortic gradient. Peak aortic velocity showed a highly significant positive independent relation with the duration of diabetes (Vmax = 0.572 + 0.0028* diabetes duration (months); F = 92.6; p less than 0.0001), but not with age, systolic or diastolic blood pressure of HB 1 AC.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory blood pressure monitoring during sustained treatment with conventional and extended-release felodipine in mild-to-moderate hypertension.

To assess the duration of the antihypertensive effect of the dihydropiridine calcium antagonist felodipine in conventional (C-F) and slow-release (ER-F) formulations, 12 patients with essential hypertension underwent ambulatory blood pressure monitoring (ABPM) at the end of a 2-week treatment period with C-F 5 mg b.d., ER-F 10 mg once daily (o.d.) and placebo. C-F, ER-F and placebo were given in a double-blind 3 x 3 latin square design 4 times replicated. There was no systematic change in the ABP profile over the three study periods regardless of the treatment. In comparison to placebo, the mean 24-h systolic and diastolic blood pressures showed a significant and similar reduction after both formulations of F. Compared to placebo, C-F and ER-F induced a significant reduction in systolic blood pressure for 15 and 21 h, respectively, and of diastolic blood pressure for 16 and 21 h, respectively. Three patients complained of headache (mild in 2, moderately severe in 1), and two patients of nocturia, with either formulation of F.

Increased exercise tolerance and reduced electrocardiographic ischaemia 3 and 12 hours after oral felodipine in effort angina.

The antianginal properties and the duration of action of two doses of felodipine, a dihydropyridine calcium antagonist with a vascular:myocardial potency ratio approximating 100:1, were investigated in 15 patients suffering from disabling effort angina pectoris with reproducible exercise tolerance. Felodipine (5 mg, 10 mg) and placebo were administered once in the morning on three different days, with a 24 h interval between them, according to a double-blind 3 x 3 latin square design, 5 times replicated. Symptom-limited cycloergometric exercise tests were performed 3 and 12 h after administration. Duration of exercise to ST segment depression of 1 mm and to peak exercise was increased (all P less than 0.01) by both doses of felodipine in comparison with placebo. Twelve hours after administration, the 10-mg dose induced a significant improvement in the exercise time and a smaller ST segment depression (all P less than 0.01) in comparison with the 5-mg dose. The relationship between ST segment depression and the pressure-rate product during exercise was favourably influenced by the 10-mg dose at 3 and 12 h after intake, and by the 5-mg dose only at 3 h after intake. These findings suggest an increase in coronary blood flow induced by felodipine. Apart from mild headache there were no other unwanted effects. In conclusion, felodipine improves exercise tolerance and reduces electrocardiographic ischaemia for up to 12 h after single oral administration in patients with effort angina. Increasing the dose from 5 mg to 10 mg produces a more prolonged effect, with increased exercise tolerance 12 h after intake.

Home ambulatory blood pressure readings do not differ from clinic readings taken at the same time of day.

In most hypertensives clinic blood pressure (BP) is variably higher than home BP, but the underlying mechanisms are uncertain. We investigated whether the 24-hour ambulatory home BP profile as well as the office-home BP discrepancy could vary with the time of day of application of the recording system (from 08.00 h to 19.00 h) in 135 untreated hypertensives who underwent non-invasive home BP monitoring (ICR 5200). Neither systolic nor diastolic 24-hour home BP (average of daily readings, area-under-the-curve) varied significantly with the time of day of application of the system. Clinic BP was about 12% higher than 24-hour home BP in the whole population, mean values being 161.4/102.9 mmHg (office BP) vs 141.2/90.8 mmHg (average 24-hour home readings), as well as in each of the subcohorts based on the time of day of application of the system (all P less than 0.01). However, in none of the subcohorts were there any statistically significant differences between clinic BP and home BP readings taken at the same time of day as the clinic readings. No correlation was found between clinic heart rate and clinic-home discrepancy. We conclude that in essential hypertension 24-hr non-invasive ambulatory BP monitoring can begin indifferently from 08.00 h to 19.00 h with no expected influence of time of application on results and that clinic BP is not dissimilar from home BP at the same time of day.

Duration of the antihypertensive action of atenolol, enalapril and placebo: a randomized within-patient study using ambulatory blood pressure monitoring.

Atenolol (A) and enalapril (E), two agents widely used as first-line monotherapy in arterial hypertension, have never been compared in their potency and duration of action by using 24-h ambulatory blood pressure monitoring (ABPM). Twelve out-patients (mean age 48.6 years - SD 7) with mild-to-moderate hypertension and supine diastolic blood pressure (Hawksley Random Zero Manometer) greater than 100 mmHg at the end of a 3-week placebo wash-out received, in double-blind and random order, A 100 mg daily, E 20 mg daily and placebo for 4 weeks each, according to a 3 x 3 latin square design. A 24-hour non-invasive ABPM (Spacelabs ICR 5200) was performed at the end of each of the 3 periods. In respect to placebo, both A and E produced a 24-h antihypertensive effect. The frequency of diastolic blood pressure values above 90 mmHg was 50.0% after placebo, 24.5% after A and 28.9% after E (a 51% reduction after A and a 42.3% reduction after E in respect to placebo - both p less than .05). Systolic blood pressure profiles differed less than 5 mmHg between placebo and A, as well as between placebo and E, between 9:30 and 10:30. Diastolic blood pressure profiles differed less than 5 mmHg between placebo and A over 2 h (between 2:30 and 3:30, and between 10:30 and 11:30), and between placebo and E over 2 other h (between 9:30 and 10:30, and between 11:30 and 12:30). None of the routine hematochemical parameters differed between placebo, A and E.(ABSTRACT TRUNCATED AT 250 WORDS)