How important is blood pressure variability?

Arterial blood pressure (BP) is a continuous variable, with a physiology characterized by significant variability stemming from the complex interaction among haemodynamic factors, neuronal reflexes, as well as hormonal, behavioural, and environmental stimuli. The homoeostatic response accounts for the physiologic variability in BP in normotensive individuals, which is more evident in hypertensive patients. Blood pressure variability is a complex phenomenon, which could be classified in various types: very short term (beat to beat), short term (during 24 h), mid-term (day by day), long term (<5 years), and very long term (>5 years). Accurate measurement of BP variability represents a complex and often controversial endeavour, despite several methodological approaches are available. Albeit a prognostic significance has been demonstrated for some indicators of BP variability, the clinical significance of this measurement is still uncertain. In fact, none of the indicators presently available for BP variability, including early morning BP rise, substantially affects, and redefines, the cardiovascular risk of the hypertensive patient, over and beyond the mere BP values. Accordingly, in defining the cardiovascular risk, the focus should be on the absolute BP values, which remain the most relevant risk factor, and the one more susceptible to modification with both non-pharmacologic and pharmacologic treatment.

Cerebral small-resistance artery structure and cerebral blood flow in normotensive subjects and hypertensive patients.

INTRODUCTION: The aim of this study was to prospectively investigate whether the structure of cerebral small-resistance arteries is related to cerebral perfusion parameters as measured with dynamic susceptibility-weighted contrast magnetic resonance imaging (DSC-MRI) in a selected cohort of hypertensive and normotensive patients. METHODS: Ten hypertensive and 10 normotensive patients were included in the study. All patients underwent neurosurgical intervention for an intracranial tumor and were investigated with DSC-MRI at 1.5 T. Cerebral small-resistance arteries were dissected from a small portion of morphologically normal cerebral tissue and mounted on an isometric myograph for the measurement of the media-to-lumen (M/L) ratio. A quantitative assessment of cerebral blood flow (CBF) and volume (CBV) was performed with a region-of-interest approach. Correlation coefficients were calculated for normally distributed variables. The institutional review board approved the study, and informed consent was obtained from all patients. RESULTS: Compared with normotensive subjects, hypertensive patients had significantly lower regional CBF (mL/100 g/min) in the cortical grey matter (55.63 ± 1.90 vs 58.37 ± 2.19, p < 0.05), basal ganglia (53.34 ± 4.39 vs 58.22. ± 4.33, p < 0.05), thalami (50.65 ± 3.23 vs 57.56 ± 4.45, p < 0.01), subcortical white matter (19.32 ± 2.54 vs 22.24 ± 1.9, p < 0.05), greater M/L ratio (0.099 ± 0.013 vs 0.085 ± 0.012, p < 0.05), and lower microvessel density (1.66 ± 0.67 vs 2.52 ± 1.28, p < 0.05). A statistically significant negative correlation was observed between M/L ratio of cerebral arteries and CBF in the cortical grey matter (r = -0.516, p < 0.05), basal ganglia (r = -0.521, p < 0.05), thalami (r = -0.527 p < 0.05), and subcortical white matter (r = -0.612, p < 0.01). CONCLUSION: Our results indicate that microvascular structure might play a role in controlling CBF, with possible clinical consequences.

Prognostic significance of the wall to lumen ratio of retinal arterioles evaluated by adaptive optics.

OBJECTIVE: Microvascular structural alterations may be considered an important form of hypertension-mediated organ damage. An increased media-to-lumen ratio of subcutaneous small arteries evaluated with locally invasive techniques (micromyography) predicts the development of cardiovascular (CV) events. However, it is not known whether retinal arteriole structural alterations evaluated with a noninvasive approach (Adaptive Optics) may have a prognostic significance. DESIGN AND METHODS: Two-hundred and thirty-seven subjects (mean age 58.7 ± 16.1 years, age range 13-89 years; 116 males) were included in the study: 65 normotensive subjects (27.4 %) and 172 patients with essential hypertension or primary aldosteronism (72.6 %). All subjects underwent a non-invasive evaluation of retinal arteriolar wall-to-lumen ratio (WLR) by Adaptive Optics. Subjects were re-evaluated after an average follow-up time of 4.55 years in order to assess the occurrence of clinical events (non CV and/or CV death or events). RESULTS: Fifty-four events occurred in the study population:26 were cardio-cerebrovascular events (ischemic or hemorragic stroke, atrial fibrillation, heart failure, coronary artery disease, peripheral artery disease, cardiac valvular disease) while the remaining were deaths for any cause, or neoplastic diseases. Subjects with events were older and had a WLR of retinal arterioles significantly greater than those without events. The event-free survival was significantly worse in those with a baseline WLR above the median value of the population (0.28) according to Kaplan-Mayer survival curves and multivariate analysis (Cox's proportional hazard model). The evidence was confirmed after restricting the analysis to CV events. CONCLUSIONS: Structural alterations of retinal arterioles evaluated by Adaptive Optics may predict total and CV events.

Platypnea and orthodeoxia in a patient with pulmonary embolism.

The platypnea-orthodeoxia syndrome is a rare clinical manifestation. Platypnea is defined as shortness of breath that worsens in the upright position, and orthodeoxia represents hypoxemia that aggravates in the upright position. We report a case of a patient with platypnea-orthodeoxia syndrome associated with pulmonary embolism and patent foramen ovale.

Effect of antihypertensive treatment on circulating endothelial progenitor cells in patients with mild essential hypertension.

It has been reported that the number of circulating endothelial progenitor cells (EPCs) reflects the endogenous vascular repair ability, with the EPCs pool declining in the presence of cardiovascular risk factors. However, their relationship with hypertension and the effects of anti-hypertensive treatment remain unclear. We randomized 29 patients with mild essential hypertension to receive barnidipine up to 20 mg or hydrochlorothiazide (HCT) up to 25 mg. Circulating EPCs were isolated from peripheral blood at baseline and after 3 and 6 months of treatment. Mononuclear cells were cultured with endothelial basal medium supplemented with EGM SingleQuots. EPCs were identified by positive double staining for both FITC-labeled Ulex europaeus agglutinin I and Dil-labeled acethylated low-density lipoprotein. After 3 and 6 months of treatment, systolic and diastolic blood pressure (BP) were significantly reduced. No difference was observed between drugs. An increase in the number of EPCs was observed after 3 and 6 months of anti-hypertensive treatment (p < 0.05). Barnidipine significantly increased EPCs after 3 and 6 months of treatment, whereas no effect was observed with HCT. No statistically significant correlation was observed between EPCs and clinical BP values. Our data suggest that antihypertensive treatment may increase the number of EPCs. However, we observed a different effect of barnidipine and HCT on EPCs, suggesting that, beyond its BP lowering effect, barnidipine may elicit additional beneficial properties, related to a healthier vasculature.

Effects of barnidipine in comparison with hydrochlorothiazide on endothelial function, as assessed by flow mediated vasodilatation in hypertensive patients.

BACKGROUND. In hypertensive patients, endothelial dysfunction is associated with an increased incidence of cardiovascular events. Calcium-channel antagonists can reverse impaired endothelium-dependent vasodilation in different vascular districts, while conflicting results are found in the brachial artery. Aim. To investigate the effect of barnidipine in comparison with hydrochlorothiazide on endothelial function of hypertensives, as assessed by flow-mediated vasodilation (FMD) of the brachial artery. METHODS. Patients with mild to moderate hypertension (age range 26-67 years) were randomized to receive barnidipine or hydrochlorothiazide. A thorough clinical examination, including blood pressure (BP) measurement, was performed at randomization as well as after 6, 12 and 24 weeks. FMD and 24-h BP monitoring was performed at randomization, after 12 and 24 weeks. RESULTS. After 12 and 24 weeks of treatment, a significant reduction in clinic BP was observed in both groups. Furthermore, a significant reduction in 24-h SBP and DBP was observed in patients receiving barnidipine but not in those receiving diuretic. The percentage change in FMD was different between the two groups of patients treated with barnidipine (at 12 weeks +1.2 ± 2.2%, p = 0.023 and at 24 weeks +1.25 ± 3.15%, p = 0.16 from baseline) or with hydrochlorothiazide (at 12 weeks -1.0 ± 3.0. p = 0.09 and at 24 weeks -1.78 ± 2.9%, p = 0.015 from baseline). A significant difference in FMD changes between the two groups was confirmed by analysis of covariance (p = 0.031). CONCLUSIONS. In presence of a similar clinic BP reduction, an improvement of endothelial function was observed during treatment with barnidipine but not with hydrochlorothiazide, suggesting that the barnidipine may exert a favourable effect on endothelial dysfunction in hypertensive patients.

The UrgeRe (Urgenze Ipertensive: Un Progetto Educazionale Fondato Sulla Vita Reale, Hypertensive Urgencies: A Project in the Real World) Project.

The approach to hypertensive emergiencies (HE) and urgencies (HU) may be different according to local clinical practice, despite recent guidelines and position papers recommendations. The Italian Society of Hypertension (Società Italiana della Ipertensione Arteriosa, SIIA) developed an online survey, in order to explore the awareness, management and treatment of HU in Italy, sending by e mail a 12 items questionnaire to the members of the SIIA. The results show that the definition of HU was correctly identified by 62% of the responders. Most physicians identified the role of pharmacological therapy or legal/illegal substances abuse as possible cause of BP elevation; the use of a benzodiazepine drugs was considered worthwhile by 65% of responders. The prescription of diagnostic test and drug administration significantly differed from guidelines recommendations and only 57% of the physicians reported to treat HU with oral drug administration. Sub-lingual nifedipine was prescribed by 13% or responders. This survey shows the need to further spread the updated scientific information on the management and treatment of HE and HU, along with the improvement of the interrelationship with the general practitioner health system in Italy.

Hypertension and heart failure with preserved ejection fraction: position paper by the European Society of Hypertension.

Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action.

Relationships between diuretic-related hyperuricemia and cardiovascular events: data from the URic acid Right for heArt Health study.

OBJECTIVE: Although the relationship between hyperuricemia and cardiovascular events has been extensively examined, data on the role of diuretic-related hyperuricemia are still scanty. The present study was designed to collect information on the relationship between diuretic-related hyperuricemia and cardiovascular events. METHODS: The URic acid Right for heArt Health (URRAH) study is a nationwide, multicentre, observational cohort study involving data on individuals recruited from all the Italy territory under the patronage of the Italian Society of Hypertension with an average follow-up period of 122.3 ±â€Š66.9 months. Patients were classified into four groups according to the diuretic use (yes vs. no) and serum uric acid (SUA) levels (higher vs. lower than the median value of 4.8 mg/dl). All-cause death, cardiovascular deaths and first cardiovascular event were considered as outcomes. RESULTS: Seventeen thousand, seven hundred and forty-seven individuals were included in the analysis. Mean age was 57.1 ±â€Š15.2 years, men were 45.3% and SBP and DBP amounted to 144.1 ±â€Š24.6 and 85.2 ±â€Š13.2 mmHg. 17.2% of individuals take diuretics of whom 58% had SUA higher than median value. Patients with hyperuricemia without diuretic use served as reference group. In multivariate adjusted analysis (sex, age, SBP, BMI, glucose, total cholesterol, and glomerular filtration rate) individuals with hyperuricemia and diuretic use exhibit a similar risk for the three outcomes as compared with the reference group. CONCLUSION: Our study showed that diuretic-related hyperuricemia carry a similar risk of cardiovascular events and all-cause mortality when compared with individuals that present hyperuricemia in absence of diuretic therapy.

Small artery remodelling in diabetes.

The aim of this article is to briefly review available data regarding changes in the structure of microvessels observed in patients with diabetes mellitus, and possible correction by effective treatment. The development of structural changes in the systemic vasculature is the end result of established hypertension. In essential hypertension, small arteries of smooth muscle cells are restructured around a smaller lumen and there is no net growth of the vascular wall, although in some secondary forms of hypertension, a hypertrophic remodelling may be detected. Moreover, in non-insulin-dependent diabetes mellitus a hypertrophic remodelling of subcutaneous small arteries is present. Indices of small resistance artery structure, such as the tunica media to internal lumen ratio, may have a strong prognostic significance in hypertensive and diabetic patients, over and above all other known cardiovascular risk factors. Therefore, regression of vascular alterations is an appealing goal of antihypertensive treatment. Different antihypertensive drugs seem to have different effect on vascular structure. In diabetic hypertensive patients, a significant regression of structural alterations of small resistance arteries with drugs blocking the renin-angiotensin system (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers) was demonstrated. Alterations in the microcirculation represent a common pathological finding, and microangiopathy is one of the most important mechanisms involved in the development of organ damage as well as of clinical events in patients with diabetes mellitus. Renin-angiotensin system blockade seems to be effective in preventing/regressing alterations in microvascular structure.

Relationship between arterial stiffness and unattended or attended blood pressure values.

BACKGROUND AND METHOD: Measurement of 'unattended' blood pressure (BP) may reduce or eliminate the 'white-coat effect'. Despite the possible advantages of this approach for BP measurement, only few studies analysed the relationship between unattended BP and cardiovascular events or with hypertension-mediated organ damage (HMOD). The aim of our study was to evaluate the relationship between 'attended' or 'unattended' BP values and carotid-femoral pulse wave velocity (PWV) in 285 individuals undergoing a visit and assessment of arterial stiffness at an ESH Excellence Centre. Unattended BP (measured with the patient alone in the room, with an oscillometric device programmed to perform three BP measurements, at 1-min intervals, after 5 min) and attended BP were measured with the same device, on the same day of the measurement of PWV, in a random order. RESULTS: Mean age was 63 ±â€Š13 years, mean BMI 26 ±â€Š4, 47% were women, 76% had hypertension (55% treated). Systolic unattended BP was lower than attended SBP (124.4 ±â€Š14.3 vs. 130.9 ±â€Š16.1 mmHg). PWV was similarly correlated with attended and unattended SBP values (r = 0.428 and r = 0.404, P < 0.0001, respectively). No difference for the prediction of increased arterial stiffness was observed at receiver operator curves (ROCs) analysis [attended SBP area under the curve (AUC) 0.665, 95% confidence interval (95% CI) 0.607-0.720 vs. unattended SBP: AUC 0.651, 95% CI 0.593-0.706, P for the comparison = ns]. CONCLUSION: Attended and unattended BP values are similarly correlated with PWV, the gold standard measure of arterial stiffness. These findings may provide further information on the clinical value of unattended BP.

Hypertensive emergencies and urgencies: a single-centre experience in Northern Italy 2008-2015.

BACKGROUND: An increasing attention is given to emergency departments (EDs) admissions for an acute and severe rise in blood pressure (BP). Data on epidemiology and treatment of hypertensive emergencies and urgencies admitted to ED are still limited. The aim of our study was to evaluate the prevalence, clinical presentation and treatment of patients admitted for hypertensive emergencies or hypertensive urgencies. METHODS: Medical records of consecutive patients aged at least 18 years, admitted to the ED of the Spedali Civili in Brescia in 2008 and in 2015 and presenting with SBP at least 180 mmHg and/or DBP at least 120 mmHg were prospectively collected and analysed. RESULTS: The prevalence of patients admitted with acute BP rise was 2.0% (n = 1551, age 70 ±â€Š14 years) in 2008 and 1.75% (n = 1214, age 69.7 ±â€Š15 years) in 2015. According to the clinical presentation and the presence of acute organ damage, patients were defined hypertensive emergencies (20.4 and 15.4%, respectively, in 2008 and 2015) or as hypertensive urgencies (79.6 and 84.5%, respectively, in 2008 and 2015). SBP and DBP values were higher in patients with emergencies than in those with urgencies (BP 193 ±â€Š15/102 ±â€Š15 vs. 189 ±â€Š13/96 ±â€Š13 mmHg in 2008 and 192 ±â€Š17/98 ±â€Š15 vs. 189 ±â€Š12/94 ±â€Š15 mmHg in 2015, P < 0.001 for both).Among hypertensive emergencies, the different forms of organ damage were 25% acute coronary syndromes and 1% aortic dissection in both periods, 34 and 38% acute heart failure, 40 and 37% stroke. CONCLUSION: Admission to the ED for hypertensive emergencies and hypertensive urgencies is still high. Diagnosis and treatment are still not appropriate and require the rapid application of recently published guidelines.

Independent association of ECG abnormalities with microalbuminuria and renal damage in hypertensive patients without overt cardiovascular disease: data from Italy-Developing Education and awareness on MicroAlbuminuria in patients with hypertensive Disease study.

OBJECTIVES: Renal abnormalities are strongly associated with cardiac damage in essential hypertension. Detection of preclinical cardiac and renal abnormalities is a key clinical step in hypertension management. This study investigated the relationship between ECG abnormalities and microalbuminuria (MAU) in hypertensive patients without overt cardiovascular disease. This relationship, in fact, has never been extensively studied. METHODS: The study population was that of Italy-Developing Education and awareness on MicroAlbuminuria in patients with hypertensive Disease, a large observational study including 4121 hypertensive patients in Italy. Patients with overt cardiovascular diseases were excluded from the present analysis. ECGs were centrally read and urinary albumin/creatinine ratio was carefully assessed. Chronic kidney disease was defined by the presence of albuminuria or by a reduction of glomerular filtration rate. RESULTS: The presence of ECG abnormalities was significantly and directly associated with chronic kidney disease [odds ratio (OR) 1.66, 95% confidence interval (CI) 1.32-2.07, P<0.001], particularly with MAU (OR 1.81, 95% CI 1.39-2.36, P<0.001). Main selected ECG abnormalities were also significantly associated with MAU [rhythm abnormalities (OR 2.94, 95% CI 1.77-4.88, P<0.001), intraventricular conduction defects (OR 1.95, 95% CI 1.32- 2.87, P<0.01), ventricular repolarization alterations (OR 1.84, 95% CI 1.26-2.70, P<0.01) and left-axis deviation (OR 1.87, 95% CI 1.26-2.79, P<0.01)]. After adjustment for confounders, an abnormal ECG and all the main ECG abnormalities remained significantly associated with MAU. CONCLUSION: This is the first large and systematic analysis of the relationship between detailed ECG abnormalities and MAU/chronic kidney disease in hypertensive patients without overt cardiovascular diseases. We report a significant and independent relationship between the presence of ECG abnormalities and renal damage in a preclinical stage of hypertension. Identification of ECG abnormalities in hypertension should prompt physicians to careful detection for renal damage, also in order to achieve an accurate risk stratification.

Vascular remodeling, macro- and microvessels: therapeutic implications.

Macrovasculature and microvasculature are deeply interrelated, since microvascular structure is not only the site of vascular resistance but probably also the origin of most of the wave reflections generating increased central systolic blood pressure. In fact, preliminary data suggest that some index of large artery stiffness is related with the media to lumen ratio of subcutaneous small resistance arteries of hypertensive patients. Microvascular structural alterations and changes in the mechanical properties of the macrovessels represent potent predictors of prognosis. Hypertension-related damage to the micro- and macrovascular system may be corrected by pharmacological agents. Among them, beta-blocking agents and diuretics have a negligible effect on microvascular structure, while renin-angiotensin system antagonists and calcium entry blockers have favorable actions, improving large artery mechanics and possibly reducing central wave reflections.

The effect of pregnancy on subsequent relapse from Graves' disease after a successful course of antithyroid drug therapy.

OBJECTIVE: Pregnancy and the postpartum (PP) period are associated with profound changes of the immune system, which largely influence the clinical activity of autoimmune diseases. The aim of this study was to evaluate the effect of pregnancy and/or the PP period in driving a clinical relapse of hyperthyroidism in patients with Graves' disease (GD) who are in remission after antithyroid drug (ATD) treatment. Data were retrospectively collected from 150 female patients with GD, who were assigned to two groups according to the occurrence of a successful pregnancy after ATD withdrawal. RESULTS: Relapsing Graves' hyperthyroidism was observed in 70 of 125 patients in group I (no pregnancy after ATD withdrawal) (56.0%) and 21 of 25 patients in group II (pregnancy after ATD withdrawal) (84.0%) (P < 0.05). Logistic regression analysis (dependent variable: relapse/nonrelapse; covariates: age, positive family history for autoimmune thyroid disease, duration of treatment with ATD, number pregnancies at diagnosis, number of pregnancies after ATD withdrawal) showed a significant effect only for the number of pregnancies after ATD withdrawal [4.257 (1.315-13.782)]. The effect was ascribed to the PP period rather than to pregnancy itself because in 20 of 21 patients of group II (95.2%), the relapse of Graves' hyperthyroidism occurred between 4 and 8 months after delivery. CONCLUSIONS: The PP period is significantly associated with a relapse of hyperthyroidism in GD patients being in remission after ATD. We therefore recommend that patients with GD in remission after a course of ATD should have their thyroid function tested at 3 and 6 months after delivery.

Reduced thyroid volume and nodularity in dyslipidaemic patients on statin treatment.

BACKGROUND: Little information is available concerning the possible antiproliferative effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) on the thyroid gland. We have hypothesized that the antiproliferative effects of statins observed in thyroid cell lines in vitro may have a clinical counterpart that could be detected by investigating the prevalence and size of thyroid nodules in patients on long-term treatment with statins. METHODS: We retrospectively evaluated 135 dyslipidaemic patients receiving statin therapy continuously for at least 5 years, and 137 controls. All the subjects were submitted to ultrasound investigation of the thyroid gland, to establish prevalence, number and volume of thyroid nodules. RESULTS: Subjects treated with statins showed markedly lower prevalence of thyroid nodules (36.3%vs. 67.9%, P < 0.001), as well as reduced number and smaller total volume of lesions, as compared to the control group. A logistic regression analysis, taking into account age, sex, risk factors for the development of thyroid nodules and concomitant drug treatment, revealed that treatment with statins remained the only important predictor of the presence of thyroid nodules [odds ratio (OR) 0.312, 95% confidence interval (CI) 0.156-0.625, P < 0.001] besides risk factors. CONCLUSIONS: Our data provide the first circumstantial evidence of an association between HMG-CoA reductase inhibitor treatment and reduced prevalence, number and volume of thyroid nodules. This finding may be explained by an antiproliferative and/or pro-apoptotic effect of long-term statin treatment on thyroid cells, in vivo.

Aggressive thyroid carcinoma showing thymic-like differentiation (CASTLE): case report and review of the literature.

Carcinoma showing thymic-like differentiation (CASTLE) is a rare tumour of the thyroid, which arises from ectopic thymic tissue or remnants of branchial pouches. A systematic review of English literature evidences less than thirty cases; from them, it clearly appears that CASTLE is considered an indolent slow-growing neoplasia even when lymph nodes metastasis are present. We describe a case of very aggressive CASTLE, which showed seeding along fine needle aspiration tract.

Determinants of the structure of resistance-sized arteries in hypertensive patients.

OBJECTIVE: It has been previously demonstrated that structural alterations of subcutaneous small resistance arteries of hypertensive patients, as indicated by an increased media to lumen (M/L) ratio, is the most potent predictor of cardiovascular events. The aim of the present study was to identify possible determinants of small resistance artery structure that may be evaluated with non-invasive approaches. MATERIALS AND METHODS: One hundred and ninety-nine subjects (normotensives, essential hypertensives and patients with secondary hypertension) were included in the present study. All subjects were submitted to a biopsy of subcutaneous fat from the gluteal or the anterior abdominal region. Small resistance arteries were dissected and mounted on an isometric myograph, and M/L ratio was measured. All patients underwent standard biochemical tests, clinic blood pressure measurement, standard echocardiography and 24-h ambulatory blood pressure measurement. Glomerular filtration rate (GFR) was calculated according to MDRD study formula and Cockroft's formula. RESULTS: Significant correlation was found between M/L ratio and, respectively: GFR calculated both with MDRD study formula and Cockroft-Gault formula, creatinine serum, blood urea nitrogen, glycaemia, circulating sodium, clinical pulse pressure, stroke volume to pulse pressure ratio, clinical systolic, diastolic and mean arterial pressure, daytime pulse pressure. However, in a multivariate regression analysis, only serum creatinine remained in the model, and proved to be an independent predictor of small artery structure. CONCLUSIONS: Indices of renal function and, probably, of large artery distensibility may be related to small arteries remodelling in hypertension.

Reduction of Cardiovascular Risk through Angiotensin II Type 1 Receptor Antagonism : Focus on Olmesartan Medoxomil.

It is well recognized that angiotensin II is involved in the pathogenesis of hypertension. Less well recognized - until recently, at least - is its involvement in the pathogenesis of atherosclerosis. However, it is now evident that angiotensin II promotes oxidative stress, vascular remodelling, inflammation, and the formation of atherosclerotic lesions. These actions, which are mediated almost exclusively by the angiotensin II type 1 (AT(1)) receptor, can be blocked by administration of angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]). Of the seven ARBs currently in clinical use, olmesartan is one of the most effective. The rapid and consistent antihypertensive efficacy of this drug, which allows a high proportion of patients to achieve their target blood pressure (BP), is associated with beneficial effects on oxidative stress, vascular remodelling, inflammation, and atherosclerotic lesion formation. These effects appear to be independent of the BP-lowering activity of olmesartan. In clinical trials, olmesartan has been shown to control microinflammation in hypertensive patients, to reduce oxidative stress in patients with type 2 diabetes mellitus, and to normalize the wall: lumen ratio of small resistance arteries (a measure of vascular remodelling) in patients with hypertension. Moreover, in a 2-year study involving hypertensive patients with carotid atherosclerosis (the MORE [Multicentre Olmesartan atherosclerosis Regression Evaluation] trial), olmesartan reduced the intima-media thickness of the carotid artery and significantly reduced the volume of large atherosclerotic plaques. These data suggest that olmesartan may reduce cardiovascular risk by simultaneously normalizing BP and reversing the proatherogenic effects of angiotensin II.

Italian society of hypertension guidelines for conventional and automated blood pressure measurement in the office, at home and over 24 hours.

This article offers instructions and recommendations on how to perform blood pressure measurements in the doctor's office, in the patient's home and in ambulatory conditions over 24 hours. Great attention is paid to some of the general aspects of blood pressure measurement, including the accuracy of blood pressure measuring devices, the importance of a 'white-coat effect', and the need for patient education. This article also deals with a number of practical details, such as the importance of patient's relaxation and position, arm position and support, arm selection and cuff selection and application. Recommendations are provided on the observer's position and performance, and on the need to pay attention to specific factors affecting the blood pressure measurement in different patient populations, namely in children, elderly and obese people, pregnant women, patients with arrhythmias and patients on treatment. This article then separately focuses on the characteristics of auscultatory and automated measurements, the latter performed either in the office, at home or over 24 hours in ambulatory settings. Home blood pressure monitoring (HBPM) is becoming increasingly important in the diagnosis and management of arterial hypertension. The importance of HBPM in cardiovascular prevention, related to a deeper involvement of patients in their long-term management, and the wide diffusion of this approach in populations, is not always accompanied by adequate knowledge of how to make proper use of this technique, which emphasizes the need for more precise recommendations. This article summarizes the available evidence and provides recommendations on the use of home blood pressure monitoring in clinical practice and in research. It updates the previous recommendations on the same topic issued in 2000. The main topics addressed include the methodology of HBPM, focusing on measurement conditions and procedures, ranging from patient/subject position, to arm selection, arm position and support, cuff selection and application and data reporting, diagnostic and therapeutic thresholds, clinical applications in hypertension (with specific reference to special populations) and its applications in research. Special attention is given to device validation and selection as well as to patient education and to the need of HBPM to be guided by the physician in charge. The final section deals with the problems related to the implementation of these recommendations in clinical practice. Finally, the methodology and clinical impact of 24-hour ambulatory blood pressure monitoring are also addressed in detail, focusing on the parameters that can be derived from the analysis of 24-hour blood pressure recordings applied both to the diagnostic and prognostic evaluation of hypertensive patients and to the assessment of the effectiveness of antihypertensive treatment in controlling blood pressure through the day and night. Instructions to users on how to properly perform HBPM are provided as an appendix.