Resistant hypertension and left ventricular hypertrophy: an overview.

Available data on subclinical cardiac damage in resistant hypertension (RH) are rather scanty. Thus, we sought to review the literature focusing on the association between RH and left ventricular hypertrophy (LVH). A MEDLINE search was performed to identify relevant articles using the key words "resistant hypertension, " "refractory hypertension," "left ventricular hypertrophy," "cardiac damage," and "left ventricular dysfunction." Full articles published in the English language in the last two decades (December 1, 1989, to July 31, 2010) reporting studies in adult or elderly individuals, were considered. Checks of the reference lists of selected articles complemented the electronic search. A total of 11 cross-sectional and longitudinal studies, including 3325 patients attending outpatient hypertension clinics, were considered. Prevalence rates of echocardiographic LVH, as assessed by updated criteria, ranged from 55% to 75% of patients with RH, peaking to 91% in the subgroup with concomitant electrocardiographic (ECG) LV strain. Reduction in ECG-LVH induced by treatment showed a relevant beneficial impact on cardiovascular prognosis. These data support the view that initial and on-treatment assessment of LVH in patients with RH is important for cardiovascular risk monitoring and therapeutic strategies decision-making.

Ambulatory blood pressure and diabetes: targeting nondipping.

A reduced fall in nocturnal blood pressure (BP) (i.e. non-dipping) has been related to an increase in target organ damage and cardiovascular (CV) events. Numerous studies have shown that non-dipping is highly prevalent in patients with type 1 and 2 diabetes mellitus. In this paper we reviewed recent literature and our personal data on the prevalence and clinical correlates of abnormal diurnal BP rhythm in diabetic patients; in particular we examined the association of this condition with renal, cardiac, and vascular pre-clinical organ damage as well as CV prognosis. A consistent body of evidence based on cross-sectional and longitudinal studies indicates that the lack of the physiologic nocturnal fall in BP may be considered a true clinical trait, a reliable marker of preclinical CV and renal disease and an independent predictor of future CV events. Thus, in the diabetic setting ambulatory BP monitoring (ABPM) should be regarded as a pivotal tool for improving CV risk stratification and therapeutic interventions.

Fixed combination of manidipine and delapril in the treatment of mild to moderate essential hypertension: evaluation by 24-hour ambulatory blood pressure monitoring.

This present study assessed the antihypertensive efficacy of the fixed combination of manidipine and delapril by ambulatory blood pressure monitoring in patients with hypertension inadequately controlled by monotherapy with either component. After a 2-week placebo period, 55 mild to moderate hypertensive patients were randomized to manidipine 20 mg o.d. or delapril 30 mg b.i.d. for 4 weeks. After this period, 30 patients, aged 30-76 years (18 males and 12 females) whose diastolic blood pressure was not adequately controlled (> or = 90 mmHg) by monotherapy were treated with the fixed combination of manidipine 10 mg plus delapril 30 mg o.d. for 8 weeks. A 24-h ambulatory blood pressure monitoring recording was performed at the end of the placebo washout, of the monotherapy and of the combination therapy. Blood pressure control over the 24 h was quantified by the trough-to-peak ratio and the smoothness index. As compared to placebo, the fixed combination of manidipine and delapril produced a statistically significant (p<0.01) decrease in sitting clinic (18 +/- 9/14 +/- 5 mmHg) and 24-h blood pressure (12 +/- 7/10 +/- 5 mmHg) without affecting heart rate. This reduction was greater than that observed with single components. At the end of the 8-week combination treatment period, the rate of normalilized patients was 73%. Treatment with the fixed combination was associated with a positively high smoothness index (1.2 +/- 0.7/13.8 +/- 0.8) and with a relatively good trough-to-peak ratio (0.46/0.60). The combination of manidipine and delapril produced significant and smooth reductions in blood pressure values, which persisted over the 24-h dosing interval. These results support the use of fixed manidipine-delapril combination in the treatment of mild to moderate hypertensive patients inadequately controlled by monotherapy.

Prevalence of home blood pressure measurement among selected hypertensive patients: results of a multicenter survey from six hospital outpatient hypertension clinics in Italy.

AIM: The purpose of this study was to evaluate the prevalence of home blood pressure (BP) measurement, the type of devices and accuracy in a large sample of hypertensive patients referred to hospital outpatient hypertension clinics. METHODS: Eight hundred and fifty-five consecutive treated hypertensive patients who attended six specialized centers during a period of 4 months were included. They underwent the following procedures: (i) detailed medical interview by a structured questionnaire; (ii) physical examination; (iii) standard 12-lead electrocardiogram; (iv) BP measurements taken by a validated mercury sphygmomanometer and patient's devices. RESULTS: A total of 640 (74.7%) of 855 patients were regularly performing home BP measurement. These patients were on average younger than those not practising it (58 vs 60 years, p<0.01); men were more numerous than women (58 vs 44%, p=0.03) and had higher educational level. Electronic arm-cuff instruments were the most frequently used devices (58%) followed by wrist devices (19%) and mercury or aneroid sphygmomanometers (23%). Significant correlations were found between BPs measured by validated mercury sphygmomanometers and patients' devices [r=0.85, p<0.0001 for systolic BP (SBP) and r=0.78, p<0.0001 for diastolic BP (DBP)]. Differences 5 mmHg in SBP or DBP were found in 50 and 60% of patients, respectively. CONCLUSIONS: Our findings indicate that: (i) home BP measurement is performed by a majority of treated hypertensives seen in specialized centers; (ii) male gender, age and educational level seem to influence the adoption of home BP monitoring; (iii) electronic arm-cuff devices are the most used instruments; (iv) a notable fraction of patient's devices do not meet the accuracy criteria recommended by US Association for the Advancement of Medical Instrumentation.

Awareness of hypertension guidelines in general practice: a pilot study in Lombardy.

BACKGROUND: An adequate knowledge of hypertension guidelines by primary care physicians is a fundamental step for the improvement of the diagnosis and treatment of hypertension in the general population. The aim of this study was to evaluate, in a local survey in the northern area of Lombardy, the general practitioners' knowledge of the WHO/ISH guidelines. METHODS: A 10-item mail questionnaire based on the 1999 WHO/ISH hypertension guidelines was sent to a sample of 280 primary care physicians. The number of answers in agreement with the guidelines was used as a measure of guidelines knowledge, that was considered adequate if a correct answer to 6 out of 10 questions, in addition to an adequate definition of hypertension, was provided. RESULTS: The analysis was based on 83 returned questionnaires, that means a 29% response rate. Guidelines knowledge was adequate in 23.5% of the total study population and the mean score of correct answers was 5.5 points. A significant negative correlation (r = 0.27, p < 0.05) was observed between the mean score of knowledge and the physician's age. CONCLUSIONS: In a sample of primary care physicians from a northern region of Italy, the hypertension guidelines knowledge is inadequate; the reasons and the extent of this poor awareness will require further studies.