The role of HDL cholesterol in metabolic syndrome predicting cardiovascular events. The Gubbio population study.

BACKGROUND AND AIMS: Metabolic syndrome (MS) has recently been claimed to be an important new risk factor for the occurrence of coronary heart disease (CHD) and cardiovascular disease (CVD) events, although it is simply a combination of known risk factors used in a dichotomized fashion. The aims of this analysis were to explore the predictive role of MS for CHD and CVD events in a population study, in comparison with using the same factors in a continuous fashion, with special emphasis on HDL cholesterol. METHODS AND RESULTS: In the second examination of the Gubbio population study from central Italy, 2650 cardiovascular disease-free men and women, aged 35-74 years around 1990, were examined and followed-up for 12 years. The classic risk factors (sex, age, systolic blood pressure, serum cholesterol and smoking habits) were studied as predictors of CHD and CVD events, alone and with the contribution of other factors (HDL cholesterol, blood glucose, serum triglycerides and waist circumference) included in the so-called MS, based on several multivariate models. MS was also tested after adjustment for other risk factors. MS produced a predictive significant relative risk of 1.67 for CHD events and 1.82 for CVD events, but considering its single risk factors, the only ones contributing to prediction were HDL cholesterol and systolic blood pressure. Dedicated analyses showed that MS does not add anything to the power of prediction beyond the role of the single risk factors treated in a continuous fashion, while the best predictive power is obtained using classic risk factors (sex, age, smoking habits, total cholesterol, systolic blood pressure) with the addition of HDL cholesterol. CONCLUSIONS: The predictive power of MS is bound only to the presence of HDL cholesterol and blood pressure and does not add anything to using the same risk factor treated in a continuous fashion.

[Management of high blood pressure in children and adolescents: Recommendations of the European Society of hypertension]. / Manejo de la hipertensión arterial en niños y adolescentes: recomendaciones de la Sociedad Europea de Hipertensión.

Hypertension in children and adolescents has been gaining ground in cardiovascular medicine, mainly due to the advances made in several areas of pathophysiological and clinical research. These guidelines arose from the consensus reached by specialists in the detection and control of hypertension in children and adolescents. Furthermore, these guidelines are a compendium of scientific data and the extensive clinical experience it contains represents the most complete information that doctors, nurses and families should take into account when making decisions. These guidelines, which stress the importance of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, should act as a stimulus for governments to develop a global effort for the early detection and suitable treatment of high pressure in children and adolescents. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Manejo de la hipertensión arterial en niños y adolescentes: recomendaciones de la Sociedad Europea de Hipertensión / Management of high blood pressure in children and adolescents: Recommendations of the European Society of hypertension

La hipertensión en niños y adolescentes ha ido ganando terreno en la medicina cardiovascular, gracias a los avances producidos en distintas áreas de la investigación fisiopatológica y clínica. Estas guías nacen del consenso al que han llegado los especialistas en la detección y control de la hipertensión en niños y adolescentes. Por otra parte, dichas guías son un compendio de los datos científicos y la extensa experiencia clínica con la que se cuenta, y constituyen la información clínica más completa que los médicos, enfermeras y familiares deberían tener en cuenta a la hora de tomar decisiones. Estas guías, que hacen hincapié en la importancia de la hipertensión en niños y adolescentes, así como en el papel que desempeña en la actual epidemia de enfermedades cardiovasculares, deberían constituir un estímulo para que los gobiernos desarrollaran un esfuerzo global para una detección precoz y un tratamiento adecuado de la hipertensión arterial en niños y adolescentes. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins(AU)

Hypertension in children and adolescents has been gaining ground in cardiovascular medicine, mainly due to the advances made in several areas of pathophysiological and clinical research. These guidelines arose from the consensus reached by specialists in the detection and control of hypertension in children and adolescents. Furthermore, these guidelines are a compendium of scientific data and the extensive clinical experience it contains represents the most complete information that doctors, nurses and families should take into account when making decisions. These guidelines, which stress the importance of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, should act as a stimulus for governments to develop a global effort for the early detection and suitable treatment of high pressure in children and adolescents. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins(AU)

European Society of Hypertension practice guidelines for home blood pressure monitoring.

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

Evaluation of subclinical cardiac damage in arterial hypertension: From guidelines to clinical practice

The increased use of echocardiography and related techniques for both research and clinical purposes is related with the identification of a variety of subclinical cardiac changes in subjects with hypertension, with special relevance of left ventricular hypertrophy (LVH). LVH, assessed by electrocardiography (EKG) or echocardiography, is a strong, independent predictor for cardiovascular events and all-cause mortality in hypertensive individuals. EKG is the standard technique for detecting LVH in patients with hypertension; however, its sensitivity is lower than echocardiography. Echocardiography provides information on cardiac anatomy and function unavailable by any other means with comparable cost-effective profile and is free of any biological risk, but the technique entails a number of technical problems in imaging acquisition and data interpretation (intra- and inter-observer variability, low quality of imaging in obese subjects and in individuals with chronic pulmonary diseases, need for adequate echocardiograms. This manuscript reviews the persistent gap between clinical practice and evidence-based medicine and guidelines for subclinical cardiac damage evaluation (AU)

La utilización aumentada de la ecocardiografía y las técnicas relacionada tanto para los objetivos clínicos como para la investigación está relacionada con la identificación de una variedad de cambios cardíacos subclínicos en sujetos con hipertensión, con especial importancia de la hipertrofía ventricular izquierda (HVI). La HVI, evaluada por la electrocardiografía (ECG) o la ecocardiografía, es un fuerte predictor independiente para los acontecimientos cardiovasculares y la mortalidad por todas las causas en individuos hipertensos. La ECG es una técnica estándar para la detección de la HVI en pacientes con hipertensión. Sin embargo, su sensibilidad es más baja que la de la ecocardiografía. La ecocardiografía nos proporciona información sobre la anatomía y función cardíaca que no está disponible por otros medios, con un perfil coste-efectivos comparable y está libre de cualquier riesgo biológico. Sin embargo, la técnica conlleva unos cuantos problemas técnicos en la adquisición de las imágenes y la interpretación de los datos (variabilidad intra- e inter- observador, baja calidad de las imágenes en los obesos y en individuos con enfermedades pulmonares crónicas, necesidad para ecocardiogramas adecuados. Este manuscrito revisa la laguna persistente entre la práctica clínica y la medicina basada en la evidencia con las guías para la evaluación del daño cardíaco subclínico (AU)

Extracardiac organ damage in essential hypertensives with left ventricular concentric remodelling.

Clinical and prognostic values of left ventricular concentric remodelling (LVCR) are based on definition of this cardiac phenotype according to outdated guidelines indications. Thus, we analysed the association of extracardiac organ damage (OD) and LVCR (relative wall thickness >42) as defined by updated diagnostic criteria. Subclinical OD was searched in 1906 patients treated and untreated in essential hypertensives with normal echocardiographic LVMI as defined by two sets of gender-specific criteria based on LV mass (LVM) indexed to body surface area (125 g m(-2) in men and 110 g m(-2) in women) and height(2.7) (49 g m(-2.7) in men and 45 g m(-2.7) in women). Overall, 568 patients (29.8%), fulfilled the criteria for LVCR. Prevalence rates of carotid plaque, carotid intima-media (IM) thickening, grade II retinopathy and microalbuminuria (MA) were significantly higher in patients with LVCR compared with those with normal geometry (53, 24, 22, 10% versus 38, 15, 15, 7%, respectively, P<0.01, at least). Furthermore, an independent association between LVCR and continuous variables of OD such as carotid IM thickness (P<0.0001) and MA (P=0.004) was confirmed by a multivariate analysis. Our results indicate that LVCR identified by updated, less conservative, diagnostic criteria, is strongly associated with subclinical vascular and renal alterations of adverse prognostic significance. These findings support the view that LVCR should be searched for and regarded as a marker of target OD with an additional value for cardiovascular risk stratification in patients with normal LVM.

Indexation of left ventricular mass to body surface area and height to allometric power of 2.7: is the difference limited to obese hypertensives?

Whether left ventricular mass (LVM) should be normalized to different indexes in relation to body size is still debated. We sought to evaluate the prevalence of left ventricular hypertrophy (LVH) defined by different indexation criteria in a cohort of hypertensive subjects categorized according to body mass index (BMI). A total of 2213 essential hypertensive subjects included in the Evaluation of Target Organ Damage in Hypertension (ETODH) were divided in three groups according to BMI thresholds (<25, 25-29.9 and >or=30 kg m(-2)). All patients underwent extensive investigations including quantitative echocardiography. LVH was defined as an LVM index equal to or higher than (1) 125 g m(-2) in men and 110 g m(-2) in women, (2) 51 g m(-2.7) in men and 47 g m(-2.7) in women. Overall, 687 out of 2213 patients (31.0%) were found to have LVH when LVM was indexed to body surface area (BSA) and 1030 (46.5%) when indexed to height(2.7). A total of 845 patients (38.2%) had normal BMI, 954 patients (43.1%) were overweight and 414 (18.7%) were obese. Prevalence rates of LVH in the three groups were 25.1, 31.6, 41.2% by indexation to BSA and 29.9, 50.5, 71.8% by indexation to height(2.7), respectively. LVM indexed to BSA markedly underestimates LVH prevalence in obese as well as overweight hypertensive patients. To avoid a systematic misclassification of cardiovascular risk, LVM should be routinely indexed to height(2.7) in overweight and obese patients representing a large percentage of the hypertensive population.

Metabolic syndrome and biventricular hypertrophy in essential hypertension.

The metabolic syndrome (MS) is associated with structural and functional alterations of the left ventricle (LV); no evidence is available on the impact of the MS on the right ventricle (RV). To assess whether MS, as defined by the ATP III report, is associated with biventricular hypertrophy, a total of 286 hypertensive subjects (mean age 58.7+/-12.2 years) attending our outpatient clinic underwent the following procedures: (1) physical examination and standard clinic blood pressure (BP) measurement; (2) routine laboratory investigations; (3) M-mode, two-dimensional and Doppler echocardiography. LV hypertrophy (LVH) was defined by LM mass index>or=51/47 g m(-2.7) in men and women, respectively. Right-sided chambers were measured in parasternal long axis at the outflow tract and subcostal view; RV hypertrophy (RVH) was defined by anterior RV wall thickness>or=6.0/5.5 mm in men and women, respectively. Filling velocities of both ventricles were assessed by pulsed Doppler echocardiography. Structural cardiac alterations were more pronounced in hypertensive men and women with MS than in their non-MS counterparts and involved both ventricles as shown by the differences in continuous variables as well as in prevalence rates of LVH (58 and 48% vs 28 and 30%, respectively, P<0.01) and RVH (48 and 54% vs 25 and 35%, respectively, P<0.01). Both LV and RV filling in MS hypertensives were more dependent on the atrial systole. Our study shows that in human hypertension, structural and functional cardiac changes induced by MS are not limited to the LV but also involve the right one.

Prevalence and correlates of multiple organ damage in referred treated hypertensives: data from the ETODH study.

This study, carried out in a large cohort of treated essential hypertensives attending an out-patient hospital hypertension clinic, extends previous observations by showing that a clustering of two or three markers of organ damage (OD) has a higher prevalence than a single organ involvement. These findings call for a systematic evaluation of cardiac and extracardiac OD in treated hypertensive patients referred to a specialist setting.

Ambulatory heart rate and target organ damage in never-treated essential hypertensives.

Limited evidence is available about the relationship between ambulatory heart rate (HR) and target organ damage (TOD) in uncomplicated hypertension. We sought to investigate the association between ambulatory HR and subclinical cardiac, vascular and renal markers of TOD in never-treated essential hypertensives. A total of 580 subjects with recently diagnosed (

Metabolic syndrome and left ventricular hypertrophy in a general population. Results from the Gubbio Study.

Aims of this study were to investigate the prevalence of metabolic syndrome (MS), diagnosed according to the International Diabetes Federation (IDF) criteria and its relationship with echocardiographic parameters of cardiac structure and function. The study was performed in 707 subjects, age 45-54 years, of the Gubbio Population Study who underwent a comprehensive examination including measurement of body size, blood pressure (BP) and heart rate, 12-lead electrocardiogram, Doppler echocardiography, standardized blood and urine laboratory tests. One hundred and fifty-three subjects were found to have MS, which was more frequent among hypertensive patients than normotensive controls (36.2 vs 13.7%, P<0.001). Apart from visceral obesity present in all subjects by definition according to the IDF criteria, high levels of BP (>130/85 mm Hg) and triglycerides (>or=150 mg/dl) were the most frequently observed components of the syndrome, since their prevalence averaged 75% of those with the syndrome. Left ventricular mass (95.6+/-22 vs 86.4+/-22 g/m(2); P<0.001) and prevalence of left ventricular hypertrophy were increased in the subgroup with MS. Waist circumference, BP and blood glucose were the components of the syndrome with stronger impact on cardiac mass. An early impairment of the diastolic function was detected in this subgroup with a reduction of the early-to-late diastolic filling (0.91+/-0.17 vs 0.99+/-0.23, P<0.001). The results of the present study indicate that MS is frequent in middle-aged general population, particularly in subjects with arterial hypertension. The syndrome is associated to the increase in ventricular mass and the early impairment of diastolic function.

Ambulatory blood pressure, target organ damage and aortic root size in never-treated essential hypertensive patients.

The relationship between ambulatory blood pressure (ABP), target organ damage (TOD) and aortic root (AR) size in human hypertension has not been fully explored to date. We investigated the relationship between ABP, different markers of TOD and AR size in never-treated essential hypertensive patients. A total of 519 grade 1 and 2 hypertensive patients (mean age 46+/-12 years) referred for the first time to our outpatient clinic underwent the following procedures: (1) routine examination, (2) 24 h urine collection for microalbuminuria (MA), (3) ambulatory blood pressure monitoring over two 24 h periods within 4 weeks, (4) echocardiography and (5) carotid ultrasonography. AR dilatation was defined by sex-specific criteria (> or =40 mm in men and > or =37 mm in women). AR diameter was increased in 3.7% of patients. Demographic variables (body mass index, age and male gender), average night-time diastolic blood pressure (BP) (but not clinic or average 48 h BP), left ventricular mass index and carotid intima-media (IM) thickness showed an independent association with AR size in both univariate and multivariate analyses. When TOD data were analysed in a categorical way, a stepwise increase in the prevalence of left ventricular hypertrophy (LVH) (I=17.5%, II=27.6%, III=35.8%) and carotid IM thickening (I=20.9%, II=28.8%, III=34.4%), but not in MA (I=6.8%, II=9.1%, III=8.7%) was found with the progression of AR size tertiles. Our results show that (1) AR enlargement in uncomplicated never-treated hypertensive patients has a markedly lower prevalence than traditional markers of cardiac and extracardiac TOD; (2) night-time BP, LVH and carotid IM thickening are independent predictors of AR dimension.

Blood pressure-dependent and independent effects of agents that inhibit the renin-angiotensin system.

OBJECTIVES: To evaluate the blood pressure-dependent and independent effects of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) on major cardiovascular events. METHODS: Using data from 26 large-scale trials comparing an ACEI or an ARB with placebo or another drug class, meta-regression analyses were conducted in which treatment-specific relative risks for major cause-specific outcomes [stroke, major coronary heart disease (CHD) events and heart failure] were regressed against follow-up blood pressure differences. RESULTS: From a total of 146 838 individuals with high blood pressure or an elevated risk of cardiovascular disease, 22 666 major cardiovascular events were documented during follow-up. The analyses showed comparable blood pressure-dependent reductions in risk with ACEI and ARB (P >or= 0.3 for all three outcomes). The analyses also showed that ACEI produced a blood pressure-independent reduction in the relative risk of CHD of approximately 9% (95% confidence interval 3-14%). No similar effect was detected for ARB, and there was some evidence of a difference between ACEI and ARB in this regard (P = 0.002). For both stroke and heart failure there was no evidence of any blood pressure-independent effects of either ACEI or ARB. CONCLUSION: There are similar blood pressure-dependent effects of ACEI and ARB for the risks of stroke, CHD and heart failure. For ACEI, but not ARB, there is evidence of blood pressure-independent effects on the risk of major coronary disease events.

Low glomerular filtration in the population: prevalence, associated disorders, and awareness.

Estimated glomerular filtration rate (eGFR) was used for analysis of kidney disease prevalence in the United States. The study investigated on prevalence, associated disorders, and kidney disease awareness in an Italian population sample. Data were collected on serum creatinine, other laboratory indices, blood pressure, and medical history in the Gubbio Population Study (n=4574, both sexes, ages 18-95 years). Analyses were carried out on eGFR (equation of Modification Diet in Renal Disease study), disorders potentially secondary to kidney dysfunction (hypertension, high serum uric acid, high serum phosphorus/low serum calcium, high serum potassium, cardiovascular disease, anemia), and kidney disease awareness. The prevalence of eGFR <60 ml/min x 1.73 m(2) increased with age in both sexes (from <1% for ages 18-24 years to >30% for ages > or =75 years, P<0.001). In the group with eGFR <60 ml/min x 1.73 m(2), number of disorders secondary to kidney dysfunction was > or =2 in the majority of persons, was higher than in persons with eGFR > or =60 ml/min x 1.73 m(2) (P<0.001), and was inversely related to eGFR (P<0.001). The prevalence of reported kidney disease was 3.3% in the group with eGFR <60 ml/min x 1.73 m(2) and directly related to serum creatinine and number of disorders secondary to kidney dysfunction (P<0.001). Low kidney function is frequent in the older population and is associated with disorders typical of kidney disease. Persons with low kidney function are rarely aware of kidney disease unless of very high serum creatinine or presence of many disorders typical of kidney disease.

ESH-ESC guidelines for the management of hypertension.

The following is a brief statement of the 2003 European Society of Hypertension (ESH)-European Society of Cardiology (ESC) guidelines for the management of arterial hypertension. The continuous relationship between the level of blood pressure and cardiovascular risk makes the definition of hypertension arbitrary. Since risk factors cluster in hypertensive individuals, risk stratification should be made and decision about the management should not be based on blood pressure alone, but also according to the presence or absence of other risk factors, target organ damage, diabetes, and cardiovascular or renal damage, as well as on other aspects of the patient's personal, medical and social situation. Blood pressure values measured in the doctor's office or the clinic should commonly be used as reference. Ambulatory blood pressure monitoring may have clinical value, when considerable variability of office blood pressure is found over the same or different visits, high office blood pressure is measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between blood pressure values measured in the office and at home, resistance to drug treatment is suspected, or research is involved. Secondary hypertension should always be investigated. The primary goal of treatment of patient with high blood pressure is to achieve the maximum reduction in long-term total risk of cardiovascular morbidity and mortality. This requires treatment of all the reversible factors identified, including smoking, dislipidemia, or diabetes, and the appropriate management of associated clinical conditions, as well as treatment of the raised blood pressure per se. On the basis of current evidence from trials, it can be recommended that blood pressure, both systolic and diastolic, be intensively lowered at least below 140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive patients, and below 130/80 mmHg in diabetics. Lifestyle measures should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment. The purpose is to lower blood pressure and to control other risk factors and clinical conditions present. In most, if not all, hypertensive patients, therapy should be started gradually, and target blood pressure achieved progressively through several weeks. To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy with more than one agent. The main benefits of antihypertensive therapy are due to lowering of blood pressure per se. There is also evidence that specific drug classes may differ in some effect or in special groups of patients. The choice of drugs will be influenced by many factors, including previous experience of the patient with antihypertensive agents, cost of drugs, risk profile, presence or absence of target organ damage, clinical cardiovascular or renal disease or diabetes, patient's preference.

The basic importance of the physiological approach in clinical medicine: the experience in the area of hypertension.

Since Claude Bernard the physiological approach has dramatically contributed to the unprecedented progress that clinical medicine has seen during the second half of the 19th and throughout the 20th century. If I go back to about fifty years ago, when I started as a medical student and investigator under the guidance of Giuseppe Moruzzi and Cesare Bartorelli our understanding of arterial hypertension was very small and our therapeutic abilities close to nothing, but progressive knowledge of the physiology of the sympathetic nervous system, of the kidney, of the renin-angiotensin system, etc, led to a progressive understanding of the mechanisms of elevated blood pressure and to the development of an array of effective blood pressure lowering drugs, thanks to which hypertension is now a controllable disease. The supremacy of the physiological approach to clinical medicine has been recently endangered by the rising of two new approaches, whose worshippers consider the ultimate ones promising solid conclusions and unforeseen progress. These are the large randomized therapeutics trials, that are often arrogantly defined as evidence-based medicine (as if they were to provide the only real "evidence") and molecular and genetic medicine. Needless to say, both are important new tools in medicine, but neither can make the physiological method obsolete. The risk of the pretended superiority of the new approaches (and the new fashions) is that these claims are unbalancing research activity and its financial support, thus weakening the very basis upon which these new methodologies are founded and have developed.

Prevalence and correlates of advanced retinopathy in a large selected hypertensive population. The Evaluation of Target Organ Damage in Hypertension (ETODH) study.

OBJECTIVE: To describe the prevalence of advanced retinal microvascular lesions and their associations with cardiac and extracardiac signs of target organ damage (TOD) in a large selected hypertensive population. METHODS: A total of 2172 non-diabetic untreated and treated uncomplicated essential hypertensives consecutively attending for the first time our hospital outpatient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension (ETODH), an observational ongoing registry of hypertension-related TOD, were considered for this analysis. Advanced hypertensive retinopathy was defined by the presence of any of the following lesions: flame-shaped haemorrhages, soft exudates or cotton wool spots and papilloedema. Left ventricular hypertrophy (LVH), carotid structural abnormalities, such as plaques and intima media (IM) thickening, and microalbuminuria were diagnosed according to the 2003 ESH/ESC guidelines criteria. RESULTS: Among the whole study population, 33 patients (1.5%) were found to have advanced hypertensive retinopathy. Patients with these retinal lesions were similar to those without for age, body mas index, known duration of hypertension, smoking habit, total serum cholesterol, fasting blood pressure and prevalence of antihypertensive treatment; whereas mean systolic and diastolic blood pressures were higher in the former group. The prevalence rates of LVH, carotid plaques, carotid IM thickening and microalbuminuria in patients with and without retinopathy were 57%, 67%, 69%, 19% and 25%, 47%, 44%, 12%, respectively. In a multivariate logistic regression analysis, advanced retinopathy was significantly associated with LVH (OR = 4.0), carotid IM thickening (OR = 2.9), carotid plaques (OR = 2.8), but not with microalbuminuria. CONCLUSIONS: Our study indicated that: (i) advanced retinopathy is a rare finding in non-diabetic hypertensive patients seen in a specialist setting; (ii) a strong relation exists between retinal microvascular lesions and cardiac and macrovascular markers of TOD.

Isolated ambulatory hypertension and changes in target organ damage in treated hypertensive patients.

Isolated ambulatory hypertension is a condition characterized by elevated ambulatory but normal clinic blood pressure (BP), and has been reported to be associated with increased cardiovascular risk in untreated subjects. However, little is known about the relationship between this condition and intermediate end points such as target organ damage (TOD) in treated hypertensives. We investigated the impact of isolated ambulatory hypertension on left ventricular hypertrophy (LVH) and microalbuminuria (MA) in a selected sample of treated nondiabetic hypertensives with effective and prolonged clinic BP control (BP<140/90 mmHg). Clinic BP measurements, routine diagnostic procedures, echocardiography and 24-h urine collection for MA, were undertaken in 80 patients (mean age 53+/-8 years) with essential hypertension attending our hospital outpatient centre at baseline and after an average follow-up of 30 months. At follow-up evaluation BP status was assessed by self-measurement of BP and ambulatory BP monitoring (ABPM). At the follow-up visit, 51 out of 80 patients (63.7%) reached a BP control according to ABP (average daytime BP<132/85 mmHg) criteria (group I) whereas the remaining 29 did not (group II); home BP was controlled (BP<135/85 mmHg) in all members of group I and in 86% of group II. In the overall study population, mean Sokolow voltage, LV mass index (LVMI) and urinary albumin excretion (UAE) decreased compared to baseline from 24.1+/-5.0 to 18.9+/-5.1 mm (P<0.05), 115.6+/-24.1 to 97.7+/-21.6 g/m(2) (P<0.01), 11.8+/-23.7 to 5.8+/-14.9 mg/24 h (P<0.05), respectively. The prevalence of ECG LVH, altered LV patterns and MA fell from 7.5 to 2.5% (P=NS), from 45 to 25 (P<0.01) and from 13.7 to 5.1% (P<0.05), respectively. However, when data were analysed separately for the two groups a significant decrease of echo LVH and MA was found only in patients with controlled ABP. LVMI and MA decreased from 117.1+/-23.1 to 95.9+/-22.1 g/m(2) (P<0.01) and 12.8+/-24.7 to 4.1+/-5.7 mg/24 h (P<0.05) in group I, and from 114.1+/-24.8 to 102.3+/-20.3 (P=NS) and 11.9+/-22.1 to 6.3+/-18.1 mg/24 h (P=NS) in group II. In conclusion, in the present study isolated ambulatory hypertension in treated patients is associated with a lack of regression in cardiac and extracardiac TOD, suggesting that a tight BP control throughout the 24 h plays a key role in lowering hypertension-induced structural and functional alterations at cardiac and renal level.