[Resistant hypertension in the elderly.] / L'ipertensione arteriosa resistente nell'anziano.

Actually, in literature there are no epidemiologic studies on the prevalence of resistant hypertension in the elderly; however the National Health and Nutrition Examination Survey observed in the adult population prevalence of 12.8% to clinical measurement. But, especially in elderly, it's necessary exclude pseudoresistance forms due to white coat hypertension, arterial stiffness, poor patient compliance to therapy, excessive salt intake, abuse of non-steroidal ant-inflammatory drugs and the forms of secondary hypertension. Arterial hypertension, which is really resistant, it is a greater cardiovascular risk and thus the need to implement adherence to healthy lifestyle and therapy and to implement a pharmacological therapy to block the renin-angiotensin system or a dihydropyridine calcium channel, if they are not already present in the therapy and/or aldosterone antagonists. Currently experimental clinical therapeutic studies are examining such methods as renal denervation and the stimulation of the baroreflex.

Assessment of right ventricular function by three-dimensional echocardiography and myocardial strain imaging in adult atrial septal defect before and after percutaneous closure.

Real-time three-dimensional (3D) echocardiography allows us to measure right ventricular (RV) end-diastolic volume irrespective of its shape. Tissue Doppler imaging (TDI) and speckle tracking imaging (STI) are new tools to assess myocardial function. We sought to evaluate RV function by 3D echocardiography and myocardial strain imaging in adult patients with atrial septal defect (ASD) before and 6 months after transcatheter closure in order to assess the utility of these new indexes in comparison with standard two-dimensional (2D) and Doppler parameters. Thirty-nine ASD patients and 39 healthy age- and sex-matched controls were studied using a commercially available cardiovascular ultrasound system. 2D-Doppler parameters of RV function (fractional area change, tricuspid annular plane systolic excursion, myocardial performance index) were calculated. 3D RV volumes were also obtained. RV peak-systolic velocities, peak-systolic strain, and peak systolic and diastolic strain-rate were measured in the basal, mid and apical segments of lateral and septal walls in apical 4-chamber view by TDI and STI. In open ASD, RV ejection fraction (3D-RVEF) and global and regional RV longitudinal strain were significantly higher than control group and decreased significantly after closure. By multivariate analysis 3D-RVEF, apical strain and strain rate were independent predictors of functional class. ROC analysis showed 3D-RVEF and apical strain to be more sensitive predictors of unfavorable outcome after defect closure compared to 2D-Doppler indexes. 3D echocardiography and myocardial strain imaging give useful insights in the quantitative assessment of RV function in ASD patients before and after closure.

Assessment of ascending aorta wall stiffness in hypertensive patients by tissue Doppler imaging and strain Doppler echocardiography.

BACKGROUND: Aortic stiffness may be associated with an increased incidence of cardiovascular events and has been reported to be related to arterial wall motion velocities as measured by tissue Doppler imaging. OBJECTIVE: To investigate the potential clinical application of tissue Doppler imaging (TDI) for assessment of aortic function parameters in healthy and hypertensive adults. METHODS: 110 hypertensive and 80 healthy adults were examined. Pulse wave velocity (PWV) and augmentation index (Aix) were measured as standard parameters of arterial stiffness by an oscillometric system. Aortic M-mode and TDI parameters were measured. Aortic distensibility (D) and aortic stiffness index (SI) were calculated using accepted formulae. Anterior wall aortic expansion velocity (S(Ao)), acceleration time (AT(Ao)), early (E(Ao)) and late (A(Ao)) diastolic retraction velocity and peak systolic radial strain (epsilon(Ao)) were determined. Comprehensive echocardiography was performed for the assessment of left ventricular (LV) systolic/diastolic function. RESULTS: S(Ao), E(Ao) and e(Ao) were significantly lower in hypertensive subjects (p<.001, p<.001, and p<.0001, respectively). Reduced D (p<.05 vs controls) and increased PWV (p<.05 vs controls) and SI (p<.01 vs controls) were consistent with evidence of increased aortic stiffness in both male and female hypertensive patients. PWV and Aix increased and D decreased with increasing age or systolic blood pressure. Multivariate analysis showed epsilon(Ao) to be independently related (R2 = 0.63) to pulse pressure, LV mass index and diastolic function. CONCLUSION: Ascending aorta TDI provides wall velocity and strain data differentiating hypertensive from healthy adults and reflecting aortic compliance changes related to age and sex and LV diastolic function.

Stress in centenarians.

Everybody is subject to a physical clock, determining the calendar age, and also to a biological clock, the speed of which depends on the interaction between the genetic reserves and the environment. Stress is taken into account more and more as one of the main factors responsible for the acceleration of the biological clock and the dishomogeneity of the aging process. Despite the fact that centenarians are prone to chronic stress due to a progressive loss of self-sufficiency, more than a half of our centenarians were not depressed and had a low trait-anxiety: they showed an emotional tendency to react with a low anxiety-intensity to stressful conditions. Their good physical conditions may be explained by a positive character-disposition and by strong adaptability to the adversities of the life. Personality traits can be reduced to five basic phenomena, the so-called Big Five: extroversion, agreeableness, conscientiousness, openness to experience and emotional stability. In our sample 65.4% were classified as extroverted, 50% as open minded and 34.5% showed good emotional stability. In the centenarians aging of all apparatuses was slowed down by a healthy lifestyle and also by good adaptability that allowed for a positive and effective response to stress throughout their whole lives.

[Circadian rhythm of blood pressure: non-dipping pattern and cardiovascular risk]. / Ritmo circadiano della pressione arteriosa: "non-dipping pattern" e rischio cardiovascolare.

24h ambulatory blood pressure monitoring (ABPM) can easily detect the circadian blood pressure (BP) pattern: usually, systolic and diastolic blood pressure (BP) show a nocturnal fall. Nocturnal BP values do not however always decline in essential hypertension: the subjects who show a nocturnal BP fall of at least 10% are called dippers; in other subjects, called non-dippers, BP behaviour is characterized by a lack of or very limited nocturnal BP fall. Several studies have investigated the relationship between the lack of or reduction of nocturnal BP fall (non-dipping pattern) and cardiovascular risk, showing not only an increase of target-organ damage (heart, brain, kidney), but a greater frequency of cardiovascular events (stroke, myocardial infarction, etc.) also and higher cardiovascular mortality in non-dippers subjects, both hypertensives and normotensives. Therefore, a non-dipping pattern may be an additional risk factor. Thus, ABPM could be a useful method to evaluate the initial global cardiovascular risk in patients with hypertension, and an adequate antihypertensive therapy should aim not only at lowering high BP values, but also at re-establishing the physiological nocturnal BP fall.

Event related brain potentials in elderly patients with recently diagnosed isolated systolic hypertension.

OBJECTIVE: Isolated Systolic Hypertension (ISH) is a known risk factor for cognitive impairment, but the time of onset of neurocognitive changes relative to the onset of ISH has yet to be established. The purpose of this study was to investigate the relationship between systolic BP values and neurocognitive function in the early stages of ISH. METHODS: Twenty elderly patients with recently (< 2 years) diagnosed ISH and 10 elderly normotensive controls underwent Ambulatory Blood Pressure Monitoring (ABPM) and neurocognitive assessment, performed using the Mini Mental State Examination (MMSE), and the recording of ERPs with an odd ball acoustic paradigm. RESULTS: There were no significant differences in MMSE scores or in the P300 latency between ISH patients and controls. The N2 latency was significantly higher in ISH patients vs. controls (p<0.0001), and showed a significant association with both clinical and ambulatory systolic BP and pulse pressure values in the overall study population. CONCLUSIONS: These findings suggest the existence of early subclinical alterations in neurocognitive function in early ISH, detectable through ERPs. SIGNIFICANCE: Our findings underscore the ISH may constitute a threat to neurocognitive health in the elderly.

Is it possible to predict one-year survival in centenarians? A neural network study.

BACKGROUND: Human life expectancy is constantly increasing: the challenge for modern geriatric medicine is to identify the means to reach successfully extreme longevity. OBJECTIVE: To determine which are the survival determinants in centenarians using a neural network. METHODS: Sample of 110 centenarians living in Rome, mean age 101.6 years (SD=1.8) with a sex ratio males:females of 1:3. We administered an extensive health interview (lasting 1-2 h) to each subject. The questionnaire, carried out according to the Geriatric Multidimensional Assessment, is made up of 100 items including a comprehensive health and psychosocial assessment aimed at various topics of general health and well-being and some scales used in geriatric practice. We applied several three-layered feed-forward neural networks by mixing in different ways the most important of the 100 items. RESULTS: The most predicting powered net is the one constructed with 23 variables regarding comorbidity, cardiovascular risk factors, cognitive status, mood, functional status and social interactions, which therefore are strictly related to survival in centenarians. CONCLUSION: Survival in longevity is a complex biological phenomenon, which is an ideal field for using the neural network as a statistic method. The net shows us that the maintenance of social relationships even in presence of disability is of major importance for survival in the oldest old.

The influence of lifestyle on cardiovascular risk factors. Analysis using a neural network.

The cardiovascular pathologies are the most common causes of death in the elderly patient. To single out the main risk factors in order to effectively prevent the onset of the disease, the authors experimented a special computerized tool, the neural network, that works out a mathematical relation that can obtain certain data (defined as output) as a function of other data (defined as input). Data were processed from a sample of 276 subjects of both sexes aged 26-69 years old. The output data were: high/low cholesterolemia, HDL cholesterol, triglyceridemia with respect to an established cut-off; the input data were: sex, age, build, weight, married/single, number of children, number of cigarettes smoked/day, amount of wine and number of cups of coffee. We conclude that: (i) a relationship exists, deduced from a neural network, between a set of input variables and a dichotomous output variable; (ii) this relationship can be expressed as a mathematical function; (iii) a neural network, having learned the data on a sufficiently large population, can provide valid predictive data for a single individual with a high probability (up to 93.33%) that the response it gives is correct. In this study, such a result is found for two of the three cardiovascular risk indicators considered (cholesterol and triglycerides); (iv) the repetition of the neural network analysis of the cases in question after a "pruning" operation provided a somewhat less good performance; (v) a statistical analysis conducted on those same cases has confirmed the existence of a strong relationship between the input and the output variables. Therefore the neural network is a valid instrument for providing predictive in a single subject on cardiovascular pathology risks.

[Risk factors for cognitive impairment]. / Fattori di rischio per il decadimento cognitivo.

Cognitive impairment is an invalidating condition and its prevalence increases significantly with age. It is very important to identify the risk factors for cognitive impairment. Aside from age, sex, familiary history and educational level, the other major risk factors (hypertension, hypercolesterolemia, diabetes mellitus and tobacco), known to be associated frequently with different cerebrovascular diseases, might also contribute to degenerative forms of cognitive impairment because they might favour cerebral microvascular alterations with hypoperfusion, demyelinization and ischemic lesions of subcortical white matter. Longitudinal epidemiological studies detected that arterial hypertension, hypercolesterolemia and tobacco are frequently associated with degenerative forms of cognitive impairment. Some studies show there is no relationship between cognitive impairment and diabetes mellitus, while other underline its role; light alcohol drinking might protect against cognitive impairment. Other recently identified risk factors might be hyperhomocysteinemia and high C-reactive protein blood levels because they seem to be associated with cognitive impairment.

Event-related brain potentials in elderly dippers and nondippers with recently diagnosed hypertension.

Several studies have shown a relationship between blood pressure (BP) and cognitive function. Yet very few studies have addressed circadian BP patterns in this context, perhaps due to poor availability of suitable methods to detect slight changes in the cognitive state. Today, brain event-related potentials (ERPs) allow us to detect subclinical changes in cognitive function. We enrolled 30 elderly patients with recently diagnosed hypertension (<2 years) that had never been treated: 18 dippers and 12 nondippers. Patients underwent 24-h ambulatory blood pressure monitoring (ABPM). Careful assessment of their cognitive state was carried out using the mini mental state examination (MMSE), and the recording of P300 and N2 ERPs. No significant differences between the two groups were found. MMSE scores in dippers and nondippers were similar (29.5+/-0.71 vs. 29.3+/-1.07, respectively; p =0.611), as were P300 latency values (377.78+/-33.28 vs. 364.67+/-35.12 in the central (Cz) position, p =0.310; 379.22+/-32.94 vs. 365.25+/-35.07 in the occipital (Pz) position, p =0.277) and N2 wave latency values (253.83+/-24.9 vs. 249.17+/-24.47 in the Cz position, p =0.617; 251.56+/-25.86 vs. 246.58+/-25.46 in the Pz position, p =0.608). These data show no association between the nondipping pattern and lower cognitive function in elderly subjects with recent hypertension.

[Smoking and survival in centenarians]. / Abitudine al fumo e sopravvivenza nei centenari.

Cigarette smoking has been clearly linked to the most common causes of death in the elderly and contributes to the higher death rate and disability rate associated with many chronic illnesses that are common in this age group. The combination of smoking along with other risk factors like hypertension and diabetes increase high frequency disease, and disability as well as adding to an increase in mortality rate. In order to verify if a healthy lifestyle really favours longevity and how much smoking is incompatible with extreme longevity, we investigated the prevalence of smokers and the total smoking exposure of a sample of centenarians as regards residual survival and health conditions. Our sample consists of 157 centenarians selected among the registered residents of Rome: 39 males and 118 females (ratio = 1:3), mean age being 101.59 years (sd = 1.8). 83.8% of the centenarians have never smoked, 13.5% are former smokers, and 2.7% are active smokers. The average starting age of smoking was 21.2 years while the average age of quitting in former smokers was 65.7 years with an average of 44.7 smoking years (sd = 17.1). The average number of smoked cigarettes per day is quite low, less than 10 cigarettes. There seemed to be a significant difference (p < 0.001) in gender results in smokers: male centenarians were 46%, while female reached only 8.1%. Statistically significant higher prevalence of diseases illnesses were noted among centenarian smokers over the age of 65 (p < 0.02). Moreover Cox's regression has shown in centenarians a lower survival rate (p < 0.05) in smokers than in non-smokers. In conclusion, our study is evidence that smoking is for all, but some exceptional subjects, incompatible with successful aging and compromises life expectancy even in extreme longevity.

Left ventricular mass in dippers and nondippers with newly diagnosed hypertension.

Hypertensive subjects can be subdivided into 2 groups, dippers and nondippers, according to the presence or the lack of a nocturnal fall of blood pressure of more than 10%. Several studies have investigated cardiac organ damage in the 2 groups with discordant results, but they included subjects with different onset, severity, and treatment of hypertension. The authors selected 23 dippers and 17 nondippers affected by newly (< 1 year) diagnosed grades 1 and 2 hypertension, never treated, who underwent 24-hour ambulatory blood pressure monitoring and M-mode echocardiography. They did not find significant differences between the 2 groups as regards the echocardiographic left ventricular and atrial dimensions or regarding the left ventricular mass, left ventricular mass index, or relative wall thickness. Also no significant differences were found in the rate of either left ventricular remodeling or left ventricular hypertrophy. These data suggest that nondipping status is not associated with a higher level of cardiac involvement in the early phases of hypertension compared to dipping status.

Blunted nocturnal fall in blood pressure and left ventricular mass in elderly individuals with recently diagnosed isolated systolic hypertension.

BACKGROUND: Few studies have investigated the relationship between the lack of or reduction of nocturnal blood pressure (BP) fall and left ventricular mass (LVM) in elderly individuals with isolated systolic hypertension (ISH), notwithstanding the fact that ISH is the most frequent subtype of uncontrolled hypertension and a powerful risk factor for organ damage. The aim of this study was to identify the relationship between blunted nocturnal BP fall and LVM in elderly individuals with ISH that was recently diagnosed (within 2 years) and had never been treated. METHODS: A total of 64 elderly patients with recent ISH were recruited among the outpatients of the Hypertension Unit at 1st Institute of Medicine of "La Sapienza" University in Rome, and they underwent 24-h ambulatory BP monitoring (ABPM). According to exclusion criteria, 37 patients were selected for the study. Based on the presence or absence of an almost 10% reduction in systolic BP (SBP) and diastolic BP (DBP) from day to night, 21 so-called dippers and 16 nondippers, respectively, were identified. All of these 37 patients underwent echocardiography. Relationships between BP recordings and echocardiographic parameters were assessed by univariate analysis. Dippers and nondippers were compared with respect to LVM. RESULTS: Nighttime SBP was closely associated with indexed LVM (LVM/h(2.7)) (r = 0.564; P=.001). Nondippers showed significantly higher LVM/h(2.7) compared with dippers (62.43 +/- 15.39 g/m(2.7) v 51.33 +/- 12.68 g/m(2.7) respectively; P=.021). CONCLUSIONS: An association between blunted nocturnal SBP fall and increased LVM was observed in the early phases of ISH in the elderly. This finding may have important prognostic implications.

[Demographic evolution, aging and frailty]. / Evoluzione demografica, invecchiamento e fragilità.

The 20th century will be remembered for its technological and scientific discoveries and for the exceptional changes in the demographic structure brought about by these and the improved economic and social conditions; in fact, the reduction in the birth rate and a fall in the death rate have caused an increase in the population of the elderly. Today the elderly population represents about 20% of the total and is much more heterogeneous than in the past, with several classes of the elderly: the young elderly from 64 to 74; the old elderly from 75 to 84, the very old from 85 to 100 and the oldest old who are living around a century. The aging of the population has brought out several problems of the elderly, among the "frailty", the effects of which increase as the years pass and which regards about one half of the very old. Frailty is a reduction of the body's ability to maintaine global homeostasis and is caused by a reduction of the functional reserves of all the organs and apparatus which occurs with aging. Screening the frail elderly with a careful multidimensional assessment is important to prevent health problems and to promote good health and it is a good parameter in evaluating the management of the geriatric assistance network and thus health and social costs.

[Hypercholesterolemia, cardiovascular risk, and hypocholesteremic treatment in the elderly]. / Ipercolesterolemia, rischio cardiovascolare e terapia ipocolesterolemizzante nell'anziano.

The role of cholesterol as a cardiovascular risk factor in the elderly is not completely clear at the moment. Epidemiologic studies show a continuous relation between cholesterol levels and cardiovascular risk even in the elderly, in fact, in spite of a lower Relative Risk, they have a greater Absolute Risk and Absolute Benefit Increase. In patients over 75-80 years old cholesterol loses its role as a risk factor, probably because of comorbidity, typical in this period. Trials show the efficacy of hypocholesterolemic therapy with statins in secondary prevention in the elderly; fewer data are available for primary prevention. Therapeutic attitudes suggest a pharmacologic intervention of secondary prevention in young and old elderly to lower LDL-C levels, which are more closely related to the events. In primary prevention we should use drugs to reach a LDL-C level lower for each additional risk factor, until 75 years old; in the old elderly we should decide on drug therapy according to the biological age and expected lifespan. Statins seem to be the most effective and safest drugs to reach this aim.