Identification of the hemodynamic modulators and hemodynamic status in uncontrolled hypertensive patients.

Only 20-30% out of the treated hypertensive patients in Europe are achieving blood pressure (BP) control. Among other recognized factors, these poor results could be attributable to the fact that for many doctors it is very difficult to detect which is the predominant hemodynamic cause of the hypertension (hypervolemia, hyperinotropy or vasoconstriction). The aim of the study was to use non-invasive thoracic electrical bioimpedance (TEB) to evaluate hemodynamic modulators and subsequent hemodynamic status in uncontrolled hypertensive patients, receiving at least two antihypertensive drugs. A number of 134 uncontrolled hypertensive patients with essential hypertension were evaluated in nine European Hypertension Excellence centers by means of TEB (the HOTMAN(®) System). Baseline office systolic and diastolic BP averaged 156/92 mmHg. Hemodynamic measurements show that almost all patients (98.5%) presented at least one altered hemodynamic modulator: intravascular hypervolemia (96.4%) and/or hypoinotropy (42.5%) and/or vasoconstriction (49.3%). Eleven combinations of hemodynamic modulators were present in the study population, the most common being concomitant hypervolemia, hypoinotropy and vasoconstriction in 51(38%) patients. Six different hemodynamic states (pairs of mean arterial pressure and stroke index) were found. Data suggest that there is a strong relation between hypertension and abnormal hemodynamic modulators. This method might be helpful for treatment individualization of hypertensive patients.

Coronary artery calcification, common carotid artery intima-media thickness and aortic pulse wave velocity in patients on peritoneal dialysis.

An increasing body of evidence suggests that atherosclerosis in patients with uremia differs from that found in general population in terms of advancement and localization of vascular lesions. It has also been suggested that different non-invasive techniques of vascular system evaluation are designed to show different types of lesions (i.e. vascular calcification, stiffness or 'classical' atherosclerosis). The aim of the study was to search for possible associations between results obtained with three different non-invasive methods of vascular system assessment in three different vascular sites in patients treated with peritoneal dialysis (PD). 61 patients (28 F, 33 M), mean age of 50.4+/-13.6 years, on maintenance PD for a median period of 10 months (range 1-96 months) were included. Coronary artery disease (CAD) was present in 21 subjects. In all subjects coronary artery calcification score (CaSc) using multi-row spiral computed tomography (MSCT), aortic pulse wave velocity (AoPWV) and ultrasound-based common carotid artery intima-media thickness (CCA-IMT) were performed as methods for assessing coronary calcium burden, arterial stiffness and atherosclerosis, respectively. Median value of CaSc equaled 11.5 Agatston units (range 0-5502.8 units). Median AoPWV was 10.4 m/s (range 7.56-18.1 m/s), and median CCA-IMT-0.6 mm (range 0.3-1.0 mm). In 16 patients (26.2%) at least one plaque in at least one common carotid artery was found on ultrasound. CaSc correlated with AoPWV (R=0.32, p<0.01) and with CCA-IMT (R=0.35, p<0.005), whereas no association was found between AoPWV and CCA-IMT. AoPWV, but not CaSc nor IMT correlated with blood pressure. The values of CCA-IMT and AoPWV increased together with consecutive Agatston categories (with p<0.001 for differences in AoPWV and p<0.05 for CCA-IMT). Patients with at least one plaque found in at least one CCA and patients with CAD were characterized with significantly higher values of CaSc, IMT and PWV, when compared to plaque-free and CAD- negative subjects, respectively. Association between CaSc and both IMT and PWV may suggest that the mechanism of three assessed vascular pathologies may be based, to some extent, on the process of pathologic calcium-phosphate deposition. Lack of correlation found between PWV and IMT may suggest that aortic stiffness and carotid atherosclerosis may partially differ in their pathologic background and/or are dissociated in time.

Ambulatory blood pressure, left ventricular mass and vascular phenotypes in relation to the endothelial nitric oxide synthase gene Glu298Asp and intron 4 polymorphisms in a population-based family study.

Reduced nitric oxide production is associated with pathological changes in the cardiovascular system. In a study of randomly chosen families, we analysed the relationship between two polymorphisms (Glu298Asp and intron 4) of the endothelial nitric oxide synthase (eNOS) and ambulatory blood pressure (ABP), left ventricular mass index (LVMI) and vascular phenotypes. The study population consisted of 127 parents and 167 offspring. All subjects underwent 24 h ABP monitoring using a SpaceLabs 90207 device. 2D and M-mode echocardiograms were obtained. Pulse wave velocity between the common carotid and femoral artery was measured with the Complior device, and the carotid intima-media thickness (IMT) was assessed by ultrasound. For statistical analysis, covariables and correlations between relatives were taken into account. The frequency of genotypes was as follows: for Glu298Asp: 55.1%-Glu/Glu, 40.1%-Glu/Asp and 4.8%-Asp/Asp; for intron 4: 65.0%-4 b/b, 33.3%-4 b/a and 1.7%-4 a/a, being in Hardy-Weinberg equilibrium (P > or = 0.29). There was no relationship between the eNOS gene polymorphisms and ABP or LVMI either in parents or their offspring. Among parents, carriers of the 298Asp allele had higher IMT values as compared with Glu/Glu homozygotes (0.94 vs 0.70 mm; P = 0.007). Among offspring, there was a similar tendency (0.60 vs 0.53 mm; P = 0.10), which was confirmed by transmission disequilibrium tests for quantitative variables (P > or = 0.07). Our findings indicate that the Glu298Asp polymorphism of eNOS identifies patients with larger carotid IMT, also in younger subjects.

Context-dependency of the relation between left ventricular mass and AGT gene variants.

In the European Project on Genes in Hypertension (EPOGH), we investigated in three populations to what extent in a family-based study, left ventricular mass (LVM) was associated with the C-532T and G-6A polymorphisms in the angiotensinogen (AGT) gene. We randomly recruited 221 nuclear families (384 parents and 440 offspring) in Cracow (Poland), Novosibirsk (Russia), and Mirano (Italy). Echocardiographic LVM was indexed to body surface area, adjusted for covariables, and subjected to multivariate analyses, using generalized estimating equations and quantitative transmission disequilibrium tests in a population-based and family-based approach, respectively. We found significant differences between the two Slavic centres and Mirano in left ventricular mass index (LVMI) (94.9 vs 80.4 g/m2), sodium excretion (229 vs 186 mmol/day), and the prevalence of the AGT -6A (55.7 vs 40.6%) and -532T (16.8 vs 9.4%) alleles. In population-based as well as in family-based analyses, we observed positive associations of LVMI and mean wall thickness (MWT) with the -532T allele in Slavic, but not in Italian male offspring. Furthermore, in Slavic male offspring, LVMI and MWT were significantly higher in carriers of the -532T/-6A haplotype than in those with the -532C/-6G or -532C/-6A allele combinations. In women, LVMI was neither associated with single AGT gene variants nor with the haplotypes (0.19 < P <0.98). In Slavic offspring carrying the AGT -532C/-6G or -532C/-6A haplotypes, LVMI significantly increased with higher sodium excretion (+3.5 g/m2/100 mmol; P=0.003), whereas such association was not present in -532T/-6A haplotype carriers (P-value for interaction 0.04). We found a positive association between LVMI and the AGT -532T allele due to increased MWT. This relation was observed in Slavic male offspring. It was therefore dependent on gender, age and ecogenetic context, and in addition it appeared to be modulated by the trophic effects of salt intake on LVM.

The selected pathophysiological aspects of PPARs activation.

Peroxisome proliferator activated receptors (PPARs) belong to a subfamily of transcription nuclear factors. Three isoforms of PPARs have been identified: alpha, beta/delta and gamma, encoded by different genes and distributed in various tissues. They play important roles in metabolic processes like regulation of glucose and lipid redistribution. They also have anti-atherogenic, anti-inflammatory as well as anti-hypertensive functions. In hypertension-induced cardiac hypertrophy, both PPARa and PPARg activation reveal cardio-protective effect. Despite these beneficial functions, several recent experimental reports point to the possibille unfavorable effects of PPARs activation in lipid metabolism (lipotoxicity) in cardiomyocytes, which can lead to pathologic cardiac hypertrophy in such diseases as diabetes type 2, metabolic syndrome or obesity. This paper reviews evidences and hypotheses about the new pathophysiological aspects of PPARs activation.

Calcium channel blockade and cardiovascular prognosis in the European trial on isolated systolic hypertension.

In the double-blind Systolic Hypertension in Europe (Syst-Eur) Trial, active treatment was initiated with nitrendipine (10 to 40 mg/d) with the possible addition of enalapril (5 to 20 mg/d) and/or hydrochlorothiazide (12.5 to 25 mg/d) titrated or combined to reduce sitting systolic blood pressure by at least 20 mm Hg to <150 mm Hg. In the control group, matching placebos were used similarly. In view of persistent concerns about the use of calcium channel blockers as first-line antihypertensive drugs, this report explored to what extent nitrendipine, administered alone, prevented cardiovascular complications. Age at randomization averaged 70.2 years and systolic/diastolic blood pressure 173.8/85.5 mm Hg. Of 2398 actively treated patients, 1327 took only nitrendipine (average dose, 23.4 mg/d), and 1042 progressed to other treatments including nitrendipine (n=757; 35.7 mg/d), enalapril (n=783; 13.4 mg/d), and/or hydrochlorothiazide (n=294; 21.0 mg/d). Compared with the whole placebo group (n=2297), patients receiving monotherapy with nitrendipine had 25% (P=0.05) fewer cardiovascular end points, and those progressing to other active treatments showed decreases (P

Blood pressure, insulin resistance and left ventricular function in alcoholics.

OBJECTIVE: To estimate the arterial blood pressure, left ventricular function and insulin secretion in alcoholics. DESIGN: We examined hospitalized patients between the second and seventh day of acute alcohol withdrawal and after a month of abstinence by 24 h ambulatory blood pressure monitoring, a standard oral glucose-tolerance test with determination of insulinaemia, two-dimensional and M-mode echocardiography and pulsed-wave Doppler statistical analysis was performed using Student's t test P < 0.05 was considered statistically significant PATIENTS: Fifty alcoholics aged 36.3 +/- 5.4 years with a history of alcohol abuse for a mean of 12 years. MAIN OUTCOME: We expected the cessation of drinking to exert an influence by lowering the blood pressure and left ventricular function with a concomitant lowering of the insulin resistance. RESULTS: During acute alcohol withdrawal the systolic (121.6 +/- 7.7 versus +115.8 +/- 8.7 mmHg) and diastolic blood pressures (74.5 +/- 6.3 versus 72.0 +/- 7.9 mmHg) were significantly higher. The nocturnal fall in blood pressure was smaller and the variability of the blood pressure was blunted. This period was characterized by hyperinsulinaemia detected by the glucose-tolerance test [In (SUMins) 8957 +/- 0.47 versus 8558 +/- 0.651] correlated to hyperdynamic circulation (cardiac index 3.38 +/- 0.86 versus 3.09 +/- 0.69 I/min per m2). The early: late atrial filling ratio had increased significantly after 1 month of abstinence (1.98 +/- 0.43 versus 2.08 +/- 0.50). CONCLUSIONS: One month of abstinence from drinking decreases the blood pressure and improves the diurnal profile of the blood pressure and the left ventricular diastolic function. Hyperinsulinaemia, which is observed during acute restriction of alcohol consumption, could be one of the causes responsible for hyperdynamic circulation.

Effect of exercise rehabilitation on heart rate variability in hypertensives after myocardial infarction.

OBJECTIVE: The aim of the study was to find out whether the presence of hypertension affects heart rate variability in patients rehabilitated after myocardial infarction. DESIGN: Echocardiography, exercise testing and 24 h Holter monitoring were performed before and after 27 days of early postdischarge cardiac rehabilitation. PATIENTS: The study population consisted of 64 patients aged 34-65 years (mean+/-SD 51.6+/-6.6) discharged from hospital after a first myocardial infarction who were subdivided into two groups, group A comprising 34 patients with arterial hypertension which had lasted 4.8+/-2.1 years and group B comprising 30 normotensives. MAIN OUTCOME: We expected exercise rehabilitation to affect heart rate variability, exercise tolerance and myocardial ischemia in patients after myocardial infarction with and without arterial hypertension. RESULTS: At baseline no intergroup differences were seen in the duration of exercise, workload and heart rate variability parameters. All parameters increased significantly after cardiac rehabilitation (P < 0.01): SD of all normal RR intervals 123.4+/-30.0 versus 123.8+/-30.0 ms; SD of the averages of normal RR intervals in all 5-min segments of the entire recording 115.1+/-30.5 versus 116.3+/-28.3 ms; mean of the SD of all normal RR intervals for all 5-min segments of the entire recording 49.0+/-12.5 versus 48.3+/-11.8 ms; square root of the mean of the sum of the squares of differences between adjacent RR intervals 29.7+/-9.1 versus 28.0+/-8.5 ms; percentage of differences between adjacent RR intervals > 50 ms 7.9+/-6.0 versus 7.1+/-6.1% (group A versus group B, respectively, NS). The duration of exercise and the workload were significantly increased (the rise was higher in normotensives). No differences were seen in the frequency and severity of silent myocardial ischemia. CONCLUSIONS: Early stationary exercise rehabilitation after myocardial infarction improves heart rate variability parameters and exercise tolerance both in hypertensives and in normotensives.

QT dispersion and hypertensive heart disease in the elderly.

AIM: To determine the predictors and risk of increased QT dispersion in the elderly hypertensive patients. METHODS: A 12-lead electrocardiogram (ECG), M-mode echocardiography and ambulatory blood pressure as well as Holter monitoring were performed for 67 patients over 60 years of age with essential hypertension (I and II(o) WHO). The presence of ischaemic changes on ECG was evaluated based on the Minnesota Code. QT intervals were corrected with Bazett's formulae and QT dispersion was determined as the difference between maximal and minimal QTc intervals. Interventricular septal thickness (IVSTd), left ventricular internal diameter (LVDd) and posterior wall thickness (PWTd) were measured and left ventricular mass index (LVMI) was calculated. Subjects were divided according to the median of QTc dispersion (0.10 s). The differences between groups were assessed using chi-squared and Student's t-test. RESULTS: Subjects with increased QTc dispersion did not differ from those with low QTc dispersion when age, gender and body mass index were analysed. Similarly, the average systolic blood pressure, diastolic blood pressure and blood pressure variability were comparable in both groups. The mean QTc interval was similar in both groups. In patients with increased QT dispersion, left ventricular hypertrophy (LVH) and ischaemic changes on ECG were more frequently recognized (respectively 41.2 versus 18.2%, P < 0.001; 47.1 versus 21.2%, P < 0.05). Moreover, these subjects presented a significantly greater number of premature ventricular beats (317.1 +/- 665.6 versus 64.88 +/- 188.6, P < 0.05) and higher classes of Lown's arrhythmia scale (classes III-IV, 23.35% versus 9.1%). LVMI was insignificantly higher in the group with greater QTc dispersion (165.82 +/- 54.5 versus 145.07 +/- 36.47 g/ m2). Other echocardiographic indices of LVH were similar in both groups. On the other hand, the analysis of regression indicated positive correlation between the dispersion of QTc interval and thickness of left ventricle walls (for IVSd - r = 0.37; for PWd - r = 0.31), relative wall thickness (r = 0.28) and LVMI (r = 0.28). CONCLUSIONS: QTc dispersion is increased in the elderly hypertensive individuals, with the presence of LVH and myocardial ischaemia on ECG. These patients are more likely to demonstrate severe ventricular dysrhythmias.

Aortic pulse wave velocity in young normotensives with a family history of hypertension.

OBJECTIVE: To assess the effect of selected clinical and biochemical parameters, with particular consideration of familial hypertension, on the pulse wave velocity (PWV) in young normotensives. SUBJECTS AND METHODS: Seventy voluntary students were enrolled (mean age 22.3+/-2.1 years), 39 men and 31 women, with normal blood pressure. A history was obtained with respect to diabetes mellitus, ischaemic heart disease, lipid disorders and arterial hypertension in the family. The subjects were subdivided into two groups: those with (n = 33) and without (n = 37) a family history of arterial hypertension, and blood pressure and heart rate were measured three times and total cholesterol and its subfractions determined in plasma. The carotid to femoral PWV was measured using an automatic computerized recorder and analysed by the Complior program. RESULTS: The subjects with a family history of arterial hypertension had higher blood pressure levels (systolic and diastolic blood pressure, pulse pressure and mean arterial pressure), as well as mean body mass index and low-density lipoprotein (LDL) cholesterol. The PWV in this group did not differ from that in the subjects without a family history of arterial hypertension (9.69+/-2.8 versus 9.32+/-2.0). However, the PWV was significantly higher in males than females (10.62+/-2.2 versus 7.86+/-1.13, P < 0.0001) and there was a significant positive correlation between male gender and PWV. CONCLUSIONS: Familial arterial hypertension does not significantly affect aortic stiffness in terms of PWV. Male gender in this population of young healthy subjects is one of the most important factors associated with central arterial stiffness.

Quality of life of elderly patients with isolated systolic hypertension: baseline data from the Syst-Eur trial. Syst-Eur Trial Investigators.

OBJECTIVE: To describe measures of quality of life of elderly patients with isolated systolic hypertension at entry to a placebo-controlled randomized trial of antihypertensive treatment and to investigate factors associated with these. DESIGN: Cross-sectional analyses at entry to a randomized controlled trial. SETTING: Patients attending hypertension clinics or general practitioners' surgeries at 30 centres in 10 European countries. PATIENTS: Six hundred and thirty-one patients aged 60 years or more, with a sitting systolic blood pressure during the run-in phase of 160-219 mmHg, a sitting diastolic blood pressure below 95 mmHg and a standing systolic blood pressure of 140 mmHg or more. MAIN OUTCOME MEASURES: Cognitive function tests (Reitan Trail Making A and B), Brief Assessment Index (a measure of depressed mood) and four subscales from the Sickness Impact Profile (Ambulation, Social Interaction, Sleep and Rest and Housework). RESULTS: Poor quality of life was generally associated with increasing age, previous treatment with antihypertensive drugs, presence of cardiovascular complications and, among women, high diastolic blood pressure, higher consumption of alcohol and high body mass index. CONCLUSIONS: At entry to the trial there was considerable heterogeneity of patients in terms of measures of quality of life and cognitive performance. It remains to be determined whether these influence subsequent quality of life during randomized treatment.

Long-term study of borderline hypertension among male industrial workers.

Out of 1,236 men aged 40-59 years working in the same industrial plant, 253 (20.5%) had borderline arterial hypertension (BH). These employees and 237 matched normotensives were followed for several years. After 13 years, 343 participants, 70% of the initial number were studied. Arterial hypertension developed in 79.1% of the group with initial BH, most frequently in those with systolic-diastolic, and less often with systolic or diastolic BH. In normotensives, hypertension was diagnosed in 30.0% (P less than 0.001). All participants showed a correlation between blood pressure rise and initial value. A smaller number of men in the group with initial BH (36%) continued to work compared with normotensive men (48.1%) (P less than 0.01). The relationship between ability to work and blood pressure level became more prominent when we took into account final diagnosis: 65.7% of the actual normotensives, 56.4% of the borderline hypertensives and 47.5% of the hypertensives were still working after 13 years. Death rate was also higher in the group with BH (15.4%) than in the controls (8.4%) (P less than 0.01). The highest death rate was found when BH was combined with other coronary risk factors.

Circadian blood pressure changes and cardiac geometry in essential arterial hypertension.

To study a relationship between ambulatory blood pressure (BP) and left ventricular geometry in mild to moderate arterial hypertension, 24 h ambulatory blood pressure monitoring (ABPM) at half-hourly intervals in the daytime and hourly at night (Spacelabs 90207) and echocardiographic examinations were performed in 60 hypertensives aged 42 +/- 7.9 years and in eight normotensives. The patients were subdivided into four groups according to the relative wall thickness (RWT) and left ventricular mass index (LVMI). Concentric remodelling was identified on the basis of increased RWT, eccentric hypertrophy in case of increased left ventricular mass, and concentric hypertrophy when both parameters were increased. Group I consisted of 15 patients with normal left ventricle; group II, 19 patients with concentric remodelling; group III, 7 patients with eccentric hypertrophy; and group IV, 19 patients with concentric hypertrophy. Analysis of correlations of maximal and mean systolic (SBP) and diastolic BP (DBP) values and BP variability with left ventricular mass and relative wall thickness revealed the strongest correlation in group IV between concentric hypertrophy and peak SBP in the entire 24 h and in the daytime, mean SBP in the daytime and SBP variability in the entire 24 h. No significant correlations were found in groups I, II, III or controls. In conclusion, SBP variability assessed non-invasively with ABPM correlates positively with left ventricular mass. BP variability seems insignificant for left ventricular geometry.

The effect of hormone replacement therapy on arterial blood pressure and vascular compliance in postmenopausal women with arterial hypertension.

Arterial pathology is a major contributor to cardiovascular disease, morbidity and mortality. Women are at higher risk of cardiovascular disease after menopause. Arterial stiffness determined by pulse wave velocity, increases with age both in men and women, whereas arterial compliance in premenopausal women is greater than in men of similar age. This difference is lost in the postmenopausal years, with evidence of rapid decline in arterial compliance in the perimenopausal period. Loss of hormonal modulation is a likely explanation for reduced arterial compliance in postmenopausal women. Long-term treatment with hormone replacement therapy (HRT) may be expected to partially reverse the increase in arterial stiffness. The aim of the study was to analyse the effect of HRT on blood pressure and arterial compliance in postmenopausal women with arterial hypertension receiving hypotensive drugs. The results in the present study of postmenopausal women with mild to moderate arterial hypertension receiving HRT showed only a transient tendency towards lower blood pressure. In our study HRT was found to improve arterial compliance at 3 months after HRT, and the effect was maintained throughout 12 months. The increased arterial compliance in women receiving HRT was independent of blood pressure. In parallel with decreasing pulse wave velocity women receiving HRT had lower total and low-density lipoprotein cholesterol. The conclusions were that after 1 year HRT in postmenopausal women with arterial hypertension improves circadian blood pressure pattern, but it does not affect significantly blood pressure values and variability. The present study also shows that HRT significantly inhibits age-related rigidity of large arteries.

Isolated systolic hypertension: pathophysiology, consequences and therapeutic benefits.

During recent decades the importance of perceiving isolated systolic hypertension (ISH) in cardiovascular pathophysiology has been changed from a benign condition to the major cardiovascular risk factor. Aging is per se associated with the deterioration in arterial compliance through both structural and functional changes in large arteries which mainly involves the intima and media. The observed changes result in a decrease of the lumen-to-wall ratio, the overall lumen cross-sectional area and an increase of arterial stiffness which especially involve the aorta and other elastic arteries. In addition to the structural changes in vessel walls, aging is associated with certain functional changes such as an increase in sympathetic system activity probably due to the age-related decreased sensitivity of beta-receptors. While the function of arterial wall alpha-receptors remains intact, in elderly subjects a shift towards arterial vasoconstriction can be observed. In many of the published studies the definition of ISH was based on the criterion 160/95 mm Hg or 160/90 mm Hg while in recognition of the high risk associated with systolic blood pressure (SBP) the WHO/ISH guidelines and Report of the Sixth Joint National Committee on Hypertension indicated that ISH should be diagnosed with SBP as > or =140 mm Hg and diastolic BP (DBP) as <90 mm Hg. Thus the setting down of normal values of SBP will lead to an earlier diagnosis and treatment of ISH. Several prospective studies, such as the US Hypertension Detection and Follow-up Programme, confirmed this and the Multiple Risk Factor Intervention Trial demonstrated that for any given level of DBP, higher SBP was associated with an increase in cardiovascular risk. Moreover, data from the Framingham Study show that ISH was associated not only with increased mortality but also cardiovascular morbidity. Risk of non-fatal stroke and myocardial infarction was increased three and two-times respectively in the presence of ISH. Three major up-to-date studies that included patients with ISH have been published. In concordance to the previously published SHEP and MCR trials, the most recent, the Systolic Hypertension in the Elderly Trial (SYST-EUR), demonstrated that active treatment significantly reduces the risk of stroke and all fatal and non-fatal cardiac end-points, including sudden death. Of note, these benefits were demonstrated with new anti-hypertensive classes such as dihydropiridyne calcium channel blocker (nitrendipine) and the angiotensin-converting enzyme inhibitor (enalapril). The necessity to carefully balance the benefits and risks of anti-hypertensive therapy in the elderly indicates that patients with suspected ISH should undergo careful BP measurements on at least three different occasions before the diagnosis is established and an orthostatic reaction should be evaluated. If non-pharmacological procedures fail, drug therapy should be considered, especially in elderly patients with a SBP over 160 mm Hg, since their risk of complications is markedly higher. Pharmacological treatment should also be strongly considered in patients with a SBP between 140 and 160 mm Hg with such concomitant cardiovascular risk factors as diabetes, angina pectoris, and left ventricular hypertrophy. The drug regimen should be simple, starting with a low dose of a single drug that is titrated slowly. The selection of the first-line anti-hypertensive agent should be based on a careful assessment of pathophysiological and clinical parameters in each individual geriatric patient.

The frequency and functional impact of hypertension overlapping on hypertrophic cardiomyopathy: comparison between older and younger patients.

BACKGROUND AND AIM: In a previous report, when hypertension (HT) overlapped on hypertrophic cardiomyopathy (HTHCM), the decreased survival rate was associated with higher NYHA classes. The study concerned only elderly patients and therefore we decided to extend it by: (1) assessment of the frequency and age-distribution of HTHCM in HCM population; and (2) the comparison of NYHA class between HTHCM and HCM both in younger and older patients. PATIENTS AND METHODS: We retrospectively viewed 123 HCM patients with regard to the presence of hypertension as a concomitant disease. The HTHCM and HCM patients were compared with regard to NYHA functional classes within younger (<50 years of age) and older (>50 years of age) subgroups. RESULTS: Of the 123 HCM patients, 24 (19.5%) had associated hypertension. Among younger patients, 15.7% had concomitant hypertension, while in older patients the percentage of HTHCM significantly increased to 38%. In younger patients, the mean values of the NYHA class were significantly higher in HTHCM in comparison to HCM patients (2.19 +/- 0.37 vs 1.94 +/- 0.56, P < 0.05), whereas in the older patients, the mean values of NYHA class were comparable between HTHCM and HCM patients (2.13 +/- 0.33 vs 2.23 +/- 0.42, P > 0.05). CONCLUSION: Hypertension associated with HCM is not rare in young patients, and this coincidence significantly increases in older patients. Hypertension overlapping on HCM additionally deteriorates functional status in younger patients whereas in the older patients NYHA class the difference between HTHCM and HCM narrows and becomes insignificant.

Progression of asymmetric pattern of left ventricular hypertrophy in patients with hypertrophic cardiomyopathy accompanied by hypertension in the elderly.

OBJECTIVE: The aim of the study was to determine the potential influence of hypertension overlapping hypertrophic cardiomyopathy (HCM) on left ventricular hypertrophy (LVH) pattern. We compared the magnitude of LVH asymmetry between younger and older patients with HCM and concomitant hypertension. MATERIAL AND METHODS: We studied 18 patients (age range from 18 to 77 years) in whom HCM was accompanied by mild-to-moderate hypertension. Patients were subdivided into two groups: (I) <50 years of age (11 patients); and (II) >50 years of age (seven patients). The thickness of ventricular septum and posterior wall was assessed by M-mode echocardiography. The pattern of LVH was determined based on the value of ventricular septum/posterior wall thickness (VS/PW) ratio and LVMI was calculated according to Devereux formula. RESULTS: The more asymmetric LVH pattern was revealed in older HCM with hypertension patients than in younger patients (VS/PW thickness ratio 2.62 +/- 0.81 vs 1.58 +/- 0.56, P < 0.05). The LVMI was similar in both groups (210 + 87 vs 191 + 30 g/m2, P > 0.5). CONCLUSION: Asymmetric pattern of LVH aggravated with increasing age in HCM with hypertension patients while LVMI was comparable between younger and older patients. Thus, the primary myocardial disease, ie, HCM, so significantly determined the asymmetric LVH pattern with aging that coexistent hypertension was not a sufficiently strong stimulus to alter LVH pattern into a more concentric one in the elderly.

Ascending aortic blood pressure waveform may be related to the risk of coronary artery disease in women, but not in men.

Recent studies have demonstrated that fractional pulse pressure and fractional diastolic pressure are related to the risk of coronary artery disease. However, the effect of the ascending aortic pressure waveform on the risk of coronary artery disease in men and women analyzed separately has not been reported. The objective of the study was to assess the relation between ascending aortic blood pressure waveform and the presence of coronary artery disease in men and in women. The study group consisted of 447 patients (302 men and 145 women; mean age: 57.6+/-9.8 years) with preserved left ventricular function who were undergoing first diagnostic coronary angiography. After multivariate stepwise adjustments, the odds ratio (OR) and confidence interval (CI) of having coronary artery disease in women was (OR are reported for standard deviation increase in each variable): pulse pressure OR 1.61 (95% CI 1.06-2.46); fractional systolic pressure OR 1.72 (95% CI 1.08-2.71); fractional diastolic pressure OR 0.58 (95% CI 0.37-0.92); fractional pulse pressure OR 1.72 (95% CI 1.08-2.71); and pulsatility index OR 1.74 (95% CI 1.09-2.78). None of the studied variables was independently related to the presence of coronary artery disease in men. In conclusion, fractional systolic and diastolic pressure, pulse pressure, fractional pulse pressure and the ratio of pulse pressure to diastolic pressure may be independently related to the risk of coronary artery disease in women, but not in men.

Silent myocardial ischaemia in patients with essential arterial hypertension and non-insulin dependent diabetes mellitus.

The concomitant presence of diabetes mellitus and arterial hypertension significantly impairs myocardial function through a direct negative effect on cardiac myocytes, coronary microvessels and precipitation of atherosclerosis in major coronary arteries. The purpose of the present study was to establish to what extent non-insulin dependent diabetes mellitus (NIDDM) modified silent myocardial ischaemia (SMI) in patients with essential hypertension and without documented coronary artery disease (CAD). The study population consisted of 41 patients with essential arterial hypertension associated with NIDDM, treated with diet and oral hypoglycaemic agents (group I) and 40 patients with essential arterial hypertension without diabetes mellitus (group II). Both groups were comparable with respect to age, gender, duration, severity and complications of hypertension. A mean duration of diabetes mellitus in group I was 6.8 years. Conventional and automatic blood pressure and heart rate measurements, continuous ECG recordings, echocardiograms and laboratory tests were obtained in all patients. SMI was more frequent in group I than in group II (29.3% vs 12.5%, P < 0.05). In group I the total duration of SMI was longer (37.3 vs 2.8 min, P < 0.001) and the total number of silent episodes was larger (15.5 vs 2.6, P < 0.001). No inter-group differences were seen in conventional and automatic blood pressure and heart rate measurements. Both groups did not differ significantly in left ventricular mass index (LVMI) or the proportion of patients with left ventricular hypertrophy (LVH) (75.6% vs 60%). Lipid profile in both groups indicated an increased risk of CAD, but without significant differences. In conclusion, in patients with essential arterial hypertension and diabetes mellitus, the incidence and severity of SMI were clearly higher than in hypertensives with normal carbohydrate metabolism. Employment of modern diagnostic techniques in hypertensives permits identification of those at greater risk, which may have further clinical implications.

Influence of long-term treatment with nifedipine on blood pressure, left ventricular mass and cardiac arrhythmias in elderly hypertensive patients.

To determine the benefits of the long-term monotherapy with nifedipine in the elderly hypertensive patients, 100 subjects > 60 years old were included to the trial. Therapeutic efficacy of nifedipine was confirmed in 69% of the patients and resulted in reduction of SBP by 20.9% and DBP by 19.0% of their initial values, from 179.7/101.3 to 142.1/82.9 mmHg (p < 0.001). On the other hand, the range of circadian changes in systolic and diastolic BM did not decrease (67.1 and 37.0 mmHg before treatment and 65.0 and 36.2 mmHg at the end of the trial). Although cardiac output and ejection fraction significantly improved, the patients showed neither a significant reduction of left ventricular mass (313.6 g before and 282.4 g after therapy) nor a decrease in cardiac arrhythmias. Usefulness of long-term monotherapy with nifedipine in elderly patients is diminished by side-effects (11%), as well as a preserved high circadian BP variability and the unchanged left ventricular morphology that may result in persistent cardiac arrhythmias despite of the significant fall in BP.