Impact of body mass index and waist circumference on the cardiovascular risk and all-cause death in a general population: data from the PAMELA study.

BACKGROUND AND AIMS: Elevated values of body mass index (BMI) and waist circumference (WC) are associated with an augmented cardiovascular (CV) risk. It is debated, however, whether and to what extent this depends on the body fat increase 'per se' or on the related cardiometabolic alterations. METHODS AND RESULTS: In 2005 subjects randomly selected from the general population of Monza (Italy), we assessed BMI, WC, office, home and 24 h blood pressure (BP), heart rate and metabolic variables. The impact of BMI and WC on the incidence of CV events, CV and all-cause mortality was estimated during a 148-month follow-up. Progressively higher values of BMI and WC were associated with a progressive increase in office, home and 24 h BP and in erratic BP variability (P < 0.0001 for trend). Metabolic variables were directly and significantly (P < 0.0001) related to BMI and WC, while an inverse significant relationship was detected with high-density lipoprotein (HDL)-cholesterol. The incidence of CV events, CV and all-cause deaths increased progressively from the lowest to the highest quintile of BMI and WC (P for trend always <0.005). Baseline BMI and WC higher by respectively 1 kg m⁻² and 1 cm were associated with an increased risk of CV events, CV and all-cause death by 8%, 12% and 7% (for baseline BMI) and 4%, 5% and 4% (for baseline WC), respectively. After adjustment for confounders, only the increased risk of CV death related to higher baseline BMI remained significant (hazard ratio (HR) 1.062, confidence interval (CI) 95% 1.003-1.126, P < 0.05). CONCLUSION: The adverse prognostic impact of the accumulation of body fat is mediated by the associated haemodynamic and metabolic alterations. Baseline values of BMI, however, are an independent predictor of CV mortality.

Management and outcomes of hepatic cirrhosis: Findings from the RING study.

BACKGROUND/AIM: Hepatic cirrhosis is a frequent reason for ordinary hospital admission (OA). The RING study collected hospital discharge files (HDF) from Italian hospital gastroenterology units (IGU). This caselist provides a broad picture of the patients admitted for this pathology. MATERIAL/METHODS: More than 50,000 HDF for OA were collected between 2001 and 2004 from 26 IGU. RESULTS: Eight thousand four hundred and eighty-seven HDF (16%) had a diagnosis of hepatic cirrhosis; Child-Pugh classes were 20.2% A, 34.8% B and 45.0% C. Patients' mean age was 63.7+/-12.1 years and 62.5% were male. A 61.1% of the cirrhosis cases had ascites, 29.9% portal-systemic encephalopathy, 29.2% hepatocellular carcinoma (HCC), 10% bleeding varices, 3.0% hepatorenal syndrome (HRS). Mortality for OA for cirrhosis was 5.7% versus 2.6% for other diagnoses. The proportion varied with the severity of the cirrhosis: 0% for Child A, 1.1% B, 10.5% C. Mortality was significantly associated with: Child-Pugh at admission (odds ratio: OR 9.2), HRS (OR 11.7), bleeding varices (OR 2.2), HCC (OR 1.8). CONCLUSIONS: Hepatic cirrhosis was found in 16% of the OA to IGU and mortality was double the rate for all the other pathologies in the same wards. Child-Pugh is a useful prognostic tool, higher classes implying a greater risk of death. HRS and bleeding varices were the complications with most influence on in-hospital mortality.

Alterations of cardiac structure in patients with isolated office, ambulatory, or home hypertension: Data from the general population (Pressione Arteriose Monitorate E Loro Associazioni [PAMELA] Study).

BACKGROUND: The prevalence and clinical significance of isolated office (or white coat) hypertension is controversial, and population data are limited. We studied the prevalence of this condition and its association with echocardiographic left ventricular mass in the general population of the PAMELA (Pressione Arteriose Monitorate E Loro Associazioni) Study. METHODS AND RESULTS: The study involved a large, randomized sample (n=3200) representative of the Monza (Milan) population, 25 to 74 years of age. Participants in the study (64% of the sample) underwent measurements of office, home, 24-hour ambulatory blood pressure, and echocardiography. Isolated office hypertension was defined as systolic or diastolic values >/=140 mm Hg or >/=90 mm Hg, respectively. Home and ambulatory normotension were defined according to criteria previously established from the PAMELA Study, for example, <132/83 mm Hg (systolic/diastolic) for home and 125/79 mm Hg for 24-hour average blood pressure. Treated hypertensive subjects were excluded from analysis that was made on a total of 1637 subjects. Depending on normotension being established on systolic or diastolic blood pressure measured at home or over 24 hours, the prevalence of isolated office hypertension ranged from 9% to 12%. In these subjects, left ventricular mass index was greater (P<0.01) than in subjects with normotension both in and outside the office. This was the case also for prevalence of left ventricular hypertrophy. Left ventricular mass index and hypertrophy were similarly greater in subjects found to have normal office but elevated home or ambulatory blood pressure ( approximately 10% of the population). CONCLUSIONS: Isolated office hypertension has a noticeable prevalence in the population and is accompanied by structural cardiac alterations, suggesting that it is not an entirely harmless phenomenon. This is the case also for the opposite condition, that is, normal office but elevated home or ambulatory blood pressure, which implies that limiting blood pressure measurements to office values may not suffice in identification of subjects at risk.

[Incidence risk of major cardiovascular events among socio-occupational classes. 11-year follow-up of the MONICA Brianza and PAMELA cohorts]. / Rischio di incidenza di eventi coronarici e cerebrovascolari maggiori tra classi socio-occupazionali. follow-up a 11 anni delle coorti MONICA brianza e PAMELA.

The aim is to assess socio-occupational (SO) class differences in incident coronary and stroke. Methods. In a prospective fixed-cohort study 2959 35-74 year old men free from coronary (CHD) and stroke events were recruited in four population-based cohorts from 1986 to 1994 and followed-up until the end of 2002 to ascertain first CHD and stroke events. At baseline, major cardiovascular risk factors were investigated according to a standardised protocol. SO classes were based on current or last employment. Age-adjusted and multi-factors-adjusted risk ratios (RR) and 95% CI were calculated from Poisson regression models. Results. In 11-year median follow-up, the cohorts accumulated 33,926 person-years and generated 168 first major CHD events and 56 stroke events. Non-manual workers showed the lowest incident rates of both endpoints, and were considered as the reference category. Higher relative risks of CHD events were foundfor lower administrators and professionals, unskilled manual workers (UMW) and self-employed. Higher relative risks of stroke were found for skilled manual workers and UMW. Higher relative risks of CVD (either CHD or stroke) were found for lower administrators and professionals, skilled and unskilled manual workers and self-employed. Adjustments for major risk factors (cholesterol, systolic blood pressure, cigarette smoking, diabetes) did not modify the RRs. Conclusion. The higher risk of major cardiovascular events among lower SO classes is confirmed. Higher relative risks of CHD among lower administrators and professionals, and self-employers were also found. Further studies are needed to assess the etiologic role of job stress conditions.

[Possible interaction of environment and genetic factors in work-related diseases: the case of hypertension]. / La possibile interazione tra ambiente e fattori genetici nelle malattie lavoro-associate: il caso dell'ipertensione.

BACKGROUND: Cardiovascular diseases are the most important cause of death and invalidity during the course of working life. The major risk factor for cardiovascular diseases is arterial hypertension, a typical example of multifactorial and polygenic disease, involving genetic, environmental, and demographic factors. OBJECTIVES: A review of studies performed sofar on hypertension which can be also defined as a work-related disease. METHODS: Several studies on association or linkage analysis showed an association between genetic polymorphisms and increased risk of hypertension. RESULTS: Till now no studies have identified one or more "major" candidate genes involved in the pathogenesis of hypertension. Recently the interaction between genetics and environment have attracted much interest since the genotypes predisposingfor hypertension have different effects according to the patient's environment and life style. CONCLUSIONS: It is likely that the aspects covered in this review will, in the near future, be studied more extensively. The identification of any correlations between genes and environment will also be influenced by the accuracy in measuring environmental exposure, where the occupational physician will play a significant role.

Effects of a perindopril-based blood pressure-lowering regimen on disability and dependency in 6105 patients with cerebrovascular disease: a randomized controlled trial.

BACKGROUND AND PURPOSE: We sought to quantify the effects of blood pressure lowering on long-term disability and dependency among patients with cerebrovascular disease. METHODS: We performed a randomized, double-blind, placebo-controlled trial. A total of 6105 participants with a history of stroke or transient ischemic attack in the past 5 years were recruited from 172 hospital outpatient clinics in 10 countries. Subjects were randomly assigned to the following groups: active treatment (angiotensin-converting enzyme inhibitor perindopril [4 mg/d] for all patients, with the diuretic indapamide added at the discretion of treating physicians) or matching placebo(s). Measurements were disability (defined as a Barthel Index score < or =99/100) and dependency (a positive response to the following question: "In the last 2 weeks has the patient required regular help with everyday activities?"). RESULTS: The median duration of follow-up was 4 years. At the last available assessment, 19% of the active treatment group and 22% of the placebo group were disabled (adjusted odds ratio, 0.76; 95% CI, 0.65 to 0.89; P<0.001). Twelve percent of the active treatment group and 14% of the placebo group were dependent (adjusted odds ratio, 0.84; 95% CI, 0.71 to 0.99; P=0.04). The effects of treatment appeared to be mediated primarily through the prevention of disability and dependency associated with recurrent stroke. Four-year treatment with the study drug regimen would be expected to result in the avoidance of 1 case of long-term disability for every 30 (95% CI, 19 to 79) patients. CONCLUSIONS: Among individuals with cerebrovascular disease, a perindopril-based blood pressure-lowering regimen not only reduced the risk of stroke and major vascular events but also substantially reduced the risks of associated long-term disability and dependency.

Ambulatory and home blood pressure normality in the elderly: data from the PAMELA population.

To determine ambulatory blood pressure (BP) means and distributions in an elderly population, we studied a random sample of 800 subjects stratified by sex and representative of residents aged 65 to 74 years of the city of Monza. Participation was 50%. Measurements consisted of clinic BP (average of three measurements with mercury sphygmomanometry), home BP (average of morning and evening measurements with a semiautomatic device), and ambulatory BP (SpaceLabs 90207). Clinic BP was obtained before and after home and ambulatory BP measurements. In normotensive and untreated hypertensive subjects (n=248), clinic, home, and ambulatory BPs were significantly related (P<.001). The means of the clinic BPs obtained on consecutive days were very similar and markedly higher than 24-hour average BP (+25 mm Hg systolic and + 10 mm Hg diastolic, P<.001). Nighttime BP was markedly less than daytime BP (-14 and -13 mm Hg, P<.001), whereas home BP values occurred approximately midway between clinic and 24-hour average BP values. Only minor differences existed between data in men and women, and the differences in clinic, home, and ambulatory BP values occurred in both normotensive and untreated hypertensive subjects. All BPs were similar in the untreated and treated hypertensive groups. Thus, as previously reported in subjects younger than 65 years, in the elderly fraction of the population, 24-hour average BP is much lower than clinic BP. The upper limit of normality for 24-hour average BP (calculated as the value corresponding to 140/90 mm Hg clinic BP) is about 120 mm Hg systolic and 76 mm Hg diastolic. At variance with data from younger subjects, home BP in the elderly is higher than 24-hour average BP. However, similar to data from younger subjects, clinic, home, and ambulatory BPs are higher in treated hypertensive than normotensive elderly subjects, indicating that in hypertensive elderly subjects, antihypertensive treatment does not commonly achieve full BP control both inside and outside the clinic environment.

Combined effects of hypertension and hypercholesterolemia on radial artery function.

Compliance and distensibility of middle-sized conduit arteries are increased in hypertension and reduced in hypercholesterolemia. Despite their frequent association in the same individual, the combined effect of these two conditions on arterial mechanical properties is unknown. We studied four groups of age- and sex-matched subjects: 10 normotensive normocholesterolemic subjects, 10 mild hypertensive normocholesterolemic subjects, 10 mild hypercholesterolemic normotensive subjects, and 10 mild hypertensive and mild hypercholesterolemic subjects. We measured radial artery diameter by an echotracking device and beat-to-beat blood pressure from an ipsilateral finger. Compliance-pressure and distensibility-pressure curves were derived by Langewouters' formula. Between-group comparisons were made by calculating for both compliance and distensibility the integral of the area under the portion of the curve common to the four groups ("isobaric" compliance and distensibility). Blood pressure was similarly elevated in the two hypertensive groups, and serum cholesterol was similarly elevated in the two hypercholesterolemic groups. Compared with values in normotensive normocholesterolemic subjects, isobaric compliance and distensibility were greater in hypertensive normocholesteroclemic (+38% and 47%, respectively) and smaller in normotensive hypercholesterolemic (-6% and -23%) subjects. However, when both hypertension and hypercholesterolemia were present, isobaric compliance and isobaric distensibility were significantly reduced (-26% and -18%, P < .05). Therefore, hypercholesterolemia reverses the effect of hypertension on arterial compliance and causes arterial stiffening, as when present alone.

Indenolol in hypertension.

After a complete washout 14 hypertensive inpatients were given placebo for 3 days. Undistinguishable 30- or 60-mg indenolol tablets were then given twice daily for 14 days in a double-blind, randomized manner. Supine and standing arterial pressure and heart rate were measured at rest three times a day. Indenolol decreased systolic and diastolic arterial pressure as well as heart rate in subjects in supine and standing positions. Placebo had no effect. The effect of indenolol on systolic arterial pressure was dose and time related, but independent of the intensity of hypertension. No dose-effect relationship was found on diastolic arterial pressure. Decrease of heart rate was dose and time related, although bradycardia was never noted. Indenolol was well tolerated.

Seasonal variations in home and ambulatory blood pressure in the PAMELA population. Pressione Arteriose Monitorate E Loro Associazioni.

OBJECTIVE: Clinic blood pressure values are known to change according to seasonal influences. We therefore examined home and 24 h ambulatory blood pressure values to determine whether these measurements are also affected by the seasons. DESIGN AND METHODS: In 2051 subjects of the Pressione Arteriose Monitorate E Loro Associazioni (PAMELA) study, we measured clinic (sphygmomanometric measurements), home (semi-automatic device) and ambulatory (Spacelabs 90207) systolic blood pressure, diastolic blood pressure and heart rate. Because the overall sample was evenly distributed over each month (except August), we were able to make a cross-sectional determination of whether the values differed between seasons. The corresponding heart rates were also evaluated. RESULTS: As expected, summer was associated with the lowest clinic blood pressure and winter with the highest, and this was the case also for home and 24 h average blood pressure, although seasonal differences in the latter were less pronounced. Seasonal clinic, home and ambulatory blood pressure patterns were similar for normotensive subjects (n = 1152), untreated hypertensives (n = 540) and treated hypertensives (n = 359). Heart rate values did not differ by season. CONCLUSIONS: Seasonal influences on blood pressure are not limited to conventional measurements but characterize daily values as well. These effects are visible in both normal and elevated blood pressure values, regardless of the effect of antihypertensive drugs. This has implications both for the clinician and for studies aimed at evaluating the effects of antihypertensive treatment.

Ambulatory blood pressure normality: results from the PAMELA study.

OBJECTIVE: To determine ambulatory and home blood pressure means and distributions in relation to clinic blood pressure in a general population. METHODS: We obtained a random sample of 2400 subjects stratified by sex and 10 year age groups to be representative of residents aged 25-64 years of the city of Monza. Participation rate was 69% (1651 subjects). Blood pressure measurements consisted of clinic blood pressure (average of three measurements, sphygmomanometry), home blood pressure (average of morning and evening measurements, semiautomatic device) and ambulatory blood pressure (automatic readings at 20 min intervals, Spacelabs 90207). Clinic blood pressure was obtained both before and after home and ambulatory blood pressures. Data analysis did not include 213 subjects receiving antihypertensive drug treatment and was therefore limited to 1438 participants. RESULTS: In the 1438 subjects, clinic, home and ambulatory blood pressure showed a normal-like distribution, with a taller peak and a narrower base for ambulatory than for home and clinic values. Clinic, home and ambulatory blood pressures were significantly related to each other (P always < 0.001). The means of the two clinic blood pressures obtained on consecutive days were superimposable (127.4 +/- 17.0/82.3 +/- 9.8 and 128.2 +/- 16.5/81.9 +/- 9.9 mmHg) and both were markedly higher than home and 24 h average blood pressures (8.2 mmHg), which were similar to one another. The differences between clinic and home or 24 h average blood pressure were similar in both sexes but increased with increasing age and clinic blood pressure values. The influence of clinic blood pressure values on the clinic-ambulatory or clinic-home blood pressure differences was more important than age. Although higher than the 24 h average value, daytime average blood pressure was also lower than clinic blood pressure. Night-time blood pressure was markedly lower than the daytime value in both sexes and at all ages. CONCLUSION: Data from a large and unbiased sample of a general population show that home and 24 h or daytime average blood pressures are much lower than clinic blood pressure. The relatively close correlation between blood pressure values measured with the different methods used has allowed calculation of home and ambulatory blood pressure values corresponding to the accepted upper limit of normality of clinic blood pressure (140/90 mmHg). The upper limit of normality for the population was for both home and ambulatory blood pressures in the range 120-130 and 75-81 mmHg for systolic and diastolic values, respectively, with slight differences depending on sex and age. Taking 140/90 mmHg as the upper normal limit of the population is therefore an error that leads to individuals whose home or ambulatory blood pressures are high being considered as normotensive.

Cardiac and vascular structural changes in normotensive subjects with parental hypertension.

OBJECTIVE: To evaluate whether a predisposition to hypertension is associated with early cardiac and vascular alterations. SUBJECTS: Twenty-five normotensive subjects with both parents hypertensive (group 1) and 28 age- and sex-matched control subjects with both parents normotensive (group 2). METHODS: In the two groups the measurements included: clinic blood pressure; left ventricular end-diastolic diameter, septal wall thickness and posterior wall thickness (by echocardiography); minimal forearm and calf vascular resistances (i.e. resistance assessed immediately after prolonged ischaemia, which depends on arteriolar wall thickness); and baseline and postischaemic radial artery compliance-pressure curves over the systolodiastolic pressure range (by echotracking device and finger blood pressure). RESULTS: Group 1 had a slightly higher clinic blood pressure, and septal and posterior wall thickness, than group 2. Minimal forearm vascular resistance was clearly greater in group 1 than in group 2, whereas minimal calf vascular resistance was not significantly different in the two groups. Radial artery compliance was also similar in the two groups. CONCLUSIONS: Parental predisposition to hypertension is accompanied by cardiac and arteriolar structural changes qualitatively similar to those found in hypertensive patients, although arteriolar structural changes do not involve all vascular beds. Arterial compliance is not altered in this condition. Vascular changes may be determined by mechanisms other than blood pressure elevation.

Pharmacokinetics and effects of propranolol in terminal uraemic patients and in patients undergoing regular dialysis treatment.

Propranolol blood and plasma levels were measured after a single oral dose of 40 mg in patients with chronic renal failure, in patients undergoing regular dialysis treatment, and in healthy volunteers. Peak levels were observed in all cases within 1.5 to 3 hours. However, peak blood and plasma concentrations of propranolol in the chronic renal failure group were 2- to 3-fold higher (161 +/- 41 ng/ml) than those observed in the dialysis patients (47 +/- 9 ng/ml) and in the healthy volunteers (26 +/- 1 ng/ml). The apparent plasma clearance was also significantly reduced in the patients with chronic renal failure. The data suggest a reduced hepatic extraction in chronic renal failure patients. A significant increase in the fraction of the dose available to the systemic circulation was also found, together with a modification of apparent plasma half-life and volume of distribution in regular dialysis patients during the dialysis day as compared with the after-dialysis day. No extraction of propranolol by the dialyzer was noticed. Marked fluctuations in propranolol blood concentrations were also observed in patients on regular dialysis following continuous propranolol treatment. The suppressive effect of propranolol on plasma renin activity did not fully correlate with the hypotensive effect of the drug. On the basis of the reported data, propranolol should be used with great caution and at low doses in chronic renal failure.

Surveillance of ischaemic heart disease: results from the Italian MONICA populations.

BACKGROUND: The major objectives are to report on coronary event mortality, incidence and attack rates and changes over time observed in the Italian MONICA populations and to assess if trends are consistent when different disease definitions are considered. An analysis of diagnostic agreement between clinical and MONICA categories is presented in the context of developing a model for estimating disease incidence in a population, based on currently available data. METHODS: Data were provided by the three Italian MONICA (MONItoring trends and determinants of CArdiovascular diseases) registers. The areas of Brianza and Friuli, both located in northern Italy, completed the 10-year period of registration. Data from the MONICA Latina area, located close to Rome, were limited to the first 3 years of registration. These data are used for assessing geographical differences in rates in the mid- 1980s and estimating the diagnostic agreement between International Classification of Diseases (ICD) codes and MONICA categories. Two diagnostic aggregates have been used: the standard MONICA diagnostic definition for myocardial infarction (MI), which includes non-fatal definite myocardial infarction and fatal coronary events, and the coronary event definition which includes, in addition, non-fatal possible myocardial infarctions. RESULTS: From the mid-1980s to the mid-1990s, a considerable reduction in all-cause, cardiovascular and coronary mortality rates occurred in the monitored populations. Data from the MONICA registers confirm the accuracy of official reports of death rates and changes in Italy. Comparisons of time differences in attack and incidence rates of myocardial infarction and all coronary events indicate that the impact of the more severe manifestations of coronary heart diseases (fatal coronary event and acute MI) reduced during the period of observation, but when less severe events (minor myocardial infarction and angina pectoris) are considered, the overall impact of the disease on the population remained stable. CONCLUSION: Epidemiological surveillance of coronary syndromes is relevant over this time period of impressive changes in prevention and treatment. Continuing restrictions in available resources necessitate the development of simplified registration systems.

Socio-occupational differences in acute myocardial infarction case-fatality and coronary care in a northern Italian population.

AIMS: To appraise 28-day case-fatality of myocardial infarction (MI) among socio-occupational classes; to assess the consistency of the results for different degrees of MI severity; to explore if such differences are related to differences in management and treatment of the acute attack. METHODS: All coronary events (n = 1077), registered in 1993-1994 among the 35-64 year old male residents in MONICA Area Brianza were investigated and classified into diagnostic categories according to MONICA criteria. For all cases standardized information on acute coronary care and interventions before and during hospitalization was collected. Classification of social classes was derived from the Erikson-Goldthorpe-Portocarero social class scheme, based on information on occupational characteristics widely available in European countries. RESULTS: An increasing rate of case-fatality for decreasing levels of socio-occupational class was found. The social gradient resulted mainly from the higher incidence of out-of-hospital cardiac arrests. Treatment before and during the acute attack cannot explain the observed differences. CONCLUSION: Combining these results with those obtained in other MONICA centres, it appears that further decreases in coronary mortality might be achieved through specific programmes addressed in particular to the reduction of out-of-hospital case-fatality in lower social classes.

Time trends of major coronary risk factors in a northern Italian population (1986-1994). How remarkable are socioeconomic differences in an industrialized low CHD incidence country?

BACKGROUND: The goals are to estimate time trends (1986-1994) of major coronary risk factors in an industrialized low CHD incidence population and to assess education class (EC) differences in risk factor prevalence and in time trends. METHODS: Three population surveys were conducted in 1986-1987, 1989-1990 and 1993- 1994 on independent and two-stage age- and gender-stratified random samples (1906 men and 1941 women) of 35-64 year old residents of Brianza, an affluent region of northern Italy. The protocol for data collection, clinical measurements and biochemical determinations adhered to the WHO MONICA manual and underwent repeated quality control assessments. EC were identified according to gender- and 5-year birth-cohort specific tertiles. RESULTS: In the initial, middle and final surveys 1258, 1259 and 1330 subjects were enrolled, corresponding to participation rates of 70.1%, 70.3% and 74.3%, respectively. Over the 8-year period, in men systolic blood pressure and smoking habits declined, body mass index and serum total cholesterol increased. In women systolic blood pressure showed a constant reduction, total cholesterol and BMI increased and the prevalence of smokers remained stable. Overall inverse associations with EC were found for body mass index, for prevalence of cigarette smokers in men and for systolic blood pressure in women. Decreases in blood pressure were more evident in the lowest EC. Cigarette smoking was on the decline in the higher EC in men. BMI and total cholesterol increased in all EC with the notable exception of the 'low' EC in women. CONCLUSIONS: Favourable changes of the risk factor profile in the low socio-economic classes may have contributed to reduce CHD rates in this population. Specific policies oriented to lowest socio-economic classes are needed to continue to combat the smoking epidemic.

Ambulatory blood pressure monitoring in the design of studies on antihypertensive drug efficacy.

Ambulatory blood pressure monitoring (ABPM) provides advantages for studies of the efficacy of antihypertensive drugs in addition to demonstrating antihypertensive effects in daily life conditions. For example, ABPM is devoid of the "white coat" effect and can thus more precisely estimate the relative proportion of responders and nonresponders to treatment. It also may reduce the study size because of the greater reproducibility of 24 h average blood pressure (BP) (as compared to clinic BP) and the lack of a substantial placebo effect, which eliminates the need for a placebo group. Some disadvantages exist, including the inability of automatic ABPM to consistently provide accurate BP readings and to estimate BP variability. Finally, hourly average BPs are less reproducible than their average 24 h counterpart, which may make it more difficult to statistically demonstrate an antihypertensive effect throughout the 24 h. Some of these disadvantages, however, may be reduced in the near future by new ABPM devices.

Ambulatory blood pressure in air traffic controllers.

Conflicting reports exist as to whether air traffic controllers (ATC) have an increase in blood pressure (BP) and prevalence of hypertension because of the stressful nature of their job. We have addressed the issue in male ATC working at the Linate airport of Milan. A total of 80 ATC participated, and the 24 h blood pressure monitoring was obtained during two working shifts separated by one night of rest. Blood pressure was measured conventionally and by 24 h ambulatory monitoring; data were compared with those of an age matched male sample three times as large, selected from the data of the Studio delle Pressioni Ambulatoriali delle Loro Associazioni (PAMELA), ie, a large sample representative of the population of the nearby town of Monza. Treated hypertensive subjects were excluded from both groups. Conventional diastolic BP and heart rate were similar in ATC and controls, whereas conventional systolic BP was significantly greater in the former than in the latter group. No difference, however, was seen between ATC and controls as far as ambulatory BP and heart rate were concerned; namely, 24 h, day, and night average systolic BP, and diastolic BP and heart rate were similar in the two groups. Thus daily life BP is not increased in ATC. This may result from the fact that, being a highly selected group with suitable training, these subjects adequately cope with the stress inherent to the job.

Indenolol pharmacokinetics and pharmacodynamics after single and repeated daily doses.

The relationship between indenolol (an investigational agent) plasma levels and the drug's effect on blood pressure and heart rate was investigated after single and repeated once daily administration at two dosage levels (60 mg and 120 mg) in two different groups of patients with first or second stage hypertension, according to the World Health Organization classification. The pharmacokinetic data were indicative of a first order absorption-elimination curve; time of maximum plasma levels was 1.5 to two hours, and elimination half-life was four hours. The drug did not accumulate in the central compartment after repeated administrations. A long-lasting decrease of both resting and isometric exercise systolic pressure values was recorded after acute indenolol administration. Diastolic pressure was affected only by repeated administrations. The lower dose (60 mg daily) of indenolol did not affect heart rate, whereas the higher dose (120 mg daily) decreased this parameter. A steady state of pressure values and heart rate was reached after 14 days of once daily treatment.

Job strain and ambulatory blood pressure levels in a population-based employed sample of men from northern Italy.

OBJECTIVES: The purpose of this cross-sectional study was to examine the associations between categories of perceived job strain and blood pressure, measured by clinical and ambulatory devices on a population-based sample of employed men in northern Italy. METHODS: The study included 527 employed normotensive or mild hypertensive nonmedicated men enrolled in an age-gender stratified random sample of 821 25- to 64-year-old residents of the city of Monza (in the vicinity of Milan). The job-strain categories were classified according to the traditional quadrant-term approach and also a new approach based on the comparison of extreme tertile categories in order to enhance contrasts. Clinical blood pressure was measured according to the standardized MONICA procedure; 24-h, work, leisure, and nighttime blood pressure values were obtained with an ambulatory device. Disparities, calculated as differences between clinical and ambulatory measurements, were also analyzed. RESULTS: Among normotensive working men the highest mean for systolic blood pressure was found in the high-strain group, and progressively lower values were found in the passive, active and low-strain categories. These patterns were observed for both the clinical and ambulatory measurements. Among the mild hypertensive subjects, lower mean values for ambulatory systolic and diastolic blood pressure were found in the passive and high job-strain categories when the tertile term approach was adopted. The passive group also showed the highest mean difference between the clinical and ambulatory measurements; this finding indicates that they may be more susceptible to alarm reactions. CONCLUSIONS: The results indicate that job strain affects blood pressure in population-based samples and the effect is consistent across sociocultural contexts.