Healthy overweight and obesity in the young: Prevalence and risk of major adverse cardiovascular events.

AIMS: To investigate the prevalence of metabolically healthy overweight/obesity and to study its longitudinal association with major adverse cardiovascular and renal events (MARCE). METHODS AND RESULTS: The study was conducted in 1210 young-to-middle-age subjects grouped according to their BMI and metabolic status. The risk of MARCE was evaluated during 17.4 years of follow-up. Forty-eight-percent of the participants had normal weight, 41.9% had overweight, and 9.3% had obesity. Metabolically healthy status was found in 31.1% of subjects with normal weight and in 20.0% of those with overweight/obesity. During the follow-up, there were 108 MARCE. In multivariate Cox analysis adjusted for confounders and risk factors, no association was found between MARCE and overweight/obesity (p = 0.49). In contrast, metabolic status considered as a two-class variable (0 versus at least one metabolic abnormality) was a significant predictor of MARCE (HR, 2.11; 95%CI, 1.21-3.70, p = 0.009). Exclusion of atrial fibrillation from MARCE (N = 87) provided similar results (HR, 2.11; 95%CI, 1.07-4.16, p = 0.030). Inclusion of average 24 h BP in the regression model attenuated the strength of the associations. Compared to the group with healthy metabolic status, the metabolically unhealthy overweight/obesity participants had an increased risk of MARCE with an adjusted HR of 2.33 (95%CI, 1.05-5.19, p = 0.038). Among the metabolically healthy individuals, the CV risk did not differ according to BMI group (p = 0.53). CONCLUSION: The present data show that the risk of MARCE is not increased in young metabolically healthy overweight/obesity suggesting that the clinical approach to people with high BMI should focus on parameters of metabolic health rather than on BMI.

Exaggerated blood pressure response to standing in young-to-middle-age subjects: prevalence and factors involved.

PURPOSE: To investigate the prevalence of orthostatic hypertension and the association of the blood pressure (BP) level, supine BP decline, and white-coat effect with the orthostatic pressor response. METHODS: We studied 1275 young-to-middle-age individuals with stage-1 hypertension. Orthostatic response was assessed three times over a 3 month period. The white-coat effect was assessed at baseline and after 3 months, and was calculated as the difference between office and average 24 h BP. In 660 participants, urinary epinephrine and norepinephrine were also measured. RESULTS: An orthostatic systolic BP increase ≥ 20 mmHg was observed in 0.6-1.2% of the subjects during the three visits. Using the 20 mmHg cut-off, the prevalence of orthostatic hypertension was 0.6%. An orthostatic BP increase of ≥ 5 mmHg was found in 14.4% of participants. At baseline, the orthostatic response to standing showed an independent negative association with the supine BP level (p < 0.001), the supine BP change from the first to third measurement (p < 0.001), and the white-coat effect (p < 0.001). Similar results were obtained in the 1080 participants assessed at the third visit. Urinary epinephrine showed higher values in the top BP response decile (systolic BP increase ≥ 6 mmHg, p = 0.002 versus rest of the group). CONCLUSION: An orthostatic systolic BP reaction ≥ 20 mmHg is rare in young adults. However, even lower BP increases may be clinically relevant. The BP level, the supine BP decline over repeated measurement, and the white-coat effect can influence the estimate of the BP response to standing and should be considered in clinical and pathogenetic studies.

Low night-time heart rate is longitudinally associated with lower augmentation index and central systolic blood pressure in hypertension.

PURPOSE: Several studies have shown that the augmentation index (AIx) is negatively correlated with heart rate (HR). This led some authors to claim that the use of HR-lowering drugs may be detrimental in hypertension. The aim of this study was to assess the longitudinal and cross-sectional relationships of HR with AIx and central blood pressure (BP) in 346 subjects from the HARVEST (mean age 30.7 ± 8.5 years). METHODS: At baseline, HR was measured with 24-h ambulatory recording. Central hemodynamics were evaluated with Specaway DAT system after a median of 8.0 years from baseline. In multivariate linear regression analyses, AIx and central systolic BP were used as dependent variables and night-time HR or office HR as predictors adjusting for several risk factors and confounders. RESULTS: In fully adjusted models, baseline night-time HR was a significant positive predictor of AIx (p < 0.001) and central BP (p = 0.014) measured 8 years later. Adjusted office HR measured at the time of arterial distensibility assessment was inversely correlated with AIx (p = 0.001) a relationship which was attenuated after physical activity (p = 0.004) and left ventricular ejection time (p = 0.015) were taken into account. In addition, office HR was inversely correlated with central BP (p = 0.039) a relationship which was no longer significant after physical activity and ejection time were accounted for. CONCLUSIONS: These data show that HR measured during sleep is longitudinally associated with AIx and central BP. Thus, low HR in the long term may have beneficial effects on central hemodynamics and the wall properties of the large arteries in hypertension.

Effects of smoking on central blood pressure and pressure amplification in hypertension of the young.

The aim of this study was to investigate the effect of cigarette smoking on peripheral and central blood pressure (BP) in a group of young stage I hypertensives. A total of 344 untreated subjects from the HARVEST study were examined (mean age 37±10 years). Patients were divided into three groups based on smoking status: non-smokers, light smokers (⩽5 cigarettes/day) and moderate-to-heavy smokers (>5 cigarettes/day); and into three groups by age: 18-29, 30-39 and ⩾40 years. Central BP measurements and augmentation index (AIx) were calculated from brachial pressure waveform, with applanation tonometry, by means of the Specaway DAT System plus a Millar tonometer. The central waveform was derived from peripheral BP using the same software system of the SphygmoCor System pulse wave analysis. In addition, two indirect measurements of arterial stiffness were calculated: pulse pressure (PP) and systolic BP amplification. Central systolic BP and PP were higher in smokers than in non-smokers (systolic BP: 121.9±13.1 mmHg in non-smokers, 127.2±16.5 mmHg in light smokers, 126.7±15.3 mmHg in those who smoked >5 cigarettes/day, p=0.009; PP: 37.7±9.8 mmHg, 41.5±13.1 mmHg, 41.9±10.5 mmHg, respectively, p=0.005). Lower systolic BP amplification (p<0.001) and PP amplification (p=0.001) were observed in smokers compared to non-smokers. In a two-way ANCOVA analysis, systolic BP amplification markedly declined across the three age groups (p=0.0002) and from non-smokers to smokers (p=0.0001), with a significant interaction between smoking and age group (p=0.05). The AIx was higher in smokers compared to non-smokers (p=0.024). In young hypertensives, smoking has a detrimental effect on central BP, accelerating the age-related decline in BP amplification.

Association of coffee consumption and CYP1A2 polymorphism with risk of impaired fasting glucose in hypertensive patients.

Whether and how coffee use influences glucose metabolism is still a matter for debate. We investigated whether baseline coffee consumption is longitudinally associated with risk of impaired fasting glucose in a cohort of 18-to-45 year old subjects screened for stage 1 hypertension and whether CYP1A2 polymorphism modulates this association. A total of 1,180 nondiabetic patients attending 17 hospital centers were included. Seventy-four percent of our subjects drank coffee. Among the coffee drinkers, 87% drank 1-3 cups/day (moderate drinkers), and 13% drank over 3 cups/day (heavy drinkers). Genotyping of CYP1A2 SNP was performed by real time PCR in 639 subjects. At the end of a median follow-up of 6.1 years, impaired fasting glucose was found in 24.0% of the subjects. In a multivariable Cox regression coffee use was a predictor of impaired fasting glucose at study end, with a hazard ratio (HR) of 1.3 (95% CI 0.97-1.8) in moderate coffee drinkers and of 2.3 (1.5-3.5) in heavy drinkers compared to abstainers. Among the subjects stratified by CYP1A2 genotype, heavy coffee drinkers carriers of the slow *1F allele (59%) had a higher adjusted risk of impaired fasting glucose (HR 2.8, 95% CI 1.3-5.9) compared to abstainers whereas this association was of borderline statistical significance among the homozygous for the A allele (HR 1.7, 95% CI 0.8-3.8). These data show that coffee consumption increases the risk of impaired fasting glucose in hypertension particularly among carriers of the slow CYP1A2 *1F allele.

Regular physical activity is associated with improved small artery distensibility in young to middle-age stage 1 hypertensives.

The aim of the present study was to investigate the association of physical activity with small artery elasticity in the early stage of hypertension. We examined 366 young-to-middle-age stage 1 hypertensives (mean blood pressure 145.6±10.3/92.5±5.8 mmHg), divided into two categories of physical activity, sedentary (n=264) and non-sedentary (n=102) subjects. The augmentation index was measured using the Specaway DAT System. Small artery compliance (C2) was measured by applanation tonometry, at the radial artery, with an HDI CR2000 device. After 6 years of follow-up, arterial distensibility assessment was repeated in 151 subjects. Heart rate was lower in active than in sedentary subjects (71.2±8.9 vs 76.6±9.7 bpm, p<0.001). After adjusting for age, sex, heart rate, smoking, and blood pressure, C2 was higher (8.0±2.6 vs 6.4±3.0 ml/mmHg × 100, p=0.008) in non-sedentary than in sedentary patients. The augmentation index was smaller in the former (8.8±20.1 vs 16.8±26.5%, p=0.044) but the difference lost statistical significance after further adjustment for blood pressure. After 6 years, C2 was still higher in the non-sedentary than sedentary subjects. In addition, an improvement in the augmentation index accompanied by a decline in total peripheral resistance was found in the former. These data show that regular physical activity is associated with improved small artery elasticity in the early phase of hypertension. This association persists over time and is independent of blood pressure and heart rate.

Instability of Healthy Overweight and Obesity Phenotypes over the Long Term in Young Participants in the HARVEST Study: Influence of Sex.

BACKGROUND: Whether healthy metabolic status is stable or only temporary is still controversial. The aim of the present study was to determine the frequency of the transition from metabolically healthy to metabolically unhealthy status, or vice versa, over the long term. METHODS: We examined 970 individuals of 18 to 45 years of age. The participants' mean age was 33.1 ± 8.6 years and mean BP was 145.5 ± 10.6/93.5 ± 5.7 mmHg. Participants were classified into four groups according to whether they had normal weight or overweight/obesity (OwOb) and were metabolically healthy or unhealthy. After 7.5 years, 24.3% of men and 41.9% of women in the metabolically healthy normal-weight group remained metabolically healthy (p < 0.0001). Among the metabolically healthy OwOb participants, 31.9% remained metabolically healthy, with a similar frequency in men and women. However, more OwOb women (19.1%) than men (5.7%) achieved normal weight (p < 0.0001). Among the metabolically unhealthy OwOb subjects, 81.8% of men and 69.3% of women remained metabolically unhealthy, 7.4% of men and 12.0% of women transitioned to OwOb healthy status, and 10.7% of men and 18.7% of women achieved normal weight (men versus women, p < 0.0001). Predictors of transition to unhealthy status were high BP, high BMI, and smoking. Male sex was a borderline predictor of progression to unhealthy status in OwOb participants (p = 0.073). CONCLUSION: These data show that metabolically healthy status is a highly unstable condition in both normal-weight and OwOb individuals. The impairment of metabolic status was more frequent in men than in women. Lifestyle counseling produced beneficial effects in almost one-third of metabolically unhealthy OwOb women and in less than one-fifth of men.

Central blood pressure is an independent predictor of future hypertension in young to middle-aged stage 1 hypertensives.

AIM: The aim of the present study was to evaluate the association of central blood pressure (BP) with organ damage and risk of future hypertension in a cohort of young to middle-aged patients. METHODS: We studied 305 subjects screened for stage 1 hypertension to determine which subjects developed hypertension needing therapy according to current guidelines. Central BP was obtained from radial artery tonometry. Organ damage was the presence of left ventricular hypertrophy and/or microalbuminuria. RESULTS: In a multiple logistic regression including ambulatory 24-h BP, central mean BP was associated with presence of end-organ damage (p = 0.003). In the subjects divided according to whether their central mean BP was above or below the median, subjects with high central mean BP presented an earlier impairment of arterial distensibility and developed sustained hypertension more frequently compared with those with low central mean BP (p < 0.001). In logistic analyses, central mean BP was an independent predictor of future hypertension (p < 0.001) and remained associated with outcome when 24-h BP was included in the same model (p = 0.006). CONCLUSIONS: In young to middle-aged subjects in the early stage of hypertension, central mean BP is a useful adjunct to brachial BPs to better define the individual risk profile.

Reproducibility and Predictive Value of White-Coat Hypertension in Young to Middle-Age Subjects.

(1) Aim. The aim of the study was to investigate the reproducibility of white-coat hypertension (WCH) and its predictive capacity for hypertension needing antihypertensive treatment (HT) in young to middle-age subjects. (2) Methods. We investigated 1096 subjects from the HARVEST. Office and 24 h blood pressures (BP) were measured at baseline and after 3 months. The reproducibility of WCH was evaluated with kappa statistics. The predictive capacity of WCH was tested in multivariate Cox models (N = 1050). (3) Results. Baseline WCH was confirmed at 3-month assessment in 33.3% of participants. Reproducibility was fair (0.27, 95%CI 0.20-0.37) for WCH, poor (0.14, 95%CI 0.09-0.19) for office hypertension, and moderate (0.47, 95%CI 0.41-0.53) for ambulatory hypertension. WCH assessed either at baseline or after 3 months (unstable WCH) was not a significant predictor of HT during 17.4 years of follow-up. However, participants who had WCH both at baseline and after 3 months (stable WCH) had an increased risk of HT compared to the normotensives (Hazard ratio, 1.50, 95%CI 1.06-2.1). (4) Conclusions. These results show that WCH has limited reproducibility. WCH diagnosed with two BP assessments but not with one showed an increased risk of future HT. Our data indicate that WCH should be identified with two sets of office and ambulatory BP measurements.

Mitral Valve Prolapse and Sudden Cardiac Death in Athletes at High Risk.

Mitral valve prolapse (MVP) is the most frequent valvulopathy in the general population, with usually a favourable prognosis. Although it can be associated with some complications, ventricular arrhythmias (VA) and sudden cardiac death (SCD) are the most worrying. The estimated risk of SCD in MVP is between 0.2% to 1.9% per year, including MVP patients with and without severe mitral regurgitation (MR). The association between SCD and MVP is expressed by a phenotype called "malignant MVP" characterized by transthoracic echocardiography (TTE) findings such as bileaflet myxomatous prolapse and mitral annulus disjunction (MAD), ECG findings such as repolarization abnormalities, complex ventricular arrhythmias (c-VAs) and LV fibrosis of papillary muscles (PMs) and inferobasal wall visualized by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Therefore, attention is raised for patients with "arrhythmic MVP" characterized from an ECG point of view by frequent premature ventricular contractions (PVCs) arising from one or both PMs as well as by T-wave inversion in the inferolateral leads. In athletes, SCD is the most frequent medical cause of death and in young subjects (< 35 years) usually is due to electrical mechanism affecting who has a silent cardiovascular disease and are not considered per se a cause of increased mortality. In MVP, SCD was reported to happen during sports activity or immediately after and valve prolapse was the only pathological aspect detected. The aim of the present paper is to explore the association between SCD and MVP in athletes, focusing attention on ECG, TTE in particular, and CMR findings that could help to identify subjects at high risk for complex arrhythmias and eventually SCD. In addition, it is also examined if sports activity might predispose patients with MVP to develop major arrhythmias.

Both Moderate and Heavy Alcohol Use Amplify the Adverse Cardiovascular Effects of Smoking in Young Patients with Hypertension.

AIM: To evaluate the association of alcohol and smoking combined with cardiovascular and renal events and investigate whether moderate and heavy alcohol consumption have a different impact on this association. METHODS: The study was conducted in 1208 young-to-middle-age stage 1 hypertensive patients. Subjects were classified into three categories of cigarette smoking and alcohol use, and the risk of adverse outcomes was assessed over a 17.4-year follow-up. RESULTS: In multivariable Cox models, smoking showed a different prognostic impact on alcohol drinkers and abstainers. In the former, an increase in the risk of cardiovascular and renal events was observed compared to nonsmokers (hazard ratio, 2.6, 95% CI, 1.5-4.3, p < 0.001), whereas in the latter, the risk did not achieve the level of statistical significance (p = 0.27) with a significant interaction between smoking and alcohol use (p < 0.001). Among the heavy smokers who also drank alcoholic beverages, the hazard ratio from the fully adjusted model was 4.3 (95% CI, 2.3-8.0, p < 0.0001). In the subjects with moderate alcohol consumption, the risk of smoking and alcohol combined was similar to that found in the whole population (hazard ratio, 2.7; 95% CI, 1.5-3.9, p < 0.001). Among the subjects with heavy alcohol consumption, the hazard ratio was 3.4 (95% CI, 1.3-8.6, p = 0.011). CONCLUSION: These findings indicate that the detrimental cardiovascular effects of smoking can be worsened by concomitant alcohol use. This synergistic effect occurs not only for heavy alcohol consumption but also for moderate use. Smokers should be aware of the increased risk associated with concomitant alcohol consumption.

In Cardiac Patients ß-Blockers Attenuate the Decrease in Work Rate during Exercise at a Constant Submaximal Heart Rate.

PURPOSE: Exercise prescription based on fixed heart rate (HR) values is not associated with a specific work rate (WR) during prolonged exercise. This phenomenon has never been evaluated in cardiac patients and might be associated with a slow component of HR kinetics and ß-adrenergic activity. The aims were to quantify, in cardiac patients, the WR decrease at a fixed HR and to test if it would be attenuated by ß-blockers. METHODS: Seventeen patients with coronary artery disease in stable conditions (69 ± 9 yr) were divided into two groups according to the presence (BB) or absence (no-BB) of a therapy with ß-blockers, and performed on a cycle ergometer: an incremental exercise (INCR) and a 15-min "HR CLAMPED " exercise, in which WR was continuously adjusted to maintain a constant HR, corresponding to the gas exchange threshold +15%. HR was determined by the ECG signal, and pulmonary gas exchange was assessed breath-by-breath. RESULTS: During INCR, HR peak was lower in BB versus no-BB ( P < 0.05), whereas no differences were observed for other variables. During HR CLAMPED , the decrease in WR needed to maintain HR constant was less pronounced in BB versus no-BB (-16% ± 10% vs -27 ± 10, P = 0.04) and was accompanied by a decreased V̇O 2 only in no-BB (-13% ± 6%, P < 0.001). CONCLUSIONS: The decrease in WR during a 15-min exercise at a fixed HR (slightly higher than that at gas exchange threshold) was attenuated in BB, suggesting a potential role by ß-adrenergic stimulation. The phenomenon may represent, also in this population, a sign of impaired exercise tolerance and interferes with aerobic exercise prescription.

Electroanatomic mapping in athletes: Why and when. An expert opinion paper from the Italian Society of Sports Cardiology.

Three-dimensional electroanatomical mapping (EAM) has the potential to identify the pathological substrate underlying ventricular arrhythmias (VAs) in different clinical settings by detecting myocardial areas with abnormally low voltages, which reflect the presence of different cardiomyopathic substrates. In athletes, the added value of EAM may be to enhance the efficacy of third-level diagnostic tests and cardiac magnetic resonance (CMR) in detecting concealed arrhythmogenic cardiomyopathies. Additional benefits of EAM in the athlete include the potential impact on disease risk stratification and the consequent implications for eligibility to competitive sports. This opinion paper of the Italian Society of Sports Cardiology aims to guide general sports medicine physicians and cardiologists on the clinical decision when to eventually perform an EAM study in the athlete, highlighting strengths and weaknesses for each cardiovascular disease at risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression, and worsening of the arrhythmogenic substrate is also addressed.

Effects of Candesartan on Left Ventricular Function, Aldosterone and BNP in Chronic Heart Failure.

PURPOSE: Heart failure (HF) is characterized by activation of neurohormonal systems such as aldosterone and natriuretic peptides. In the absence of published data, CandHeart trial was designed to assess the effects on left ventricular (LV) function, aldosterone and brain natriuretic peptide (BNP) of candesartan in patients with HF and preserved (LVEF ≥ 40%) or depressed (LVEF <40%) LV systolic function. METHODS: A total of 514 patients with stable symptomatic NYHA II-IV HF and any left ventricular ejection fraction (LVEF)were randomized to candesartan (target dose 32 mg once daily) as add-on therapy or standard medical therapy alone. Standardized echocardiographic exams were performed locally under central quality control, whereas biomarkers were assayed in a core laboratory. RESULTS: The majority of patients (73.3%) were NYHA II and on ACE inhibitors (91.8%) and beta-blockers (85.4%). Mean age was 66 ± 11 years. Mean LVEF was 36.2 ± 9.7% and 24.9% of patients had LVEF ≥ 40%. LVEF increased significantly more in the candesartan group (p = 0.09 at 12 weeks and p = 0.01 at 48 weeks) and left ventricular end-diastolic diameter decreased in candesartan group (p = 0.05 at 12 weeks). Candesartan significantly reduced aldosterone at 48 weeks (p = 0.009). BNP was reduced similarly over time in both study groups (p = 0.35 and p = 0.98 at 12 and 48 weeks, respectively). There were 6.6% of discontinuations of candesartan for adverse events. CONCLUSIONS: In CandHeart, the addition of candesartan to standard medical treatment did not reduce circulating BNP more than standard therapy (primary endpoint), but it significantly improved LV function and produced a marked decrease in aldosterone levels at study end.

Leisure-Time Physical Activity Has a More Favourable Impact on Carotid Artery Stiffness Than Vigorous Physical Activity in Hypertensive Human Beings.

Aim. To assess the effect of leisure time versus vigorous long-term dynamic physical activity (PA) on carotid stiffness in normotensive versus hypertensive subjects. Methods. The study was conducted on 120 leisure-time exercisers and 120 competitive athletes. One hundred and twenty sedentary subjects served as controls. In addition, participants were classified according to whether their systolic blood pressure was ≥130 mmHg (hypertensives, n = 120) or normal (normotensives, n = 240) according to the ACC/AHA 2017 definition. Carotid artery stiffness was assessed with an echo-tracking ultrasound system, using the pressure-strain elastic modulus (EP) and one-point pulse wave velocity (PWVß) as parameters of stiffness. Results. The effect of the two levels of PA differed in the normotensives and the hypertensives. Among the normotensives, there was an ongoing, graded reduction in EP and PWVß from the sedentary subjects to the athletes. By contrast, among the hypertensives, the lowest levels of EP and PWVß were found among the leisure-time PA participants. EP and PWVß did not differ between the hypertensive sedentary subjects and the athletes. A significant interaction was found between PA and BP status on EP (p = 0.03) and a borderline interaction on PWVß (p = 0.06). In multiple regression analyses, PA was a negative predictor of EP (p = 0.001) and PWVß (p = 0.0001). The strength of the association was weakened after the inclusion of heart rate in the models (p = 0.04 and 0.007, respectively). Conclusions. These data indicate that in people with hypertension, leisure-time PA has beneficial effects on carotid artery stiffness, whereas high-intensity chronic PA provides no benefit to vascular functions.

Blood Pressure Hyperreactivity to Standing: a Predictor of Adverse Outcome in Young Hypertensive Patients.

The prognostic significance and the mechanisms of blood pressure (BP) hyperreactivity to standing remain controversial. This study aims to evaluate the association of orthostatic hyperreactivity with major adverse cardiovascular and renal events in a cohort of young hypertensive subjects. We studied 1207 untreated subjects screened for stage I hypertension with a mean age of 33.1±8.6 years. The orthostatic BP change was calculated as the difference between 6 standing and 6 supine BP readings obtained during 2 separate visits. Hyperreactivity to standing was defined as the standing-supine systolic BP difference in the top decile. The mean difference in the whole group was -2.5±7.3/4.6±5.4 mm Hg. Ambulatory hypertension evaluated with 24-hour recordings was more common in Hyperreactors than Normoreactors (90.8% versus 76.4%, P=0.001). In 630 participants in whom 24-hour urinary catecholamines were measured, epinephrine/creatinine ratio was higher in hyperreactors (118.4±185.6 versus 77.0±90.1 nmol/mol, P=0.005). During a 17.2-year follow-up, 105 major adverse cardiovascular and renal events were accrued. In a multivariate Cox model, hyperreactivity to standing was an independent predictor of major adverse cardiovascular and renal events with a hazard ratio of 1.97 (95% CI, 1.10-3.52). Hyperreactivity remained an independent predictor of adverse events even when ambulatory BP data and incident hypertension during follow-up were included in the Cox model (hazard ratio, 1.94 [95% CI, 1.10-3.44]). Our data indicate that in young-to-middle-age hypertensive subjects an exaggerated systolic BP response to standing is associated with sympatho-adrenergic hyperreactivity and is an independent predictor of major adverse cardiovascular and renal events. Orthostatic BP assessment gives the advantage of simple acquisition and provides prognostic information on top of ambulatory BP.

Blood pressure response to standing is a strong determinant of masked hypertension in young to middle-age individuals.

OBJECTIVE: The pathophysiologic mechanisms of masked hypertension are still debated. The aim of this study was to investigate whether the blood pressure response to standing is a determinant of masked hypertension in young individuals. DESIGN AND METHODS: We studied 1078 individuals (mean age 33.2 ±â€Š8.5 years) with stage-1 untreated hypertension at baseline. Orthostatic response was defined as the difference between six SBP measurements in the orthostatic and supine postures. People with a response more than 6.5 mmHg (upper decile) were defined as hyperreactors. After 3 months of follow-up, 24-h ambulatory BP was measured and the participants were classified as normotensives (N = 120), white-coat hypertensive individuals (N = 168), masked hypertensive individuals (N = 166) and sustained hypertensive individuals (N = 624). In 591 participants, 24-h urinary epinephrine was also measured. RESULTS: Orthostatic response was an independent predictor of masked hypertension after 3 months (P = 0.001). In the whole group, the odds ratio for the Hyperreactors was 2.5 [95% confidence interval (95% CI) 1.5-4.0, P < 0.001]. In the participants stratified by orthostatic response and urinary epinephrine, the odds ratio for masked hypertension was 4.2 (95% CI, 1.8-9.9, P = 0.001) in the hyperreactors with epinephrine above the median and was 2.6 (95% CI, 0.9-7.3, P = 0.069) in those with epinephrine below the median. The association between orthostatic response and masked hypertension was confirmed in the cross-sectional analysis after 3 months (P < 0.001). CONCLUSION: The present findings indicate that hyperreactivity to standing is a significant determinant of masked hypertension. The odds ratio for masked hypertension was even quadrupled in people with an orthostatic response more than 6.5 mmHg and high urinary epinephrine suggesting a role of sympathoadrenergic activity in the pathogenesis of masked hypertension.

Dipping pattern and short-term blood pressure variability are stronger predictors of cardiovascular events than average 24-h blood pressure in young hypertensive subjects.

AIMS: The role of increased blood pressure (BP) variability and a blunted day-night BP drop is still being debated, particularly in young hypertensive subjects. We investigated the contribution of BP variability and day-night BP changes combined to cardiovascular events in initially untreated young hypertensive individuals. METHODS AND RESULTS: We selected 1794 subjects aged ≤45 years from the HARVEST and the PIUMA studies, two long-term observational studies in subjects with hypertension. The outcome was a composite pool of non-fatal myocardial infarction or stroke, heart failure needing hospitalization, death from cardiovascular causes, and myocardial or limb revascularization procedures. During an 11.3-year follow-up, 140 cardiovascular events were accrued. A multivariable Cox model which included BP variability and non-dipping was more informative (Akaike Information Criterion = 1536.9) than the model which included average of 24-h BP (Akaike Information Criterion = 1553.6). A higher hazard ratio (HR) was observed for non-dipping [HR 2.22; 95% confidence interval (CI): 1.55-3.17; P < 0.0001] and for high BP variability (HR 1.84; 95% CI: 1.26-2.65; P = 0.0015) than for high average 24-h BP (HR 1.58; 95% CI: 1.07-2.33; P = 0.020). When average 24-h ambulatory BP was included in a nested model, the -2log likelihood decreased from 1524.9 to 1519.3, and there was a tendency for an interactive effect between 24-h BP and non-dipping on risk of cardiovascular events (P = 0.092). CONCLUSION: In young hypertensive individuals, prognostic models including BP variability and non-dipping pattern provide better information than models with average 24-h ambulatory BP alone. More consideration should be given to BP variability and the day-night BP pattern beyond the average 24-h ambulatory BP in young hypertensive subjects.

The Athlete after COVID-19 infection: what the scientific evidence? What to do?

The coronavirus-19 disease (COVID-19) related pandemic have deeply impacted human health, economy, psychology and sociality. Possible serious cardiac involvement in the infection has been described, raising doubts about complete healing after the disease in many clinical settings. Moreover, there is the suspicion that the vaccines, especially those based on mRNA technology, can induce myopericarditis. Myocarditis or pericarditis related scars can represent the substrate for lifethreatening arrhythmias, triggered by physical activity. A crucial point is how to evaluate an athlete after a Covid-19 infection ensuring a safe return to play without increasing the number of unnecessary disqualifications from sports competitions. The lack of conclusive scientific data significantly increases the difficulty to propose recommendations and guidelines on this topic. At the same time, the psychological and physical negative consequences of unnecessary sports restriction must be taken into account. The present document aims to provide an updated brief review of the current knowledge about the COVID-19 cardiac involvement and how to recognize it and to offer a roadmap for the management of the athletes after a Covid-19 infections, including subsequent impact on exercise recommendations. Our document exclusively refers to cardiovascular implications of the disease, but pulmonary consequences are also considered.

Molecular genetic testing in athletes: Why and when a position statement from the Italian Society of Sports Cardiology.

Molecular genetic testing is an increasingly available test to support the clinical diagnosis of inherited cardiovascular diseases through identification of pathogenic gene variants and to make a preclinical genetic diagnosis among proband's family members (so-called "cascade family screening"). In athletes, the added value of molecular genetic testing is to assist in discriminating between physiological adaptive changes of the athlete's heart and inherited cardiovascular diseases, in the presence of overlapping phenotypic features such as ECG changes, imaging abnormalities or arrhythmias ("grey zone"). Additional benefits of molecular genetic testing in the athlete include the potential impact on the disease risk stratification and the implications for eligibility to competitive sports. This position statement of the Italian Society of Sports Cardiology aims to guide general sports medical physicians and sports cardiologists on clinical decision as why and when to perform a molecular genetic testing in the athlete, highlighting strengths and weaknesses for each inherited cardiovascular disease at-risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression and worsening of the arrhythmogenic substrate is also addressed.