Ambulatory blood pressure in hypertension with dysautonomia

The purpose of the study was to evaluate the interest of ambulatory blood pressure (BP) recording (ABPR) in the management of arterial hypertension (AH) with dysautonomia. The study concerned 8 hypertensive patients (pts), 5 men, 3 females 52 +/- 10 years old, with orthostatic hypotension (OH): BP was 162 +/- 19/87 +/- 16 mmHg and 129 +/- 15/76 +/- 8 mmHg in lying and standing position respectively. In two cases AH was associated with a central degenerative disorder whereas the six other pts had a diabetic dysautonomia: bad metabolic control (HBA1c 14.4 +/- 2.7%), and incipient or over nephropathy (4 pts). ABPR was performed in all pts during 24 hours (space-labs system). In these hypertensive pts with OH, the mean 24 hour-BP was surprisingly normal at 128 +/- 11/76 +/- 6 mmHg. ABPR demonstrated the loss of nocturnal decline in BP: diurnal and nocturnal BP were respectively 125 +/- 13/74 +/- 6 mmHg and 133 +/- 16/78 +/- 10 mmHg (NS). 6 of 8 pts had an increase in BP at night resulting for the population (n = 8) in a nocturnal increase (%) of + 5.6%, this pattern widely differs from controls--13%. The decrease in heart rate during sleep was blunted but significant from 89 +/- 9 b/min to 81 +/- 9 b/min (p 0.01). Diurnal and nocturnal BP variability (V), assessed by variation coefficient were not significantly different: SBP-V was 10.3 +/- 6.4% day and 12.3 +/- 4.2% night, DBP-V 7.5 +/- 6.3% day and 12.5 +/- 3.1% night.(ABSTRACT TRUNCATED AT 250 WORDS)     

Attenuation of heart rate recovery after exercise in hypertensive patients with blunting of the nighttime blood pressure fall

OBJECTIVES: To evaluate whether hypertensive patients with attenuation of nighttime blood pressure (BP) fall exhibit a delay of the recovery of heart rate (HR) after exercise as an index of a general decrease in the vagal tone. METHODS: Mild-moderate hypertensive patients (n = 219, age 55 +/- 3, 77% men) underwent a maximal exercise test (Bruce > 85% heart rate limited) in whom we calculated the recovery of HR as the percent decrease of HR from peak to 1 min after stopping exercise (%HR fall-1 min), a 24-h ambulatory BP monitoring, calculating the percent decrease of nighttime vs. daytime BP (% night SBP fall). Left ventricular mass index (LVMI) was measured by echo and aortic stiffness by pulse wave velocity (PWV). Sixty percent were on antihypertensive drugs (not on beta-blockers nor on non-dihydropiridine calcium blockers); 12 subjects were type 2 diabetics. RESULTS: The "% night SBP fall" ranged from - 6.3% to 38.9% and the "%HR fall-1 min" ranged from 3.3% to 43.7%. There was a significant positive correlation between these two variables (r = 0.594, p < 0.001). Population was divided into five groups according to quintiles of values for the "% night SBP fall". For similar daytime BP and age, the lowest quintile for % night SBP fall (- 6.3% to 7.2%) showed the lower "%HR fall-1 min" (3.1 +/- 0.5%), and the higher LVMI (92 +/- 3 g/m(2)) and PWV (12.1 +/- 0.4 m/s) values comparing to the other quintiles (p < 0.02). CONCLUSIONS: In hypertensives, blunting of the nocturnal fall of BP is associated with a delayed recovery in heart rate after graded maximal exercise and with greater aortic stiffness and ventricular mass. This may indicate that in non-dipper subjects a relative general decrease of parasympathetic reactivation after exercise is linked to the failure of nighttime fall of BP, both of which might contribute to target-organs deterioration.     

Diurnal variation of blood pressure; reproducibility and association with left ventricular hypertrophy in hemodialysis patients

OBJECTIVE: The objective of this paper is to describe the pattern of diurnal blood pressure (BP) change in hemodialysis patients, determine the association of the non-dipping pattern of diurnal BP with left ventricular mass index (LVMI), and to determine if the nocturnal profile of BP is reproducible when repeated over time. METHODS: In a cross-sectional study, ambulatory blood pressure monitoring (ABPM) was performed over a midweek 44-h period and echocardiography was performed on the interdialytic day. Patients with a night/day systolic and diastolic BP ratio on both days >0.9 were defined as non-dippers. Ambulatory blood pressure monitoring was repeated at 6 and 12 months follow-up. RESULTS: Of the 59 patients, 88% were African-American, and 48% were non-dippers. Mean LVMI was significantly higher in the non-dipper (68.3+/-25 g/height) compared to the dipper patients (55.6+/-16, P<0.05). Mean nocturnal systolic BP (r=0.35) and the night/day systolic BP ratio (r=0.39) had a higher correlation with M-mode LVMI than pre-dialysis (r=0.32). After adjustment for 44-h mean SBP, night/day systolic BP ratio remained independently associated with LVMI (beta coefficient 147.62, P=0.004). Of 12 patients who had a non-dipper profile at baseline, 11 (92%) demonstrated the same profile after 6 months and 1 year of follow-up. CONCLUSION: Many hemodialysis patients demonstrate a non-dipper profile; the degree of decline in nocturnal BP is independently associated with LVMI even after adjustment for mean BP. Patients who are identified as non-dippers consistently reproduce the same profile over time.     

Role of insulin resistance in nondipper essential hypertensive patients.

In hypertensive patients, diminished nocturnal blood pressure (BP) fall is associated with poor prognosis for cardiovascular events. However, the relation of insulin resistance with the etiology of nondipper essential hypertension remains unclear. The aim of the present study was to assess the role of insulin resistance in diminished nocturnal BP fall, left ventricular hypertrophy (LVH), and increased plasma atrial (ANP) and brain natriuretic peptides (BNP) in essential hypertensive patients. One hundred and three patients with essential hypertension were divided into dippers (n = 57; age: 57 +/- 5 years, mean +/- SD) or age-matched nondippers (n = 46; 57 +/- 4 years), based on ambulatory BP (ABP) monitoring. Although the systolic and diastolic ABP values were similar during the day, those at night were higher in nondippers than in dippers ( p < 0.0001 for each). Echocardiographic findings revealed that the left ventricular mass index (LVMI) was higher in nondippers (p < 0.0001). Plasma ANP and BNP were also higher in nondippers (p < 0.0001 for each). Fasting plasma concentrations of glucose and insulin (p < 0.0001 for each) and the homeostasis model assessment (HOMA) index (p < 0.0001) were also higher in nondippers. Multivariate analysis revealed that systolic ABP at night was a significant factor for LVMI, ANP and BNP. In addition, the HOMA index was a significant factor for LVMI and BNP. These observations suggest that diminished nocturnal BP fall is closely related to the development of LVH with concomitant increase in BNP in essential hypertensive patients, and that insulin resistance may play a key role in these processes.     

Associations between nondipping of nocturnal blood pressure decrease and cardiovascular target organ damage in strictly selected community-dwelling normotensives

BACKGROUND: In hypertensives, nondippers are more likely than dippers to suffer silent, as well as overt, hypertensive target organ damage. In this study, we investigated whether a nondipper status was associated with target organ damage in normotensives. METHODS: We performed ambulatory blood pressure (BP) monitoring, echocardiography, and carotid ultrasonography and measured natriuretic peptides and urinary albumin (UAE) in 74 normotensive subjects with the following criteria: 1) clinical BP <140/90 mm Hg; 2) average 24-h ambulatory BP <125/80 mm Hg. RESULTS: The left ventricular mass index (LVMI) and the relative wall thickness (RWT) measured by echocardiography were greater in nondippers than dippers (LVMI: 103 +/- 26 v 118 +/- 34 g/m(2), P <.05; RWT: 0.38 +/- 0.07 v 0.43 +/- 0.09, P <.01). Plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were higher in nondippers than dippers (ANP: 14 +/- 10 v 36 +/- 63 pg/mL, P <.01; BNP: 16 +/- 12 v 62 +/- 153 pg/mL, P <.05). There were no significant differences in UAE and intima-media thickness measured by carotid ultrasonography. CONCLUSIONS: Normotensive nondipping may not reflect renal damage, but may have a predominant effect on cardiac damage. Nondipping of nocturnal BP seems to be a determinant of cardiac hypertrophy and remodeling, and may result in a cardiovascular risk independent of ambulatory BP levels in normotensives.     

Natural course of kidney function in Type 2 diabetic patients with diabetic nephropathy.

AIMS: To determine the natural course of kidney function and to evaluate the impact of putative progression promoters in Caucasian Type 2 diabetes mellitus (DM) patients with diabetic nephropathy who had never received any antihypertensive treatment. METHODS: A long-term observational study of 13 normotensive to borderline hypertensive Type 2 DM patients with diabetic nephropathy. Glomerular filtration rate (GFR) was measured approximately every year (51Cr-EDTA plasma clearance technique). Albuminuria, blood pressure (BP) and haemoglobin A1c (HbA1c) was determined 2-4 times per year and serum cholesterol every second year. RESULTS: The patients (12 males/one female), age 56+/-9 (mean +/- SD) years, with a known duration of diabetes of 10+/-6 years, were followed for 55 (24-105) (median (range)) months. GFR decreased from 104 (50-126) to 80 (39-112) ml x min(-1) x 1.73 m(-2) (P = 0.002) with a median rate of decline of 4.5 (-0.4 to 12) ml x min(-1) x year(-1). During follow-up, albuminuria rose from 494 (301-1868) to 908 (108-2169) mg/24 h (P = 0.25), while BP, HbA1c and serum cholesterol remained essentially unchanged. In univariate analysis the rate of decline in GFR did not correlate significantly with neither baseline nor mean values during follow-up of BP, albuminuria, HbA1c and serum cholesterol. CONCLUSIONS: Our study suggests that normotensive to borderline hypertensive Type 2 DM patients with diabetic nephropathy have a rather slow decline in kidney function, but we did not unravel the putative progression promoters responsible for the variation in rate of decline in GFR.     

Lack of correlation between QTc dispersion and morning blood pressure surge in recently diagnosed essential hypertensive patients.

BACKGROUND: Cardiovascular events are known to occur more frequently in patients with a high morning surge in blood pressure (BP), but the correlation between a morning BP surge and corrected QT dispersion (QTc) has not been confirmed to date. METHODS AND RESULTS: The correlation between the morning BP surge and QTc was studied in 82 patients recently diagnosed with high BP (47 males, 35 females). Twenty-four-hours BP monitoring was conducted to classify patients into dipper (n=45) or nondipper (n=37) groups according to the degree of nocturnal BP reduction. QTc was found to be significantly longer in the nondippers compared with the dippers (36.1+/-17.2 vs 47.6+/-20.7, p<0.001). In addition, there was a significant increase in the end-diastolic interventricular septum thickness (IVSd), left ventricular posterior wall thickness in diastole (PWT) and left ventricular mass index (LVMI) in the nondippers vs the dippers (respectively, 0.93+/-0.09 vs 1.03+/-0.05, p<0.001, 0.94+/-0.09 vs 1.01+/-0.04, p<0.01, 109.7+/-12.8 vs 129.1+/-20.9, p<0.001). QTc had a significant positive correlation with nighttime BP, IVSd, PWT, and LVMI, but negatively correlated with the nocturnal BP reduction rate. These results were maintained even after adjusting for age and gender. However, a significant correlation between the morning BP surge and QTc was not confirmed. CONCLUSION: In the present nondipper hypertensive patients, QTc, nighttime BP, LVMI, and wall thickness were significantly greater than in the dipper patients. However, there was no significant correlation between the morning BP surge and QTc.     

Belonging to a diabetes patients' association is predictive of better metabolic control

AIM: Diabetes mellitus (DM) management requires the patient's involvement, but it is unknown whether belonging to a patient's association leads to better metabolic control. METHODS: A total of 323 type 1 (T1) and 494 type 2 (T2) outpatient diabetics were analyzed according to whether or not they were members of a diabetes patients' association. RESULTS: T1 members (M; N=138) were older and had longer diabetes durations than non-members (nM; N=185). Both groups had similar BP, kidney function, lipid profile, BMI and socioeducational status. HbA(1c) (means+/-SD) were lower in M than in nM: 8.1+/-1.2% versus 8.4+/-1.4%, respectively; P<0.04. T1M practised more frequent self-monitoring of blood glucose (SMBG). T2M (N=97) were also older and had longer diabetes durations than nM (N=397), and both groups had similar BP, kidney function, BMI and socioeducational status. Although M had lower HOMA beta-cell function (50.6+/-31.5% versus 63.5+/-44.3%; P<0.01), they had a similar HbA(1c) and a better lipid profile. T2M practised more frequent SMBG and were more likely to use insulin. Oral antidiabetic, antihypertensive and dyslipidaemic drug use was also similar, except for a higher use of calcium-channel blockers in T2M. CONCLUSION: Belonging to a patients' organization was associated with better HbA(1c) in T1DM. In T2DM, which progresses relentlessly, similar HbA(1c) levels and better lipid profiles were observed, despite longer known disease durations and lower beta-cell function. These were not explained by gender, clinical, renal, therapeutic or educational parameters, but might reflect more responsibility, empowerment and/or compliance in terms of the condition or its management.     

Loss of nocturnal increase in plasma concentration of atrial natriuretic peptide in hypertensive chronic renal failure.

Diurnal change of plasma atrial natriuretic peptide (ANP) concentration was investigated in 12 patients with hypertension due to chronic renal failure (CRF) and in 12 patients with essential hypertension (EH) of comparable degree. Blood pressure (BP) monitoring was performed at 15-min intervals, while peripheral blood samples were obtained at 4-hour intervals starting from 8.00 h. The mean 24-hour plasma levels (+/- SEM) of ANP were 24.3 +/- 1.8 pmol/l in EH and 23.4 +/- 1.2 pmol/l in CRF. In EH, plasma ANP concentration was highest at 4.00 h (33.5 +/- 0.8 pmol/l) and lowest at 16.00 h (15.5 +/- 0.6 pmol/l). In CRF, no significant circadian change was present (22.2 +/- 3.1 and 20.4 +/- 3.6 pmol/l, respectively), and the nocturnal fall in BP was lost. Our data demonstrate that in CRF the loss and possible reversal of the nocturnal decline in BP is associated with the disappearance of any significant circadian variation in the circulating concentrations of ANP. These findings suggest a role for ANP in the alteration of BP variability of CRF, possibly mediated by autonomic dysfunction, and are further evidence for the existence of a relation between the circadian rhythms of ANP and BP.     

Diabetic cardiomyopathy: the relationship between 201-thallium myocardial scintigraphic perfusion defect and left ventricular function in asymptomatic diabetics

To investigate the significance of perfusion defects in asymptomatic diabetics, 40 mildly diabetic men, mean age 49 +/- 9.7 years, without clinical or exercise electrocardiographic evidence of ischemic cardiac disease, were evaluated: 1) sixteen (40%) showed no filling defect (G1). Mild defects (G2) and moderate defects (G3) were observed in 12 and 12, respectively; 2) the percent washout ratio was diminished in none of G1, in 3 of G2 and in 11 of G3; 3) there were no differences in age, duration of diabetes, FBS, HbA1c, serum cholesterol, smoking or BP. Obesity index was greater in G3 (121 +/- 15%, p less than 0.01) compared to G1 and 2 (103 +/- 9%, 108 +/- 9%); 4) the percent fractional shortening by echo was decreased in G2 and G3 (35 +/- 6%, 33 +/- 8%, p less than 0.01) compared to G1 (42 +/- 5%). The systolic time interval was higher in G3 (0.42 +/- 0.09, p less than 0.05) compared to G1 and G2 (0.35 +/- 0.05, 0.36 +/- 0.06); 5) radionuclide ventriculographic studies showed a lower peak filling rate at rest in G2 (2.4 +/- 0.5 EDV/sec, p less than 0.025) compared to G3 and G1 (2.9 +/- 0.6 EDV/sec, 3.2 +/- 0.7 EDV/sec). The rate of increase in cardiac output was significantly lower in G3 compared to G1 and G2 (59 +/- 28%, 96 +/- 49%, 97 +/- 31%, p less than 0.05). These results suggest the possibility of detecting metabolic derangements was myocardial scintigraphic perfusion abnormalities which might be a causal factor of myocardial dysfunction in diabetics.     

Sleep apnea and hypertension

STUDY OBJECTIVES: To examine the central inspiratory drive response to hypoxia in patients with obstructive sleep apnea (OSA), according to their circadian BP profile, and in healthy control subjects. Another objective was to evaluate the relationships among sleep architecture, hypoxic sensitivity, urinary catecholamine excretion, and BP in OSA patients. PATIENTS AND INTERVENTIONS: Polysomnography, 24-h ambulatory BP recording, and urinary excretion of catecholamines were simultaneously examined in 24 consecutive OSA patients and 11 healthy subjects. OSA patients were categorized as being normotensive (type 1), having BP elevation only during sleep (type 2), and as being hypertensive with elevated BP at all times (type 3). The response of mouth occlusion pressure at 0.1 s after onset (P(0.1)) to progressive isocapnic hypoxic stimulation was measured. RESULTS: There was a significant difference in the P(0.1) response to hypoxia among control subjects ([mean +/- SD] 0.353 +/- 0.129 cm H(2)O/%) and type 1 (0.228 +/- 0.062 cm H(2)O/%), type 2 (0. 345 +/- 0.106 cm H(2)O/%), and type 3 (0.508 +/- 0.118 cm H(2)O/%) OSA patients. In OSA patients, chemosensitivity was related to the apnea-hypopnea index and to the nocturnal excretion of epinephrine. Significant relationships between the nocturnal excretion of epinephrine and BP were noted. On multiple linear regression analysis, the P(0.1) response to hypoxia was the only variable significantly related to diurnal (r(2) = 0.364; p = 0.005) and nocturnal mean BP (r(2) = 0.461; p = 0.002). CONCLUSION: The findings of the present study suggest a possible mediating role of the peripheral chemosensitivity in the association between sleep apnea and hypertension.     

Effect of antihypertensive treatment in elderly hypertensive patients with cardiac hypertrophy]

In elderly hypertensive patients effect of antihypertensive treatment with Ca antagonist or ACE inhibitor on the heart were examined. Twenty-four elderly hypertensive patients with cardiac hypertrophy, aged 65-79 years old (mean +/- SEM, 71 +/- 1) were treated with Ca antagonist (nifedipine or nicardipine) or ACE inhibitor (captopril or enalapril) for 3 months. Thirteen patients had essential hypertension (EH: SBP greater than or equal to 160 mmHg and DBP greater than or equal to 95 mmHg, 70 +/- 1 years) and 11 had isolated systolic hypertension (ISH: SBP greater than or equal to 160 mmHg and DBP less than 95 mmHg, 74 +/- 2 years). Blood pressure (BP) and heart rate were measured every two weeks. In all patients, M-mode echocardiography was performed to measure left ventricular mass index (LVMI) and ejection fraction (EF), and the sympathetic nervous (plasma norepinephrine and epinephrine) and the renin-angiotensin system (plasma renin activity and aldosterone concentration), were assessed before and after 3 months of treatment. BP significantly decreased from 174 +/- 3/97 +/- 1 to 149 +/- 4/84 +/- 2 mmHg in EH and from 167 +/- 3/82 +/- 2 to 144 +/- 4/74 +/- 2 mmHg in ISH. LVMI was significantly reduced from 204 +/- 14 to 174 +/- 16 g/m2 in EH and from 179 +/- 14 to 156 +/- 12 g/m2 in ISH. EF showed no significant changes in either group. In ISH, the change in LVMI was significantly correlated with the change in systolic BP (r = 0.74, p less than 0.05). In EH, there was no significant relation between BP and LVMI changes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Peculiarities of regulatory mechanisms of autonomic nervous system in patients with arterial hypertension and disturbed 24-hour blood pressure profile

BACKGROUND: Insufficient nocturnal blood pressure (BP) decline is associated with elevated risk of complications of hypertensive disease. Heart rate variability (HRV) reflects activity of sympathetic and parasympathetic parts of autonomic nervous system. AIM: To elucidate special characteristics of HRV in patients with various types of 24-hour BP rhythm. Material and methods. Bifunctional 24-hour monitoring and echocardiography were carried out in 42 men with stage I-II hypertensive disease and I-II degree of arterial hypertension (mean age 21.7+/-4.5 years) and 16 practically healthy young people (mean age 24.6+/-5.2 years). RESULTS: Subjects with insufficient (<10%) and adequate nocturnal BP decline (non-dippers and dippers) were distinguished (groups ND and D, respectively). Patients with hypertension in group ND had elevation of systolic BP variability during night and day time, augmentation of nocturnal and diurnal HRV low frequency power, lowering of nocturnal high frequency power, lowering of pNN50 and rMSSD values at night. HRV parameters of control subjects in this group did not differ from those of healthy people. All HRV parameters in group D were characterized by significant 24-hour rhythmicity. This rhythmicity was substantially disturbed in patients of group ND. Parameters of central hemodynamics were similar in groups D and ND. CONCLUSION: These results evidence for the presence of enhanced activity of sympathetic part of autonomic nervous system in non-dipper patients with hypertensive disease throughout 24 hours and during night time and for disturbed circadian rhythm of autonomic nervous system activity. This can serve as a basis for increased rate of cardiovascular complications in this category of patients.     

Relationship between home blood pressure and longitudinal changes in target organ damage in treated hypertensive patients.

Cross-sectional studies have shown that home blood pressure (BP) correlates with hypertensive target organ damage better than clinic BP. However, there have been few longitudinal studies regarding the predictive value of home BP on the changes in organ damage in treated hypertensive patients. Clinic and home BP over a 12-month period, antihypertensive medication use, echocardiographic and electrocardiographic results, and serum creatinine and urinary protein levels were examined in 209 treated hypertensive patients in 1993. These patients were prospectively followed for 5 years. The patients were divided into 4 subgroups according to hypertension control as follows: good control (<140/90 mmHg for clinic BP, <135/85 mmHg for home BP), improved, worsened, and poor control. The average clinic BP was 147.0+/-14.9/87.0+/-7.6 mmHg (mean+/-SD) in 1993 and 146.0+/-13.7/84.1+/-7.5 mmHg in 1998. The average home BP was 136.8+/-10.4/84.3+/-7.6 mmHg in 1993 and 136.1+/-9.7/81.2+/-7.7 mmHg in 1998. The left ventricular mass index (LVMI) positively correlated with both home systolic BP and clinic systolic BP in 1998 but not in 1993. The correlation tended to be closer for home BP than for clinic BP. LVMI did not change in patients with good or improved home systolic BP, while it increased in those with poor or worsened home systolic BP. The relationship between changes in LVMI and clinic BP was not significant. In conclusion, Home BP was more effective than clinic BP as a predictor of changes in left ventricular hypertrophy in treated hypertensive patients. Home BP should be controlled to below 135/85 mmHg to prevent cardiac hypertrophy.     

Small artery remodeling is the most prevalent (earliest?) form of target organ damage in mild essential hypertension

BACKGROUND: The heart and blood vessels are exposed to elevated blood pressure (BP) in hypertensive patients, but their changes in response to BP or non-hemodynamic stimuli may be different, and occur with different time-courses. To evaluate this, we studied the prevalence of structural and functional alterations of resistance arteries and cardiac hypertrophy in patients with mild essential hypertension. METHODS: Resistance arteries were dissected from gluteal subcutaneous tissue from 38 hypertensive patients (47 +/- 1 years; 71% male; BP 148 +/- 2/99 +/- mmHg), studied on a pressurized myograph, and compared to those from 10 normotensives (44 +/- 3 years; 40% male; BP 113 +/- 4/76 +/- 2 mmHg). RESULTS: The prevalence of abnormal structure (media-to-lumen ratio, M/L) and impaired endothelial function (maximal acetylcholine response) was 97 and 58% (abnormal was defined as greater than mean + 1 SD of normotensives), or 63 and 34% (abnormal defined as greater than mean +/- 2SD). Thirty four percent of hypertensive patients exhibited left ventricular hypertrophy by echocardiography. When grouped into tertiles according to increasing ambulatory systolic BP (SBP), the highest BP tertile showed increased M/L (P< 0.01) and left ventricular mass index (LVMI, P < 0.05) and marginally decreased endothelial function (P= 0.07). LVMI was greatest in the tertile of patients with highest M/L (P< 0.05). Endothelial function was decreased in the tertile with greatest vascular stiffness (P< 0.01). By multivariate analysis, M/L correlated with ambulatory SBP (beta = 0.40, P= 0.02), and LVMI correlated with ambulatory SBP (beta = 0.41, P = 0.001) and body mass index (beta = 0.30, P< 0.05). Female sex influenced endothelial function negatively (beta = -0.63, P< 0.01). CONCLUSION: Structural alterations of resistance arteries were demonstrated in most hypertensive patients, followed by endothelial dysfunction and cardiac hypertrophy in a smaller number of hypertensives. Small artery structural remodeling may precede most clinically relevant manifestations of target organ damage in mild essential hypertension.     

The degree of albuminuria is related to left ventricular hypertrophy in hypertensive diabetics and is associated with abnormal left ventricular filling: a pilot study

The association of albuminuria and left ventricular (LV) hypertrophy (LVH) in diabetics aggravates the prognosis. The authors studied the relation between LVH and the degree of albuminuria in diabetics and investigated the relationship of albuminuria to LV filling. A comparison was made between 30 hypertensive diabetics, 10 of whom had microalbuminuria (MIC) and 20 had macroalbuminuria (MAC), and 18 diabetics who were normotensive and normalbuminuric (NOR). LV mass index (LVMI) and LV ejection fraction (LVEF) were measured during echocardiography. LV filling pattern at rest and at peak standardized isometric exercise (IME) using handgrip was assessed by measuring E/A (peak velocity of the early/atrial filling waves) of the transmitral flow during Doppler and echocardiography. Each patient underwent a stress ECG test. LVMI was higher in MAC (132.3 +/- 55.4) than in MIC (115.6 +/- 32.5) or NOR (90.0 +/- 31.8) (p<0.01). There were more patients in MAC with LVH (n = 13) and abnormal filling (n = 9 at rest and 16 with IME) than in MIC (LVH = 5, abnormal filling = 1 at rest and 10 during IME) or NOR (LVH = 3, abnormal filling = 1 at rest and 9 during IME) (p < 0.02). LVMI was not related to LVEF. Although blood pressure was not different between MAC and MIC groups, it was significantly higher than in the NOR group. This study suggests that a high degree of albuminuria in hypertensive diabetics is associated with greater value for LVMI and an increased incidence of LVH independent of blood pressure level or systolic LV function. LVH is associated with abnormal LV filling. The degree of albuminuria may predict LVMI and LVH, which are associated with abnormal LV filling. This association of abnormal LV filling with albuminuria in hypertensive diabetic patients may account for their high risk of cardiovascular events.     

Cigarette smoking enhances increased urine albumin excretion as a risk factor for glomerular filtration rate decline in primary hypertension

BACKGROUND: Subjects with severe compared with mild primary hypertension are at greater risk for decline in glomerular filtration rate (GFR), but additional risk factors are poorly defined. METHODS: Seventy-five subjects referred for assistance with blood pressure control ("severe") and 150 not-referred hypertensive subjects ("mild") were prospectively followed for 7 years. The primary outcome was the change in calculated GFR during follow-up as predicted by various clinical parameters, including urine albumin excretion measured as urine albumin (mg)-to-creatinine (g) (alb/cr) ratio. RESULTS: Calculated GFR declined faster (more negative slope) in patients with severe hypertension than in those with mild hypertension (-0.188+/- 0.025 versus -0.120+/- 0.008 mL/min/month; P=0.010), despite similar follow-up systolic blood pressure (133.4+/-1.2 versus 131.9+/-0.8 mm Hg). Severe subjects had higher entry alb/cr (241.3+/- 29.1 versus 11.4+/- 0.5) and a greater proportion of cigarette smokers than mild subjects (56 versus 19%). Regression analysis comparing GFR decline to alb/cr showed that GFR changed minimally for alb/cr up to 200 but declined at a progressively faster rate as alb/cr increased above 200. GFR declined faster (more negative slope) in smokers than in nonsmokers (-0.231+/- 0.023 versus -0.102+/- 0.008 mL/min/month; P<0.001). Cigarette smoking increased the risk for GFR decline in subjects with alb/cr <200 and in those with alb/cr >200, but the effect was much more robust for subjects with alb/cr >200. CONCLUSIONS: Urine alb/cr >200 increases the risk for subsequent GFR decline in primary hypertension, and this risk is enhanced by cigarette smoking.     

No deleterious effects of tight blood glucose control on 24-hour ambulatory blood pressure in normoalbuminuric insulin-dependent diabetes mellitus patients

Intensive therapy aiming at near normalization of glucose levels effectively delays the onset and slows the progression of complications in insulin-dependent diabetes mellitus (IDDM) and is recommended in most patients. However, in a recent report, intensive insulin treatment was found to be associated with deleterious effects on nocturnal blood pressure (BP), the proposed mechanisms being subclinical nocturnal hypoglycemia or hyperinsulinemia. The aim of the present study was to evaluate the association between glycemic control, insulin dose, and 24-h ambulatory BP (AMBP) in a group of well-characterized IDDM patients. Twenty-four-h AMBP was measured in 123 normoalbuminuric [urinary albumin excretion (UAE) < 20 microg/min] IDDM patients using an oscillometric technique (SpaceLabs 90207) with readings at 20-min intervals. UAE was measured by RIA and expressed as geometric mean of three overnight collections made within 1 week. Tobacco use and level of physical activity was assessed by questionnaire. HbA1c was determined by high-pressure liquid chromatography (nondiabetic range, 4.4-6.4%), and patients were stratified into quartiles according to HbA1c levels. Mean HbA1c values in the four groups were 7.0% (n = 31), 8.0% (n = 31), 8.6% (n = 31), and 9.7% (n = 30). The groups were comparable regarding age, gender, diabetes duration, body mass index, UAE, smoking status, and physical activity. AMBP levels were almost identical in the HbA1c quartiles with night values of (increasing HbA1c order): 110/63, 112/66, 112/66, and 113/65 mm Hg (P = 0.69/P = 0.32). There was no association between tight glucose control and higher nocturnal BP or a more blunted circadian BP variation. On the contrary, a weak positive correlation between night to day ratios of mean arterial BP and HbA1c values was found (r = 0.26, P = 0.005), i.e. blunted circadian BP variation is most frequent in patients with high HbA1c values. Neither did we find doses of insulin to be associated with night BP (r = 0.04, P = 0.68). Tight blood glucose control is not associated with deleterious effects on 24-h AMBP in normoalbuminuric IDDM patients. Intensive therapy can be implemented without concerns of inducing high nocturnal BP and accelerating diabetic complications.     

Diurnal blood pressure variation in progressive autonomic failure

To investigate the role of the autonomic nervous system (ANS) in the generation of the circadian blood pressure (BP) variation, the degree of impairment of the ANS was related to the results of ambulatory BP recordings in 212 patients with progressive autonomic failure due to familial amyloid polyneuropathy. On the basis of BP and/or heart rate (HR) responses to the Valsalva maneuver, 60 degrees head-up tilting, deep-breathing tests, and plasma norepinephrine levels, 4 groups of patients were distinguished. In all patients and in 38 age-matched control subjects, ambulatory BP was monitored. Patients of group I (n=40, aged 32+/-3 y), with no evidence yet of impairment of their ANS, had circadian BP and HR variations indistinguishable from controls. Patients of group II (n=41, aged 34+/-5 y) had a variable degree of impairment of their parasympathetic ANS, but their sympathetic ANS was still intact. Twenty-four-hour HR was higher in these patients than in controls (88+/-11 versus 78+/-7 bpm, P<0.01). Their circadian HR variation was maintained, but their circadian BP variation was diminished (10+/-6/11+/-4 versus 17+/-6/16+/-4 mm Hg in controls, P<0.01) because of an attenuation of the nocturnal BP decline. Patients of group III (n=69, aged 36+/-6 y), with parasympathetic failure and intermediate sympathetic dysfunction, had a blunted diurnal BP variation, whereas patients of group IV (n=62, aged 38+/-6 y), with parasympathetic failure and severe sympathetic dysfunction, had an absent diurnal BP variation. In patients of groups III and IV, a decrease in daytime BP accounted for the blunted circadian BP variation. This extensive study in progressive autonomic failure confirms the important role of the ANS in the generation of circadian BP variation. For the maintenance of a normal circadian BP pattern, not only an intact sympathetic but also an intact afferent parasympathetic ANS is a prerequisite.     

Ambulatory blood pressure in the young adult with hypertension history during childhood]

The tendency of subjects to maintain their relative position within the distribution of blood pressure (BP) has been defined as "tracking". Regarding this phenomenon, the purpose of the study was to evaluate the interest of ambulatory BP monitoring (ABPM) in the assessment of arterial hypertension in young adults (YA) with childhood hypertension history (CHH). 52 subjects, 20.1 +/- 2.4 years old, 26 men, 26 women issued from a cohort of 150 children with high BP levels (greater than 97.5 th percentile) during their infancy (school check-up), were included in the study. An ABPM was performed with space-labs system 90202 from 8 a.m. to 6 p.m., measurements every 15 minutes (37.6 +/- 7.4 readings). Left ventricular mass index (LVMI) was determined with echocardiography, (Penn convention). Office BP, measured with mercury apparatus in lying and standing position, was respectively, 131.0 +/- 14.6/81.9 +/- 9.7 and 130.1 +/- 14/86.6 +/- 9.9. According to JNC 1988, this casual BP identified 40 normotensives (NT), 9 borderlines (BL) and 5 hypertensives (HT); 10 of them had a "high normal" diastolic BP (85-90 mmHg) ABP recordings of the study group were compared to day-time reference values of NT. Three subgroups are individualized: G1 NT, G2 HT, G3 BL. [table; see text] *p: less than 0.001; p: less than 0.01. Wall thickness (WTh) and LVMI were significantly higher in hypertensives (G2 + G3) than in normotensives (G1): [table; see text] There was a significant correlation between LVMI and mean systolic ABP (p less than 0.01: r = 0.44), but not with office SBP.(ABSTRACT TRUNCATED AT 250 WORDS)