[Antihypertensive therapy in the elderly: results of large trials]

The aim of this review was to evaluate if antihypertensive treatment in elderly hypertensive patients is able to lower the incidence of cardiovascular events when compared to hypertensive controls who received placebo. All trials agree in that the greater blood pressure reduction in hypertensive patients randomized to active treatment is associated with a minor incidence of cerebrovascular, cardiac and all cardiovascular events in comparison to placebo-treated control groups. Therefore the chronic antihypertensive treatment makes more good than bad. All antihypertensive agents have been used for the treatment of arterial hypertension in the elderly and all have shown a good efficacy and tolerability, even if, as in the adult hypertensives, the combination of two or more agents is necessary in the great majority of hypertensive patients to reach the target blood pressure. Because life expectancy is progressively longer and the prevalence of hypertension, in particular isolated systolic hypertension, is age-dependent, it is clinically relevant to investigate if there is an upper limit for the benefit of antihypertensive therapy. The results so far available suggest a benefit up to the age of 80 years, while an ongoing study is aimed at evaluating the benefit of antihypertensive therapy in patients > 80 years. Finally, according to our personal point of view, there are sufficient data to sustain the indication of a diastolic blood pressure reduction between 80 and 90 mmHg, while the indication to a reduction in systolic blood pressure below 140 mmHg is less strong and supported.

Interaction between nonsteroidal anti-inflammatory drug intake and calcium-channel blocker-based antihypertensive treatment in the Syst-Eur trial

OBJECTIVE

To assess the relationship between chronic intake of nonsteroidal anti-inflammatory drugs (NSAID) and outcome, in particular (gastrointestinal) bleeding and to investigate whether the effect of chronic NSAID intake was similar in untreated and treated elderly hypertensives.

METHODS

Eligible patients (> or = 60 years, with systolic blood pressure 160-219 mm Hg and diastolic blood pressure < 95 mm Hg) were randomised to active treatment or placebo. Active treatment consisted of nitrendipine, with the possible addition of enalapril, hydrochlorothiazide, or both, titrated or combined to reduce the sitting systolic blood pressure by at least 20 mm Hg to below 150 mm Hg. Patients never taking NSAIDs (n = 2882) were compared with patients on chronic NSAID intake (n = 861), defined as reporting NSAID intake on at least 50% of the patient forms.

RESULTS

There was a tendency towards lower mortality (relative hazard rate (95% confidence interval (CI), 0.77 (0.56-1.06)) and higher incidence of bleeding (1.13 (0.63-2.05) with chronic NSAID intake. Although there was no significant interaction between calcium-channel blocker (CCB)-based treatment and chronic NSAID intake for any of the end points, chronic NSAID intake tended to be associated with a lower incidence of bleeding on active treatment as compared to placebo (P-value of the interaction term = 0.07).

CONCLUSION

The effect of chronic NSAID intake on outcome was similar in patients on active treatment based on a dihydropyridine CCB or on placebo. However, chronic NSAID intake might have a less deleterious effect on bleeding on active treatment as compared to placebo.

Risk assessment and treatment benefit in intensively treated hypertensive patients of the hypertension Optimal Treatment (HOT) study

BACKGROUND

The Hypertension Optimal Treatment (HOT) Study provided information about cardiovascular events in 18,790 hypertensives, subjected to pronounced blood pressure lowering for a mean of 3.8 years.

METHODS AND RESULTS

The HOT Study data have been further analysed after risk stratification of the patients (1999 World Health Organization and International Society of Hypertension guidelines criteria): (i) no patients of the HOT Study were classified as low risk, 50% were classified as medium risk, 20.2% as high risk and 29.8% as very high risk; (ii) incidence of cardiovascular events in these patients with excellent blood pressure control [92% had diastolic blood pressure (DBP) < or = 90 mmHg] remained proportional to pretreatment risk. The relative risk of very high- versus medium-risk strata was between two and three both when HOT Study patients were considered independently of, or within the DBP target group they had been randomized to; and (iii) event rates in all risk strata were calculated to be much lower (possibly 60% lower) than rates expected from baseline risk calculated approximately by the Framingham equation.

CONCLUSIONS

The low event rate in HOT Study patients is likely to result from pronounced blood pressure lowering, and is not explained by a lower risk profile than in previous controlled trials of antihypertensive treatment. The persistence of a risk gradient despite intensive blood pressure lowering suggests a combination of blood pressure control with other strategies of risk correction and the need to initiate antihypertensive therapy before complications develop.

Immunostaining by complement C9: a tool for early diagnosis of myocardial infarction and application in forensic medicine

Before the first 12 hours, diagnosis of early myocardial infarctions is always difficult for forensic pathologists. We tested complement C9 expression in 121 formalin-fixed and paraffin-embedded heart samples by an immunohistochemical procedure. The heart specimens were separated into four groups: 33 cases in group 1 with typical ischemic damages histologically located, 20 cases in group 2 with death related to myocardial infarction on the basis of ischemic presentation on electrocardiogram but no obvious histological ischemic damage, 35 cases in group 3 with severe coronary disease without cause of death found at the autopsy, and 33 cases in group 4 without sign of myocardial infarction and without coronary disease. In the first group, all 33 heart samples showed a well-defined C9 expression in the necrotic areas. The second group in 17 of 20 cases showed positive areas for C9 expression. In the other three heart specimens, only few stained cells were observed whereas the painful symptoms had begun less than 1 h before death. The third group showed C9 immunopositive areas in six of 35 cases, few stained cells in 8 cases, and no C9 deposition in the 21 other cases. The last group showed no staining area. To avoid nonspecific C9 staining due to tissue autolysis, we studied C9 expression during a controlled putrefactive process in four cases included in group 1; staining was found only in infarcted myocardial areas, and was observed up to ten days. Specificity of C9 expression was evaluated to be 100% [89.4 to 100%] and sensitivity to be 85% [62.11 to 96.79%]. In conclusion, evaluation of immunohistochemical expression of C9 appears to be a highly sensitive and specific marker of early myocardial infarction, useful in forensic medicine if survival is more than 1 h after the beginning of myocyte damage.

Cardiovascular risk stratification in hypertensive patients: impact of echocardiography and carotid ultrasonography

BACKGROUND

Decision about the management of hypertensive patients should not be based on the level of blood pressure alone, but also on the presence of other risk factors, target organ damage (TOD) and cardiovascular and renal disease.

OBJECTIVE

To evaluate the impact of echocardiography and carotid ultrasonography in a more precise stratification of absolute cardiovascular risk.

METHODS

Never-treated essential hypertensives (n = 141; 73 men, 68 women, mean age 46 +/- 11 years) referred for the first time to our out-patient clinic were included in the study. They underwent the following procedures: (1) family and personal medical history, (2) clinical blood pressure (BP) measurement, (3) routine blood chemistry and urine analysis, (4) electrocardiogram, (5) echocardiogram, (6) carotid ultrasonogram. Risk was stratified according to the criteria suggested by the 1999 WHO/ISH guidelines. TOD was initially evaluated by routine procedures only, and subsequently reassessed by using data on cardiac and vascular structure obtained by ultrasound examinations (left ventricular hypertrophy (LVH) as left ventricular mass index (LVMI) > 134 g/m2 in men and > 110 g/m2 in women; carotid plaque as focal thickening > 1.3 mm).

RESULTS

According to the first classification 20% were low-risk patients, 50% medium-risk, 22% high-risk and 8% very-high-risk patients. A marked change in risk stratification was obtained when TOD was assessed by adding ultrasound examinations: low-risk patients 18%, medium-risk 28%, high-risk 45%, very-high-risk patients 9%.

CONCLUSIONS

The detection of TOD by ultrasound techniques allowed a much more accurate identification of high-risk patients, who represented a very large fraction (45%) of the patient population seen at our hypertension clinic. In particular, a large proportion of patients classified as at moderate risk by routine investigations were instead found to be at high risk when ultrasound examinations were added. The results of this study suggest that cardiovascular risk stratification only based on simple routine work-up can often underestimate overall risk, thus leading to a potentially inadequate therapeutic management especially of low-medium risk patients.

Follow-up of renal function in treated and untreated older patients with isolated systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators

BACKGROUND

In the outcome trials that provided information on renal function in older hypertensive patients, diuretics and beta-blockers were mostly used as first-line drugs. The long-term renal effects of calcium-channel blockers remain unclear.

OBJECTIVE

To compare the changes in renal function in 2,258 treated and 2,148 untreated patients with isolated systolic hypertension, of whom 455 had diabetes mellitus and 390 had proteinuria.

METHODS

We performed a post-hoc analysis of the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial. Active treatment was initiated with nitrendipine (10-40 mg/day) with the possible addition of enalapril (5-20 mg/day), hydrochlorothiazide (12.5-25 mg/day), or both, titrated or combined to reduce the sitting systolic blood pressure by at least 20 mmHg, to less than 150 mmHg. The main outcome measures were serum creatinine concentration and creatinine clearance calculated by the formula of Cockroft and Gault.

RESULTS

Serum creatinine concentration at the time when participants were randomly allocated to study groups was less than 176.8 micromol/l (2.0 mg/dl), averaging 88 micromol/l. At the time of the last serum creatinine measurement, the blood pressure difference (P< 0.001) between the two groups was 11.6/4.1 mmHg. In the intention-to-treat analysis (11,427 patient-years), serum creatinine and the calculated creatinine clearance were not influenced by active treatment. However, in the patients assigned randomly to receive active treatment, the incidence of mild renal dysfunction (serum creatinine at least 176.8 mmol/l) decreased by 64% (P= 0.04) and that of proteinuria by 33% (P= 0.03). Active treatment reduced the risk of proteinuria more in diabetic than in non-diabetic patients: by 71%, compared with 20% (P= 0.04). In non-proteinuric patients, active treatment did not influence serum creatinine, whereas in patients with proteinuria at entry to the study, serum creatinine decreased on active treatment (P< 0.001). Furthermore, in on-randomized treatment comparison stratified for risk at baseline, serum creatinine concentration did not change (P= 0.98) in patients continuing to receive monotherapy with nitrendipine, whereas it increased by 6.73 mmol/l (P < 0.001) in patients who received hydrochlorothiazide alone or in combination with other study medication (P < 0.001 for difference in trends).

CONCLUSIONS

In older patients with isolated systolic hypertension, antihypertensive treatment starting with the dihydropyridine calcium-channel blocker, nitrendipine, did not decrease blood pressure at the expense of renal function and prevented the development of proteinuria, especially in diabetic patients.

Postmortem assessment of fetal diaphyseal femoral length: validation of a radiographic methodology

Depending on the general condition of fetal remains, forensic specialists might face difficulties concerning age estimation. Reference tables and regression equations are helpful devices in this task, although they are generally applied for complete fetuses or fetal remains including soft tissues. However, the problem of age estimation stays for osseous remains, both for entire bones and ossified parts, since most of the reference tables come from ultrasonographic measurements, which are not easily reproducible on fetal osseous remains. Furthermore, the ultrasonographic measurements contain slight errors in comparison to the real anatomical ones. This study describes a radiographic protocol and a measurement technique that facilitate and improve bone measurements, and therefore, facilitate age estimation, too. A qualitative criterion, namely a clear-cut bony endplate, was defined and tested. Its reliability (repeatability and reproducibility) turned out to be good, showing nonsignificative differences to the threshold of 0.05, with average errors of 0.26 and 0.44 mm respectively. Moreover, concerning the test of eventual size differences between the right and left femurs showed a P value < 0.0001. The test of the qualitative criterion was based on the comparison of the radiographic in situ femur measurements and the radiographic measurements of the same bones after dissection. The results were satisfactory, since an average error of 0.58 mm was obtained, which did not give any significant differences to the threshold of 0.05. It was concluded that this methodology provides an easy and precise new measurement tool for forensic practice, and can allow us to establish some nonultrasonographic tables, which fit our population.

Different baseline sympathovagal balance and cardiac autonomic responsiveness in ischemic and non-ischemic congestive heart failure

BACKGROUND

A profound autonomic unbalance is present in heart failure: its correlation with the etiology of the disease has never been investigated.

AIMS

We characterized the sympatho-vagal balance and autonomic responsiveness of 42 patients (21 with ischemic heart failure, 21 with idiopathic dilated cardiomyopathy). Patients had comparable NYHA class, ejection fraction, exercise pVO(2), exercise ventilatory response, incidence of beta-blocking treatment. None showed periodic breathing or nocturnal arterial desaturation.

METHODS

Heart rate variability was assessed in the time and frequency domain during: (1) 10 min of quiet supine resting and free breathing; (2) 10 min of regular breathing at a frequency of 20 acts/min (=parasympathetic stimulus); and (3) 10 min of active standing (=sympathetic stimulus). The ratio of the low- to high-frequency components of each autospectrum obtained in the frequency domain (LF/HF) was used as an index of sympathovagal balance.

RESULTS

Patients with ischemic heart failure had a greater baseline sympathetic activation (higher LF/HF) than those with idiopathic dilated cardiomyopathy, maintaining some parasympathetic responsiveness as well (reduced LF/HF with regular breathing).

CONCLUSIONS

There is a distinct autonomic control according to the etiology of heart failure, a finding that may help understanding its pathophysiology, and could be useful in the clinical management of patients.

A comparison of indapamide SR 1.5 mg with both amlodipine 5 mg and hydrochlorothiazide 25 mg in elderly hypertensive patients: a randomized double-blind controlled study

OBJECTIVE

To analyse the efficacy of indapamide sustained-release (SR) 1.5 mg in reducing blood pressure versus amlodipine 5 mg and hydrochlorothiazide 25 mg, in elderly hypertensive patients.

DESIGN

Double-blind, randomized, 12 week study using three parallel groups.

SETTING

European teaching hospitals and general practices.

PATIENTS

Randomized patients, (n = 524) including 128 patients with isolated systolic hypertension (ISH); mean age: 72.4 years; mean systolic/diastolic blood pressures (SBP/DBP): 174.5/97.9 mmHg.

MAIN OUTCOME MEASURES

Clinic systolic and diastolic blood pressure variations.

RESULTS

Indapamide SR 1.5 mg demonstrates a similar efficacy to that of amlodipine 5 mg, as well as to that of hydrochlorothiazide 25 mg (equivalence P < 0.001); the mean decreases in SBP/DBP were -22.7/-11.8 mmHg, -22.2/-10.7 mmHg and -19.4/-10.8 mmHg, respectively. In the ISH subgroup, indapamide SR 1.5 mg tends to have greater efficacy than hydrochlorothiazide 25 mg in reducing the SBP (-24.7 versus -18.5 mmHg, respectively; equivalence P = 0.117), while similar results are obtained with amlodipine 5 mg (-23 mmHg, equivalence P < 0.001). The normalization rate was relatively high for indapamide SR 1.5 mg (75.3%), when compared with amlodipine (66.9%) and hydrochlorothiazide (67.3%), especially in the subgroup of isolated systolic hypertensive patients: 84.2 versus 80.0% for amlodipine, and versus 71.4% for hydrochlorothiazide.

CONCLUSIONS

Indapamide SR 1.5 mg shows similar antihypertensive efficacy to amlodipine 5 mg and hydrochlorothiazide 25 mg in elderly hypertensive patients, while in patients with isolated systolic hypertension, indapamide SR 1.5 mg shows a similar efficacy to amlodipine 5 mg but a greater efficacy than hydrochlorothiazide 25 mg.

Improvement of patients' knowledge by a single educational meeting on hypertension

OBJECTIVES

A poor therapeutic compliance is a major cause of insufficient control of hypertension. As education of patients is fundamental in order to improve their compliance, we organised two pilot educational meetings aimed at (1) assessing the support of patients to this kind of meetings, and (2) verifying the impact on patient's education.

METHODS

We invited 225 consecutive patients referred to our Hypertension Clinic (some of them regularly followed up and some referred for the first time) to participate to an educational meeting on hypertension. Patients were divided in two groups, for organising reasons each attending a single meeting. Each meeting included four sessions: (1) the first session included a multiple choice questionnaire (nine questions, with answers collected by an interactive electronic system) in order to evaluate the degree of patient's information about hypertension (definition, prevalence, aetiology, complications and treatment), (2) a traditional teaching session, (3) an interactive phase aimed to assess the improvement of knowledge in which the same questions as in the first session have been asked again, and (4) a general discussion session.

RESULTS

A total of 144 patients (mean age 54 +/- 12 years; 76 M, 68 F) of the 225 invited attended the meeting. The answers to our questions in the initial session were correct in a percentage ranging from 60% to 80%. During the third phase immediately after the teaching session, the percentage of correct answers increased significantly (range: 75--98%, P < 0.05 at least in all questions).

CONCLUSIONS

This study shows: (1) a satisfactory adherence of patients to this educational initiative; (2) a positive impact of a single educational meeting on patient's knowledge about issues related to hypertension. The potential role of improving patient's education on clinical outcomes such as blood pressure levels and the rate of blood pressure control requires future controlled studies. Journal of Human Hypertension (2001) 15, 57-61

Patterns of hypertension management in Italy: results of a pharmacoepidemiological survey on antihypertensive therapy. Scientific Committee of the Italian Pharmacoepidemiological Survey on Antihypertensive Therapy

OBJECTIVE

To collect statistically significant information on patterns of antihypertensive therapy in medical practice, with particular attention to the drugs used in the pharmacological management of hypertensive patients and the reasons for the limited achievement of therapeutic goals during treatment

DESIGN

A survey conducted among general practitioners, specialists, and hypertensive patients.

METHODS

A total of 28,000 physicians were contacted by letter and 3,394 declared their willingness to participate and received a questionnaire. Subsequently, 1,255 questionnaires suitable for analysis (corresponding to 37.0% of adhering physicians) were received. In addition, 4,612 questionnaires completed by patients were pooled and evaluated. The prevalence of hypertension was calculated from a base of 254,192 patients, seen by general practitioners.

RESULTS

The prevalence of hypertension, defined as systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg, or current treatment, was 19.7%. The average number of hypertensive patients in each general practitioner's file, covering the previous 12 months, was approximately 230. Physicians reported a 66% rate of discontinuation of treatment or switching to another drug. Physicians and patients both considered inadequate blood pressure control and side effects to be the two main reasons for switching antihypertensive therapy, but in opposite order. Furthermore, physicians indicated a prevalence of drug side effects between 10 and 20%, according to class of drug used, whereas 69% of patients reported to have experienced side effects. In the doctors' opinions, there were many reasons for poor patient adherence: complexity of the drug regimen, appearance of side effects, forgetfulness, reduced patient understanding of the need for long-term continuation of treatment, and refusal to accept a chronic pathological condition.

CONCLUSIONS

The survey showed awareness of the disease among physicians and provides a representation of the experiences of both general practitioners and specialists, in addition to that of their patients. During antihypertensive therapy, a disconcerting degree of discontinuation and switching of drugs occurred. Insufficient blood pressure control and side effects accounted for most of the observed treatment changes. This survey revealed the existence of a gap between the physicians' perception of tolerability and the real experience of patients, a clear need for greater tolerability of treatments, and a need for an enhancement of patient-physician communication.

Impact of blood pressure control on prevalence of left ventricular hypertrophy in treated hypertensive patients

AIM

The aim of the present study was to evaluate (1) the prevalence and patterns of left ventricular hypertrophy (LVH) and (2) the impact of blood pressure (BP) control, assessed by clinical and 24-hour ambulatory BP monitoring (ABPM) criteria on the persistence of LVH in a representative sample of treated patients attending our Hypertension Clinic.

METHODS

One hundred consecutive essential hypertensives (61 m/39 f, age 56+/- 9 years) regularly followed up by the same medical team (average period 52 months, 12-156 months) were included in the study and underwent 24-hour ABPM and complete echocardiographic examination.

RESULTS

Twenty-eight of the 100 patients were found to have LVH [left ventricular mass index (LVMI) >125 g/m(2) in men and >110 g/m(2) in women]; LVH was eccentric in 20 patients and concentric in the remaining 8. LVMI did not correlate with clinical BP values but only with ABPM values (mean 24 h systolic r = 0.34, p <0.01; diastolic r = 0.37, p <0.01). The prevalence of LVH in patients controlled according to clinical BP criteria (n = 43, BP <140/90 mm Hg) was 19%, in patients controlled according to ABPM criteria (n = 30, BP during daytime <132/85 mm Hg) 17%, and in those controlled with both criteria (n = 16) 6% (p <0. 01).

CONCLUSIONS

The results of this study suggest that the eccentric type of LVH is the prevalent pattern in chronically treated patients. The persistence of LVH is significantly dependent on BP levels achieved during treatment; indeed the prevalence of LVH is very low in patients with an optimal BP control, whereas it is elevated (37%) in uncontrolled patients.

Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators

BACKGROUND

The goal of the present study was to assess the effect of antihypertensive therapy on clinic (CBP) and ambulatory (ABP) blood pressures, on ECG voltages, and on the incidence of stroke and cardiovascular events in older patients with sustained and nonsustained systolic hypertension.

METHODS AND RESULTS

Patients who were >/=60 years old, with systolic CBP of 160 to 219 mm Hg and diastolic CBP of <95 mm Hg, were randomized into the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial. Treatment consisted of nitrendipine, with the possible addition of enalapril, hydrochlorothiazide, or both. Patients enrolled in the Ambulatory Blood Pressure Monitoring Side Project were classified according to daytime systolic ABP into 1 of 3 subgroups: nonsustained hypertension (<140 mm Hg), mild sustained hypertension (140 to 159 mm Hg), and moderate sustained hypertension (>/=160 mm Hg). At baseline, patients with nonsustained hypertension had smaller ECG voltages (P<0.001) and, during follow-up, a lower incidence of stroke (P<0.05) and of cardiovascular complications (P=0.01) than other groups. Active treatment reduced ABP and CBP in patients with sustained hypertension but only CBP in patients with nonsustained hypertension (P<0.001). The influence of active treatment on ECG voltages (P<0.05) and on the incidence of stroke (P<0.05) and cardiovascular events (P=0.06) was more favorable than that of placebo only in patients with moderate sustained hypertension.

CONCLUSIONS

Patients with sustained hypertension had higher ECG voltages and rates of cardiovascular complications than did patients with nonsustained hypertension. The favorable effects of active treatment on these outcomes were only statistically significant in patients with moderate sustained hypertension.

Long-term lifestyle changes maintain the autonomic modulation induced by rehabilitation after myocardial infarction

The altered autonomic balance observed after myocardial infarction is shifted toward a higher parasympathetic tone by rehabilitation. This effect persists after 1 year, however we observed a discrete variability in the long-term sympathovagal balance among patients. We postulated that such variability derives from the disparate adherence of patients to lifestyle prescriptions regarding exercise continuance and smoking avoidance. To test this hypothesis, we reviewed the data of 40 patients, who completed with a favourable autonomic modulation the initial rehabilitation phase after myocardial infarction and underwent the annual follow-up. One year after infarction, 23 patients complied to the advice about regular exercise and smoking avoidance (adherent, Group 1); 17 did not (non-adherent, Group 2). Groups were similar for age, site of infarction, left ventricular function, stress test duration and therapy. The ratio LF/HF, derived from the power spectral density of RR intervals variability, was used as an index of the sympathovagal balance. It was obtained from 15 min of ECG at rest, assessed 1 month after MI (baseline), and repeated 3 months (rehabilitation) and 1 year (follow-up) afterwards. Rehabilitation increased parasympathetic tone in all patients, reducing LF/HF by 33%. At follow-up, this potentially favourable autonomic profile persisted only in Group 1 patients. In conclusion, after a first myocardial infarction, the persistence of the potentially beneficial effect of rehabilitation on the sympathovagal balance depends on the compliance to the lifestyle changes proposed during the initial phase.

Is systolic pressure a better target for antihypertensive treatment than diastolic pressure?

BACKGROUND

Diastolic blood pressure has been evaluated in different prospective cohort studies and in pharmacological intervention trials, which have shown the increased risk of cardiovascular events in hypertensive patients and the benefits of antihypertensive therapy.

AIMS

To show that systolic blood pressure is at least as important as, or even more important than, diastolic blood pressure as a risk factor for cardiovascular complications.

METHODS

Review of medical literature.

RESULTS

Large epidemiological trials such as the Multiple Risk Factors Intervention Trial (MRFIT) and the Framingham study have shown that systolic blood pressure is an independent, continuous and modifiable risk for all cardiovascular complications, and in elderly subjects isolated systolic hypertension is the most frequent form of hypertension. In elderly subjects the increased stiffness of large arteries is responsible for the early reflection of pulse wave and for the decrease in diastolic blood pressure due to reduced recoil of large arteries. This is summarized in the increase in pulse pressure, which is directly related to the risk of cardiovascular complications. Three large intervention trials in elderly patients with isolated systolic hypertension have shown the relevant cardiovascular benefit of pharmacological reduction of elevated systolic blood pressure and normal diastolic values: the cardiovascular benefit is similar to that found in the general hypertensive population and in elderly patients with systolic-diastolic hypertension.

CONCLUSION

Systolic blood pressure represents an important risk factor for cardiovascular events which can be prevented or reduced with pharmacological treatment.

Markers of electrical instability in hypertensive patients with and without ventricular arrhythmias. Are they useful in identifying patients with different risk profiles?

BACKGROUND

Markers of electrical instability of the ventricular myocardium, namely abnormal repolarization and late potentials, are frequently observed in patients with hypertension when both ventricular arrhythmias and left ventricular hypertrophy are present. This information cannot be extrapolated to the population of hypertensive patients with ventricular arrhythmias but without left ventricular hypertrophy.

OBJECTIVE

To evaluate QT duration, QT dispersion and the incidence of ventricular late potentials in patients with essential hypertension, already on anti-hypertensive therapy, both with and without non-sustained ventricular arrhythmia.

DESIGN

The study population consisted of 49 patients with essential hypertension who were compared to 89 control normotensive subjects both with and without frequent (> 30 per h) ventricular ectopic beats (VPBs). Patients were divided into four groups: (1) hypertensive patients without VPBs (H, n = 19), (2) hypertensive patients with VPBs (HA, n = 30), (3) normotensive subjects without VPBs (C, n = 28), and (4) normotensive subjects with VPBs (CA, n=61).

METHODS

Echocardiographic parameters, QT interval, QT dispersion and signal-averaged ECG were evaluated without withdrawing anti-hypertensive drugs.

RESULTS

In no case was left ventricular hypertrophy documented. The number of VPBs during 24 h Holter recording (median 11 343 versus 7617) and the incidence of repetitive VPBs (37 versus 46% of patients) were similar in the two groups of patients (HA versus CA). Signal-averaged ECG parameters were normal and not different between the four groups. QT interval was longer in hypertensive patients compared to controls irrespective of the presence of VPBs. QT dispersion was slightly greater in subjects with VPBs, both hypertensive and normotensive, compared to subjects without arrhythmias.

CONCLUSIONS

In patients with hypertension well-controlled by drug therapy and without left ventricular hypertrophy, frequent VPBs are not associated with markers indicating an electrophysiological substrate for re-entrant arrhythmias. However, QT prolongation suggests the persistence of a higher risk of cardiovascular mortality that is independent of the presence of VPBs.

Prevalence of target organ damage in treated hypertensive patients: different impact of clinic and ambulatory blood pressure control

OBJECTIVES

First, to evaluate the prevalence of left ventricular (LV) hypertrophy, LV concentric remodelling and microalbuminuria in a selected sample of treated hypertensive patients with effective and prolonged clinic blood pressure (BP) control (BP < 140/90 mmHg). Second, to compare the prevalence of these markers of organ damage in patients with and without ambulatory BP (ABP) control, defined as average daytime BP < 132/85 mmHg).

DESIGN AND METHODS

Fifty-eight consecutive hypertensive patients who attended our hypertension outpatient clinic over a period of 3 months and were regularly followed up by the same medical team were included in the study. Obesity, diabetes mellitus, history or signs of cardiovascular or renal complications and major noncardiovascular diseases were the exclusion criteria from the study. Each patient underwent 24 h ABP monitoring, echocardiography and 24 h urine collection for albumin measurement.

RESULTS

The prevalence of LV hypertrophy (LV mass index > 125 g/m2 in both sexes), LV concentric remodelling (relative wall thickness > 0.45) and microalbuminuria (urinary albumin excretion < 300 mg/ 24 h) in this selected group of patients (32 men, 26 women; mean age 53 +/- 9 years; mean clinic BP 122 +/- 9/ 78 +/- 6 mmHg) was markedly low (6.9, 8.6 and 5.1%, respectively). The 26 patients with effective ABP control (group I) were similar to the 32 patients without effective ABP control (group II) in age, gender, body surface area, clinic BP, smoking habit, glucose, cholesterol and creatinine plasma levels. Prevalence of LV hypertrophy, LV concentric remodelling and microalbuminuria was lower in group I than in group II (0 versus 12.9% P< 0.01, 7.7 versus 9.4% NS, 3.8 versus 6.2% NS, respectively).

CONCLUSIONS

This study demonstrates that nonobese, nondiabetic hypertensive patients with an effective clinic BP control have a very low prevalence of target organ damage and that LVH is present only in individuals with insufficient ABP control.

Antihypertensive efficacy of manidipine and enalapril in hypertensive diabetic patients

Recent studies showed that in diabetic hypertensive patients, administration of angiotensin-converting enzyme (ACE)-inhibitors or calcium antagonists can effectively lower blood pressure (BP) and prevent diabetes-related cardiovascular complications with no adverse metabolic effects. We sought to assess the antihypertensive and metabolic effects of the new dihydropyridine calcium antagonist manidipine (M) in patients with diabetes mellitus and essential hypertension as compared with the ACE inhibitor enalapril (E). After 3 weeks of placebo, 101 (62 men; age range, 34-72 years) hypertensives with type II diabetes mellitus were randomized to M 10-20 mg or E 10-20 mg, od, for 24 weeks. At the end of the placebo period and the active-treatment phase, BP was measured with a mercury sphygmomanometer (office, O) and over the 24 h by ambulatory (A) monitoring. ABP recordings were analyzed to obtain 24-h, day (6 a.m. to midnight), and night (midnight to 6 a.m.) average systolic (S) and diastolic (D) BP and heart rate (HR) values. Homogeneity of the antihypertensive effect over the 24 h was assessed by the smoothness index [SI: i.e., the ratio between the average of the 24 hourly BP changes after treatment and the corresponding standard deviation (the higher the SI, the more uniform is the BP control by treatment over the 24 h]. The O SBP and DBP were significantly (p < 0.01) and similarly reduced by M (16 +/- 10 and 13 +/- 6 mm Hg, n = 49) and E (15 +/- 10 and 13 +/- 6 mm Hg, n = 45). The percentage of patients whose O DBP was reduced < or = 85 mm Hg (i.e., the value indicated to be the optimal DBP goal in diabetic hypertensives) was similar for M (37%) and E (40%). The reduction of 24-h BP also was similar between M (n = 38) and E (n = 38) for both drugs (systolic, 6 +/- 11 and 8 +/- 10 mm Hg; diastolic, 5 +/- 8 and 5 +/- 7; NS, M vs. E). The antihypertensive effect was distributed in a similar homogeneous fashion throughout the dosing interval, as shown by the similar SI values (M, 0.6 +/- 1.2 for SBP and 0.6 +/- 0.9 for DBP; E, 0.6 +/- 0.8 for SBP and 0.5 +/- 0.7 for DBP; NS, M vs. E). O and A HR were unchanged by either treatment. Markers of glucose and lipid metabolism and renal function were not significantly modified by treatment both with M and with E. In the diabetic hypertensives, M was as effective and metabolically neutral as the ACE-inhibitor E.

Influence of gender and age on preventing cardiovascular disease by antihypertensive treatment and acetylsalicylic acid. The HOT study. Hypertension Optimal Treatment

OBJECTIVE

We have assessed the influence of gender and age on the main outcome results of the Hypertension Optimal Treatment (HOT) study.

DESIGN AND INTERVENTIONS

The aims of the HOT study were to study the relationship between three levels of target office diastolic blood pressure (BP) (< or = 90, < or = 85 or < or = 80 mmHg) and cardiovascular (CV) events in hypertensive patients, and to examine the effects of 75 mg acetylsalicylic acid (ASA) daily versus placebo.

SETTING

Outpatient clinical trial in 26 countries.

PATIENTS

A total of 18790 patients (mean age 61.5 years, range 50-80) were randomized and followed for an average of 3.8 years until 71051 patient-years and 683 events had occurred.

MAIN OUTCOME MEASURES

CV death, myocardial infarction (MI) and stroke.

RESULTS

There were significantly fewer MIs in those in the lower diastolic BP target groups (3.0 versus 1.2 and 1.7 MIs/1000 patient-years, P for trend = 0.034) in women (n = 8883), whereas the similar but smaller trend (4.1 versus 4.1 and 3.4 MIs/1000 patient-years) was not statistically significant in men nor in the subgroup analysis of younger and older subjects. The effect of ASA on preventing MI was not influenced by age < 65 years (P= 0.02) or age > or = 65 years (P = 0.04) but was influenced by gender (P = 0.38 in women and P = 0.001 in men, lowered by 42% corresponding to a reduction from 5.0 to 2.9 MIs/1000 patient-years).

CONCLUSIONS

The data of this HOT study sub-analysis suggest somewhat differentiated optimal gender- and age-dependent effects of anti-hypertensive and anti-platelet therapies; lowering of diastolic BP to about 80 mmHg in hypertensive women and, in addition, the administration of 75 mg of ASA to well-treated hypertensive men appear to effectively reduce the most common cardiovascular complication, i.e. myocardial infarction, in patients with essential hypertension.

Clinical positioning of indapamide sustained release 1.5mg in management protocols for hypertension

Indapamide sustained release (SR) 1.5mg is a new galenic formulation that is characterised by a relatively constant plasma concentration at steady state, with only minor fluctuations during the 24-hour period. A dose-titration study of 3 doses of indapamide SR (1.5, 2 and 2.5mg) given once daily has shown that the 3 dosages are equipotent in lowering blood pressure, and have an effect similar to that of indapamide immediate-release (IR) 2.5mg; all were statistically more effective than placebo. The percentage of hypertensive patients whose serum potassium was less than 3.4 mmol/L was significantly lower after indapamide SR 1.5mg than after indapamide IR 2.5mg. Neither indapamide formulation had any significant effects on lipid profile, glucose, urea and serum creatinine; only uric acid was slightly raised during the 2-month study. In an equivalence study, indapamide SR 1.5mg and IR 2.5mg produced similar blood pressure reductions (within the equivalence limit of +/-5mm Hg), whereas the percentage of patients whose serum potassium fell to less than 3.4 mmol/L was lower in the IR 1.5mg group than in the SR 2.5mg group. Antihypertensive treatment with indapamide SR 1.5mg once daily produced reductions in blood pressure in elderly patients with systolic/diastolic or isolated systolic hypertension that were similar to reductions with amlodipine 5 mg/day. The incidence of adverse effects was very low in all studies with indapamide SR 1.5mg and very similar to that in the placebo group, confirming thereby the improvement in the efficacy: tolerance ratio with the new indapamide compound.

Relationship between baseline sympatho-vagal balance and the autonomic response to cardiac rehabilitation after a first uncomplicated myocardial infarction

BACKGROUND

After a first uncomplicated myocardial infarction, cardiac rehabilitation increases the parasympathetic tone, in a direction linked to a reduced risk of sudden cardiac death. This change in sympatho-vagal balance may be related to other clinical variables. The aim of this study was to define the factors implicated in determining the autonomic response to cardiovascular rehabilitation after myocardial infarction.

METHODS

In 55 patients (39-80 years) we evaluated the modulation of the autonomic profile induced by 8 weeks of rehabilitation: we analyzed the changes in pNN50 derived from time-domain analysis (deltapNN50) and in the low frequency/high frequency (LF/HF) ratio derived from autoregressive power spectral analysis (deltaLF/HF). A control group of 15 patients not undergoing rehabilitation was also studied. Variables considered at 4 weeks postinfarction and related to deltapNN50 and deltaLF/HF ratio were: age, site of myocardial infarction, previous thrombolysis, ejection fraction, stress test duration, baseline LF/HF ratio.

RESULTS

Patients not undergoing rehabilitation did not change their autonomic profile. On the contrary, rehabilitation induced a higher vagal tone (pNN50 from 6.5 +/- 1.5 to 16.2 +/- 3.1; LF/HF ratio from 8.3 +/- 5.2 to 5.1 +/- 2.9, p < 0.05). Eleven patients (20%) had baseline LF/HF ratio exceeding the mean value by 1.5 SD (19.4 +/- 1.4): in this subgroup, pNN50 was very low. In these patients, rehabilitation increased pNN50 and decreased LF/HF ratio. Indeed, both deltapNN50 and deltaLF/HF ratio were significantly related to their baseline values (p < 0.001), even considering thrombolysis, site of myocardial infarction, age, and beta-blocker therapy.

CONCLUSIONS

After a first uncomplicated myocardial infarction, sympatho-vagal balance may be very disturbed in some patients, despite a preserved ventricular function, good exercise capability and beta-blockers. These patients should be encouraged to undergo rehabilitation, since the significant improvement in the parasympathetic tone may protect them against subsequent arrhythmic events.

Lack of correlation between left ventricular mass and diameter of left coronary artery main trunk in hypertensive patients

The study was designed to evaluate whether the increase in left ventricular (LV) mass in essential hypertensives (H) is associated with a proportional increase in diameter of the left coronary artery (LCA) trunk. Twenty-six hypertensives, 14 with left ventricular hypertrophy (LVH) (left ventricular mass index [LVMI] > or =134 g/m2 in men and > or =110 g/m2 in women) and 12 without LVH, and 10 normotensive controls (C) underwent clinical laboratory and echocardiographic transthoracic examination. LV dimensions were measured according to the Penn convention and LV mass calculated by the formula of Devereux. The LCA main trunk was visualized by two-dimension short axis view at the level of the great vessels section, and the diameter measured as intima-intima distance at end-diastole. Hypertensives with and without LVH and C had similar age, sex, and body surface area distribution. LVMI was, by definition, significantly higher in H with LVH than in H without LVH and in C (144+/-21, 113+/-13, and 98+/-10 g/m2, P<.01), whereas the diameter of the LCA trunk was similar in all groups (0.48+/-0.1, 0.48, and 0.46 cm, respectively). There was no significant correlation between LVMI and LCA diameter in H (r = 0.21, P = not significant). The diameter of LCA trunk was significantly correlated only with BSA (r = 0.5, P<.01), LV end-systolic and end-diastolic diameters (r = 0.5 and r = 0.4, P<.05). Our data suggest that in H the increase in LVM is not associated with a concomitant increase of epicardial coronary artery diameter, and this finding may account in part for the impairment of coronary blood flow reserve in LVH.

Increased left ventricular dimensions in patients with frequent nonsustained ventricular arrhythmia and no evidence of underlying heart disease

INTRODUCTION

To test the hypothesis that frequent nonsustained ventricular premature beats (VPBs) in patients without underlying heart disease are the first marker of mild systolic dysfunction of the left ventricle, we evaluated whether a subclinical abnormality of left ventricular function and/or an intraventricular conduction defect was present at the first clinical documentation of the arrhythmia.

METHODS AND RESULTS

We compared 57 patients (mean age 46 +/- 14 years) with > 30 VPBs/hour and no heart disease (A) to 32 healthy volunteers (mean age 42 +/- 12 years) without arrhythmia (B). Left ventricular echocardiographic parameters and signal-averaged ECG were evaluated. Filtered QRS duration (98 +/- 10 msec in A vs 98 +/- 7 msec in B) was similar in the two groups. End-diastolic left ventricular diameter (EDLVD) was 50 +/- 6 mm in A versus 47 +/- 3 mm in B (P < 0.005); 15 patients (26%) and none of the controls had EDLVD > or = 55 mm (P < 0.005). Filtered QRS interval was longer in the subgroup of patients (n = 15) with increased EDLVD (> or = 55 mm) compared with the subgroup (n = 42) with EDLVD < 55 mm (106 +/- 9 msec vs 95 +/- 9 msec; P < 0.001) and was related to greater left ventricular mass.

CONCLUSION

We documented a subclinical but significant increase of left ventricular dimensions that suggests that frequent VPBs may be an initial marker of mild systolic dysfunction of the left ventricle. However, an effect of VPBs per se in modifying left ventricular dimensions cannot be excluded.

Impact of nocturnal fall in blood pressure on early cardiovascular changes in essential hypertension

OBJECTIVE

To evaluate in a selected population of subjects with a recent diagnosis of hypertension whether a blunted nocturnal fall in blood pressure is associated with more advanced cardiac and vascular damage.

METHODS

One hundred and eleven recently diagnosed and never-treated patients with mild essential hypertension underwent 24-h ambulatory blood pressure monitoring (ABPM), echocardiography and carotid ultrasonography.

RESULTS

The 78 patients with normal (> 10%) night-time fall in systolic blood pressure (SBP) and diastolic blood pressure (DBP) (dippers) were similar to the 33 patients with a small (< or = 10 %) fall (non-dippers) for age, sex, body surface area, smoking habit, clinic and 24-h blood pressure. There were no differences between dippers and non-dippers in left ventricular mass index (104 versus 105 g/m2), common carotid internal diameter (5.8 versus 5.9 mm), intima-media thickness (0.66 versus 0.64 mm) and carotid plaques prevalence (25 versus 29%). Furthermore, no differences were found in the correlation of daytime and night-time SBP and DBP with left ventricular mass and carotid wall thickness. When the 77 men and 34 women were analysed separately, similar results were obtained.

CONCLUSION

These results suggest that a blunted reduction in night-time blood pressure does not play a major role in the development of cardiovascular changes during the early phase of essential hypertension.

Compliance with aspirin or placebo in the Hypertension Optimal Treatment (HOT) study

OBJECTIVE

The Hypertension Optimal Treatment (HOT) study is a large, prospective trial aimed at defining the level of diastolic blood pressure required during anti-hypertensive therapy in order to achieve maximal protection against cardiovascular complications. A further aim is to assess the effects on morbidity and mortality of a 75 mg daily dose of aspirin compared with placebo.

SUBJECTS AND METHODS

Compliance with double-blind administration of aspirin or placebo added to anti-hypertensive treatment was evaluated for 1 year in a subset (n = 530) of the study population (n = 18 790) by placing the medication in a container closed with an electronic cap that records precisely the time of each opening.

RESULTS

The 1-year compliance rate (percentage of days with one opening per day) could be assessed in 501 patients. It averaged 78.3 +/- 25% in aspirin-treated patients (n = 236, mean +/- SD), compared with 78.5 +/- 25% in patients having received placebo (n = 265), and was not influenced by age, sex or country (Germany, Italy, Switzerland, UK). The compliance rate was also similar irrespective of whether the patients had reached their target blood pressure, but was significantly better during the first than the second 6-month monitoring period (84.1 +/- 22% versus 72.3 +/- 32%, n = 501).

CONCLUSIONS

The high rate of compliance with aspirin or placebo observed in the HOT study suggests that the patients were highly motivated and may account for the unusually good blood pressure control achieved in this trial during long-term anti-hypertensive treatment.

Blood pressure control in a hypertension hospital clinic

OBJECTIVES

First, to evaluate the prevalence of clinic blood pressure (BP) control (BP < or = 140/90 mm Hg) in a representative sample of treated hypertensive patients followed in our hypertension clinic. Second, to assess in a subgroup of these patients: (a) the proportion of BP control with both clinic blood pressure (CBP < or =140/90 mm Hg) and daytime ambulatory blood pressure (ABP) (< or =132/85 mm Hg) criteria, and (b) the prevalence of echocardiographic left ventricular hypertrophy (LVH) (left ventricular mass index, LVMI>125 g/m2 in men and >110 g/m2 in women).

DESIGN AND METHODS

Seven hundred consecutive hypertensive patients who attended our hypertension centre clinic during a period of 6 months and who had regularly been followed up by the same medical team were included in the study. BP was taken in the clinic by a doctor using a mercury sphygmomanometer with the participants seated. Seventy-four patients with similar demographic and clinical characteristics to the entire population of participants underwent complete echocardiographic examination and 24 h ABP monitoring.

RESULTS

During follow-up, 352 of the treated patients had clinic BP < or =140/90 mm Hg, 198< or =160/95 mm Hg and 150>160/95 mm Hg, indicating that BP control was satisfactory in 50.3%, borderline in 28.3% and unsatisfactory in 21.4% of the cases. In the subgroup of 74 patients, the proportion of individuals with satisfactory clinic BP control (CBP< or =140/90 mm Hg) was higher (50.0 versus 33.6%) than with satisfactory ABP control (daytime ABP values < or =132/85 mm Hg). LVH was found in 21 of the 74 patients (28.3%): 12 of them had unsatisfactory CBP control and 19 had unsatisfactory ABP control. LVMI did not correlate with CBP values but only with ABP values (mean 24 h systolic r = 0.47, diastolic r = 0.40, P<0.001; mean daytime systolic r = 0.45, mean daytime diastolic r = 0.39, P<0.001; mean night-time systolic r = 0.38, mean night-time diastolic r = 0.38, P<0.001).

CONCLUSION

This study demonstrates that hypertensive patients managed in a hypertension centre clinic have satisfactory CBP control in 50% of cases, but this rate seems to over-estimate the effective BP control during daily life. A large fraction of patients show persistence of LVH and this evidence of organ damage almost entirely concerns individuals with poor ABP control.

The elusive diploic veins: anthropological and anatomical perspective

Diploic veins (Canales diploicae), which were identified in dogs by Dupuytren more than 200 years ago (Hecker [1845] Die anatomische Verhaltnisse und Krankheiten der Venae diploicae und Vasa emissaria. Erfahrungen und Abhandlungen im Gebiete der Chirurgie und Augenheilkunde. Erlangen), have remained inadequately understood and scantily referenced in the anatomical and anthropological literature. The tunnels formed by diploic veins are among the few known skeletal markers of soft tissue alteration. Protected by two bony laminae, diploic vein tunnels often resist postdepositional destruction and may provide a new way to assess living and extinct hominid populations. This basic research was carried out to enable future utilization of the diploic venous channels in anthropologic research. In the present study, diploic venous channels were observed radiographically in 108 human adults aged 19 years and above, 18 infants and children aged 1-18 years (Hamann-Todd Osteological Collection), eight fetuses aged 7-9 months (the Johns Hopkins Collection), and seven nonhuman primates (Hamann-Todd Osteological Collection). In addition, seven documented cases of parents and children were radiographed for genetic evaluation (Osteological Collection of The Hungarian Natural History Museum). Five distinct diploic distribution patterns were identified and described in this study. This was at variance with the impressions reported in dissection-based studies. Independence of diploic vein pattern from demographic (gender and age) and size factors and their tendency to be symmetrical make them amenable and reliable traits for skeletal population study. Diploic vein patterns appeared to be more complicated in humans than in nonhuman primates, raising the possibility of future phylogenetic applications.

The elusive diploic veins: anthropological and anatomical perspective

Diploic veins (Canales diploicae), which were identified in dogs by Dupuytren more than 200 years ago (Hecker [1845] Die anatomische Verhaltnisse und Krankheiten der Venae diploicae und Vasa emissaria. Erfahrungen und Abhandlungen im Gebiete der Chirurgie und Augenheilkunde. Erlangen), have remained inadequately understood and scantily referenced in the anatomical and anthropological literature. The tunnels formed by diploic veins are among the few known skeletal markers of soft tissue alteration. Protected by two bony laminae, diploic vein tunnels often resist postdepositional destruction and may provide a new way to assess living and extinct hominid populations. This basic research was carried out to enable future utilization of the diploic venous channels in anthropologic research. In the present study, diploic venous channels were observed radiographically in 108 human adults aged 19 years and above, 18 infants and children aged 1-18 years (Hamann-Todd Osteological Collection), eight fetuses aged 7-9 months (the Johns Hopkins Collection), and seven nonhuman primates (Hamann-Todd Osteological Collection). In addition, seven documented cases of parents and children were radiographed for genetic evaluation (Osteological Collection of The Hungarian Natural History Museum). Five distinct diploic distribution patterns were identified and described in this study. This was at variance with the impressions reported in dissection-based studies. Independence of diploic vein pattern from demographic (gender and age) and size factors and their tendency to be symmetrical make them amenable and reliable traits for skeletal population study. Diploic vein patterns appeared to be more complicated in humans than in nonhuman primates, raising the possibility of future phylogenetic applications.

Systolic Hypertension in Europe (Syst-Eur) trial phase 2: objectives, protocol, and initial progress. Systolic Hypertension in Europe Investigators

The Systolic Hypertension in Europe (Syst-Eur) trial proved that blood pressure (BP) lowering therapy starting with nitrendipine reduces the risk of cardiovascular complications in older (> or = 60 years) patients with isolated systolic hypertension (systolic BP > or = 160 mm Hg and diastolic BP < 95 mm Hg). After the completion of the Syst-Eur trial on 14 February 1997, 3506 consenting patients (93.0% of those eligible) were enrolled in phase 2 of the Syst-Eur trial. This open follow-up study aims to confirm the safety of long-term antihypertensive therapy based on a dihydropyridine. To lower the sitting systolic BP below 150 mm Hg (target BP), the first-line agent nitrendipine (10-40 mg/day) may be associated with enalapril (5-20 mg/day), hydrochlorothiazide (12.5-25 mg/day), both add-on study drugs, or if required any other antihypertensive agent. On 1 November 1998, 3248 patients were still being followed, 86 patients had proceeded to non-supervised follow-up, and 43 had died. The median follow-up in Syst-Eur 2 was 14.3 months. At the last available visit, systolic/diastolic BP in the patients formerly randomised to placebo (n = 1682) or active treatment (n = 1824), had decreased by 13.2/5.2 mm Hg and by 4.6/1.6 mm Hg, respectively, so that the between-group BP difference was 1.7 mm Hg systolic (95% Ci: 0.8 to 2.6 mm Hg; P < 0.001) and 0.9 mm Hg diastolic (95% Cl: 0.4 to 1.5 mm mm Hg; P < 0.001). At the beginning of Syst-Eur 2, the goal BP was reached by 25.4% and 50.6% of the former placebo and active-treatment groups; at the last visit these proportions were 55.9% and 63.1%, respectively. At that moment, 45.9% of the patients were on monotherapy with nitrendipine, 29.3% took nitrendipine in combination with other study drugs. Until the end of 2001, BP control of the Syst-Eur 2 patients will be further improved. Cardiovascular complications and adverse events, such as cancer or gastro-intestinal bleeding, will be monitored and validated by blinded experts.

Evaluation of biological stress markers in police officers

This study was performed on 18 police officers, in order to evaluate relations between behavior and the activity of the main hormonal systems implicated in stress management. All subjects were male volunteers with more than 2 years on the job, a type A psychological profile according to Friedman and Rosenman, suffering from no mental or physical illness. The experimental setting used to study the role of different stress factors consisted of a series of tests that re-created stressful situations that the subject might encounter in his job. The study showed that during stressful states, not only did peripheral secretion of catecholamines increase, but that the ratio of epinephrine to norepinephrine was a determinant factor. Epinephrine secretion which was elevated at the beginning, decreased when the stressful situation was clarified or controlled, whereas norepinephrine secretion remained elevated as long as the subject had to remain alert. Cortisol secretion seemed to depend upon anticipation of the stressful event more than its actual happenning.

The Verapamil in Hypertension and Atherosclerosis Study (VHAS): results of long-term randomized treatment with either verapamil or chlorthalidone on carotid intima-media thickness

BACKGROUND

It is unclear whether the carotid intima-media thickness can be influenced by antihypertensive treatment and whether some antihypertensive agents, such as calcium antagonists, may have a greater effect on this parameter than others, such as diuretics. The present paper reports the principal results of the ultrasound substudy of the randomized, prospective, controlled, Verapamil in Hypertension and Atherosclerosis Study (VHAS).

DESIGN AND METHODS

In 498 hypertensive patients in eight Italian centres, randomized to either verapamil (240 mg once a day) or chlorthalidone (25 mg once a day), a B-mode ultrasound scan was performed according to a standardized procedure at baseline and after 3, 12, 24, 36 and 48 months of treatment. The maximum intima-media thicknesses of the far walls of common, bifurcation and internal carotid arteries were measured bilaterally, and the following indices calculated: the mean thickness at the six measured sites, the mean thickness at the common and bifurcation sites and the single maximum thickness. The primary endpoint for treatment efficacy was the slope of the change over 4 years (rate of change, mm/year), corrected by using the initial mean over the six sites (baseline + 3 months) as a covariate (mm/year per mm). The patients were also classified into three strata according to their baseline single maximum thickness: those with normal carotid arteries (single maximum ( 1 mm), those with thickened carotid arteries (single maximum > 1 and < or = 1.5 mm and those with carotid plaques (single maximum > 1.5 mm).

RESULTS

Among the 456 patients with satisfactory baseline ultrasound readings, 33% were classified with normal carotid arteries, 27% with thickened carotid arteries and 40% with plaques. In the intention-to-treat population (377 patients with ultrasound measurements taken on at least three different occasions over a period of at least 2 years), the rate of change in the mean thickness at the six sites measured was rather small (0.015 mm/year), but significantly (P < 0.05) smaller in patients with plaques (0.003 mm/year) than in patients with thickened or with normal carotids (0.023 and 0.025 mm/year, respectively). When related to initial values, the rate of change in the mean thickness at the six sites had a negative slope (-0.059 mm/year per mm, P < 0.01). Although rates of change in the carotid intima-media thickness in unstratified patients were not different in those treated with verapamil or with chlorthalidone, when changes in the mean thickness of six sites were related to the initial value, the slope of this relationship was significantly different in the two treatment groups (verapamil -0.082 versus chlorthalidone -0.037 mm/year per mm, P < 0.02). The blood pressure-lowering effect of the two randomized treatments was similar. Taking fatal and nonfatal, major and minor cardiovascular events together, there were 19 events in the verapamil group and 35 in the chlorthalidone group, with a significantly (P < 0.01) greater incidence in patients with plaques, and among patients with plaques in those who were randomized to chlorthalidone (P < 0.05).

CONCLUSIONS

In accord with evidence from animal models of atherosclerosis, the calcium antagonist verapamil was more effective than the diuretic chlorthalidone in promoting regression of thicker carotid lesions. Changes in the carotid intima-media thickness were small in both groups, and the differences between the changes under the two treatments were consequently small, but the observation that these small differences in carotid wall changes were paralleled by differences in the incidence of cardiovascular events (better intima-media thickness regression with verapamil paralleled by a lower cardiovascular event rate) suggests that even small effects on carotid plaques may have clinical and prognostic relevance.

Subgroup and per-protocol analysis of the randomized European Trial on Isolated Systolic Hypertension in the Elderly

BACKGROUND

In 1989, the European Working Party on High Blood Pressure in the Elderly started the double-blind, placebo-controlled, Systolic Hypertension in Europe Trial to test the hypothesis that antihypertensive drug treatment would reduce the incidence of fatal and nonfatal stroke in older patients with isolated systolic hypertension. This report addresses whether the benefit of antihypertensive treatment varied according to sex, previous cardiovascular complications, age, initial blood pressure (BP), and smoking or drinking habits in an intention-to-treat analysis and explores whether the morbidity and mortality results were consistent in a per-protocol analysis.

METHODS

After stratification for center, sex, and cardiovascular complications, 4695 patients 60 years of age or older with a systolic BP of 160 to 219 mm Hg and diastolic BP less than 95 mm Hg were randomized. Active treatment consisted of nitrendipine (10-40 mg/d), with the possible addition of enalapril maleate (5-20 mg/d) and/or hydrochlorothiazide (12.5-25 mg/d), titrated or combined to reduce the sitting systolic BP by at least 20 mm Hg, to below 150 mm Hg. In the control group, matching placebo tablets were employed similarly.

RESULTS

In the intention-to-treat analysis, male sex, previous cardiovascular complications, older age, higher systolic BP, and smoking at randomization were positively and independently correlated with cardiovascular risk. Furthermore, for total (P = .009) and cardiovascular (P = .09) mortality, the benefit of antihypertensive drug treatment weakened with advancing age; for total mortality (P = .05), the benefit increased with higher systolic BP at entry, while for fatal and nonfatal stroke (P = .01), it was most evident in nonsmokers (92.5% of all patients). In the perprotocol analysis, active treatment reduced total mortality by 24% (P = .05), reduced all fatal and nonfatal cardiovascular end points by 32% (P<.001), reduced all strokes by 44% (P = .004), reduced nonfatal strokes by 48% (P = .005), and reduced all cardiac end points, including sudden death, by 26% (P = .05).

CONCLUSIONS

In elderly patients with isolated systolic hypertension, stepwise antihypertensive drug treatment, starting with the dihydropyridine calcium channel blocker nitrendipine, improves prognosis. The per-protocol analysis suggested that treating 1000 patients for 5 years would prevent 24 deaths, 54 major cardiovascular end points, 29 strokes, or 25 cardiac end points. The effects of antihypertensive drug treatment on total and cardiovascular mortality may be attenuated in very old patients.

Effects of cardiac rehabilitation and beta-blocker therapy on heart rate variability after first acute myocardial infarction

After acute myocardial infarction (AMI), rehabilitation with physical training increases parasympathetic tone. It is unknown whether such a favorable effect of exercise on the sympathovagal balance interacts with effects of other widespread therapies, such as beta blockers. In 53 patients after a first, uncomplicated AMI, we studied the combined short- and long-term influence on heart rate variability (HRV) of rehabilitation and beta blockade. Patients were divided into 3 groups: group 1 (n = 19) underwent rehabilitation with physical training; group 2 (n = 20) was taking beta blockers and underwent rehabilitation; group 3 (n = 14) was taking beta blockers and did not enter the rehabilitation program for logistic reasons. Patients were similar as to age, site of infarction, ejection fraction, left ventricular diameter, and baseline stress test duration. Measures of HRV (obtained from a 15-minute resting electrocardiogram) were the standard deviation of the mean RR interval (RRSD), the mean squared successive differences (MSSD), the percent of RR intervals differing >50 ms from the preceding one (pNN50), the low-(LF) and high-(HF) frequency components of the autoregressive power spectrum of the RR intervals and their ratio (LF/HF). Four weeks after AMI, there was less sympathetic predominance in groups 2 and 3 (i.e., patients taking beta blockers [p <0.05]). Rehabilitation modified HRV in groups 1 and 2 (p <0.05), with signs of increased parasympathetic tone (group 1: MSSD +25%, pNN50 +69%, LF/HF -40%; group 2: MSSD +41%, pNN50 +48%, LF/HF -39%). These changes persisted in the long term. In group 3, HRV was unchanged over time. Hence, after AMI, the effects of rehabilitation and beta blockers on HRV are not redundant: their association induces a more favorable sympathovagal balance, accelerating the recovery of a normal autonomic profile.

[Ballistic data for plastic surgeons]

After a brief review of portable firearms or small caliber guns, the authors discuss various concepts concerning wound ballistics. Kinetic energy plays an important part in the damaging action of bullets, while the concepts of "shock wave" and "stopping power" have been supereded by the definition of wound profiles. These profiles are characteristic of each bullet. Clinically, they take the form of a temporary cavitation zone and a permanent cavity. The reaction of tissues crossed by the bullet largely depend on the elasticity of these tissues and the presence of bone. The concept of high velocity bullets should be abandoned. The phenomenon of cavitation alone and its dramatic clinical consequences should be taken into account and must guide the therapeutic approach.

[Gunshot injuries of the face. Clinical observations in 21 cases]

The authors report their experience of facial ballistic trauma based on a series of twenty one homogeneous cases. After a review of the aetiopathogenesis, the characteristics of facial shocks by missiles of fire arms are described, with particular emphasis on specific wounds encountered in the head and neck. Two classifications are suggested: on based on the main clinical features and the other based on the various types of bullets organized according to wound profiles and modern ballistics. This new ballistic classification is related to the clinical features. Although a better approach to ballistics and wound profiles helps to guide the clinical assessment, the medical and surgical treatments are based on same principles and approaches in war surgery and in civilian practice.

Clinical results of the Verapamil inHypertension and Atherosclerosis Study. VHAS Investigators

OBJECTIVE

The Verapamil in Hypertension and Atherosclerosis Study (VHAS) is a prospective randomized study the objective of which was to compare the long-term effects of verapamil and chlorthalidone on the blood pressure, clinical safety, and the progression/regression of carotid wall lesions in members of a large population of hypertensive patients.

DESIGN

After a 3-week placebo run-in period, 1414 hypertensive patients [692 men and 722 women, aged 53.2 +/- 7 years, blood pressure 168.9 +/- 10.5/ 102.2 +/- 5.0 mmHg (means +/- SD)] were assigned randomly to be administered either 240 mg sustained-release verapamil (n = 707) or 25 mg chlorthalidone (n = 707) once a day for 2 years. The study design was double blind for the first 6 months and open thereafter. 25-50 mg/day captopril were added to the treatment of non-responding patients; subsequently, patients not responding to combined therapy were switched to any therapy chosen by the treating doctors (free therapy). The blood pressure of the sitting subject, heart rate, and a standard clinical safety profile (electrocardiogram, laboratory tests, adverse events, cardiovascular events, and deaths) were assessed regularly throughout the study.

RESULTS

After 2 years the systolic and diastolic blood pressures were reduced significantly in members of both treatment groups (by 16.3/16.6% with verapamil and by 16.9/16.2% with chlorthalidone, both by analysis of variance, P < 0.0001). The patients for whom we added captopril treatment constituted 22.6% of the verapamil and 26.2% of the chlorthalidone group; while 11.6 and 12.2% of patients in these groups, respectively, were administered free therapy. Normalization of the diastolic blood pressure (to < or = 90 mmHg or to < or = 95 mmHg with a > or = 10% decrease) was achieved for 69.3% of the verapamil and 66.9% of the chlorthalidone group. A decrease in heart rate (by 5.8%) occurred in members of the verapamil group only. A decrease in total serum cholesterol (from 223.6 to 216.9 mg/dl, P < 0.01) and in the total cholesterol: high-density lipoprotein cholesterol ratio (from 4.9 to 4.5, P < 0.01) was noted for the verapamil group only, whereas significantly greater rates of hyperuricemia (plasma urate > 7.0 mg/dl; 10.8 versus 3.9%) and hypokalemia (serum K < 3.5 mmol/l; 24.6 versus 4.4%) were observed for the chlorthalidone group (P < 0.01, versus verapamil for both). Adverse events were reported by 32.5% of patients treated with verapamil and by 33.4% of those treated with chlorthalidone. The most frequent adverse events were constipation in members of the verapamil group (13.7%) and asthenia in members of the chlorthalidone group (8.5%). In total 315 dropped out (153 from the verapamil and 162 from the chlorthalidone group). The occurrence of cardiovascular events was similar for both treatments (42 events for verapamil and 43 for chlorthalidone, NS).

CONCLUSION

Similar antihypertensive efficacies, tolerabilities and cardiovascular event rates were observed with verapamil and with chlorthalidone. However, treatment with chlorthalidone was associated with significantly higher incidences of hyperuricemia and hypokalemia than was treatment with verapamil.

An effective approach for treating elderly patients with isolated systolic hypertension: results of an Italian multicenter study with fosinopril

Cardiovascular diseases are the most common causes of mortality, and hypertension is the most common cardiovascular disease in all ages. The Systolic Hypertension in the Elderly Program (SHEP) trial has shown that the pharmacologic reduction of isolated systolic hypertension can significantly reduce the incidence of cardiovascular complications. The aim of the Italian multicenter study reported here is to compare the efficacy, safety, and tolerability of fosinopril, a novel angiotensin converting enzyme (ACE) inhibitor with a dual route of excretion, with chlorthalidone, the diuretic administered in the SHEP study, in 312 elderly patients with isolated systolic hypertension. Our results show that fosinopril and chlorthalidone produce identical and statistically significant reductions in systolic blood pressure (-23.9 +/- 11.6 mm Hg and -23.7 +/- 10.9 mm Hg, respectively) and, to a lesser extent, in diastolic blood pressure (-7.1 +/- 3.1 mm Hg and -5.2 +/- 2.3 mm Hg, respectively). Only chlorthalidone caused a statistically significant change in uric acid, total cholesterol, blood urea, and serum potassium concentrations. Fosinopril was also somewhat better tolerated than chlorthalidone. In conclusion, the novel ACE inhibitor fosinopril is an effective and well-tolerated antihypertensive agent for use in elderly patients with isolated systolic hypertension and appears to be a suitable alternative for the treatment of isolated systolic hypertension.

Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators

BACKGROUND

Isolated systolic hypertension occurs in about 15% of people aged 60 years or older. In 1989, the European Working Party on High Blood Pressure in the Elderly investigated whether active treatment could reduce cardiovascular complications of isolated systolic hypertension. Fatal and non-fatal stroke combined was the primary endpoint.

METHODS

All patients (> 60 years) were initially started on masked placebo. At three run-in visits 1 month apart, their average sitting systolic blood pressure was 160-219 mm Hg with a diastolic blood pressure lower than 95 mm Hg. After stratification for centre, sex, and previous cardiovascular complications, 4695 patients were randomly assigned to nitrendipine 10-40 mg daily, with the possible addition of enalapril 5-20 mg daily and hydrochlorothiazide 12.5-25.0 mg daily, or matching placebos. Patients withdrawing from double-blind treatment were still followed up. We compared occurrence of major endpoints by intention to treat.

FINDINGS

At a median of 2 years' follow-up, sitting systolic and diastolic blood pressures had fallen by 13 mm Hg and 2 mm Hg in the placebo group (n = 2297) and by 23 mm Hg and 7 mm Hg in the active treatment group (n = 2398). The between-group differences were systolic 10.1 mm Hg (95% CI 8.8-11.4) and diastolic, 4.5 mm Hg (3.9-5.1). Active treatment reduced the total rate of stroke from 13.7 to 7.9 endpoints per 1000 patient-years (42% reduction; p = 0.003). Non-fatal stroke decreased by 44% (p = 0.007). In the active treatment group, all fatal and non-fatal cardiac endpoints, including sudden death, declined by 26% (p = 0.03). Non-fatal cardiac endpoints decreased by 33% (p = 0.03) and all fatal and non-fatal cardiovascular endpoints by 31% (p < 0.001). Cardiovascular mortality was slightly lower on active treatment (-27%, p = 0.07), but all-cause mortality was not influenced (-14%; p = 0.22).

INTERPRETATION

Among elderly patients with isolated systolic hypertension, antihypertensive drug treatment starting with nitrendipine reduces the rate of cardiovascular complications. Treatment of 1000 patients for 5 years with this type of regimen may prevent 29 strokes or 53 major cardiovascular endpoints.

Lack of effect of short-term lisinopril administration on left ventricular filling dynamics in hypertensive patients with diastolic dysfunction

Arterial hypertension may be associated with altered left ventricular filling dynamics. The specific goal of this study was to evaluate whether short-term administration of the ACE inhibitor lisinopril in hypertensive patients with an altered diastolic pattern induced an improvement of left ventricular dynamics, assessed by the echocardio-Doppler technique, independently of effects on left ventricular mass. In a double-blind cross-over study 39 essential hypertensive patients with a ratio of peak early to peak atrial velocity (E/A) < 1 were randomized, after a run-in period of 2 weeks without any antihypertensive treatment, to receive lisinopril (20 mg once a day) and placebo for 4 weeks, respectively. At the end of both the run-in and the treatment periods, blood pressure and heart rate were measured and an echocardio-Doppler examination was carried out. The echocardio-Doppler evaluation was performed both at rest and at the peak of a hand-grip test (3 min at 30% of maximal strength). Left ventricular dimensions were obtained from two-dimensionally guided M-mode tracings using the criteria of the American Society of Echocardiography. Left ventricular peak filling rates and filling rate integrals were measured by a pulsed Doppler technique. Lisinopril caused a significant reduction in systolic and diastolic blood pressure at rest (-13/-9 mmHg vs baseline values, p < 0.05; -6/-4 mmHg vs placebo values, p < 0.05) and during isometric exercise (-17/-9 mmHg vs baseline period, p < 0.05; -6/-5 mmHg vs placebo, p < 0.05). Lisinopril did not induce any significant change in left ventricular structure and systolic function. All the left ventricular filling parameters considered (E velocity, A velocity, E/A ratio) both at rest and during isometric exercise did not significantly differ after lisinopril treatment when compared to those obtained in basal conditions and after placebo administration. This double-blind cross-over study demonstrates that short-term afterload reduction induced by lisinopril does not modify altered diastolic dynamics in hypertensive patients. Diastolic dysfunction of the left ventricle is a complex process influenced by a number of functional and structural factors and apparently cannot be significantly improved by short-term blood pressure reduction by antihypertensive therapy.

Evidence of pin implantation as a means of verifying death during the Great Plague of Marseilles (1722)

The evidence obtained for the methods used in verification of death during the Great Plague of Marseilles in 1722 is presented here. This evidence was gathered during the excavation of a mass grave dating from this epidemic, and is based on two adjacent interments. The technique used at that time was the implantation of bronze pins into the toes. This method is precisely described in the medical treatises dating from this period, which list different death verification methods. The fear of "false death" and the burial of still living people characterized the end of the 17th and the 18th centuries. It should be noted that the main cause of apparent death is presented in the same medical treatises as the plague. This observation is the first anthropological evidence of the use of this forensic method to verify the fact of death.

Adults with childhood-onset growth hormone deficiency: effects of growth hormone treatment on cardiac structure

OBJECTIVES

To evaluate the effects of growth hormone deficiency (GHD) and of growth hormone (GH) therapy on cardiac structure in adults with childhood-onset GHD.

SETTING

Out-patient clinic in the Italian Institute for Auxology, Milan.

SUBJECTS

Eight adults with childhood-onset GHD and eight healthy controls, matched for sex, age, exercise and body mass index.

INTERVENTIONS

Recombinant GH (Saizen Serono, Italy), administered in a conventional dose of 0.5 IU kg-1 week-1 for 6 months.

MAIN OUTCOME MEASURES

Cardiac structure parameters, evaluated by two-dimensional, M-mode and Doppler echocardiograms, and stress test, by means of a modified Bruce protocol with a bicycle ergometer, were determined before and after 6 months GH therapy.

RESULTS

Before treatment, mean (+/- SE) intraventricular septal thickness (IVST: 7.1 +/- 0.2 mm), LV posterior wall thickness (LVPT: 5.2 +/- 0.1 mm), LV mass (LVM: 94.6 +/- 5.0 g), LV mass index (LVM/body surface area, LVMI: 65.1 +/- 3.0 g m-2) and left ventricular end-diastolic diameter (LVED: 41.4 +/- 0.6 mm) of patients were significantly lower (P < 0.01) than in controls, whilst LV end-systolic diameter (LVES) of patients (25.5 +/- 0.7 mm) was similar to controls (27.5 +/- 0.7). GH treatment significantly (P < 0.01) increased LVPT (6.8 +/- 0.2 mm), LVM (111.6 +/- 4.6 g) and LVMI (80.5 +/- 3.5 g m-2); no significant changes were observed in LVED, LVES and IVST values. The stress test showed a significant improvement of cardiac performance, as demonstrated by the reduction of blood pressure x heart rate product at the same workload (basal: 32,722.5 +/- 897.4 vs. after: 25,574.6 +/- 439.7).

CONCLUSIONS

GH plays a role in the maintenance of a normal cardiac structure in adulthood. The present study suggests that GH treatment might be able to improve the cardiac structure of patients with childhood-onset GHD.

Left ventricular concentric remodelling and carotid structural changes in essential hypertension

AIM

Left ventricular concentric remodelling defines a modified left ventricular geometry in the presence of a normal left ventricular mass; it is an early and frequent adaptation in arterial hypertension. The present study was designed to evaluate the extent of carotid structural changes in essential hypertensives with left ventricular remodelling.

PATIENTS AND METHODS

Two groups of hypertensive patients, who had never previously received anti-hypertensive treatment, 14 with left ventricular concentric remodelling (group I, relative wall thickness 0.48 +/- 0.02) and 48 with normal left ventricular geometry (group II, relative wall thickness 0.37 +/- 0.04) underwent clinical and laboratory examination, echocardiography, carotid artery ultrasonography and 24 h ambulatory blood pressure monitoring (ABPM). The left ventricular dimensions and mass were obtained according to the Penn convention. The intima-media thickness (IMT) of the posterior wall of both common carotid arteries was measured 5, 10 and 20 mm caudally to the bulb and the average value was used for analysis.

RESULTS

In both groups age (group I 44 +/- 9 years; group II 40 +/- 9 years), body surface area (group I 1.85 +/- 0.2 m2; group II 1.80 +/- 0.2 m2), duration of hypertension (group I 4.4 +/- 4; group II 3.8 +/- 3.9 years), metabolic parameters and smoking habits were similar. Both clinic and 24 h ABPM values were higher in group I (clinic 157 +/- 12/102 +/- 5; 24 h ABPM 145 +/- 10/95 +/- 7 mmHg) than they were in group II (clinic 146 +/- 11/97 +/- 5; 24 h ABPM = 134 +/- 10/87 +/- 8 mmHg, P < 0.01). The left ventricular mass index (LVMI) and IMT were found to be slightly but significantly greater in group I than they were in group II (LVMI 106 +/- 7 versus 98 +/- 12 g/m2, P < 0.05; IMT 0.68 +/- 0.13 versus 0.61 +/- 0.10 mm, P < 0.05). A significant correlation was found between LVMI and common carotid IMT in the whole group of hypertensive patients (r = 0.43, P < 0.01).

CONCLUSIONS

Our results indicate that left ventricular concentric remodelling does not represent the only early cardiovascular change in arterial hypertension but rather is associated often with carotid intima-media thickening.

Similarities and differences in structural and functional changes of left ventricle and carotid arteries in young borderline hypertensives and in athletes

OBJECTIVE

To investigate the association between increased left ventricular mass and the intima-media thickening of carotid arteries in hypertensive patients and the simultaneous involvement of the heart and the conductance vessels by the hypertensive process.

METHODS

Because no data are available concerning the ultrasonographic characteristics of large arteries in athletes with physiological increases in left ventricular mass, we measured the intima-media thickness (IMT) of the common carotid artery (CCA) in 14 normotensive subjects (group I, aged 22 +/- 4 years), in 14 borderline hypertensives (group II, aged 24 +/- 6 years) and in 14 Japanese wrestling players (group III, aged 23 +/- 4 years). The IMT of the posterior wall of the CCA was measured at 5, 10 and 20mm caudally to the bifurcation and the measurements were averaged. Left ventricular diameters and thicknesses of the interventricular septum and posterior wall were obtained from two-dimensionally guided M-mode tracings and measured according to the Penn convention. Left ventricular mass was calculated by the formula of Devereux. Left ventricular filling was measured by a pulsed Doppler technique.

RESULTS

Both systolic and diastolic blood pressure values were significantly higher in group II (145 +/- 7/91 +/- 5 mmHg) than they were in group I (116 +/- 11/75 +/- 5 mmHg) and in group III (120 +/- 8/78 +/- 6 mmHg). In athletes and hypertensives both the left ventricular mass index and the IMT of the CCA were significantly greater than they were in control subjects (80 +/- 12 g/m2 and 0.45 +/- 0.05 mm in group I; 106 +/- 15 g/m2 and 0.57 +/- 0.08 mm in group II; and 122 +/- 17 g/m2 and 0.55 +/- 0.05 mm in group III). The mitral early:late peak flow velocity ratio was significantly lower in group II (1.9 +/- 0.58) than it was in the other two groups (2.3 +/- 0.66 in group I and 2.6 +/- 0.64 in group III).

CONCLUSIONS

The results of our study suggest that both hypertension and physical training can induce parallel changes in cardiac and in arterial walls, and that physiological left ventricular hypertrophy in athletes is accompanied by a normal diastolic filling pattern in contrast to the pathological pattern found in hypertensives. Further investigation is required to explore possible differences in carotid structure and function between these two conditions.