Left ventricular mass assessed by electrocardiography and albumin excretion rate as a continuum in untreated essential hypertension

Hypertension in women: latest findings and clinical implications

Cardiovascular disease claims more women's lives than any other disease. Hypertension is an important risk factor for cardiovascular disease in women but is often underestimated and undiagnosed and there is an ongoing misperception that women are at a lower risk of cardiovascular disease than men. The attainment of clinical blood pressure goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive women have uncontrolled blood pressure. Furthermore, there are special risk factors that are unique for women that needs acknowledgement in order to help prevent the great number of hypertension-related events in women. Guidelines for treatment of hypertension are similar for men and women. More studies on the interaction between gender and response to antihypertensive drugs would be of interest.

Biliary pancreatic diversion and laparoscopic adjustable gastric banding in morbid obesity: their long-term effects on metabolic syndrome and on cardiovascular parameters

Background

Bariatric surgery is able to improve glucose and lipid metabolism, and cardiovascular function in morbid obesity. Aim of this study was to compare the long-term effects of malabsorptive (biliary pancreatic diversion, BPD), and restrictive (laparoscopic gastric banding, LAGB) procedures on metabolic and cardiovascular parameters, as well as on metabolic syndrome in morbidly obese patients.

Methods

170 patients studied between 1989 and 2001 were called back after a mean period of 65 months. 138 patients undergoing BPD (n = 23) or LAGB (n = 78), and control patients (refusing surgery and treated with diet, n = 37) were analysed for body mass index (BMI), blood glucose, cholesterol, and triglycerides, blood pressure, heart rate, and ECG indexes (QTc, Cornell voltage-duration product, and rate-pressure-product).

Results

After a mean 65 months period, surgery was more effective than diet on all items under evaluation; diabetes, hypertension, and metabolic syndrome disappeared more in surgery than in control patients, and new cases appeared only in controls. BPD was more effective than LAGB on BMI, on almost all cardiovascular parameters, and on cholesterol, not on triglyceride and blood glucose. Disappearance of diabetes, hypertension, and metabolic syndrome was similar with BPD and with LAGB, and no new cases were observed.

Conclusion

These data indicate that BPD, likely due to a greater BMI decrease, is more effective than LAGB in improving cardiovascular parameters, and similar to LAGB on metabolic parameters, in obese patients. The greater effect on cholesterol levels is probably due to the different mechanism of action.

From treatment to organ damage; a 5-year follow-up study of ambulatory blood pressure in essential hypertension. Diversity between development of left ventricular hypertrophy and urinary albumin excretion

This study aimed to assess blood pressure (BP) profile, BP control, left ventricular hypertrophy (LVH) and albumin/creatinine ratio (ACR) in urine after 5 years of antihypertensive treatment in subjects with newly diagnosed essential hypertension. Fifty-four subjects were included and prescribed calcium-channel blocker in monotherapy during an 8-week period, and later 46 subjects (34 men, 12 women, 53.1+/-8.6 years) attended a 5-year follow-up visit at the hypertension clinic. They underwent 24-h ambulatory BP monitoring (ABPM), ECG and ACR at baseline and after 5 years. Echocardiography performed after 5 years revealed LVH in 54% of the subjects, while there was no change in Cornell product, an ECG criterion for LVH. BP control assessed by office BP was 33%, and only 20% using 24-h ABP. Night-time fall in BP was significantly attenuated from 13.2+/-5.9% to 10.7+/-6.0%, p = 0.01 for systolic BP and from 13.3+/-6.9% to 9.8+/-6.8%, p = 0.004 for diastolic BP. The number of dippers decreased after 5 years, but this did not reach statistical significance. In contrast to the lack of change in Cornell product, there was a significant decrease in ACR, and 93% of the subjects had ACR<1.5 mg/mmol after 5 years compared with 57% at baseline (p<0.001). Thus, ABPM should be encouraged in the follow-up of all hypertensive subjects as it reveals better inadequate BP control than office BP and gives information about night-time fall, as this may explain the high prevalence of LVH. The diversity in development of LVH and ACR during antihypertensive treatment needs to be verified.

Night-time blood pressure patterns and target organ damage: a review

BACKGROUND

Individuals who do not have a 10% to 20% reduction in blood pressure (BP) during the night are known as 'nondippers'. The cause of this nondipping phenomenon is not fully understood; however, there is a growing body of evidence linking a nondipping BP pattern with target organ damage.

OBJECTIVE

To review the literature and present an overview of the target organ damage found to be associated with a nondipping BP pattern.

METHODS

PubMed, CINAHL and Medscape searches of all available English language articles from 1986 to 2005 were performed. Search terms included 'BP nondipping', 'BP dipping' and 'target organ damage'.

RESULTS

There is evidence to suggest that individuals with hypertension who exhibit a nondipping BP profile are at higher risk of cardiac and extracardiac morbidity and mortality. In particular, nondippers with essential hypertension have been found to have more advanced left ventricular hypertrophy, left ventricular mass and left ventricular mass index, carotid artery wall thickness, carotid artery atherosclerotic plaques, silent cerebral infarct, stroke, cognitive impairment and microalbuminuria.

CONCLUSION

A better understanding of the importance of the circadian variations of BP may help to identify those at higher risk of cardiovascular morbidity and mortality, as well as lay the foundation for interventions to prevent/treat alterations in night-time BP patterns.

Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients: losartan intervention for endpoint reduction in hypertension study

Few data are available to clarify whether changes in albuminuria over time translate to changes in cardiovascular risk. The aim of the present study was to examine whether changes in albuminuria during 4.8 years of antihypertensive treatment were related to changes in risk in 8206 patients with hypertension and left ventricular hypertrophy in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. Urinary albumin/creatinine ratio (UACR) was measured at baseline and annually. Time-varying albuminuria was closely related to risk for the primary composite end point (ie, when UACR decreased during treatment, risk was reduced accordingly). When the population was divided according to median baseline value (1.21 mg/mmol) and median year 1 UACR (0.67 mg/mmol), risk increased stepwise and significantly for the primary composite end point from those with low baseline/low year 1 (5.5%), to low baseline/high year 1 (8.6%), to high baseline/low year 1 (9.4%), and to high baseline/high year 1 (13.5%) values. Similar significant, stepwise increases in risk were seen for the components of the primary composite end point (cardiovascular mortality, stroke, and myocardial infarction). The observation that changes in UACR during antihypertensive treatment over time translated to changes in risk for cardiovascular morbidity and mortality was not explained by in-treatment level of blood pressure. We propose that monitoring of albuminuria should be an integrated part of the management of hypertension. If albuminuria is not decreased by the patient's current antihypertensive and other treatment, further intervention directed toward blood pressure control and other modifiable risks should be considered.

Left ventricular hypertrophy and QT interval in obesity and in hypertension: effects of weight loss and of normalisation of blood pressure

BACKGROUND

Left ventricular hypertrophy (LVH) and prolonged QT interval at ECG (QTc) are common in both obesity and arterial hypertension (AH), and are risk factors for cardiovascular disease and sudden death.

METHODS

We compared the frequencies of LVH (ECG criteria) and QTc in obese-AH (n=41), in normotensive obese (n=75), in lean-AH (n=30), and in lean controls (n=68) comparable for age and sex; in obese patients, LVH and QTc were evaluated under basal conditions and 1 y later, that is, after a significant weight loss induced by bariatric surgery.

RESULTS

LVH was more frequent, and QTc was longer, in obese-AH, in normotensive obese, and in lean-AH than in lean controls; after weight loss, frequency of LVH decreased in obese subjects becoming normotensive (n=87), not in obese subjects remaining hypertensive (n=29), while QTc decreased in all obese subjects.

CONCLUSION

Weight loss can effectively reduce QTc; when concomitant AH disappears, weight loss can also reduce the prevalence of LVH. In obese patients remaining hypertensive, aggressive pharmacological treatment is therefore indicated to correct LVH.

Outcome studies in diabetic nephropathy

Outcome studies in diabetic nephropathy have focused on strategies to prevent progression of diabetic nephropathy, the leading cause of ESRD in the United States. Once diabetics develop overt nephropathy, prognosis is poor. Risk factors for diabetic nephropathy are discussed, and include hyperglycemia, hypertension, angiotensin II, proteinuria, dyslipidemia, smoking, and anemia. Major outcomes as well as outcome studies in diabetic nephropathy for patients with microalbuminuria and macroalbuminuria are reviewed. Furthermore, the role of therapy with angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, and mineralocorticoid receptor antagonists as well as selected combination therapy are discussed. Recommendations for therapy with ace inhibitors and angiotensin II receptor blockers are made based on this evidence.

Relationship between microalbuminuria and cardiac structural changes in mild hypertensive patients

The aim of this study was to determine the relationship between urinary albumin excretion (UAE), cardiac structural changes upon echocardiography and 24-h ambulatory blood pressure (ABPM) levels. Twenty mild hypertensive patients (mean age 56.8 +/- 9.6 years) were evaluated. After 2 weeks of a washout period of all antihypertensive drugs, all patients underwent an echocardiographic evaluation, a 24-h ABPM and an overnight urine collection. Systolic and diastolic blood pressure during 24-h ABPM was 145 +/- 14/91 +/- 10 mmHg (daytime) and 130 +/- 14/76 +/- 8 mmHg (nighttime), respectively. Seven (35%) patients presented UAE > or = 15 microg/min, and for the whole group, the geometric mean value for UAE was 10.2 x// 3.86 microg/min. Cardiac measurements showed mean values of interventricular septum thickness (IVS) of 11 +/- 2.3 mm, left ventricular posterior wall thickness (PWT) of 10 +/- 2.0 mm, left ventricular mass (LVM) of 165 +/- 52 g, and left ventricular mass index (LVMI) of 99 +/- 31 g/m2. A forward stepwise regression model indicated that blood pressure levels did not influence UAE. Significant correlations were observed between UAE and cardiac structural parameters such as IVS (r = 0.71, P<0.001), PWT (r = 0.64, P<0.005), LVM (r = 0.65, P<0.005) and LVMI (r = 0.57, P<0.01). Compared with normoalbuminuric patients, those who had microalbuminuria presented higher values of all cardiac parameters measured. The predictive positive and negative values of UAE > or = 15 microg/min for the presence of geometric cardiac abnormalities were 75 and 91.6%. These data indicate that microalbuminuria in essential hypertension represents an early marker of cardiac structural damage.