Extracardiac Target Organ Damage Research Articles

«Гіпертензія білого халата»: сучасний стан проблеми

Від першого описання в науковій літературі поняття «гіпертензія білого халата» пройшло понад 30 років, але відтоді все більше уваги вчені приділяють цьому стану. «Гіпертензію білого халата» констатують у випадку, коли показники артеріального тиску, визначеного в кабінеті лікаря, відповідають критеріям артеріальної гіпертензії, але остання не підтверджується показниками амбулаторного або домашнього моніторування артеріального тиску. Спочатку цей термін відносили лише до пацієнтів, які не отримували антигіпертензивного лікування, але нещодавно це визначення поширили й на осіб, які регулярно приймають ліки, що знижують артеріальний тиск, і цей стан отримав назву «неконтрольована гіпертензія білого халата». Одні з найвпливовіших організацій світу у галузі кардіології не дійшли консенсусу щодо єдиних критеріїв визначення «гіпертензії білого халата», що призвело до розбіжностей порогових значень артеріального тиску за даними амбулаторного моніторування. Доволі багато досліджень минулих років були присвячені вивченню клінічної та прогностичної значущості «гіпертензії білого халата» відносно таких наслідків, як метаболічні розлади, субклінічні й екстракардіальні ураження органів-мішеней, серцево-судинної захворюваності та смертності, а також смертності загалом. На теперішній час безсумнівним є той факт, що «гіпертензія білого халата» – це стан, який потребує корекції; однак досі спірними є гіпотези стосовно прогностичної ролі цього стану та ведення таких пацієнтів. Питання щодо лікування «гіпертензії білого халата» як стану залишається відкритим і потребує подальшого вивчення. Сьогодні вважається доцільним для осіб, у яких показники офісного артеріального тиску в нормі або нижчі від цільових, не призначати антигіпертензивне лікування, а інтенсифікувати модифікацію способу життя та скерувати всі зусилля на зниження серцево-судинного ризику.

Electrocardiography for Assessment of Hypertensive Heart Disease: A New Role for an Old Tool

Left ventricular (LV) hypertrophy (LVH), detected either by electrocardiography (ECG) or echocardiography (ECHO), has long been recognized as a powerful predictor of serious cardiovascular (CV) sequelae. A very large and highly consistent body of evidence indicates that LVH is not only an adaptation to increased hemodynamic load in hypertension, but is also independently associated with an enhanced risk for myocardial infarction, cardiac sudden death, congestive heart failure, and stroke in the general population, as well as in patients with systemic hypertension, coronary heart disease, chronic kidney disease, and atrial fibrillation. Intriguingly, the cumulative incidence of cardiovascular events increases progressively with increasing LV mass (LVM), without evidence of any threshold separating the postulated “compensatory” from “pathological” LVH. In other words, patients with LVM in the upper-normal range already have increased risk for CV events. Moreover, various studies suggest that LVH reversal is beneficial beyond blood pressure (BP) reduction and treatment by demonstrating that CV events occur in a higher proportion of individuals in whom LVH progresses rather than regresses. There are several determinants for the development of LVH. Hemodynamic factors such as BP, large artery structure and stiffness, and volume load are important. In addition, nonhemodynamic mechanisms such as trophic factors mediated by the sympathetic nervous system, the renin-angiotensin-aldosterone system, and other neurohormonal mediators play an important role in the development of LVH. ECHO is more sensitive than ECG in diagnosing LVH and may help in the more precise stratification of overall risk and in the determination of therapy for hypertensive patients. Furthermore, ECHO measurement of LV cavity size and of myocardial relative wall thickness allows the assessment of LV geometry. The traditional classification of LV geometry in hypertensive heart disease comprised the condition of normal LVM and geometry and three abnormal LV geometric patterns: concentric LV remodeling, eccentric LVH, and concentric LVH. These LV geometric patterns have been associated with different demographic and clinical characteristics including age, sex, metabolic factors, BP levels, LV systolic and diastolic function, hemodynamic profile, extracardiac target organ damage, and CV morbidity and mortality. In particular, it has been reported that concentric LVH, connoting severe pressure overload, is associated with worse outcome than eccentric LVH or concentric remodeling. However, whether abnormal LV geometric patterns carry prognostic information beyond that provided by LV mass remains uncertain. More recently, the investigators of the Dallas Heart Study (DHS) refined this classification of hypertensive LV geometric abnormalities by introducing the concept that LVH could exist in dilated or nondilated forms, adding concentric dilated and nondilated as well as eccentric dilated and nondilated subtypes. The authors of the DHS suggested that eccentric LVH with no dilatation appeared to provide a lower risk for coronary artery disease and myocardial function impairment than in the remaining three groups of cardiac hypertrophy. However, this cross-sectional study did not present results on outcome, and the subsequent prospective investigations yielded conflicting results regarding the prognostic role of these new subtypes of LV geometric abnormalities. Nevertheless, the correct indication for ECHO in hypertensive patients is still a matter of debate. Indeed, advocating ECHO for the assessment of LVH in all hypertensive individuals would have enormous cost implications, as a result of the high number of patients. This imaging modality is more time-consuming than ECG and requires considerable skill to perform. Even though more accurate and sophisticated modalities to diagnose LVH exist, such as ECHO, computerized tomography, magnetic resonance, and, more recently, three-dimensional ECHO, ECG remains the first-choice technique to diagnose LVH in patients with hypertension because it is widely available, easy to perform, specific, inexpensive, reproducible, and of established prognostic value. ECG can also be used to detect patterns of ventricular overload or “strain” (known to indicate more severe risk), ischemia, conduction defects, and arrhythmias. Current guidelines for the management of hypertension strongly recommend ECG as the only examination to be performed in all hypertensive patients for detection of LVH. Even if ECG assessment of LVH has been incorporated among standard tests in hypertension guidelines, a recent Italian survey showed that such a recommendation is largely ignored in current clinical practice. Indeed, in this survey, <40% of the study sample had Address for correspondence: Giuseppe Mul e’, MD, Via Monte San Calogero, 29 90146 Palermo, Italy E-mail: giuseppe.mule@unipa.it

Blood Pressure, Heart Rate Variability, and Renal Function in Nonsmoker and Smoker Hypertensive Patients.

Blood Pressure, Heart Rate Variability, and Renal Function in Nonsmoker and Smoker Hypertensive Patients.

How to identify hypertensive patients at high cardiovascular risk? The role of echocardiography.

Scientific authorities recommend that patients with arterial hypertension should be managed not only on the basis of blood pressure (BP) levels, but also on the assemement of total cardiovascular risk. In particular, evaluation of target organ damage (TOD) is of major relevance for identifying hypertensive individuals at high cardiovascular risk independently of clinic BP levels. Evidence of cardiac and extra-cardiac TOD has been consistently associated with worse cardiovascular prognosis. Unfortunately, detection of TOD markedly depends on sensitivity of diagnostic tools, at difference from evaluation of risk factors and associated diseases, usually reliably provided by accurate clinical examination and routine investigation. The purpose of this paper was to provide an updated, comprehensive review on the role of echocardiography in identifying hypertensive patients apparently uncomplicated, but exposed to a high cardiovascular risk due to the presence of subclinical structural and functional cardiac alterations of adverse prognostic significance.

Metabolic syndrome and multiple organ damage in essential hypertension

ObjectiveTo investigate the influence of the metabolic syndrome (MS) on essential hypertention-related target organ damage (TOD), and assess the value of a systematic search for cardiac and extra-cardiac TOD in...

Lack of Association Between Serum Uric Acid and Organ Damage in a Never-Treated Essential Hypertensive Population at Low Prevalence of Hyperuricemia

It is still undefined whether serum uric acid (SUA) is an independent risk factor for target organ damage (TOD) and cardiovascular events in human hypertension. We sought to investigate the association of SUA with subclinical cardiac, vascular, and renal alterations in never-treated uncomplicated essential hypertensives. A total of 580 subjects with recently diagnosed (<1 year) grade 1 and 2 hypertension, categorized by sex and tertiles of SUA levels, were considered for this analysis. All subjects underwent extensive clinical, laboratory, and ultrasonographic investigations searching for cardiac and extracardiac TOD. Hyperuricemia (SUA >7.0 mg/dL in men and >6 mg/dL in women) was present in 8.3% of the patients. The overall prevalence of left-ventricular hypertrophy (LVH), carotid alterations, and microalbuminuria was 28%, 27%, and 8%, respectively. No differences in the prevalence rates of these TOD markers were present across all SUA tertiles in the entire population, as well as in both sexes. The SUA levels were similar in patients with and without LVH, carotid alterations, or microalbuminuria. When patients were classified according to the number of organs involved, those with multiple TOD (2 or 3 organs) had significantly higher SUA levels (5.1 +/- 1.3 or 5.2 +/- 1.4 mg/dL), as compared with those with a single or no organ involvement (4.9 +/- 1.3 or 4.9 +/- 1.4 mg/dL, P < .05). The association, however, between SUA levels and multiple TOD was not confirmed in a logistic regression analysis. Our findings do not support the role of SUA as an independent risk factor for subclinical TOD in a selected population of recently diagnosed uncomplicated hypertensives at low prevalence of hyperuricemia.

Ambulatory blood pressure, target organ damage and aortic root size in never-treated essential hypertensive patients

The relationship between ambulatory blood pressure (ABP), target organ damage (TOD) and aortic root (AR) size in human hypertension has not been fully explored to date. We investigated the relationship between ABP, different markers of TOD and AR size in never-treated essential hypertensive patients. A total of 519 grade 1 and 2 hypertensive patients (mean age 46+/-12 years) referred for the first time to our outpatient clinic underwent the following procedures: (1) routine examination, (2) 24 h urine collection for microalbuminuria (MA), (3) ambulatory blood pressure monitoring over two 24 h periods within 4 weeks, (4) echocardiography and (5) carotid ultrasonography. AR dilatation was defined by sex-specific criteria (> or =40 mm in men and > or =37 mm in women). AR diameter was increased in 3.7% of patients. Demographic variables (body mass index, age and male gender), average night-time diastolic blood pressure (BP) (but not clinic or average 48 h BP), left ventricular mass index and carotid intima-media (IM) thickness showed an independent association with AR size in both univariate and multivariate analyses. When TOD data were analysed in a categorical way, a stepwise increase in the prevalence of left ventricular hypertrophy (LVH) (I=17.5%, II=27.6%, III=35.8%) and carotid IM thickening (I=20.9%, II=28.8%, III=34.4%), but not in MA (I=6.8%, II=9.1%, III=8.7%) was found with the progression of AR size tertiles. Our results show that (1) AR enlargement in uncomplicated never-treated hypertensive patients has a markedly lower prevalence than traditional markers of cardiac and extracardiac TOD; (2) night-time BP, LVH and carotid IM thickening are independent predictors of AR dimension.

Short-term reproducibility of a non-dipping pattern in type 2 diabetic hypertensive patients

Little information is available on the reproducibility of nocturnal variations in blood pressure in type 2 diabetic hypertensive patients. We aimed to compare the intrasubject short-term reproducibility of a nocturnal non-dipping pattern and the prevalence of cardiac and extracardiac signs of target organ damage, in a group of type 2 diabetic hypertensive patients and in an age/gender-matched group of non-diabetic hypertensive subjects. Thirty-six treated hypertensive patients with long-lasting type 2 diabetes (> 10 years duration) consecutively attending our hospital out-patient hypertension clinic (group I; mean age, 65 +/- 9 years), and 61 untreated non-diabetic subjects with grade 1 and grade 2 uncomplicated essential hypertension, matched for age and gender, and chosen from patients attending an outpatient clinic (group II; mean age, 65 +/- 5 years), were considered for this analysis. All patients underwent blood sampling for routine blood chemistry, 24-h urine collection for microalbuminuria, two 24-h periods of ambulatory blood pressure monitoring (ABPM) within a 4-week period, echocardiography, and carotid ultrasonography. A dipping pattern was defined as a greater than 10% reduction in the average systolic and diastolic blood pressure at night compared with average daytime values. A reproducible nocturnal dipping and non-dipping profile was found in 11 (30.6%) and 21 (58.3%) diabetic patients, respectively; while only in four (11.1%) patients was a variable dipping profile observed. Of the 23 patients with a non-dipping pattern during the first ABPM period, 21 (91.3%) also had this type of pattern during the second ABPM recording. In group II (non-diabetic hypertensive patients), 30 patients (49.2%, P < 0.05) had a dipping pattern, 13 patients (21.3%, P < 0.01) had a non-dipping profile pattern and 18 patients (29.5%, P < 0.01) had a variable dipping pattern. Of the 20 patients with a non-dipping pattern during the first ABPM period, 13 (65.0%) confirmed this type of pattern during the second ABPM recording. Finally, the prevalence of left ventricular hypertrophy (77.7 versus 41.4%, P < 0.01), carotid plaques (80.5 versus 38.3%, P < 0.01), carotid intima-media thickening (54.3 versus 44.0%, P < 0.05) and microalbuminuria (11.1 versus 2.0%, P < 0.01) was significantly higher in group I than in group II. According to a logistic regression analysis, diabetes, left ventricular hypertrophy and carotid plaques were the main independent predictors of the non-dipping (pattern in the overall population. These findings indicate that intrasubject variability of non-dipper pattern is lower in diabetic than in non-diabetic hypertensive patients, that classification of diabetic hypertensive patients as dipper or non-dipper on the basis of a single ABP recording is more reliable than in non-diabetic patients, and that the more frequent and reproducible non-dipping (pattern in diabetic patients is associated with a more prominent cardiac and extracardiac target organ damage.

Prevalence and correlates of aortic root dilatation in patients with essential hypertension: relationship with cardiac and extracardiac target organ damage

To assess the prevalence of aortic root dilatation in a large cohort of uncomplicated hypertensive patients and to evaluate the relations of aortic root size to different markers of cardiac and extracardiac target organ damage (TOD). A total of 3366 untreated and treated essential hypertensive patients (mean age, 53 +/- 12 years) consecutively attending our out-patient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension (an observational ongoing registry of hypertension-related TOD) were considered for this analysis. All patients underwent routine examinations, 24-h urine collection for microalbuminuria, echocardiography and carotid ultrasonography. Aortic root dilatation, defined by the sex-specific echocardiographic criteria of 40 mm in men and 38 mm in women, was present in 8.5% of men and in 3.1% of women. Compared with 3160 patients with normal aortic size, the group of 206 patients with an enlarged aortic root was older, had higher diastolic blood pressure values and included a greater fraction of subjects under antihypertensive treatment, with type 2 diabetes and metabolic syndrome. The prevalence of left ventricular hypertrophy, carotid intima-media thickening, plaques and microalbuminuria was significantly higher in patients with aortic root dilatation. According to a logistic regression analysis, left ventricular hypertrophy, carotid atherosclerosis, overweight and metabolic syndrome were the main independent and potentially modifiable predictors of aortic root dilatation in the whole hypertensive population as well as in untreated and treated hypertensive patients separately. Our study shows that hypertensive patients with aortic root enlargement have more pronounced alterations in cardiac structure and geometry as well as in carotid artery morphology compared with those without the enlargement. Aortic root dilatation therefore appears to be a useful marker of high cardiovascular risk related to TOD. Whether this alteration independently predicts cardiovascular morbidity remains to be proven.

Isolated ambulatory hypertension and changes in target organ damage in treated hypertensive patients

Isolated ambulatory hypertension is a condition characterized by elevated ambulatory but normal clinic blood pressure (BP), and has been reported to be associated with increased cardiovascular risk in untreated subjects. However, little is known about the relationship between this condition and intermediate end points such as target organ damage (TOD) in treated hypertensives. We investigated the impact of isolated ambulatory hypertension on left ventricular hypertrophy (LVH) and microalbuminuria (MA) in a selected sample of treated nondiabetic hypertensives with effective and prolonged clinic BP control (BP<140/90 mmHg). Clinic BP measurements, routine diagnostic procedures, echocardiography and 24-h urine collection for MA, were undertaken in 80 patients (mean age 53+/-8 years) with essential hypertension attending our hospital outpatient centre at baseline and after an average follow-up of 30 months. At follow-up evaluation BP status was assessed by self-measurement of BP and ambulatory BP monitoring (ABPM). At the follow-up visit, 51 out of 80 patients (63.7%) reached a BP control according to ABP (average daytime BP<132/85 mmHg) criteria (group I) whereas the remaining 29 did not (group II); home BP was controlled (BP<135/85 mmHg) in all members of group I and in 86% of group II. In the overall study population, mean Sokolow voltage, LV mass index (LVMI) and urinary albumin excretion (UAE) decreased compared to baseline from 24.1+/-5.0 to 18.9+/-5.1 mm (P<0.05), 115.6+/-24.1 to 97.7+/-21.6 g/m(2) (P<0.01), 11.8+/-23.7 to 5.8+/-14.9 mg/24 h (P<0.05), respectively. The prevalence of ECG LVH, altered LV patterns and MA fell from 7.5 to 2.5% (P=NS), from 45 to 25 (P<0.01) and from 13.7 to 5.1% (P<0.05), respectively. However, when data were analysed separately for the two groups a significant decrease of echo LVH and MA was found only in patients with controlled ABP. LVMI and MA decreased from 117.1+/-23.1 to 95.9+/-22.1 g/m(2) (P<0.01) and 12.8+/-24.7 to 4.1+/-5.7 mg/24 h (P<0.05) in group I, and from 114.1+/-24.8 to 102.3+/-20.3 (P=NS) and 11.9+/-22.1 to 6.3+/-18.1 mg/24 h (P=NS) in group II. In conclusion, in the present study isolated ambulatory hypertension in treated patients is associated with a lack of regression in cardiac and extracardiac TOD, suggesting that a tight BP control throughout the 24 h plays a key role in lowering hypertension-induced structural and functional alterations at cardiac and renal level.

Retinal microvascular changes and target organ damage in untreated essential hypertensives.

The clinical and prognostic significance of initial retinal alterations in hypertensive patients remains controversial. Therefore, we assessed the relationship of microvascular abnormalities with prognostically validated markers of target organ damage (TOD), such as left ventricular mass (LVM), carotid intima-media thickness (IMT) and microalbuminuria, in early stages of untreated essential hypertension. A total of 437 consecutive, never-treated patients with grade 1 or 2 essential hypertension, referred to our outpatient clinic, underwent the following procedures: (1) clinical and routine laboratory examinations, (2) 24-h ambulatory blood pressure monitoring, (3) 24-h urine collection for microalbuminuria, (4) echocardiography, (5) carotid ultrasonography, (6) non-mydriatic retinography. Patients were divided into group I, with either a normal retinal pattern (n=65, 14.9%) or arteriolar narrowing (n=185, 42.4%) and group II with arteriovenous crossings (n=187, 42.7%). The two groups were similar for gender, body mass index, smoking habit, heart rate, clinic and ambulatory blood pressure (BP) values, while mean age was slightly but significantly higher in group II than in group I (47.6 +/- 10.7 versus 44.5 +/- 12.5 years, P=0.008). No differences occurred between the two groups in LVM index (101.8 +/- 18.5 versus 99.9 +/- 20.4 g/m), carotid IMT (0.67 +/- 0.12 versus 0.66 +/- 0.20 mm), urinary albumin excretion rate (14.4 +/- 27.7 versus 13.3 +/- 27.7 mg/24 h) as well as in the prevalence of LV hypertrophy (14.3 versus 14.0%), IM thickening and/or plaques (26.5 versus 27.2%) (both defined according to 2003 ESH-ESC guidelines) and microalbuminuria (10.1 versus 8.7%). Furthermore, the three different retinal artery patterns were similarly distributed among tertiles of LV mass index, IMT and urinary albumin excretion rate. These results show that: (1) a very large fraction (more than 80%) of untreated, recently diagnosed hypertensive patients have initial retinal microvascular abnormalities detectable by non-mydriatic retinography, (2) the presence of arteriovenous crossings is not associated with more prominent cardiac and extracardiac TOD, (3) fundoscopic examination has a limited clinical value to detect widespread organ involvement in early phases of grade 1 and 2 hypertension.

Cardiovascular target organ damage in essential hypertensives with or without reproducible nocturnal fall in blood pressure.

The clinical significance of classifying patients as dippers and non-dippers on the basis of a single period of ambulatory blood pressure monitoring (ABPM) has been questioned. The aim of this study was to evaluate the relationship between nocturnal dipping status, defined on the basis of two periods of ABPM, and cardiac and extracardiac target organ damage in essential hypertension. A total of 375 never-treated essential hypertensive patients [mean 24-h blood pressure (BP) > or = 125/80 mmHg; mean +/- SD age 45.9 +/- 11.9 years] referred for the first time to our outpatient clinic underwent the following procedures: (i) repeated clinic BP measurements; (ii) blood sampling for routine chemistry examinations; (iii) 24-h urine collection for microalbuminuria; (iv) ABPM over two 24-h periods within 4 weeks; (v) echocardiography; and (vi) carotid ultrasonography. A reproducible nocturnal dipping (decrease in BP > 10% from mean daytime BP in both ABPM periods) and non-dipping profile (decrease in BP < or = 10% in both ABPM periods) was found in 199 (group I) and 79 patients (group II), respectively; 97 patients (group III) had a variable dipping profile. The three groups did not differ with regard to age, gender, body mass index, clinic BP, 48-h BP and heart rate. Left ventricular mass index, interventricular septum thickness, left atrium and aortic root diameters were significantly higher in group II compared with group I (mean +/- SD 108.5 +/- 19.5 versus 99.7 +/- 19.6 g/m, P < 0.05; 9.3 +/- 0.9 versus 9.1 +/- 0.9 mm, P < 0.05; 33.6 +/- 3.6 versus 32.2 +/- 3.7 mm, P < 0.01; 36.9 +/- 4.6 mm versus 35.5 +/- 4.6, P < 0.05, respectively). The smaller differences seen between groups II and III and between groups I and III were not statistically significant. The prevalence of left ventricular hypertrophy (defined as a left ventricular mass index > 134 g/m in men and > 110 g/m in women) was greater in group II (19%) than in group I (6%) (P < 0.05), whereas the differences between groups II and III and between groups I and III did not reach statistical significance. Differences among the three groups in the prevalence of carotid structural alterations (such as carotid plaques or intima-media thickening) were not statistically significant, and microalbuminuria had a similar prevalence in all three groups. Despite similar clinic and 48-h BP values, never-treated hypertensive patients with a persistent non-dipper pattern showed a significantly greater extent of cardiac structural alterations compared with subjects with a reproducible dipping pattern, but not those with a variable BP nocturnal profile. A non-dipping pattern diagnosed on two concordant ABPM periods instead of a single monitoring therefore represents a clinical trait associated with more pronounced cardiac abnormalities. Finally, in non-dipping middle-aged hypertensives, echocardiography appears to provide a more accurate risk stratification than carotid ultrasonography or microalbuminuria.

High prevalence of retinal vascular changes in never‐treated essential hypertensives: an inter‐ and intra‐observer reproducibility study with non‐mydriatic retinography

Background: The clinical significance of stratifying cardiovascular risk in hypertensive patients on the basis of retinal changes such as arteriolar narrowing or arterio‐venous crossing has been criticized. Aim: Objectives of the study were: (i) to compare the prevalence of retinal abnormalities detected by non‐mydriatic retinography with that of other quantitative markers of target organ damage (TOD), such as echocardiographically determined left ventricular hypertrophy (LVH), carotid structural abnormalities and microalbuminuria in recently diagnosed and never treated hypertensives; (ii) to assess the inter‐ and intra‐observer reproducibility in evaluating retinal microvascular changes. Methods: One hundred ninety‐seven grade 1 (73%) and grade 2 essential hypertensives (119 males; mean age 46.8 ± 12.0 years, duration of hypertension: 2.3 ± 1.8 years) referred for the first time to our outpatient hypertension hospital clinic were subjected to the following procedures: (i) repeated clinic blood pressure (BP) measurements; (ii) electrocardiogram; (iii) routine blood chemistry and urinalysis; (iv) 24‐h urine collection for microalbuminuria; (v) 24‐h ambulatory BP monitoring; (vi) non‐mydriatic retinography; (vii) echocardiogram; (viii) carotid ultrasonography. Retinal changes were evaluated according to a modified Keith, Wagener and Barker (KWB) classification by two physicians, who had no knowledge of the patients' characteristics. These following markers of TOD were considered: (i) left ventricular mass index ≥125 g/m2in men and ≥110 g/m2in women; (ii) at least one carotid plaque (focal thickening >1.3 mm) or diffuse common carotid thickening (≥0.9 mm); (iii) microalbuminuria (urinary albumin excretion ≥30 and <300 mg/24 h). Results: The prevalence rates of LVH, carotid structural alterations and microalbuminuria were 12.9, 26.0 and 8.6% respectively; while the distribution of patients in the different degrees of hypertensive retinopathy made by two independent readers (1 and 2) was: 0 = 15.2, I = 25.4, II = 58.9, III = 0.5% (1); 0 = 14.7, I = 27.9, II = 56.8, III = 0.5% (2), p = NS. The overall prevalence of retinal changes was 84.3% and 84.7%, respectively, and the inter‐ and intra‐observer reproducibility 89.1, 91.6 (1) and 90.2% (2), respectively. Conclusions: Our data indicate that: (i) the prevalence of initial retinal changes is far higher than that of other prognostically validated quantitative markers of cardiac and extracardiac TOD; (ii) the inter‐ and intra‐observer reproducibility between two skilled readers in detecting these abnormalities with non‐mydriatic retinography is excellent; (iii) the high prevalence of retinal changes in untreated subjects with mild hypertension offers a new piece of evidence that they cannot be considered a proof of TOD.

Left ventricular concentric remodelling and extracardiac target organ damage in essential hypertension.

Left ventricular (LV) concentric remodelling is an adaptive change in cardiac geometry frequently observed in arterial hypertension. This study was addressed to investigate the extent of extracardiac target organ damage (TOD) in patients with LV concentric remodelling. Two groups of never-treated essential hypertensives, 31 with normal LV geometry (group I, relative wall thickness: 0.39) and 31 with LV concentric remodelling (group II, relative wall thickness: 0.47) matched for age, sex, body mass index and mean 24-h systolic blood pressure (BP), were included in the study. They underwent clinical and laboratory examination, 24-h ambulatory BP monitoring (ABPM), 24-h urinary collection for microalbuminuria, non-mydriatic photography of ocular fundi, echocardiography and carotid ultrasonography. In both groups age (I: 51 +/- 11 years; II: 51 +/- 11 years), body mass index (I: 25 +/- 3 kg/m(2); II: 26 +/- 3 kg/m(2)), clinic and 24-h ABPM values (I: 149 +/- 11/95 +/- 8, 142 +/- 11/91 +/- 7 mm Hg; II: 150 +/- 11/98 +/- 9, 142 +/- 12/92 +/- 9 mm Hg) were similar by design. There were no differences between patients with normal LV geometry and with LV concentric remodelling in LVM index (97 +/- 16 vs 99 +/- 16), carotid intima-media thickness (0.7 +/- 0.02 vs 0.7 +/- 0.02) and carotid plaques prevalence (35% vs 35%). Furthermore, no significant differences among the two groups were found in the prevalence of retinal changes and microalbuminuria. These results suggest that in hypertensive patients with similar BP and LVMI levels, LV concentric remodelling is not associated with more prominent TOD.

Relation of left ventricular geometry and function to aortic root dilatation in patients with systemic hypertension and left ventricular hypertrophy (the LIFE study)

Echocardiographically detemined left ventricular (LV) hypertrophy is an independent predictor of increased cardiovascular morbidity and mortality in hypertensive patients. 1 Casale P.N Devereux R.B Milner M Zullo G Harshfeld G.A Pickering T.G Laragh J.H Value of echocardiographic assessment of left ventricular mass in predicting cardiovascular morbid events in hypertensive men. Ann Intern Med. 1986; 105: 173-178 Crossref PubMed Scopus (1034) Google Scholar , 2 Koren M.J Devereux R.B Casale P.N Savage D.D Laragh J.H Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med. 1991; 114: 345-352 Crossref PubMed Scopus (2160) Google Scholar Recent reports have described associations between LV geometric adaptation and extracardiac target organ damage in essential hypertension, with hypertensive patients with concentric LV geometry having the most advanced fundoscopic abnormalities, the greatest renal dysfunction, 3 Shigematsu Y Hamada M Mukai M Matsuoka H Sumimoto T Hiwada K Clinical evidence for an association between left ventricular geometric adaptation and extracardiac target organ damage in essential hypertension. J Hypertens. 1995; 13: 155-160 Crossref PubMed Scopus (92) Google Scholar and the most severe abnormalities of carotid artery structure and function. 4 Roman M.J Pickering T.G Schwartz J.E Pini R Devereux R.B Relation of arterial structure and function to left ventricular geometric patterns in hypertensive adults. J Am Coll Cardiol. 1996; 28: 751-756 Abstract Full Text PDF PubMed Google Scholar , 5 Bella J.N Roman M.J Pini R Shwartz J.E Pickering T.G Devereux R.B Assessment of arterial compliance by carotid midwall strain-stress relation in hypertension. Hypertension. 1999; 33: 793-799 Crossref PubMed Scopus (13) Google Scholar However, although geometric and functional abnormalities of medium-sized capacitance arteries associated with LV hypertrophy have been identified in relatively mild, uncomplicated hypertension, 4 Roman M.J Pickering T.G Schwartz J.E Pini R Devereux R.B Relation of arterial structure and function to left ventricular geometric patterns in hypertensive adults. J Am Coll Cardiol. 1996; 28: 751-756 Abstract Full Text PDF PubMed Google Scholar , 5 Bella J.N Roman M.J Pini R Shwartz J.E Pickering T.G Devereux R.B Assessment of arterial compliance by carotid midwall strain-stress relation in hypertension. Hypertension. 1999; 33: 793-799 Crossref PubMed Scopus (13) Google Scholar relations of the size of the most proximal portion of the systemic arterial tree (the aortic root) to LV geometry and function have not been elucidated in patients with more severe hypertension. Therefore, the purpose of the present study was to identify the clinical and echocardiographic characteristics of hypertensive patients with aortic root dilatation and to examine the relation of cardiac geometry and function to aortic size in hypertensive participants enrolled in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiography substudy.

High prevalence of cardiac and extracardiac target organ damage in refractory hypertension.

Target organ damage (TOD) in chronically treated hypertensives is related to effective blood pressure (BP) control. The aim of this study was to evaluate the prevalence of cardiac and extracardiac TOD in patients with refractory hypertension (RH) compared with well-controlled treated hypertensives (C). Fifty-four consecutive patients with RH (57 +/- 10 years), selected according to WHO/ISH guidelines definition, and 51 essential hypertensives (55 +/- 10 years) with satisfactory BP control obtained by association therapy, underwent the following procedures: (1) clinic BP measurement; (2) blood sampling for routine chemistry examinations; (3) 24 h urine collection for microalbuminuria; (4) non-mydriatic retinography; (5) echocardiogram; (6) carotid ultrasonogram. In order to exclude 'office resistance' (defined as clinic BP > 140/90 mmHg and average 24 h BP </= 125/79 mmHg), all patients with RH were subjected to 24-hour ambulatory BP monitoring. Both groups were similar for age, gender, body surface area, smoking habit and duration of hypertension, glucose, creatinine and lipid levels. By definition, clinic BP was significantly higher in RH than C (161 +/- 19/96 +/- 9 versus 127 +/- 6/80 +/- 5 mmHg, respectively, P < 0.01). The increased prevalence of left ventricular hypertrophy (LVH) and carotid intima-media (IM) thickening (40 versus 12%, P < 0.01, according to a non-gender-specific partition value of 125 g/m2; and 36 versus 14%, P < 0.01, according to IM thickness > or =1.0 mm, respectively); a higher prevalence of carotid plaques (65 versus 32%, P < 0.05), a more advanced retinal involvement (grade II and III, 73 and 5% versus 38 and 0%, P < 0.01) and a greater albumin urinary excretion (22 +/- 32 mg/24 h versus 11 +/- 13 mg/24 h, P < 0.01) were found in RH compared to C. Our study suggests that RH is a clinical condition associated with a high prevalence of TOD at cardiac, macro- and microvascular level and consequently with high absolute cardiovascular risk, which needs a particularly intensive therapeutic approach aimed to normalize BP levels and to induce TOD regression.

Relation between Left Ventricular Geometric Alteration and Extracardiac Target Organ Damage in Hypertensive Patients.

To study the relation between left ventricular geometric alteration and extracardiac target organ damage in hypertensive patients. A retrospective study of 298 patients with essential hypertension was performed. Left ventricular mass index (LVMI) and relative wall thickness (RWT) were calculated using echocardiographic data. Patients were divided into four groups based on their left ventricular geometric pattern as determined using LVMI and RWT. Each of the four left ventricular geometric patterns was associated with a different degree of extracardiac organ damage. In multivariate analysis, LVMI and RWT showed strong, significant correlation to retinal changes and increases in serum creatinine levels, respectively. Alteration of left ventricular geometry resulted in an increase in the degree of extracardiac target organ damage. Echocardiographic classification of left ventricular geometry can further stratify hypertensive patients according to risk, and possibly according to the indications for intensive treatment.

Plasma Concentration of Atrial and Brain Natriuretic Peptides in the Patients with Essential Hypertension

Background:Left ventricular hypertrophy (LVH is one of the complications of hypertension and has been known as an independent risk factor of cardiovascular complications. Recently, it has been reported that hypertensive patients with LVH had the most advanced extracardiac target-organ damage compared with other groups. Previous reports have shown that mean plasma atrial natriuretic peptide (ANP and brain natriuretic peptide (BNP levels in hypertensive patients are higher than in normotensive subjects. Therefore, in this study, we investigated the relationships between the plasma ANP and BNP levels and the degree of LVH in hypertensive patients and in normotensive subjects and also investigated the clinical significance of measurement of plasma ANP and BNP levels. Methods:In all study subjects, left ventricle mass index (LVMI and left ventricle geometry were measured by M-mode echocardiography. Measurements were made by the recommend- ations of the American Society of Echocardiography. Plasma ANP and BNP levels were measured by radioim- munoassay method. Results:1 57% of the hypertensive patients had eccentric hypertrophy and 6% had concentric hypertrophy. 2 LV mass and LVMI of normotensive subjects and hypertensive patients were 169± 53 g, 229±64 g and 99±27.3 g/m 2 , 142±37.7 g/m 2 , respectively (p<0.05. 3 There were statistically signifi- cant correlations between blood pressure and LVMI in all subjects (r=0.43, p<0.05. 4 Plasma ANP levels were significantly increased in hypertensive patients than normotensive subjects (28.2±14.3 pg/mL and 42.8±26 pg/mL, respectively;p<0.05. 5 Plasma BNP levels were significantly increased in hypertensive patients than normotensive subjects (18.4±5.4 pg/mL and 36.5±26 pg/mL;respectively, p<0.05. 6 Plasma BNP levels were significantly increased in 63% of the hypertensive patients with LVH (p<0.05. 7 There were statistically significant correlations between blood pressure and plasma ANP and BNP levels (ANP:r=0.39, p<0.05, BNP:r=0.31, p<0.05. Conclusions:Plasma ANP and BNP levels were increased in the hyperten- sive patients but only plasma BNP levels were significantly increased in the hypertensive patients with LVH. Measurement of plasma BNP levels may be useful for early detection of LVH, an independent risk factor of cardiovascular complications. Therefore intensive blood pressure control in these patients may reduce cardio-

Left ventricular geometry as an independent predictor for extracardiac target organ damage in essential hypertension

Left ventricular hypertrophy (LVH) is an independent cardiovascular risk factor. It has not been established, however, whether left ventricular geometry is an independent predictor of extracardiac target organ damage in essential hypertension. Study groups were classified according to relative wall thickness: 27 patients with concentric LVH and 50 patients with eccentric LVH. Age and left ventricular mass indexes of two groups were matched. As indexes of extracardiac target organ damage, retinal funduscopic grade, and serum creatinine level were measured. The severity of hypertensive retinopathy and the renal involvement were more severe in patients with concentric LVH than in patients with eccentric LVH. Extracardiac target organ damage was consistently higher in patients with concentric LVH than in those with eccentric LVH. Systemic hemodynamics paralleled ventricular geometric patterns, with higher peripheral resistance and lower aortic compliance in patients with concentric LVH, whereas end-diastolic volumes and stroke volumes were higher in patients with eccentric LVH than in patients with concentric LVH. In addition, total peripheral resistance was related to retinal fundoscopic grade (r = 0.41, P < .01), and serum creatinine level (r = 0.28, P < .05). Even in the presence of an identical degree of LVH, echocardiographically determined left ventricular geometry may provide a further independent stratification of extracardiac target organ damage in essential hypertension.

A35 Left ventricular geometry is a major determinant of extracardiac target organ damage in essential hypertension

A35 Left ventricular geometry is a major determinant of extracardiac target organ damage in essential hypertension