No abstract

Ambulatory blood pressure monitoring allows a better understanding of blood pressure fluctuations over 24 h than simple clinic measurements. In this way the diagnosis of "white coat" versus "sustained" hypertension and that of "dipper" (patient with blood pressure fall during nighttime > 10% of daytime levels) versus "nondipper" status were made possible. This pilot study has been undertaken to investigate whether patients with recently discovered, never-treated, mild, sustained hypertension have cardiovascular abnormalities according to their dipper/nondipper status. Patients with long-standing (n = 123) and newly discovered (n = 56) sustained hypertension were classified according to their nighttime blood pressure fall, and compared with normotensive controls. Ambulatory blood pressure monitoring was performed noninvasively. Parameters of left ventricular structure, cardiac systolic and diastolic function, and carotid anatomy were determined noninvasively by echographic methods. Significant increases in parameters of cardiac structure as well as abnormalities in diastolic function were observed in patients with long-standing hypertension, regardless of their dipper status. In the group with newly discovered hypertension, left atrium (3.4+/-0.3, 3.7+/-0.5, 3.2+/-0.4 cm in dippers, nondippers, and controls, respectively), end-diastolic diameter index (2.9+/-0.3, 3.0+/-0.2, 2.8+/-0.2 cm/m), and atrial filling fraction (0.50+/-0.07, 0.52+/-0.05, 0.42+/-0.04) were significantly altered only in the nondipper subgroup, in comparison with controls. Significant changes in cardiac structure and diastolic function were observed in nondipper patients with recently discovered hypertension, who, at variance with dippers, show changes similar to those in patients with long-standing hypertension. Hypertensives with the observed abnormalities may benefit from active antihypertensive treatment, which appears, therefore, justified even in an early phase of mild hypertension, in terms of potential reduction of end-organ complications as well as cost-effectiveness.

Summary Although there is little information from primary or secondary prevention trials on cholesterol‐lowering medication in diabetic patients, the reduction of elevated cholesterol is widely recommended for this group. The American Diabetes Association (ADA) recommends drug therapy in diabetic patients if low density lipoprotein (LDL)‐cholesterol remains at > 130 mg/dl, or > 100 mg/dl in patients with macroangiopathy, after dietary intervention. When cholesterol‐lowering medication is indicated, the choice of the drug must take into account the other lipid abnormalities that are often present and the need to maintain optimal glycaemic control. In the present study we compared the efficacy and safety of the novel HMG‐CoA reductase inhibitor atorvastatin at the dose of 10 mg/day with simvastatin , lovastatin and pravastatin at doses of 10, 20 and 20 mg/day, respectively, and placebo, in type 2 diabetic patients with moderate elevation of LDL‐cholesterol with or without elevation of triglycerides. All the quoted agents are enzyme inhibitors effective in lowering LDL‐cholesterol in humans. The efficacy endpoints were the mean per cent changes in plasma LDL‐cholesterol (primary), total cholesterol, triglycerides, and high‐density lipoprotein (HDL)‐cholesterol concentrations from baseline to the end of treatment (24 weeks). Atorvastatin at a dose of 10 mg/day produced: (1) a significant reduction in LDL‐cholesterol (− 37%) in comparison with equivalent doses of simvastatin (− 26%), pravastatin (− 23%), lovastatin (− 21%), and placebo (− 1%); (2) HDL‐cholesterol increases (7.4%) comparable to or greater than those obtained with simvastatin (7.1%), pravastatin (3.2%), lovastatin (7.21%), and placebo (− 0.5%); (3) a significantly greater reduction in total cholesterol (− 29%) than that obtained with simvastatin (− 21%), pravastain (− 16%), lovastatin (− 18%), and placebo (1%); and (4) a significantly greater reduction in triglycerides than that obtained with all the other drugs and placebo. In all treatment groups no significant variation in fibrinogen concentration was observed. All reductase inhibitors studied had similar levels of tolerance. There were no incidents of persistent elevations of serum aminotransferases or myositis.

These results indicate that in addition to the degenerative changes of the common carotid wall, the diameter of the carotid artery and the relation to parietal stress show an early impairment in patients with uncomplicated hypertension.

Arterial hypertension is frequently responsible for arteriosclerotic damage in the carotid region. Nevertheless, there is as yet no general agreement that hypertension is correlated with lesions detected by noninvasive means in the carotid arteries. We studied, by noninvasive echotomographic technique, 70 uncomplicated primary hypertensive individuals without clinically evident end-organ complications and 30 normotensive matched control subjects to detect early lesions of carotid arteries. The presence of other cardiovascular risk factors was assessed, and heart structure and function were studied by echocardiography. Although hypertensive individuals were comparable to control subjects for other risk factors, they showed a marked increase in the thickness of the intimal-medial complex of the carotid wall (0.71±0.4 versus 0.56±0.2 mm, P<.001 in the right carotid and 0.83±0.3 versus 0.58±0.2, P<.003 in the left), in left ventricular mass (203±52 versus 176±37 g, P<.05), and in the prevalence of definite plaques of the carotid wall, both monolaterally and bilaterally (P<.003 by A rterial hypertension is a well-recognized risk fac-/ \ tor for early degenerative lesions in the arterial JL \ . tree. Epidemiological studies have shown that high blood pressure (BP) levels are correlated with increased prevalence and incidence of coronary and cerebrovascular diseases. 16 Moreover, antihypertensive treatment has been found to reduce the incidence of stroke and myocardial infarction, although in the latter to a smaller extent. 715 The recent development of noninvasive techniques has allowed investigation of carotid arteries to detect early degenerative changes, to measure plaque dimension, and to follow the progression of arterial lesions. 16 In particular, measurement of the thickness of intimalmedial layers, which are portrayed as being limited by a pair of roughly parallel echogenic lines, has attracted the interest of several investigators. 17 Poli and coworkers 18 found that the thickness of the intimal-medial complex is increased in hypercholesterolemic patients, and Kawamori and coworkers 19 detected a similar finding in diabetic patients. Although there is still debate over whether the intimal plus medial thickening might be considered an initial arteriosclerotic lesion, it is X 1 test). Among the different factors contributing to the increase in thickness of the carotid artery wall, standing blood pressure, serum triglycerides, and age were found to be the best predictors (they accounted for about 16% of the variability, /><.OO5). These results indicate that carotid arteries of hypertensive individuals undergo degenerative changes, just as shown for hypercholesterolemic and diabetic patients in other studies. This supports the use of B-mode ultrasound imaging to detect early involvement of the carotid region before the appearance of any end-organ damage of hypertension. Moreover, this finding sheds new light on the relationship between arterial wall damage and insulin resistance, since all the main contributors ...