Search

Background: Women have a lower risk for cardiovascular (CV) disease compared to men. Whether this difference is influenced by the presence of hypertension-mediated organ damage is unknown., Objective: To assess whether the presence of carotid plaque (CP) impacts the sex difference in risk for CV events in treated hypertensive patients., Methods: From the Campania Salute Network Registry 2419 women and men <51 years of age with treated hypertension and free from prevalent CV disease were included. The presence of CP was identified by Doppler ultrasound (intima-media thickness≥1.5 mm). The primary outcome was a composite of fatal and non-fatal stroke or myocardial infarction, sudden death, TIA, myocardial revascularization, de novo angina, and atrial fibrillation., Results: Among patients without CP at baseline (n = 1807), women were older, with higher systolic blood pressure, serum cholesterol level and prevalence of LVH but lower serum triglycerides and eGFR, compared to men (all p < 0.001). Among patients with CP (n = 612), women were older, used higher number of antihypertensive drugs, had higher serum cholesterol level and prevalence of left ventricular hypertrophy (LVH), but had lower serum triglycerides and eGFR compared to men (all p < 0.001). During follow-up, women without CP had a lower risk for CV disease than men (hazard ratio, HR, 0.51, 95 % confidence intervals, CI, 0.27-0.99, p = 0.04) after accounting for cardiovascular risk factors, LVH, and antihypertensive treatment. In contrast, among patients with CP, women had similar risk for CV disease compared with men (HR 1.3, 95 % CI, 0.59-2.9, p = 0.48)., Conclusions: Our findings suggest that the presence of CP in young patients with treated hypertension offsets the CV disease protection in women., Trial Registration: NCT02211365., Competing Interests: Conflict of interest The authors reported no conflict of interest with the present manuscript., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aims: In the present study, we assessed correlates and their consistency of ascending aorta (AscAo) measurement in treated hypertensive patients., Methods and Results: A total of 1634 patients ≥ 18 years old with available AscAo ultrasound were included. Ascending aorta was measured at end-diastole with leading edge to leading edge method, perpendicular to the long axis of the aorta in parasternal long-axis view at its maximal identifiable dimension. Correlations of AscAo and AscAo normalized for height (AscAo/HT) or body surface area (AscAo/BSA) with demographics and metabolic profile were explored. Multi-variable regression was also used to identify potential confounders influencing univariate correlations. Sensitivity analysis was performed using cardiovascular (CV) outcome. Correlations with age, estimated glomerular filtration rate, systolic blood pressure (BP), and heart rate (HR) were similar among the three aortic measures. Women exhibited smaller AscAo but larger AscAo/BSA than men with AscAo/HT offsetting the sex difference. Obesity and diabetes were associated with greater AscAo and AscAo/HT but with smaller AscAo/BSA (all P < 0.001). In multi-variable regression model, all aortic measure confirmed the sign of their relations with sex and metabolic profile independently of age, BP, and HR. In Kaplan-Mayer analysis, only dilated AscAo and AscAo/HT were significantly associated with increased risk of CV events (both P < 0.008)., Conclusions: Among patients with long-standing controlled systemic hypertension, magnitude of aortic remodelling is influenced by the type of the measure adopted, with physiological consistency only for AscAo and AscAo/HT, but not for AscAo/BSA., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Arterial hypertension causes cardiac functional and structural alterations. In hypertensive patients without flow-limiting epicardial coronary artery disease, we investigated possible relationships between positron emission tomography/computed tomography-derived myocardial blood flow (MBF) and echocardiographic parameters of left ventricular (LV) performance, including mechano-energetic efficiency indexed for myocardial mass (MEEi)., Methods: Seventy-eight hypertensive patients without flow-limiting epicardial coronary artery disease underwent echocardiography, including MEEi computation, and cardiac positron emission tomography/computed tomography with assessment of MBF/mass ratio at rest and after stress and myocardial flow reserve. The lowest MEEi tertile (MEEi<0.031 mL/s/g) was compared to the merged second and third tertiles (MEEi≥0.031)., Results: Patients in the lowest MEEi tertile were older, had higher systolic blood pressure and body mass index. They also had higher prevalence of LV hypertrophy, whereas lower resting and stress MBF/mass ratio. MEEi was significantly correlated with both resting (r=0.51; P <0.0001) and hyperemic (r=0.54; P <0.0001) MBF/mass ratios, whereas it was not related to myocardial flow reserve. Delta of MBF/mass ratio was lower in the lowest MEEi tertile than in the highest ( P <0.0001). In separate multiple linear regression models, after adjusting for sex, systolic blood pressure, body mass index, prevalence of LV hypertrophy, left atrial volume index, and diuretic therapy, the association between LV MEEi and both hyperemic (beta coefficient=0.44; P =0.003) and resting (beta coefficient=0.35; P =0.008) MBF/mass ratio remained significant., Conclusions: In hypertensive patients without flow-limiting epicardial coronary artery disease, low values of MEEi could detect an early LV dysfunction involving an impairment of both resting and hyperemic MBF/mass ratios. MEEi has the advantage of simpler detection, cheaper costs than positron emission tomography/computed tomography, and a lack of radiation exposure., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT02211365., Competing Interests: Disclosures None.

Background and Aim: Recently, the European Society of Cardiology task force released a Consensus document (ESC-CD) on pediatric hypertension (HTN) supporting the use of normative tables (age range 6-16 years) for the diagnosis of HTN, while the Hypertension Canada Guidelines (HTN-CGs) proposed static cutoffs. We aimed to assess the prevalence of HTN by ESC-CD or HTN-CGs and their association with glomerular function and left ventricular (LV) geometry in youths with overweight/obesity (OW/OB)., Methods and Results: Data of 3446 youths were analyzed. HTN by was defined using normative tables (ESC-CD) or static cutoffs of BP ≥ 120/80 in children (age <12 years) and ≥130/85 mmHg in adolescents (age ≥12 years) (HTN-CGs). Mildly reduced glomerular filtration rate was defined by GFR <90 ≥ 60 mL/min/1.73 m 2 . Concentric LV hypertrophy (cLVH) was assessed in 500 youths and defined by LVH and high relative wall thickness as proposed by ESC-CD. Prevalence of HTN was 27.9% by ESC-CD and 22.7% by HTN-CGs. The association with mildly reduced glomerular filtration rate was significant only in hypertensive adolescents classified by HTN-CGs [Odds Ratio (OR), 95%Cl] 2.16 (1.44-3.24), whereas the association with cLVH was significant using both criteria: children OR 2.18 (1.29-3.67) by ESC-CD and 2.27 (1.32-3.89) by HTN-CGs; adolescents OR 2.62 (1.17-5.84) by ESC-CD and 2.83 (1.14-7.02) by HTN-CGs., Conclusion: Although static cutoffs may represent a simplification for HTN identification, tables by ESC-CD detect a higher number of hypertensive youths before a clear appearance of glomerular impairment, which offers advantages in terms of primary cardiovascular prevention., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2023 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

There is strong evidence that sex chromosomes and sex hormones influence blood pressure (BP) regulation, distribution of cardiovascular (CV) risk factors and co-morbidities differentially in females and males with essential arterial hypertension. The risk for CV disease increases at a lower BP level in females than in males, suggesting that sex-specific thresholds for diagnosis of hypertension may be reasonable. However, due to paucity of data, in particularly from specifically designed clinical trials, it is not yet known whether hypertension should be differently managed in females and males, including treatment goals and choice and dosages of antihypertensive drugs. Accordingly, this consensus document was conceived to provide a comprehensive overview of current knowledge on sex differences in essential hypertension including BP development over the life course, development of hypertension, pathophysiologic mechanisms regulating BP, interaction of BP with CV risk factors and co-morbidities, hypertension-mediated organ damage in the heart and the arteries, impact on incident CV disease, and differences in the effect of antihypertensive treatment. The consensus document also highlights areas where focused research is needed to advance sex-specific prevention and management of hypertension., Competing Interests: Conflict of interest: E.G.: Bayer Health, NOKLUS, Fürst laboratories; I.S. Amgen, Astra Zeneca, Daiichi Sankio, Medtronic, Merck Sharpe & Dohme, Novartis, Recordati, Sanofi and Servier; SB Daiichi Sankyo; Merck, Sanofi, Menarini and Servier; C.B. Menarini Corporate, Servier, Novo Nordisk and Novartis; R.M.B. Medtronic; C.C.: none; V.C.: none; F.D.: none; M.F.: none; T.K.: TK Medtronics, and ReCor Medical; M.L.L.: Bayer Health, Sanofi, Bristol Myers Squibb and Pfizer; AHEMM: Organon, Novartis, Abbott and Omron; F.M.: Medtronic, ReCor Medical, Astra-Zeneca, Bayer, Boerhringer-Ingelheim, Medtronic, Merck and ReCor Medical; A.S.M.: Servier and SCAI; T.M.: none; G.P.: none; G.d.S.: none., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.)

Definition and management of arterial hypertension in children and adolescents are uncertain, due to different positions of current guidelines. The European Society of Cardiology task-force, constituted by Associations and Councils with interest in arterial hypertension, has reviewed current literature and evidence, to produce a Consensus Document focused on aspects of hypertension in the age range of 6-16 years, including definition, methods of measurement of blood pressure, clinical evaluation, assessment of hypertension-mediated target organ damage, evaluation of possible vascular, renal and hormonal causes, assessment and management of concomitant risk factors with specific attention for obesity, and anti-hypertensive strategies, especially focused on life-style modifications. The Consensus Panel also suggests aspects that should be studied with high priority, including generation of multi-ethnic sex, age and height specific European normative tables, implementation of randomized clinical trials on different diagnostic and therapeutic aspects, and long-term cohort studies to link with adult cardiovascular risk. Finally, suggestions for the successful implementation of the contents of the present Consensus document are also given., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: In a hypertensive population with optimal blood pressure control with a long-term follow-up, we aimed at analysing possible predictors of left ventricular (LV) ejection fraction (LVEF) reduction, including indexed mechano-energetic efficiency (MEEi), a well-recognized echo-derived parameter of LV performance., Methods and Results: The study population included 5673 hypertensive patients from the Campania Salute Network with a long-term follow-up, normal baseline LVEF (≥50%), and no prevalent cardiovascular (CV) disease. Patients developing LVEF impairment (LVEF < 50% or a reduction of at least 10 percentage points compared with baseline) were compared with patients with persistently normal LVEF. Optimal blood pressure control was achieved in about 80% of patients. Patients who experienced LVEF reduction were 2.41% during a long-term follow-up (mean duration 5.6 ± 3.9 years). At baseline, they were older (59.46 ± 11.58 vs. 53.40 ± 11.41, P < 0.0001) and showed higher LV mass index (53.3 ± 12.83 vs. 47.56 ± 9.58, P < 0.0001), left atrial (LA) volume index (14.4 ± 4.2 vs. 13.1 ± 2.8, P < 0.0001) and carotid intima-media thickness (1.99 ± 0.86 vs. 1.61 ± 0.73, P < 0.0001), lower MEEi (0.32 ± 0.08 vs. 0.34 ± 0.07, P = 0.037), and higher prevalence of CV events during follow-up (13.9% vs. 3%, P < 0.0001) compared with patients with persistently normal LVEF. A logistic regression analysis, performed after running univariate analyses and selecting parameters significantly associated with LVEF reduction, showed that having a CV event [odds ratio (OR) 7.57, P < 0.0001], being in the lowest MEEi quartile (OR 2.43, P = 0.003), and having a larger LA volume index (OR 1.08, P = 0.028) were all parameters independently associated with the development of LV systolic dysfunction. A further logistic regression model, performed by excluding patients experiencing CV events, demonstrated that the lowest MEEi quartile was independently associated with the evolution towards LVEF reduction (OR 2.35, P = 0.004), despite significant impact of LA volume index (OR 1.08, P = 0.023) and antiplatelet therapy (OR 1.89, P < 0.01). Receiver operating characteristic curves showed that the model including MEEi had higher accuracy than the model without MEEi in predicting LVEF reduction (areas under the curve 0.68 vs. 0.63, P = 0.046)., Conclusions: Lower values of MEEi at baseline identify hypertensive patients more liable to develop LVEF reduction. In hypertensive setting, MEEi evaluation improves risk stratification for development of LV systolic dysfunction during long-term follow-up., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background The 2018 European Society of Cardiology/European Society of Hypertension arterial hypertension guidelines do not recommend routine carotid ultrasound as a tool to identify hypertension-mediated organ damage, unless clinically indicated. However, carotid plaque (CP) is a strong correlate of increased arterial stiffness, which influences blood pressure (BP) control over time. Thus, we assessed whether evidence of CP at first visit could predict BP control during follow-up. Methods and Results From the CSN (Campania Salute Network) Registry, 6684 patients with hypertension had complete carotid ultrasound examination and were categorized by the presence of CP at baseline. Optimal BP control was defined as average BP <140/90 mm Hg and <135/85 during follow-up for office and home BP, respectively. At baseline, participants with CP (n=3061) were more likely to be men, to be older, to have diabetes, and to exhibit higher systolic BP, lower diastolic BP, worse lipid profile, and higher prevalence of left ventricular hypertrophy (all P <0.0001) than patients without CP. Optimal office BP control was adjudicated in 54% with and 62% without CP ( P <0.0001), and optimal home BP in 51% with and 58% without CP ( P <0.01). Presence of CP was significantly associated with the reduced probability of controlled office BP during follow-up (both P <0.0001), independently of significant effect of older age, male sex, higher baseline BP values, classes of medication, and presence of left ventricular hypertrophy, and only attenuated by duration of hypertension. Conclusions Presence of CP in treated patients with hypertension is associated with suboptimal BP control during follow-up, independently of worse metabolic profile and presence of left ventricular hypertrophy.

Background: Exaggerated variability of blood pressure (BP) poses additional stress on cardiovascular system independent of BP average value, increasing risk of target organ damage (HMOD) and cardiovascular events. We assessed the impact of visit-to-visit variability (VVV) of BP on development of cardiovascular events and HMOD., Methods: Standard deviation (SD) and coefficient of variability of mean SBP and DBP were calculated in 3555 patients from the Campania Salute Network registry, with available echocardiogram and more than six visits during follow-up. Values from the first visit were excluded. The impact of VVV of BP on cardiovascular events, and mediation of HMOD were assessed at final visit., Results: Mean number of visits was 11 ± 6 with mean interval between visits of 9.1 ± 3.7 months. Mean visit-to-visit SD during follow-up was 13 ± 5 for systolic and 8 ± 3 mmHg for DBP; coefficients of variability were 9.7 ± 3.5 and of 9.6 ± 3.2, respectively. In multivariable analysis, left ventricular mass at follow-up was correlated with systolic VVV of BP independently of significant effect of age, BMI, mean SBP during follow-up and initial left ventricular mass. Follow-up GFR was inversely associated with systolic and diastolic VVV, independently of significant effect of age, mean glucose and SBP during follow-up, and initial GFR. In Cox regression, high VVV of BP was also associated with increased risk of cardiovascular events (hazard ratio 1.49, 95% confidence interval 1.08-2.06, P = 0.015), independently of significant effect of HMOD., Conclusion: VVV is associated with prevalent HMOD and development of cardiovascular events, independently of mean BP value during follow-up and HMOD., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Aortic valve stenosis (AS) is the third most common cardiovascular disease. The prevalence of both AS and arterial hypertension increases with age, and the conditions therefore often co-exist. Co-existence of AS and arterial hypertension is associated with higher global left ventricular (LV) pressure overload, more abnormal LV geometry and function, and more adverse cardiovascular outcome. Arterial hypertension may also influence grading of AS, leading to underestimation of the true AS severity. Current guidelines suggest re-assessing patients once arterial hypertension is controlled. Management of arterial hypertension in AS has historically been associated with prudence and concerns, mainly related to potential adverse consequences of drug-induced peripheral vasodilatation combined with reduced stroke volume due to the fixed LV outflow obstruction. Current evidence suggests that patients should be treated with antihypertensive drugs blocking the renin-angiotensin-aldosterone system, adding further drug classes when required, to achieve similar target blood pressure (BP) values as in hypertensive patients without AS. The introduction of transcatheter aortic valve implantation has revolutionized the management of patients with AS, but requires proper BP management during and following valve replacement. The purpose of this document is to review the recent evidence and provide practical expert advice on management of hypertension in patients with AS., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: Hypertensive urgencies (HypUrg) are defined as severe elevation in blood pressure (BP) without acute target organ damage. In the office setting, treated asymptomatic patients, with severe BP elevation meeting criteria for urgency are often seen. We evaluate incident Cardiovascular (CV) events (n = 311) during follow-up (FU) in patients with HypUrg at first outpatient visit., Methods: HypUrg was defined by systolic BP ≥180 mm Hg and/or diastolic BP ≥110 mm Hg. Patients were >18 years old, with available ultrasound data, without prevalent CV disease, and no more than stage III Chronic Kidney Disease. BP control was defined as the average BP during FU <140/90 mm Hg., Results: Four hundred and sixty-nine of 6,929 patients presented with HypUrg at first visit. Patients with HypUrg were more likely to be women, obese and diabetic and with higher prevalence of left ventricle (LV) hypertrophy and carotid plaque (all P <  0.05). During FU patients with HypUrg had 5-fold higher risk of uncontrolled BP (95% confidence interval (CI) 4.1-6.8, P < 0.0001). In Cox regression presenting with HypUrg was not associated with increased CV risk after adjusting for significant covariates, including age, sex, BP control, LV hypertrophy, and carotid plaque (hazard ratio (HR) 1.42, 95% CI (0.96-2.11), P = 0.08)., Conclusions: Patients with HypUrg have worst CV risk profile, reduced probability of BP control during FU and greater prevalence of target organ damage, but the excess CV event risk appears to be mediated through BP control, non-BP cardio-vascular disease risk factors, and demographic attributes., Clinicaltrials.gov Identifier: NCT02211365., (© American Journal of Hypertension, Ltd 2020. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background It is debated whether echocardiography should be part of the diagnostic workup in all hypertensive patients. We identified some factors potentially associated with left ventricular hypertrophy (LVH) at echocardiography in untreated hypertensive patients. Methods and Results We studied 2150 patients without LVH at ECG. All patients underwent standard 12-lead ECG and echocardiography. Mean age was 48.7 years, and mean office blood pressure was 154/97 mm Hg. Prevalence of echocardiographic LVH (LV mass >47.0 g/m 2.7 in women and >50.0 g/m 2.7 in men) was 37.1%. We developed a nomogram based on 7 items (age, smoking, body mass index, office systolic and diastolic blood pressure, Cornell voltage, and chronic kidney disease) on the basis of a multivariable logistic regression analysis. We internally validated the model by bootstrap recalibration and obtained a calibration curve to assess agreement in the validation data set. Probability of LVH at echocardiography ranged from <10% (score, ≤100 points) to >90% (score, ≥180 points). Proportion of patients with LVH progressively increased with the total score (χ 2 =444.8; P <0.001). Prevalence of LVH was <2% and 90% at the lower 5th and upper 95th percentile of its distribution, respectively. Conclusions We developed and validated a novel score to assess the probability of LVH at echocardiography in hypertensive patients without LVH at ECG. The score may guide the appropriateness of echocardiographic study in low-risk hypertensive patients. Echocardiography appears most appropriate for score values >136 in men and >124 in women.

Objectives: Results of the SPRINT study have influenced recent guidelines on arterial hypertension, in the identification of target SBP, but scarce attention has been paid to the consequences on DBP. However, there is evidence that reducing DBP too much can be harmful., Methods: We analyzed outcome in 4005 treated hypertensive patients (22% obesity, 8% diabetes and 21% current smoking habit) with target attended office SBP less than 140 mmHg, in relation to quintiles of DBP, cardiovascular risk profile and target organ damage (LV hypertrophy, carotid plaque and left atrial dilatation). Composite fatal and nonfatal cardiovascular event was the outcome variable in this analysis (stroke and myocardial infarction, sudden cardiac death, heart failure requiring hospitalization, transient ischemic attack, myocardial revascularization, de novo angina, carotid stenting and atrial fibrillation)., Results: Lower DBP was associated with greater proportion of women and diabetes, older age, decline in kidney function and greater values of LV mass index and left atrial volume and greater prevalence of carotid plaque (all 0.04 < P < 0.0001). The lowest quintile of DBP (74.1 ± 3.7 mmHg) was associated with 1.49 higher hazard of composite cardiovascular events, independently of significant effect of older age, female sex, LV hypertrophy and borderline effect of left atrial dilatation (0.04 < P < 0.001)., Conclusion: Increased risk associated with aggressive reduction of DBP should be balanced with the advantage of reducing aggressively SBP to predict the net benefit of antihypertensive treatment, especially in the oldest old individuals.

Objectives: Increased arterial stiffness is associated with advanced arteriosclerosis, abnormal left ventricular (LV) geometry and function. Whether increased arterial stiffness is associated with incident cardiovascular (CV) event (MACE), independent of other markers of target organ damage needs to be clarified. Methods: We selected hypertensive participants of the Campania Salute Network free of prevalent CV disease, with available echocardiogram and carotid ultrasound, ejection fraction ≥50%, and ≤ stage III Chronic Kidney Disease ( n  = 6907). Median follow-up was 63 months. End-point was incident MACE (fatal and non-fatal stroke and myocardial infarction, sudden cardiac death, carotid stenting and heart failure requiring hospitalization). Arterial stiffness was assessed from ratio of brachial pulse pressure/stroke index (i.e. normalized for body height in meter to 2.04 power) (PP/SVi). High PP/SVi ( n  = 980) was defined as >95th sex-specific percentile of the normal distribution from a reference normal population (>2.63/>2.82 mmHg/ml in men and women, respectively). Results: Patients with high PP/SVi were more likely to be women, older, diabetic, with higher systolic blood pressure (BP) and heart rate, more LV concentric geometry, left atrial dilatation and more carotid plaque (all p  < .01). At given increase in SVi, patients with high PP/SVi exhibited two-fold increase in PP compared to normal PP/SVi. In Cox regression, patients with high PP/SVi had 63% increased hazard of MACE [95% CI (1.02-2.59) p  = .04], independently of significant effect of older age, male sex, carotid plaque and less frequent anti-RAS therapy. Conclusions: In treated hypertensive patients, high PP/SVi predicted increased rate of MACE, independent of common confounders.

Arterial hypertension is a leading risk factor for developing atrial fibrillation. CHA 2 DS 2 -VASc score can help to decide if patients with atrial fibrillation need anticoagulation. Whether CHA 2 DS 2 -VASc may predicts incident atrial fibrillation and how it interacts with left atrial dilatation is unknown. We tested this hypothesis in a large registry of treated hypertensive patients. From 12154 hypertensive patients we excluded those with prevalent atrial fibrillation (n 51), without follow-up (n 3496), or carotid ultrasound (n 1891), and low ejection fraction (i.e. <50%, n 119). A CHA 2 DS 2 -VASc score ≥3 was compared with CHA 2 DS 2 -VASc score ≤2. Incident symptomatic or occasionally detected atrial fibrillation was the end-point of the present analysis. At baseline, 956 (15%) patients exhibited high CHA 2 DS 2 -VASc; they were older, most likely to be women, obese and diabetic, with lower glomerular filtration rate, and higher prevalence of left ventricular hypertrophy, left-atrial dilatation and carotid plaque (all p < 0.005). Prevalent Stroke/TIA was found only in the subgroup with high CHA 2 DS 2 -VASc. During follow-up (median = 54 months) atrial fibrillation was identified in 121 patients, 2.57-fold more often in patients with high CHA 2 DS 2 -VASc (95% Cl 1.71-4.86 p < 0.0001). In multivariable Cox analysis, CHA 2 DS 2 -VASc increased incidence of atrial fibrillation by 3-fold, independently of significant effect of left-atrial dilatation (both p < 0.0001) and other markers of organ damage. Incident AF is more than doubled in hypertensive patients with CHA 2 DS 2 -VASc ≥3. Coexisting CHA 2 DS 2 -VASc score >3 and LA dilatation identify high risk subjects potentially needing more aggressive management to prevent AF and associated cerebrovascular ischemic events.

Objectives: The aim of this study was to compare the impact of the European Society of Hypertension Guidelines 2016 (ESHG2016) and the American Academy of Pediatrics Guidelines 2017 (AAPG2017) on the screening of hypertension and classification of abnormal left ventricular geometry (ALVG) in overweight/obese youth., Methods: This study included 6137 overweight/obese youth; 437 had echocardiographic assessment. Hypertension was defined using either ESHG2016 or AAPG2017. ALVG was defined using 95th percentile for age and sex of left ventricular mass index (LVMi) and/or relative wall thickness (RWT) more than 0.38 (juvenile cut-offs) according to ESHG2016 or LVMi more than 51 g/h and/or RWT more than 0.42 (adult cut-offs) according to AAPG2017., Results: Prevalence of youth at a high risk of hypertension was 13% higher using AAPG2017 than ESHG2016. The increase was larger in overweight youth at least 13 years of age (+43%). Using the juvenile cut-offs for ALVG, youth at a high risk of hypertension by ESHG2016 had an odds ratio [95% confidence interval (95% CI)] of 3.03 (1.31-7.05) for left ventricular concentric remodelling (LVcr) and 2.53 (1.43-4.47) for concentric left ventricular hypertrophy (cLVH) as compared with youth with normal LVG. Similarly, in youth at a high risk of hypertension by AAPG2017, the odds ratio for LVcr was 3.28 (1.45-7.41, P < 0.001) and 3.02 (95% CI: 1.73-5.27, P < 0.001) for cLVH. Using the adult cut-offs, no significant difference in ALVG was found with both guidelines., Conclusion: The prevalence of overweight/obese youth at a high risk of hypertension increased by 13% comparing AAPG2017 vs. ESHG2016. The juvenile cut-offs for ALVG were more effective than the adult criteria in intercepting individuals with a potentially higher cardiovascular risk.

Background and Aims: Reduction of left ventricular mass index (LVMi) during antihypertensive treatment is less likely to occur in obese subjects. The aim of the study was to assess whether weight loss influences reduction of LVMi in treated, obese, hypertensive patients., Methods and Results: From the Campania Salute Network registry, we identified 1546 obese hypertensive patients (50 ± 9 years, 43% women) with more than 12 months follow-up. Echocardiographic reduction of LVMi was considered as achievement of normal values (<47 g/m 2.7 in women or <50 g/m 2.7 in men) or a reduction of ≥10% during follow-up. Weight loss was considered as ≥5% reduction in body weight, and occurred in 403 patients (26%) during a median follow-up of 50 months (IQrange:31-93). Median weight loss was 8.6% (IQrange:6.5-12). Patients with weight loss had higher baseline body mass index (p < 0.05), while there was no difference in age, sex, duration of hypertension, prevalence of diabetes, metabolic syndrome and average blood pressure during follow-up. During follow-up, 152 patients (9.8%) exhibited reduction of LVMi. Reduction of LVMi was more frequent (12.9% vs 9.1%, p < 0.030) in patients losing weight than in those who did not. In logistic regression analysis, weight loss was associated with reduction of left ventricular mass index (OR 1.51 [95%CI 1.02-2.23], p = 0.039), independent of significant associations with younger age, lower average systolic blood pressure during follow-up, longer follow-up time and higher LVMi at baseline., Conclusion: In treated obese hypertensive patients, weight loss during follow-up promotes significant reduction of LVMi, independent of baseline characteristics and blood pressure control., (Copyright © 2018 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Hypertensive emergencies are those situations where very high blood pressure (BP) values are associated with acute organ damage, and therefore, require immediate, but careful, BP reduction. The type of acute organ damage is the principal determinant of: (i) the drug of choice, (ii) the target BP, and (iii) the timeframe in which BP should be lowered. Key target organs are the heart, retina, brain, kidneys, and large arteries. Patients who lack acute hypertension-mediated end organ damage do not have a hypertensive emergency and can usually be treated with oral BP-lowering agents and usually discharged after a brief period of observation.

These practice guidelines on the management of arterial hypertension are a concise summary of the more extensive ones prepared by the Task Force jointly appointed by the European Society of Hypertension and the European Society of Cardiology. These guidelines have been prepared on the basis of the best available evidence on all issues deserving recommendations; their role must be educational and not prescriptive or coercive for the management of individual subjects who may differ widely in their personal, medical and cultural characteristics. The members of the Task Force have participated independently in the preparation of these guidelines, drawing on their academic and clinical experience and by objective examination and interpretation of all available literature. A disclosure of their potential conflict of interest is reported on the websites of the ESH and the ESC.

Background: Aortic root (AR) dimension (ARD) at the Valsalva sinuses has been associated with incident cardiovascular (CV) events in population-based studies, but this effect could be due to the association with increased left ventricular (LV) mass. There is also uncertainty on how to define clear-cut AR dilatation. Thus, we analyzed the Campania Salute Network (CSN) registry to (i) establish criteria for evaluation of ARD, (ii) propose cut-points for AR dilatation, and (iii) determine whether AR dilatation has prognostic value independent of LV hypertrophy (LVH)., Methods: We analyzed hypertensive patients with available follow-up, in sinus rhythm and free of prevalent valvular and CV disease (n = 8,573). AR exceeding the 75th percentile of the AR z-score (Ao-Z) obtained by comparison with the value predicted by age, sex, and height (i.e., Ao-Z > 0.80) was considered dilated., Results: Patients with baseline-dilated ARD by Ao-Z were more likely to be younger, men, and obese and had higher baseline blood pressure (BP; all <0.02) but similar kidney function as those without ARD dilatation. In multivariable Cox regression model, dilated ARD predicted 36% increased rate of CV events, independently of older age, male sex, systolic BP, LVH, and class of antihypertensive medications used during follow-up (95% confidence interval: 1.07-1.71, P = 0.011)., Conclusions: In the context of a population of treated hypertensive patients, ARD defined by z-score of predicted values is an independent predictor of CV events regardless of LVH and other common confounders., Clinical Trials Registration: Trial Number NCT02211365.

Background: Left atrial (LA) volume is a predictor of outcome in hypertension. It is unclear whether or not this effect depends on coexisting target organ damage (TOD)., Purpose: To investigate whether LA volume predicts outcome independently of TOD [left ventricular (LV) hypertrophy (LVH) and/or carotid plaque] in a registry of hypertensive treated patients., Methods: From the Campania Salute Network registry, we selected 5844 young adult hypertensive patients <65 years old (mean age 50 ± 9 years, 41% women, 8% diabetic) without prevalent CV or valvular heart disease more than mild, with normal LV ejection fraction, stage III or less CKD and available follow-up. LA volume was estimated from LA diameter applying a validated nonlinear equation, and indexed to body height in meters to the second power (eLAVI). Composite fatal and non-fatal stroke, myocardial infarction, sudden cardiac death, heart failure, TIA, myocardial revascularization, de novo angina, carotid stenting or atrial fibrillation (AF) were adjudicated as incident CV events., Results: 565 (10%) patients exhibited dilated initial eLAVI. During a median follow-up of 49 months, 233 patients developed CV events. Multivariable Cox regression analysis, demonstrated that dilated eLAVI increased risk of incident composite CV events (HR 1.90, 95%CI 1.26-2.88, p = 0.002), independently of significant effect of older age, male sex, presence LVH and carotid plaque. Conclusions In middle aged, treated hypertensive patients, dilated eLAVI is associated with adverse CV risk profile and is a predictor of CV events independently of other markers of TOD. LA dilatation should be considered as a TOD., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background and Aims: Circulating uric acid (UA) is positively associated with body mass index (BMI), blood glucose, blood pressure (BP), markers of inflammation, and altered lipid profile. UA has also anti-oxidative properties which might be beneficial for cardiovascular (CV) system. It is still debated whether or not UA is independently associated with increased CV morbidity and/or mortality., Methods and Results: We studied prognostic impact of UA in 8833 hypertensive adults (mean age 53 ± 12 yrs, 3857 women) from the Campania Salute Network, without prevalent CV disease and more than stage 3 CKD. We calculated standardized UA Z-score, adjusted for age, sex, glomerular filtration rate, and BMI. Low and high UA and UA Z-score quartiles were compared to the 2 middle quartiles assumed to be "normal". Prevalence of obesity and diabetes was higher in low and high than in normal UA Z-score group (all p < 0.001). Systolic BP, left ventricular mass, carotid intima thickness were significantly higher and ejection fraction was reduced in the presence of high UA Z-score (all p < 0.001). Over 33-months average follow-up, incident major CV end-points (MACE) were not significantly different among low, normal and high UA or UA Z-score. In the latter analysis, however, incident MACE tended to be more frequent in the low than the high UA Z-score. Despite the results of multivariable analyses, the effect of less aggressive therapy in low UA Z-score cannot be excluded with certainty., Conclusion: In treated hypertensive patients, high levels of UA normalized for major biological determinants do not independently predict CV outcome. CLINICALTRIALS., Gov Identifier: NCT02211365., (Copyright © 2018 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Background: Elevated left ventricular (LV) mass/end-diastolic volume ratio (LVM/EDV) has been associated with higher evidence of myocardial fibrosis and dysfunction in hypertensive patients by cardiac magnetic resonance, a technique with limited availability., Objectives: We investigated the ability of three-dimensional (3D) echocardiography in identifying a phenotype of LV concentric geometry according to LVM/EDV ratio, possibly detecting early myocardial damage in native-hypertensive patients., Methods: One hundred and twenty-eight native-hypertensive patients underwent 2D and 3D-echocardiography. The population was divided into two groups, according to cut-off point values of 3D-LVM/EDV ratio corresponding to its upper 95% confidence interval in a population of 90 healthy normotensive individuals: LVM/EDV ratio cut-off was 1.22 in men and 1.23 in women., Results: An increased 3D-LVM/EDV ratio identified a higher rate of LV concentric geometry in comparison with 2D-derived relative wall thickness (37 versus 24%, P = 0.03). Patients with LVM/EDV ratio of 1.22 or more in men and 1.23 or more in women were significantly older, had smaller 3D-LV end-diastolic and end-systolic volumes and higher LV mass index, without difference in ejection fraction. 3D-stroke volume (P < 0.0001) was lower in patients with elevated LVM/EDV ratio. By a multilinear regression analysis, after adjusting for sex, age, heart rate, mean blood pressure and BMI, stroke volume was independently and negatively associated to LVM/EDV ratio (β = -0.55, P < 0.0001)., Conclusion: In native hypertensive patients, 3D-echo-derived LVM/EDV ratio identifies a higher prevalence of LV concentric geometry than 2D-relative wall thickness. Stroke volume is independently and negatively associated with LVM/EDV ratio and its reduction represents an early marker of myocardial dysfunction in hypertensives with LV concentric geometry.

Hypertension is a condition characterized by pressure and/or volume overloads and echocardiography is helpful and feasible to understand hemodynamic mechanisms. Echocardiographic information is sometimes critical and susceptible of modifying decision making. In this review, we provide detailed descriptions of the parameters that can be derived from a standard transthoracic echocardiogram, including some more recent techniques. We will also explain how each parameter might have impact in the evaluation of the hypertensive patient and give indications on when to refer patients to echo-labs, which parameters are critical and which ones might be redundant, and how to use the information obtained in the report. Cardiac geometry, LV systolic and diastolic function, LV pump performance, output impedance and left atrial function are parameters that might be altered in arterial hypertension, but not necessarily doctors need the whole information for decision making. The critical measures are provided.

Background: Lowering systolic blood pressure (SBP) below the conventional threshold (140 mm Hg) reduces left ventricular (LV) hypertrophy and incident cardiovascular (CV) events. We assessed whether different thresholds of SBP as the average value during follow-up (FU) have different impact on changes in target organ damage (TOD)., Methods: From the Campania Salute Network registry, we selected 4,148 hypertensive patients with average SBP-FU <140 mm Hg, and without history of prevalent CV or chronic kidney disease (i.e.,

Background: In general, women have lower risk for cardiovascular disease. We tested whether this sex-specific protection persists also in the presence of hypertensive left ventricular hypertrophy (LVH)., Methods: 12,329 women and men with hypertension and free from prevalent cardiovascular disease enrolled in the prospective Campania Salute Network registry were followed over a median of 4.1years. Subjects were grouped according to the absence or the presence of LVH identified by echocardiography using validated sex-specific cut-off values of LV mass index (>47g/m 2.7 in women and >50g/m 2.7 in men). Main outcome was major cardiovascular events (MACE; combined acute coronary syndromes, stroke, hospitalization for heart failure and incident atrial fibrillation)., Results: The cardiovascular risk profile accompanying LVH did not differ between sexes, but presence of obesity and diabetes carried higher probability for LVH in women, and LVH was more prevalent in women than men (43.4 vs. 32.1%, p<0.001). Among patients without LVH (n=7764), women had a 35% lower hazard rate (HR) for MACE (n=179) than men (95% confidence interval [CI] 0.44-0.96, p=0.031) in Cox regression analysis adjusting for cardiovascular risk factors and antihypertensive treatment during follow up. In contrast, among patients with LVH (n=4565), women had a similar HR for MACE as men (HR 0.94 [95% CI 0.69-1.30], p=0.720)., Conclusion: This study demonstrates that presence of LVH in hypertension offsets the female sex-protection in cardiovascular risk. Thus among hypertensive subjects with LVH, women and men have comparable cardiovascular risk., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Hypertension is a leading cause of chronic kidney disease (CKD) and a decrease in glomerular filtration rate (GFR) is associated with a higher prevalence of hypertension and an increased proportion of suboptimal blood pressure (BP) control., Methods: To investigate characteristics associated with GFR decline, we selected 4539 hypertensive patients from the Campania Salute Network (mean age 53 ± 11 years) with at least 3 years of follow-up (FU) and no more than Stage III CKD. GFR was calculated at baseline and at the last available visit using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. GFR decline was defined as a ≥30% decrease from initial GFR for patients in Stage III CKD or by a composite ≥30% decrease from baseline and a final value of <60 for those < with Stage III or higher CKD., Results: At a mean FU of 7.5 years, 432 patients (10%) presented with GFR decline. Those patients were older, more likely to be diabetic, with lower GFR and ejection fraction, higher systolic and lower diastolic BP and higher left ventricular (LV) mass and relative wall thickness at baseline; during FU, patients with GFR decline exhibited higher systolic BP, took more drugs and developed more atrial fibrillation (all P < 0.02). The probability of GFR decline was independently associated with older age, prevalent diabetes, baseline lower GFR, higher systolic BP during FU, FU duration, increased LV mass and incident AF with no impact from antihypertensive and antiplatelet medications., Conclusions: During antihypertensive therapy, kidney function declines in patients with initially lower GFR, increased LV mass and suboptimal BP control during FU., (© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Aim of study was to examine experimentally the adult female hypertensive heart in order to determine the role of ovary function in the response of the heart to salt-dependent hypertension. Dahl salt-sensitive rats, age 12 weeks, with/without ovariectomy were fed a standard (0.3% NaCl) or high-salt diet (8%) for 16 weeks. Mean arterial blood pressure monitored noninvasively in conscious state increased significantly by high salt. Echocardiography was performed at baseline and endpoint. Heart function and molecular changes were evaluated at endpoint by left ventricle catheterization, by sirius red staining for collagen and by gene expression using quantitative RT-PCR for selected genes. At endpoint, significant concentric hypertrophy was present with high salt. Increase in relative wall thickening with high salt compared to normal diet was more pronounced with intact ovaries (0.33 ± 0.02 and 0.57 ± 0.04 vs. 0.29 ± 0.00 and 0.46 ± 0.03) as was the reduction in midwall fractional shortening (20 ± 0.6 and 14 ± 2 vs. 19 ± 0.9 and 18 ± 1). Ovariectomy increased stroke volume and decreased the ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (E') (E/E' ratio) when compared to hearts from intact rats. High salt increased expression of collagen I and III genes and perivascular collagen in the heart slightly, but % interstitial collagen by sirius red staining remained unchanged in intact rats and decreased significantly by ovariectomy. Added volume load but not deterioration of function or structure characterized the nonfailing hypertensive heart of salt-sensitive females ovariectomized at mature age when compared to corresponding intact females., (© 2018 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of The Physiological Society and the American Physiological Society.)

Hypertension (HTN) is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease (CAD), stroke, peripheral artery disease and chronic renal failure. Hypertensive heart disease can manifest as many types of cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in HTN patients, especially in those with left ventricular hypertrophy (LVH), CAD, or HF. In addition, high doses of thiazide diuretics commonly used to treat HTN, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesaemia), contributing further to arrhythmias, while effective blood pressure control may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between HTN and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit of comprehensively reviewing the available evidence and publishing a joint consensus document on HTN and cardiac arrhythmias, and providing up-to-date consensus recommendations for use in clinical practice. The ultimate judgment on the care of a specific patient must be made by the healthcare provider and the patient in light of all individual factors presented. This is an executive summary of the full document co-published by EHRA in EP-Europace., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For Permissions, please email: journals.permissions@oup.com.)

Background: Whether increasing body mass index (BMI) is independently associated with parallel increased prevalence of hypertensive vascular and cardiac target organ damage (TOD) needs further clarification., Methods: We analyzed 8815 hypertensive patients without prevalent cardiovascular disease, participating in the Campania Salute Network, grouped into BMI classes (normal 20-24.9kg/m 2 , overweight 25-29.9kg/m 2 and obese ≥30kg/m 2 ). Vascular and cardiac TOD was defined as ultrasound plaque (intima-media thickness>1.5mm) in >1 of the common or internal carotid arteries and echocardiographic left ventricular (LV) hypertrophy (LVH) (LV mass/height 2.7 >47g/m 2.7 in women and >50g/m 2.7 in men), respectively., Results: A majority of patients were either overweight (49%) or obese (27%). In spite of more use of combination therapy, the obese group had higher blood pressure (BP) and prevalence of TOD. In multivariate logistic analyses, obesity was associated with a 6.9 times higher prevalence of LVH (95% confidence interval [CI] 5.84-8.17, p=0.0001), independent of significant associations with female sex, age, diabetes mellitus, office systolic BP, antihypertensive and antiplatelet treatment. In contrast, only a 17% increased prevalence of carotid plaques (OR=1.17; 95% CI 1.02-1.33, p=0.02) was found in obese patients independent of significant effect of male sex, older age and higher clinic systolic BP, an association that disappeared once effect of metabolic risk factors and related therapy was also considered., Conclusions: In hypertensive patients participating in the Campania Salute Project, concomitant obesity was associated with a modestly increased prevalence of carotid plaques and a pronounced increase in prevalent LVH., (Copyright © 2017 Elsevier B.V. All rights reserved.)

: Arterial hypertension accounts for the largest amount of attributable cardiovascular mortality worldwide, and risk stratification in hypertensive patients is of crucial importance to manage treatment and prevent adverse events. Asymptomatic involvement of different organs in patients affected by hypertension represents an independent determinant of cardiovascular risk, and the identification of target organ damage is recommended to further reclassify patients' risk. Noninvasive cardiovascular imaging is progressively being used and continues to provide new technological opportunities to target organ damage evaluation at early stage. The aim of this article is to provide the community of cardiology with an update on appropriate and justified use of noninvasive imaging tests in the growing population of hypertensive patients.

Arterial hypertension (HTN) accounts for the largest amount of attributable cardiovascular (CV) mortality worldwide, and risk stratification in hypertensive patients is of crucial importance to manage treatment and prevent adverse events. Asymptomatic involvement of different organs in patients affected by HTN represents an independent determinant of CV risk and the identification of target organ damage (TOD) is recommended to further reclassify patients' risk. Non-invasive CV imaging is progressively being used and continues to provide new technological opportunities to TOD evaluation at early stage. The aim of this article is to provide the community of cardiology with an update on appropriate and justified use of non-invasive imaging tests in the growing population of hypertensive patients., (© The Authors, 2017. This article has been co-published in European Heart Journal - Cardiovascular Imaging and Journal of Hypertension The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can be used when citing this article.)

Objectives: Deficient plasminogen activator inhibitor-1 (PAI-1) prevented hypertension in mice. Plasma PAI-1 was associated with hypertension in cross-sectional analyses, but the prospective association of PAI-1 with incident hypertension in large epidemiological studies is scarce., Methods: Leveraging two longitudinal cohorts of American Indians in the Strong Heart Study (SHS, N = 1019) and the Strong Heart Family Study (SHFS, N = 1502), we examined the prospective association of plasma PAI-1 with incident hypertension by multivariate logistic regression, adjusting for age, sex, study site, smoking, drinking, dietary sodium, obesity, lipids, fasting glucose, kidney function, inflammation, and follow-up years. Family relatedness in the SHFS was accounted for using the GLIMMIX procedure. Plasma PAI-1 level at baseline was measured by immunoassay. All participants were free of hypertension, cardiovascular diseases, and chronic kidney disease at baseline., Results: A total of 305 and 258 participants, respectively, from the SHS (57 ± 7 years) and the SHFS (33 ± 13 years) developed incident hypertension during follow-up. In the SHS, higher level of log-transformed PAI-1 was associated with 1.35-fold increased risk of hypertension [odds ratio (OR) (95% confidence interval): 1.35 (1.06-1.72)]. Analysis using categorical PAI-1 (in tertiles) showed that participants in the highest tertile (≥58 ng/ml) had 63% increased risk for hypertension [OR = 1.63 (1.12-2.37)] compared with those in the lowest tertile (<33 ng/ml). This association was confirmed in the SHFS with similar effect sizes [OR = 1.41 (1.11-1.81) for log-transformed PAI-1; OR = 1.64 (1.08-2.50) for categorical PAI-1: ≥58 vs. <33 ng/ml]., Conclusion: A higher level of plasma PAI-1 is significantly associated with hypertension in American Indians, independent of established risk factors. The potential causality warrants further investigation.

Background and Aims: Hypertension (HTH) is a frequent complication in pediatric obesity. To simplify the screening of HTH in overweight/obese (Ow/Ob) youth, we compared the performance of a new index (High Blood Pressure index, HBPi) with respect to the standard criteria of the IV Report [systolic BP (SBP) and/or diastolic BP (DBP) ≥95th percentile for age, gender and height]. We also compared the performance of HBPi with other simplified indices such as the BP/height ratio and the absolute height-specific BP thresholds. Ten pediatrics' outpatient centers participating in the "CARdiometabolic risk factors in ITALY study" provided medical records of 4225 Ow/Ob children and adolescents (age 6-16 years)., Methods and Results: Centers were divided into two groups: training set (TS) (n = 2204 participants) and validation set (VS) (n = 2021 participants). The simplified HBPi (mmHg) was: (SBP/2 + DBP/10) - age + (1 × female gender). In the TS, a HBPi value ≥57 mmHg in both children and adolescents had high sensitivity (0.89), specificity (0.97), positive (0.89) and negative (0.97) predictive values in classifying youth at high risk of HTN compared with the IV Report. In the VS, the HBPi showed a better performance than high levels of BP/height ratio and height-specific BP thresholds in classifying individuals at risk of HTN: area under curves 0.95 (0.93-0.96), 0.80 (0.78-0.82), 0.76 (0.74-0.79), respectively; specificities 0.95 (0.94-0.96), 0.69 (0.67-0.72), 0.60 (0.57-0.62), respectively., Conclusions: HBPi, combining SBP and DBP, gender and age, may help pediatricians to implement HTN screening in Ow/Ob youth., (Copyright © 2017 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

We tested the prognostic impact of a marker of arterial stiffness, pulse pressure/stroke volume index (PP/SVi), in patients with hypertension and left ventricular (LV) hypertrophy. We used data from 866 patients randomized to losartan or atenolol-based antihypertensive treatment, over a median of 4.8 years, in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. The association of PP/SVi with outcomes was tested in Cox regression analyses and reported as hazard ratio (HR) and 95% confidence intervals (CI). In multivariate regression, reduction of PP/SVi was independently associated with male gender, reduction in systolic blood pressure (BP) and relative wall thickness and with an increase in left ventricular ejection fraction (all p < .05). After adjusting for confounders, higher baseline PP/SVi predicted a 38% higher hazard of combined major fatal and non-fatal cardiovascular events (95% CI 1.04-1.84), and higher hazard of cardiovascular mortality (HR 2.35 (95% CI 1.59-3.48) and stroke (HR 1.45 (95% CI 1.06-1.99) (all p < .05). Higher PP/SVi also predicts higher rate of hospitalization for HF (HR 2.15 (95% CI 1.48-3.12) and a 52% higher hazard of all-cause mortality (95% CI 1.10-2.09) (both p < .05). In hypertensive patients with electrocardiographic LV hypertrophy, higher PP/SVi was associated with increased cardiovascular morbidity and mortality.

Reduced myocardial mechano-energetic efficiency (MEE), estimated as stroke volume/heart rate ratio per g of left ventricular (LV) mass (LVM), and expressed in μl s -1  g -1 (MEEi), is a strong predictor of cardiovascular (CV) events, independently of LV hypertrophy and other confounders, including type II diabetes (DM). Decreased MEEi is more frequent in patients with diabetes. In the present analysis we evaluated the interrelation among MEEi, DM and metabolic syndrome (MetS) in the setting of arterial hypertension. Hypertensive patients from the Campania Salute Network, free of prevalent CV disease and with ejection fraction >50% (n=12 503), were analysed. Coexistence of MetS and DM was ordinally categorized into 4 groups: 8235 patients with neither MetS nor DM (MetS-/DM-); 502 without MetS and with DM (MetS-/DM+); 3045 with MetS and without DM (MetS+/DM-); and 721 with MetS and DM (MetS+/DM+). After controlling for sex, systolic blood pressure, body mass index, relative wall thickness (RWT), antihypertensive medications and type of antidiabetic therapy, MEEi was 333 μl s -1  g -1 in MetS-/DM-, 328 in MetS-/DM+, 326 in MetS+/DM- and 319 in MetS+/DM+ (P for trend <0.0001). In pairwise comparisons (Sidak-adjusted), all conditions, except MetS-/DM+, were significantly different from MetS-/DM- (all P<0.02). No statistical difference was detected between MetS-/DM+ and MetS+/DM-. Both MetS and DM are associated with decreased MEEi in hypertensive patients, independently to each other, but the reduction is statistically less evident for MetS-/DM+. MetS+/DM+ patients have the lowest levels of MEEi, consistent with the alterations of energy supply associated with the combination of insulin resistance with insulin deficiency.

Background: Regression of left ventricular (LV) hypertrophy (LVH) has been a goal in clinical trials. This study tests the external validity of results of clinical trials on LVH regression using a large registry from a tertiary care center, to identify phenotypes less likely to achieve regression of LVH., Methods and Results: Patients from the Campania Salute Network, free of prevalent cardiovascular disease, but with echocardiographic LVH (defined as LV mass index [LVMi] >47 g/m 2.7 in women and >50 g/m 2.7 in men) were included. During a median follow-up of 67 months, clear-cut regression of LVH was documented in 14% of patients (13±8% reduction of initial LVMi) or 23% when also considering those with a reduction of LVMi ≥5 g/m 2.7 . Patients with persistent LVH were older with longer duration of hypertension, suboptimal blood pressure (BP) control, larger body mass index, LV mass, and carotid intima-media thickness and included more women and subjects with diabetes mellitus, isolated systolic hypertension, and metabolic syndrome (all P <0.05). Number and class of antihypertensive drugs during follow-up did not differ between groups. In multiple logistic regression analysis, older age, female sex, obesity, higher baseline LVMi and carotid intima-media thickness, and suboptimal BP control were significant covariates of persistent LVH (all P ≤0.01), independent of diabetes, duration of hypertension, isolated systolic hypertension, follow-up time and number and class of antihypertensive drugs., Conclusions: Early initiation of antihypertensive treatment, aggressive BP control, and attention to metabolic aspects are critical to avoid irreversible LVH., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

There is little information on left ventricular (LV) hypertrophy (LVH) development during antihypertensive treatment. We evaluate incident LVH in a treated hypertensive cohort, the Campania Salute Network registry. We analyzed prospectively 4290 hypertensives (aged 50.3±11.1 years, 40% women) with at least 1-year follow-up, without LVH at baseline. Incident LVH was defined as the first detection of echocardiographic LV mass index ≥47 in women or ≥50 g/m 2.7 in men. During a median 48-month follow-up, 915 patients (21.3%) developed LVH. They were older, more frequently women, and obese (P<0.0001), with initial higher fasting glucose, diastolic and systolic blood pressure, LV mass index, lower heart rate and glomerular filtration rate, longer hypertension history and follow-up, and higher average systolic blood pressure during follow-up (all P<0.05), despite a more frequent treatment with Ca ++ -channel blockers and diuretics (both P<0.02). At multivariable Cox regression, incident LVH was independently associated with older age, female sex, obesity, higher average systolic blood pressure during follow-up, and initial greater LV mass index (all P<0.02). By categorizing patients according to obesity and sex, obesity independently increased the risk for incident LVH in both sexes (obese versus nonobese men: hazard ratio, 1.34; confidence interval, 1.05-1.72; P=0.019; and obese versus nonobese women: hazard ratio, 1.34; confidence interval, 1.08-1.66; P=0.007). Despite more aggressive antihypertensive therapy, 21% of hypertensive patients develop clear-cut LVH. After adjusting for confounders, risk of incident LVH is particular relevant among women and is further increased by the presence of obesity., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02211365., (© 2016 American Heart Association, Inc.)

Background: Left atrial (LA) dilatation is associated with unfavorable outcome in hypertension. However, there are few data on clinical, demographic, and echocardiographic findings correlated with LA dilatation development., Methods: From the Campania-Salute Network registry, we identified 5,375 hypertensive patients (52±11 years, 38% women) in normal sinus rhythm, with normal LA diameter (parasternal short-axis <24.0 in women and <25.4mm/m in men), with normal left ventricular (LV) ejection fraction, and with at least 12 months of echocardiographic follow-up. We included in the clinic evaluation type of antihypertensive drugs., Results: Follow-up duration was of 70±48 months. During follow-up, 647 patients (12%) showed LA dilatation. Patients with incident LA dilatation were older, most likely to be women, more obese, more diabetics, with lower Modification of Diet in Renal Disease, higher total cholesterol, lower uric acid, higher pulse pressure, lower heart rate, higher LV mass, concentric geometry and lower E/A ratio at mitral level, longer E deceleration time, and higher intima-media carotid thickness. They take more drugs, and follow-up was longer (overall P < 0.05). In the Cox analysis, age, female gender, obesity, higher LV mass, LA diameter at baseline, and longer E deceleration time were determinants of LA dilatation. Furthermore, the use of diuretics protected against LA dilatation., Conclusions: Our data identify a risk profile for LA dilatation, characterized by older age, female sex, obesity, higher LV mass, and worse diastolic function. In this subgroup of patients, the use of diuretics seems to protect against LA dilatation., (© American Journal of Hypertension, Ltd 2016. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background and Purpose: Myocardial mechano-energetic efficiency (MEE) can be easily approximated by the ratio of stroke work [i.e. SBP times stroke volume (SV)] to a rough estimate of energy consumption, the 'double product' [SBP times heart rate (HR)], which can be simplified as SV/HR. We evaluated whether MEE is associated with adverse prognosis in relation to the presence of left ventricular hypertrophy (LVH)., Methods: Hypertensive participants of the Campania Salute Network (n = 12 353) without prevalent coronary or cerebrovascular disease and with ejection fraction more than 50% were cross-sectionally and longitudinally analyzed, over a median follow-up of 31 months. MEE was estimated by echocardiographic SV (z-derived)/(HR × 0.6)., Results: Due to the close relation with left ventricular mass (LVM) (P < 0.0001), MEE was normalized for LVM (MEEi) and divided into quartiles. The lowest quartile of MEEi (<0.29 ml/s per g) was considered 'low MEEi'. MEEi was greater in women than in men (P < 0.0001). Progressively lower MEEi was associated with older age, male sex, obesity, diabetes, LVH, concentric geometry, inappropriate LVM and diastolic dysfunction, more use of antihypertensive therapy, and higher BP (all P < 0.002). In Cox regression, after controlling for LVH, age, sex, and average follow-up SBP, low MEEi exhibited increased hazard of composite fatal and nonfatal cardiovascular end-points (P < 0.01), independently of antihypertensive therapy and associated cardiovascular risk factors., Conclusion: A simple estimate of low myocardial mechano-energetic efficiency is associated with altered metabolic profile, LVH, concentric left ventricular geometry, and diastolic dysfunction and predicts cardiovascular end-points, independently of age, sex, LVH antihypertensive therapy, and cardiovascular risk factors.

Little is known about the potential progression of hypertensive patients towards isolated systolic hypertension (ISH) and about the phenotypes associated with the development of this condition. Aim of this study was to detect predictors of evolution towards ISH in patients with initial systolic-diastolic hypertension. We selected 7801 hypertensive patients free of prevalent cardiovascular (CV) diseases or severe chronic kidney disease and with at least 6-month follow-up from the Campania Salute Network. During 55±44 months of follow-up, incidence of ISH was 21%. Patients with ISH at the follow-up were significantly older (P<0.0001), had longer duration of hypertension, higher prevalence of diabetes and were more likely to be women (all P<0.0001). They exhibited higher baseline left ventricular mass index (LVMi), arterial stiffness (pulse pressure/stroke index), relative wall thickness (RWT) and carotid intima-media thickness (IMT; all P<0.001). Independent predictors of incident ISH were older age (odds ratio (OR)=1.14/5 years), female gender (OR=1.30), higher baseline systolic blood pressure (OR=1.03/5 mm Hg), lower diastolic blood pressure (OR=0.89/5 mm Hg), longer duration of hypertension (OR=1.08/5 months), higher LVMi (OR=1.02/5 g m(-2.7)), arterial stiffness (OR=2.01), RWT (OR=1.02), IMT (OR=1.19 mm(-1); all P<0.0001), independently of antihypertensive treatment, obesity, diabetes and fasting glucose (P>0.05). Our findings suggest that ISH is a sign of aggravation of the atherosclerotic disease already evident by the target organ damage. Great efforts should be paid to prevent this evolution and prompt aggressive therapy for arterial hypertension should be issued before the onset of target organ damage, to reduce global CV risk.

Objectives: Little is known about the impact of pulse pressure on left ventricular systolic function. The aim of our study was to evaluate whether high pulse pressure is associated with subclinical left ventricular systolic dysfunction., Methods: The study population included 143 participants (68 newly diagnosed, never-treated hypertensive, and 75 normotensive individuals) evaluated by echo-Doppler, including determination of global longitudinal strain (GLS) by speckle tracking. According to pulse pressure tertiles, participants were divided in two groups: the first group merging the first and second pulse pressure tertiles (n = 93, pulse pressure <55 mmHg) and the second group including the highest pulse pressure tertile (HPPT; n = 50, pulse pressure ≥55 mmHg)., Results: The two groups were comparable for sex, BMI, and heart rate, whereas age was higher in individuals with the HPPT (P < 0.0001). Left ventricular mass index was significantly higher in individuals with the HPPT (P < 0.01), with no significant difference in relative wall thickness. Among several indices of left ventricular systolic function, only GLS was lower in individuals with the HPPT (P < 0.001). Transmitral E/A ratio (P = 0.006) was lower and E/e' ratio higher (P < 0.001) in the HPPT group. By a multilinear regression analysis, HPPT (P < 0.020) and overweight (P = 0.025) were independent correlates of low GLS. Replacing HPPT with the highest systolic blood pressure tertile, GLS was independently associated with BMI (P = 0.040), but not with the highest systolic blood pressure tertile (P = 0.069)., Conclusion: Elevated pulse pressure negatively influences left ventricular longitudinal mechanics in a mixed population of normotensive and untreated hypertensive individuals.