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Background: The aim of the present study was to evaluate the association between heart failure (HF) and chronic kidney disease (CKD) in tertiary care centers using the clinical records of patients enrolled in internal medicine departments.Patients and methods: We used the clinical records of 1380 elderly patients to identify patients with a history of HF and CKD using admission ICD codes and glomerular filtration rate (GFR) formulas. Magnitude and strength of such associations were investigated by univariable and multivariable analysis.Results: Of the 1380 patients enrolled, 27.9% had HF (age 80 ± 7, BMI 27 ± 6 kg/m2) and 17.4% CKD (age 81 ± 7, BMI 26.8 ± 6 kg/m2). Both groups were significantly older (P <' 0.0001) with BMI higher than the patients without those diagnosis (P < 0.02). Patients with a history of CKD showed higher non-fasting glycaemia (140 ± 86 vs. 125 ± 63 mg/dL, P < 0.001). CKD was significantly associated with HF (P < 0.0001). Patients with HF had an estimated GFR lower than patients without HF (P < 0.0001). Comorbidity and severity indices were significantly higher in subjects with HF (P < 0.0001) and CKD (P < 0.0001) than in those without. Multivariable analysis showed a significant association between HF and age (for five years increase OR 1.13, P < 0.009), BMI (for each 3 kg/m2 increase OR 1.15, P < 0.001), GFR (for each decrease of 10 mL/min increase OR 0.92, P < 0.002) and severity index (IS) (for each 0.25 units increase OR 1.43, P < 0.001).Conclusion: HF on admission is strongly associated with CKD, older age, BMI, and SI. These data focus the value of epidemiological studies such REPOSI in identifying and monitoring multimorbidity in elderly.

The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists. Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient.

Pharmacological thromboprophylaxis (TP) is known to reduce venous thromboembolism (VTE) in medical inpatients, but the criteria for risk-driven prescription, safety and impact on mortality are still debated. We analyze data on elderly patients with multimorbidities admitted in the year 2010 to the Italian internal medicine wards participating in the REPOSI registry to investigate the rate of TP during the hospital stay, and analyze the factors that are related to its prescription. Multivariate logistic regression, area under the ROC curve and CART analysis were performed to look for independent predictors of TP prescription. Association between TP and VTE, bleeding and death in hospital and during the 3-month post-discharge follow-up were explored by logistic regression and propensity score analysis. Among the 1,380 patients enrolled, 171 (15.2 %) were on TP during the hospital stay (162 on low molecular weight heparins, 9 on fondaparinux). The disability Barthel index was the main independent predictor of TP prescription. Rate of fatal and non-fatal VTE and bleeding during and after hospitalization did not differ between TP and non-TP patients. In-hospital and post-discharge mortality was significantly higher in patients on TP, that however was not an independent predictor of mortality. Among elderly medical patients there was a relatively low rate of TP, that was more frequently prescribed to patients with a higher degree of disability and who had an overall higher mortality.

Objective. To describe the prevalence of advanced retinal microvascular lesions and their associations with cardiac and extracardiac signs of target organ damage (TOD) in a large selected hypertensive population. Methods. A total of 2172 non-diabetic untreated and treated uncomplicated essential hypertensives consecutively attending for the first time our hospital outpatient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension (ETODH), an observational ongoing registry of hypertension-related TOD, were considered for this analysis. Advanced hypertensive retinopathy was defined by the presence of any of the following lesions: flame-shaped haemorrhages, soft exudates or cotton wool spots and papilloedema. Left ventricular hypertrophy (LVH), carotid structural abnormalities, such as plaques and intima media (IM) thickening, and microalbuminuria were diagnosed according to the 2003 ESH/ESC guidelines criteria. Results. Among the whole study population, 33 patients (1.5%) were found to have advanced hypertensive retinopathy. Patients with these retinal lesions were similar to those without for age, body mass index, known duration of hypertension, smoking habit, total serum cholesterol, fasting blood glucose and prevalence of antihypertensive treatment; whereas mean systolic and diastolic blood pressures were higher in the former group. The prevalence rates of LVH, carotid plaques, carotid IM thickening and microalbuminuria in patients with and without retinopathy were 57%, 67%, 69%, 19% and 25%, 47%, 44%, 12%, respectively. In a multivariate logistic regression analysis, advanced retinopathy was significantly associated with LVH (OR=4.0), carotid IM thickening (OR=2.9), carotid plaques (OR=2.8), but not with microalbuminuria. Conclusions. Our study indicates that: (i) advanced retinopathy is a rare finding in non-diabetic hypertensive patients seen in a specialist setting; (ii) a strong relation exists between retinal microvascular le

Coarctation of the aorta is the fourth most frequent form of congenital cardiovascular disease, which is diagnosed by the presence of higher blood pressures in the arms than in the legs. In this report we describe 3 cases of aortic coarctation, in which the correct diagnosis was suspected only months or years after the detection of hypertension, when a renal ultrasound examination was requested, despite the fact that the hallmarks of the disease were present at the physical examination in all patients. A marked reduction in renal flow velocities was suggestive of proximal aortic stenosis in all 3 cases. We conclude that the diagnosis of aortic coarctation, an uncommon but not so rare form of secondary hypertension, by renal ultrasonography rather than by a complete physical examination, reflects a commitment failure of physicians in everyday management of hypertension. © 2005 CEPI Srl.

Background: The cardiac effects of hypertension include a variety of structural changes such as increases in left ventricular mass (LVM) and left atrium (LA) size. Although data on hypertension-induced left ventricular changes are extensive, relatively little information is available on LA size from large-scale studies. Objective: We sought to assess the prevalence of LA enlargement in a large selected hypertensive population and to determine the relations of LA size to several biologic variables including left ventricular hypertrophy (LVH) and metabolic disturbances. Methods: A total of 2500 untreated and treated uncomplicated essential hypertensives consecutively attending, for the first time, our hospital out-patient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension, an observational ongoing registry of hypertension-related target organ damage (TOD), were considered for this analysis. All patients underwent extensive clinical, laboratory and ultrasonographic investigations searching for cardiac (and extracardiac) TOD. The LA was considered enlarged when its anteroposterior diameter exceeded 3.7 cm in women and 4.1 cm in men. LVH was defined according to two different criteria: ≥ 125 g/m2 in men and ≥ 110 g/m2 in women; or ≥ 51 g/m2.7 in men and ≥47 g/m2.7 in women. Results: Enlarged LA diameter was present in 24.5% of women and in 21.5% of men. Compared with 1925 patients with normal LA size, the 575 patients with enlarged LA were older, more frequently overweight, had higher systolic blood pressure and included a greater proportion of subjects under antihypertensive treatment, with diabetes and metabolic syndrome. Both LA size and prevalence of LA enlargement differed significantly in relation to left ventricular geometry and LVM, being greater in patients with concentric or eccentric LVH than in those with left ventricular concentric remodeling or normal geometry. The prevalence of LA enlargement was similar in patients w

Background and purpose: 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 intimamedia thickness (IMT) and microalbuminuria, in early stages of untreated essential hypertension. Methods: 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, 42.70/0). Results: 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/m2), 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. Conclusions: These results show that: (1) a very large fraction (more than 80%) of untreated, recently diagnosed

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/m2 in men and ≥110 g/m2 in 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 rea

Objective: 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. Methods: A total of 375 never-treated essential hypertensive patients [mean 24-h blood pressure (BP) ≥ 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. Results: A reproducible nocturnal dipping (decrease in BP > 10% from mean daytime BP in both ABPM periods) and non-dipping profile (decrease in BP < 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/m2, 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/m2 in men and > 110 g/m2 in women) was greater in group II (19%) than In group I (6%) (P < 0.05), whereas the differences bet

Objective: The aim of this study was to examine whether an impaired reduction in nocturnal blood pressure (BP), defined on the basis of two periods of ambulatory BP monitoring (ABPM), is present in hypertensive patients with metabolic syndrome, as defined by the NCEP criteria. Methods: 460 grade 1 and 2 untreated essential hypertensives (mean age 45.9 ± 11.9 years) referred for the first time to our outpatient hospital clinic underwent the following procedures: 1) medical history and physical examination; 2) repeated clinic BP measurements; 3) routine examinations; 4) ABPM over two 24-hour periods within 4 weeks. Metabolic syndrome was defined as at least three of the following alterations: increased waist circumference, increased triglycerides, decreased HDL-cholesterol, increased BP, or high fasting glucose. Nocturnal dipping was defined as a night-time reduction in average SBP and DBP > 10% compared to average daytime values. Results: The 135 patients with metabolic syndrome (group I) were similar for age, gender and known duration of hypertension to the 325 patients without it (group II). There were no significant differences between the two groups in average 48-hour, daytime, night-time SBP/DBP values and the percentage nocturnal SBP and DBP decrease (-17.7/-15.7 vs.-18.4/-16.2, p = ns). A reproducible nocturnal dipping (decrease in BP > 10% from mean daytime in both ABPM periods) and non-dipping profile (decrease in BP ≤ 10% in both ABPM periods) was found in 74 (54.8%) and 29 (21.4%) in group I and in 169 (52.1%) and 73 (22.4%) in group II, respectively (p = ns); 32 patients (23.7%) in group I and 83 patients (25.5%) in group II had a variable dipping profile (p = ns). Conclusions: This study shows that no significant difference exists in nocturnal BP patterns, assessed by two ABPMs, in untreated essential hypertensive patients with metabolic syndrome compared to those without it. © 2004 Taylor & Francis on licence from Blood Pressure.

Background: The prevalence and the relationship between metabolic syndrome, and target organ damage (TOD) in essential hypertensive patients has not been fully explored to date. Objective: To investigate the association between metabolic syndrome, as defined by the ATP III report, and cardiac and extracardiac TOD, as defined by the 2003 ESH-ESC guidelines for management of hypertension, in a large population of never-treated essential hypertensives. Methods: A total of 447 grade 1 and 2 hypertensive patients (mean age 46 ± 12 years) who were attending a hypertension hospital outpatient clinic for the first time underwent the following procedures: (i) physical examination and repeated clinic blood pressure measurements; (ii) routine examinations; (iii) 24-h urine collection for microalbuminuria; (iv) 24-h ambulatory blood pressure monitoring; (v) echocardiography; and (vi) carotid ultrasonography. Metabolic syndrome was defined as involving at least three of the following alterations: increased waist circumference, increased triglycerides, decreased high-density lipoprotein cholesterol, increased blood pressure, or high fasting glucose. Left ventricular hypertrophy (LVH) was defined according to two different criteria: (i) 125 g/m2 in men and 110 g/m2 in women; (ii) 51 g/h2.7 in men and 47 g/h2.7 in women. Results: The 135 patients with metabolic syndrome (group I) were similar for age, sex distribution, known duration of hypertension and average 24-h, daytime and night-time ambulatory blood pressure to the 312 patients without it (group II). The prevalence of altered left ventricular patterns (LVH and left ventricular concentric remodelling) was significantly higher in group I (criterion a = 30%, criterion b = 42%) than in group II (criterion a = 23%, criterion b = 30%, P < 0.05 and P < 0.01, respectively). A greater urinary albumin excretion (17 ± 35 versus 11 ± 23 mg/24 h, P = 0.04) was also found in group I compared to group II. There were no significant differen

Background: The 2003 European Society of Hypertension/European Society of Cardiology (ESH-ESC) guidelines have recently proposed a new risk stratification scheme for estimating absolute risk for cardiovascular disease. At variance from the previous 1999 World Health Organization–International Society of Hypertension (WHO/ISH) guidelines, the new criteria include some additional risk factors such as obesity, abnormal high-density (HDL) or low-density lipoprotein (LDL) cholesterol levels and define a slight increase in creatinine and microalbuminuria as signs of target organ damage (TOD). Objective: The aim of the study was to assess overall cardiovascular risk in uncomplicated hypertensives according to the 2003 ESH-ESC guidelines comparing this approach with the stratification scheme of the 1999 WHO/ISH guidelines. Methods: Four hundred and twenty-five never-treated grade 1 and 2 essential hypertensive patients, referred for the first time to our outpatient clinic without diabetes mellitus, were included in the study. They underwent the following procedures: (i) repeated clinical blood pressure measurements; (ii) routine blood chemistry and urine analysis; (iii) electrocardiogram; (iv) 24-h urine collection for microalbuminuria; (v) echocardiogram; and (vi) carotid ultrasonogram. Risk was assessed according to both stratification schemes suggested by the 2003 ESH-ESC and 1999 WHO/ISH guidelines. Results: According to the 2003 ESH-ESC guidelines, 15.5% of the 425 patients were considered at low added risk, 47.8% at medium added risk and 36.7% at high added risk; 146 patients (34.3%) were classified in the high-risk stratum because of at least one manifestation of TOD and 5.6% having three or more risk factors. The accuracy in detecting TOD of the combined approach with ultrasound procedures and microalbuminuria was approximately 10-fold higher than that provided by routine investigation. As a result of the 1999 WHO/ISH stratification scheme, 34.5% were low-risk, 34.4

Objective: The aim of the study was to evaluate the prevalence of left ventricular hypertrophy (LVH) in treated patients with good blood pressure (BP) control during multiple home BP (HBP) measurements and during 24-h ambulatory BP monitoring (ABPM), but with unsatisfactory BP control in the clinic. These patients were compared with treated hypertensives whose BP was well controlled under the three circumstances. Methods: Seventy-two treated consecutive patients (group I, age 56 ± 10 years) with clinic BP values ≥ 140/90 mmHg, and a difference between clinic and self-measured HBP > 10 mmHg for diastolic blood pressure (DBP) and/or > 20 mmHg for systolic blood pressure (SBP), underwent the following procedures: (1) clinic BP measurement; (2) routine diagnostic work-up; (3) HBP monitoring; (4) 24-h ABPM; (5) echocardiography. Thirty-five hypertensive patients with satisfactory BP control according to clinic (< 140/90 mmHg), HBP (≤ 131/82 mmHg) and ABP criteria (≤ 125/79 mmHg) were included as the control group (group II, age 55 ± 9 years). Results: In group I, 33 subjects out of the 72 (46%) with clinic BP > 140/90 mmHg had BP values controlled outside the clinic (23 according to HBP criteria and 22 according to ABP criteria). The prevalence of LVH (LV mass index > 134 g/m2 in men and > 110 g/m2 in women) was significantly higher in these patients (15.1 versus 2.8%, P < 0.01) than in group II (BP also controlled in the clinic), despite the fact that HBP and ABP were reduced to similar levels in the two groups. Conclusions: Our data provide evidence that treated hypertensive patients with good BP control at home or during ambulatory monitoring, but incomplete BP control in the clinic, have more pronounced cardiac alterations than patients with both clinic and out of the clinic BP control. This finding offers a new piece of information about the diagnostic value of BP measurement in the clinic to assess BP control during antihypertensive treatment. © 2003 Lippincott Wil

Background: It has been shown that aging and arterial hypertension are both associated with an increased prevalence of carotid structural abnormalities, such as intima-media (IM) thickening or plaques, which are a powerful independent predictor of cardiovascular (CV) events. We investigated the impact of carotid IM thickening in profiling the absolute CV risk stratification according the 1999 World Health Organization/International Society of Hypertension (WHO/ISH) guidelines in elderly hypertensive patients. Methods: Two hundred and thirty untreated elderly patients (>65 years) referred to our outpatient hospital clinic were included in the study. They underwent the following procedures: (i) medical history, physical examination and clinic blood pressure measurement; (ii) routine blood chemistry and urine analysis; (iii) electrocardiogram. The risk was initially stratified according to the routine procedures indicated by WHO/ISH guidelines and subsequently reassessed by adding the results of carotid ultrasonography (IM thickening as diffuse IM thickness >0.9 and <1.3 mm). Results: According to routine classification 56% (=129) were medium-risk patients, 29% (n = 67) high-risk and 15% (n = 34) very-high-risk patients. The overall prevalence of carotid IM thickening was 54% (49% in medium-risk vs 60% in high or very high-risk patients, p < 0.05). A marked change in risk stratification was observed when IM thickening was taken in consideration: medium-risk patients decreased to 29% and high-risk rose to 56% (p < 0.01). Conclusions: Ultrasound assessment of large artery damage is extremely useful for a more accurate estimate of global CV risk in elderly hypertensives, because stratification based on diagnostic routine procedures can underestimate the overall risk in a large fraction of medium-risk subjects.

Background: Non-dipping pattern in hypertensive patients has been shown to be associated with an excess of target organ damage and with an adverse outcome. The aim of our study was to assess whether a reduced nocturnal fall in blood pressure (BP), established on the basis of a single 24-h BP monitoring, in treated essential hypertensives is related to more prominent cardiac alterations. Methods: We enrrolled 229 treated hypertensive patients attending the out-patient clinic of our hypertension centre; each patient was subjected to the following procedures: 1) clinic BP measurement; 2) blood and urine sampling for routine blood chemistry and urine examination; 3) standard 12-lead electrocardiogram; 4) echocardiography; 5) ambulatory BP monitoring (ABPM). For the purpose of this study ABPM was carried-out in three subgroups with different clinic BP profile: 1) patients with satisfactory BP control (BP < 140/90 mmHg; group I, n = 58); 2) patients with uncontrolled clinic BP (clinic BP values ≥ 140 and/or 90 mmHg) but lower self-measured BP (< 20 mmHg for systolic BP and/or 10 mmHg for diastolic BP; group II, n = 72); 3) patients with refractory hypertension, selected according to WHO/ISH guidelines definition (group III, n = 99). Left ventricular hypertrophy (LVH) was defined by two gender-specific criteria (LV mass index ≥125/ m2 in men and 110 g/m2 in women, ≥51/gm2.7 in men and 47/g/m 2.7 in women). Results: Of the 229 study participants 119 (51.9%) showed a fall in SBP/DBP < 10% during the night (non-dippers). The prevalence of non-dippers was significantly lower in group I (44.8%) and II (41.6%) than in group III (63.9%, p < 0.01 III vs II and I). The prevalence of LVH varied from 10.3 to 24.1% in group I, 31.9 to 43.1% in group II and from 60.6 to 67.7% in group III (p < 0.01, III vs II and I). No differences in cardiac structure, analysed as continuous variable as well as prevalence of LVH, were found in relationship to dipping or non-dipping status in the three