To determine the prognostic significance of ambulatory blood pressure, we prospectively followed for up to 7.5 years (mean, 3.2) 1187 subjects with essential hypertension and 205 healthy normotensive control subjects who had baseline off-therapy 24-hour noninvasive ambulatory blood pressure monitoring. Prevalence of white coat hypertension, defined by an average daytime ambulatory blood pressure lower than 131/86 mm Hg in women and 136/87 mm Hg in men in clinically hypertensive subjects, was 19.2%. Cardiovascular morbidity, expressed as the number of combined fatal and nonfatal cardiovascular events per 100 patient-years, was 0.47 in the normotensive group, 0.49 in the white coat hypertension group, 1.79 in dippers with ambulatory hypertension, and 4.99 in nondippers with ambulatory hypertension. After adjustment for traditional risk markers for cardiovascular disease, morbidity did not differ between the normotensive and white coat hypertension groups (P = .83). Compared with the white coat hypertension group, cardiovascular morbidity increased in ambulatory hypertension in dippers (relative risk, 3.70; 95% confidence interval, 1.13 to 12.5), with a further increase of morbidity in nondippers (relative risk, 6.26; 95% confidence interval, 1.92 to 20.32). After adjustment for age, sex, diabetes, and echocardiographic left ventricular hypertrophy (relative risk versus subjects with normal left ventricular mass, 1.82; 95% confidence interval, 1.02 to 3.22), cardiovascular morbidity in ambulatory hypertension was higher (P = .0002) in nondippers than in dippers in women (relative risk, 6.79; 95% confidence interval, 2.45 to 18.82) but not in men (P = .91). Our findings suggest that ambulatory blood pressures stratifies cardiovascular risk in essential hypertension independent of clinic blood pressure and other traditional risk markers including echocardiographic left ventricular hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)

In essential hypertension, a reduction in LV mass during treatment is a favorable prognostic marker that predicts a lesser risk for subsequent cardiovascular morbid events. Such an association is independent of baseline LV mass, baseline clinic and ambulatory BP, and degree of BP reduction.

Abstract-Diabetes may develop in nondiabetic hypertensive subjects during treatment, but the long-term cardiovascular implications of this phenomenon are not clear. We determined the prognostic value of new diabetes in hypertensive subjects. In a long-term cohort study, 795 initially untreated hypertensive subjects, 6.5% of whom with type 2 diabetes, underwent diagnostic procedures including 24-hour ambulatory blood pressure (BP) monitoring and electrocardiography (ECG). Procedures were repeated after a median of 3.1 years in the absence of cardiovascular events. Key Words: hypertension Ⅲ echocardiography Ⅲ hypertrophy Ⅲ blood pressure Ⅲ epidemiology Ⅲ diuretics T he coexistence of hypertension and diabetes is frequent. 1 Type 2 diabetes accounts for Ͼ90% of these cases 2 and cardiovascular risk is markedly increased when hypertension and diabetes coexist. [3][4][5] Despite the evidence of the excess risk associated with the coexistence of hypertension and type 2 diabetes, very limited information exists on the prognostic significance of new diabetes in treated hypertensive subjects. The issue is clinically relevant because widely used antihypertensive agents such as thiazide diuretics and ␤-blockers may increase blood glucose. 6 -8 Some intervention trials showed a lesser incidence of diabetes in hypertensive subjects treated with drugs different from diuretics and ␤-blockers. 9 -12 In this study, we investigated the prognostic value of new type 2 diabetes in a cohort of hypertensive subjects without previous cardiovascular events who repeated some diagnostic procedures before and during treatment. After the follow-up study, subjects continued to be followed-up for detection of major cardiovascular events. Nondiabetic subjects who developed diabetes during treatment and those with established diabetes at entry were compared in their subsequent incidence of cardiovascular events with the nondiabetic subjects who remained free of diabetes. MethodsThe Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study [13][14][15] is an observational registry of morbidity and mortality in initially untreated subjects with essential hypertension. The study was initiated on June 1986. Entry criteria included an office blood pressure (BP) Ն140 mm Hg systolic and/or Ն90 mm Hg diastolic on at least 3 visits and absence of secondary causes of hypertension, previous cardiovascular disease, and lifethreatening conditions. BP was measured by a physician with a mercury sphygmomanometer, with subjects sitting and relaxed for at least 10 minutes. Three measurements were averaged for analysis. Systolic and diastolic BPs were identified by Korotkoff phases I and V. Standard 12-lead ECG was recorded at 25 mm/s and 1 mV/cm calibration. Subjects with complete right or left bundle branch block, previous myocardial infarction, Wolff-Parkinson-White syndrome, and atrial fibrillation were excluded. None of the subjects was being treated with digitalis. Diagnosis of left ventricular (LV) hypertrophy by electrocardiography was made ...

Concentric remodeling of the left ventricle, defined by the thickness of the septum or posterior wall divided by the left ventricular radius at end-diastole > or = 0.45, is an important and independent predictor of increased cardiovascular risk in hypertensive patients with normal left ventricular mass on echocardiography.

Abstract-Incidence, determinants, and outcome of atrial fibrillation in hypertensive subjects are incompletely known. We followed for up to 16 years 2482 initially untreated subjects with essential hypertension. At entry, all subjects were in sinus rhythm. Subjects with valvular heart disease, coronary artery disease, preexcitation syndrome, thyroid disorders, or lung disease were excluded. During follow-up, a first episode of atrial fibrillation occurred in 61 subjects at a rate of 0. (both PϽ0.001) were the sole independent predictors of atrial fibrillation. For every 1 standard deviation increase in left ventricular mass, the risk of atrial fibrillation was increased 1.20 times (95% CI, 1.07 to 1.34). Atrial fibrillation became chronic in 33% of subjects. Age, left ventricular mass, and left atrial diameter (all PϽ0.01) were independent predictors of chronic atrial fibrillation. Ischemic stroke occurred at a rate of 2.7% and 4.6% per year, respectively, among subjects with paroxysmal and chronic atrial fibrillation. These data indicate that in hypertensive subjects with sinus rhythm and no other major predisposing conditions, risk of atrial fibrillation increases with age and left ventricular mass. Increased left atrial size predisposes to chronicization of atrial fibrillation. Key Words: fibrillation Ⅲ hypertension, essential Ⅲ stroke Ⅲ hypertrophy Ⅲ echocardiography Ⅲ aging T he most important risk factors for atrial fibrillation (AF) are age, male gender, hypertension, thyrotoxicosis, smoking, diabetes, left ventricular (LV) hypertrophy, left atrial enlargement, valvular and coronary heart disease, congestive heart failure, and stroke. [1][2][3][4][5] In the Framingham Heart Study, hypertension and diabetes were the sole cardiovascular risk factors to be predictive of AF after controlling for age and other predisposing conditions. 5 The role of hypertension as risk factor for AF is established but still incompletely known. In the Manitoba Follow-up study, prevalence of hypertension was 53%, and the risk of AF was 1.42 times higher in hypertensive subjects as compared with normotensive subjects. 2 Because of its high prevalence in the population, hypertension independently accounts for more AF cases than any other risk factor. 5 However, despite its leading importance as a highly prevalent and modifiable risk factor, only a few data are available regarding predictors and outcome of AF in large populations of subjects with essential hypertension free of coexisting valvular or coronary heart disease, congestive heart failure, hyperthyroidism, or other predisposing conditions. In particular, the clinical value of LV mass as a potential independent predictor of AF in the specific setting of essential hypertension has never been examined in a large cohort of subjects. MethodsThe Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study started in 1986 as an observational registry of morbidity and mortality in initially untreated subjects with essential hypertension. Details on protocol have been pu...