Abstract-In the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, office, home, and ambulatory blood pressure (BP) values were measured contemporaneously between 1990 and 1993 in a large population sample (nϭ2051). Cardiovascular (CV) and non-CV death certificates were collected over the next 148 months, which allowed us to assess the prognostic value of selective and combined elevation in these 3 BPs over a long follow-up. There were 69 CV and 233 all-cause deaths. Compared with subjects with normal office and 24-hour BP, the hazard ratio for CV death showed a progressive increase in those with a selective office BP elevation (white-coat hypertension), a selective 24-hour BP elevation (masked hypertension), and elevation in both office and 24-hour BP. This was the case also when the above conditions were identified by office versus home BP values. Selective elevation in home versus ambulatory BP or vice versa also carried an increased risk. There was indeed a progressive increase in both CV and all-cause mortality risk from subjects in whom office, home, and ambulatory BP were all normal to those in whom 1, 2, or all 3 BPs were elevated, regardless of which BP was considered. The trends remained significant after adjustment for age and gender, as well as, in most instances, after further adjustment for other cardiovascular risk factors. Thus, white-coat hypertension and masked hypertension, both when identified by office and ambulatory or by office and home BPs, are not prognostically innocent. Indeed, each BP elevation (office, home, or ambulatory) carries an increase in risk mortality that adds to that of the other BP elevations.

Background-Studies in hypertensive patients suggest that ambulatory blood pressure (BP) is prognostically superior to office BP. Much less information is available in the general population, however. Obtaining this information was the purpose of the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Methods and Results-Office, home, and 24-hour ambulatory BP values were obtained in 2051 subjects between 25 and 74 years of age who were representative of the general population of Monza (Milan, Italy). Subjects were followed up for an average of 131 months, during which time cardiovascular and noncardiovascular fatal events were recorded (nϭ186). Office, home, and ambulatory BP values showed a significant exponential direct relationship with risk of cardiovascular or all-cause death. The goodness of fit of the relationship was greater for systolic than for diastolic BP and for night than for day BP, but its overall value was not better for home or ambulatory than for office BP. The slope of the relationship, however, was progressively greater from office to home and ambulatory BP. Home and night BP modestly improved the goodness of fit of the risk model when added to office BP. Conclusions-In the PAMELA population, risk of death increased more with a given increase in home or ambulatory than in office BP. The overall ability to predict death, however, was not greater for home and ambulatory than for office BP, although it was somewhat increased by the combination of office and outside-of-office values. Systolic BP was almost invariably superior to diastolic BP, and night BP was superior to day BP. (Circulation. 2005;111:1777-1783.)

Background-The prevalence and clinical significance of isolated office (or white coat) hypertension is controversial, and population data are limited. We studied the prevalence of this condition and its association with echocardiographic left ventricular mass in the general population of the PAMELA (Pressione Arteriose Monitorate E Loro Associazioni) Study. Methods and Results-The study involved a large, randomized sample (nϭ3200) representative of the Monza (Milan) population, 25 to 74 years of age. Participants in the study (64% of the sample) underwent measurements of office, home, 24-hour ambulatory blood pressure, and echocardiography. Isolated office hypertension was defined as systolic or diastolic values Ն140 mm Hg or Ն90 mm Hg, respectively. Home and ambulatory normotension were defined according to criteria previously established from the PAMELA Study, for example, Ͻ132/83 mm Hg (systolic/diastolic) for home and 125/79 mm Hg for 24-hour average blood pressure. Treated hypertensive subjects were excluded from analysis that was made on a total of 1637 subjects. Depending on normotension being established on systolic or diastolic blood pressure measured at home or over 24 hours, the prevalence of isolated office hypertension ranged from 9% to 12%. In these subjects, left ventricular mass index was greater (PϽ0.01) than in subjects with normotension both in and outside the office. This was the case also for prevalence of left ventricular hypertrophy. Left ventricular mass index and hypertrophy were similarly greater in subjects found to have normal office but elevated home or ambulatory blood pressure (Ϸ10% of the population). Conclusions-Isolated office hypertension has a noticeable prevalence in the population and is accompanied by structural cardiac alterations, suggesting that it is not an entirely harmless phenomenon. This is the case also for the opposite condition, that is, normal office but elevated home or ambulatory blood pressure, which implies that limiting blood pressure measurements to office values may not suffice in identification of subjects at risk.

Abstract-It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. Key Words: masked hypertension Ⅲ white-coat hypertension Ⅲ ambulatory blood pressure monitoring Ⅲ prognosis N o conclusive evidence exists as to whether isolated office or white-coat hypertension (HT; WCHT) and masked HT (MHT), ie, the conditions in which, respectively, only office or out-of-office blood pressure (BP) is elevated, are clinically innocent or rather associated with an increase in cardiovascular (CV) risk. [1][2][3] This is because in white-coat and masked hypertensive individuals, the prevalence of structural organ damage has not invariably been found to be greater than in "truly" normotensive individuals. [3][4][5][6][7] It is also because the longitudinal studies that have addressed this issue by assessing the incidence of morbidity and mortality have been based on a small number of CV events and/or a relatively short observation period. 8 -14 Information on the clinical significance of WCHT and MHT can also be obtained by investigating whether, compared with "true" normotension, these conditions are accompanied by a greater rate of development of a "sustained" hypertensive state, ie, HT both in and outside the clinical environment. We have addressed this issue in the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) population by identifying subjects with WCHT and MHT through in-office and out-of-office BP measurements and by detecting the development of sustained HT (SHT) over a 10-year time interval, ie, a long follow-up that allowed a large number of cases to occur. A peculiar aspect of the study was that out-of-office BP was measured both at home and over 24 hours, which allowed us to obtain 2 separate identifications of WCHT and MHT. MethodsThe methodology used in the PAMELA Study has been reported in detail elsewhere. 12,15 Briefly, 3200 individuals were randomly selected from the white residents of Monza (a town in the northeast outskirts of Milan), to be representative of its residents for sex, age (25 to 74 years), and socioeconomic characteristics, according to the criteria used by the World Health Organization Monitoring Diseases Project 16 conducted in the same geographic area. 6 Data were collected in 2051 subjects (64% of the original sample), and survivors were contacted 10 years later to be re-examined. All of the subjects agreed to participate in the study after explanation of its nature and purpose the study, and protocol was approved by the ethics committee of the institutions involved.Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.

Abstract-The prevalence of the metabolic syndrome (National Cholesterol Education Program Adult Treatment Panel III criteria) and its relationships with daily life blood pressures, cardiac damage, and prognosis were determined in 2013 subjects from a Northern Italian population aged 25 to 74 years. Home blood pressure, 24-hour blood pressure, and left ventricular mass index (echocardiography) were also measured. Cardiovascular and noncardiovascular deaths were registered over 148 months. Metabolic syndrome was found in 16.2% of the sample, an office blood pressure elevation being the most frequent (95.4%) and the blood glucose abnormality the least frequent (31.5%) component. There was in metabolic syndrome a frequent elevation in home and/or 24-hour average blood pressure, as well as a greater left ventricular mass index and prevalence of left ventricular hypertrophy, which was manifest even when data were adjusted for between-group differences, including blood pressure. The adjusted risk of cardiovascular and all-cause mortality was greater in metabolic syndrome subjects (ϩ71.0% and ϩ37.0%; PϽ0.05), a further marked increase being observed with left ventricular hypertrophy or "in-office" and "out-of-office" blood pressure elevations. The increased risk was related to the blood pressure and the blood glucose component of metabolic syndrome, with no contribution of the remaining components. Thus, metabolic syndrome is common in a Mediterranean population in which it significantly increases the long-term risk of death. Cardiac abnormalities and increases in home and 24-hour blood pressure are common in metabolic syndrome, and their occurrence further enhances the risk. The contribution of metabolic syndrome components to the risk, however, is unbalanced and mainly related to blood pressure and glucose abnormalities. Key Words: metabolic syndrome Ⅲ blood pressure Ⅲ cardiac hypertrophy Ⅲ cardiovascular morbidity Ⅲ cardiovascular mortality I n the last few years, growing attention has been devoted to a condition defined as metabolic syndrome (MS) based on the various clustering of alterations in glucose and lipid metabolism and blood pressure (BP). Several studies have shown that this syndrome has a high prevalence in many populations from various continents. 1-5 Cross-sectional and longitudinal studies have also shown that MS is associated with an increase in risk of cardiovascular (CV) disease and death, 5,6 -15 posing the problem of which therapeutic interventions are needed to protect affected individuals.In the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) Study, we measured office, home, and ambulatory BP together with a number of metabolic and echocardiographic variables in a large sample of a population from an urban district in the northeast outskirts of Milan. Patients were then followed for Ͼ12 years during which information on the incidence of CV and all-cause deaths was obtained by collection of death certificates. This gave us a chance to obtain, in the context of a general population, i...

The CUORE Project predictive equation showed better accuracy of the FHS and PROCAM equations, overcoming frequently reported risk overestimates. The CUORE equation may be adopted to identify men with high coronary risk in Italy.

Abstract-The hypothesis has been advanced that cardiovascular prognosis is related not only to 24-hour mean blood pressure but also to blood pressure variability. Data, however, are inconsistent, and no long-term prognostic study is available. In 2012 individuals randomly selected from the population of Monza (Milan), 24-hour ambulatory blood pressure (Spacelabs 90207) was measured via readings spaced by 20 minutes. Systolic and diastolic blood pressure variability was obtained by calculating the following: (1) the SD of 24-hour, day, and night mean values; (2) the day-night blood pressure difference; and (3) the residual or erratic blood pressure variability (Fourier spectral analysis). Fatal cardiovascular and noncardiovascular events were registered for 148 months. When adjusted for age, sex, 24-hour mean blood pressure, and other risk factors, there was no relationship between the risk of death and 24-hour, day, and night blood pressure SDs. In contrast, the adjusted risk of cardiovascular death was inversely related to day-night diastolic BP difference (␤ coefficientϭϪ0.040; PϽ0.02) and showed a significant positive relationship with residual diastolic blood pressure variability (␤ coefficientϭ0.175; PϽ0.002). Twenty-four-hour mean blood pressure attenuation of nocturnal hypotension and erratic diastolic blood pressure variability all independently predicted the mortality risk, with the erratic variability being the most important factor. Our data show that the relationship of blood pressure to prognosis is complex and that phenomena other than 24-hour mean values are involved. They also provide the first evidence that short-term erratic components of blood pressure variability play a prognostic role, with their increase being accompanied by an increased cardiovascular risk. Key Words: population science Ⅲ risk factors Ⅲ blood pressure monitoring Ⅲ blood pressure variability Ⅲ morbidity Ⅲ mortality S everal years ago, the hypothesis was advanced that the deleterious effects of hypertension on the cardiovascular (CV) system depend not only on the increase in average blood pressure (BP) but also on an increase in the magnitude of the BP variability throughout the day and night. [1][2][3] This found support in the studies that have measured the SD of average BP over the 24 hours or shorter time intervals and showed that BP variability is greater in hypertensive than in normotensive individuals 4 -7 and that for the same increase in mean 24-hour BP, its magnitude is related to the degree of CV damage. 1-3 However, in other studies, the correlation between BP variability and organ damage disappeared after adjustment for other CV and/or metabolic and demographic variables. 8,9 Furthermore, and more importantly, the prognostic value of BP variability has never been tested by proper longitudinal studies, the few available ones 2,3 being limited by a small study size, a short follow-up, or a conclusion based on surrogate prognostic markers (progression of left ventricular hypertrophy or arterial wall thickening) ra...

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