Riassunto. L'ipertensione arteriosa rappresenta il principale fattore di rischio per lo sviluppo di malattie cardiovascolari e renali. Numerose e solide evidenze sono disponibili a sostegno dei beneficî derivanti dalla riduzione dei valori pressori in termini di riduzione del rischio di sviluppare infarto del miocardio, ictus cerebrale e morte per cause cardiovascolari. È importante sottolineare, tuttavia, come i pazienti affetti da ipertensione arteriosa abbiano anche un rischio aumentato di sviluppare insufficienza cardiaca, indipendentemente dalla presenza di ipertrofia o disfunzione ventricolare sinistra. È stato, inoltre, dimostrato come il controllo dei valori pressori determini una significativa riduzione del rischio di sviluppare questa complicanza. In particolare, studi di meta-analisi condotti nel corso degli ultimi anni hanno consentito di dimostrare come l'impiego di diuretici o di farmaci in grado di antagonizzare il sistema renina-angiotensina sia maggiormente efficace in termini di prevenzione dello sviluppo di insufficienza cardiaca rispetto a strategie basate su calcio-antagonisti e beta-bloccanti.Nel presente articolo verranno discussi ed analizzati i principali aspetti fisiopatologici coinvolti nella progressione dall'ipertensione arteriosa allo scompenso cardiaco e le possibili strategie terapeutiche in grado di ridurre o prevenire tale progressione.Parole chiave. Ipertensione arteriosa, prevenzione cardiovascolare, scompenso cardiaco, terapia antiipertensiva.The progression from hypertension to congestive heart failure. Summary.Arterial hypertension still represents one of the major modifiable risk factors for cardiovascular and renal disease. Solid evidences are available demonstrating the large and significant benefits deriving from blood pressure lowering therapies in terms of reduced incidence of major cardiovascular events, including myocardial infarction, ischemic stroke and cardiovascular death. It should be also noted, however, that hypertensive patients are at increased risk of developing congestive heart failure, being this risk substantially independent by the concomitant presence of left ventricular hypertrophy or dysfunction. Indeed, it has been demonstrated that blood pressure reduction and control significantly reduce the risk of developing congestive heart failure. In particular, several recent meta-analyses have demonstrated that the use of diuretics and renin-angiotensin system blockers is superior to calcium-antagonists and betablockers in terms of prevention of new-onset heart failure.The present paper overviews the main pathophysiological aspects of the progression from arterial hypertension to congestive heart failure and the potential therapeutic interventions able to reduce or prevent this progression.

SUMMARY The impact of cardiovascular disease was compared in non-diabetics and diabetics in the Framingham cohort. In the first 20 years of the study about 6% of the women and 8% of the men were diagnosed as diabetics. The incidence of cardiovascular disease among diabetic men was twice that among nondiabetic men. Among diabetic women the incidence of cardiovascular disease was three times that among nondiabetic women.Judging from a comparison of standardized coefficients for the regression of incidence of cardiovascular disease on specified risk factors, there is no indication that the relationship of risk factors to the subsequent development of cardiovascular disease is different for diabetics and non-diabetics.This study suggests that the role of diabetes as a cardiovascular risk factor does not derive from an altered ability to contend with known risk factors.THE DISCOVERY OF INSULIN in 1921 and the later availability of the oral hypoglycemic agents has shifted the problem of diabetes from the acute metabolic consequences of ketoacidosis and coma resulting in early death, to the cardiovascular sequelae in later life. Despite the availability of effective hypoglycemic agents and more sensitive diagnostic methods allowing earlier treatment, physicians continue to encounter an excessive incidence of coronary heart disease, strokes, renal failure, retinopathy, neuropathy, and congestive heart failure among their diabetic patients. There is a need to explore further the details of the relation of diabetes to the development of cardiovascular disease (CVD).In this report we examine the relationship of the evidence of diabetes to subsequent CVD in the presence of other cardiovascular risk factors. In particular, the question of interaction between diabetes and other cardiovascular risk factors is explored. A description of the method of measurement of risk factors and the precise criteria for a definition of diabetes may be found elsewhere.' A person was diagnosed as having diabetes mellitus if he or she was under treatment for diabetes or had elevated casual blood glucose determinations at two successive examinations.Follow-up of the cohort has been reasonably complete, with 3% lost to follow-up for cardiovascular mortality in 20 years. For each examination there was an 85% participation level. The rest were examined at less frequent intervals, with 69% total population participation over all examinations up to and including the tenth biennial examination or until the time of their death. Few cardiovascular events were unaccounted for, since we arranged later examinations for those missed, had daily hospital surveillance and obtained other ancillary information.

This report examines prospectively, in the Framingham cohort, the relation of diabetes and impaired glucose tolerance to each of the cardiovascular sequelae, taking into account age, sex, and associated cardiovascular risk factors. The incidence of cardiovascular disease, as well as the levels of cardiovascular risk factors, were found to be higher in diabetic than in nondiabetic men and women. The relative impact of diabetes on coronary heart disease, peripheral vascular disease, or stroke incidence was the same in men and women, but for cardiovascular mortality and cardiac failure the impact is greater for women. Present evidence suggests that alleviation of associated cardiovascular risk factors is the most promising course in reducing cardiovascular sequelae in diabetic patients.

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miological studies have reported positive associations between the risk of coronary heart disease (CHD) and plasma fibrinogen levels. Fibrinogen is the major coagulation protein in blood by mass, the precursor of fibrin, and an important determinant of blood viscosity and platelet aggregation. [38][39][40][41] Because fibrinogen levels can be reduced considerably by lifestyle interventions that also affect levels of established risk factors (such as regular exercise, smoking cessation, and moderate alcohol consumption), there is interest in the possibility that measurement (or modification) of fibrinogen may help in disease prediction or prevention. [38][39][40]42 A meta-analysis of published data from 18 such studies, involving about 4000 CHD cases, indicated a relative risk of 1.8 (95% confidence interval [CI], 1.6-2.0) per 1-g/L increase in plasma fibrinogen level. 43 However, such analyses are not able to provide detailed assessments of the nature of any independent association of fibrinogen level with CHD or with other vascular and nonvascular outcomes. [43][44][45] This meta-analysis differs from previous analyses in several ways that should increase its reliability and scientific value. First, it is large and comprehensive: the data comprise 6944 first nonfatal myocardial infarction (MI) or stroke events and 13 210 deaths (cause-*The Authors/Writing Committee, Authors/Members, and Other Members of the Fibrinogen Studies Collaboration are listed at the end of this article.