Objective: Blood pressure (BP) evaluation and management in patients with end stage renal disease (ESRD) is a precarious matter. During hemodialysis (HD) hypotension as well as a paradoxical rise in BP may be documented. We investigated circadian BP behavior in the setting of ESRD. Design and method: We studied 19 patients with ESRD (68% men, mean age 62 ± 19 years, 52% hypertensive) that underwent HD three times a week in the HD unit of our hospital. Ambulatory blood pressure monitoring was applied one hour before an HD session and was set to measure BP every 30 minutes and until arrival for the next HD session, for a total of two subsequent 24-hour periods. Dipping was defined as (daytime systolic BP – nighttime systolic BP)/ daytime systolic BP. Results: Body weight before and after the HD session was 78 ± 28Kgr and 75 ± 27mmHg respectively. Clinic systolic/diastolic BP before the HD session was 133 ± 23/66 ± 11mmH and at the end was 126 ± 25/69 ± 12mmHg. Four patients (21%) exhibited intradialytic hypertension defined as a systolic BP increase > or = 10 mmHg from pre- to post HD. Ambulatory systolic/diastolic BP increased not significantly from 127 ± 23/70 ± 13 mmHg to 130 ± 19/71 ± 11mmHg from the first to the second 24-hour period. Increases were also non-significant for daytime and nighttime BP (128 ± 22 mmHg vs 129 ± 19 mmHg and 126 ± 25 mmHg vs 131 ± 21 mmHg respectively, p > 0.05). Mean dipping was 1.5 ± 7.8% in the first day and further decreased to −0.94 ± 6.8% in the second day. Accordingly, in the first 24-hour period, only 3 patients (16%) were dippers and reduced to 1 patient in the following day (5%). Eight patients (42%) and 9 patients (47%) were risers at the first and second 24-hour period respectively. Conclusions: Daytime systolic BP does not substantially change during the 48-hour period extending from HD to HD session. Yet, a non-dipper as well as a riser pattern are highly prevalent and increase during the interdialytic period.

Objective: Data regarding the prognosis of resistant hypertension (RHT) with respect to its severity is limited. We investigated the cardiovascular risk of severe RHT among patients with treated uncontrolled hypertension. Design and method: In a prospective observational study, 1700 hypertensive patients (aged 57±12 years, 50% males) with office blood pressure (BP) >or = 140 and/or 90mmHg despite antihypertensive treatment, were followed for a mean period of 3.6±1.8 years. At baseline, clinical data were collected and patients underwent echocardiographic measurements, routine blood testing and additional workup for exclusion of secondary causes of RHT. Three groups were identified depending on presence of RHT (office-based uncontrolled hypertension under at least 3 drugs including a diuretic) and levels of office systolic BP: 1,187 patients (70%) without RHT, 313 (18%) with not-severe RHT (systolic BP < 160mmHg) and 200 (12%) with severe RHT (systolic BP >or = 160mmHg). Endpoint of interest was cardiovascular morbidity set as the composite of coronary heart disease and stroke. Results: During follow-up, 58 events were recorded (9.5 cases per 1,000 person-years). Incidence rates of cardiovascular events were 7.1 cases per 1,000 person-years in the group without RHT, 12.4 cases per 1,000 person-years in the group with not-severe RHT and 18 cases per 1,000 person-years in the severe RHT group. Unadjusted analysis showed that compared to uncontrolled patients without RHT, patients with not-severe RHT exhibited a similar risk but patients with severe RHT had a significantly higher risk by 2.5 times (CI: 1.28–4.73, p = 0.007) for the composite cardiovascular outcome. Multivariate cox regression revealed that even after adjusting for a series of established risk factors, severe RHT remained as an independent predictor of the cardiovascular outcome, (OR:2.57, CI:1.27–5.19, p = 0.008). Conclusions: Among treated yet uncontrolled hypertensive patients, severe RHT exhibits a significantly higher cardiovascular risk indicating the need for prompt management.

Objective: Rates of hypertension (HT) increase with advancing age, but there is little data about young hypertensive patients. We investigated clinical, blood pressure (BP) and laboratory data of adults less than 30 years of age visiting a specialized HT unit. Design and method: We studied 139 individuals aged 18–30 years that visited our clinic for evaluation of high BP. Clinical history and demographics were collected and 24-hour BP monitoring, echocardiography and routine blood testing was performed in all participants. Further testing for secondary causes of HT was run where appropriate. Based on uncontrolled office BP (>140/90mmHg) and ambulatory BP (>130/80mmHg), participants with sustained HT, white-coat HT, masked HT and normal BP were identified. A fall of BP by <10% at night-time was defined as non-dipping. Left ventricular hypertrophy was defined as a left ventricular mass index greater than 115gr/m2 for men and 95gr/m2 for women. Results: Participants had a mean age of 23 ± 5 years and were mostly male (80%). Prevalence of a BMI over 30Kg/m2 and abdominal obesity was 30% and 31% respectively, while 37% of patients were smokers. A family history of HT was reported by 38% of participants. Mean office systolic/diastolic BP was 139 ± 17/87 ± 13mmHg and mean ambulatory BP was 129 ± 13/76 ± 11mmHg. Fourteen patients (10%) were under antihypertensive treatment and 8 patients (5.8%) were diagnosed with a secondary cause of HT. Out of the untreated patients, 39 patients (31%) had sustained HT, 36 patients (29%) had white-coat HT, 15 patients (12%) had masked HT and 35 individuals (28%) were normotensive. Prevalence of non-dipping was 52%. Left ventricular mass index was 75 ± 16 gr/m2 and only 2% of patients had left ventricular hypertrophy. Conclusions: Young adults visiting a specialized HT unit have multiple risk factors and are often non-dippers, while secondary HT remains a rare cause. Ambulatory BP monitoring is important for the diagnosis of sustained HT in such a population.

We investigated whether the type of left ventricular (LV) geometry is associated with left atrial (LA) size as determined either by LA diameter or by volume, indexed for body surface area, in essential hypertensives. A total of 339 consecutive, untreated, hypertensives (aged 51.8 years, 234 males) underwent 24-h ambulatory blood pressure (BP) monitoring and estimation of LA diameter and volume, as well as LV structure and function by echocardiography. LV hypertrophy was present in 130 (38.3%) patients whereas normal geometry (LV-NG), concentric remodeling (LV-CR), concentric hypertrophy (LV-CH) and eccentric hypertrophy (LV-EH) represented 34.5, 27.1, 25.7 and 12.7%, respectively. Patients with either LV-CH or LV-EH had increased LA diameter index compared with those with either LV-NG (by 1.1 mm m–2, P<0.01 and 1.4 mm m–2, P=0.003, respectively) or LV-CR (by 1.3 mm m–2, P=0.003 and 1.6 mm m–2, P=0.001, respectively). Similarly, patients with either LV-CH or LV-EH had significantly increased LA volume index compared with those with either LV-NG (by 3.2 ml m–2, P<0.001 and 3.4 ml m–2, P<0.005, respectively) or LV-CR (by 4.5 and 4.7 ml m–2, respectively, P<0.001 for both). Multiple linear regression analysis showed that the independent predictors of both LA volume and diameter index were LV mass index, 24-h pulse pressure and E/Em.LA size assessed either by its diameter or by volume is closely related only to LV mass index and not to any specific LV geometric pattern in the early stages of essential hypertension.