To investigate the effects of the acute administration of aminophylline and nitroglycerin on effort ischemia, 20 patients with syndrome X underwent 3 bicycle exercise tests after sublingual nitroglycerin (0.3 mg) and after 90 minutes of oral administration of aminophylline (400 mg). Compared with the basal test, only aminophylline induced a significant increase in the time to ischemic threshold and to angina; these findings support the potential therapeutic role of this adenosine receptor blocking agents and suggest a possible role of ''steal phenomenon'' in the pathogenesis of effort angina in patients with syndrome X.

The pharmacological treatment, mainly based on diuretics, of isolated systolic hypertension (ISH) has recently been shown to reduce the risk of stroke and coronary heart disease in the elderly. The purpose of this study was to compare the antihypertensive effect and tolerability of different drug regimens in elderly subjects with ISH (systolic blood pressure--SBP-- > or = 160 mmHg and diastolic blood pressure--DBP-- < 90 mmHg). A multicentre, randomized, controlled open trial was planned in the general practice setting. Four widely used treatment schedules were tested: hydrochlorothiazide 25 mg plus amiloride 2.5 mg (H+Am), nifedipine slow release 20 mg (N), atenolol 50 mg (At) and atenolol 25 mg plus chlorthalidone 6.25 mg (At+C). After a baseline evaluation, 308 patients (76.3% female, mean age 75.3 +/- 7.1 years) were randomized and followed up for 6 months. After 3 months the drug dosage was doubled if the systolic blood pressure goal (SBP < 160 mmHg and SBP reduction of at least 20 mmHg) had not been reached. Ninety-four subjects (30.5%) presented contraindications to beta-blockers. At the 3rd- and 6th-month visits all treatment groups, except At, showed a significant reduction in SBP compared to the control group; DBP showed no significant reduction in any group at any time. At the end of the follow-up the percentage of hypertensives who had reached the BP goal was 14.6% in the control group, 52.9% in H+Am, 54.8% in N, 28.6% in At and 52.2% in At+C.(ABSTRACT TRUNCATED AT 250 WORDS)

Two exercise tests, one under basal conditions and one after sublingual nitroglycerin (NTG), were performed in 39 patients with stable angina pectoris-16 with critical coronary stenoses and 23 with normal coronary arteries (syndrome X). Under basal conditions, times at ischemic threshold, at peak exercise, and at complete ECG recovery were similar in the two groups. Peak ST depression was significantly higher in patients with coronary artery disease (CAD). In a similar proportion of patients, ST-segment depression developed earlier or at a low heart rate. Patterns of heart rate, blood pressure, and rate-pressure product during exercise and recovery were also similar. After NTG an increase in the ischemic threshold was observed in a significantly higher proportion of patients with CAD (93.8% vs 39.1%). Furthermore, a subgroup of patients with syndrome: X showed a worsening of exercise performance. This suggests that NTG does not directly affect small coronary vessels. Our results confirm that no relevant differences exist in exercise responses between patients with CAD and those with syndrome X under basal conditions. NTG-induced changes in this response could be useful in identifying patients with normal coronary arteries. Moreover this test could be used as a guide to therapeutic approaches.

The prevalence of orthostatic hypotension (OH) in an elderly outpatient population was assessed according to the most common criteria given in the literature. Short-term OH variability and relationships between OH and its known risk factors were also analysed. A sample of 3858 elderly outpatients aged 65 years or more was randomly recruited by 444 Italian general practitioners. The patients' blood pressure (BP) and heart rate were recorded in both lying and standing positions at two visits 7 days apart. Three definitions were used for the identification of OH: (1) a decrease in systolic BP greater than 20 mmHg (SOH); (2) a decrease in both systolic (greater than 20 mmHg) and diastolic (greater than 10 mmHg) BP (SDOH); (3) any decrease in systolic BP associated with symptoms (SyOH). Prevalence figures for SOH were 13.8% at the first and 12.6% at the second visit, and respectively 5.3 and 4.8% for SDOH, 14.1 and 11.8% for SyOH. All the criteria were met by less than 2% of subjects at each visit. The diagnosis of OH was confirmed at both visits in 36.3% of cases for SOH, in 25.7% for SDOH, and in 43.9% for SyOH. Each different OH definition identifies a population subgroup characterized by different sets of risk-factors. The presence and prevalence of OH is difficult to define because different people may be identified by the currently accepted criteria or by the same criterion over a short time.

In 50 patients with stable effort angina the effect of three drugs, metoprolol, nifedipine, and diltiazem was assessed by analyzing exercise stress test response and ambulatory ECG recordings. Both metoprolol and diltiazem caused a significant increase in time to ischemic threshold during exercise and a significant decrease of maximum ST-segment depression (during exercise and ambulatory ECG monitoring) and in the average number of daily ischemic episodes. Only metoprolol significantly reduced heart rate and rate-pressure product at the ischemic threshold during exercise. In the group of patients treated with nifedipine no significant improvement was observed in exercise tolerance or in number of ischemic episodes/24 h. Moreover, the subset of nonresponders in the two methods was larger than in the other two groups. In some of these patients a clearcut worsening of total ischemic load was observed, despite the control of symptoms. This adverse effect might be attributed to the different consequences of the vasodilatory effect of nifedipine on blood flow through stenosed vessels.

It is not well established if blood pressure control is associated with an improvement in diastolic function, whose impairment represents an early marker of cardiac involvement in systemic hypertension. The purpose of this study was to evaluate whether a prolonged treatment with an alpha 1-blocking agent can lead to a reversal of the abnormalities of left ventricular filling. Eleven never-treated patients with mild to moderate essential hypertension were examined before and after at least six months of treatment with prazosin. Cardiac function and left ventricular mass were measured by means of radionuclide ventriculography and echocardiography. Average blood pressure values significantly decreased during the treatment period: from 163.54 +/- 17.80 mm Hg to 146.81 +/- 13.14 mm Hg for systolic blood pressure and from 106.09 +/- 6.96 mm Hg to 92.90 +/- 8.93 mm Hg for diastolic blood pressure. All the indices of left ventricular mass showed a trend toward reduction, but the differences with respect to the baseline values did not reach statistical significance. Average value of ejection fraction was normal before treatment and did not change significantly after treatment. All indices of diastolic function were significantly lower than normal controls' values at the beginning of the study and tended to worsen at the end of the study. Our findings suggest that diastolic function is not consistently affected by the therapy with alpha 1-adrenoreceptor antagonists despite good blood pressure control.

The effect of a population screening for hypertension was assessed through a subsequent survey performed 1 year later. All the hypertensives identified at the first visit (239 subjects, 15.6% of the whole screened population) were invited for a re-examination: the adhesion rate was 84.5%.After the screening, a high proportion of subjects (74.7%) had contacted their physicians because of their blood pressure. The most common advice physicians gave was to have further measurements of blood pressure (72.8%). Laboratory tests were prescribed in 62 patients (41.1%), but a complete assessment of a target organ damage was carried out in few cases (1.9%).Only 19.5% of patients started a course of treatment during the year following the screening and no more than one-third of those with moderate to severe hypertension. Out of the 176 subjects showing other cardiovascular risk factors at the screening, only 12 reported they had modified their habits 1 year later. Our results suggest that a screening for hypertension, when performed without any liaison with other medical facilities, seems to have a poor impact on physicians' and patients' attitudes towards hypertension.

While the sitting bicycle and treadmill are both adequate for exercise stress testing, the supine ergometric test allows better ECG and blood pressure recordings during exercise. Recently a greater frequency of ST-segment depression has been reported with supine versus upright exercise, but the ischemic significance of this finding has been challenged. We compared the ECG and hemodynamic pattern during sitting and supine bicycle exercise in 50 subjects with chest pain and no history of myocardial infarction; 31 had angiographically documented coronary artery disease (CAD) and 19 had normal coronary vessels. Myocardial perfusion during exercise was measured by thallium-201 radionuclide ventriculography in a subgroup of 41 patients (22 with CAD and all 19 subjects without CAD). The initial workload and further graded increases were identical for both postures. The frequency of ST-segment depression was higher with supine exercise (84% vs. 74%). The increase of sensitivity was + 7% when the results of the supine exercise were compared with coronary arteriography and + 13% when a more direct measurement of myocardial ischemia was adopted as reference standard. No decrease in specificity was observed. In the supine position the threshold for exercise induced ST-segment depression was significantly lower. Chest pain occurred more frequently and at a lower workload. The reason why supine exercise induced a more pronounced and earlier onset ischemia could be ascribed, at least in part, to an increased imbalance between myocardial oxygen supply and demand. In fact, at equivalent workload and heart rate changes, systolic blood pressure and rate-pressure product were significantly higher in the supine, compared with the sitting position. Due to the diagnostic and prognostic significance of ST-segment depression on exercise electrocardiograms, the potentiating effect of supine posture on myocardial ischemia may be clinically relevant, and should be considered when comparing responses obtained by different methods that evaluate exercise induced myocardial ischemia.

Abnormalities of the diastolic function of the left ventricle are the first sign of cardiac involvement in arterial hypertension. We have studied the diastolic function in a group of normotensive adolescents with confirmed family history of hypertension. M‐mode echocardiography was performed in 86 normotensive males aged 14‐19 years: 41 sons of at least one hypertensive parent (SHT) and 45 sons of normotensive parents (SNT). Cross‐sectional area of the left ventricle and left ventricular (LV) mass index were significantly greater in the SHT than in the SNT group (10.05 ± 1.84 vs. 8.9 ± 1.56 cm/m2, p < 0.01 and 129.3 < 29.3 vs. 109.23 ± 25.7 g/m2, p < 0.002, respectively). No significant difference between the two groups was observed in the indices of left ventricular diastolic function, except for mitral valve opening rate (463.51 ± 90.45 in SHT vs. 416.71 ± 78.84 mm/s in SNT; p ± 0.02). From the analysis of the subgroup of adolescents having left ventricular mass greater than the upper normal value, we observed that they showed mean time of rapid filling significantly longer than SNT: this could represent an early marker of the pathological character of such hypertrophy. Our results suggest that the higher LV mass observed in the SHT is not associated with chamber and myocardial stiffness abnormalities.

In order to assess the antihypertensive care received by the elderly, where clear therapeutic guidelines are lacking, a population of 3,858 aged over 64 years was studied. Data were derived from a large Italian 'Study on Blood Pressure in the Elderly', carried out in general practice. Over 90% of the 2,059 known hypertensive patients were receiving drug treatment, with no age or sex-related differences. A single drug was prescribed to 50.2% of treated patients; only 5.5% were receiving three or more drugs. Diuretics and older sympatholytic agents were by far the most frequently prescribed categories, with four drugs (hydrochlorothiazide, amiloride, methyldopa and chlorthalidone) accounting for over 50% of all prescriptions. Low-dosage treatment schedules were frequently used, often associated with less-often-than-daily drug administration. Our study shows that physicians' attitudes to the treatment of arterial hypertension in the elderly are fairly uniform, with treatment of all subjects but with low drug dosages.

In arterial hypertension the indexes of left ventricular hypertrophy are not related to resting blood pressure, whereas a positive association with exercise blood pressure has been observed. It has not been investigated a possible relationship between response to stress and left ventricular diastolic function, the latter being early involved in arterial hypertension even before the development of ventricular hypertrophy. The present study was aimed at assessing a possible relationship between blood pressure response to dynamic exercise and index of left ventricular mass, systolic and diastolic function in a group of untreated hypertensives. fourty hypertensives aged 16-56 years were studied, 27 with mild hypertension and 13 with moderate or severe hypertension. The control group consisted of 23 normotensive healthy subjects, aged 14-40 years. All the subjects underwent a maximum-graded bicycle exercise in the supine position and a M-mode echocardiogram under the B-mode drive. Average values of the indexes of ventricular hypertrophy and of systolic function were overlapping in the 3 groups. Significant differences were observed in the indexes of diastolic function; with regard to normatensive controls, hypertensive subjects showed an increase in isovolumic relaxation time and rapid filling time, a decrease of isovolumic and rapid filling rates and a reduction of mitral valve closing and opening velocities.(ABSTRACT TRUNCATED AT 250 WORDS)

In 3858 ambulatory elderly people (age greater than or equal to 65 years) prevalence of hypertension was 67.8%. The hypertensive status was unknown to both the doctor and the patient in 21.4% of cases. More than 90% of known hypertensives were treated, but hypertension could be considered as controlled in less than 30% of them.

Though sitting bicycle and treadmill are the commonest devices used in exercise stress testing, supine ergometric test shows some advantages, especially in research investigations. The latter allows better ECG and blood pressure recordings during exercise. Recently, a greater frequency of ST-segment depression has been reported with supine vs upright exercise, but some doubt as to the ischemic significance of this result has been raised. Thus, we compare the ECG and hemodynamic pattern during upright and supine bicycle exercise in 50 subjects with chest pain, without prior myocardial infarction: 31 had documented coronary artery disease (CAD) and 19 had normal coronary vessels. In a subgroup (22 CAD patients and all subjects without CAD) a measurement of myocardial perfusion was performed during exercise using thallium-201 radionuclide ventriculography. Initial work-load and the further graded increases were identical for both postures. The frequency of ST-segment depression was higher during supine exercise (84% vs 74%). The increase in sensitivity (+7% vs CAD) was wider if a more direct measurement of myocardial ischemia was adopted as gold standard (+13% vs TI-201 responses) and was not associated with a decreased specificity (Tab. II). In the supine position the threshold of exercise-induced ST-segment depression was significantly lower. Chest pain appeared more frequently and at a lower work-load. Accentuation and precocity of exercise-induced ischemia in the supine-position could be attributed to an increased imbalance between supply and demand of MVO2 at equivalent work-load, heart rate changes, systolic blood pressure and double product were significantly higher.(ABSTRACT TRUNCATED AT 250 WORDS)

Diastolic function of the left ventricle was assessed in 29 untreated patients with mild to moderate hypertension and in 21 normotensive control subjects using gated radionuclide ventriculography. In hypertensive patients, the time to peak filling rate was significantly longer (p less than 0.01) than that in control subjects, and first-third filling fraction and peak filling rate were significantly reduced (p less than 0.001). The ejection fraction and peak ejection rate were also significantly reduced in hypertensive patients (p less than 0.001). No relation was observed between diastolic functional impairment and age, cardiac hypertrophy, or severity of hypertension. Thus, early impairment of ventricular filling is present in hypertension, even in young patients without evidence of cardiac hypertrophy.

Aim of this study was to assess the reliability of blood pressure (BP) response to exercise compared with the occasional BP measurements in evaluating the efficacy of an antihypertensive therapy. We have studied 40 subjects (22 M, 18 F mean age 33.3 +/- 6.6) with essential hypertension (19 with mild hypertension, 8 with moderate hypertension, 13 with severe hypertension). Every patient underwent a maximum graded exercise test in the supine position on a bicycle ergometer before starting the antihypertensive treatment. An exercise test was repeated with the same procedure after resting BP had been normalized for at least six months. Both systolic and diastolic BP at peak exercise were significantly reduced (systolic BP from 212.13 +/- 25.79 mmHg to 194.38 +/- 21.58 mmHg; diastolic BP from 128.00 +/- 16.52 to 114.1 +/- 11.02 mmHg) during the second test. An excessive BP increase (above the 95% confidence limits of the BP response to exercise in a group of normotensives) was observed in 32 subjects during the first test. A "hypertensive" response to stress persisted in 13 subjects during the second test even if the resting BP values were normalized. Our data support the value of stress testing in both the evaluation of the hypertensive patient and the assessment of the individual response to treatment.

Au-195m is a radio-isotope with an ultra-short half-life with which multiple sequential evaluations of ventricular function can be made. In order to evaluate the reliability and reproducibility of analyses of overall and regional ventricular function by radio-isotope ventriculography with Au-195m we studied 10 healthy volunteers and 12 patients with coronary artery disease. Each subject underwent 4 first-pass studies: 1 with Tc-99m and, 10 minutes later, 3 with Au-195m (2 basal studies separated by 3-5 minutes interval and, 10 minutes later, 1 after s.l. nitroglycerin administration). Regional wall motion was analyzed and ejection fraction and peak count rate were determined in each test. Our study showed that the ejection fraction obtained with Au-195m was reproducible (r = 0.98) and correlated well with the ejection fraction determined by using Tc-99m (r = 0.98). The values of the peak count rate obtained with Tc-99m were higher than those obtained with Au-195m. Due to the specially designed collimator and the technical characteristics of the gamma-camera we used, we were able to record sufficiently high count-rates to evaluate regional wall motion, and this analysis was also found to be reliable and reproducible. After s.l. nitroglycerin administration, normal volunteers showed a significant increase of ejection fraction in comparison with basal acquisitions (p less than 0.05), while a wide range of responses was observed in the group of patients with coronary artery disease. We conclude that radio-isotope ventriculography with Au-195m is reliable and reproducible and could be a valid method of monitoring rapid variations induced in overall and regional left ventricular function.