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Prevalence of episodes of ST-segment depression among mild-to-moderate hypertensive patients in northern Italy: the
M Stramba-Badiale1, O Bonazzi, G Casadei
1Centro di Fisiologia Clinica e Ipertensione, University of Milan, Ospedale Maggiore, Italy.
Insights
Silent myocardial ischemia, indicated by ST-segment depression, affects 15% of hypertensive patients without coronary artery disease. Episodes are often asymptomatic and more prevalent in women, suggesting a need for further investigation in this population.
Area of Science:
- Cardiology
- Hypertension Research
- Diagnostic Electrocardiography
Background:
- Mild-to-moderate essential hypertension is a significant cardiovascular risk factor.
- Subclinical coronary artery disease can be present in hypertensive individuals without overt symptoms.
- ST-segment depression on electrocardiography can indicate myocardial ischemia.
Purpose of the Study:
- To determine the prevalence of ST-segment depression episodes in hypertensive patients without clinical coronary artery disease.
- To identify factors associated with silent myocardial ischemia in this population.
- To evaluate the utility of exercise stress testing and Holter monitoring for detecting silent ischemia.
Main Methods:
- A multicenter study enrolled 414 hypertensive patients (aged 50-70) free of coronary artery disease symptoms.
- Patients underwent exercise stress testing and 48-hour Holter monitoring.
- ST-segment depression was defined as > or = 100 microV, 80 ms after the J point, lasting at least 1 min.
Main Results:
- ST-segment depression occurred in 6.1% during exercise stress testing and 10.9% during Holter monitoring.
- Overall, 15% of patients exhibited ST-segment depression, predominantly asymptomatic.
- Female sex was the only significant predictor of silent myocardial ischemia (Odds Ratio 2.56).
Conclusions:
- A notable percentage of hypertensive patients without clinical coronary artery disease experience silent myocardial ischemia.
- Asymptomatic ST-segment depression is not strongly linked to hypertension severity or other common risk factors.
- Holter monitoring and exercise stress testing can detect silent ischemia, potentially guiding further investigation and treatment in hypertensive individuals, especially women.
Objectives:
To assess the prevalence of episodes of ST-segment depression in a population of consecutive patients with mild-to-moderate essential hypertension who are free of clinical signs of coronary artery disease.
Methods:
The study involved 28 Italian centers that enrolled 414 hypertensive patients (aged 50-70 years; diastolic blood pressure > or = 95-115 mmHg or systolic blood pressure > or = 150-220 mmHg, or both, 10 days after withdrawal of medications). Silent myocardial ischemia was assessed by means of exercise stress testing and 48 h Holter monitoring. An ischemic episode was defined as a horizontal or downward sloping ST-segment depression > or = 100 microV, occurring 80 ms after the J point, and lasting for at least 1 min.
Results:
Of the 414 patients enrolled, 411 completed the exercise stress test. During the test significant ST-segment depression occurred for 25 patients (6.1%) and all episodes but one were asymptomatic and not associated with arrhythmias. Of the 396 patients for whom we analyzed a 48 h Holter recording, 43 (10.9%) had at least one episode of ST-segment depression and seven of these had also had one during the exercise stress test The median number of episodes per patient was five (range 1-19), median duration was 9 min (range 1-20 min), and the mean amplitude of the ST-segment depression was 190 +/- 180 microV. None of these episodes was associated with symptoms and all of them occurred under resting condition. Patients with (n = 61) and without (n = 335) ST-segment depression during Holter monitoring or exercise stress testing had similar ages (59 +/- 6 versus 58 +/- 6 years) and did not differ for tobacco smoking, plasma lipid levels, blood pressure values and prevalence of echocardiographic left ventricular hypertrophy (57% of patients had left ventricular mass indexes > or = 134 g/m2 for men and > or = 110 g/m2 for women in both groups). Women had a higher prevalence of ST-segment depression than did men during Holter monitoring [32 of 183 (17.5%) versus 11 of 213 (5.2%)], whereas the prevalences of ischemia during the exercise stress test were similar. Female sex was the only significant factor associated with the occurrence of silent myocardial ischemia [odds ratio 2.56 (95% confidence interval 1.40-4.71)].
Conclusions:
Our results show that 15% of patients with mild-to-moderate hypertension, who are free of clinical signs of coronary artery disease, experience episodes of ST-segment depression during Holter monitoring or exercise stress testing. Most of these episodes are asymptomatic and are not associated with the severity of hypertension, the presence of left ventricular hypertrophy, and other risk factors for coronary artery disease. Episodes of ST-segment depression are more common for women than they are for men, particularly during Holter monitoring. The early detection of silent myocardial ischemia by Holter monitoring or by the exercise stress test might be useful for the identification of hypertensive patients who should be investigated further and administered a more specific treatment.