Franco Veglio

Università degli Studi di Torino, Torino, Piedmont, Italy

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Publications (339)964.09 Total impact


  • No preview · Article · Jan 2016 · Hypertension

  • No preview · Article · Dec 2015 · Artery Research
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    ABSTRACT: Identification and management of patients with primary aldosteronism are of utmost importance because it is a frequent cause of endocrine hypertension, and affected patients display an increase of cardio- and cerebro-vascular events, compared to essential hypertensives. Distinction of primary aldosteronism subtypes is of particular relevance to allocate the patients to the appropriate treatment, represented by mineralocorticoid receptor antagonists for bilateral forms and unilateral adrenalectomy for patients with unilateral aldosterone secretion. Subtype differentiation of confirmed hyperaldosteronism comprises adrenal CT scanning and adrenal venous sampling. In this review, we will discuss different clinical scenarios where execution, interpretation of adrenal vein sampling and subsequent patient management might be challenging, providing the clinician with useful information to help the interpretation of controversial procedures.
    No preview · Article · Nov 2015 · Hormone and Metabolic Research
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    ABSTRACT: Autonomic failure (AF) is characterized by orthostatic hypotension, supine hypertension, and increased blood pressure (BP) variability. AF patients develop cardiac organ damage, similarly to essential hypertension (EH), and have higher arterial stiffness than healthy controls. Determinants of cardiovascular organ damage in AF are not well known: both BP variability and mean BP values may be involved. The aim of the study was to evaluate cardiac organ damage, arterial stiffness, and central hemodynamics in AF, compared with EH subjects with similar 24-hour BP and a group of healthy controls, and to evaluate determinants of target organ damage in patients with AF. Twenty-seven patients with primary AF were studied (mean age, 65.7±11.2 years) using transthoracic echocardiography, carotid-femoral pulse wave velocity, central hemodynamics, and 24-hour ambulatory BP monitoring. They were compared with 27 EH subjects matched for age, sex, and 24-hour mean BP and with 27 healthy controls. AF and EH had similar left ventricular mass (101.6±33.3 versus 97.7±28.1 g/m(2), P=0.59) and carotid-femoral pulse wave velocity (9.3±1.8 versus 9.2±3.0 m/s, P=0.93); both parameters were significantly lower in healthy controls (P<0.01). Compared with EH, AF patients had higher augmentation index (31.0±7.6% versus 26.1±9.2%, P=0.04) and central BP values. Nighttime systolic BP and 24-hour systolic BP predicted organ damage, independent of BP variability. AF patients develop hypertensive heart disease and increased arterial stiffness, similar to EH with comparable mean BP values. Twenty-four-hour and nighttime systolic BP were determinants of cardiovascular damage, independent of BP variability.
    No preview · Article · Oct 2015 · Hypertension
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    ABSTRACT: Q fever is a infectious disease caused by Coxiella burnetii. Its clinical presentation is often nonspecific and the serological diagnosis difficult to make, especially in the absence of specific and suspected medical history. This article presents a case of fever of unknown origin (FUO), interpreted as an autoimmune hepatitis, later proven by the liver biopsy to be a granulomatous hepatitis caused by C. burnetii. The approach to FUO, the features of granulomatous hepatitis and Q fever are presented and discussed.
    Preview · Article · Oct 2015 · Italian Journal of Medicine
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    ABSTRACT: Experimental evidence suggests that aldosterone directly contributes to organ damage by promoting cell growth, fibrosis, and inflammation. Based on these premises, this work aimed to assess the glomerular effects of aldosterone, alone and in combination with salt. After undergoing uninephrectomy, 75 rats were allocated to five groups: control, salt diet, aldosterone, aldosterone + salt diet, aldosterone + salt diet and eplerenone, and they were all studied for four weeks. We focused on glomerular structural, functional, and molecular changes, including slit diaphragm components, local renin-angiotensin system activation, as well as pro-oxidative and profibrotic changes. Aldosterone significantly increased systolic blood pressure, led to glomerular hypertrophy, mesangial expansion, and it significantly increased the glomerular permeability to albumin and the albumin excretion rate, indicating the presence of glomerular damage. These effects were worsened by adding salt to aldosterone, while they were reduced by eplerenone. Aldosterone-induced glomerular damage was associated with glomerular angiotensin-converting enzyme (ACE) 2 downregulation, with ACE/ACE2 ratio increase, ANP decrease, as well as with glomerular pro-oxidative and profibrotic changes. Aldosterone damages not only the structure but also the function of the glomerulus. ACE/ACE2 upregulation, ACE2 and ANP downregulation, and pro-oxidative and profibrotic changes are possible mechanisms accounting for aldosterone-induced glomerular injury. © The Author(s) 2015.
    Full-text · Article · Aug 2015 · Journal of Renin-Angiotensin-Aldosterone System
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    ABSTRACT: Co-existing prolactinoma-primary aldosteronism (PA) is infrequently reported. Identify patients with prolactinoma-PA and test the hypothesis that elevated prolactin (PRL) concentrations play a role in PA pathogenesis. Hyperprolactinemia/prolactinoma was diagnosed in PA patients from 2 referral centres (Munich and Turin) and in essential hypertensive (EH) patients from 1 center (Turin). PRL receptor (PRLR) gene expression was determined by microarrays on aldosterone-producing adenomas (APA) and normal adrenals and validated by qPCR. H295R adrenal cells were incubated with 100 nM PRL and gene expression levels were determined by qPCR and aldosterone production was quantified. Seven patients with prolactinoma-PA were identified: 4 out of 584 and 3 out of 442 patients from the Munich and Turin PA cohorts, respectively. A disproportionate number presented with macroprolactinomas (5 out of 7). There were 5 cases of hyperprolactinemia with no cases of macroprolactinoma out of 14,790 patients in a general EH cohort. In a population of PA patients case-control matched 1:3 with EH patients there were 2 cases of hyperprolactinemia out of 270 PA patients and no cases in the EH cohort (n=810). PRLR gene expression was significantly upregulated in APA compared to normal adrenals (1.7-fold and 1.5-fold by microarray and qPCR, respectively). In H295R cells, PRL treatment resulted in 1.3-fold increases in CYP11B2 expression and aldosterone production. Elevated PRL caused by systemic hyperprolactinemia may contribute to the development of PA in those cases where the two entities co-exist.
    No preview · Article · Jul 2015 · The Journal of Clinical Endocrinology and Metabolism
  • Article: PP.09.26
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    ABSTRACT: Objective: The aim of our study was to investigate the ambulatory blood pressure monitoring (ABPM)-derived short-term BP variability (BPV) in patients with primary aldosteronism (PA), either idiopathic hyperaldosteronism (IHA) or aldosterone-producing adenoma (APA), in comparison with patients with essential hypertension (EH) and normotensive (NT) controls. Design and method: Thirty PA patients (16 IHA, 14 APA), 30 EH patients and 30 NT, matched for sex, age, BMI and antihypertensive therapy, were studied. Short-term BPV was derived from ABPM and calculated as the following: (1) standard deviation (SD) of 24-h, daytime, and nighttime BP; (2) 24-h weighted SD of BP; and (3) average real variability (ARV), i.e., the average of the absolute differences between consecutive BP measurements over 24 h. Results: Standard Deviation (SD) of 24-h, daytime and nighttime BP, 24-h weighted SD of BP, and 24-h BP ARV were not different between PA and EH patients (P ns). All BPV indices were higher in PA, either IHA or APA subtypes, and EH patients, compared to NT (P < 0.001 to P < 0.05). Conclusions: ABPM-derived short-term BPV is increased in PA patients, and it may represent an additional cardiovascular risk factor in this disease. The role of aldosterone excess in BPV has to be clarified. Copyright
    No preview · Article · Jun 2015 · Journal of Hypertension
  • Article: 9B.01
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    ABSTRACT: Objective: Adrenal vein sampling (AVS) is recognized by Endocrine Society guidelines as the only reliable mean to distinguish between aldosterone producing adenomas and bilateral adrenal hyperplasia, the two most common subtypes of primary aldosteronism (PA). However, despite being the gold-standard procedure, AVS protocols are not standardized and vary widely between centers. The objective of the present study was to assess whether the presence or absence of contralateral adrenal (CL) suppression has an impact on the postoperative clinical and biochemical parameters in patients who underwent unilateral adrenalectomy for PA. Design and method: The study was retrospectively carried out in eight referral hypertension centers in Italy, Germany and Japan. Case detection and subtype differentiation were performed according to the Japan Endocrine Society and The Endocrine Society guidelines and a total of 234 AVS procedures were included in the study. CL suppression was defined as aldosterone/cortisol non dominant adrenal vein/aldosterone/cortisol peripheral vein less than 1. Results: Overall, 82% of patients displayed CL suppression at AVS, with no statistically significant differences among centers. This percentage was significantly higher in ACTH-stimulated compared with basal procedures (90% vs 77%). The contralateral ratio was inversely correlated with the aldosterone level at diagnosis and, among AVS parameters, with the lateralization index (P < 0.02 and P < 0.01, respectively). To investigate whether the presence of CL suppression was correlated with response to adrenalectomy, we analyzed the CL suppression status with regard to the patient's clinical and biochemical postoperative parameters. No differences were observed between the two groups for the main clinical and biochemical parameters (systolic and diastolic blood pressure, aldosterone, PRA, PRC, K+, number of drugs, reduction of blood pressure levels, and the number of classes of drugs assumed), but patients with CL suppression underwent a significantly larger reduction in aldosterone levels after adrenalectomy. Conclusions: For patients with lateralization indices of greater than 4 (which comprised the great majority of subjects in this study), contralateral suppression should not be required to refer patients to adrenalectomy because it is not associated with a larger blood pressure reduction and might exclude patients from curative surgery. Copyright
    No preview · Article · Jun 2015 · Journal of Hypertension
  • Article: PP.31.04
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    ABSTRACT: Objective: Current guidelines suggest Home Blood Pressure Monitoring (HBPM) as a complementary measurement method compared with Ambulatory Blood Pressure Monitoring (ABPM), in identification of arterial hypertension (AH). The main purpose of our study was to identify which factors increase HBPM accuracy, testing a short HBPM schedule compared with ABPM. We tried to identify the best HBPM device and which patients were more reliable in HBPM execution. Design and method: We enrolled 321 consecutive patients who performed ABPM in our Hypertension Centre and completed a short HBPM schedule (two measurements, twice daily, for four days) between November 2011 and December 2014. First we compared three techniques: arm and wrist automated devices and manual sphygmomanometers. For the better accuracy we continued our analyses on 270 people who used automated arm devices. Results: Pearson correlation coefficients of arm and wrist automated devices and manual sphygmomanometers for systolic blood pressure (SBP) were 0.59, 0.20 and 0.62, and for diastolic blood pressure (DBP) were 0.72, 0.33 and 0.59. ROC curves for automated arm devices described AUC for SBP of 0.795 and for DBP of 0.847. Box plots of daily mean pressure values did not show significant differences. No significant difference was found between first day coefficient and the others for SBP, p-value 0.06, and for DBP, p-value 0.262. Men and women correlation coefficient were respectively 0.65 and 0.51 for SBP and 0.75 and 0.67 for DBP. Dividing patients by age, the correlation coefficient for SBP were 0.52 (<= 40 years), 0.55 (40-65), 0.69 (>= 65) and for DBP were respectively 0.74, 0.62, 0.66. Conclusions: HBPM has a moderate correlation and a good accuracy in the identification of AH compared with ABPM. We confirm the need to use automated arm devices in HBPM execution. In contrast with current guidelines we do not suggest the elimination of first day measurements. Men and over 65 years patients have more reliability in HBPM execution. Copyright
    No preview · Article · Jun 2015 · Journal of Hypertension
  • Article: PP.40.19
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    ABSTRACT: Objective: renal sympathetic denervation with radiofrequency (RDN) and baroreflex activation therapy (BAT) have been recently developed as invasive options for the treatment of drug-resistant hypertension (RH). The aim of the study was to analyze the presence of a correlation between the change in office blood pressure (officeBP) and 24 hours blood pressure monitoring (ABPM) and modifications in arterial stiffness measured by pulse wave velocity (PWV) in patients with RH who underwent invasive treatment. Design and method: 6 patients underwent RDN and 3 patients BAT; 1 patient was treated with both methods for lack of response to BAT. All patients were receiving at least 5 antihypertensives at full dose and had been followed for at least 6 months in a referral center for high blood pressure. Office BP measurement, ABPM and PWV were performed at baseline and 6 months after RDN/BAT, considering as responders patients with a reduction of the office BP > 10%. Results: Analyzing overall data of 9 patients we observed a 34 mmHg reduction in office BP, a 12 mmHg reduction in 24-hour systolic BP and a 1.15 m/s reduction in PWV. Subsequently, data were analyzed dividing patients into two groups according to the responder status. Six months after the procedure, the 2 responders had a office SBP -reduction of 93 mmHg, ABPM SBP reduction of 59 mmHg and PWV reduction of 0.8 m/s; among the non responders the changes in office SBP, ABPM SBP and PWV were respectively -5 mmHg, +1.5 mmHg and -1.3 m/s. Conclusions: Both in responders and in non responders we observed a trend towards PWV reduction that appears independent of the reduction in BP values. Copyright
    No preview · Article · Jun 2015 · Journal of Hypertension
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    ABSTRACT: Pheochromocytomas and paragangliomas (PPGLs) are rare neoplasms often releasing cathecolamines, mainly originating from adrenals but occasionally observed in sympathetic and parasympathetic ganglia, with a genetic base up to 25% of the cases. After radical surgery of these tumors, disease recurrence was believed to be under 10% but recent studies reported a higher rate even after many years. Apart from familiar forms, little evidence exist about predictors of disease relapse, so we aimed to research predictors of recurrence with a retrospective analysis on patients referred to our Centers from 2000. We collected data of patients with diagnosis of PPGL that underwent radical surgery. 76 subjects were recorded (Men/women: 42/34, Age: 45.9 ± 16.2 years) for a mean follow up of 64.9 ± 66.5 months. Genetic test for mutation of known susceptibility genes was performed in 37 cases, resulting positive in 23. 20/76 (26.3%) patients had disease recurrence. These patients were younger (30.7 ± 14.8 vs 51.4 ± 12.9 years; p = 0.000), had higher rate of positive familiarity and genetic mutations (53.3% vs 13.0%; p = 0.002 and 75% vs 14.3%; p = 0.000, respectively), lower rate of abnormal metanephrines levels (27.3% vs 64.4%, p = 0.003), larger tumors (72.4 ± 37.6 vs 45.3 ± 20.2 mm; p = 0.000) and lower biochemical normalization rate (66.6% vs 96.3%, p = 0.004). We also analysed data on follow-up with Kaplan Meier curves, searching for variables associated with cumulative incidence of recurrence by Log Rank test: age at diagnosis < 45 years (p = 0.003), neoplasm dimension > 40 mm (p = 0.009), positive familiarity (p = 0.007) or genetic test (p = 0.000) and lack of biochemical normalization after surgery (p = 0.004) were associated to disease recurrence. Recurrence in PPGLs develops more frequently in young subjects, in patients with mutations in susceptibility genes, larger tumors, normal levels of metanephrines and incomplete normalization of biochemical markers after radical surgery. Patients with these characteristics should be monitored with strictly follow-up.
    No preview · Article · Jun 2015 · Journal of Hypertension
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    ABSTRACT: Renin-angiotensin-aldosterone system (RAAS) is recognized as the main regulatory system of hemodynamics in man, and its derangements have a key role in the development and maintenance of arterial hypertension. Classification of the hypertensive states according to different patterns of renin and aldosterone levels ("RAAS profiling") allows the diagnosis of specific forms of secondary hypertension and may identify distinct hemodynamic subsets in essential hypertension. In this review, we summarize the application of RAAS profiling for the diagnostic assessment of hypertensive patients and discuss how the pathophysiological framework provided by RAAS profiling may guide therapeutic decision-making, especially in the context of uncontrolled hypertension not responding to multi-therapy. © Georg Thieme Verlag KG Stuttgart · New York.
    No preview · Article · Jun 2015 · Hormone and Metabolic Research
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    ABSTRACT: Primary aldosteronism (PA) is the most frequent cause of secondary hypertension responsible for an increased rate of cardiovascular events. According to the Endocrine Society Guidelines, up to 50% of hypertensive patients should be screened for PA, using the aldosterone to renin (or plasma renin activity, PRA) ratio (AARR and ARR, respectively). The automated Diasorin LIAISON® chemiluminescent immunoassay for renin and aldosterone measurement became available and in many laboratories is currently used instead of the classical radioimmunometric PRA and aldosterone assay. Aim of the study was to prospectively compare the diagnostic accuracy of AARR and ARR as screening test for PA and the two aldosterone assays also during confirmatory test in patients with a positive screening test. One hundred patients were screened for PA and 44 patients underwent confirmatory test (either by intravenous saline load or by captopril challenge test). We considered as cut off for the AARR 2.7 (ng/dL/mU/L) and for the ARR 30 (ng/dL/ng/mL/h). All patients positive to one of the two screening test underwent confirmatory test; patients with positive confirmatory test underwent subtype diagnosis by CT scanning and adrenal vein sampling. Seventy three patients were diagnosed as essential hypertensives, 22 had bilateral adrenal hyperplasia and 5 had an aldosterone producing adenomas (APA). The AARR displayed a sensitivity of 78% and a specificity of 100%, whereas the ARR had a sensitivity of 96% and a specificity of 90%. Of the 6/27 PA patients missed by AARR, none resulted to be affected by APA. All PA patients were correctly diagnosed by chemiluminescence at confirmatory test. In the overall sample of 181 measurements available both the correlation for the PRA with renin and for aldosterone in chemiluminescence and radioimmunoassay were highly significant (Rho = 0.66, p < 0.0001 and Rho = 0.80, p < 0.0001, respectively). On ROC curves, the AUC for AARR was 0.905 (95% CI 0.821-0.988) and for ARR 0.947 (95% CI 0.903-0.991) and they were not significantly different. The automated aldosterone and renin chemiluminescent assay is a reliable alternative to the well-established radioimmunometric method, especially for the detection of APA.
    No preview · Article · Jun 2015 · Journal of Hypertension
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    ABSTRACT: Adrenal glands removed for unilateral primary aldosteronism (PA) display marked histological heterogeneity. Recently reported somatic mutations in KCNJ5, ATP1A1, ATP2B3 and CACNA1D can partially account for these differences. In this study we aimed at combining phenotypic and genotypic characteristics, integrating genetic and immunohistochemistry correlates in sporadic PA. Seventy-one adrenal glands have been included in the study and analyzed for mutations in KCNJ5, ATP1A1, ATP2B3 and CACNA1D. Histological examination and immunohistochemical staining for CYP11B1 (11β-hydroxylase) and CYP11B2 (aldosterone synthase) were performed on aldosterone-producing adenomas (APAs) and adjacent adrenal cortex. In our cohort, the final histopathological diagnosis was multinodular hyperplasia in 22.5% of the patients and single nodule in 77.5%. Forty-five percent of the removed adrenals displayed extra-APA CYP11B2-positive cell nests (B2-CN). Amongst adrenal vein sampling parameters the suppression of contralateral adrenal was more frequent and the lateralization index higher in the subgroup of patients without extra-APA B2-CN compared to the subgroup with extra-APA B2-CN. KCNJ5-mutated APAs were composed mainly of zona fasciculata-like cells with high expression of CYP11B1, while ATP1A1, ATP2B3 and CACNA1D-mutated APAs presented more frequently a zona-glomerulosa-like phenotype with high expression of CYP11B2. We observed a significant inverse correlation between CYP11B2 expression and the size of the nodules and, if CYP11B2 expression was corrected for tumor volume, a significant correlation with plasma aldosterone and aldosterone to renin ratio. Our findings indicate that combination of genotyping and immunohistochemistry improves the final histopatological diagnosis between single nodule and multinodular hyperplasia of the assessed adrenals. Copyright © 2015. Published by Elsevier Ireland Ltd.
    No preview · Article · May 2015 · Molecular and Cellular Endocrinology
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    Preview · Article · May 2015
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    ABSTRACT: Adrenal vein sampling (AVS) is recognized by Endocrine Society guidelines as the only reliable mean to distinguish between aldosterone producing adenomas and bilateral adrenal hyperplasia, the two most common subtypes of primary aldosteronism (PA). However, despite being the gold-standard procedure, AVS protocols are not standardized and vary widely between centers. The objective of the present study was to assess whether the presence or absence of contralateral adrenal (CL) suppression has an impact on the postoperative clinical and biochemical parameters in patients who underwent unilateral adrenalectomy for PA. The study was retrospectively carried out in eight referral hypertension centers in Italy, Germany and Japan. Case detection and subtype differentiation were performed according to the Japan Endocrine Society and The Endocrine Society guidelines and a total of 234 AVS procedures were included in the study. CL suppression was defined as aldosterone/cortisol non dominant adrenal vein/aldosterone/cortisol peripheral vein less than 1. Overall, 82% of patients displayed CL suppression at AVS, with no statistically significant differences among centers. This percentage was significantly higher in ACTH-stimulated compared with basal procedures (90% vs 77%). The contralateral ratio was inversely correlated with the aldosterone level at diagnosis and, among AVS parameters, with the lateralization index (P < 0.02 and P < 0.01, respectively). To investigate whether the presence of CL suppression was correlated with response to adrenalectomy, we analyzed the CL suppression status with regard to the patient's clinical and biochemical postoperative parameters. No differences were observed between the two groups for the main clinical and biochemical parameters (systolic and diastolic blood pressure, aldosterone, PRA, PRC, K+, number of drugs, reduction of blood pressure levels, and the number of classes of drugs assumed), but patients with CL suppression underwent a significantly larger reduction in aldosterone levels after adrenalectomy. For patients with lateralization indices of greater than 4 (which comprised the great majority of subjects in this study), contralateral suppression should not be required to refer patients to adrenalectomy because it is not associated with a larger blood pressure reduction and might exclude patients from curative surgery.
    No preview · Article · May 2015
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    ABSTRACT: The aim of this study was to investigate the short-term blood pressure (BP) variability (BPV) derived from ambulatory blood pressure monitoring (ABPM) in patients with primary aldosteronism (PA), either idiopathic hyperaldosteronism (IHA) or aldosterone-producing adenoma (APA), in comparison with patients with essential hypertension (EH) and normotensive (NT) controls. Thirty patients with PA (16 with IHA and 14 with APA), 30 patients with EH, and 30 NT controls, matched for sex, age, body mass index, and antihypertensive therapy, were studied. The standard deviation (SD) of 24-hour, daytime, and nighttime BP; 24-hour weighted SD of BP; and 24-hour BP average real variability were not different between patients with PA and those with EH (P=not significant). All BPV indices were higher in patients with PA, either IHA or APA subtypes, and patients with EH, compared with NT controls (P<.001 to P<.05). ABPM-derived short-term BPV is increased in patients with PA, and it may represent an additional cardiovascular risk factor in this disease. The role of aldosterone excess in BPV has to be clarified. ©2015 Wiley Periodicals, Inc.
    No preview · Article · Apr 2015 · Journal of Clinical Hypertension
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    ABSTRACT: Primary aldosteronism (PA) is associated with a high rate of cardio- and cerebrovascular complications and metabolic alterations. PA is also recognized as the most frequent, although often unrecognized, secondary form of hypertension. Guidelines have been released to assist clinicians in the diagnostic work-up and subtype differentiation of PA. In this review we discuss and compare the available guidelines in the context of our professional experience and evaluate diagnostic and therapeutic aspects that are still a matter of debate.
    No preview · Article · Apr 2015 · High Blood Pressure & Cardiovascular Prevention
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    ABSTRACT: Patients with autonomic failure are characterized by orthostatic hypotension, supine hypertension, high blood pressure variability, blunted heart rate variability, and often have a "non-dipping" or "reverse dipping" pattern on 24-h ambulatory blood pressure monitoring. These alterations may lead to cardiovascular and cerebrovascular changes, similar to the target organ damage found in hypertension. Often patients with autonomic failure are on treatment with anti-hypotensive drugs, which may worsen supine hypertension. The aim of this review is to summarize the evidence for cardiac, vascular, renal, and cerebrovascular damage in patients with autonomic failure.
    No preview · Article · Mar 2015 · Clinical Autonomic Research

Publication Stats

5k Citations
964.09 Total Impact Points

Institutions

  • 1984-2015
    • Università degli Studi di Torino
      • • Department of Medical Science
      • • Dipartimento di Scienze Cliniche e Biologiche
      Torino, Piedmont, Italy
  • 2009
    • Ospedale San Giovanni Battista, ACISMOM
      Torino, Piedmont, Italy
  • 2006
    • Spedali Civili di Brescia
      Brescia, Lombardy, Italy
  • 2005
    • Ospedali Vito Fazzi
      Lecce, Apulia, Italy
  • 2004
    • Ospedale Amedeo di Savoia
      Torino, Piedmont, Italy
  • 2002
    • University of Camerino
      • Dipartimento di Medicina Sperimentale e Sanità Pubblica
      Camerino, The Marches, Italy
    • University of Mississippi Medical Center
      Jackson, Mississippi, United States
  • 2000
    • Università degli Studi di Messina
      Messina, Sicily, Italy
  • 1995-1999
    • Sapienza University of Rome
      • Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences
      Roma, Latium, Italy