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The prognostic value of white coat hypertension (WCH) is still debated. In 2051 subjects representative of the general population of Monza, we measured office, ambulatory, and home blood pressure (BP). The risk of cardiovascular and all-cause mortality was assessed over 16 years in normotensive, sustained hypertensive, and WCH subjects, the last group being defined as usually done in clinical practice (ie, by normality of 1 out-of-office [ambulatory or home] BP with an office BP elevation). Compared with normotensive subjects, the risk of cardiovascular mortality, as adjusted for potential confounders, showed a progressive significant increase in WCH and sustained hypertensive subjects (2.04 and 2.94; P=0.006). In either group, a significant increase in adjusted risk was also seen for all-cause mortality. However, when the WCH group was subdivided into 2 subgroups, that is, subjects in whom both out-of-office BPs were normal (true WCH, 42%) or one BP was normal whereas the other was elevated (partial WCH, 58%), only the latter showed a significantly greater adjusted risk of cardiovascular and all-cause mortality (2.76 and 1.58; P<0.03). Compared with normotensive subjects, the partial WCH group also exhibited a marked increase in adjusted risk of developing sustained hypertension over a 10-year time period (2.58; P<0.0001), but in this case the risk was also increased in true WCH subjects (2.89; P<0.0001). Thus, WCH includes subjects with a widely different long-term risk of a cardiovascular event. To identify those at higher risk, measurements of both out-of-office BPs are desirable.

PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) is an epidemiological study, originally designed to determine the normality of home and ambulatory blood pressure values. The study was performed on 3,200 subjects, aged 25 to 74 years, randomly selected from the general population of Monza (Milan, Italy). In the study context we performed clinical, home and ambulatory blood pressure measurements, echocardiographic assessment of cardiac structure and function as well as laboratory examinations (glucose and lipids). Personal and family histories were collected. The same procedures were repeated 10 years later. During a 12-year follow-up, the incident cardiovascular events were validated. Cardiovascular and all-cause fatal events were collected for a 16-year follow-up. This article will review the main results of the PAMELA study, with particular emphasis on (1) the prognostic value of the different blood pressure measurements, (2) the relationships between metabolic variables and blood pressure and (3) the clinical relevance and prognostic importance of left ventricular mass values and alterations.

Objective: SunTech 247 is an oscillometric blood pressure (BP) monitor manufactured by SunTech Medical Inc., Morrisville, North Carolina, USA. The aims of this study were (i) to determine its accuracy using the 1993 modified British Hypertension Society (BHS) protocol, the 2002 International Protocol (IP) and the 2002/2003 Association for the Advancement of Medical Instrumentation (AAMI) standards, (ii) to compare the performance of BHS protocol and IP., Methods: Systolic BP (SBP) and diastolic BP (DBP) were recorded to the nearest 2 mmHg and measured with the arm supported at heart level. For each participant, nine sequential same arm measurements were taken by two trained observers, comparing the device to standard mercury sphygmomanometers. Procedures and data analysis were carried out following protocols guidelines., Results: First, we recruited 33 participants required by the IP. Then, data collection continued to obtain 85 participants for the BHS protocol/AAMI standard. Readings differing by less than 5, 10 and 15 mmHg for SBP and DBP fulfilled IP recommendations. According to the BHS protocol, for the better observer, the percentage of test device readings differing from the mercury standard by 5, 10 and 15 mmHg or less were: 92.9, 100 and 100% for SBP and 94.9, 98.8 and 99.6% for DBP. The mean differences +/- standard deviation between the device and mercury sphygmomanometer readings were 1.7 +/- 3.1 mmHg for SBP and 1.1 +/- 3.2 mmHg for DBP, achieving AAMI requirements. Standard deviation of mean differences were 2.4 for SBP and 2.1 for DBP, following the IP, and 3.1 and 3.2, respectively, for BHS protocol. The variance of all 99 differences (total deviance), with 98 degree of freedom, was 585.6 for SBP and 444.1 for DBP. The 33 differences obtained from the mean differences for each participant (between-subject variance), with 32 degree of freedom, were 275.6 and 152.1, respectively. F test was 1.83 with P = 0.0191 for SBP, and 1.07 (P = 0.3936) for DBP., Conclusion: (i) The device achieved the requirements stated by the 2002 IP, fulfilled the standards stated by the AAMI, and on the basis of the standards indicated by the 1993 modified BHS protocol, can be classified as 'A' grade both for SBP and DBP. Therefore, SunTech 247 may be recommended for clinical use, (ii) IP and BHS protocol provide complementary features for device validation; the comparison of total deviance and between-subject variance confirms the estimates of IP authors for SBP.

It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. The condition of WCHT was identified as office BP >140/90 mm Hg and 24-hour BP mean <125/79 mm Hg or home BP <132/82 mm Hg. Corresponding values for MHT diagnosis were office BP <140/90 mm Hg, 24-hour BP > or =125/79 mm Hg, and home BP >or =132/82 mm Hg. SHT was identified when both office and 24-hour BP means or home BP were over threshold values and normotension was under the threshold value. Subjects were reassessed 10 years later to evaluate the BP status of the various conditions defined previously. At the first examination, 758 (54.1%), 225 (16.1%), 124 (8.9%), and 293 (20.9%) subjects were normotensive, WCHT, MHT, and SHT subjects, respectively. At the second examination, 136 normotensives (18.2%), 95 WCHT (42.6%), and 56 MHT (47.1%) subjects became SHT. As compared with normotensives, adjusting for age and sex, the risk of becoming SHT was significantly higher for WCHT and MHT subjects (odds ratio: 2.51 and 1.78, respectively; P<0.0001). Similar results were obtained when the definition of the various conditions was based on home BP. Independent contributors of worsening of hypertension status were not only baseline BP, but also, although to a lesser extent, metabolic variables and age. Subjects with WCHT and MHT are at increased risk of developing SHT. This may contribute to their prognosis that appears to be worse as compared with that of normotensive subjects.

Alterations in blood glucose and cholesterol are more frequently detectable in hypertensive than in normotensive conditions. However, no information exists as to whether this phenomenon involves only office or also home and 24-hour ambulatory blood pressure (ie, when values are representative of daily life). In 2045 subjects enrolled in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study, we measured home, 24-hour, and office blood pressure. Measurements also included fasting blood glucose and serum total and HDL cholesterol values. Prevalence of diabetes (> or =126 mg/dL or use of antidiabetic drugs), impaired fasting blood glucose (> or =110 to <126 mg/dL), and hypercholesterolemia (serum total cholesterol > or =240 mg/dL or 200 mg/dL) increased progressively from "optimal" to "normal," "high-normal," and "elevated" office systolic or diastolic blood pressure. Fasting blood glucose and total serum cholesterol also increased progressively from the first to the fourth group, with HDL cholesterol values showing a concomitant progressive decrease. This was also the case for quartiles of office, home, and 24-hour blood pressure. In the whole population, there was a positive correlation between serum cholesterol or blood glucose and all blood pressure values (P always <0.0001), with a much smaller and less consistent relationship with heart rate. In a multivariate analysis that included gender, body mass index, age, and antihypertensive treatment, all blood pressure values remained highly significantly related to values of either metabolic variables. Thus, in the PAMELA population, glucose and lipid values are independently related to blood pressure. This is also the case when daily life blood pressure values are considered.