Cugini's syndrome: a new cardiovascular entity. Interview by G. M. Fara

Abstract

Because of recent papers on "Cugini's syndrome", as a new nosographic cardiovascular entity, the writer of this article has seen of medical interest to interview Prof. Cugini in person for a better elucidation of this syndrome. It must be stressed that the syndrome we are dealing with has been identified by reviewing Cugini's investigations carried out in Italy between 1997-1999 on subjects considered to be normotensive at the casual Riva-Rocci sphygmomanometry but unexplicably showing initial signs of hypertensive organ damage. The syndrome consists of the binomium "Minimal change hypertensive retinopathy/Pre-hypertension", in that the apparently normotensive subjects were seen to be characterized by a minimally accentuated reflex of retinal arterioles, as it occurs in I Stage of Keith-Wagener-Barker classification for hypertensive retinopathy, being neither "truly normotensive" nor "truly hypertensive". As a matter of fact, these subjects were classified by Prof. Cugini as "pre-hypertensive" in that the 24-h values of their blood pressure (BP), measured via Ambulatory Blood Pressure monitoring (ABPM), were invariably below the upper reference limits given at that time by WHO, but, notwithstanding that, their systolic (S) and diastolic (D) daily average was significantly higher than in "true normotensive" subjects. Furthermore, at the chronobiometric analysis of the ABPM, these pre-hypertensive subjects resulted to have a well-phased BP circadian rhythm and an amplified oscillation in their 24-h BP values. Interestingly, Prof. Cugini documented that the clinical condition of "Pre-hypertension" could be also found in putatively normotensive subjects with an initial hypertensive damage of other target organs, suggesting that the "Cugini's syndrome" could be intended more extensively via the binomium, i.e., "Minimal change hypertensive cardiovascular damage/Pre-hypertension". Having statistically found a significant difference in BP 24-h mean values between "true normotensives" and "pre-hypertensives", it can be inferred that Prof. Cugini used the term "Pre-hypertension" to taxonomically indicate a para-physiological hemodynamic status characterized by an increase in BP 24-h mean values, quantifiable and documentable via ABPM, staying in between normotension and hypertension, describing with a large anticipation of time the "normal-high" grade of the classification reported years later in 2003 by JNC in its VII Report on arterial hypertension. Moreover, it is important to stress at the time of Cugini's studies the Stage I of hypertensive retinopathy was considered to be an initial sign of damage already indicative of a high BP regimen. But, even more important, it is to remark that at the time of Cugini's studies the term "Pre-hypertension" was used just to indicate a presumable stage of predisposition to develop hypertension in subjects with a positive familiarity for high BP. Therefore, Prof. Cugini transposed the meaning of the term "Pre-hypertension" from a merely putative preclinical asymptomatic status to an objective clinical symptomatic status documentable via the daily average of BP values, being associated with documentable signs of initial tensive target organ damage in subjects "falsely normotensive". With this connotation, the Cugini's syndrome shows the following indications: 1. in the presence of a minimal sign of hypertensive organ damage in subjects considered to be normotensive at the casual sphygmomanometry, it is mandatory to perform the ABPM with the suspicion not only of an "odd-hour hypertension" or a "non-dipping phenomenon" but also of a "pre-hypertension"; 2. in the presence of a pre-hypertension diagnosed at the ABPM, it is mandatory to perform an accurate investigation of cardiovascular organs susceptible to hypertensive damage with the suspicion of a Cugini's syndrome. Further studies are needed to verify whether or not the Cugini's syndrome needs to be preventively cured and which drugs have to be eventually used. A non-pharmacological treatment of life-style seems to be necessary.