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Manolis AJ, Kallistratos MS, Koutsaki M, Doumas M, Poulimenos LE, Parissis J, Polyzogopoulou E, Pittaras A, Muiesan ML, Mancia G. The diagnostic approach and management of hypertension in the emergency department. Eur J Intern Med 2024; 121:17-24. [PMID: 38087668 DOI: 10.1016/j.ejim.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 03/08/2024]
Abstract
Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.
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Mancia G, Cappuccio FP, Burnier M, Coca A, Persu A, Borghi C, Kreutz R, Sanner B. Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension. J Intern Med 2023; 294:251-268. [PMID: 37401044 DOI: 10.1111/joim.13678] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.
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Rodriguez O, Mahfoud F, Schmieder R, Schlaich M, Narkiewicz K, Ruilope L, Williams B, Fahy M, Mancia G, Boehm M. Blood pressure reduction in higher cardiovascular risk patients in the Global SYMPLICITY Registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Introduction
The Global SYMPLICITY Registry (GSR) was designed to evaluate the safety and efficacy of renal denervation (RDN) in real-world patients. Inclusion and exclusion criteria are limited to allow assessment of the effects of RDN on patients with a wide range of comorbidities. The current analysis examines blood pressure (BP) reduction after RDN in higher cardiovascular risk patients.
Purpose
To evaluate blood pressure reduction after RDN in higher cardiovascular risk patients in GSR.
Methods
GSR is a prospective all-comers registry to evaluate the safety and efficacy of RDN. Patients are enrolled in GSR and receive radiofrequency RDN using the Symplicity Flex or Symplicity Spyral catheter. Office and ambulatory BP are measured at each follow-up (3, 6, 12, 24, and 36 months). In this post-hoc analysis, changes from baseline in office and 24-hour ambulatory systolic blood pressure were assessed in patients at higher cardiovascular risk. Higher risk was defined using baseline office systolic or diastolic BP as well as additional risk factors (Figure 1).
Results
As of March 2021, there were 2621 patients characterized as higher cardiovascular risk in GSR. Baseline characteristics included mean age 60.7±12.1 years, 57.6% male, 37.9% type 2 diabetes, 35.8% hypocholesterolemia, 19.7% eGFR <60 mL/min/1.73 m2, 16.2% left ventricular hypertrophy, 10.2% previous stroke and 9.3% previous myocardial infarction. Baseline office systolic BP (OSBP) was 168.8±22.7 mmHg and baseline ambulatory systolic BP (ASBP) 155.3±18.6 mmHg. Mean OSBP reductions after RDN in this higher risk population ranged from −13.1 mmHg at 3 months to −17.5 mmHg at 24 months and −18.9 mmHg at 36 months, and mean ASBP reductions ranged from −7.8 mmHg at 3 months to −9.8 mmHg at 24 months and −9.3 mmHg at 36 months (Figure).
Conclusions
Higher risk patients in GSR had sustained office and ambulatory systolic BP reductions out to 3 years after catheter-based radiofrequency RDN.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Medtronic
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De Champvallins M, Brzozowska-Villatte R, Mancia G. Successful perindopril/amlodipine+indapamide treatment as second line in uncontrolled hypertensive patients in line with european guidelines. Eur J Prev Cardiol 2022. [DOI: 10.1093/eurjpc/zwac056.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): The study was sponsored by Servier.
Background
ESC/ESH guidelines recommend use of a RAAS inhibitor + CCB + Thiazide as second step treatment for hypertensive patients with uncontrolled blood pressure (BP), preferably as single-pill combination.
Purpose
We investigated the results of adding indapamide SR 1.5 mg to the single-pill combination of perindopril/amlodipine (Per/Aml) in a context of a randomized double-blind controlled trial.
Method
The study compared 2 treatment strategies over 6 months: initiation with Per/Aml with further conditional uptitration up to Per/Amlo 14/10 mg, followed after 3 months of bi-therapy by addition of indapamide SR 1.5 mg for 3 additional months, versus initiation with Valsartan (Val) and further addition of amlodipine, then uptitration up to Val/Amlo 160/10 mg. The study was completed by an additional 8-month extension period (M14) at the same dose for the patients controlled at M6, for safety purposes.
Results
Compared with initiation of Val alone, initiation of treatment with Per/Amlo led to lower number of patients needing further uptitration at M3 (23% vs 31%). In 202 patients uncontrolled with Per/Amlo 14/10, the addition of indapamide SR 1.5 mg led to a large additional decrease in systolic BP (-14.8±13.3 mmHg) and diastolic BP (-7.2±9.7 mmHg) with BP control achieved in 82.5% of the patients (<140/90 mmHg) and BP response in 94%. During the whole period (11 months), 5.9% of the patients (n=10) discontinued the triple therapy due to 11 adverse reactions, versus 3.9% of those receiving Per/Amlo 14/10 over the same period.
Conclusion
These findings confirm the BP-lowering efficacy and safety of adding the thiazide-like indapamide to a previous ACE inhibitor+CCB (Per/Amlo) combination providing clinical evidence for this triple therapy, preferably to be given as single-pill combination.
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Mahfoud F, Mancia G, Ukena C, Schmieder R, Narkiewicz K, Ruilope L, Schlaich M, Williams B, Fahy M, Boehm M. Application of win ratio methodology in the Global SYMPLICITY Registry for patients with atrial fibrillation or obstructive sleep apnea. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
The win ratio is a new methodology which utilizes multiple hierarchical endpoints to evaluate clinical outcomes in trials. The win ratio may have added benefit in device therapy trials like renal denervation (RDN) where anti-hypertensive medication burden can influence blood pressure (BP) changes.
Purpose
In this analysis, we applied the win ratio to patients in the Global SYMPLICITY Registry (GSR) to quantify potential differences in RDN efficacy according to different comorbidities, specifically atrial fibrillation and obstructive sleep apnea.
Methods
All patients in GSR had an RDN procedure with the Symplicity Flex or Symplicity Spyral catheter. For the win ratio analysis, ambulatory systolic BP (ASBP) measurements, office systolic BP (OSBP) measurements and the number of prescribed anti-hypertensive medications at 6 months were included as hierarchical endpoints. Patients were divided into 1 of 2 groups: with or without atrial fibrillation (AF) at baseline. Each patient was compared with every other patient in the opposing group first according to ASBP to determine “win”, “lose” or “tie” with a threshold of 5 mmHg. Then, ties from the ASBP comparison underwent the comparison using OSBP with a threshold of 10 mmHg. Any tie for a pair comparing OSBP resulted in comparison of number of anti-hypertensive medications with a threshold of 1. Comparisons of ASBP and OSBP were adjusted for baseline SBPs by using residuals from a linear regression. The analysis was repeated for patients grouped according to history of obstructive sleep apnea (OSA) at baseline.
Results
In March 2020, 336 patients with AF at baseline and 2,394 patients with no AF were compared in GSR, resulting in 336 x 2394 = 804,384 pairwise comparisons for the win ratio analysis. A total of 285,709 “wins”, indicating greater ASBP reduction, OSBP reduction, and/or fewer number of anti-hypertensive medications occurred in the AF group compared to the no AF group. Conversely, 256,511 “losses”, meaning greater BP reduction and/or number of medications occurred in the no AF group. The win ratio was thus calculated as 1.11 (95% CI: 0.98, 1.28, p=0.081) indicating similar BP reduction and medication burden after RDN in patients with or without AF in GSR (Figure). Using these methods, the win ratio for patients with and without OSA was calculated to be 0.98 (95% CI: 0.85, 1.13, p=0.81), also indicating similar RDN efficacy regardless of presence of OSA at baseline (Figure). Previously published results of the win ratio analysis of RDN and sham control patients in the SPRYAL HTN-ON MED trial reported a win ratio in favor of RDN of 2.78 (95% CI: 1.58, 5.48, p<0.001).
Conclusions
Application of the win ratio methodology to patients in GSR demonstrated similar efficacy of RDN to patients regardless of whether they had comorbidities of atrial fibrillation or obstructive sleep apnea.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Medtronic
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Rea F, Savaré L, Corrao G, Mancia G. Better adherence to lipid-lowering treatment by a fixed-dose than a free combination of statin and ezetimibe. Atherosclerosis 2020. [DOI: 10.1016/j.atherosclerosis.2020.10.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kristensen A, Rosberg V, Vishram-Nielsen J, Pareek M, Linneberg A, Giampaoli S, Mancia G, Cesana G, Kuulasmaa K, Salomaa V, Sans S, Ferrieres J, Soderberg S, Moitry M, Olsen M. Simple cardiovascular risk stratification using anthropometric measures instead of serum cholesterol. The MORGAM Prospective Cohort Project. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Body composition predicts cardiovascular outcomes, but it is uncertain whether anthropometric measures can replace the more expensive serum total cholesterol for cardiovascular risk stratification in low resource settings.
Purpose
The purpose of the study was to compare the additive prognostic ability of serum total cholesterol with that of body mass index (BMI), waist/hip ratio (WHR), and estimated fat mass (EFM, calculated using a validated prediction equation), individually and combined.
Methods
We used data from the MORGAM (MONICA, Risk, Genetics, Archiving, and Monograph) Prospective Cohort Project, an international pooling of cardiovascular cohorts, to determine the relationship between anthropometric measures, serum cholesterol, and cardiovascular events, using multivariable Cox proportional-hazards regression analysis. We further investigated the ability of these measures to enhance prognostication beyond a simpler prediction model, consisting of age, sex, smoking status, systolic blood pressures, and country, using comparison of area under the receiver operating characteristics curve (AUCROC) derived from binary logistic regression models. The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of death from coronary heart disease, myocardial infarction, or stroke.
Results
The study population consisted of 52,188 apparently healthy subjects (56.3% men) aged 47±12 years ranging from 20 to 84, derived from 37 European cohorts, with baseline between 1982–2002 all followed for 10 years during which MACE occurred in 2465 (4.7%) subjects. All anthropometric measures (BMI: hazard ratio (HR) 1.04 [95% confidence interval (CI): 1.03–1.05] per kg/m2; WHR: HR 7.5 [4.0–14.0] per unit; EFM: HR 1.02 [1.01–1.02] per kg) as well as serum total cholesterol (HR 1.20 [1.16–1.24] per mmol/l) were significantly associated with MACE (P<0.001 for all), independently of age, sex, smoking status, systolic blood pressures, and country. The addition of serum cholesterol significantly improved the predictive ability of the simple model (AUCROC 0.818 vs. 0.814, P<0.001), as did the combination of WHR, BMI, and EFM (AUCROC 0.817 vs. 0.814, P=0.004). When assessed individually, BMI (AUCROC 0.816 vs. 0.814, P=0.004) and WHR (AUCROC 0.815 vs. 0.814, P=0.02) improved model performance, while EFM narrowly missed significance (AUCROC 0.815 vs. 0.814, P=0.06). There was no significant difference in the predictive ability of a model including serum cholesterol versus that including all three anthropometric measures (AUCROC 0.818 vs. 0.817, P=0.13). The figure shows the pertinent areas under the ROC curve in predicting MACE.
Conclusion
In this large population-based cohort study, the addition of a combination of anthropometric measures, i.e. BMI, WHR, and EFM, raised the predictive ability of a simple prognostic model comparable to that obtained by the addition of serum total cholesterol.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Hua X, Lung TWC, Woodward M, Salomon JA, Hamet P, Harrap SB, Mancia G, Poulter N, Chalmers J, Clarke PM. Self-rated health scores predict mortality among people with type 2 diabetes differently across three different country groupings: findings from the ADVANCE and ADVANCE-ON trials. Diabet Med 2020; 37:1379-1385. [PMID: 31967344 PMCID: PMC7496988 DOI: 10.1111/dme.14237] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 01/19/2023]
Abstract
AIMS To explore whether there is a different strength of association between self-rated health and all-cause mortality in people with type 2 diabetes across three country groupings: nine countries grouped together as 'established market economies'; Asia; and Eastern Europe. METHODS The ADVANCE trial and its post-trial follow-up were used in this study, which included 11 140 people with type 2 diabetes from 20 countries, with a median follow-up of 9.9 years. Self-rated health was reported on a 0-100 visual analogue scale. Cox proportional hazard models were fitted to estimate the relationship between the visual analogue scale score and all-cause mortality, controlling for a range of demographic and clinical risk factors. Interaction terms were used to assess whether the association between the visual analogue scale score and mortality varied across country groupings. RESULTS The visual analogue scale score had different strengths of association with mortality in the three country groupings. A 10-point increase in visual analogue scale score was associated with a 15% (95% CI 12-18) lower mortality hazard in the established market economies, a 25% (95% CI 21-28) lower hazard in Asia, and an 8% (95% CI 3-13) lower hazard in Eastern Europe. CONCLUSIONS Self-rated health appears to predict 10-year all-cause mortality for people with type 2 diabetes worldwide, but this relationship varies across groups of countries.
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Seravalle G, Dell'oro R, Gardini M, Quarti Trevano F, Marro G, Mancia G, Grassi G. P3405Association between heart rate thresholds for cardiovascular risk defined by new ESC/ESH Guidelines and neuroadrenergic markers. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The ESC/ESH Guidelines for hypertension issued in 2018 identify resting heart rate (HR) values greater than 80 beats/minute as predictors of cardiovascular risk, with the undocumented evidence that this detection might represent the occurrence of a sympathetic cardiovascular overdrive.
Purpose
In the present study we tested this hypothesis throughout the use of direct and indirect markers of sympathetic neural function.
Methods
In 167 untreated and uncomplicated mild-to moderate essential hypertensives recruited for different investigations and aged 51.8±3.2 years (mean±SEM) without other cardiovascular or non-cardiovascular disease, we measured clinic and ambulatory blood pressure (BP), HR (EKG), venous plasma norepinephrine (NE, HPLC assay) and efferent postganglionic muscle sympathetic nerve traffic (MSNA, microneurography). We then subdivided the study population in 2 groups according to HR values ≤ or >80 beats/minute.
Results
Sixty-eight patients displayed resting HR >80 beats/minute while the remaining 99 below this threshold value, the 2 groups showing superimposable age values and gender distribution. Body mass index, clinic and ambulatory BP were similar in the 2 groups this being the case also for LVMI and metabolic variables. In contrast MSNA values were significantly greater (P<0.02) in the former than in the latter group both when expressed as bursts incidence over time (49.2±1.8 vs 39.5±1.4 bs/min) and when corrected for HR (60.7±3.0 vs 51.4±2.5 bs/100 hb). NE showed a tendency to be greater in the former group without achieving, however, statistical significance. In the whole population there was a significant direct relationship between MSNA and HR values (r=0.61, P<0.01)
Conclusions
Thus hypertensive patients displaying HR >80 beats/minute are characterized by a marked sympathetic overdrive, particularly when direct adrenergic markers are employed. This finding suggests that cardiac and peripheral sympathetic activation may participate at the increased cardiovascular risk detected in this group of patients.
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Mahfoud F, Mancia G, Schmieder R, Narkiewicz K, Ruilope L, Schlaich M, Williams B, Fahy M, Bohm M. 1199Reduction in blood pressure following renal denervation for patients with differing baseline cardiovascular risk. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Lowering blood pressure (BP) reduces clinical events. Renal denervation (RDN) is under investigation for treatment of uncontrolled hypertension and might represent a particularly attractive option for patients with high cardiovascular (CV) risk. To evaluate this proposal, it is important to determine whether baseline CV risk impacts the efficacy of RDN in lowering BP.
Purpose
We evaluated whether BP changes after RDN were dependent on baseline CV risk.
Methods
AHA/ACC Atherosclerosis CV Disease (ASCVD) risk score was calculated for patients in the Global Symplicity Registry (GSR; NCT01534299), a global registry of RDN in patients with uncontrolled hypertension, using baseline office systolic BP, total/HDL cholesterol measurements, diabetic and smoking status, gender, age, and number of baseline anti-hypertensive medications. Patients were separated into 3 groups based on ASCVD risk scores: <10%, ≥10% and <20% and ≥20%. Baseline demographics and 24-hour systolic BP changes at 6 months and 1, 2 and 3 years were compared between groups, as well as rates of adverse events at 3 years.
Results
Individual ASCVD risk scores were calculated for 1,434 patients in GSR. The median ASCVD risk score was 19.4% and 403 patients had a risk score of <10%, 326 a risk score of ≥10 and <20%, and 705 a risk score ≥20%. Patients with ASCVD risk score ≥20% had a higher baseline office systolic BP, were significantly older, and had higher rates of prior myocardial infarction and/or diabetes (all p<0.0001 compared to patients with lower risk scores). RDN reduced BP similarly across all groups of patients. Changes in 24-hour systolic BP at 6 months and 1, 2 and 3 years are shown in Figure 1. Adverse events at 3 years are shown in Table 1.
Adverse events at 3 years ASCVD risk score <10% ASCVD risk score ≥10% & <20% ASCVD risk score ≥20% p-value (N=265) (N=224) (N=468) Death 3 (1.1) 5 (2.2) 41 (8.8) <0.0001 Cardiovascular death 3 (1.1) 2 (0.9) 23 (4.9) 0.0017 Myocardial infarction 6 (2.3) 6 (2.7) 11 (2.4) 0.9513 Stroke 8 (3.0) 9 (4.0) 24 (5.1) 0.3894 Hospitalization for new onset heart failure 4 (1.5) 7 (3.1) 26 (5.6) 0.0194 Values are proportions reported as n (%).
Conclusions
BP changes after RDN were similar for patients with varying baseline ASCVD risk scores, suggesting uniform BP-lowering efficacy of RDN regardless of patients' baseline CV risk. The impact of baseline risk on clinical event reduction by RDN-induced BP reduction will need to be evaluated in further studies.
Acknowledgement/Funding
The Global SYMPLICITY Registry is funded by Medtronic.
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Seravalle G, Quarti Trevano F, Dell'oro R, Bertoli G, Mancia G, Grassi G. P1688Behavior of indices of sympathetic activity in relation to sleep time duration in untreated hypertensives. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Short sleep duration and poor sleep quality has been reported to be associated with increased cardiovascular risk and increased incidence of cardiovascular events.
Purpose
Whether and what extent the pathophysiology of this association includes sympathetic abnormalities has never been examined via microneurography.
Methods
In 28 untreated mild-to moderate essential hypertensives aged 66.4±3.1 (mean±SEM) without other cardiovascular or non-cardiovascular disease (including obstructive sleep apnea) recruited from the outpatient clinic and referred for short sleep duration, we directly assessed at patients home via actigraphy (actiwatch spectrum activity monitor, Phillips) time sleep duration and efficiency. Measurements, performed during a day preceding or following the 7 day actigraphy evaluation, included microneurographic recording of efferent postganglionic sympathetic nerve traffic (MSNA), venous plasma norepinephrine (HPLC), clinic, 24 hour and beat to beat blood pressure and heart rate values. Sleep diary and a sleep questionnaire were also administered.
Results
Nine patients slept less than 6 hours per night (LSD), while the remaining ones between 6 to 7 (MSD, n=8) or more than 7 hours (GSD,N=11). The 3 groups showed similar age and gender distribution and a body mass index amounting to 28.1±0.8, 28.6±0.5 and 27.3±0.5 kg/m2 (P=NS). For similar mean blood pressure values LSD showed MSNA values significantly greater than GSD (53.4±4.9 vs 40.1±3.8bs/100hb, P<0.03), this being the case also for MSD (49.7±4.4, P<0.05 vs GSD but not SLD). HR was significantly elevated only in LSD group when compared to GSD, while no significant difference was found in plasma NE between the 3 groups.
Conclusions
The present study provides the first microneurographic direct evidence that short sleep duration is linked to a marked sympathetic activation, which may participate at the high cardiovascular risk of these subjects. The sympathetic overdrive affects both the cardiac and peripheral district but is not reflected by NE, which thus does not represent in this condition a valuable adrenergic marker.
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Saeed S, Mancia G, Rajani R, Parkin D, Chambers JB. P2650Antihypertensive treatment with calcium channel blockers in patients with moderate or severe aortic stenosis: relationship with all-cause mortality. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hypertension is prevalent in patients with aortic stenosis (AS) and optimal blood pressure (BP) control is advised to reduce arterial load and avoid cardiovascular events. Whether calcium channel blockers (CCB) are safe is not known.
Methods
A total of 314 patients (age 65±12 y, 68% men) with moderate or severe asymptomatic AS were included.
Results
The prevalence of hypertension was 73.6%, and 65% took antihypertensive treatment. Patients who used a CCB (25%) (CCB+) were older, had higher clinic systolic BP, were more likely to have hypercholesterolemia and coronary artery disease (CAD), and to use a diuretic or alpha blocker compared to CCB- patients (all p<0.05) (Table). During the baseline ETT, patients who used a CCB achieved a lower peak heart rate, a shorter exercise time and were more likely to have a blunted BP response compared to those who did not use a CCB (all p<0.05) (Table). Event-free survival was significantly lower in CCB+ than CCB- patients (Fig) (all-cause mortality 16 [20.3%] versus 13 (5.6%); p<0.001). In a multivariable Cox regression model, CCB+ was associated with a 6.8-fold increased hazard ratio (HR) for all-cause mortality (HR 6.77 95% CI 1.66–27.54, p=0.008), independent of age, gender, systolic BP, hypertension, diabetes, CAD, hypercholesterolemia and aortic valve area.
Table 1. Baseline characteristics of patients CCB− (n=234) CCB+ (n=80) p Age, y 64±12 70±10 <0.001 CAD, % 45 66 0.006 Hypercholesterolemia, % 62 78 0.015 Clinic systolic BP, mmHg 139±19 150±17 <0.001 Left atrial diameter, cm 3.7±0.7 3.9±0.6 0.007 LV end-diastolic diameter, cm 4.5±0.7 4.8±0.6 0.002 LV mass index, g/m2.7 50±17 57±17 0.007 Aortic valve area, cm2 0.94±0.22 0.93±0.22 0.716 LV stroke work, g-m/bmp 155±46 175±69 0.046 Peak HR at baseline ETT, bmp 138±24 120±25 <0.001 Blunted BP response, % 33 49 0.013 Exercise duration, min 10.1±4.5 8.3±3.7 0.001 Double Product, mmHg·bmp 1.85±0.43 2.08±0.54 <0.001
Figure 1
Conclusion
The use of calcium channel blockers was associated with an adverse effect on treadmill exercise and reduced survival in apparently asymptomatic patients with moderate or severe AS.
Acknowledgement/Funding
None
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Saeed S, Mancia G, Rajani R, Parkin D, Chambers J. HYPERTENSION IN AORTIC STENOSIS. J Hypertens 2019. [DOI: 10.1097/01.hjh.0000570416.62104.c9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Castiglioni P, Mancia G, Parati G, Pedotti A, Di Rienzo M. Critical Appraisal of Indices for the Assessment of Baroreflex Sensitivity. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1636857] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Abstract:The sequence technique and the spectral estimation of the alpha coefficient are currently employed for the assessment of “spontaneous” baroreflex sensitivity (BRS). The comparison of performance and effectiveness of these techniques is obtained by the analysis of systolic blood pressure (SBP) and pulse interval (PI) tracings recorded in conscious cats before and after baroreceptor denervation. Results indicate that (1) the average BRS estimates obtained by the sequence technique and by the alpha coefficient at the respiratory frequency are similar, (2) the alpha coefficients computed at the respiratory frequency tend to be higher than alpha coefficients estimated at 0.1 Hz, and (3) in spite of what is traditionally claimed, the PI-SBP coherence does not seem to represent a reliable parameter to enhance the specificity of the spectral estimate, because coherence values often remain above the 0.5 threshold also after baroreceptor denervation.
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Seravalle G, Brambilla G, Quarti Trevano F, Dell'oro R, Prata Pizzalla D, Ravaro S, Oliverio G, Mancia G, Grassi G. 273Visit-to-visit blood pressure variability is related to sympathetic neural drive and baroreflex sensitivity in hypertensive patients. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sormani P, Colombo G, Greco A, Maloberti A, Franzosi C, Meani P, Varrenti M, Vallerio P, De Chiara B, Casadei F, Moreo A, D’Addario M, Magrin M, Miglioretti M, Sarini M, Vecchio L, Steca P, Grassi G, Mancia G, Giannattasio C. [PP.32.04] PREDICTORS OF PWV PROGRESSION OVER A THREE YEARS FOLLOW UP. J Hypertens 2016. [DOI: 10.1097/01.hjh.0000492274.66436.7b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mancia G, Cha G, Gil-Extremera B, Harvey P, Lewin AJ, Villa G, Kjeldsen SE. Blood pressure-lowering effects of nifedipine/candesartan combinations in high-risk individuals: subgroup analysis of the DISTINCT randomised trial. J Hum Hypertens 2016; 31:178-188. [PMID: 27511476 PMCID: PMC5301082 DOI: 10.1038/jhh.2016.54] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/02/2016] [Accepted: 03/14/2016] [Indexed: 11/09/2022]
Abstract
The DISTINCT study (reDefining Intervention with Studies Testing Innovative Nifedipine GITS-Candesartan Therapy) investigated the efficacy and safety of nifedipine GITS/candesartan cilexetil combinations vs respective monotherapies and placebo in patients with hypertension. This descriptive sub-analysis examined blood pressure (BP)-lowering effects in high-risk participants, including those with renal impairment (estimated glomerular filtration rate<90 ml min-1, n=422), type 2 diabetes mellitus (n=202), hypercholesterolaemia (n=206) and cardiovascular (CV) risk factors (n=971), as well as the impact of gender, age and body mass index (BMI). Participants with grade I/II hypertension were randomised to treatment with nifedipine GITS (N) 20, 30, 60 mg and/or candesartan cilexetil (C) 4, 8, 16, 32 mg or placebo for 8 weeks. Mean systolic BP and diastolic BP reductions after treatment in high-risk participants were greater, overall, with N/C combinations vs respective monotherapies or placebo, with indicators of a dose-response effect. Highest rates of BP control (ESH/ESC 2013 guideline criteria) were also achieved with highest doses of N/C combinations in each high-risk subgroup. The benefits of combination therapy vs monotherapy were additionally observed in patient subgroups categorised by gender, age or BMI. All high-risk participants reported fewer vasodilatory adverse events in the pooled N/C combination therapy than the N monotherapy group. In conclusion, consistent with the DISTINCT main study outcomes, high-risk participants showed greater reductions in BP and higher control rates with N/C combinations compared with respective monotherapies and lesser vasodilatory side-effects compared with N monotherapy.
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Böhm M, Schumacher H, Schmieder RE, Mann JFE, Teo K, Lonn E, Sleight P, Mancia G, Linz D, Mahfoud F, Ukena C, Sliwa K, Bakris G, Yusuf S. Resting heart rate is associated with renal disease outcomes in patients with vascular disease: results of the ONTARGET and TRANSCEND studies. J Intern Med 2015; 278:38-49. [PMID: 25431275 DOI: 10.1111/joim.12333] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Resting heart rate (RHR) is associated with cardiovascular disease outcomes in high-risk patients. It is not known whether RHR is predictive of renal outcomes such as albuminuria, end-stage renal disease (ESRD) or doubling of creatinine. We evaluated whether RHR could predict renal endpoints in patients at a high risk of cardiovascular disease. We also tested the effects of RHR at different levels of systolic blood pressure (SBP). METHODS We analysed data from 28 757 patients in the ONTARGET and TRANSCEND trials. RHR and SBP were available for a mean of 4.9 ± 0.4 visits (range 3-5) within the first 2 years of the studies. Albuminuria was determined at baseline, at 2 years and at study end. RESULTS Mean RHR was predictive of incident micro-albuminuria [hazard ratio (HR) for RHR ≥80 vs. <60 beats min(-1) 1.49, 95% confidence interval (CI) 1.29-1.71, P < 0.0001], incident macro-albuminuria (HR 1.84, 95% CI 1.39-2.42, P < 0.0001), doubling of creatinine (HR 1.47, 95% CI 1.00-2.17, P = 0.050) and ESRD (HR 1.78, 95% CI 1.00-3.16, P = 0.050), and the combined renal end-point (HR 1.51, 95% CI 1.32-1.74, P < 0.0001). Associations were robust at SBPs from <120 to ≥150 mmHg, with the lowest risk at a SBP of 130-140 mmHg. CONCLUSION Resting heart rate is a potent predictor of these renal outcomes, as well as their combination, in patients with cardiovascular disease. RHR at all SBP levels should be considered as a possible renal disease risk predictor and should be investigated as a treatment target with RHR-reducing agents.
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Grosso G, Erba G, Valena C, Riva M, Betelli M, Allevi E, Bonomi F, Barbarossa S, Ricci M, Facchetti R, Pozzi M, Grassi G, Mancia G. THU0139 Cardiovascular Risk Factor Profile in an Italian Cohort of Patients with Rheumatoid Arthritis: Results of a Three Year Follow-up. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.5177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Seravalle G, Trevano FQ, Boggioni I, Buzzi S, Mancia G, Grassi G. 2B.01. J Hypertens 2015. [DOI: 10.1097/01.hjh.0000467406.56290.0a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mancia G, Cannon CP, Tikkanen I, Zeller C, Ley L, Hach T, Woerle HJ, Broedl UC, Johansen OE. BP reduction with the sodium glucose co-transporter 2 inhibitor (SGLT-2i) empagliflozin (EMPA) in type 2 diabetes (T2D) is similar in treatment naïve as in those on one or ≥2 antihypertensive agents – further insights from a dedicated 24h ABPM study. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0035-1549550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Grassi G, Bolla GB, Turri C, Bertinieri G, Pozzi M, Mancia G. Old and new approaches for evaluating autonomic control of circulation in man. CONTRIBUTIONS TO NEPHROLOGY 2015; 119:165-72. [PMID: 8783610 DOI: 10.1159/000425469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Mancia G, Giannattasio C, Pozzi M. Cardiovascular and renal disease in untreated and treated hypertension. CONTRIBUTIONS TO NEPHROLOGY 2015; 109:65-9. [PMID: 7956231 DOI: 10.1159/000423289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Hyperuricemia is associated with hypertension, kidney disease, vascular and cardiovascular (CV) events. In experimental models, the inhibition of hepatic uricase induces hyperuricemia, hypertension and mild renal disease. Notably, the micro- and macrovascular changes observed in the experimental model of hyperuricemia resemble the histological changes of human hypertension. This paper presents and discusses the epidemiological correlation between high serum uric acid levels and hypertension, and reviews current evidence supporting the protective effects of the normalization of uric acid levels. This review is based on a PubMed/Embase database search for articles on hyperuricemia and its impact on cardiovascular and renal function.
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