Rationale and Design of the ACS-BP Study: Prognostic Value of In-Hospital Blood Pressure and Indices of Atherosclerosis in Acute Coronary Syndromes

BACKGROUND

High blood pressure (BP) is a leading risk factor for coronary artery disease and other major cardiovascular events.

OBJECTIVE

Blood pressure variability (BPV), ambulatory arterial stiffness index (AASI) and ankle- brachial index (ABI) have been proposed as indices that can improve risk stratification for an adverse cardiac outcome. However, their utility in the setting of acute coronary syndromes (ACS) is unclear.

METHODS

The ACS-BP study is a single-centre observational cohort study designed to investigate the prognostic role of haemodynamic load and arterial stiffness indices for cardio-renal outcomes in patients with acute myocardial infarction (AMI). All consecutive patients admitted with a diagnosis of acute AMI with or without ST segment elevation were screened for inclusion in the study. The management of AMI will follow current guidelines.

RESULTS AND DISCUSSION

Data from baseline clinical and laboratory parameters during their hospitalization were collected. The haemodynamic load of each patient was determined by clinical BP values as well as 24-h ambulatory BP monitoring. The AASI was calculated from the raw 24-h BP data and ABI was measured after the third day of hospitalization using a certified device. Patients were followed-up for 12 months in order to collect data for hard cardiovascular and renal endpoints.

CONCLUSION

The study results should clarify the role of these non-invasive tools in secondary risk stratification of such patients.

The relationship between blood pressure and risk of atrial fibrillation: a Mendelian randomization study

AIMS

Observational studies suggest elevated blood pressure (BP) as the leading risk factor for incident atrial fibrillation (AF), but whether this relationship is causal remains unknown. In this study, we used Mendelian randomization (MR) to investigate the potential causal association of BP levels with the risk of developing AF.

METHODS AND RESULTS

Genetic variants associated with the BP traits were retrieved from the International Consortium of Blood Pressure-Genome Wide Association Studies (N = 299 024). From 901 reported variants, 894 were assessed in a dedicated Genome-Wide Association Study of AF genetics, including >1 000 000 subjects of European ancestry. We used two-sample MR analyses to examine the potential causal association of systolic BP (SBP) and diastolic BP (DBP) as well as of pulse pressure (PP) with AF. MR analysis identified a potentially causal association between AF and SBP [odds ratio (OR): 1.018 per 1 mmHg increase, 95% confidence interval (CI): 1.012-1.024, P < 0.001], DBP (OR: 1.026, 95% CI: 1.016-1.035, P < 0.001), and PP (OR: 1.014, 95% CI: 1.001-1.028, P = 0.033). These findings were robust in sensitivity analyses, including the MR-Egger method and the MR pleiotropy residual sum and outlier test (MR-PRESSO). The causal relationship of BP and AF did not change when single-nucleotide polymorphisms associated with possible confounders (i.e. coronary artery disease and obesity) of the causal relationship were excluded.

CONCLUSIONS

The association between increased BP levels and the risk of AF is likely causal and applies for different BP indices. Independently from other risk factors, optimal BP control might represent an important therapeutic target for AF prevention in the general population.

Peripartum management of hypertension: a position paper of the ESC Council on Hypertension and the European Society of Hypertension

Hypertensive disorders are the most common medical complications in the peripartum period associated with a substantial increase in morbidity and mortality. Hypertension in the peripartum period may be due to the continuation of pre-existing or gestational hypertension, de novo development of pre-eclampsia or it may be also induced by some drugs used for analgesia or suppression of postpartum haemorrhage. Women with severe hypertension and hypertensive emergencies are at high risk of life-threatening complications, therefore, despite the lack of evidence-based data, based on expert opinion, antihypertensive treatment is recommended. Labetalol intravenously and methyldopa orally are then the two most frequently used drugs. Short-acting oral nifedipine is suggested to be used only if other drugs or iv access are not available. Induction of labour is associated with improved maternal outcome and should be advised for women with gestational hypertension or mild pre-eclampsia at 37 weeks' gestation. This position paper provides the first interdisciplinary approach to the management of hypertension in the peripartum period based on the best available evidence and expert consensus.

The combined use of electrocardiography, echocardiography and cardiac magnetic resonance imaging in left atrium evaluation among beta-thalassemia patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Beta-thalassemia major (β-TM) patients are subjected to iron overload as a consequence of chronic blood transfusions. The redundant iron affects, among other organs, the heart resulting in myocardial dysfunction. Iron deposition does not only affect ventricular myocardium but atrial myocardium as well. According to current practice, the overall myocardial iron status is estimated by calculating T2* at the middle section of the ventricular septum using cardiac magnetic resonance imaging (CMR). Current CMR technology limits the direct estimation of atrial iron status. 

Purpose

The current study evaluates left atrial function by novel echocardiographic techniques and correlates these findings with CMR data.

Methods

37 β-TM patients (mean age 41.17 years (SD = 8.33), 51.4% male), were subjected to electrocardiography, echocardiography and CMR imaging and P wave axis, PR segment duration, left atrial volume index (LAVI), left atrial strain at reservoir phase (LASr) and T2* were measured. 

Results

No correlation between T2* and LASr (r = 0.253, p = 0.131) or T2* and LAVI (r = 0.044, p = 0.796) were found. However, a correlation was found between the echocardiographic parameters LAVI and LASr (r = -0.676, p &lt;0.001). P wave axis did not correlate with any other parameter, while PR segment duration was correlated with LASr (r = -0.399, p = 0.015). Regression analysis revealed correlation between LAVI and LASr (r2 = 0.457, p &lt;0.001).

Conclusions

The current study suggests that despite the undisputed contribution of CMR in left ventricular iron load estimation, it may be less accurate in atrial iron status estimation. Considering the limitations of current CMR technology regarding the iron status of the thin atrial and right ventricular walls, our study highlights the role of speckle tracking in combination with CMR imaging for a more comprehensive evaluation of β-TM patients.

Correlation table P axis PR segment T2* LAVI LASr P axis 0,151 (p = 0,373) 0,112 (p = 0.,508) -0,140 (p = 0,410) -0,117 (p = 0,489) PR segment 0,151 (p = 0,373) 0,051 (p = 0,766) 0,278 (p = 0,096) -0,399 (p = 0,015) T2* 0,112 (p = 0.,508) 0,051 (p = 0,766) 0,044 (p = 0,796) 0,253 (p = 0,131) LAVI -0,140 (p = 0,410) 0,278 (p = 0,096) 0,044 (p = 0,796) -0,676 (p &lt;0,001) LASr -0,117 (p = 0,489) -0,399 (p = 0,015) 0,253 (p = 0,131) -0,676 (p &lt;0,001) T2*: obtained by cardiac magnetic resonance imaging LAVI left atrial volume index (ml/m2) LASr left atrial strain at reservoir phase Abstract Figure. Correlation between LASr and T2*

Elevated heart rate and cardiovascular risk in hypertension

Epidemiological studies have shown that chronically elevated resting heart rate (HR) is significantly associated with organ damage, morbidity and mortality in a wide range of patients including hypertensive patients. Evidence is also available that an increased HR reflects sympathetic nervous system overdrive which is also known to adversely affect organ structure and function and to increase the risk of unfavourable outcomes in several diseases. The causal relationship between elevated HR, organ damage, and cardiovascular outcomes can thus be explained by its relationship with sympathetic cardiovascular influences although evidence of sympathetically-independent adverse effect of HR increases per se makes it more complex. Interventions that target HR by modulating the sympathetic nervous system have therefore a strong pathophysiological and clinical rationale. As most clinical guidelines now recommend the use of combination therapies in patients with hypertension, it might be desirable to consider as combination components drugs which lower HR, if HR is elevated such as, according to guideliines, when it is above 80 b/min.

Cardiac Masses: The Role of Cardiovascular Imaging in the Differential Diagnosis

Cardiac masses are space occupying lesions within the cardiac cavities or adjacent to the pericardium. They include frequently diagnosed clinical entities such as clots and vegetations, common benign tumors such as myxomas and papillary fibroelastomas and uncommon benign or malignant primary or metastatic tumors. Given their diversity, there are no guidelines or consensus statements regarding the best diagnostic or therapeutic approach. In the past, diagnosis used to be made by the histological specimens after surgery or during the post-mortem examination. Nevertheless, evolution and increased availability of cardiovascular imaging modalities has enabled better characterization of the masses and the surrounding tissue. Transthoracic echocardiography using contrast agents can evaluate the location, the morphology and the perfusion of the mass as well as its hemodynamic effect. Transesophageal echocardiography has increased spatial and temporal resolution; hence it is superior in depicting small highly mobile masses. Cardiac magnetic resonance and cardiac computed tomography are complementary providing tissue characterization. The scope of this review is to present the role of cardiovascular imaging in the differential diagnosis of cardiac masses and to propose a step-wise diagnostic algorithm, taking into account the epidemiology and clinical presentation of the cardiac masses, as well as the availability and the incremental value of each imaging modality.

Association of Soluble Suppression of Tumorigenesis-2 (ST2) with Endothelial Function in Patients with Ischemic Heart Failure

Soluble suppression of tumorigenesis-2 (sST2) has been introduced as a marker associated with heart failure (HF) pathophysiology and status. Endothelial dysfunction is a component underlying HF pathophysiology. Therefore, we examined the association of arterial wall properties with sST2 levels in patients with HF of ischemic etiology. We enrolled 143 patients with stable HF of ischemic etiology and reduced left ventricular ejection fraction (LVEF) and 77 control subjects. Flow-mediated dilation (FMD) was used to evaluate endothelial function and pulse wave velocity (PWV) to assess arterial stiffness. Although there was no significant difference in baseline demographic characteristics, levels of sST2 were increased in HF compared to the control (15.8 (11.0, 21.8) ng/mL vs. 12.5 (10.4, 16.3) ng/mL; p < 0.001). In the HF group, there was a positive correlation of sST2 levels with age (rho = 0.22; p = 0.007) while there was no association of LVEF with sST2 (rho = −0.119; p = 0.17) nor with PWV (rho = 0.1; p = 0.23). Interestingly, sST2 was increased in NYHA III [20.0 (12.3, 25.7) ng/mL] compared to patients with NYHA II (15.0 (10.4, 18.2) ng/mL; p = 0.003) and inversely associated with FMD (rho = −0.44; p < 0.001) even after adjustment for possible confounders. In patients with chronic HF of ischemic etiology, sST2 levels are increased and are associated with functional capacity. There is an inverse association between FMD and sST2 levels, highlighting the interplay between the dysfunctional endothelium and HF pathophysiologic mechanisms.

Recent advances in managing primary hypertension

Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.

Correlations of attended and unattended blood pressure with sympathetic nervous system activity in essential hypertension

Background/Introduction

Measurement of unattended blood pressure (BP) may provide additional information over conventionally attended BP. Moreover, hypertension is related to sympathetic drive while there are scarce data on the diverse links of attended and unattended BP with muscle sympathetic nerve activity (MSNA) in hypertensive patients.

Purpose

The aim of this study was to appraise the relation of BP levels in the attended and unattended setting with MSNA in patients with essential hypertension.

Methods

We studied 117 patients with essential hypertension (age: 58±11 years, 60 males, office BP: 142/85±17/10 mmHg, 24-hour BP: 133/80±11/9 mmHg). In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Both unattended BP (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements, at 1-minute intervals, after 5 minutes) and attended BP were measured with the same device, on the same day of MSNA recording, in random order. Patients were divided into the combined attended and unattended hypertensive group when BP≥140/90 mmHg in both attended and unattended BP estimations and to the attended hypertensive group when only attended BP≥140/90 mmHg.

Results

Patients with combined attended and unattended hypertension (n=70) compared to those with attended hypertension (n=47) did not differ regarding 24-h ambulatory BP levels, glucose levels, renal function and left ventricular mass index (p=NS for all). Moreover, patients with combined attended and unattended hypertension compared to those with attended hypertension were characterized by greater levels of MSNA (43.7±9.9 vs 37.7±9.7 bursts per minute, p=0.032). In all participants, sympathetic nerve traffic as assessed by resting MSNA was related to attended systolic BP (r=0.270, p=0.003), attended diastolic BP (r=0.344, p=0.001), unattended systolic BP (r=0.263, p=0.004) and unattended diastolic BP (r=0.274, p=0.003).

Conclusions

The phenotype of combined attended and unattended hypertension compared to attended hypertension is accompanied by higher sympathetic nervous system activation. Moreover, the close association of MSNA with attended and unattended BP levels in essential hypertension, further supports the key role of sympathetic drive in modulating BP.

Funding Acknowledgement

Type of funding source: None

Blood pressure response in exercise is associated with future cardiac structural alterations in hypertensive patients

Background/Introduction

Exaggerated blood pressure response (EBPR) during the exercise treadmill test (ETT) is often observed in individuals without known cardiovascular disease. Although it is generally considered as an abnormal response and a risk factor for hypertension development, its clinical significance remains controversial. On the other hand, regression of left ventricular hypertrophy (LVH) is independently associated with improved cardiovascular outcome.

Purpose

In this study we aimed to investigate the role of EBPR during exercise in LVH regression in hypertensive subjects over time.

Methods

1413 hypertensive subjects, (mean age 57±11 years), 51% males, with baseline office blood pressure (BP) 144/89mmHg were followed for a mean period of 6.4±3.0 years. At baseline and last follow-up visit all patients underwent office BP, laboratory tests and echocardiographical determination of left ventricular mass index (LVMI). At baseline, all subjects underwent treadmill exercise testing (Bruce protocol) in order to identify the presence of EBPR based on the systolic BP elevation at peak exercise (&gt; or =210 mmHg for men and &gt; or =190 mmHg for women). Main outcome variable was LVH Regression/prevention (LVH Regr/prev), defined as: LVH at baseline visit with normal LVMI values at last visit or absence of LVH at baseline and last visit. BP control was considered optimal when the mean of office BP measurements during follow-up was &lt;140/90mmHg.

Results

46% of study population presented LVH Regr/prev during follow-up period. Cox-regression analysis, after adjustment for clinical and biochemical variables, revealed that low levels of baseline LVMI (HR=0.98, 95% CI 0.97–0.99, p&lt;0.0001), absence of EBPR (HR=0.81, 95% CI 0.67–0.98, p=0.02) and optimal BP control during follow-up (HR=1.19, 95% CI 1.01–1.56, p=0.03) were independent predictors of LVH Regr/prev during follow-up.

Conclusions

Beyond optimal BP control, EBPR is a significant predictor of left ventricular mass changes overtime. Hence, ETT can provide clinical relevant information, including EBPR, which may help in the improvement of risk stratification of hypertensive subjects.

Funding Acknowledgement

Type of funding source: None

Dietary approaches to stop hypertension (DASH) diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials

Background

The dietary approaches to stop hypertension (DASH) diet is recognized as an effective dietary intervention to reduce blood pressure (BP). However, among randomized controlled trials (RCTs) investigating the DASH diet mediated BP reduction,there are significant methodological and clinical differences.

Purpose

The purpose of this study was to comprehensively assess the effect of the DASH diet on BP levels in adults with and without hypertension, accounting for underlying methodological and clinical confounders.

Methods

We systematically searched Medline and the Cochrane Collaboration Library databases and identified 30 RCTs (n=5,545 participants) that investigated the BP effects of the DASH diet compared to a control diet in hypertensive and non-hypertensive adults. Both random-effects and fixed-effect models were used to calculate the mean attained systolic BP (SBP) and diastolic BP (DBP) differences during follow-up. Subgroup and meta-regression analyses were also conducted.

Results

The DASH diet reduced SBP and DBP significantly more compared to the control diet (difference in means: −3.2 mm Hg; 95% CI: −4.2, −2.3; P&lt;0.001, and −2.5 mm Hg; 95% CI: −3.5, −1.5; P&lt;0.001, respectively). Hypertension status did not modify the effect on BP reduction. The DASH diet compared to the control diet reduced SBP levels to a higher extent in trials with sodium intake &gt;2,400 mg/day compared to trials with sodium intake ≤2,400 mg/day, while both SBP and DBP were reducedmore in trials with mean age &lt;50 years compared to trials of older participants. The quality of evidence was rated as moderate forboth outcomes according to the Grading of Recommendations, Assessment, Development and Evaluation approach.

Conclusion

The adoption of the DASH diet was accompanied by significant BP reduction in adults with and without hypertension, while higher daily sodium intake and younger age enhanced the BP-lowering effect of the intervention. This meta-analysis was registered in the International Prospective Register of Systematic Reviews as CRD42019128120.

Funding Acknowledgement

Type of funding source: None

Time in blood pressure range for different blood pressure targets and risk of cardiovascular disease: an analysis of a 7-year follow-up registry

Objective

Recent guideline recommendations have revisited the optimal target blood pressure (BP) for hypertensive patients. The Time in BP Range (TBPR) is an alternative metric for evaluation of long-term achieved BP. We investigated the association of TBPR for different levels of BP control with cardiovascular outcome among treated hypertensives.

Design and method

This is a retrospective analysis of 1202 treated hypertensive patients (age 59±11 years) without a history of cardiovascular disease followed for a mean period of 7±3 years. We calculated the TBPR [(No of Visits in BP range/ Total No of Visits) x 100%] for office systolic BP targets of 130–139mmHg, 120–129mmHg and &lt;120mmHg and examined the associated cardiovascular risk. The outcome studied was the composite of stroke and coronary artery disease. Time spent in systolic BP≥140mmHg served as the reference.

Results

In the entire population, mean TBPR for systolic BP 130–139mmHg, 120–129mmH, and &lt;120mmHg were 26%, 19% and 11% respectively. A TBPR of ≥50% for systolic BP 130–139mmHg, 120–129mmHg and &lt;120mmHg was observed in 332 (28%), 226 (19%) and 107 (9%) patients respectively. The composite endpoint occurred in 54 patients (4.5%). Patients with a TBPR for 120–140mmHg of ≥50% presented with a HR: 0.6 (95% CI: 0.34–1.06) for cardiovascular events. The TBPR of ≥50% for systolic BP 130–139mmHg, 120–129mmHg and &lt;120mmHg was associated with HR of 0.48 (95% CI: 0.23–1.01, p=0.05), 0.64 (95% CI: 0.29–1.39, p=0.26) and 0.72 (95% CI: 0.26–2.05) respectively. This pattern was sustained but further attenuated after controlling for standard risk factors. In comparison, a mean BP across visits of 130–139mmHg, 120–129mmHg and &lt;120mmHg was associated with a HR of 0.54 (5% CI: 0.28–1.03), 0.61 (95% CI: 0.29–1.26) and 0.80 (95% CI: 0.24–2.65).

Conclusions

Among treated hypertensives, a time in BP of 130–140mmHg of more than 50% is associated with the greatest reduction in cardiovascular risk. The TBPR is a potentially useful measure of BP control for evaluation of risk reduction in hypertensive patients.

Funding Acknowledgement

Type of funding source: None

Exercise duration as apredictor ofcardiovascular disease in arterial hypertension. Data from a 6-year follow-up study

Background

Current hypertension guidelines necessitate an individualized cardiovascular risk assessment through a process that includes several parameters and remains challenging. Exercise capacity has been strongly associated with prognosis in cardiovascular disease and can be easily assessed by the exercise treadmill test (ETT).

Purpose

The aim of the present study was to investigate theprognostic role of exercise capacity for future cardiovascular events in a cohort of essential hypertensive subjects.

Methods

We followed up 1037 hypertensive adults (mean age 56 years, 53% males) with no previous history of cardiovascular disease, for a mean period of 6±3 years. During the baseline visit all subjects underwent a complete echocardiographic study, office blood pressure measurements, ECG, routine blood testing and an ETT with a Bruce protocol.During follow-up, all subjects were reviewed at least annually. Exercise capacity was expressedwithexercise duration the distribution of which was split by the median (9min). Accordingly, the subjects were classified into those with high (51%) and low exercise capacity (49%). The cardiovascular endpoint of interest was the composite of coronary artery disease and stroke.

Results

The incidence of cardiovascular eventsduring the follow-up period was 4.1% (35 cases of coronary artery disease and 10 cases of stroke).Cox regression analysis revealed that high exercise capacity was associated with a lower risk for future cardiovascular events (HR = 0.35 (95% CI 0.172–0.741, p=0.006). In multivariate models adjusting for standard clinical and laboratory cardiovascular risk factors this association was sustained.

Conclusion

Exercise duration shows a significant prognostic value for future CV events among hypertensivepatients. Exercise capacity assessment by means of TTE could enhance the identification of asymptomatic hypertensives at higher risk.

Funding Acknowledgement

Type of funding source: None

Combined lack of blood pressure and lipid control is a major risk factor for mortality in hypertensive patients: a single-center study

Background

Hypertension and dyslipidemia are well-known risk factors for cardiovascular disease (CVD). In such patients, lowering blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) and targeting to values below pre-specified cut-offs prevents CV events and improves prognosis. However, the impact of both BP and LDL-C control as compared to control of only one and/or none of these two risk factors is not well-studied.

Methods

Among 2,380 treated patients with hypertension and no overt CVD at baseline, we assessed the trajectory of BP control in 1,142 subjects with 4 or more follow up visits; BP control was defined as BP&lt;140/90 mmHg in half or more visits. In the same subgroup, data on lipid control according to LDL-C goals were available in 1,032 patients in 2 or 3 visits. The HeartScore was used to estimate the risk of all-cause death at baseline.

Results

Across a median follow up of 108 months, 26 deaths (2.44%) were recorded. Despite appropriate anti-hypertensive treatment, 376 patients (32.92%) did not achieve conventional BP control in half or more of follow-up visits. Respectively, 59.83% of the study population did not meet the LDL-C goals in at least one assessment. Patients with suboptimal BP control had almost 3-fold increased risk for all-cause mortality (HR=2.85, 95% CI 1.31–6.21, P=0.008) as compared to subjects with effective control. This association was not attenuated after taking into account age, gender, body mass index, smoking, and diabetes mellitus (adjusted HR=2.54, 95% CI 1.13–5.72, P=0.025). Ineffective LDL-C control was not related to death (HR=1.31, 95% CI 0.688–2.48). However, patients who did not reach treatment goals for both BP and LDL showed substantially increased risk for all-cause mortality (HR=5.42, 95% CI 1.09–26.9, P=0.039). Importantly, suboptimal BP control in our cohort of hypertensive patients was associated with death independently of the HeartScore (adjusted HR=2.65, 95% CI 1.22–5.77, P=0.014) and conferred incremental reclassification value on top of the baseline risk (continuous NRI=0.467, P=0.016).

Conclusions

Suboptimal BP control was related to all-cause mortality in our cohort of hypertensive patients; importantly, this association was substantially stronger in concurrent presence of LDL-C values above treatment targets, thus, highlighting the need for combined achievement of BP and LDL-C control. Moreover, association of suboptimal BP controlwith death was independent of the HeartScore, suggesting that BP control should be considered in risk stratification of hypertensive patients

Funding Acknowledgement

Type of funding source: None

Prevalence, pattern and associated cardiovascular risk of t-wave inversion in hypertensive patients: a 5-year follow-up study

Background

Data on prevalence and associated prognosis of repolarization abnormalities among hypertensive patients are limited.

Purpose

We investigated the presence and extent of ST-segment and T-wave changes in a hypertensive population and their predictive ability for cardiovascular disease.

Methods

We studied 1851 white Caucasian hypertensive patients (age 58±12 years, 51%females) without a history of cardiovascular disease for a mean period of 5.3±3.4 years. At the baseline examination, all patients underwent standard 12-lead electrocardiography. T-wave inversion (TWI) was defined as T-wave deflection ≥−0.1 mV in ≥2 contiguous leads,unless associated with bundle branch block. Anterior, lateral or inferior TWI was defined as TWIin leads V2-V4 or V5,V6, I, AVL or II, aVF respectively. Thedepth in millimeters of TWI in each lead was recorded and the maximum depth per location was calculated. ST depression was defined as ≥1mm in depth in two or more contiguous leads.During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was theincidence of cardiovascular morbidity set as the composite of non-fatal coronary artery disease and stroke.

Results

In the entire population, prevalence of TWI was 3.8%, of which 39% presented withanterior TWI, 73% withlateral TWI and 11% with inferior TWI. ST depression was observed in 3.6% of patients (anterior in 0.8%, inferior in 0.9% and lateral in 2.6%). Incidence of the composite endpoint during follow-up was 4%. Cox regression analysis revealed that presence of TWI was associated with a significantly greater risk for cardiovascular events (HR: 2.6, 95% CI: 1.1–5.9, p=0.025). The association was stronger for lateral TWI (HR: 3.3, 95%: CI: 1.34–8.30, p=0.01) compared to other locations. In multivariate models controlling for standard confounders these associations were overall sustained. Depth of TWI and presence of ST depression were not associated with cardiovascular risk.

Conclusions

Among hypertensive patients without cardiovascular disease, TWI is infrequent but significantly associated with future cardiovascular events.Lateral TWI carries the worse prognosis

Funding Acknowledgement

Type of funding source: None

Renal Functional Reserve Is Related to the Nondipping Phenotype and to the Exercise Heart Rate Response in Patients with Essential Hypertension and Preserved Renal Function

BACKGROUND

Renal functional reserve (RFR), defined as the difference between stress and resting glomerular filtration rate (GFR), may constitute a diagnostic tool to identify patients at higher risk of developing acute kidney injury or chronic kidney disease. Blunted RFR has been demonstrated in early stages of hypertension and has been attributed to impaired vascular reactivity due to an overactive sympathetic nervous system (SNS).

OBJECTIVE

The purpose of this study was to investigate whether RFR correlates with other phenotypes expressing overactivity of the SNS in patients with essential hypertension and preserved renal function.

METHODS

Thirty-six patients with untreated essential hypertension and a GFR >60 mL/min/1.73 m2 were enrolled. The following parameters were measured: RFR, 24-h ambulatory blood pressure (BP) profile, a treadmill stress test, and an echocardiographic examination. Urine and venous samples were obtained at specific time points for the determination of clinical parameters, and both resting and stress GFR were calculated by using endogenous creatinine clearance for the measurement of RFR after an acute oral protein load (1 g/kg).

RESULTS

Twenty-one patients had a RFR <30 mL/min/1.73 m2 and 15 had a RFR above this cutoff. A nondipping pattern of 24-h BP was significantly more frequent in patients with low RFR (57.1 vs. 25.0%, p < 0.05 for systolic BP and 52.3 vs. 10.0%, p < 0.02 for diastolic BP). Moreover, patients with lower RFR values showed a blunted heart rate (HR) response to exercise during treadmill test (r = 0.439, p < 0.05). None of the echocardiographic parameters differed between the two groups of patients.

CONCLUSIONS

In hypertensive patients with preserved GFR, reduced RFR is related to nondipping BP phenotype as well as to attenuated exercise HR response. Overactivity of the SNS may be a common pathway. Since loss of RFR may represent a risk factor for acute or chronic kidney injury, hypertensive patients with blunted RFR might need a more careful renal follow-up.

Anticoagulation in Deep Venous Thrombosis: Current Trends in the Era of Non- Vitamin K Antagonists Oral Anticoagulants

:

Anticoagulation therapy is the cornerstone of treatment in acute vein thrombosis (DVT) and it aims to reduce symptoms, thrombus extension, DVT recurrences, and mortality. The treatment for DVT depends on its anatomical extent, among other factors. Anticoagulation therapy for proximal DVT is clearly recommended (at least for 3 months), while AT for isolated distal DVT should be considered, especially in the presence of high thromboembolic risk factors. The optimal anticoagulant and duration of therapy are determined by the clinical assessment, taking into account the thromboembolic and bleeding risk in each patient in a case-by-case decision making. Non-Vitamin K antagonists oral anticoagulants (NOACs) were a revolution in the anticoagulation management of DVT. Nowadays, NOACs are considered as first-line therapy in the anticoagulation therapy for DVT and are recommended as the preferred anticoagulant agents by most scientific societies. NOACs offer a simple route of administration (oral agents), a rapid onset-offset of their action along with a good efficacy and safety profile in comparison with Vitamin K Antagonists (VKAs). However, there are issues about their efficacy and safety profile in specific populations with high thromboembolic and bleeding risks, such as renal failure patients, active-cancer patients, and pregnant women, in which VKAs and heparins were the standard care of treatment. Since the available data are promising for the use of NOACs in end-stage chronic kidney disease and cancer patients, several ongoing randomized trials are currently trying to solve that issues and give evidence about the safety and efficacy of NOACs in these populations.

The Role of Angiotensin-(1-7)/Mas Axis and Angiotensin Type 2 Receptors in the Central Nervous System in Cardiovascular Disease and Therapeutics: A Riddle to be Solved

In recent years, the Angiotensin-(1-7)/Mas receptor [Ang-(1-7)/Mas] sub-branch of the Renin-Angiotensin System (RAS) in the brain, and Angiotensin Type 2 Receptors (AT2R), have attracted scientific interest, as there is evidence that they constitute an essential pathway in cardiovascular regulation, in health and in disease. By acting centrally, the Ang-(1-7)/Mas axis - that has been termed 'the axis of good'- can exert blood pressure-lowering effects, while also favourably altering baroreflex sensitivity and noradrenergic neurotransmission. Thus, research has focused on the possible neuro- and cardioprotective effects of this pathway in the setting of cardiovascular disease, ultimately aiming to evaluate the potential for development of novel therapeutic strategies based on its modulation. We summarize the available evidence from experimental studies in this context, aiming to assess current limits of scientific knowledge relevant to this newly-described 'player' in haemodynamic regulation, that may become a potential therapeutic target.

Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension

BACKGROUND

Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve.

OBJECTIVE

To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease.

METHODS

We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease.

RESULTS

Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis.

CONCLUSION

Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.

Efficacy and safety of renal denervation for the management of arterial hypertension: A systematic review and meta-analysis of randomized, sham-controlled, catheter-based trials

Despite the availability of a numerous antihypertensive agents, hypertension treatment and control rates remain low in many countries. The role of the sympathetic nervous system has long been recognized, but recent sham control renal denervation studies demonstrated conflicting results. In this reviewe paper, the authors performed a systematic review and meta-analysis to examine outcomes of sham-controlled studies utilizing new technologies and procedures. Six published randomized, sham-controlled studies were included in this meta-analysis. Of those, three trials used the first-generation radiofrequency renal denervation device and technique and the other three used second-generation devices and techniques. In total, 981 patients with hypertension were randomized in all 6 trials to undergo renal denervation (n = 585) or sham procedure (n = 396). Overall, renal denervation resulted in a decrease of 24-hours systolic ambulatory blood pressure (ABP) by 3.62 mm Hg (95% CI: -5.28--1.96; I2  = 0%), compared to sham procedure (GRADE: low). Renal denervation also reduced daytime systolic ABP by 5.51 mm Hg (95% CI: -7.79--3.23; I2  = 0%), compared to sham procedure but not nighttime systolic ABP. Office systolic blood pressure was reduced by 5.47 mm Hg (95% CI -8.10--2.84; I2  = 0%), compared to sham control. Further analysis demonstrated that second-generation devices were effective in reducing blood pressure, whereas the first-generation devices were not. These results indicate that effective renal denervation can result in significant and clinically meaningful blood pressure reduction. The second-generation devices provide better renal nerve ablation.

Presence of Hypertension Is Reduced by Mediterranean Diet Adherence in All Individuals with a More Pronounced Effect in the Obese: The Hellenic National Nutrition and Health Survey (HNNHS)

Hypertension is a major risk of cardiovascular diseases. This study’s aim was to examine associations between hypertension and a priori known lifestyle risk factors, including weight status and Mediterranean diet adherence. The study included a representative sample of the adult population (N = 3775 (40.8% males)), from the Hellenic National Nutrition and Health Survey (HNNHS), which took place from September 2013 to May 2015. Demographic and anthropometric data were collected using validated questionnaires, and blood pressure (BP) measurements were performed for the two main metropolitan areas (N = 1040; 41.1%). Hypertension diagnosis was according to the International Classification of Diseases (ICD-10) guidelines. Weighted proportions, extended Mantel–Haenszel (M–H) analyses, and multiple logistic regressions (for the survey data) were performed. Mean systolic BP (SBP) and diastolic BP (DBP) were 118.6 mmHg and 72.2 mmHg respectively, with both values being higher in males compared to females in all age groups (p < 0.001). Study participants with hyperlipidemia or diabetes, and those overweight, were almost twice as likely to be hypertensives, with the odds increasing to 4 for those obese (p for all, < 0.05). Stricter Mediterranean diet adherence significantly decreased the likelihood of hypertension by 36% (OR: 0.64; 95% CI: 0.439, 0.943), and a significant interaction was found between Mediterranean diet adherence and weight status on hypertension. The presence of hypertension is clustered with comorbidities, but is significantly associated with modifiable risk factors, including Mediterranean diet and weight status, underlining the need for personalized medical nutritional treatment.