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<0.001, and −2.5 mm Hg; 95% CI: −3.5, −1.5; P<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 >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 <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

Cardiovascular risk and outcome in patients with hypertensive emergencies and urgencies in an emergency department. an italian greek collaboration

Background

At present, few data are available on the prognosis of hypertensive emergencies and urgencies admitted to Emergency Departments (ED). The aim of our study was to evaluate the incidence of total and cardiovascular events during follow-up in hypertensive patients admitted in 2 ED in Italy and Greece with hypertensive emergencies or urgencies.

Methods

Medical records of patients aged >18 yrs, admitted to the ED with blood pressure values ≥180 mmHg (SBP) and/or ≥120 mmHg (DBP) were collected and analysed (24% of patients were classified as “hypertensive emergency” and 76% as “hypertensive urgency”). Data in 1218 patients (556 men and 662 women, mean age 70±13 years) were analysed; the mean duration of follow-up after admission to the ED was 19.5±7 months years.

Results

During the follow-up cardiovascular events occurred in 148 patients (69 cardiac events, 43 cerebrovascular events). In 272 pts (22%) a new episode of acute BP rise was recorded. A total of 87 deaths was recorded during follow-up (in 28 patients for cardiovascular causes). All cause and CV mortality were greater in patients with a previous hypertensive emergency (14.7 vs 4.7%, chi-square p=0.0001 and 5.8 vs 1.2% chisquare p<0.0001 for all-cause and for CV mortality, respectively). The incidence of non fatal cardiovascular events was 10,11 and 2,11 per 100 patient-years in patients with hypertensive emergency and urgency, respectively and similar results were obtained when we considered separately the occurrence of cerebrovascular events.

Conclusions

Admission to the ED for hypertensive emergencies identifies hypertensive patients at increased risk for fatal and non fatal cardiovascular events. Our results underline the need for an accurate follow-up in patients with hypertensive emergencies and urgencies.

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

Predicted Skeletal Muscle Mass and 4-Year Cardiovascular Disease Incidence in Middle-Aged and Elderly Participants of IKARIA Prospective Epidemiological Study: The Mediating Effect of Sex and Cardiometabolic Factors

The sex-specific effect of skeletal muscle mass (SMM) index (SMI) on 4-year first fatal/non-fatal cardiovascular disease (CVD) event in free-of-disease individuals was examined. In 2009, n = 1411 inhabitants (mean age = 64(12)) from Ikaria were selected. Follow-up was performed in 2013. SMI was created to reflect SMM through appendicular skeletal muscle mass (indirectly calculated through formulas) divided by body mass index (BMI). Fifteen and six tenths percent of participants exhibited CVD (19.8% in men/12% in women, p = 0.002). Significant U-shape trends were observed in participants >65 years old and women irrespective to age confirmed through multi-adjusted Cox regression analysis; in age >65 years, Hazard Ratio (HR)_{(2nd vs. 1st SMI tertile)} = 0.80, 95% Confidence Interval (95%CI) (0.45, 0.96) and in women HR_{(2nd vs. 1st SMI tertile)} = 0.71, 95% CI (0.33, 0.95), while, as for the 3rd SMI tertile, no significant trends were observed. Mediation analysis revealed that mediators of the aforementioned associations in men were the arterial distensibility and total testosterone, while, in women, inflammation, insulin resistance, and arterial distensibility. High SMM accompanied by obesity may not guarantee lower CVD risk. Specific cardiometabolic factors seem to explain this need for balance between lean and fat mass.

Low rate of intracerebral hemorrhage after cardiac catheterization in patients with acute ischemic stroke in a large case series

BACKGROUND AND AIMS

Myocardial infarction complicating acute ischemic stroke (IS) is associated with high mortality, but evidence guiding the acute management is scarce. In particular, data on the risk of intracerebral hemorrhage (ICH) due to early cardiac catheterization including the peri-procedural application of antithrombotic drugs in patients with acute ischemic stroke are limited. Here, we aimed to evaluate the incidence and patient characteristics of ICH after cardiac catheterization in acute stroke patients to help to govern the risk of intracranial bleeding versus the benefits of myocardial reperfusion via cardiac catheterization.

METHODS

We screened a consecutive cohort of n = 126 patients with acute ischemic stroke (IS) who underwent cardiac catheterization during the same hospital stay at a large German neurovascular center (LMU Munich). Eventually, we identified n = 42 patients with cardiac catheterization after acute stroke. N = 22/42 patients did not receive neuroimaging post cardiac catheterization and were discharged without any new neurological deficits, n = 20/42 had neuroimaging after cardiac catheterization and were included for final analysis.

RESULTS

Cardiac catheterization was performed within a median of 3,6 days after ischemic stroke (No-ICH 7,3 days (IQR, 3,8-16,2) vs. ICH 1,1 days (IQR, 0,8-74,6), p = 0,40), One patient showed new neurological deficits after cardiac procedures (n = 1/42, 2,4 %). New or progressive ICH was ultimately found in 15 % (3/20) of cases. They were classified as HT1, PH1 and PH2 according to ECASS II criteria, respectively. With regards to the coronary catheterization, 85 % of all patients undergoing catheterization ultimately received percutaneous cardiac intervention. ICH was not significantly associated with any of the independent variables. Intrahospital death due to either ischemic stroke, ICH or cardiovascular events did not occur.

CONCLUSION

The incidence of ICH in ischemic stroke followed by early cardiac catheterization and application of antithrombotic drugs was comparable to studies reporting on the incidence of ICH in ischemic stroke patients without catheterization. This study's results strengthen the hypothesis that in presence of both, acute myocardial infarction and acute ischemic stroke, the general risk for ICH is not prohibitive of cardiac catheterization.

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.

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.

Restructuring career counselling ventures of a mentoring program for medical students in the course of the COVID-19 pandemic

Objectives: Due to the COVID-19 pandemic, medical curricula face major challenges. This also applies to mentoring programs, where face-to-face meetings are considered essential. Methods: The LMU Munich medical faculty mentoring program (MeCuM-Mentor) adapted to counteract the unforeseen pause of conventional course formats and associated uncertainty of many students. We here present an approach to transform the established large scale or group mentoring events of our program into online formats. Three projects are presented as examples: 1. HowTo Klink (HK), mainly informative in nature and with peer-mentoring character, 2. FacharztDuell (FAD) and 3. "Auf ein Gespräch mit... (AEGM)", both with a focus on career counseling. Results: Initial evaluations show a similarly high participation rate and a high level of satisfaction among the participating students. Students' evaluation of whether the projects presented should take place in presence or in online format has so far shown no clear trend. Conclusion: Prospective studies are necessary to investigate the effectiveness of these online formats and analyse differences in participant behaviour. The extent to which online mentoring can replace classic mentoring functions has to be discussed anew.

P3409Comparison of the European Society of Hypertension stratification and European Society of Cardiology HeartScore for prediction of coronary artery disease and stroke in essential hypertension

Background/Introduction

For estimation of overall cardiovascular risk the European Society of Hypertension (ESH) proposes stratification according to blood pressure (BP), prevalence of risk factors, asymptomatic target organ damage, diabetes, kidney and symptomatic cardiovascular disease, while the European Society of Cardiology (ESC) HeartScore constitutes another potent predictive tool of adverse outcome.

Purpose

The aim of the present study was to compare the predictive role of ESH stratification and ESC HeartScore for the incidence of the composite end-point of coronary artery disease (CAD) and stroke in a cohort of essential hypertensive patients.

Methods

We followed up 2150 essential hypertensives (mean age 55.7 years, 1085 males, office BP=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit. Patients were divided based on the ESH risk categories as well as according to the ESC HeartScore. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure. Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings.

Results

The incidence of CAD, stroke and their composite over the follow-up period were 2.8% (n=60), 1.11% (n=24) and 3.9% (n=84), respectively. By using the ESH stratification, regarding the total population 15.3% (n=329) was of low and moderate risk, 54.4% (n=1170) was of moderate to high and high risk and 30.3% (n=651) was high to very high and very high risk. According to the ESC HeartScore 89.2% (n=1918) was of low to moderate risk, 10% (n=215) of high risk and 0.8% (n=17) of very high risk. Cox-regression analyses revealed that high to very high and very high ESH risk category was related to increased risk for the composite end-point of CAD and stroke (hazard ratio=4.5, p<0.0001), while focusing on the ESC Heart Score the composite end-point was predicted by the high risk category (hazard ratio=3.43, p<0.0001). Using the Akaike's information criterion the ESH risk model had better fit than the ESC HeartScore due to the lowest Akaike's values (1442.66 vs 1498.31, respectively).

Conclusions

In essential hypertensive patients categorization of patients by means of the ESH stratification and the ESC HeartScore are both predictive of future cardiovascular events. Based on our results, the ESH risk stratification constitutes a better prediction model for CAD and stroke than the ESC HeartScore in essential hypertension and its estimation is essential in order to improve overall risk assessment in this setting.

P5464Visit-to-visit glomerular filtration rate variability as a predictor for cardiovascular and renal outcomes in essential hypertension: Data from a Greek 8-year-follow-up study

Background/Introduction

Renal dysfunction is related with adverse prognosis in hypertension, however there are scarce data on the predictive cardiovascular and renal impact of kidney function variability in this setting.

Purpose

The aim of the present study was to assess the predictive role of visit-to-visit renal function changes on the incidence of coronary artery disease (CAD), stroke and end-stage renal disease in a cohort of essential hypertensive patients.

Methods

We followed up 2380 essential hypertensives (mean age 58.9 years, 1240 males, office blood pressure (BP)=144/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and blood sampling was performed in all visits for estimation of glomerular filtration rate (GFR). We calculated standard deviation (SD) of mean GFR from visits from 6 months onward in patients with ≥5 visits during follow-up. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure, while stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings. End-stage renal disease was defined as GFR<15 mL/min/1.73 m2 or the need for long-term dialysis or transplantation.

Results

The incidence of CAD, stroke and end-stage renal disease over the follow-up period were 2.8% (n=68), 1.09% (n=26) and 0.6% (n=14). Hypertensives who developed CAD compared to those without CAD at follow-up (n=2312) had at baseline higher left ventricular mass index (115.7±24.6 vs 103.7±27.3 g/m2, p<0.0001), whereas there was no difference with respect to baseline GFR (78±19.6 vs 79.3±18.6 mL/min/1.73 m2 (p=0.573). In multivariate Cox regression models visit-to-visit glomerular filtration rate predicted end-stage renal disease (hazard ratio=1.758, p=0.01) but not CAD and stroke (p=NS for both). Baseline left ventricular mass index independently predicted CAD (hazard ratio=1.042, p=0.015) and stroke (hazard ratio=1.035, p=0.002).

Conclusions

In essential hypertensive patients GFR variability predicts future development of end-stage renal disease but exhibits no independent prognostic value for CAD and stroke. These results suggest that fluctuations of renal function are related with damage at the kidneys and not at the cardiac and cerebrovascular level.

P5466Exaggerated exercise blood pressure response is accompanied by increased sympathetic activity and arterial stiffness in subjects with high normal blood pressure

Background/Introduction

The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity and arterial stiffening are linked with adverse cardiovascular prognosis.

Purpose

The aim of this study was to assess the relation of HRE with sympathetic drive as assessed by muscle sympathetic nerve activity (MSNA) and arterial stiffness in subjects with high normal BP.

Methods

42 subjects with high normal office BP [defined as office systolic BP=130–139 mmHg and office diastolic BP=85–89 mmHg (age: 53±9 years, 29 males, office BP: 134/84 mmHg, 24-hour BP: 114/72 mmHg)] with a negative treadmill exercise test (Bruce protocol) were divided into those with HRE (n=12) (peak exercise systolic BP ≥210mmHg in men and ≥190 mmHg in women) and those without HRE (n=30). Arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV) values. In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography).

Results

Subjects with a HRE compared to those without exhibited higher waist circumference (108.2±5.3 vs 94.7±9.2 cm, p=0.001) and were characterized by greater levels of carotid to femoral PWV (8.5±0.8 vs 7.0±0.9 m/sec, p<0.001) and sympathetic nerve traffic as reflected by MSNA levels (41.1±1.5 vs 32.1±1.9 bursts per 100 heart beats, p<0.001), while did not differ regarding metabolic profile and left ventricular mass index (p=NS). In the total population, peak exercise systolic BP was related to 24-h systolic BP (r=0.229, p<0.05), PWV (r=0.218, p=0.002), and MSNA (r=0.214, p<0.05). Moreover, MSNA was related to waist circumference (r=0.33, p=0.004) and office systolic BP levels (r=0.31, p<0.05) but there was no association with PWV values (p=NS).

Conclusion

In subjects with high normal BP, a HRE identifies a state of arterial stiffening and sympathetic overdrive, as reflected by increased PWV and MSNA levels respectively. These finding suggest that exercise testing provides additional clinical information regarding the vascular status and modulation of sympathetic tone in this setting.

P6577Isolated systolic hypertension versus combined systolic-diastolic hypertension as predictors of atrial fibrillation: data from a 8-year-follow-up study

Background/Introduction

Isolated systolic hypertension (ISH) and combined systolic-diastolic hypertension (CH) are related with increased cardiovascular risk.

Purpose

The aim of the present study was to compare the predictive role of ISH and CH for the incidence of atrial fibrillation (AF) in a cohort of essential hypertensive patients.

Methods

We followed up 1605 essential hypertensives with office systolic blood pressure (BP)≥140 mmHg [mean age 58.1 years, 842 males, office BP=153/92 mmHg] for a mean period of 8 years. All subjects had at least one annual visit and at baseline underwent echocardiographic study and blood sampling for estimation of metabolic profile. Patients with baseline ISH exhibited office systolic BP ≥140 mmHg and office diastolic BP <90 mmHg, while those with CH had office systolic BP ≥140 mmHg and office diastolic BP ≥90 mmHg. Moreover, new-onset AF was defined as hospitalization for AF or compatible electrocardiographic tracings.

Results

The incidence of new-onset AF over the follow-up period was 3.4% (n=55). Patients with ISH (n=510) compared to those with CH (n=1095) were older (65±10 vs 55±11 years, p<0.0001), had at baseline lower waist circumference (95.5±12 vs 98±12 cm, p<0.0001), office systolic BP (149±10 vs 155±13 mmHg, p<0.0001), office diastolic BP (80±5 vs 98±7 mmHg, p<0.0001), while did not differ regarding left ventricular mass index and lipid levels (p=NS for all). Univariate Cox regression analysis revealed that baseline ISH (hazard ratio=4.612, p=0.013) and CH (hazard ratio=1.794, p=0.036) predicted new-onset AF. However, in multivariate Cox regression model, age (hazard ratio=1.078, p<0.001), left ventricular mass index (hazard ratio 1.012, p=0.014), left atrium diameter (hazard ratio=1.102, p<0.001) and ISH (hazard ratio=1.551, p=0.035) but not CH turned out to be independent predictors of new-onset AF episodes.

Conclusions

In essential hypertensive patients, ISH but not CH exhibits independent prognostic value for AF. These findings support that ISH constitutes a hypertensive phenotype of particularly increased arrhythmia risk needing careful evaluation and treatment.

P5469Isolated systolic hypertension and combined systolic-diastolic hypertension for prediction of new-onset diabetes mellitus: Data from a 8-year-follow-up study

Background/Introduction

Isolated systolic hypertension (ISH) and combined systolic-diastolic hypertension (CH) are related with increased cardiovascular risk, while new-onset diabetes mellitus (NOD) is linked with atherosclerosis progression.

Purpose

The aim of the present study was to compare the predictive role of ISH and CH for the incidence of NOD in a cohort of essential hypertensive patients.

Methods

We followed up 1435 non-diabetic essential hypertensives with office systolic blood pressure (BP)≥140 mmHg [mean age 57 years, 730 males, office BP=153/92 mmHg] for a mean period of 8 years. All subjects had at least one annual visit and at baseline underwent echocardiographic study and blood sampling for estimation of metabolic profile. Patients with baseline ISH exhibited office systolic BP ≥140 mmHg and office diastolic BP <90 mmHg, while those with CH had office systolic BP ≥140 mmHg and office diastolic BP ≥90 mmHg. Moreover, NOD was defined if at one or more of the follow-up visits a previously non-diabetic patient reported being on insulin or an oral hypoglycemic drug or if casual plasma glucose concentration ≥200 mg/dl or fasting glucose concentration ≥126 mg/dl or 2-h post load glucose ≥200 mg/dl during an oral glucose tolerance test.

Results

The incidence of NOD over the follow-up period was 4.2% (n=60). Patients with ISH (n=460) compared to those with CH (n=975) were older (65±11 vs 54±10 years, p<0.0001), had at baseline lower waist circumference (94.5±11 vs 99±13 cm, p<0.0001), office systolic BP (149±12 vs 155±13 mmHg, p<0.0001), office diastolic BP (80±8 vs 98±6 mmHg, p<0.0001), while did not differ regarding left ventricular mass index, glucose and lipid levels (p=NS for all). Univariate Cox regression analysis revealed that baseline ISH (hazard ratio=2.143, p=0.016) and CH (hazard ratio=1.272, p=0.029) predicted NOD. However, in multivariate Cox regression model, age (hazard ratio=1.039, p<0.001), baseline glucose levels (hazard ratio 1.011, p=0.016), waist circumference (hazard ratio=1.067, p<0.001) and ISH (hazard ratio=1.651, p=0.029) but not CH turned out to be independent predictors of NOD.

Conclusions

In essential hypertensive patients, ISH but not CH exhibits independent prognostic value for NOD. These findings support that ISH constitutes a hypertensive phenotype of increased metabolic risk needing careful evaluation and treatment.

P4388Acute detrimental effects of e-cigarette and tobacco cigarette smoking on blood pressure and sympathetic nerve activity in healthy subjects

Background/Introduction

Tobacco cigarette smoking is related with atherosclerosis progression, blood pressure increase and changes in sympathetic nerve activity. However, there are scarce data on the impact of e-cigarettes that have been proposed as less harmful alternatives on the cardiovascular system and sympathetic drive.

Purpose

This study aimed to assess the acute effects of tobacco cigarettes, e-cigarettes and sham smoking on blood pressure and sympathetic nervous system in healthy subjects.

Methods

We studied 10 normotensive male habitual smokers (mean age 33 years, body mass index: 24.1 kg/m2, office blood pressure=117/72 mmHg) free of cardiovascular disease. The study design was randomized and placebo controlled with 3 experimental sessions (sham smoking, tobacco cigarette smoking, and e-cigarette smoking) in random order, each session on a separate day. Subjects smoked 2 tobacco cigarettes containing 1.1 mg nicotine or simulate smoking (sham smoking) with the 2 cigarettes separated by 5 minutes, while 45 minutes after finishing the second cigarette, subjects smoked a third cigarette or sham cigarette. Additionally, participants smoked e-cigarettes for a period of 5 and 30 minutes. In all occasions, sympathetic drive was assessed by muscle sympathetic nerve activity (MSNA) (baroreflex-dependent) and skin sympathetic nerve activity (SSNA) (baroreflex-independent) based on established methodology (microneurography).

Results

After the first, second and third tobacco cigarette smoking there was markedly and significantly increase in mean arterial pressure (by 11.2±1.4%, 12.3±1.3% and 13.1±1.4%, respectively, p<0.05 for all) and heart rate (by 25.1±3.7%, 26.3±2.7% and 25.9±3.7%, respectively, p<0.05 for all). Similarly e-cigarette smoking at 5 and 30 minutes was accompanied by augmentation of mean arterial pressure (by 10.9±1.2% and 12.8±1.4%, respectively, p<0.05 for both) and heart rate (by 22.5±3.3% and 23.9±3.8%, respectively, p<0.05 for both). Regarding the effect on sympathetic nervous system, the first, second and third tobacco cigarette smoking was accompanied by lower MSNA (by 28.1±4.4%, 29.6±5.3% and 30.1±5.2%, respectively, p<0.05 for all), whereas SSNA was increased (by 98.2±19.4%, 100.2±22.7% and 101.5±21.6%, respectively, p<0.05 for all). Additionally, e-cigarette smoking at 5 and 30 minutes caused a decrease in MSNA (by 26.9±3.6%, and 28.3±5.1%, respectively, p<0.05 for both), and an augmentation in SSNA (by 97.9±20.1% and 100.9±20.6%, respectively, p<0.05 for both). Sham smoking was devoid of any effects on blood pressure, MSNA and SSNA.

Conclusions

E-cigarette smoking acutely increases blood pressure and has a detrimental effect on sympathetic nerve activity regulation similar to tobacco smoking in healthy subjects. Our findings underscore the negative impact of e-cigarettes on cardiovascular and autonomic nervous system and could aid further recommendation in their use.

P5459Comparison of the predictive role of changes in left ventricular mass and arterial stiffness for coronary artery disease in essential hypertension: Data from a 8-year-follow-up study

Background/Introduction

Although arterial stiffening is related to atherosclerosis progression, its prognostic role in hypertension is not fully elucidated, while augmented left ventricular mass index (LVMI) is linked to adverse outcome.

Purpose

The aim of the present study was to compare the predictive role of changes in arterial stiffness and LVMI for the incidence of coronary artery disease (CAD) in a cohort of essential hypertensive patients.

Methods

We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and at baseline and last visit underwent complete echocardiographic study for estimation of LVMI and measurements of arterial stiffness on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method. The distribution of PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Moreover, LV hypertrophy (LVH) was defined as LVMI ≥125 g/m2 in males and LVMI ≥110 g/m2 in females, while CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure.

Results

The incidence of CAD over the follow-up period was 3.5%. Hypertensives who developed CAD (n=38) compared to those without CAD at follow-up (n=1044) had at baseline higher waist circumference (101.7±10.1 vs 96.2±11.6 cm, p=0.004), LVMI (123.9±22.1 vs 105.8±21.3 g/m2, p=0.026), prevalence of LVH (46% vs 25%, p=0.018) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with CAD and those without CAD with respect to baseline office BP, serum creatinine and lipid levels (p=NS for all). By univariate Cox regression analysis, it was revealed that changes in PWV levels between baseline and last visit predicted CAD (hazard ratio=1.243, p=0.014). However, in multivariate Cox regression model baseline glomerular filtration rate (hazard ratio=1.029, p=0.015) and changes in LVMI (hazard ratio=1.036, p<0.0001) but not alterations of PWV turned out to be independent predictors of CAD.

Conclusions

In essential hypertensive patients changes in LVMI predict future development of CAD, whereas PWV alterations exhibit no independent prognostic value. These findings support that LVMI constitutes a superior prognosticator of events than PWV and its estimation is essential in order to improve overall risk stratification in hypertension.

P802Interrelationships of sympathetic nervous system activity with attended and unattended blood pressure levels in essential hypertensive patients

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 assess the relation of BP levels in the attended and unattended setting with MSNA in patients with essential hypertension.

Methods

We studied 38 patients with essential hypertension (age: 59±11 years, 20 males, office BP: 142/86±19/11 mmHg, 24-hour BP: 137/80±14/12 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=18) compared to those with attended hypertension (n=20) were older (61±11 vs 57±11 years, p=0.03), whereas 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 (41.2±11.6 vs 32.2±10.1 bursts per minute, p=0.031). In all participants, sympathetic nerve traffic as assessed by resting MSNA was related to attended systolic BP (r=0.459, p=0.004), attended diastolic BP (r=0.503, p=0.001), unattended systolic BP (r=0.433, p=0.007) and unattended diastolic BP (r=0.423, p=0.008).

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.

P805Changes in arterial stiffness independently predict stroke in patients with essential hypertension: Data from a 8-year-follow-up study

Background/Introduction

Although arterial stiffening is related to atherosclerosis progression, the prognostic role of its alterations in cerebrovascular events in hypertension is not fully elucidated.

Purpose

The aim of the present study was to assess the predictive role of changes inarterial stiffness for the incidence of stroke in a cohort of essential hypertensive patients.

Methods

We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit and underwent blood sampling for assessment of metabolic profile, whilearterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method at the initial and last visit. The distribution of baseline PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by computed tomography and magnetic resonance angiography and/or cerebrovascular angiography findings.

Results

The incidence of stroke over the follow-up period was 2.2%. Hypertensives who had stroke (n=24) compared to those without stroke at follow-up (n=1058) were older at baseline (65±9 vs 56±12 years, p=0.032), had higher office BP levels (155±13 vs 145±15mmHg, p=0.014) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with stroke and those without stroke with respect to baseline renal function and lipid levels (p=NS for all). By univariate Cox regression analysis it was revealed that changes in PWV levels between baseline and last visit predicted stroke (hazard ratio=1.352, p=0.004). Moreover, in multivariate Cox regression model, baseline age (hazard ratio=1.087, p=0.03), changes in PWV (hazard ratio=1.115, p=0.024) but not changes in office BP levels turned out to be independent predictors of stroke.

Conclusions

In essential hypertensive patients, changes in PWV predict future development of stroke, independently of established confounders, including BP. These findings support that PWV constitutes a potent prognosticator of cerebrovascular events and its estimation is essential in order to improve risk stratification in hypertension.

P5468Systolic versus diastolic blood pressure as predictors of cardiovascular events among treated hypertensive patients: a 6-year prospective study

Background/Introduction

There has been a long debate regarding the association of systolic versus diastolic blood pressure with cardiovascular outcome and data regarding hypertensive patients under treatment have been conflicting.

Purpose

To investigate the association of different patterns of uncontrolled blood pressure (BP) among treated hypertensive patients.

Methods

We prospectively studied 1507 treated hypertensive patients (age 59±11 years) that are followed in the setting of a single-center, clinic-based registry. During follow-up, patients underwent regular visits for hypertension and risk factor management. Based on the cut-off limits for uncontrolled hypertension of office systolic BP≥140mmHg and diastolic BP≥90mmHg, study participants were divided into four groups: those with controlled hypertension (796 patients, 53% of the population), uncontrolled systolic BP (257 patients, 17%), uncontrolled diastolic BP (135 patients, 9%) and uncontrolled systolic and diastolic BP (319 patients, 21%). The outcome studied was the composite of cardiovascular morbidity set as coronary artery disease and stroke, and the controlled hypertension group served as reference.

Results

The median follow-up period was 6.4±3.0 years and the composite endpoint (13 strokes and 41 cases of coronary artery disease) occurred in 54 patients (3.6%). Unadjusted Cox regression analysis showed that, compared to the reference group of controlled hypertensives, the risk for cardiovascular morbidity was similar in patients with uncontrolled diastolic BP (HR: 0.88, 95% CI: 0.26–2.97) but significantly higher in patients with uncontrolled systolic BP (HR: 2.17, 95% CI: 1.08–4.36), while patients with both uncontrolled systolic and diastolic BP showed the worse prognosis (HR: 2.35, 95% CI: 1.24–4.43). This pattern of risk was overall sustained after adjusting for different sets of confounders.

Conclusions

Among treated hypertensive patients, uncontrolled systolic BP is associated with a greater risk for cardiovascular events compared to uncontrolled diastolic BP while uncontrolled systolodiastolic hypertension presents with the worse prognosis.