bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of left atrial diameter on outcome in patients undergoing edge-to-edge mitral valve repair: results from the German TRAnscatheter Mitral valve Interventions registry (TRAMI)
Authors: Iliadis C , Baldus S , Kalbacher D , Boekstegers P , Schillinger W , Ouarrak T , Zahn R , Butter C , Zuern C.S , Von Bardeleben R.S , Senges J , Bekeredjian R , Eggebrecht H , Pfister R
Published: November 2020

Background

Left atrium (LA) dimension is a marker of disease severity and outcome in primary and secondary mitral regurgitation. In transcatheter mitral valve repair LA enlargement might additionally impact on device handling and technical success through an altered anatomy and atrial annular dilatation.

Methods

Data from the multicenter German transcatheter mitral valve intervention registry “TRAMI” were used to analyse the association of baseline LA diameter by tertiles and efficacy, safety and long-term clinical outcome in patients undergoing edge-to-edge repair with the MitraClip.

Results

In 520 of 843 patients prospectively enrolled in TRAMI baseline LA diameter were reported (median [interquartile range] LA diameter in tertiles: 44 [40–46] mm, 51 [48–53] mm and 60 [55–66] mm). Larger LA diameters were significantly associated with secondary etiology of mitral regurgitation, lower ejection fraction, larger left ventricle, male sex and atrial fibrillation (all p<0.05). Technical success was not different across tertiles (96%, 95.4%, 98.4% respectively, p=0.43) as were major in-hospital cardiovascular and cerebral adverse events (mortality, myocardial infarction or stroke) (1.8%, 1.2% and 4.4%, p=0.11 across tertiles). However, 4-year mortality significantly increased with larger LA diameter (32.9%, 46.4% and 51.7% respectively, p<0.01), as did hospitalization in survivors (60%, 67.6% and 78.9% respectively, p<0.05). The association between LA diameter and all-cause mortality remained significant after multivariable adjustment including baseline left ventricular end-diastolic diameter.

Conclusion

LA enlargement is a strong and independent predictor of adverse long-term outcome in mitral regurgitation suggesting that timely transcatheter mitral valve repair may have the potential to modify outcome.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The TRAMI registry has been supported by proprietary means of IHF. Additional funding is provided by “Deutsche Herzstiftung” and a grant from Abbott Vascular.
Transseptal transcatheter mitral valve implantation versus redo surgical mitral valve replacement for degenerated mitral bioprostheses
Authors: Fuchs A , Iung B , Nguyen C , Carrasco J.L , Cimadevilla C , Kerneis C , Eugene M , Ghodhbane W , Ducrocq G , Brochet E , Provenchere S , Vahanian A , Himbert D , Urena-Alcazar M
Published: November 2020

Background

The growing use of surgical bioprostheses raises concerns about a future reoperation for bioprosthesis degeneration. There are few data on outcome after transcatheter mitral valve-in-valve implantation (TMVI) compared with redo surgical mitral valve replacement (SMVR).

Purpose

To compare the feasibility, safety and outcomes of TMVI versus SMVR for degenerated mitral bioprosthesis in high-risk patients.

Methods

In our institution, 52 patients underwent TMVI by transseptal approach and 33 SMVR for degenerated mitral bioprosthesis. The composite endpoint of event-free survival included cardiovascular mortality, stroke, major bleeding, hospitalization for heart failure or mitral valve reintervention.

Results

Mean age and EuroSCORE II were higher in TMVI group vs. SMVR group (age 63±21 years vs. 51±15 years, p=0.002; EuroSCORE II 12.5±12.2% vs. 6.2±3.3%, p=0.001) (Table). In-hospital mortality was 3.8% after TMVI vs. 3.0% after SMVR (p=1.0).

Median follow-up was 2.2 years. At 5 years, survival was 69.7±9.4% after TMVI vs. 86.6±7.6% after SMVR (p=0.10) and event-free survival was lower after TMVI (40.1±9.9% vs 78.7±8.8% respectively, p=0.003) (Figure). In multivariate analysis, older age (p=0.02), neurologic history (p=0.05) and non-elective procedure (p<0.0001) were associated with lower event-free survival, while TMVI vs. SMVR was no longer significant (p=0.17). At last follow-up, 84% patients from TMVI group and 78% from SMVR group were NYHA I-II class. Mean mitral valve gradient and pulmonary artery systolic pressure were respectively 6.8±2.5 mmHg and 45±14 mmHg in TMVI group, and 4.8±2.0 mmHg and 37±11 mmHg in SMVR group.

Conclusion

TMVI is an alternative to SMVR in high-risk patients with degenerated mitral bioprosthesis. Comparison of mid-term results of the two techniques must take into account the differences in patient characteristics.

Event-free survival

Funding Acknowledgement

Type of funding source: None
Echocardiographic and clinical outcomes of MitraClip therapy in patients with severe mitral regurgitation
Authors: Rashi Y , Turyan Medvedovsky A , Tonchev I , Perez A , Elioz R , Lotan C , Gilon D , Planer D , Danenberg H.D , Beeri R , Shuvy M
Published: November 2020

Background

MitraClip implantation improves mitral regurgitation (MR), however its impact on pulmonary hypertension (PHT) is not fully elucidated. Our hypothesis was that changes in pulmonary pressure after MitraClip implantation might predict outcomes.

Methods

We studied a cohort of 149 consecutive patients who underwent MitraClip implantation between August 2015 and September 2019. We compared echocardiographic and clinical variables between a group with not-severe PHT and a group with severe PHT according to Pulmonary artery systolic pressure (PASP) >55 mmHg.

Results

Mean age of the cohort was 73±10 years, 75% were men, and 80% had functional MR. There are no differences in baseline characteristics between the two groups. There was a significant reduction of 13.6 mmHg in PASP at the severe PHT group from 68.2±10.9 mmHg before the procedure to 54.6±14.9 after (P=0.001) compared to the absence of a significant change in the second group. This reduction was maintained in the 6 months follow-up. Although PHT is considered a poor prognostic measure, and the severe PHT group had a baseline PASP higher than the not-severe group (P<0.001), however the Kaplan Meier curve did not show any significant difference in overall survival (p=0.468), and there is also no difference in one-year survival.

Conclusions

MitraClip therapy improves PASP in patients with severe MR and severe PHT. These patients showed the same survival as patients with not-severe PHT. MitraClip is a safety and effective procedure even for patients with severe PHT, that should not be excluded.

Funding Acknowledgement

Type of funding source: None
3-Dimensional assessment of tricuspid annular geometry after percutaneous edge-to-edge repair in patients with severe tricuspid regurgitation
Authors: Da Rocha E Silva J.G , Ruf T.F , Kreidel F , Tamm A.R , Geyer M , Petrescu A , Hell M , Schmidt P , Tang G.H.L , Munzel T , Von Bardeleben R.S
Published: November 2020

Background

Transcatheter tricuspid valve repair (TTVR) using edge-to-edge leaflet therapy (E2E) has evolved as a feasible therapy to treating severe tricuspid regurgitation (TR). The TRILUMINATE trial using the new TriClip NT has shown promising clinical and functional improvements. However, the 3rd generation MitraClip XTr (Abbott Structural Heart, Santa Clara, CA, USA) has a broad off-label experience in the European Union to address tricuspid TR with wider gaps. There is insufficient data on the secondary effects of E2E on tricuspid annular geometry. The aim of this study was to address this lack of knowledge by evaluating the acute effects of E2E using the MitraClip XTr.

Methods

We retrospectively analyzed the imaging data of procedures using the MitraClip XTr to treat severe symptomatic TR at our Institution in 2018. Tricuspid annular geometry was assessed before and immediately after clip implantation by 3D TEE analysis of biplane and manual and automated volume data.

Results

During 2018, 69 patients were treated for severe TR using a transcatheter approach. In 61 patients, E2E was used, in 58 patients the MitraClip XTr was utilized (Pascal: n=3, Edwards Lifesciences, Irvine, CA, USA). Mean age was 79.0 years ± 6.4. Percutaneous TTVR using the MitraClip XTr significantly decreased the diastolic septal-lateral diameter (S/L: 4.1±0.7cm vs. 3.6±0.7cm; p<0.001), annulus area (14.9±6.7 vs. 12.8±6.2 cm2; p<0.001) and annulus perimeter (14.7±25.0 vs. 13.8±24.4 cm; p<0.001) whereas the diastolic anterior-posterior diameter was not significantly affected (A/P: 4.5±1cm vs. 4.4±0.8cm; p=0,45).

Conclusions

Percutaneous TTVR using MitraClip XTr showed significant changes in TV annulus geometry by focal perimeter and area reduction. This highlights a new mechanism of E2E therapy through indirectly adressing the dilated annulus in patients with severe TR.

Annulus geometry by TOE, 3D- and autoMPR

Funding Acknowledgement

Type of funding source: None
Effects of diabetes and obesity in patients undergoing coronary artery bypass graft surgery: ten-year results from the Arterial Revascularisation Trial
Authors: Stefil M , Taggart D , Podesser B , Benedetto U , Gaudino M , Gerry S , Gray A , Lees B , Krzych L , Flather M
Published: November 2020

Background

Coronary artery bypass graft (CABG) surgery is an effective way to manage advanced coronary heart disease. Diabetes is associated with higher risk of mortality in patients undergoing CABG but the effects of obesity, and the interactions between diabetes and obesity in the context of CABG, have not been fully explored.

Methods

The Arterial Revascularisation Trial (ART) compared ten-year mortality in patients undergoing CABG randomised to single or bilateral internal thoracic arterial grafts. Effects of diabetes and obesity on mortality and risk (sternal wound complications) were explored. Diabetes was defined according to clinical history at baseline and combined insulin and non-insulin dependent patients, and obesity was defined as body mass index (BMI) ≥30kg/m2 at baseline.

Results

Information on diabetes, obesity and ten-year mortality were documented for 3094 patients who were included in the analysis. Mean age was 64 years, 86% male, mean weight 82kg and BMI 28. Diabetes was documented in 24% and obesity in 30% and as expected obese patients were more likely to be diabetic. The hazard ratios (95% confidence intervals) for ten-year mortality using the no diabetes, non-obese group as a reference were 1.33 (1.08, 1.64) (diabetes, non-obese), 0.93 (0.75, 1.16) (no diabetes, obese) and 1.18 (0.91, 1.54) (diabetes, obese) groups (Figure 1). Similar patterns of risk were observed whether patients were randomised to receive single or bilateral internal thoracic arteries and diabetes appeared to be the main driver of elevated risk of early sternal wound complications following CABG.

Conclusions

Obesity and diabetes are closely associated but our analysis shows that patterns of risk of death after CABG are not additive for these characteristics, and obesity may actually be associated with lower death rates in patients with and without diabetes. These findings will be explored further to understand mechanisms and interactions with other factors.

Figure 1. Hazard ratios at 10 years

Funding Acknowledgement

Type of funding source: None
Multiple vs single arterial grafting in coronary surgery among diabetic patients: a meta-analysis
Authors: Leite-Moreira J.P , Saraiva F.A , Barros A.S , Leite-Moreira A.F , Lourenco A.P
Published: November 2020

Background and aim

The use of more than one arterial conduit in coronary surgery has been widely associated with better long-term results. We sought to investigate the benefits of Multiple Arterial Grafts (MAG) over Single Arterial Grafts (SAG), among diabetic patients, in short and long-term results throughout a meta-analysis of propensity score matching (PSM) studies.

Methods

MEDLINE and ISI Web of Science were used to find relevant literature (1960–2018). We included cohort studies with at least 200 patients and that reported one of these outcomes: long-term survival, early mortality or sternal wound infection (SWI). Survival was collected through hazard ratio (HR) along with their variance and the other endpoints using frequencies or odds ratio (OR) from the matched sample. Fixed effect models were used to compute statistical combined measures and 95% confidence intervals (CI).

Results

Eleven studies were included performing a total of 9670 diabetic patients: 4833 MAG and 4837 SAG (1:1 PSM in all studies). MAG group consisted in bilateral internal mammary artery (BIMA) in 8 studies; single IMA (SIMA)+radial artery (RA) in 5 studies; and one study reported several MAG approaches: BIMA+RA+Gastroepiploic artery (GEA), SIMA+RA+GEA, SIMA+GEA or BIMA+GEA. SAG group consisted in SIMA with or without saphenous vein graft in all studies, except for one that included also patients with GEA instead of SIMA. Ten studies reported long-term survival and mean follow-up time ranged from 5 to 12 years (max. follow-up 30y). Overall, MAG had significantly improved long-term survival compared with SAG (pooled HR=0.79, 95% CI: 0.74–0.85, p<0.01). In-hospital mortality was reported by 6 studies (4202 patients: 2099 MAG and 2103 SAG) and occurred in 3.0% vs. 3.3% in MAG vs. SAG patients, respectively (pooled OR: 0.91, 95% CI: 0.65–1.29, p=0.60). SWI was reported by 6 studies (4432 patients: 2216 MAG and 2216 SAG) and occurred in 2.8% vs. 2.2% in MAG vs. SAG patients, respectively (pooled OR: 1.31, 95% CI: 0.90–1.92, p=0.15). Excluding one article in which MAG group consisted in IMA+RA, the remaining 5 BIMA vs. SIMA studies reported an higher risk of SWI in MAG group (pooled OR: 1.63, 95% CI: 1.07–2.49, p=0.02)

Conclusion

Considering PSM studies, MAG provides superior long-term survival compared to SAG in diabetic patients. This surgical technique does not implement additional risk regarding in-hospital mortality, but MAG with BIMA was associated with a higher risk of SWI in this specific subgroup of patients.

Forest plot survival

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Universidade do Porto/FMUP e FSE-Fundo Social Europeu, NORTE 2020-Programa Operacional Regional do Norte,-Programas Doutorais
Echocardiography-guided transcatheter closure of perimembranous ventricular septal defects without arterial access:a fluoroscopy-free technique for alternative use in children
Authors: Bu H , Yang Y , Wu Q , Zhang W , Hu S , Zhao T
Published: November 2020

Background

Traditional percutaneous device closure of perimembranous ventricular septal defects (PmVSDs) is a minimally invasive technique, but can result in high radiation exposure and potential arterial complications. The feasibility of another alternative surgical repair technique for closure of VSDs by percardiac device has been proven. However, the disadvantages of surgical trauma and incision in the inferior sternum cannot avoid.

Purpose

In an effort to avoid radiation exposure, arterial access, surgical incision and complications, we established a novel technique for transcatheter VSD closure via the femoral vein approach under the guidance of transesophageal echocardiography (TEE) without fluoroscopy. And the feasibility and safety of this new strategy have been assessed.

Methods

From January 2015 to June 2019, a total of 48 PmVSD patients (mean age, 7.5±2.4 years [range, 4.3– 12.0 years]; mean body weight 24.6±6.8 kg [range, 16.5–38.5 kg]; VSD diameter, 4.3±0.6 mm [range, 3.2–5.0 mm]) underwent attempted transcatheter closure via the femoral vein approach under the guidance of TEE without fluoroscopy.

Results

The transcatheter occlusion procedure under TEE guidance was successful in 46 (95.8%) patients. Surgery was necessary in 2 (4.2%) patients. The mean procedural duration, post-operative mechanical ventilation duration, intensive care unit (ICU) residence, and in-hospital durations were 27.2±7.4 min (range, 12.0–42.0 min), 63.2±5.3 min (range, 56.0–78.0 min), 2.1±0.1 h (mean, 2.0–2.4 h), and 2.7±0.3 d (range, 2.5–3.0 d), respectively. One patient had immediate post-operative trivial residual shunt and four patients had immediate incomplete right bundle branch block (IRBBB) after operation; the new IRBBB in 2 cases were noted in the first postoperative month. No residual shunt was noted at 3 months after the procedure, and no intervention related complications were detected at 1–36 months follow-up.

Conclusion

Echocardiography-guided percutaneous device closure of PmVSDs solely by femoral vein approach is effective and safe, avoids radiation exposure, potential arterial complications and a surgical incision.

Procedure of percutaneous closure PmVSD

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry.
Standardization of bicuspid valve repair with aortic annuloplasty provides similar results to tricuspid aortic valve repair
Authors: Le Breton C , Lansac E , Amabile N , Khelil N , Berrebi A , Mankoubi L , Noghin M , Debauchez M , Monin J.L
Published: November 2020

Background

Bicuspid aortic valves (BAV) represent the main cause of severe dystrophic aortic insufficiency in young patients and are mostly replaced with high rates of valve-related events and altered quality of life in case of mechanical prosthesis. Valve repair is now recommended for root aneurysm and tricuspid aortic valves (TAV) when feasible. However, concerns remain regarding the long-term durability of BAV repair, compared to TAV.

Purpose

Our objective is to compare the long-term results of repair between TAV and BAV, in consecutive patients operated on with a standardized approach according to each phenotype of the dystrophic ascending aorta.

Methods

Data were prospectively collected into the multicenter international AVIATOR registry (AorticValve repair InternATiOnal Registry). Between 2003 and 2019, according to ascending aorta phenotypes, 226 patients with BAV and 309 patients with TAV underwent either isolated valve repair with external ring annuloplasty (26,2%), or root remodeling with external ring (59,4%), or a supra-coronary graft with external ring (14,4%).

Results

Cusp repair was performed in 95,1% patients in the BAV group and in 63,8% in the TAV group. The 30-day operative mortality was 0,93% (n=5). Mean follow-up was 5,5±4,4 years. The actuarial survival rate at 12 years was 93,2% in the BAV group and 87,8% in the TAV group (p=0,14). Freedom from reoperation at 12 years was similar between groups being 94,9% for bicuspid and 93,2% for tricuspid (p=0,75). Freedom from major adverse valve-related events at 12 years was 82,8% and 82,9% in BAV and TAV groups respectively (p=0,17). At 12 years, freedom from AI ≥Grade 2 or ≥Grade 3 was 68,7% and 94,3% for BAV and 76,5% and 94,7% for TAV group, with no significant difference (respectively p=0,16 and p=0,92).

Conclusion

Aortic valve repair with a standardized approach adapted to the aorta phenotype provides excellent long-term results with a low rate of valve-related events. Similar results were achieved between BAV and TAV patients.

freedom from reoperation for BAV and TAV

Funding Acknowledgement

Type of funding source: None
Anticoagulation for mechanical aortic valve replacement: an international survey
Authors: Gupta S , Belley-Cote E , McEwen C , Hou W , Eikelboom J , Whitlock R
Published: November 2020

Introduction

Mechanical valves are preferred over biologic valves in younger patients because they are more durable but require long-term anticoagulation which increases the risk of bleeding. For patients with a mechanical aortic valve, the ACCP guidelines recommend a target INR of 2.5 (range 2.0–3.0) for all patients, whereas the ACC/AHA and ESC guidelines recommend a higher target for selected patients with additional risk factors for thromboembolism (TE). Data supporting the guideline recommendations are largely historical and of low quality.

Purpose

We surveyed physicians who manage anticoagulation for patient with mechanical heart valves to determine their usual practice, perceptions regarding guideline recommendations, and interest in participating in a randomized controlled trial (RCT) comparing lower with higher INR targets in patients with a mechanical aortic valve.

Methods

A 33-question web-based survey was sent to 75 cardiologists, cardiac surgeons and thrombosis specialists at centres in Canada and internationally (western Europe, South America, and the United States) who participated in previous anticoagulation trials led by investigators at McMaster University.

Results

Of the 55 respondents (73.3% response rate), 77.8% worked in academic teaching hospitals. Respondents had been in practice for a mean of 23.6 years; 40.9% followed AHA/ACC guidelines, 34.1% followed the ACCP guidelines and 22.7% followed the ESC guidelines. In patients with a mechanical aortic valve and no additional TE risk factors, 80% of respondents targeted an INR of 2.5 (range 2.0–3.0); among patients with additional TE risk factors, 48% targeted an INR of 2.5 (range 2.0–3.0) and 44% targeted an INR of 3.0 (range 2.5–3.5). With respect to guidelines: 57.1% of respondents agreed or strongly agreed that that the evidence for the guidelines was contemporary, 53.1% agreed or strongly agreed that the evidence was derived from patients with modern bi-leaflet mechanical valves, and 57.2% of respondents agreed or strongly agreed that the evidence was not of high quality. A majority of respondents (65.9%) reported that they would accept an increase in TE risk to reduce the risk of a major bleeding event; 86.4% are willing to randomize patients with a mechanical aortic valve to a target INR of 2.0 (range 1.5–2.5) if they had no risk factors for TE and 36.4% would randomize patients to a target INR of 2.0 with additional risk factors for TE.

Conclusions

Clinicians who participated in the survey followed different guidelines and employed different INR targets for patients with a mechanical aortic valve. A majority of respondents would be willing to randomize these patients to lower INR targets.

Mechanical Aortic Valves and INR Targets

Funding Acknowledgement

Type of funding source: None
Haplotype of receptor for advanced glycation end products is associated with arterial stiffness in essential hypertension
Authors: Mahmud A , Zhou S , Yasmin Y , Spiers J.P , Feely J , Silke B
Published: November 2020

Background

What causes us to age has been extensively explored. The receptor for AGEs (RAGE) expression is up-regulated in atherosclerotic plaques and its activation leads to oxidative stress, cytokine and adhesion molecule formation, activation of nuclear factor-κB and cell apoptosis. We hypothesized that genetic variation in the RAGE receptor may be associated with arterial stiffness.

Methods

309 untreated hypertensive subjects were tested for genotypes of –374T>A and –429T>C polymorphisms with polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP). Arterial stiffness was measured as pulse wave velocity (PWV), augmentation index (AIx) and central aortic blood pressure (BP). Data was analysed using JMP Version 13 (SAS for Windows).

Results

Both polymorphisms were in Hardy-Weinberg equilibrium. The –374A A allele carriers had significantly lower aortic systolic BP (143±2 vs. 154±1, p<0.001) while –429C allele carriers had lower aortic systolic BP (151±1 vs. 157±2, p<0.01) compared with T carriers. –429C allele carriers had lower PWV compared to 429TT individuals (8.86±1 vs. 10.70±2.5). –374A allele carriers had lower PWV compared to 374TT individuals (9.7±1.43 vs. 10.65±2.6). Subjects with the AC haplotype had the lowest and those with the TT haplotype the highest PWV and aortic BP than any of the other haplotypes containing one or more of the at-risk alleles.

Conclusions

The combined effect of the two genotypes was additive with AA homozygotes of –374T>A and C allele carriers of –429T>C and the haplotype AC, associated with lowest aortic BP and arterial stiffness.

PWV & RAGE haplotypes

Funding Acknowledgement

Type of funding source: None
What is the optimal blood pressure level for kidney in the general population?
Authors: Ohno K , Takase H , Machii M , Nonaka D , Takayama S , Sugiura T , Ohte N , Dohi Y
Published: November 2020

Background/Introduction

Hypertension induces kidney dysfunction, and vice versa. Furthermore, kidney dysfunction can be a risk factor for cardiovascular diseases as well as end-stage of kidney disease. Although blood pressure (BP) control is necessary to prevent deterioration of kidney function, strict BP control may deteriorate kidney function.

Purpose

The present observational study investigated effects of BP levels on the incidence of chronic kidney disease (CKD) in the general population.

Methods

A total of 12,753 subjects with normal kidney function (estimated glomerular filtration rate [eGFR] ≥60 mL/min per 1.73 m2) (male 7,707, mean age 51.8 years) who visited our hospital for an annual physical check-up from April 2010 to March 2018 were enrolled. After baseline examination, subjects were followed up until March 2019 (median 1769 days) with the endpoint being the development of CKD (eGFR<60 mL/min per 1.73 m2). The modified MDRD formula for Japanese was used to calculate eGFR. Hypertension was defined as BP ≥140/90mmHg or the use of antihypertensive medication.

Results

During the follow-up period, 1,604 subjects developed CKD (26.9 per 1,000 person-years) with the incidence being more frequent in hypertensive (n=3,098) than normotensive (n=9,655) subjects at enrollment (44.2 vs. 21.5 per 1,000 person-years, respectively; hazard ratio [95% confidence interval] from multivariate Cox proportional analysis 1.205 [1.061–1.369]). Hazard ratio of systolic BP at baseline was 1.006 [1.002–1.010] in a multivariate Cox proportional hazard regression model adjusted for possible risk factors. The incidence was lower in subjects without hypertension throughout the follow-up period (normotension group, n=7,866) than those who were diagnosed as having hypertension at least once during the period (hypertension group, n=4,887) (23.1 vs. 32.3 per 1,000 person-years, p<0.001). In the normotension group, subjects with average BP <120/80mmHg had lower incidence of CKD than in those with BP ≥120/80mmHg (17.2 vs. 36.1 per 1,000 person-years, p<0.001). In contrast, in the hypertension group, the incidences of CKD in subjects with average BP <120/80, 120–139/80–89 and ≥140/90mmHg were 34.3, 25.8, and 54.4 per 1,000 person-years, respectively (p<0.001). Moreover, in hypertensive subjects under medication (n=2,002) with average BP <120/80, 120–139/80–89 and ≥140/90mmHg, the incidence of CKD was 65.5, 41.3, and 64.3 per 1,000 person-years, respectively (p<0.01).

Conclusions

The incidence of CKD was higher in hypertensive than in normotensive subjects. The lower BP was associated with the lower incidence of CKD in normotensive subjects, while strict BP control may increase the risk of CKD in hypertensive subjects.

Funding Acknowledgement

Type of funding source: None
The impact of resting heart rate measured on cardiovascular events in subject with hypertension
Authors: Sobieraj P , Lewandowski J , Sinski M
Published: November 2020

Background

Available evidence does not indicate whether resting heart rate (RHR) is an independent risk factor or just marker of elevated risk. None of the studies assessed impact of RHR on cardiovascular events, when RHR was measured using automated blood pressure measurements (AOBPM).

Purpose

To assess the relationship between RHR (measured using AOBPM) and cardiovascular events risk in subjects with hypertension.

Methods

The data of SPRINT trial obtained via NHLBI were used to perform the analysis. SPRINT trial assessed intensive lowering of systolic BP to a target <120 mm Hg in comparison to standard goal (<140 mm Hg).

RHR was measured using AOBPM device and calculated as an average of 3 measurements during the baseline visit of the study.

Clinical composite endpoint (CE) of the study was defined as: myocardial infarction, acute coronary syndrome, decompensation of heart failure, stroke or cardiovascular death.

The relationship between RHR and CE was assessed according to presence of cardiovascular disease (CVD) in past medical history.

The statistical methods included t-test and chi-square test, Cox proportional risk models. The Cox models were adjusted for adjusted for age, sex, current smoking status and mean SBP during the trial. Restricted cubic splines were used to describe the relationship between RHR and hazard ratio.

Results

Data of 1877 participants with CVD and 7484 participants without CVD were analyzed. Subjects with cardiovascular disease were older (69.7±9.5 vs 67.5 years ± 9.4, p<0.001), more often were men (72.8% vs 62.3%, p<0.001) and had prior chronic kidney disease (34.3% vs 26.8%, p<0.001) than subjects without CVD. CE was more than twice often when CVD was present (10.9% vs 4.8%, p<0.001). RHR was lower in subjects with CVD disease than in subjects without CVD (63.6±11 vs 66.9±11.6 bpm, p=0<00.1). Elevated RHR was associated with increased risk both in subjects with and without CVD (Figure 1).

The multivariable Cox proportional hazard risk model revealed that RHR>80 bpm is an independent risk factor for CE in subjects without CVD (hazard ratio 1.37, 95% CI 1.01–1.85, p=0.043) while not in subjects with CVD (hazard ratio 0.99, 95% CI 0.57–1.71, p=0.98).

Conclusion

Elevated RHR (>80 bpm) measured using AOBPM is an independent risk factor for cardiovascular events in subjects with hypertension and without CVD.

Figure 1. Heart ratio vs hazard ratio.

Funding Acknowledgement

Type of funding source: None
Haemodynamic characteristics and blood pressure evolution of hypertension subtypes in young to middle age adults
Authors: Saladini F , Fania C , Mos L , Mazzer A , Vriz O , Garavelli G , Palatini P
Published: November 2020

Aim

The prognostic significance of different hypertension subtypes in young hypertensives, in particular of isolated systolic hypertensives (ISHs) is still debated. The aim of the present study was to investigate clinical and haemodynamic characteristics and blood pressure (BP) evolution of different hypertension subtypes in young stage I hypertensives.

Methods

We investigated 1206 young subjects from the HARVEST study: 81 normotensives (NTs), 146 ISHs, 281 isolated diastolic hypertensives (IDHs) and 698 systolic-diastolic hypertensives (SDHs) according to office BP values at baseline. Data on baseline haemodynamic and metabolic characteristics, BP and heart rate changes during follow-up (mean 7 years) were collected. ANCOVA analysis was used for all comparisons adjusting for age and sex.

Results

Males were more frequent among ISHs (90.4%) compared to other categories (70.4, 67.3, 71.5% among NTs, IDHs, SHDs). Moreover, ISHs were younger compared to the others (25.6±6.6 years, p<0.001) and thinner compared to SDHs (24.6±.2.6 vs 25.8±3.6 kg/m2, p=0.028). Heart rate was higher among ISHs (75.7±9.4 bpm) and SDHs (75.8±9.7) compared to other categories (p<0.001). Metabolic characteristics were not significantly different among groups. ISHs were more active in sports (55.5%) and drank less alcohol compared to others (p<0.001, p=0.05 respectively). Systolic white coat effect was higher among ISH (17.6±12.4 mmHg) compared to others (p<0.001), as was cardiac output ISH (6.3±1.2 ml/min) compared to NTs and IDHs (p<0.001); Peripheral resistances were similar in ISHs and NTs and were lower than in IDHs and SDHs (p<0.001). Small and large artery compliance was higher, central systolic BP and augmentation index were lower among NTs and ISHs compared to IDHs and SDHs, even if these differences were not statistically significant. During follow-up systolic BP decreased (−7.6±14.4 mmHg) among ISHs, while it increased among NTs and IDHs (p<0.001). Heart rate decreased in all categories but to a higher extent among ISHs (−3.8±10.9 bpm) and SDHs (−3.4±10.8 bpm) (p=0.002 vs others). Changes in diastolic BP were similar among ISHs and NTs and higher than those observed among IDHs and SDHs (p<0.001). The percent of patients who started pharmacological treatment during follow-up was 70.6% among SDHs, 54.1% among IDHs, 41.1% among ISHs, and 39.5% among NTs (p<0.001).

Conclusions

ISHs had increased cardiac output and white coat effect and lower peripheral resistances compared to other hypertension subtypes while distensibility parameters did not differ significantly among groups. The percent of patients who developed hypertension needing treatment was lower among ISHs than other hypertensives. This was due to a favourable time course of BP during follow-up. Longer follow-ups are needed to confirm the lower risk profile of ISH of the young

Funding Acknowledgement

Type of funding source: None
The associations among arterial stiffness, endothelial dysfunction and the progression of carotid atherosclerosis in hypertensive subjects with/without carotid atherosclerosis
Authors: Nakano H , Tomiyama H , Fujii M , Iwasaki Y , Matsumoto C , Shiina K , Chikamori T , Yamashina A
Published: November 2020

Background

While arterial stiffness and endothelial dysfunction, which are diffuse vascular damage, are phenotypes of vascular damage, their associations with the progression of atherosclerosis, which is focal vascular damage, has not been fully clarified. The present prospective observational study was conducted to examine whether arterial stiffness and endothelial dysfunction predict the progression of carotid atherosclerosis in subjects medicated for hypertension with/without carotid atherosclerosis.

Methods and results

In 617 subjects receiving antihypertensive treatment, we conducted flow-mediated vasodilatation (FMD), brachial-ankle pulse wave velocity (baPWV) and common carotid artery intima-media thickness mean and maximal (IMTmean and IMTmax) at the baseline and the end (3 years' later) of study periods. During the study period, FMD was decreased and baPWV, IMTmean and IMTmax were increased significantly. In subjects without carotid atherosclerosis (IMTmax <1.1mm, n=416), baPWV, but not FMD, at baseline had significant associations with IMTmean and IMTmax at both the baseline and end of study period. As shown in Figure, the changes of IMTmean and also IMTmax during the study period were higher in the highest tertile ranges of baPWV at the baseline than in the lowest tertile range of baPWV. On the other hand, in subjects with carotid atherosclerosis (IMTmax >1.1mm, n=201), both baPWV and FMD were not associated with any markers of carotid atherosclerosis and also their changes during the study period.

Conclusion

In subjects with hypertension, arterial stiffness rather than endothelial dysfunction may be associated with the progression of carotid atherosclerosis, and this association may be significant in the premature stage of atherosclerosis.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Omron Healthcare, Asahikasei Calpis
Elevation of pulse pressure in middle age is associated with the risk of dementia: data from a population-based cohort
Authors: Kim D , Jung H , Yang P.S , Yu H.T , Kim T.H , Jang E , Sung J.H , Pak H.N , Lee M.Y , Lee M.H , Lip G.Y.H , Joung B
Published: November 2020

Aims

Pulse pressure (PP) is a well-known risk factor for cardiovascular disease. However, the association between the PP and dementia is not well identified. This study aimed to determine the effect of PP on the risk of dementia development in different age subgroups using a longitudinal, population-based, and stroke-free cohort from the general population.

Methods

The association of PP with the development of incident dementia was assessed from January 1, 2005, to December 31, 2013, in 433,154 participants without a history of dementia or stroke from the Korea National Health Insurance Service-Health Screening cohort. The diagnosis of dementia was defined using the 10th revision of the International Classification of Disease codes.

Results

The mean age of the cohort was 55.7±9.2 years, 45.7% were women. Hypertension was 23.6%. The mean systolic and diastolic blood pressure of the entire cohort were 125.9±16.6 and 78.4±10.7 mmHg, respectively. Mean PP was 47.5±10.9 mmHg. In the middle-age group (40 to 50 year-old), increasing of 10 mmHg of PP was associated with incident dementia after adjusting mean blood pressure and clinical variables with a hazard ratio (HR) of 1.21 (95% confidence interval [CI]: 1.19–1.23, p<0.001). The association was still significant even after censoring for stroke (HR: 1.16, 95% CI: 1.08–1.22, p<0.001). In the older population, elevation of PP was not associated with dementia development (HR: 0.98, 95% CI: 0.95–1.01, p=0.247)

Conclusion

PP was associated with increased risk of dementia only in middle-aged population beyond that of mean arterial pressure.

Funding Acknowledgement

Type of funding source: None
Defining the electrocardiographic and echocardiographic abnormalities in a population of older adults with cardiovascular disease in rural south africa
Authors: Ferro E.G , Abrahams-Gessel S , Wagner R , Montana L , Gomez-Olive X , Tollman S , Gaziano T
Published: November 2020

Background

The African continent is undergoing an epidemiologic transition from infectious to cardiovascular (CV) diseases. National health systems face a critical shortage of population-level data to target the growing burden of hypertension (HTN). Very little is known on the impact of HTN on the rural population in many African countries, where over 85% of the rural population will migrate to cities and shape the modern CV disease spectrum of Africa in the next decade.

Purpose

To characterize the prevalence of HTN and HTN-related EKG and TTE abnormalities in a rural cohort in South Africa (n=5,059).

Methods

Between 2014 and 2015, 804 EKGs and 158 TTEs were performed on participants aged 40 or older randomly sampled from a longitudinal cohort residing in the Agincourt sub-district of rural South Africa. EKGs and TTEs were interpreted by two blinded physicians, and clinically meaningful variables defined using the Minnesota code (EKG) and European Association of Cardiovascular Imaging guidelines (TTE). Chi-square tests were conducted to define the association of EKG/TTE abnormalities with HTN, and stratify by gender.

Results

Over 55% of the sample (n=810) met blood pressure criteria for HTN, with a high prevalence of obesity (29%). On EKG, 36.5% participants had left ventricular hypertrophy (LVH), 13.6% T wave abnormalities, 7.5% Q wave abnormalities and 18.8% prolonged QT interval. Males (n=291) had more LVH (45% vs 30.8%, p<0.01) and Q wave abnormalities (10% vs 5.9%, p=0.04) than females. Instead, females (n=438) had more prolonged QT intervals (28.8% vs 21%, p=0.02). Compared to those without HTN, participants with HTN had more LVH (45.4% vs 22.1%, p<0.01), ST segment abnormalities (17.4% vs 10.7%, p<0.01) and prolonged QT interval (23.4% vs 11.4%, p<0.01). On TTE, there was a high prevalence of moderate (31%) / severe (25.8%) diastolic dysfunction, and concentric LVH (31.6%). Females had more concentric LVH (40.8% vs 13.5%, p<0.01), and high relative wall thickness (70% vs 18.1%, p<0.01) than males. Participants with HTN had more concentric LVH (42.5% vs 8.2%, p<0.01), LV mass (58.5% vs 20.4%, p<0.01) and LV mass index (52.8% vs 30.6%, p<0.01), than those without HTN.

Conclusions

The rural population in South Africa is already affected by a high burden of HTN and high obesity levels. Within this cohort, patients with HTN have significantly more EKG and TTE abnormalities that predict adverse CV outcomes. EKG and TTE evaluation can be used to identify high-risk groups that national health systems should prioritize with frequent monitoring and more aggressive medical treatment.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Brigham and Women's Hospital
Combined lack of blood pressure and lipid control is a major risk factor for mortality in hypertensive patients: a single-center study
Authors: Magkas N , Georgiopoulos G , Konstantinidis D , Manta E , Kouremeti M , Dilaveris P , Chrysochoou C , Tzorovili E , Antoniou C , Tsiamis E , Tousoulis D , Tsioufis C
Published: November 2020

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<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
Effective reflection distance and its association with pressure augmentation index under a variety of acute hemodynamic perturbation
Authors: Uemura K , Nishikawa T , Kawada T , Sugimachi M
Published: November 2020

Effective reflection distance (ERD), a conceptual distance to a major reflection site from the aortic root, is associated with aging and pressure augmentation index (AIx) in clinical population. However, it is poorly understood how ERD varies and associates with AIx within a subject when the hemodynamic condition is changed extensively by acute pharmacological interventions.

Methods

In 13 anesthetized dogs, we measured aortic pressure (AP) and flow (AF) and femoral arterial flow (FF). Using AP, AF and FF, ERD based on an arterial model comprising a tube with frequency-dependent load (ERD_TL) was determined as a physiologically valid reference. ERD was also determined by wave separation (ERD_WSA) and pressure-only analyses (ERD_AW). Hemodynamic condition was changed by administrating zatebradine (bradycardic agent), nitroprusside, noradrenaline, dobutamine, and dextran.

Results

ERD_TL shortened significantly in response to infusion of nitroprusside or dobutamine. ERD_TL was significantly and negatively associated with AIx in multivariate analysis (Figure/Table). Changes in ERD_WSA or ERD_AW, and their association with AIx were not necessarily concordant with those observed in ERD_TL.

Conclusion

For the first time, we demonstrated that under diverse hemodynamic conditions, ERD_TL can change sensitively, and associates with AIx physiologically. This substantiates importance of tight attention to medication at clinical analysis of wave reflection phenomena. ERD_WSA or ERD_AW may not be a surrogate of ERD_TL.

Responses of ERD to drugs

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science (JSPS)
Effectiveness of personalized selection of antihypertensive therapy based on genetic polymorphism
Authors: Shlyk S.V , Drobotya N.V , Khaisheva L.A , Arytyunyan L.V , Pirozhenko A.A
Published: November 2020

Recent data indicate that it is important to develop the problem of genetic polymorphism in patients with arterial hypertension (AH) for the long-term possibility of using it as a justification for choosing the optimal treatment strategy. Currently, despite the availability of effective antihypertensive agents, the percentage of patients who have reached the target blood pressure level remains still not enough. A rational basis for choosing a particular class of drugs and / or their combinations in a concrete patient with AH can be the detection of genetic markers that determine the degree of sensitivity to therapy, since the relationship of its effectiveness with the genetic features is not in doubt today.

Material and methods

The work is based on the results of a clinical, instrumental, laboratory and genetic examination of 41 patients with AH with insufficient effectiveness of previous antihypertensive therapy. The median age and duration of the disease were 54 (32; 70) years and 7 (1; 20) years, respectively. Taking into account the identified gene polymorphism, a fixed combination of an ACE inhibitor (perindopril 10 mg) and a thiazide-like diuretic (indapamide 2.5 mg) was assigned. The comparative dynamics of blood pressure daily monitoring, left ventricle echocardiographic parameters, as well as indicators of vascular wall stiffness were analyzed before therapy and 3 months later.

Results

The study established a relationship between the clinical and morpho-functional features of AH in the examined patients with polymorphism of the AGT, AGTR2, CYP11B2, GNB3, NOS3 genes:-786 of their heterozygotes and “mutant” homozygotes, of which 3 polymorphic genes (AGT, AGTR2, CYP11B2) encode the activity of ACE.

The obtained results allowed to establish that positive dynamics of the studied indicators was revealed in all patients. Though patients, carriers of the mutant allele C of polymorphic marker T704C AGT gene, had statistically significant more expressed benefit changes in blood pressure daily profile, echocardiographic parameters (such as left ventricular mass index, indicators of left ventricular diastolic function) and all parameters of arterial wall stiffness compared with patients who do not carry the “mutant” allele.

Conclusion

Thus, the selected treatment regimen demonstrated maximum antihypertensive, cardio - and vasoprotective effectiveness in the group of AH patients with the presence of the allele 704C of the polymorphic marker T704C of the AGT gene, which indicates the perspectivity of using genetic approaches to develop personalized tactics of AH patients drug treatment.

Funding Acknowledgement

Type of funding source: None