bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence of restenosis after drug-coated balloon percutaneous coronary intervention in patients with diabetes mellitus - a single-centre experience
Authors: Hanzek A , Percin L , Loncaric F , Ostojic Z , Krcmar T , Maric-Besic K , Radic D , Dosen D , Pasalic M , Jurin H , Skoric B , Bulum J , Margetic E , Milicic D
Published: November 2023

Background and aim

Diabetes mellitus (DM) is related to higher rates of complications after coronary revascularization.1 The efficiency of drug-coated balloon (DCB) percutaneous coronary intervention (PCI) has been shown for in-stent restenosis (ISR) and native small-vessel disease, however data on outcomes in DM is scarce. 2 The aim is to compare the incidence of target lesion restenosis at follow-up (FUP) coronary angiography in patients with and without DM receiving DCB PCI.

Material and methods

The registry included patients undergoing a DCB PCI at our university hospital centre from February 2011 to January 2022 (n=645). Patient demographics, comorbidities, pharmacotherapy, as well as data on the initial and FUP coronary angiography/PCI was collected. An FUP angiography was performed in 50% of patients (n=317), with a median FUP of 6 (interquartile range 3-17) months.

Results

Data is shown in Table 1. The cohort was 75% male, mean age 65 ± 10 years. DM was present in 35% (n=223) of patients, equally in both sexes, and was associated with a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke; as well as arterial hypertension, and renal insufficiency. No age difference was noted between groups. At initial PCI, more DM patients had multivessel coronary disease and ISR as the indication for DCB (DM vs non-DM: 41% vs 31%, p=0.023). After DCB, no group difference was noted in regards to the need for a bail-out PCI. FUP was performed in an equal percentage of patients in both groups (54% vs 48%, p=0.181), with no differences seen in the incidence of restenosis (17% vs. 18%, p=0.879), the need for target lesion PCI (14% vs. 13%, p=0.863), or the use of anti-anginal drugs.

Conclusion

The findings of our single-centre analysis show that although DM is related to more advanced comorbidities it does not increase the risk of target lesion restenosis after DCB PCI. DCB PCI should be considered as a therapeutic option in candidate patients regardless of DM status.Comparison between diabetic and non diab
Coronary angiography and intervention after transcatheter aortic valve implantation (TAVI): the nationwide SWEDEHEART registry
Authors: Nilsson K , Shahim B , Settergren M , James S
Published: November 2023

Background

Coronary access after transcatheter aortic valve implantation (TAVI) can be challenging and complicate percutaneous coronary intervention (PCI). Therefore, pre-existing severe coronary stenosis is usually treated either before or during the TAVI procedure. However, due to the progressive nature of coronary artery disease (CAD), some patients require urgent or elective coronary angiography and intervention after their TAVI procedure.

Purpose

To assess the indication, the incidence, and feasibility of coronary angiography and intervention after TAVI.

Methods

All patients undergoing TAVI between 2008 and 2021 from the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY) were included. SWENTRY was further linked to the Swedish Coronar Angiography and Angioplasty Registry (SCAAR) and the National Cause of Death Registry.

Results

Among 8819 patients undergoing TAVI, 697 angiograms were performed in 515 patients (5.8%) after TAVI (43.1 % after balloon-expandable bioprosthesis, 49.5 % after self-expandable bioprosthesis) at a median follow up of 841 days (interquartile range: 346 to 1457 days). PCI was performed in 347 patients (49.8%) with a success rate of 92.5% with no significant differences between patients implanted with balloon-expandable and self-expandable bioprostheses (93.0% vs.91.5%; p=0.62). The most common indications for PCI after TAVI were non-ST elevation acute coronary syndrome (NSTE-ACS) (45.8%), chronic coronary syndrome (30.3%), ST elevation myocardial infarction (6.9%) and congestive heart failure (3.5%). The cumulative incidence of angiograms with or without PCI at 30 days, 1 year, 2 years and 5 years were 6.9, 37.2, 60.2 and 90.2 percent of the total number of angiograms respectively (Figure).

Conclusion

Coronary angiogram and interventions after TAVI are rare, with an incidence declining over time after TAVI. The main indication for coronary angiogram and PCI was NSTE-ACS. PCIs were successfully performed after TAVI, with no apparent differences between balloon-expandable and self-expandable bioprostheses.
Clinical outcomes of isolated tricuspid valve surgery: a systematic review
Authors: Chick W , Alkhalil M , Egred M , Gorog D , Malik I , Zaman A , Khawaja S , Lucarelli C , Khokhar A , Mikhail G , Farag M
Published: November 2023

Background/Introduction

Patients with isolated tricuspid valve (ITV) disease have a poor prognosis with no consensus on their management. Transcatheter ITV intervention is emerging as a valid option in patients with prohibitive surgical risk.

Purpose

We aimed to analyse the characteristics and clinical outcomes of patients who underwent ITV surgery to inform the clinical decision making in patients undergoing transcatheter ITV intervention and to advance the development of future technologies.

Methods

Digital databases were searched from inception through to 2022 for studies reporting clinical outcomes on ITV surgeries, namely ITV repair, ITV replacement with a bioprosthetic valve (ITVR-B), or ITV replacement with a mechanical valve (ITVR-M). Overall estimates of treatment effect were calculated with a random-effects model.

Results

Twenty-seven studies involving 10,478 patients (4,931 ITV repair, 3,821 ITVR-B, 1,713 ITVR-M) were included. Overall, early mortality occurred in 9.0% of patients and did not differ between different ITV surgical approaches. Late mortality was 27.1% at a median follow-up of 3.9 (3.0-6.0) years and was significantly higher for all ITV replacement surgeries (30.2% vs. 24.7%, RR 1.18, 95% CI 1.05-1.31, P=0.004) compared to ITV repair. Late mortality did not differ between ITVR-B and ITVR-M. Early and late clinical outcomes after ITV surgery differed according to the surgery performed. Compared to all ITV replacement surgeries and despite its favourable late mortality outcomes, ITV repair was observed to have a relatively higher risk of cerebrovascular accidents or need for permanent pacemaker implantation in the post-operative period, as well as TV regurgitation recurrence after 1 year.

Conclusions

Amongst ITV surgeries, ITV repair has favourable long-term mortality compared to ITV replacements. This supports the development and refinement of transcatheter ITV repair approaches in suitable patients.
Role of right ventricular remodeling in functional status and prognosis after transcatheter tricuspid valve repair
Authors: Iliadis C , Ehrenfels M A , Fretter C , Von Stein J , Koerber M I , Baldus S , Pfister R
Published: November 2023

Background

Severe tricuspid regurgitation (TR) is associated with chronic volume overload and right ventricular remodeling (RVR). Transcatheter tricuspid valve repair (TTVr) reduces TR and can improve quality of life (QoL), but the role of preprocedural RVR on functional and clinical outcomes after TTVr remains unclear.

Purpose

Aim of this study was to investigate the role of RVR on functional and clinical outcomes after TTVr for severe TR.

Methods

RVR was defined as dilation of right ventricular mid-level diameter (>35 mm) according to current guidelines. In 226 patients undergoing TTVr (edge-to-edge repair or annuloplasty) for severe TR with heart failure (HF), outcomes were compared between 139 patients with RVR and 87 patients without RVR. Functionality and QoL were evaluated using NYHA class, Minnesota Living With Heart Failure Questionnaire (MLHFQ), 36-Item Short-Form Health Survey (SF-36), and 6-Minute-Walking-Distance (6MWD) 30 days after TTVr. Clinical outcome was assessed through one-year and long-term mortality, HF rehospitalization and need for repeat TV intervention.

Results

Symptomatic improvement of at least one NYHA class was achieved regardless of RVR (58% vs. 66% of patients with vs. without RVR). Functionality and QoL improved without statistical difference in both groups, with clinically relevant 6MWD improvement of ≥50m in 34% vs. 36% of patients with vs. without RVR; clinically relevant MLHFQ improvement of ≥5 points was present in 70% vs. 81% of patients with vs. without RVR; and clinically relevant SF-36 improvement of ≥2.5 points in 65% vs. 69% with vs. without RVR. One-year mortality after TTVr was 24% vs. 8% in patients with RVR vs. without RVR (p=0.02). One-year HF rehospitalization after TTVr was 30% vs. 13% in patients with vs. without RVR (p=0.04), whereas need for repeat TTVr was not associated with RVR. Long-term follow-up was available after 457±403 days. In multivariable analysis, RVR remained an independent predictor of long-term mortality (HR 2.3, 95%CI [1.03-5.1], p=0.04) and of the combined endpoint of long-term mortality or HF rehospitalization (HR 2.4, 95%CI [1.06-5.5], p=0.04).

Conclusion

TTVr resulted in clinically relevant improvement of functionality and QoL in patients with HF already after one month, irrespective of RVR. Patients with preprocedural RVR had higher rates of one-year mortality and HF hospitalization. However, preprocedural RVR should not be considered as marker of TTVr futility.
Comparative analysis between transcranial doppler and transesophageal echocardiogram in diagnosing residual shunt after persistent foramen ovale closure
Authors: Jang A Y , Shin Y H , Lee J P , Won Y S , Yang T I , Kim J H , Kang W C
Published: November 2023

Background

The degree of residual shunt (RS) after patent foramen ovale (PFO) closure is a potent predictor for the recurrence of stroke. Evaluating the extent of residual shunt grade is thus essential. Currently, there is no gold standard on guidelines of how to evaluate RS. Although transesophageal echocardiography (TEE) is known to be most accurate in evaluating RS, it is not routinely performed due to its invasiveness and expensive costs. Conversely, the transcranial doppler (TCD) test is a less invasive convenient test for detecting RS. Accordingly, we sought to comparatively analyze the accuracy of TCD compared to TEE on assessing RS after PFO closure.

Methods

We analyzed patients who underwent PFO closure for cryptogenic stroke (CS), who received a TCD and TEE test within 1 year of procedure. All patients received TEE and TCD on the same day within one year (288±38 days) after PFO closure.

Results

We analyzed a total of 55 patients (age: 55.2 ± 11.1, male sex: 74.2%, PFO grade ≥ moderate: 83.6%, follow up duration: 28.9 ± 14.9 months). RS was confirmed in 24 (44%) and 23 (42%) of patients in the TCD and TEE test, respectively. The sensitivity and specificity of TCD was 0.77 and 0.96 for predicting the presence of RS, respectively. The predictive performance of TCD was consistent over age ≤65 (sensitivity 0.73, specificity 0.96) and RS≤mild (sensitivity 0.83, specificity 0.96) subgroups. Positive TCD (adjusted odds ratio 101.2; 95%CI, 9.5-1074.8; p<0.0001) was a highly significant independent predictor for the presence of RS.

Conclusion

We demonstrate for the first time that TCD may be a reliable non-invasive test for substituting TEE in evaluating RS. Physicians may be able to rule out the presence of RS and minimize the prescription of TEE when TCD test is negative due to the high specificity.
Association of high normal blood pressure defined by different criteria with all-cause and cardiovascular mortality
Authors: Zhang Y I , Zhao Y , Li M O R A N , Han J U N
Published: November 2023

By grouping population according to guideline definition, in terms of all-cause mortality and cardiovascular death, there was no significant difference between population with normal blood pressure (NT) and with high normal blood pressure (HNBP). But both groups had significantly lower risk compared with hypertension group (HTN). Multivariate Cox regression results indicated the lowest risk of all-cause mortality in the HNBP group and no difference in risk of all-cause mortality between the NT and HTN groups, which was illogical and inconsistent with real-world clinical practice.

By grouping population according to SBP, we found that the grouping could better distinguish the all-cause and cardiovascular mortality among groups. Multivariate COX regression analysis found that NT and HNBP groups had no difference in risk of all-cause and cardiovascular death.

The restricted cubic spline curve of DBP showed the lowest HR were found when DBP was between 83 and 95 mmHg, which were defined as high normal blood pressure or hypertension according to guideline-directed classification. This result may be the primary reason for the difference between guideline and SBP-directed classification.

Conclusion and clinical significance

In this study, our analysis showed that the blood pressure classification based on SBP had a higher association with both all-cause mortality and cardiovascular mortality than the guide-directed definition. DBP inclusion could be a confounding factor for the classification. People with high normal blood pressure did not show a worse prognosis than those with normal blood pressure.abstract figure
Kidney subclinical lesions in hypertension phenotypes defined by Home Blood Pressure Monitoring among young adults enrolled in a Family Health Strategy unit
Authors: Neno J O G , Mello T S , Moura C A P M , Tostes F R C , Bandeira H O M R , De Castro R B , Junqueira L L M B , Falcao M F , Brazil L M A , Lopes C C , Guimaraes K S , Boghossian R B , Maselli G F F , Muxfeldt E S , Pecly I M D
Published: November 2023

Introduction

The association between kidney lesion, hypertension (HTN) and cardiovascular risk (CV) is well established. Asymptomatic patients with decreased glomerular filtration rate (GFR) and/or increased albuminuria seem to have increased CV risk. The refinement of HTN diagnosis using Home Blood Pressure Monitoring (HBPM) allows to identify individuals with different phenotypes: normotension, sustained HTN (SHT), masked HTN (MHT) and white-coat HTN (WHT), increasing diagnostic accuracy.

Objective

To assess kidney subclinical lesions among different hypertension (HTN) phenotypes identified by Home Blood Pressure Monitoring (HBPM) in an adult population enrolled in a Family Health Strategy unit.

Design and Methods: Cross-sectional, populational study with adults between 20-50 years old enrolled in a Family Health Strategy unit in a metropolis. Sociodemographic, anthropometric and CV risk factors were registered. Office blood pressure (BP) was the average of two consecutive measurements, and HBPM followed a 7-day protocol. HBPM < 135x85 mmHg and office BP < 140x90mmHg were considered normal, identifying four phenotypes: normotension (controlled office BP and HBPM); white-coat hypertension (uncontrolled office BP and controlled HBPM); masked hypertension (controlled office BP and uncontrolled HBPM) and sustained hypertension (uncontrolled office BP and HBPM). Albuminuria was dosed in an isolated urine sample whereas glomerular filtration rate was calculated by CKD Epi formula using serum creatinine.

Results

A total of 483 individuals were evaluated (39% male; mean age: 37.6 ± 8.8 years). More often, individuals with white-coat hypertension (9.3%) are male, with greater neck circumference and higher prevalence of metabolic syndrome. Individuals with masked hypertension (10%) are more obese, with increased neck and waist circumferences whereas those who present sustained hypertension are predominantly male, more obese, with increased neck and waist circumferences and higher prevalence of diabetes and metabolic syndrome. Analyzing four phenotypes, a progressive albuminuria increase was observed among normotensive patients: white-coat hypertension 4.0 ± 2.2; masked hypertension 5.3 ± 3.4 and sustained hypertension 7.1 ± 1.4 mg/g creatinine. We also observed an increased serum creatinine and decreased GFR: white-coat hypertension 0.74 ± 0.16/132 ± 34; masked hypertension 0.79 ± 0.17/123 ± 28; sustained hypertension 0.81 ± 0.32/120 ± 59, respectively, although without statistical significance.

Conclusion

The performance of HBPM refined HTN diagnosis and was able to early identify a progressive worsening of kidney function parameters in the different phenotypes.
Performance of a cuffless blood pressure monitor in the adult and elderly population - a comparative validation study
Authors: Paggi De Almeida T , Sola J , Theiler K , Damianaki A , Alexandre J , Vermare P , Perruchoud D , Wuerzner G
Published: November 2023

Background

Cuffless blood pressure (BP) monitoring devices are emerging as powerful tools for BP monitoring and management of hypertension, particularly in the elderly, in whom prevalence of hypertension is high. Some cuffless BP monitors allow the hourly and daily tracking of blood pressure. It remains unclear, however, whether cuffless devices yield equivalent performance across age categories.

Purpose

To compare the performance of BP measurements conducted by a cuffless BP monitor in different body positions in adult and elderly participants with a wide range of BP levels.

Methods

2 cohorts of patients (adult, 21-65 years; elderly, 65-85 years) were recruited for a prospective clinical study (NCT04027777) between August/2019–March/2022. During 4 visits over a month, systolic/diastolic BP (SBP, DBP) measurements obtained by the investigated cuffless wrist bracelet were compared to the reference measurement – double auscultation – in a sitting, standing and lying position after a unique initial calibration. The two ISO 81060-2 criteria were used for the comparison of BP measurements by the cuffless monitor and auscultation (BP-reading-level – criterion 1; subject-level – criterion 2) in the sitting position (there are no ISO criteria for other body positions). The mean differences on SBP and DBP between cohorts both at BP-reading-level and at subject-level were compared (unpaired t-test).

Results

96 adult (38±12 years)/35 elderly (73±6 years) were included in the study. Of those, 84 adult/35 elderly patients were investigated in sitting position; 91 adult/35 elderly in all body positions. SBP and DBP were significantly higher in the elderly cohort (SBP 116.4±20.3 vs. 133.9±17.7 mmHg, P≤0.0001; DBP 74.5±12.0 vs. 77.9±11.7 mmHg, P≤0.0001). The results for the analyses at BP-reading-level and subject-level are shown in Table 1. For the analyses on sitting position at BP-reading-level, SBP and DBP for both cohorts were within ISO targets for mean error and SD. At subject-level, the SD of the mean paired differences per subject were within individual ISO targets for SBP and DBP on both cohorts. Statistically significant differences between cohorts were found only at BP-reading-level for all body positions, although the magnitude of differences were not clinically relevant (Table 1, bold and *). Figure 1 highlights the biases and correlations of SBP and DBP readings between the cuffless BP monitor and auscultation for both adult and elderly cohorts.

Conclusions

The cuffless BP monitor investigated in the present study yielded equivalent BP measurements compared to auscultation, with similar performance in the adult and elderly populations.Table 1Figure 1
Effect of initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy on ambulatory blood pressure indices
Authors: Nolde J , Atkins E , Marschner S , Hillis G S , Chalmers J , Billiot L , Nelson M R , Reid C M , Hay P , Burke M , Jansen S , Usherwood T , Rodgers A , Chow C K , Schlaich M P
Published: November 2023

Background

The QUARTET trial showed that a combination of four ultra-low-dose blood pressure (BP) medications lowered mean unattended office BP more effectively than initial monotherapy.

Purpose

To investigate the effects of a combination of four ultra-low-dose blood pressure (BP) medications on ambulatory BP changes.

Methods

Australian adults (≥18 years) with hypertension who were untreated or on monotherapy were eligible for participation in the QUARTET study. Overall, 591 participants were randomly assigned to receive either the quadpill (containing irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg) or an indistinguishable monotherapy control (irbesartan 150 mg). The difference in 24-hour, daytime and night-time systolic and diastolic ambulatory BP at 12 and 52 weeks were pre-defined secondary outcomes. Reported parameters for this analysis were derived from ambulatory BP recordings of 576 participants that fulfilled pre-defined validation criteria.

Results

Of 576 participants, 289 were randomized to the quadpill group and 287 to the monotherapy group. At baseline, 24-h systolic/diastolic BP was 139.2/81.0 mmHg in the monotherapy vs. 139.8/81.3 in the quadpill group, daytime BP was 142.5/83.5 vs 143.4/84.0 mmHg, and night-time BP was 125.1/70.7 vs. 125.4/70.7 mmHg. At 12 weeks, mean 24-h ambulatory systolic and diastolic BP were 7.7 (95%CI: 9.6, 5.8) and 5.3 (95%CI: 6.5, 4.1) mmHg lower in the quadpill versus monotherapy group (p<0.001 for both). Similar reductions were observed for daytime (8.1/5.7 mmHg lower in quadpill compared to montherapy group) and night-time (6.3/4.0 mmHg lower in quadpill compared to monotherapy group) BP (all p<0.001) at 12 weeks. The reduction in systolic and diastolic ambulatory BP variability were more pronounced in the quadpill group at 12 weeks, the 24-h standard deviation was reduced by -1.2 (-1.8, -0.5) mmHg for systolic and -0.9 (-1.5, -0.4) mmHg diastolic BP. The rate of BP control (24 hours BP ≥130 and/or ≥80 mmHg) at 12 weeks was higher in the quadpill group (77% vs 50%; p<0.001). These effects were maintained at 52 weeks.

Conclusion

A quadruple quarter-dose combination compared to monotherapy resulted in greater ambulatory BP lowering across the entire 24-hour period with higher ambulatory BP control rates at both 12 and 52 weeks. These findings further substantiate the efficacy of an ultra-low-dose quadpill-based BP lowering strategy – which has been previously shown not to increase the rate of side effects - and extends it to ambulatory BP measurements.
A physiologic, precision-medicine approach to guided pharmacological treatment of hypertension substantially improves blood pressure in a large community-based cohort
Authors: Romer D , Vered Z , Cleland J , Froehlich J , Perez M , Colangelo F , Crossey R , Bottorff M , Matthews R , Hardtke C , Kaiser R , Granov I , Sobotka P
Published: November 2023

Background

Worldwide blood pressure (BP) control rates remain poor. Hypertension (HTN) guidelines provide BP targets and recommend drug treatment algorithms but ignore the potential to treat the underlying haemodynamic reason.

Patient’s poor adherence to medication is often identified as a potential cause of poor HTN control.

Purpose

To improve rates of BP control by matching patients’ non-invasive haemodynamics to specific pharmacologic treatments and increasing patient engagement.

Methods

13,715 hypertensive patients were identified via the electronic medical record (EMR) from two US primary care groups between 2014 and 2023. Impedance Cardiography (ICG) was done when BP was >140/90. Physiologic measurements included blood pressure, mean arterial pressure, cardiac index, cardiac power index, total peripheral resistance index, stroke index and heart rate (Figure 1). HTN etiology was classified as: Vasoconstriction, Hyperdynamic, or Mixed pattern based on the haemodynamic findings of the ICG. Printed clinical decision support (CDS) tools and later an EMR integrated CDS application were used to communicate recommendations to physicians. Printed reports were shared with patients to increase their engagement. Rates of successful blood pressure treatment were tracked by analysis of EMR data.

Results

The demographics of 13,715 patients were 14% black, 50% women, 17% age 18-49, 45% age 50-69, and 38% age ≥ 70 years. A total of 21,246 ICGs were performed classifying patients as Vasoconstriction 46%, Hyperdynamic with high heart rate (HR) or high stroke index (SI) 25%, and Mixed Haemodynamic (combination of Vasoconstriction and Hyperdynamic) 29% (Figure 1). No demographic features predicted the physiologic grouping. 7,892 patients in the first cohort were treated from 2014 thru 2023 and obtained >90% BP control rate in 2016. This high control rate has been sustained for 6 years. 5,823 patients in the second cohort were treated from 2019 thru 2023 and obtained >86% BP control rate.

Conclusions

Haemodynamic data may help personalize anti-hypertensive therapy and improve control of HTN to >86-90%.

Providing patients with insights about why their BP is high and providing rationale for selecting treatment may motivate their adherence and persistence with therapy.

Hypertension physiology is not predicted by demographic features among patients managed in a primary care setting.Haemodynamic Status (ICG Test Results)
Effects of blood pressure lowering according to baseline cardiovascular disease: systematic review and meta-analysis of randomized trials
Authors: Manta E , Thomopoulos C , Kariori E , Konstantinidis D , Tsioufis P , Polyzos D , Tatakis F , Siafi E , Tsoumpou I , Grigoriou K , Drogkaris S , Tsioufis K
Published: November 2023

Background

Blood pressure (BP)-lowering is accompanied by reduced cardiovascular (CV) outcomes and death in hypertensive patients. There are no data on the effect of BP lowering in patients with a history of CV disease [i.e., coronary heart disease (CHD), stroke, or heart failure with preserved ejection fraction (HFpEF)].

Purpose

To demonstrate the effect of BP-lowering treatment on CV events in patients with different types of baseline CV disease.

Methods

A systematic review was conducted to identify randomized trials in electronic databases (Pubmed and CENTRAL, search from 1966 to 11/2022) for the effect of BP-lowering treatment against placebo or less aggressive BP reduction on fatal or nonfatal cardiovascular outcomes and all-cause death. Trials or subgroups of trials were identified, including patients with a history of CV disease. We excluded heart failure studies with reduced ejection fraction, acute myocardial infarction, or acute stroke. Risk ratios (RR) were calculated with their 95% confidence interval (CI) under the random-effects model.

Results

We included 18 BP-lowering treatment trials with 52,359 CHD patients (mean follow-up, 4.2 years; achieved systolic/diastolic BP, 129.2/76.1 mmHg). Despite the fact that mortality outcomes, stroke, and recurrent CHD were not decreased as a result of BP-lowering therapy, the risk of the combined outcome of major CV events (i.e., myocardial infarction, stroke, and heart failure) was reduced by 11% (95% CI, 3-18%) and the risk of recurrent heart failure hospitalization by 28% (95% CI, 18-38%). In addition, we examined 8 trials with 37,866 patients with a history of stroke (mean follow-up, 2.7 years; achieved systolic/diastolic BP, 136.5/79.8 mmHg), in which BP-lowering treatment reduced recurrent stroke by 18% (95% CI, 7-27%) and CV death by 12% (95% CI, 3-21%). Among 5 heart failure trials with 11,597 patients (mean follow-up, 3.4 years; achieved systolic/diastolic BP, 130.8/76.7 mmHg), the combined outcome of major CV events was decreased by 10% (95% CI, 4-16%), and recurrent heart failure hospitalization by 12% (95% CI, 4-19%).

Conclusions

Maximum CV protection is offered when systolic BP is reduced to levels < 130 mmHg in patients with CHD, to 130-140 mmHg levels in patients with a history of stroke, and to levels of approximately 130 mmHg in patients with heart failure. These findings support the recommendation for more aggressive BP lowering in patients with a history of CHD or optimally treated patients with HFpEF, and for less aggressive BP reduction in post-stroke patients.
Bariatric surgery and blood pressure control in patients with hypertension: a systematic review and meta-analysis
Authors: Huang R , Jing Z Q , Liu Y H , Li Z Y , Wu S S
Published: November 2023

Background

Bariatric surgery remains the most effective method for sustained weight loss in patients with class II or III obesity. However, the effects of bariatric surgery on BP control in obese patients with hypertension are not consistent across studies.

Purpose

The purpose of this study was to compare the effects of bariatric surgery versus nonsurgical treatment on blood pressure control in patients with hypertension.

Methods

Randomized controlled trials evaluating the effects of bariatric surgery versus nonsurgical treatment on blood pressure reduction were searched in PubMed, Embase, Cochrane Database and Cochrane Clinical Trials Registry, and nineteen randomized controlled trials (in 1,375 obese patients) were finally included. The primary outcome was the rate of hypertension remission, and the follow-up periods ranged from 12 to 60 months.

Results

The results showed that bariatric surgery was associated with a higher hypertension remission rate (RR: 4.61, 95% CI: 2.27–9.35, P < 0.0001) and a greater decrease in diastolic blood pressure (WMD: -3 mmHg, 95% CI: -4.28 to -1.72, p<0.00001). However, no significant difference was observed in systolic blood pressure (WMD: -2.4 mmHg, 95% CI: -5.8 to 1, p=0.17). Furthermore, the following metabolic conditions and cardiovascular risk factors were also improved by bariatric surgery in patients with hypertension.

Conclusion

In conclusion, our study confirmed that bariatric surgery was associated with a higher rate of short-to-medium-term hypertension remission and a greater decrease in diastolic blood pressure for patients with hypertension. Bariatric surgery should be considered in these patients.
Efficacy and safety aspects of renal denervation in treatment of arterial hypertension: a systematic review and meta-analysis
Authors: Vukadinovic D , Lauder L , Ukena C , Boehm M , Mahfoud F
Published: November 2023

Introduction

Current guidelines for the management of arterial hypertension 2018 of European Society for Cardiology (ESC) do not recommend use of renal denervation (RDN) (as device-based therapy) for treatment of hypertension except as part of clinical studies. However, in the meantime several randomized sham-controlled clinical trials were designed using second generation radiofrequency (RF) (SPYRAL HTN-OFF MED, SPYRAL HTN-ON MED), ultrasound (RADIANCE-HTN SOLO, RADIANCE-HTN TRIO) or alcohol-mediated renal denervation (TARGET BP-OFF) devices. We aimed to perform a comprehensive meta-analysis from all published and unpublished randomized, sham-controlled clinical trials which explored the effects of renal denervation on blood pressure across different devices.

Methods

We searched MEDLINE and Embase via OVID@ for eligible trials. Of note, we also included unpublished data from the SPYRAL-ON Extension and TARGET BP OFF trials. Pooling the data from all studies, we explored the efficacy (ambulatory and office systolic and diastolic BP) and safety (all cause death, vascular complication, renal artery stenosis >70%, hypertensive crisis) of RDN.

Results

Analysis included 9 eligible trials (i.e. SYMPLICITY HTN-3, ReSET, SPYRAL HTN OFF MED, Desch et al., RADIANCE-HTN SOLO, RADIANCE-HTN TRIO, RADIANCE, TARGET BP OFF, SPYRAL HTN ON MED extension) comprising 2,091 patients (Table 1). RDN reduced ambulatory systolic (-3.10 mmHg, 95% CI -4.22, -1.97, p<0.00001) and office systolic (-5.15 mmHg, 95% CI -6.65, -3.66, p<0.00001) BP and ambulatory diastolic (-1.58 mmHg, 95% CI -2.54, -0.63, p=0.001) and office diastolic (-2.74 mmHg, 95% CI -3.65, -1.83, p<0.00001) BP compared with sham groups. There was no difference concerning ambulatory SBP reduction between trials with ON medication design (-2.94 mmHg, p<0.0001) and those with OFF medication design (-3.37 mmHg, p<0.0001) (p for interaction 0.69). Similarly, office SBP reduction was comparable between trials with (-4.38 mmHg, p<0.0001) and without concomitant antihypertensive drugs prescription (-6.27 mmHg, p<0.00001) (p for interaction 0.22).

The rate of vascular complications (OR 1.21, 95% CI 0.28, 5.25, p=0.80), renal artery stenosis (OR 1.50, 95% CI 0.06, 36.97, p=0.80), hypertensive crisis (OR 1.39, 95% CI 0.50, 3.92, p=0.53) and all cause death (OR 0.52, 95% CI 0.10, 2.83, p=0.45) was not different between treatment and sham groups.

Conclusions

RDN is associated with clinically significant reductions in ambulatory and office SBP as compared with sham in the presence and absence of antihypertensive medication. The procedure use was not associated with an excess in safety events compared with sham group.
The impact of longitudinal changes in BMI and serum uric acid levels on new-onset atrial fibrillation
Authors: Munakata J , Senoo K , Nakata M , Yamaoka M , Kumagai M , Nishimura H , Teramukai S , Matoba S
Published: November 2023

Background

The worldwide prevalence of atrial fibrillation (AF) is already estimated at 33 million and it is still increasing. In order to prevent the increase in the prevalence of AF, it is important to understand the risk of developing AF and to take preventive intervention. Obesity and serum uric acid level (UA) are both associated with the incidence of AF. However, it is unclear about synergistic effect of longitudinal changes in both BMI and UA on the new-onset AF. We assessed the impact of longitudinal changes in BMI and UA on the subsequent incidence of new-onset of AF. We also estimate the number of new-onset AF that could be prevented by maintaining BMI and UA.

Methods

We retrospectively analyzed 17,994 Japanese without a history of AF from a cohort of employees undergoing annual health examinations conducted between April 2013 and April 2022. Exclusion criteria included missing laboratory values, three or fewer visits, developed AF by Visit 3, Visit 1 to 3 was less than 1.5 years or more than 4 years, medication for hyperuricemia, and renal dysfunction (serum Cre≥1.2 mg/dL in men and 1.0 mg/dL in women).

Result

During a follow-up period of 3.77 years, the incidence of AF was 70 (1.04/1,000 person-years). A multivariable Cox regression analysis showed that the new-onset AF was associated with age, gender, weight gain, UA at baseline and increased UA. A multivariable Cox regression analysis with interaction term between weight gain (≥10 kg weight gain since age 20) and increased UA (1 mg/dl) showed that significant increased risk for new-onset AF were age (HR: 3.15, [95%CI; 2.44-4.06], P<0.001), gender (HR: 0.41, [95%CI; 0.20-0.84], P=0.016), weight gain (HR: 1.46, [95%CI; 1.16-1.84], P=0.001), systolic blood pressure at baseline (HR: 1.01, [95%CI; 1.00-1.03], P=0.048), UA at baseline (HR: 1.29, [95%CI; 1.02-1.63], P=0.036), and interaction term (HR:1.93, [95%CI; 1.36-2,72], p for interaction=0.006). Using the prediction model for developing AF including the interaction term, we estimated the number of new-onset AF in Japanese male aged 40-69 years in the next 5 years. An increase in uric acid of 1 mg/dL and BMI of 2 units over the past two years was predicted to result in approximately 460 000 new cases of AF/5 years, but it was estimated that maintaining uric acid levels and BMI could reduce the number of cases by 75% (preventing 344 000 new cases of AF/5 years).

Conclusion

Weight gain and increased uric acid had a synergistic effect on the risk of developing AF. Particularly in men, maintaining serum uric acid levels in those who gained weight (≥10 kg weight gain since age 20) was found to prevent 75% of new-onset of AF over a five-year period, based on our modelling analysis.Multivariable Cox Regression AnalysisEstimated number of AF incidents
Depression and heart failure - the incidence of depressive symptoms assessed by the PHQ9 and their association with HF outcomes
Authors: Certo Pereira J , Presume J , Araujo I , Carvalho Gouveia C , Rodrigues Silva S , Ferreira P , Carvalho R , Pepe B , Maia Das Neves N , Rodrigues C , Henriques C , Marques F , Guerreiro R , Fonseca C
Published: November 2023

Background

Depression is a prevalent, debilitating, and potentially modifiable comorbidity that affects heart failure (HF) patients and is associated with increased mortality and morbidity. Current HF guidelines recommend addressing depression using questionnaires, including the Patient Health Questionnaire-9 (PHQ-9), which is a 9-item questionnaire that can be self-administered in less than 3 minutes.

Objectives

To evaluate the performance of PHQ-9 in a Portuguese cohort of HF patients and present a practical approach for the screening and management of depression in patients with HF.

Methods

We conducted a prospective study enrolling consecutive patients observed in the HF clinic from June 2022 to August 2022. Patients answered the PHQ-9 before the beginning of the appointment, during which the physician evaluated the results and managed them according to the suggested protocol. – figure 1. We then evaluated the severity of depression by PHQ-9 at baseline and its association with the levels of serum NT-proBNP, the severity of HF symptoms, and the incidence of a composite of all-cause mortality and HF exacerbation at 90-days follow-up.

Results

A total of 124 patients were observed in the HF consultation and answered PHQ-9: mean age of 74±12,1years, 68% (n=84) male, 82% (n=102) with NYHA I-II, 48% (n=60) with preserved ejection fraction, 23% (n=29) with a previous diagnosis of depression and on antidepressant therapy.

After the evaluation of PHQ-9, 52% (n=65), 27% (n=33), 10% (n=12), 8% (n=10) and 3% (n=4) had minimal, mild, moderate, moderately severe, and severe depression symptoms, respectively.

In the no previous depression diagnosis group, 49% (n=46) had at least mild depressive symptoms.

The presence of depressive symptoms was associated with higher levels of serum NT-proBNP (r=0.31; p<0.001) and worse HF symptoms assessed by the NYHA classification (p<0,001). Patients who met the composite outcomes (death or HF exacerbation) during follow-up had a significantly higher PHQ-9 score (10±7 vs. 5±5; p<0,001).

Conclusions

This study confirmed the high prevalence of depressive symptoms in this real-world cohort of HF patients and demonstrated that screening for depressive symptoms can be efficiently integrated in the HF consultation. A higher burden of depressive symptoms was associated with higher serum NT-proBNP, more severe symptoms and higher incidence of death or HF admissions.
Alcohol and cause-specific mortality among 150,000 participants in the Mexico City Prospective Study
Authors: Trichia E , Alegre-Diaz J , Aguilar-Ramirez D , Ramirez-Reyes R , Gnatiuc Friedrichs L , Wade R , Collins R , Peto R , Berumen J , Emberson J , Kuri-Morales P , Tapia-Conyer R
Published: November 2023

Background

The Global Burden of Disease and Risk Factor models assess alcohol to be a leading cause of premature death both globally and in Mexico, but direct epidemiological evidence from Mexico is limited. We investigated the relevance of alcohol to mortality at ages 35-74 in a large prospective study of Mexican adults followed for nearly two decades.

Methods

Between 1998 and 2004, 150,000 adults aged ≥35 years were recruited into the Mexico City Prospective Study, and followed for median 19 years. Cox regression was used to relate baseline-reported alcohol consumption (never, former, ‘occasional’ [defined as less than monthly], and ‘regular’ [defined as at least monthly, and split into <70, ≥70 to <140, ≥140 to <210 and ≥210g/week]) to mortality at ages 35-74 from all causes, and from underlying causes selected a priori as being potentially ‘alcohol-related’. Analyses were adjusted for age at risk, sex, residential district, education, smoking, physical activity and diabetes. They excluded those who at recruitment were aged ≥75 years, had incomplete data, or had vascular disease or any other chronic condition (except diabetes) recorded.

Results

Among 45,262 men and 93,607 women aged 35-74 years, 6% of men and 26% of women reported being never drinkers, 45% of men and 56% of women reported being occasional drinkers, and 33% of men and 7% of women reported being regular drinkers. There were 12,597 deaths from any cause before age 75, including 3,433 deaths from the selected underlying causes. Compared with occasional drinkers, never drinkers had 16% higher all-cause mortality (RR 1.16, 95% CI 1.10-1.22) but similar mortality from the subset of deaths considered potentially alcohol-related (RR 1.06, 95% CI 0.96-1.17). Among regular drinkers, all-cause mortality increased progressively across the four studied categories. Compared with occasional drinkers, regular drinkers of ≥140 to <210g/week had 20% higher mortality (RR 1.20, 95% CI 1.08-1.34) while regular drinkers of >210g/week had 46% higher mortality (RR 1.46, 95% CI 1.33-1.61). For the subset of deaths considered to be alcohol-related these RRs were 1.61 (1.35-1.93) and 2.42 (2.10-2.79) respectively. Liver disease was especially strongly related to alcohol consumption: the RR comparing regular drinkers of >210g/week with occasional drinkers was 5.89 (95% CI 4.75-7.29). Associations were similar in those with and without diabetes, so the absolute relevance of alcohol to mortality was larger in those with diabetes.

Conclusions

In this Mexican cohort, higher alcohol consumption was associated with higher mortality.
Association of physical activity with the risk of major adverse cardiac and cerebrovascular events and mortality in patients with concomitant atrial fibrillation and coronary artery disease
Authors: Jin M , Lee H
Published: November 2023

Background

Although regular physical activity benefits cardiovascular health, there is a concern that intense exercise is linked to the promotion of atrial fibrillation (AF) and coronary plaque rupture. However, the impact of physical activity on the outcomes of patients with concomitant AF and coronary artery disease (CAD) remains unclear.

Purpose

This study aimed to evaluate the association with clinical outcomes according to the level of physical activity in patients with concomitant AF and CAD.

Methods

We assessed 551 patients with AF and CAD (mean age, 67.1±9.8 years) who completed a self-reported questionnaire for physical activity from 2015 to 2020 in a single tertiary-care hospital. Physical activity levels were converted into metabolic equivalent of task (MET) per week and categorized to correspond with multiple public health recommendations. We examined the association between physical activity, all-cause mortality, and major adverse cardiac and cerebrovascular events (MACCE).

Results

The risks of all-cause mortality (P for linear trend=0.017) and MACCE (P for linear trend=0.05) were appeared inverse trend with a greater level of physical activity. Compared with inactive patients, patients who met the recommended target range of physical activity (500–1,000 MET-min/week: unadjusted hazard ratio [HR]=0.58, 95% confidence interval [CI]=0.36–0.99) and highly active patients who exceeded the minimum recommended level (≥1,000 MET-min/week: unadjusted HR=0.47, 95% CI=0.25–0.88) had a lower risk of all-cause mortality in the unadjusted model; however, these associations did not remain significant after adjusting for the model. There was no evidence of increased risk of all-cause mortality and MACCE at levels of physical activity above the recommended target range, even with vigorous intensity physical activity exceeding the recommended target range.

Conclusions

There appears to be an inverse trend between physical activity levels and all-cause mortality and MACCE in patients with concomitant AF and CAD. No excess risk of mortality or MACCE was found at exercise levels above the recommended target range. Further large-scale studies are warranted to create an improved evidence base concerning the effects of physical activity in patients with AF and CAD.
Prognostic value of coronary computed tomography angiography parameters, non-alcoholic fatty liver and metabolic syndrome status in symptomatic patients suspected of coronary artery disease
Authors: Agoston Coldea L , Gligor R , Orzan R I , Agoston R
Published: November 2023

Background

Metabolic syndrome (MetS) is a well-established risk factor for major adverse cardiovascular events (MACE). Previous studies have shown the relationship between MetS, computed tomography derived epicardial fat volume (EFV), non-alcoholic fatty liver disease (NAFLD) status and coronary artery calcium score (CACS) in asymptomatic patients.

Objective

To assess the prognostic value of coronary computed tomography angiography (CCTA) derived EFV, NAFLD status, CACS and the number of plaques (NoP) in symptomatic patients with and without MetS and to design a new risk score for predicting MACE.

Methods

We conducted a single-centre, cross-sectional study on 2038 patients with intermediate risk of CAD, which underwent CCTA between March 2019 and May 2022. Data regarding MetS status and other comorbidities were assessed at the moment of the inclusion in the study. CCTA assessment included: CACS, NoP, EFV and NAFLD status. The endpoint was the occurrence of MACE (late revascularization, myocardial infarction, sudden cardiac death). Cox regression was used to assess the relationship between MetS and CCTA derived variables on the occurrence of MACE. Receiver operating characteristic curve analysis was used to determine the prediction value of CCTA derived parameters and of the new risk score. Net reclassification improvement was used to compare the risk score with CACS ability to predict MACE.

Results

Patients were prospectively followed up during a mean time of 26.9 (standard deviation: 9.5) months. 361 (17.7%) patients developed a MACE (myocardial infarction, n=67; late revascularization, n=282; sudden cardiac death, n=12). More events were seen in MetS+ patients (n=244) versus MetS- patients (n=117) (p<0.001). MetS, age, male gender, CACS, NoP, EFV and NAFLD were all associated with the occurrence of MACE: unadjusted hazard ratios (HR) of: 1.56, 1.25, 1.87, 1.0013, 1.16, 1.053 and 1.67 (p<0.001 for all). However, in the multivariate analysis only the CCTA derived variables showed a significant association with MACE: CCS HR=1.001, NoP HR=1.097, EFV HR=1.035, NAFLD HR=1.843 (p<0.001 for all). Our risk score for predicting MACE included CACS, NoP, EFV and NAFLD. It had an area under the curve (AUC) of 0.948, a sensitivity of 89.7%, a specificity of 92.9% and a negative predicting value of 97.7%. When compared to CCS alone, the risk score correctly reclassified 24 (6.6%) events and 101 (6.2%) non-events, with a net reclassification index of 0.128 (p<0.001).

Conclusion

MetS is associated with an increased risk for MACE, but not after adjustment for CCS, NoP, EFV, and NAFLD. Adding NoP, EFV and NAFLD to CCS in a risk score further improves the accuracy in predicting MACE, when compared to CCS alone.