bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes following permanent pacemaker implantation in patients undergoing tricuspid valve surgery
Authors: Kassab J , Harb S C , Desai M Y , El Dahdah J , Chedid El Helou M , Nakhla S , Elgharably H , Kapadia S , Cremer P C , Mentias A
Published: November 2023

Background

PPM implantation are commonly described after cardiac surgeries and notably after tricuspid valve surgery (TVS).

Purpose

Our study aimed to compare outcomes in patients who underwent PPM placement versus patients who did not following TVS.

Methods

We included 13 294 patients from the Medicare database who underwent isolated TV repair (N=1319 (10%)), isolated TV replacement (N=2123 (16%)), or concomitant TV repair or replacement with different combinations of surgical aortic valve replacement (SAVR), mitral valve repair or replacement (MVR), and coronary artery bypass graft (CABG). Patients who underwent TV surgery for endocarditis were excluded. The primary exposure of interest for the study was new pacemaker placement after TV surgery and before discharge, or within 30 days from discharge date. Each patient from the pacemaker group was matched to up to 3 controls from the no pacemaker group. The primary study outcome was all-cause mortality in follow-up in patients who underwent pacemaker placement after TV surgery versus patients who did not. The study’s secondary outcomes included 1-year mortality and the risk of hospital readmission with a diagnosis of endocarditis or heart failure (HF) in follow-up.

Results

Among the included patients, 2518 (18.9%) required a PPM placement after surgery. PPM placement was associated with a longer length of hospital stay (median 12 days (IQR 8-19 days) vs. 10 (7-17 days), P<0.001). It was not associated with a difference in risk of 1-year mortality (18.9% vs. 20.7%, OR 0.90, 95% CI 0.79-1.03, P=0.1). After a median follow-up of 3.1 years (IQR 1-5.5 years), PPM placement was also not associated with a significant increase in the risk of mortality in comparison to patients who did not require PPM (HR 1.02, 95% CI 0.93-1.12, P=0.7) (Figure 1). However, it was associated with a higher risk of HF readmission in follow-up (HR 1.28, 95% CI 1.14-1.43, P<0.001) when compared to no PPM (Figure 2). Finally, PPM was not associated with any difference in risk of endocarditis in follow-up (HR 1.03, 95% CI 0.74-1.45, P=0.8).

Conclusion

Post-procedural PPM implantation is a frequent complication of TVS. While mortality is not increased, PPM placement leads to higher HF hospitalization rates. Adequate risk stratification and counseling of patients before surgery decision is essential.Survival after TVSHeart Failure after TVS
The anemia conundrum in contemporary redo cardiac surgery
Authors: Montella A P , Rubino A S , Golini Petrarcone C , Palmieri L , De Feo M , De Santo L S
Published: November 2023

Aims

Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known on its prognostic value in the setting of redo procedure. This study aimed to investigate whether preoperative anemia is an independent determinant of adverse events in this augmented risk patients subset.

Methods

A retrospective, observational, cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020 (mean age of 62 ± 12.7 years, octogenarians 5.6%, female sex 52.8%, diabetes 19.5%, chronic kidney disease 30%, urgent/emergent status 34.8%, third-time sternotomy 9.8%). The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. The prevalence of preoperative anemia (according to World Health Organization definition) and its relationships with postoperative morbidity were obtained. Selection bias was assessed with propensity-adjustment method.

Results

The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and non-anemic group emerged in the risk of postoperative stroke (0.6% vs 4.4%, p = 0.023), postoperative renal dysfunction (29,7% vs 15.6%, p = 0.001), need for prolonged ventilation (18.1% vs 7.2%, p = 0.002), high dosage inotropes (53.1% vs 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2±15.9 vs 4.3±5.4 days, p=0.003 and 18.8±17.4 vs 14.9±11.1, p=0.012 ). After propensity matching (143 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke and need for high dosage inotropes cardiac morbidity. Anemia proved also a significant predictor of acute kidney injury at univariate analysis.

Conclusions

Preoperative anemia is significantly associated with acute kidney injury, stroke and need for high dosage inotropes in patients referred for redo procedures. Further studies are warranted to determine whether preoperative low hemoglobin concentration is a marker of severity of illness or a modifiable risk factor.
Ten-year mortality after percutaneous coronary intervention, off-pump and on-pump surgery for complex coronary artery disease - who is the winner?
Authors: Kageyama S , Serruys P W , Ninomiya K , Colombo A , Van Genus R J , Milojevic M , Mack M J , Soo A , Onuma Y , Davierwala P
Published: November 2023

Aim

The very long-term mortality of off-pump and on-pump CABG versus PCI in a randomized complex coronary artery disease (CAD) population is unknown. This study aims to investigate the impact of on-pump and off-pump coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) on 10-year all-cause mortality.

Methods and results

The SYNTAXES trial randomized 1800 patients with three-vessel and/or left main CAD to PCI or CABG and assessed their survival at 10 years. In this sub-study, the hazard of mortality over 10 years was compared according to the technique of revascularization: on-pump CABG (n=725), off-pump CABG (n=128), and PCI (n=903). There was substantial inter-site variation in the use of off-pump CABG despite baseline characteristics being largely homogeneous amongst the three groups. The crude rate of mortality was significantly lower following on-pump CABG versus PCI (25.6% vs 28.4%, Hazard Ratio [HR] 0.79, 95% Confidence Interval [CI] 0.65-0.96), whilst it was comparable between off-pump CABG and PCI (28.5% vs 28.4%, HR 0.98, 95%CI 0.69-1.40). After adjusting for the nine variables included in the SYNTAX score II 2020, 10-year mortality remained significantly lower with on-pump CABG than PCI (HR 0.75 against PCI, p=0.009) (central figure).

Conclusion

In the SYNTAXES trial, 10-year mortality adjusted for major confounders was significantly lower following on-pump CABG compared to PCI, whilst off-pump CABG offered no prognostic survival benefit over PCI. Site heterogeneity in the technique used in bypass surgery has had measurable effects on treatment performance. Given its impact on outcomes, it should be pre-stratified in future studies.Central figure
Associations of long-term visit-to-visit blood pressure variability with subclinical kidney damage and albuminuria in adulthood: a 30-year prospective cohort study
Authors: Wang Y , Zhao P , Chu C , Du M F , Zhang X Y , Zou T , Hu G L , Jia H , Liao Y Y , Ma Q , Wang D , Chen F Y , Mu J J
Published: November 2023

Background

Recent evidence indicates that long-term visit-to-visit blood pressure variability (BPV) may be associated with the risk of cardiovascular disease. We therefore aimed to determine the potential associations of long-term BPV from childhood to middle age with subclinical kidney damage (SKD) and albuminuria in adulthood.

Methods

Using data from the ongoing cohort of Hanzhong Adolescent Hypertension study, which recruited children and adolescents aged 6 to 18 years at baseline, we assessed BP variability by standard deviation (SD) and average real variability (ARV) for 30 years (6 visits). Presence of SKD was defined as estimated glomerular filtration rate (eGFR) between 30 and 60 ml/min/ 1.73 m2 or elevated urinary albumin-to creatinine ratio (uACR) at least 30 mg/g. Albuminuria was defined as uACR ≥ 30 mg/g.

Results

During a follow-up of 30 years, of the 1771 participants, 204 SKD events occurred. After adjustment for demographic, clinical characteristics and mean BP during 30 years, higher SDSBP, ARVSBP, SDDBP, ARVDBP, SDMAP, ARVMAP and ARVPP were significantly associated with higher risk of SKD [ORs (95% CIs) were 1.14(1.06-1.23), 1.15(1.08-1.21), 1.12(1.06-1.17), 1.16(1.08-1.25), 1.12(1.07-1.17), 1.18(1.10-1.27) and 1.11(1.03-1.21), respectively]. When we used cumulative exposure to BP from childhood to adulthood instead of mean BP as adjustment factors, results were similar. In addition, greater long-term BPV was also associated with the risk of albuminuria [ORs (95% CIs) were 1.07(1.03-1.10) for SDSBP, 1.13(1.06-1.20) for ARVSBP, 1.11(1.06-1.17) for SDDBP, 1.14(1.06-1.23) for ARVDBP, 1.18(1.09-1.27) for ARVMAP and 1.08(1.01-1.17) for ARVPP]. Long-term BP variability for 30 years from childhood to middle age was associated with higher risk of SKD and albuminuria in adulthood, independent of mean BP or cumulative exposure to BP during follow-up.The example of SBP across 6 visits
Profile of miRNAs expression on serum of hypertensive patients with chronic kidney disease
Authors: Nadruz W , Minin E O Z , Schreiber R , Lopes E C P , Paim L R , Carvalho-Romano L F R S , Marques E R , Vegian C F L , Pio-Magalhaes J A , Velloso L A , Coelho-Filho O R , Sposito A C
Published: November 2023

Background/Introduction

Arterial hypertension is a major risk factor for chronic kidney disease (CKD). MicroRNAs (miRNAs) are a group of small non-coding RNA molecules that pair with messenger RNA sequences of target genes, causing transcriptional repression for protein synthesis. Several studies suggest that the aberrant expression of miRNAs may be involved in the development of cardiovascular diseases, however little is known about the role of miRNA expression in the development of CKD in hypertensive patients.

Purpose

The present study evaluated the differential expression of miRNAs in the serum of hypertensive patients comparing individuals with CKD with those without CKD.

Methods

We evaluated the clinical and laboratory characteristics of 42 hypertensive patients followed at a tertiary university hospital and determined the serum expression of 754 miRNAs using an Array system. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR): group 1 (normal eGFR [≥60 mL/min/m2]) and group 2 (altered eGFR [<60 mL/min/m2]). Differences in miRNAs expression between individuals with and without CKD were assessed by Student's t test and adjusted logistic regression analysis. P value<0.05 was considered statistically significant.

Results

There were 33 patients in group 1and 9 patients in group 2. The groups had statistically similar prevalence of women and mean values of age and body mass index (BMI) (age=57±10 years, 66% women, BMI=27.1±4.1 kg/m2 in group 1; age=58±8 years, 42% Women, BMI=30.1±4.6 kg/m2). Among the studied miRNAs, 9 showed differential expression (Figure 1), 8 of which were upregulated (miR-125a, miR-215, miR-146b, miR-127, miR-339-5p, miR-18a, miR-30b and miR-199a) and one was downregulated (miR-451) in hypertensive patients with low eGFR when compared to hypertensive patients with normal eGFR. Logistic regression analysis adjusted for systolic blood pressure, diabetes mellitus and antihypertensive medications use showed that miR-125a, miR-146b and miR-451 remained differently expressed between the studied groups.

Conclusions

Our analysis showed that CKD is accompanied by distinct expression of circulating miRNAs in individuals with hypertension, especially miR-125a, miR-146b and miR-451, suggesting that these miRNAs might play a role in CKD and could be potential biomarkers of development of this disease in hypertensive patients.Figure 1
Severity of obstructive sleep apnea is associated with left ventricular abnormality in patients with hypertension in the young
Authors: Silaruks S , Wongwattanakij S , Khamsai S , Sawanyawisuth K
Published: November 2023

Background

Hypertension in the young is defined as the presence of hypertension in individuals with an age of onset before 35 years. A previous study found that obstructive sleep apnea (OSA) may be a contributing factor of hypertension in the young up to 90% if other causes of secondary hypertension were excluded. Left ventricular (LV) abnormality is a marker of future cardiovascular consequences. There is limited data on risk factors of LV abnormality in patients with hypertension in the young with OSA.

Objectives

We aim to evaluate risk factors of LV abnormality in patients with hypertension in the young.

Methods

This study was a retrospective study. The eligible patients were adult patients who diagnosed as hypertension at age before 35 years and evaluated for echocardiogram. Those with causes of secondary hypertension or pregnant women were excluded. The study period was between October 2017 and January 2021. OSA was categorized as mild, moderate, and severe by an apnea-hypopnea index of 5-14.9, 15-29.9, and 30 or over times/hour. LV abnormality defined by relative wall thickness (RWT) over 0.42 mm. by a Doppler echocardiography. Other echocardiographic findings were also reported including left ventricular mass (LVM), left ventricular mass index (LVMI), and ejection fraction (EF). Differences of variables among severities of OSA were computed by a one-way ANOVA, while differences of proportions between groups were calculated by Chi square test. Multivariable analyses, linear and logistic regressions were performed to find the association between OSA and LV abnormality.

Results

There were 52 patients who met the study criteria. Mild OSA group had lower LVM, LVMI, and RWT than moderate OSA and severe OSA group (172.98 vs 232.16 vs 177.78 g; p 0.036 for LVMI; 83.03 vs 107.87 vs 84.99 g/m2; p 0.013 for LVMI; and 0.38 vs 0.45 vs 0.47 mm; p 0.010 for RWT). There was no significant difference in EF among the three groups. Severe OSA was found have an increased association with the presence of LV abnormality compared to patients with mild to moderate OSA (OR 3.28, 95% CI 0.96-12.5), however this was not statistically significant (p-value 0.07) Patients with severe OSA was found to have a correlation with RWT measurements of greater than 0.42 (correlation co-efficient 0.2, 95% CI 0.01-0.39, p-value 0.04).

Conclusion

Hypertensive patients under the age of 35 with severe OSA have a higher proportion of LV abnormality compared to mild and moderate OSA. Severe OSA was found to be correlated to RWT measurements of greater than 0.42. This finding might be one of prognostic indicators of the future adverse cardiovascular events and be required proper management. However, this relationship should be needed further study.
Association of hydrochlorothiazide treatment compared to alternative diuretics with overall and skin cancer risk: a propensity-matched cohort study
Authors: Goetzinger F , Wilke T , Hardtstock F , Krieger J , Maywald U , Kunz M , Lauder L , Schulz M , Mahfoud F , Boehm M
Published: November 2023

Introduction

Hydrochlorothiazide (HCT) has been suggested to induce photosensitivity, thereby increasing the incidence of skin cancers. After a pharmacovigilance alert, HCT was frequently withdrawn or substituted by other diuretics. The aim of this study was to compare the association of exposure to HCT with cancer risk versus alternative diuretics.

Methods

A retrospective cohort study was conducted based on data from the AOK PLUS, a large German statutory health insurance fund. Patients with HCT treatment were propensity score matched (PSM) to patients using non-HCT diuretics. Incidence of cancer of any kind and, specifically, skin cancer was assessed in both groups. Time to incident cancer diagnosis was evaluated and compared between the groups.

Results

A total of 199,708 patients were included in the final analysis (n=76,855 in the HCT-group; n=122,853 in the non-HCT-diuretics group). After PSM, 122,554 patients remained in the sample (n=61,277 for both groups, of which >96% had hypertension, mean age 73 years, 61% female). HCT treatment was associated with a lower incidence of cancer of any kind, compared with non-HCT diuretics (Incidence rate ratio (IRR) per 100 patient years 0.84 95% Confidence interval (CI): 0.82-0.87). HCT treatment was associated with a small albeit significantly higher IRR of skin cancer (1.14 95% CI: 1.06-1.24) with significant variances over time. Although numerically higher, the difference accounts to only 0.05 more skin cancer diagnoses in 100 patient years.

Conclusions

HCT treatment compared to alternative diuretics was associated with a lower all-cancer risk and was not associated with a meaningful increase in skin cancer risk in a large German population. Nevertheless, advice for skin protection is warranted in all patients taking thiazide or thiazide-like diuretics.HR of overall and skin cancerTime to cancer diagnosis - time to event
Association between hepatic steatosis and blood pressure: analysis of the NHANES 2017- 2020
Authors: Wattanachayakul P , Rujirachun P , Phichitnitikorn P , Lopimpisuth C , Lalitnithi P , Tantisattamo E
Published: November 2023

Background

Recent studies have shown that hepatic steatosis is associated with increased risk of incidence hypertension and cardiovascular events, whether the association between hepatic steatosis stratified by controlled attenuation parameter (CAP) grading and blood pressure remains unclear.

Methods

We examined a cross-sectional study from the National Health and Nutrition Examination Survey (NHANES) 2017-2020 that included participants ≥18 years old. CAP, the indicator for hepatic steatosis, was obtained from Fibroscan™ and was stratified into four grading groups, including absent (S0): CAP <238 dB/m, mild (S1): 238-260 dB/m, moderate (S2): 260-290 dB/m, severe (S3): 290-400 dB/m. We used multiple linear regression to examine the association between the degree of hepatic steatosis and blood pressure.

Results

Of 9,698 patients with Fibroscan™ results, the mean age was 44+/-20 years old, and 49.9% were female. We observed that White individuals accounted for 33.7%, followed by Black (26.3%), Mexican American (12.5%), Asians (11.7%), Hispanic (10.1%), and others (5.6%). The mean SBP and DBP were 121±18 and 72±11 mmHg, respectively. Participants with S1, S2, and S3 steatosis had significantly higher SBP values of 4.7, 6.1, and 8.1 mmHg and DBP values of 3.4, 4.8, and 7.1 mmHg, respectively, compared with those without steatosis (S0) (β SBP S1: 4.7, 95%CI 3.4, 5.9; S2: 6.1, 95%CI 5.0, 7.3; S3: 8.1, 95%CI 7.2, 9.0 and β DBP S1: 3.4, 95%CI 2.7, 4.2; S2: 4.8, 95%CI 4.1, 5.5; S3: 7.1, 95%CI 6.6, 7.7). After adjusting for age, gender, race, BMI, smoking status, diabetic status, and serum creatinine, a positive correlation between hepatic steatosis and blood pressure was still observed. Specifically, there was a 1.7, 1.6, and 2.7 mmHg statistically increase in SBP values and a 1.8, 2.3, and 3.9 mmHg increase in DBP values among participants with S1, S2, and S3 steatosis, respectively. (β SBP S1: 1.7, 95%CI 0.5, 3.0; S2: 1.6, 95%CI 0.4, 2.8; S3: 2.7, 95%CI 1.6, 3.8 and β DBP S1: 1.8, 95%CI 0.9, 2.7; S2: 2.3, 95%CI 1.5, 3.1; S3: 3.9, 95%CI 3.2, 4.6).

Conclusion

The degree of hepatic steatosis is positively associated with blood pressure values. However, further studies are required to demonstrate the long-term clinical outcomes of this observed relationship.
Blood pressure variability as a prognostic factor in patients with acute myocardial infarction. Data from the ACS-BP study
Authors: Konstantinou K , Koumeli A , Apostolos A , Dimitriadis K , Sakalidis A , Papelis K , Fragoulis C , Mantzouranis M , Vaina S , Tsioufis K
Published: November 2023

Background

Blood pressure variability (BPV) is considered a modern cardiovascular risk factor. There are many data relating BPV to mortality, risk of stroke and target organs damage mainly in hypertensive patients.

Purpose

The purpose of the present study is to investigate whether BPV in patients with acute myocardial infarction (AMI) who all underwent percutaneous coronary intervention (PCI) was associated with short and and/or long-term cardiovascular mortality.

Methods

A total of 402 patients (67.2% male, mean age: 62.7 years, 70.1% hypertensive, 46.9% STEMI) underwent 24-ambulatory blood pressure monitoring (ABPM) during hospitalization for MI. Both during their hospitalization and in a period of 6 and 12 months, they were reviewed to assess cardiovascular mortality. BPV extracted from the ABPM recordings using the coefficient of variation (CV) of systolic (SBP) and diastolic (DBP) blood pressure. Patients were classified into 4 quartile-intervals based on CV.

Results

After full adjustment of data (age, sex, type of ACS, BP, Diabetes, Chronic Kidney Disease <3rd stage) patients in the quartile with the highest CV of SBP (Q4 n= 92) have a higher in-hospital (OR = 2, 07, 95% CI: 1.02-2.99, p=0.001), 6-month (OR = 1.94, 95% CI: 1.22– 3.170, p<0.001) and long-term (1-year follow-up) mortality (OR = 1.81, 95% CI: 1.08-2.77, p=0.03) compared to patients presenting lower BPV and classified in the corresponding quartiles (Q1-Q3, n=310). Corresponding results were obtained from the control of the CV of DBP.

Conclusions

In the context of patients admitted for AMI and underwent PCI, higher post-infarction BPV of both SBP and DBP expose these patients to a higher risk of short - and long-term mortality. Consequently, monitoring of BPV in patients with AMI may identify patients with potential hemodynamic instability and contribute to early clinical decision-making.
Estimation of blood pressure levels in healthy newborns
Authors: Oliveira Blackman A , Oliveira G S O , Melo J O M , Bernardes M P B , Piantino V P , Bicudo G B , Haubert N H , Moura M D R M , Machado L B O M
Published: November 2023

Background

Adequate blood pressure (BP) parameters in newborns are essential indicators of clinical stability for neonates. Despite its importance, the BP measurement in the delivery room are mainly collected from sick newborns in neonatal units. Current normative values are pivotal.

Methods

A prospective observational [AOB1] study selected 1167 healthy-term newborns in a private hospital [AOB2] in Brazil from August 2019 to September 2022. The Ethics Committee approved the research The gestational age considered full-term was between 37 and 42 weeks. Blood pressures were measured in the delivery room within the first two hours of life using an MX-600 GE automatic oscillometer device, following the hospital's standardized protocol.

Results

The mean systolic blood pressure (SBP) values were 68,0 ± 12.1 mmHg, diastolic blood pressure (DBP) 49,0 ± 12.3 mmHg. The 5th percentile of SBP corresponded to 48 mmHg and DBP to 32 mmHg, while the 95th percentile was 90 mmHg of SBP and 73 of DBP mmHg.[AOB3]

Conclusion

This study provided current blood pressure values from healthy neonates along with systolic, diastolic, and mean blood pressure ranges. These parameters serve as a valuable reference for dealing with the management of heathy terms newborns.Systolic BP Diastolic BP Mean pressure
Estimation of antihypertensive effect after initiating continuous positive airway pressure treatment in Japanese patients with sleep disordered breathing
Authors: Takama N , Ueba S , Isobe I , Sano Y , Amanai S , Kuno T , Ishibashi Y , Kato T , Ishii H
Published: November 2023

Introduction

It is true that patients with cardiovascular diseases including hypertension have already suffered from sleep disordered breathing (SDB). Furthermore, Continuous Positive Airway Pressure (CPAP) treatment shows antihypertensive effect by improving sympathetic nervous activity. On the other hand, we reported that CPAP treatment had a beneficial effect on hypertension, but 70% patients still remain inadequately treated. As a result, we need the strict blood pressure follow up for patient with SDB after initiating CPAP treatment at ESC congress 2022.

Purpose

Our aim in this study is to estimate the antihypertensive effect after initiating CPAP treatment, also estimate the differences of CPAP effect by focusing on Japanese non-obese body.

Methods

All patients were conducted full night polysomnography. One-hundred eighty patients showed obstructive SDB {apnea hypopnea index (AHI) >20/hour}, and CPAP treatment were initiated. We divided into three groups by using body mass index (BMI). Group A showed BMI < 25 kg/m2 (n = 59). Group B showed 25 ≦BMI < 30 kg/m2 (n = 68), and Group C showed 30 ≦ BMI kg/m2 (n = 53). If patients had already taken blood pressure-lowering agents, they had to continue blood pressure-lowering agents without changing other agents or dose intensification. According to Japanese society of hypertension guidelines for the managements of hypertension 2019 (JSH2019), we estimated the improvement of blood pressure to assess effectiveness of CPAP treatment after six-month follow up.

Results

The study group consisted of 180 SDB patients (152 males, 28 females). The mean age was 53 ± 12 years. Figure 1 showed polysomnographic data before initiating CPAP treatment. Group A was significantly lower apnea hypopnea index (AHI) than in Group B and C (p < 0.0001). Figure 2 showed the changes of blood pressure after initiating CPAP treatment (six-month). There was no significant difference respect to changes of systolic blood pressure (ΔSBP), but Group A showed the tendency for worsening SBP compared with other groups.

Conclusions

We could estimate that CPAP treatment had only limited effects in antihypertensive effect for Japanese patients, who especially had non-obese body and lower AHI level. We need the strict blood pressure follow up for patient with SDB after initiating CPAP treatment.Figure
Adherence to ESC guidelines for antihypertensive drug therapy: real-world survey from an EU country
Authors: Selvek M , Vallova K , Muzik R , Tulejova H , Istokovicova P , Tkac I , Hatala R
Published: November 2023

Background

Achieving optimal BP control in hypertensive patients (pts) remains a continuous challenge worldwide. Multiple factors are responsible for the low rates of BP control with suboptimal drug choice playing a key role. Practice guidelines should serve as evidence based foundation for optimal antihypertensive drug therapy but their impact in the real-world is variable.

Purpose

This retrospective study aimed: 1. To assess the prescription pattern of main classes of antihypertensive drugs and its association with comorbidities. 2. To compare prescription before and after the publication of the 2018 ESC/ESH guidelines for management of arterial hypertension, translated into local language (in 2019). Thus, prescriptions in the years 2018 and 2020 were compared. Dual combination of ACEi/ARB + CCB/thiazide-like diuretics (THI) or triple combination of ACEi/ARB + CBB + THI were considered as guidelines directed first line drugs (FLAD) i.e. adherence to guideline. Spironolactone (MRA) was considered as recommended drug for patients requiring ≥4 drugs.

Methods

We analysed prescribed drug therapy in a large patient cohort from the years 2018 and 2020 with 264 237 and 272 934 hypertensive pts, respectively. Pts were considered hypertensive after meeting at least one of two criteria: 1. Having been prescribed ≥ 121 standard drug doses of antihypertensive drugs in the year before the studied period. 2. Having at least 2 medical visits with the diagnosis of hypertension within 2 years before the studied period. Following comorbidities were considered as potential modifiers of drug therapy: ischemic heart disease (IHD), chronic heart failure (CHF), atrial fibrillation (AF), diabetes (DM) and chronic kidney disease (CKD).

Results

Overall, first line therapy was prescribed to 21.5% and 22.4% of pts in the year 2018 and 2020, respectively (p<0.0001). In pts taking ≥3 drugs 30.4% did not use THI, in those taking ≥4 drugs only 10.7% used spironolactone (MRA). Selected results are in the attached table.

Conclusion

Adherence to guideline recommended FLAD in this large survey improved but remained low during the first year after publishing ESC 2018 guidelines: only 22.4% of pts received FLAD in this cohort where 58.6% were free of comorbidities. In pts with AF, the use of FLAD was the lowest with 7.3%. Preferred use of BB and low use of THI and MRA were mostly behind this trend. BB (alone or in combination) were the most prescribed drug group – to 57.3% of pts both in 2018 and 2020. Their prescription was high in all pts with comorbidities, notably worrisome for diabetic pts (66.0%). Continuous efforts to improve dissemination of knowledge of FLAD according to guidelines appear mandatory.Attached table
Immediate post-ablation renal nerve stimulation predicted blood pressure reductions 6 months following renal denervation
Authors: Wang T D , Huang H C
Published: November 2023

Background

Renal denervation (RDN) has been recognized as an alternative treatment strategy for blood pressure (BP) control. There is no consensus on which intra-procedural parameters could reliably predict BP-lowering responses following RDN, which usually occur months later.

Purpose

This study aimed to evaluate systolic BP (SBP) changes induced by renal nerve stimulation (RNS) during RDN and its associations with BP-lowering responses 6 months following RDN.

Methods

Seventeen patients with hypertension who underwent radiofrequency RDN between February 2019 and March 2021 were prospectively included. RNS was performed immediately before and after RDN in bilateral proximal and distal main renal arteries under general anesthesia. The responder was defined as 24-hour SBP reduction of ≥10 mmHg 6 months following RDN.

Results

RNS-induced SBP changes significantly decreased after RDN in all 4 sites of bilateral main renal arteries (all p<0.05). The mean 24-hour SBP were 144±16 mmHg and 131±15 mmHg at baseline and 6 months after RDN, respectively. Nine (53%) patients were responders. Compared to non-responders, the responders had significantly lower RNS-induced SBP changes in proximal main renal arteries immediately after RDN (right, 15.3±9.6 mmHg vs. 31.6±9.6 mmHg, p=0.005; left, 11.6±6.9 mmHg vs. 27.9±10.2 mmHg, p=0.002). All 7 patients with RNS-induced SBP increases of <20 mmHg after RDN in bilateral proximal main renal arteries were responders.

Conclusions

An RNS-induced SBP increase of <20 mmHg in bilateral proximal main renal arteries immediately after RDN was associated with significant 24-hour SBP reductions 6 months following RDN. Whether RNS-induced SBP changes could predict or even guide RDN strategies awaits further verifications.
Central systolic blood pressure as a risk for the accelerated progression of arterial stiffness
Authors: Takahashi T , Shina K , Fujii M , Nakno H , Tomiyama H , Chikamori T
Published: November 2023

In the arterial tree, the systolic blood pressure (SBP) exhibits a pressure gradient from central to peripheral and is higher in the periphery because of pressure wave reflection.

However, this gradient is attenuated with the elevation of central SBP (cSBP) in case with abnormal pressure wave reflection in arterial tree. It remains unclear whether increase of the cSBP might be an independent risk for the accelerated progression of arterial stiffness.

Using the latent growth curve model (LGCM) analysis, this prospective observational study was conducted to examine whether elevation of the cSBP might be an independent risk for the accelerated progression of arterial stiffness in middle-aged Japanese men.In this 9-year prospective observational study, 3862 middle-aged Japanese men (42 ± 9 years old) without cerebrocardiovascular disease at the study baseline underwent annual measurements of the brachial-ankle pulse wave velocity (baPWV), and cSBP, estimated by radial pressure wave analysis as the second peak of radial pressure wave form (SBP2).

During the follow-up period (6.4 ± 2.5), significant increases of baPWV and SBP2 were observed in all subjects. Analysis using the LGCM confirmed that the SBP2, a maker of cSBP (B=0.260, P < 0.001) was significant determinants of the slope of annual changes of baPWV during the study period.

Our finding suggests that elevated cSBP is an independent risk for the accelerated progression of arterial stiffness in middle-aged Japanese men.
Genetic predisposition to high blood pressure and out-of-office hypertension: insights from a population sample in Liechtenstein
Authors: Narula S , Mohammadi-Shemirani P M , Aeschbacher S , Chong M R , Le A , Theriault S , Grossman K , Pare G , Risch L , Risch M , Conen D
Published: November 2023

Genetic predisposition is a risk factor for office hypertension. We tested whether genetic background could identify individuals with ambulatory daytime hypertension in a sample of white Europeans from Liechtenstein. We evaluated two measures of predisposition to hypertension: family history and polygenic risk scores (PRS). Our analytic sample contained 1444 participants aged 25 to 41. 12% of participants had office hypertension, while 37% had out-of-office hypertension. The correlation between blood pressure PRS and family history of hypertension was low (R2 = 4.96x10-3), but both were strongly associated with ambulatory blood pressure (2.2 mmHg per 1 SD increase [95% CI: 1.6, 2.7] & 2.4 mmHg increase with positive family history [95% CI: 1.3, 3.4], respectively). PRS provides incremental improvement in predicting ambulatory systolic blood pressure beyond a validated blood pressure prediction algorithm (ΔAIC = -33), whereas family history does not (ΔAIC = 1). The difference in performance between a baseline algorithm for identifying ambulatory systolic daytime hypertension (positive likelihood ratio of 6.87 [95% CI: 5.56, 8.49]; negative likelihood ratio of 0.45 [95% CI: 0.39, 0.51]) and the same model with PRS integrated (positive likelihood ratio of 7.69 [95% CI: 6.18, 9.57]; negative likelihood ratio of 0.43 [95% CI: 0.37, 0.49]) was modest. In conclusion, in a European sample from Liechtenstein, PRS and family history represent distinct constructs associated with ambulatory blood pressure. Unlike family history, polygenic risk scores provide incremental information identifying individuals with ambulatory hypertension. However, these gains are modest and warrant further development to improve performance at the point-of-care.
Different systolic blood pressure targets and outcomes: a systematic review and meta-analysis of randomized trials
Authors: Manta E , Thomopoulos C , Konstantinidis D , Tatakis F , Tsioufis P , Tsoumpou I , Iliakis P , Siafi E , Drogkaris S , Andrikou I , Zamanis I , Tsioufis K
Published: November 2023

Background

Blood pressure (BP)-lowering is accompanied by a reduction of fatal or nonfatal outcomes in hypertensive patients. However, the achieved systolic BP target associated with higher outcome benefits remains unsettled.

Purpose

The aim was to determine the effects of BP-lowering treatment on outcome incidence at different achieved systolic BP strata.

Methods

A systematic review was conducted to identify randomized trials in electronic databases (Pubmed and CENTRAL, search between 1966 and 11/2022) for the effect of BP-lowering treatment against placebo or less aggressive treatment on the composite outcome of major cardiovascular (CV) events (i.e., myocardial infarction, stroke, and heart failure). Selected studies reported outcomes in patients with or without a history of previous CV disease. Studies were categorized according to the achieved level of systolic BP in the active or more actively treated group. Risk ratios (RR) were calculated with their 95% confidence interval (CI) under the random-effects model.

Results

We included 51 primary prevention studies (i.e., 16 trials in which systolic BP was lowered to values no less than 140 mmHg, n=36,189 patients; 22 trials with achieved systolic BP between 130 and 140 mmHg, n=84,952; and 13 trials with achieved systolic BP less than 130 mmHg, n=41,660) and 44 secondary prevention studies (i.e., 11 trials in which systolic BP was lowered to values no less than 140 mmHg, n=12,518 patients; 19 trials with achieved systolic BP between 130 and 140 mmHg, n=71,449; and 14 trials with achieved systolic BP less than 130 mmHg, n=39,085). For a standard systolic/diastolic BP reduction of 10/5 mmHg, the relative risk of the composite outcome was reduced in all achieved systolic BP strata, without a significant trend from higher to lower systolic BP targets, in both prevention groups. In addition, there was no difference in the absolute risk reduction of the combined outcome, as calculated by the number of events prevented in every 1000 patients treated for 5 years, between the systolic BP targets in each prevention group. However, only in primary prevention did a significant negative incremental trend from higher to lower systolic BP targets for the residual risk of the combined outcome become apparent.

Conclusions

Although antihypertensive treatment provides CV protection to all hypertensive patients, the lower systolic BP target is associated not only with outcome benefits but also with a lower rate of residual risk in primary prevention only.
Early lowering of LDL-C is a more cost-effective strategy than lowering LDL-C later in life: a cost-effectiveness analysis using Mendelian Randomisation
Authors: Morton J , Marquina C , Lloyd M , Watts G F , Zoungas S , Liew D , Ademi Z
Published: November 2023

Background

Early control of low-density lipoprotein-cholesterol (LDL-C) is an effective way to reduce the risk of coronary heart disease (CHD). However, a comprehensive assessment of cost-effectiveness of different lipid-lowering strategies (LLS) for primary prevention of CHD across different ages is lacking.

Objective

To assess the cost-effectiveness of four different LLS initiated at ages 30, 40, 50, and 60 years on the primary prevention of CHD from the UK National Health Service perspective.

Design, setting and participants: We developed a microsimulation model, based on the causal effect of LDL-C on myocardial infarction (MI) or coronary death derived from Mendelian randomisation, comparing initiation of an LLS to current standard of care (control). Data were primarily drawn from 458,727 participants of the UK Biobank study with available data on date of birth, LDL-C, and who were free of MI at first assessment (between 2006 and 2010), with follow-up until 2021.

Interventions: The four LLS were: 1) low/moderate intensity statins; 2) high intensity statins; 3) low/moderate intensity statins and ezetimibe; and 4) inclisiran.

Main outcomes measures: The incremental cost-effectiveness ratio (ICER), defined as the incremental healthcare costs divided by the incremental quality-adjusted life years (QALYs) for each LLS compared to control, with 3.5% annual discounting.

Results

The most effective intervention, low/moderate intensity statins and ezetimibe, was projected to lead to a gain in QALYs of 0.068 per person at age 30 and 0.026 at age 60 compared to control (Figure). The age of intervention with the lowest ICER was age 40, with ICERs of £2,524 (95% uncertainty interval: 1,383, 3,796), £4,466 (3,163, 6,134) £11,118 (8,632, 14,177), and £1,405,123 (1,117,1113, 1,789,012) per QALY gained for strategies 1-4 from age 40 years, respectively (Table).

Conclusions

LDL-C lowering from early ages is a more cost-effective strategy than late intervention. The approach to primary prevention of CHD may improve with a shift to early and sustained lowering of LDL-C.

Figure – Results of 1,000 probabilistic sensitivity analyses presented in a common cost-effectiveness plane, by age of intervention. Inclisiran excluded due to very high costs. Solid line: £20,000 per quality-adjusted life year (QALY) willingness-to-pay threshold; dashed line: £30,000 per QALY willingness-to-pay threshold. Any dot to the right of these lines is considered cost-effective.

Table – Summary of LLS interventions by age of intervention.

Abbreviations: MI – Myocardial infarction; YLL – Years of life lived; QALYs – Quality-adjusted life-years; ICER – Incremental cost-effectiveness ratio.FigureTable
Social, behavioral, and metabolic risk factors for racial disparities in cardiovascular disease mortality in US adults
Authors: He J , Bundy J D , Geng S , Tian L , He H , Mills K T , Chen J I N G
Published: November 2023

Background

Cardiovascular disease (CVD) mortality is persistently higher in the Black population than in other race and ethnicity groups in the US.

Purpose

To determine whether social, behavioral, and metabolic risk factors mediate racial disparities in CVD mortality and to assess the contribution of these risk factors to CVD mortality in the US general population.

Methods

A nationally representative sample of 50,808 individuals aged ≥20 years from National Health and Nutrition Examination Surveys (NHANES) 1999-2018 were included in the analysis. Data on social, behavioral, and metabolic factors were collected in each NHANES survey using standard methods. CVD deaths were ascertained from linkage to the National Death Index with follow-up through 2019.

Results

Over an average of 9.4 years of follow-up, 2,598 CVD deaths were confirmed. In a multivariable Cox regression model stratified by NHANES cycle and adjusted for age, sex, race, and social, behavioral, and metabolic risk factors simultaneously, individuals who were unemployed, had a lower family income, did not own a home, were not married nor living with a partner, were current smokers, reported no leisure-time physical activity, slept <6 or >8 hours/day, had obesity, hypertension, or diabetes, or had an albumin-to-creatinine ratio ≥30 mg/g or estimated-glomerular filtration rate <60 ml/min/1.73 m2 were at significantly higher risk for CVD mortality. After adjusting for these risk factors, hazard ratios (95% CI) of CVD mortality for Black individuals compared to White individuals decreased from 1.54 (1.34-1.77) to 0.86 (0.75-1.00). Social risk factors explained 72.9% Black-White differences in CVD mortality in a multivariable mediation analysis. The population attributable fractions (95% CI) for the top five risk factors for CVD mortality were 12.5% (5.6-19.3%) for hypertension, 10.6% (6.9-14.3%) for albuminuria, 9.4% (5.3-13.6) for physical inactivity, 9.1% (4.6-13.7%) for family income-to-poverty ratio <300%, and 7.2% (4.5-9.9%) for estimated-glomerular filtration rate <60 ml/min/1.73 m2 in the US general population.

Conclusion

Social, behavioral, and metabolic risk factors fully explained the Black-White difference in CVD mortality. Hypertension, albuminuria, physical inactivity, low family income, and reduced kidney function are leading risk factors for CVD mortality in the US population.
Kidney function and future risk of atherosclerotic cardiovascular disease: a study from, approximately half million adults
Authors: Rana J , Liu J , Moffet H , Gulati M , Virani S , Karter A , Sidney S
Published: November 2023

Background

Data are lacking regarding contribution of kidney function towards atherosclerotic cardiovascular diseases (ASCVD) in young to middle aged adults.

Purpose

To evaluate the impact of kidney function on future risk of ASCVD in a large, young contemporary population without prior ASCVD.

Methods

This observational cohort study included young to middle aged adults (ages 30-55 years) without established ASCVD (as of January 1, 2006) who were members of an integrated healthcare delivery system in Northern California. Adjusted multivariate models (age, sex, race, diabetes, hypertension, HDL-C, LDL-C, total cholesterol, smoking, albuminuria) were specified to estimate risk ratios (RRs) for incident ASCVD events by kidney function (eGFR mL/min/1.732). Incident ASCVD events were defined as a composite of nonfatal myocardial infarction, ischemic stroke, or coronary heart disease death through December 31, 2020.

Results

A total of 426,735 individuals met the selection criteria. Mean age was 45.4 (±7.0) years. Fifty-five percent were women, and the median follow-up was 12.7 (IQR=11) years. In fully adjusted models, risk of future ASCVD, compared to patients with eGFR ≥ 60 was 1.7 (95% CI 1.5-1.9) for eGFR 30-59 RR and RR of 2.2 (95% CI 1.8- 2.7) for eGFR < 30. The kidney function-ASCVD associations were similar by sex for eGFR 30-59, but risks were accentuated among women with eGFR<30 (figure).

Conclusions

There was increased risk of future ASCVD with worsening kidney function. This risk was more pronounced among women. Using eGFR as part of risk assessment can inform targeting early interventions to prevent both kidney disease and subsequent ASCVD, especially in the era where effective pharmacotherapy such as SGLT2-Inhibitors have demonstrated renal and cardioprotective effects in high-risk populations.
Genetic risk, modifiable risk factors, and atrial fibrillation in the Danish diet, cancer, and health cohort
Authors: Frederiksen T C , Christiansen M K , Benjamin E J , Overvad K , Olsen A , Grarup N , Andersen M K , Hansen T , Jensen H K , Dahm C C
Published: November 2023

Background

The etiology of AF is multifactorial. Genetic susceptibility and lifestyle contribute to atrial fibrillation (AF) risk.(1,2) However, the relationship between combined genetic predisposition and lifestyle risk factors on AF risk is unclear.

Purpose

We aimed to assess a possible interaction between modifiable risk factors and genetics on AF risk.

Methods

We included AF cases and a randomly drawn subcohort of 4,040 participants from the Danish Diet, Cancer, and Health study. Modifiable risk factors were assessed including smoking, body mass index, physical activity, diet, alcohol consumption, total cholesterol, and blood pressure. Based on cumulation of risk factors, a risk factor profile was determined for all participants and categorized as poor, intermediate, and ideal. Based on DNA sequence polymorphisms, we calculated a genetic risk score for AF, and categorized participants as having a low (quintile 1), intermediate (quintile 2-4) or high (quintile 5) genetic risk. Diagnoses of AF and/or atrial flutter were obtained from the Danish National Patient Register. We used weighted Cox proportional hazards regression to assess hazard ratios of AF.

Results

3,094 AF cases occurred during a median follow-up of 12.9 years. Median age at baseline in the subcohort was 55 years (25th-75th percentile 52-60) and 2,092 (55%) were women. Participants at intermediate and high genetic risk had higher rates of AF compared with those at low genetic risk. Likewise, intermediate, and poor risk factor profiles were associated with higher rates of AF compared with those having ideal risk factor profiles. Weighted cumulative incidence proportions and hazard ratios of AF according to genetic risk and modifiable risk factors are shown in Figure 1. Within each category of genetic risk, incidence rates per 1,000 person-years were gradually higher with worse modifiable risk factor profiles. (Figure 2). For participants with high genetic risk, the incidence rates of AF per 1,000 person years were 5.0 (95% CI 3.4-7.3) for ideal, 6.6 (95% CI 5.4-8.1) for intermediate, and 10.4 (95% CI 9.2-11.8) for poor risk factor profiles. On an additive scale, there was a statistically significant interaction between genetic risk and modifiable risk factors (relative excess risk due to interaction=0.86 (95% 0.68-1.03, p<0.001).

Conclusions

A genetic risk score and modifiable risk factors were each associated with AF risk. The rates of AF increased gradually with cumulation of modifiable risk factors within each category of the genetic risk score, and we found an additive interaction between genetic risk and the modifiable risk factor profile. This underlines the importance of risk factor modification in primary AF prevention.Figure 1Figure 2