Showing papers by "Giuseppe Mancia published in 2016"

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Abstract: Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Unattended Blood Pressure Measurements in the Systolic Blood Pressure Intervention Trial: Implications for Entry and Achieved Blood Pressure Values Compared With Other Trials

Abstract: The Systolic Blood Pressure Intervention Trial (SPRINT) enrolled 9361 participants aged ≥50 years in ≈100 expert medical centers and clinical practices throughout the United States.1 SPRINT excluded patients with diabetes mellitus and stroke survivors since previous clinical trials included those populations.2,3 Between 2010 and 2013, the SPRINT investigators randomly allocated the study participants into a standard treatment group receiving an average of 2 different blood pressure (BP) medications to achieve a systolic BP (SBP) target <140 mm Hg and into an intensive treatment group receiving an average of 3 BP medications to achieve a SBP target <120 mm Hg. The Director of the National Heart, Lung, and Blood Institute stopped SPRINT early because of a positive effect. The significant preliminary results of SPRINT were announced on September 11, 20154 and the study results were quickly and favorably commented on by the New York Times5 and the Washington Post.6 The target SBP <120 mm Hg had reduced rates of the composite primary outcome that included myocardial infarction (MI), other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes by 25% and the risk of death from all causes by 27%, when compared with the target SBP of <140 mm Hg. The primary results of the trial were presented at the Scientific Sessions of the American Heart Association in Orlando on November 9, 2015 and published on the same day.7 The SPRINT study was published with an accompanying statement from the Editor of New England Journal of Medicine 8 saying that “This clinical trial will change practice, and we are proud to publish it and to defend the importance of the expedited peer-review and publication process that it has undergone. The report is now in the public domain, and the investigators’ data …

Long-term Benefits of Intensive Glucose Control for Preventing End-Stage Kidney Disease: ADVANCE-ON

Abstract: OBJECTIVE The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial reported that intensive glucose control prevents end-stage kidney disease (ESKD) in patients with type 2 diabetes, but uncertainty about the balance between risks and benefits exists. Here, we examine the long-term effects of intensive glucose control on risk of ESKD and other outcomes. RESEARCH DESIGN AND METHODS Survivors, previously randomized to intensive or standard glucose control, were invited to participate in post-trial follow-up. ESKD, defined as the need for dialysis or kidney transplantation, or death due to kidney disease, was documented overall and by baseline CKD stage, along with hypoglycemic episodes, major cardiovascular events, and death from other causes. RESULTS A total of 8,494 ADVANCE participants were followed for a median of 5.4 additional years. In-trial HbA 1c differences disappeared by the first post-trial visit. The in-trial reductions in the risk of ESKD (7 vs. 20 events, hazard ratio [HR] 0.35, P = 0.02) persisted after 9.9 years of overall follow-up (29 vs. 53 events, HR 0.54, P P = 0.04) and at lower baseline systolic blood pressure levels ( P = 0.01). The effects of glucose lowering on the risks of death, cardiovascular death, or major cardiovascular events did not differ by levels of kidney function ( P > 0.26). CONCLUSIONS Intensive glucose control was associated with a long-term reduction in ESKD, without evidence of any increased risk of cardiovascular events or death. These benefits were greater with preserved kidney function and with well-controlled blood pressure.

An Expert Opinion From the European Society of Hypertension-European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects.

Abstract: Two years after the publication of the 2013 guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC),1 the ESH and the European Union Geriatric Medicine Society have created a common working group to examine the management of hypertensive subjects aged >80 years. The general term hypertension in the elderly is not sufficiently accurate because it mixes younger old patients (60–70 years) with the oldest old. Our group believes that the management of hypertension in individuals aged ≥80 years should be specifically addressed. Although arbitrary, this cutoff value identifies a population that is expanding faster than any other age group with a 50% increase of life expectancy during the past 50 years2,3; furthermore, the incidence and prevalence of comorbidities, frailty, and loss of autonomy greatly increases after the age of 80 years4; finally, although there is limited evidence on the management of hypertension in this age group, the latest clinical studies indicate that in these patients, treatment may not be the same as in patients in the lower age strata. The aim of this Working Group was to discuss more in-depth treatment aspects of hypertensive patients aged ≥80 years or older, with special focus on the difficulties and uncertainties posed by very old frail individuals. We focused, in particular, on the following points of the 2013 ESH/ESC guidelines: The 2013 ESH/ESC guidelines1 reported the results of the Hypertension in the Very Elderly Double Blind Trial (HYVET). This showed that in hypertensive patients aged ≥80 years, the administration of the thiazide-like diuretic indapamide supplemented, if necessary, by the angiotensin-converting enzyme inhibitor perindopril led to a significant reduction in the …

Reduced blood pressure-lowering effect of catheter-based renal denervation in patients with isolated systolic hypertension: data from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry

Abstract: Aims Catheter-based renal artery denervation (RDN) has been shown to lower blood pressure (BP) in certain patients with uncontrolled hypertension. Isolated systolic hypertension (ISH) (systolic BP [SBP] ≥140 mmHg and diastolic BP <90 mmHg), characterized by increased vascular stiffness, is the predominant hypertensive phenotype in elderly patients. This study compared baseline characteristics and SBP change at 6 months between patients with ISH and combined systolic–diastolic hypertension (CH). Methods and results This study pooled data from 1103 patients from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. A total of 429 patients had ISH, and 674 had CH. Patients with ISH were significantly older than those with CH (66 vs. 55 years), had more type 2 diabetes mellitus (52.9 vs. 34.6%), and a lower estimated glomerular filtration rate (71.8 vs. 78.6 mL/min/1.73 m2); all P < 0.001. At 6 months, the SBP drop for CH patients was −18.7 ± 23.7 mmHg compared with a reduction of −10.9 ± 21.7 mmHg for ISH patients (−7.8 mmHg, 95% confidence interval, CI, −10.5, −5.1, P < 0.001). The change in 24-h SBP at 6 months was −8.8 ± 16.2 mmHg in patients with CH vs. −5.8 ± 15.4 mmHg in ISH (−3.0 mmHg, 95% CI −5.4, −0.6, P = 0.015). Presence of ISH at baseline but not age was associated with less pronounced BP changes following the procedure. The strongest predictor of office SBP reduction at 6 months was CH, followed by aldosterone antagonist use and non-use of vasodilators. Conclusion The reduction in BP among patients with ISH following RDN was less pronounced than the reduction in patients with CH. Clinical.Trials.gov identifiers NCT01534299 and [NCT01418261][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01418261&atom=%2Fehj%2Fearly%2F2016%2F09%2F16%2Feurheartj.ehw325.atom

Methodology and technology for peripheral and central blood pressure and blood pressure variability measurement: Current status and future directions - Position statement of the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability

Abstract: Office blood pressure measurement has been the basis for hypertension evaluation for almost a century. However, the evaluation of blood pressure out of the office using ambulatory or self-home monitoring is now strongly recommended for the accurate diagnosis in many, if not all, cases with suspected hypertension. Moreover, there is evidence that the variability of blood pressure might offer prognostic information that is independent of the average blood pressure level. Recently, advancement in technology has provided noninvasive evaluation of central (aortic) blood pressure, which might have attributes that are additive to the conventional brachial blood pressure measurement. This position statement, developed by international experts, deals with key research and practical issues in regard to peripheral blood pressure measurement (office, home, and ambulatory), blood pressure variability, and central blood pressure measurement. The objective is to present current achievements, identify gaps in knowledge and issues concerning clinical application, and present relevant research questions and directions to investigators and manufacturers for future research and development (primary goal).

Hypertension types defined by clinic and ambulatory blood pressure in 14 143 patients referred to hypertension clinics worldwide. Data from the ARTEMIS study.

Abstract: Objective:The Ambulatory blood pressure Registry TEleMonitoring of hypertension and cardiovascular rISk project was designed to set up an international registry including clinic blood pressure (CBP) and ambulatory blood pressure (ABP) measurements in patients attending hypertension clinics in all five continents, aiming to assess different daily life hypertension types.Methods:Cross-sectional ABP, CBP and demographic data, medical history and cardiovascular risk profile were provided from existing databases by hypertension clinics. Hypertension types were evaluated considering CBP (140/90mmHg) and 24-h ABP (130/80mmHg).Results:Overall, 14143 patients from 27 countries across all five continents were analyzed (Europe 73%, Africa 3%, America 9%, Asia 14% and Australia 2%). Mean age was 5714 years, men 51%, treated for hypertension 46%, cardiovascular disease 14%, people with diabetes 14%, dyslipidemia 33% and smokers 19%. The prevalence of hypertension was higher by CBP than by ABP monitoring (72 vs. 60%, P<0.0001). Sustained hypertension (elevated CBP and ABP) was detected in 49% of patients. White-coat hypertension (WCH, elevated CBP with normal ABP) was more common than masked hypertension (elevated ABP with normal CBP) (23 vs. 10%; P<0.0001). Sustained hypertension was more common in Europe and America and in elderly, men, obese patients with cardiovascular comorbidities. WCH was less common in Australia, America and Africa, and more common in elderly, obese women. Masked hypertension was more common in Asia and in men with diabetes. Smoking was a determinant for sustained hypertension and masked hypertension.Conclusion:Our analysis showed an unbalanced distribution of WCH and masked hypertension patterns among different continents, suggesting an interplay of genetic and environmental factors, and likely also different healthcare administrative and practice patterns.

Cardiovascular outcomes at different on-treatment blood pressures in the hypertensive patients of the VALUE trial

Abstract: Aims Recent hypertension guidelines recommend that also in high cardiovascular (CV) risk, hypertensive patients blood pressure (BP) is lowered to <140/90 mmHg as no evidence is available supporting the lower target of <130/80 mmHg recommended in previous guidelines. Whether this represents the optimal treatment strategy is debated, however. Methods and results The high CV risk hypertensive patients of the Valsartan Antihypertensive Long-term use Evaluation (VALUE) trial were divided into subgroups according to (i) the percentage of on-treatment visits in which BP was reduced to <140/90 or <130/80 mmHg or (ii) the mean systolic or diastolic BP (SBP/DBP) values achieved during the entire treatment period or up to the occurrence of an event. A progressive increase from <25 to ≥75% of the visits in which BP was <140/90 mmHg was accompanied by a significant, progressive marked decrease in the covariate adjusted risk of CV morbidity and mortality, cause specific CV events (myocardial infarction, heart failure, and stroke), and all-cause mortality. Except for a persistent progressive decrease in stroke, no significant trend to a risk decrease occurred for a similar progressive increment of the proportion of visits with BP <130/80 mmHg. Increasing the proportion of visits with a BP <140/90 mmHg (but not <130/80 mmHg) was accompanied by a decreased risk of events also when differences in baseline risk were adjusted using a propensity score. Finally, compared with patients remaining at a mean on-treatment SBP ≥140 or DBP ≥90 mmHg, the risk of all events was markedly reduced when on-treatment mean SBP was lowered to a mean SBP of 130–139 mmHg or a mean DBP of 80–89 mmHg, whereas at on-treatment mean SBP <130 mmHg or DBP <80 mmHg, an additional risk reduction was found for stroke but for any other type of event, the risk of which remained similar or only slightly greater than that seen at the higher BP target. Conclusions In the high CV risk, hypertensives of the VALUE trial reducing BP consistently to <140/90 mmHg had marked beneficial effects both when data were calculated as proportion of visits at BP target or as on-treatment mean BP. Reducing BP to <130/80 mmHg led only to some possible further benefit on stroke, whereas the risk of other outcomes remained substantially similar to or slightly greater than that seen at the higher target. Thus, aggressive BP reductions when CV risk is high may not offer substantial advantages, except perhaps in patients or conditions in which stroke risk is particularly common.

Management of the hypertensive patient with elevated heart rate: Statement of the Second Consensus Conference endorsed by the European Society of Hypertension

Abstract: In June 2015, a panel of experts gathered in a consensus conference to plan updating recommendations on the management of the hypertensive patient with elevated heart rate (HR), previously released in 2006. The issues examined during that meeting and further discussed by the participants during the following months involved the assessment of HR, the relevance of HR as a cardiovascular risk factor, the definition of tachycardia and the treatment of the hypertensive patient with high HR. For the measurement of resting HR the panel experts recommended that scientific investigations focusing on HR should report information on length of resting period before measurement, information about temperature and environment, method of measurement, duration of measurement, number of readings, time interval between measurements, body position and type of observer. According to the panellists there is convincing evidence that HR is an important risk factor for cardiovascular disease and they suggest to routinely include HR measurement in the assessment of the hypertensive patient. Regarding the definition of tachycardia, the panellists acknowledged that in the absence of convincing data any threshold used to define tachycardia is arbitrary. Similarly, as there are no outcome studies of HR lowering in tachycardia hypertension, the panellists could not make practical therapeutic suggestions for the management of such patients. However, the experts remarked that absence of evidence does not mean evidence against the importance of tachycardia as a risk factor for cardiovascular disease and that long-term exposure to a potentially important risk factor may impair the patient's prognosis. The main aims of the present document are to alert researchers and physicians about the importance of measuring HR in hypertensive patients, and to stimulate research to clarify unresolved issues.

Microvascular and Macrovascular Disease and Risk for Major Peripheral Arterial Disease in Patients With Type 2 Diabetes.

Abstract: OBJECTIVE Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis in type 2 diabetes, but the relationship between other vascular diseases and PAD has been poorly investigated. We examined the impact of previous microvascular and macrovascular disease on the risk of major PAD in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS We analyzed 10,624 patients with type 2 diabetes free from baseline major PAD in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) clinical trial. The primary composite outcome was major PAD defined as PAD-induced death, peripheral revascularization, lower-limb amputation, or chronic ulceration. The secondary end points were the PAD components considered separately. RESULTS Major PAD occurred in 620 (5.8%) participants during 5 years of follow-up. Baseline microvascular and macrovascular disease were both associated with subsequent risk of major PAD after adjustment for age, sex, region of origin, and randomized treatments. However, only microvascular disease remained significantly associated with PAD after further adjustment for established risk factors. The highest risk was observed in participants with a history of macroalbuminuria (hazard ratio 1.91 [95% CI 1.38–2.64], P P = 0.01). Baseline microvascular disease was also associated with a higher risk of chronic lower-limb ulceration (2.07 [1.56–2.75], P P = 0.006), whereas baseline macrovascular disease was associated with a higher rate of angioplasty procedures (1.75 [1.13–2.73], P = 0.01). CONCLUSIONS Microvascular disease, particularly macroalbuminuria and retinal photocoagulation therapy, strongly predicts major PAD in patients with type 2 diabetes, but macrovascular disease does not.

Guía ESC 2016 sobre prevención de la enfermedad cardiovascular en la práctica clínica

Abstract: Las declaraciones de conflictos de intereses de los expertos participantes en el desarrollo de esta guia estan disponibles en la pagina web de la ESC: www.escardio.org/guidelines

No evidence for a J-shaped curve in treated hypertensive patients with increased cardiovascular risk: The VALUE trial

Abstract: Previous studies have debated the notion that low blood pressure (BP) during treatment, particularly diastolic (DBP), is associated with increased risk of cardiovascular disease. We evaluated the impact of low BP on cardiovascular outcomes in a high-risk population of 15,244 hypertensive patients, almost half of whom had a history of coronary artery disease (CAD). In the prospective Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial, patients were randomized to valsartan or amlodipine regimens and followed for 4.2 years (mean) with no difference in the primary cardiovascular endpoint. A Cox proportional hazards model was used to evaluate the relationship between average on-treatment BP and clinical outcomes. The relationship between BP and cardiovascular events was adjusted for age, gender and body mass index, and baseline qualifying risk factors and diseases (smoking, high total cholesterol, diabetes mellitus, proteinuria, CAD, previous stroke and left ventricular hypertrophy). DBP ≥ 90 mmHg, compared with < 90 mmHg, was associated with increased incidence of the primary cardiovascular endpoint (all cardiac events); however, DBP < 70 mmHg, compared with ≥ 70 mmHg, was not associated with increased incidence after covariate adjustment (no J-shaped curve). Similar results were observed for death, myocardial infarction (MI), heart failure and stroke, considered separately. Nadir for MI was at DBP of 76 mmHg and for stroke 60 mmHg. The ratio of MI to stroke increased with lower DBP. In CAD patients the MI to stroke ratio was more pronounced than in patients without CAD but there was no significant J-curve in either group. Systolic BP ≥ 150 but not < 130 mmHg, compared with 130-149 mmHg, similarly was associated with increased risk for primary outcome. In conclusion, patients in BP strata ≥ 150/90 mmHg, but not patients in BP strata < 130/70 mmHg, were at increased risk for adverse outcomes in this hypertensive, high-risk population. Although benefit in preventing MI in relation to preventing stroke levels off for the lowest BPs, these data provide no support for a J-curve in the treatment of high-risk hypertensive patients . The increase in the ratio of MI to stroke with lower DBP indicates target organ heterogeneity in that the optimal on-treatment DBP for cerebroprotection is below that for cardioprotection.

The harms of smoking and benefits of smoking cessation in women compared with men with type 2 diabetes: an observational analysis of the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron modified release Controlled Evaluation) trial

Abstract: Objectives In general populations, the adverse effects of smoking on coronary risk have been demonstrated to be greater in women than in men; whether this is true for individuals with diabetes is unclear. Design Cohort study. Setting 20 countries worldwide participating in the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron modified release Controlled Evaluation) trial. Participants 11 140 patients with type 2 diabetes aged ≥55 years and in cardiovascular risk at the time of randomisation. Primary and secondary outcome measures Major cardiovascular events (death from cardiovascular disease, non-fatal stroke or non-fatal myocardial infarction (MI)), all cardiovascular events (major cardiovascular event or peripheral arterial disease or transient ischaemic attack), and all-cause mortality. Secondary outcome measures were major coronary events (fatal and non-fatal MI), major cerebrovascular events (fatal and non-fatal stroke), nephropathy (new or worsening renal disease), and all cancer. Results At baseline, 6466 (56% women) participants were never-smokers, 1550 (28% women) were daily smokers and 3124 (21% women) were former smokers. Median follow-up time was 5 years. In Cox regression models after multiple adjustments, compared with never smoking, daily smoking was associated with increased risk of all primary and secondary outcomes with the exception of major cerebrovascular disease. Only for major coronary events was there any evidence of a stronger effect in women than in men (ratio of the adjusted HRs women:men; 1.64 (0.83 to 3.26) p=0.08). For all other outcomes considered, the hazards of smoking were similar in men and women. Quitting smoking was associated with a 30% reduction in all-cause mortality (p=0.001) in both sexes. Conclusions In individuals with diabetes, the effects of smoking on all major forms of cardiovascular disease are equally as hazardous in women and men with the possible exception of major coronary events where there was some evidence of a greater hazard in women. Trial registration number NCT00145925.

Trends in Prevalence, Awareness, Treatment, and Control of Blood Pressure Recorded From 2004 to 2014 During World Hypertension Day in Italy

Abstract: Estimates of blood pressure (BP) control in real life are not systematically collected in Italy. We evaluated trends in systolic/diastolic BP levels, as well as prevalence, awareness, treatment, and control rates of hypertension among adult individuals visiting open checkpoints during the 2004 to 2014 annual editions of World Hypertension Day. Hypertension was defined as BP level ≥140/90 mm Hg or use of antihypertensive medication, whereas BP control was defined as BP level <140/90 mm Hg. We included 10,051 individuals (53.2% female, age 56.2±16.8 years, body mass index 25.7±7.6 kg/m(2) , systolic/diastolic BP 131.9±18.6/79.1±10.5 mm Hg). Hypertension prevalence and treatment were substantially unchanged, whereas awareness appears to increase over time. Controlled hypertension in diagnosed treated patients increased from 50.0% in 2004-2010 to 55.5% in 2011-2012 towards 57.6% in 2013-2014. This analysis provides real-life snapshots of hypertension over the years in the occasion of World Hypertension Day, showing increased awareness and improved control rates among treated hypertensive patients attending open checkpoints during 2004 to 2014 in Italy.

Risks associated with permanent discontinuation of blood pressure-lowering medications in patients with type 2 diabetes.

Abstract: Objective The associations of discontinuation of the study medication on major outcomes were assessed in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation Trial. Methods ADVANCE was a factorial randomized controlled trial of blood pressure lowering (a fixed combination of perindopril and indapamide vs. placebo) and intensive glucose control (vs. standard glucose control) in patients with type 2 diabetes. Patients who permanently discontinued the randomized blood pressure-lowering medication during the study period (n = 1557) were compared with others (n = 9583). Cox's proportional hazards models were used to estimate the effects of the discontinuation on the risks of macrovascular events, microvascular events together and separately and all-cause mortality, using discontinuation as a time-dependent covariate. Results In multivariable analyses, discontinuation was associated with increased risks of combined macro and microvascular events (hazard ratio 2.24, 95% CI 1.96-2.57), macrovascular events (3.23, 2.75-3.79), microvascular events (1.38, 1.11-1.71), and all-cause mortality (7.99, 6.92-9.21) compared to continuing administration of randomized medications during the trial period, which were highest in the first year after discontinuation. These associations were similar in active and placebo groups, except in the first year after discontinuation during which event rates were lower in the active group than in the placebo group (P ≤ 0.01). Conclusion Discontinuation of study medication is a potent risk marker for identifying high-risk patients. Thus it is important that clinicians seek to identify such patients early after discontinuation of treatment. Although some short-term residual effects of previous active treatment can be expected, patients who discontinue require further urgent investigation and management.

The SPRINT study: Outcome may be driven by difference in diuretic treatment demasking heart failure and study design may support systolic blood pressure target below 140 mmHg rather than below 120 mmHg

Abstract: The Systolic Blood Pressure Intervention Trial (SPRINT) began in the autumn of 2009 and enrolled more than 9300 participants aged 50 and older in about 100 medical centres and clinical practices th...

Treatment of high blood pressure in elderly and octogenarians: European Society of Hypertension statement on blood pressure targets.

Abstract: The European Society of Hypertension recommend the following main rules for treatment of hypertension in elderly and octogenarians: 1) In elderly hypertensives with SBP ≥ 160 mmHg there is solid evidence to recommend reducing SBP to between 140 mmHg and 150 mmHg. 2) In fit elderly patients less than 80 years old treatment may be considered at SBP ≥ 140 mmHg with a target SBP < 140 mmHg if treatment is well tolerated. 3) In fit individuals older than 80 years with an initial SBP ≥ 160 mmHg it is recommended to reduce SBP to between 150 mmHg and 140 mmHg. 4) In frail elderly patients, it is recommended to base treatment decisions on comorbidity and carefully monitor the effects of treatment. 5) Continuation of well-tolerated antihypertensive treatment should be considered when a treated individual becomes octogenarian. 6) All hypertensive agents are recommended and can be used in the elderly, although diuretics and calcium antagonists may be preferred in isolated systolic hypertension.

Nondipping pattern and carotid atherosclerosis: a systematic review and meta-analysis

Abstract: Evidence on the association of nondipping pattern with carotid atherosclerosis is scarce. We performed a meta-analysis in order to provide comprehensive information on subclinical carotid alterations in nondipping as compared with dipping individuals. A computerized search was performed using PubMed, OVID, EMBASE and Cochrane library databases from 1 January 1990 up to 31 March 2015. Full articles providing data on carotid intima-media thickness (IMT) and plaque in nondipping and dipping individuals, as assessed by ultrasonography, were analyzed. A total of 2753 adult individuals (1003 nondipping and 1750 dipping) included in 13 studies were considered. Common carotid IMT was higher in nondipping than in dipping individuals [807 ± 36 μm vs. 746 ± 28 μm, standard means difference, SMD: 0.37 ± 0.09, confidence interval (CI): 0.19-0.56, P < 0.01]. From data on plaque prevalence provided by five studies, the odds ratio for carotid plaques resulted 67% higher in nondipping (95% CI: 1.26-2.21, P < 0.01) than in dipping individuals. Our findings support an association between nondipping pattern and increased risk of subclinical carotid alterations. In a practical perspective, the present meta-analysis reinforces the view that an effective blood pressure control over the entire 24-h period, in particular at night, may prevent the progression of vascular damage associated with nondipping phenotype.

Effects of hypobaric hypoxia exposure at high altitude on left ventricular twist in healthy subjects: data from HIGHCARE study on Mount Everest.

Abstract: Aims Previous studies investigating the effect of hypoxia on left ventricle focused on its global function, an approach that may not detect a selective dysfunction of subendocardial layers that are most sensitive to an inadequate oxygen supply. In the HIGHCARE study, aimed at exploring the effects of high altitude hypoxia on multiple biological variables and their modulation by an angiotensin receptor blocker, we addressed the effects of hypobaric hypoxia on both systolic and diastolic left ventricular geometry and function, focusing on echocardiographic assessment of left ventricle twist to indirectly examine subendocardial left ventricular systolic function. Methods and results In 39 healthy subjects, physiological and echocardiographic variables, including left ventricular twist and a simplified torsion-to-shortening ratio (sTSR), were recorded at sea level, at 3400 m, and at 5400 m altitude (Mount Everest base camp). Both left ventricular twist and sTSR were greater at 5400 m than at sea level (12.6° vs. 9.6° and 0.285 vs. 0.202, P < 0.05 for both), were linearly related to the reduction in arterial oxygen partial pressure ( P < 0.01 for both), and were associated with significant changes in LV dimensions and contractility. No effects of angiotensin receptor blockade were observed on these variables throughout the study. Conclusion Our study, for the first time, demonstrates an increase in left ventricular twist at high altitude in healthy subjects exposed to high altitude hypoxia, suggesting the occurrence of subendocardial systolic dysfunction in such condition.

Continuation of the ESH-CHL-SHOT trial after publication of the SPRINT: rationale for further study on blood pressure targets of antihypertensive treatment after stroke

Abstract: Alberto Zanchetti, Lisheng Liu, Giuseppe Mancia, Gianfranco Parati, Guido Grassi, Marco Stramba-Badiale, Vincenzo Silani, Grzegorz Bilo, Giovanni Corrao, Antonella Zambon, Lorenza Scotti, Xinhua Zhang, Ting Rui Guan, Yuqing Zhang, Xuezhong Zhang, Eivind Berge, Josep Redon, Krzysztof Narkiewicz, Anna Dominiczak, Peter Nilsson, Margus Viigimaa, Stéphane Laurent, Enrico Agabiti-Rosei, Zhaosu Wu, Dingliang Zhu, José Luis Rodicio, Luis Miguel Ruilope, Nieves Martell-Claros, Fernando Pinto Roland E. Schmieder, Michel Burnier, Maciej Banach, Renata Cifkova, Csaba Farsang, Alexandra Konradi, Irina Lazareva, Yuriy Sirenko, Maria Dorobantu, Arman Postadzhiyan, Rok Accetto, Bojan Jelakovic, Dragan Lovic, Athanasios J. Manolis, Philippos Stylianou, Dror Dicker, Gangzhi Wei, Chengbin Xu, Hengge Xie, Antonio Coca, John O’Brien, Gary Ford, on behalf of the ESH-CHL-SHOT trial investigators

White coat hypertension : to treat or not to treat?

Abstract: Definition of white coat hypertension (WCH) traditionally relies on elevated office blood pressure (BP) during repeated visits concomitant with normal out-of-office BP values, as assessed by home and/or 24-h ambulatory BP monitoring measurements. Accumulating evidence focusing on the association of WCH with target organ damage and, more importantly, with cardiovascular events indicates that the risk conveyed by this condition is intermediate between normotension and sustained hypertension. This article will review a number of issues concerning WCH with particular emphasis on the following: (1) prevalence and clinical correlates, (2) association with target organ damage and cardiovascular events, (3) therapeutic interventions. Data will refer to the original WCH definition, based on out-of-office BP determined by 24-h ambulatory BP monitoring; at variance from home BP measurement, this approach rules out the potentially confounding effect of a clinically relevant abnormal BP phenotype such as isolated nocturnal hypertension.

Unobserved automated office blood pressure measurement in the Systolic Blood Pressure Intervention Trial (SPRINT): systolic blood pressure treatment target remains below 140 mmHg.

Abstract: The Systolic Blood Pressure Intervention Trial (SPRINT) enrolled 9300 participants age 50 years and older without diabetes or previous stroke in ∼100 expert medical centres and clinical practices throughout the USA.1 Between 2010 and 2013, the SPRINT investigators randomly allocated the study participants into a standard treatment group receiving an average of two different blood pressure (BP) medications to achieve a systolic BP (SBP) target of <140 mmHg, and an intensive treatment group receiving an average of three BP medications to achieve an SBP target of <120 mm Hg. SPRINT was stopped early because of effect. The target SBP of <120 mmHg had reduced rates of the composite primary outcome that included myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes by 25% and the risk of death from all causes by 27%, as compared with the target SBP of <140 mmHg.2 However, …

Effects of chronic carotid baroreceptor activation on arterial stiffness in severe heart failure

Abstract: Heart failure with reduced ejection fraction (HFrEF) is characterized by activation of the sympathetic nervous system and increased arterial stiffness, leading to an impaired ventricular-vascular coupling. Baroreflex activation therapy (BAT) has been shown to reduce muscle sympathetic nerve activity (MSNA) and improve clinical status of patients with HFrEF. The purpose of this investigation was to determine the effects of BAT on arterial stiffness in HFrEF. MSNA, clinical variables, and parameters of central blood pressure (BP) and arterial stiffness were collected in 18 NYHA Class III HFrEF patients, nine receiving BAT and nine continuing with optimal medical management alone. Patients were followed for 3 months, with measurements at that time compared to baseline evaluation. Baseline characteristics of the groups were well matched. At 3 months, BAT did not improve central BP and arterial stiffness despite a significant amelioration of MSNA, NYHA class, Minnesota living with heart failure questionnaire score, number of heart failure medications and six-minute walking distance. The control group exhibited no significant changes in all the measured variables. Despite significant reductions in MSNA and clinical improvement, BAT does not appear to chronically modify arterial stiffness within this HFrEF cohort. Additional study is required to determine if this result applies to the HFrEF population as a whole.

Renal denervation reduces office and ambulatory heart rate in patients with uncontrolled hypertension: 12-month outcomes from the global SYMPLICITY registry

Abstract: Objectives:Renal denervation (RDN) can reduce sympathetic activity and blood pressure (BP) in patients with hypertension. The effects on resting and ambulatory heart rate (HR), also regulated by the sympathetic nervous system, are not established.Methods:Herein, we report 12-month outcomes from the

Nocturnal Hypertension and Subclinical Cardiac and Carotid Damage: An Updated Review and Meta-Analysis of Echocardiographic Studies.

Abstract: Evidence on the association of nocturnal hypertension (NH) with subclinical cardiac and vascular damage is scanty. The authors performed a meta-analysis to provide comprehensive information on this clinically relevant issue. Full articles providing data on subclinical cardiac and carotid damage as assessed by ultrasonographic methods in patients with NH as compared with patients with nocturnal normotension (NN) were considered. A total of 3657 patients (NH=2083, NN=1574) of both sexes were included in seven studies. Left ventricular mass index was higher in individuals with NH than in those with NN (112±4.7 g/m2 vs 98±4.8 g/m2; standard mean difference [SMD], 0.54±0.16; confidence interval [CI], 0.23–0.85; P<.01). Similarly, common carotid intima-media thickness was greater in patients with NH than in those with NN (751±34 μm vs 653±14 μm; SMD, 0.44±0.08; CI, 0.29–0.59; P<.01). The present meta-analysis shows an association between NH pattern and increased likelihood of cardiac and carotid structural alterations.

Clinical significance of white-coat hypertension.

Abstract: This issue of Hypertension includes a report by Julius and colleagues on a topic of great importance for the diagnosis of hypertension, that is, the alerting reaction and blood pressure rise triggered by blood pressure measurements and commonly referred to as the \"white coat\" phenomenon. The first observation that blood pressure measurement may trigger an alerting reaction and a pressor response in the patient was made by Riva-Rocci in his original report on the sphygmomanometric technique, which was published near the end of the last century. This pressor response was then described in several other papers\" and quantified in subjects in whom sphygmomanometric assessment of blood pressure by the physician was obtained during prolonged intra-arterial ambulatory blood pressure monitoring. The data showed that the peak increase in intra-arterial systolic and diastolic blood pressure occurring during the procedure was so pronounced that it averaged 27/14 mm Hg. However, although a blood pressure rise was observed in most subjects, the pressor response showed a pronounced interindividual variability, with the maximal increase in mean arterial pressure ranging from 2 to 53 mm Hg.