Showing papers by "European Society of Hypertension published in 2020"

Disequilibrium between the classic renin-angiotensin system and its opposing arm in SARS-CoV-2-related lung injury.

Abstract: A dysregulation of the renin-angiotensin system (RAS) has been involved in the genesis of lung injury and acute respiratory distress syndrome from different causes, including several viral infections. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of pneumocytes, the hallmark of the pandemic coronavirus disease 2019 (COVID-19) involving both alveolar interstitium and capillaries, is linked to angiotensin-converting enzyme 2 (ACE2) binding and its functional downregulation. ACE2 is a key enzyme for the balance between the two main arms of the RAS: the ACE/angiotensin (Ang) II/Ang II type 1 receptor axis ("classic RAS") and the ACE2/Ang(1-7)/Mas receptor (MasR) axis ("anti-RAS"). The ACE2 downregulation, as a result of SARS-coronaviruses binding, enhances the classic RAS, leading to lung damage and inflammation with leaky pulmonary blood vessels and fibrosis, when the attenuation mediated by the anti-RAS arm is reduced. ACE inhibitors (ACE-I) and Ang II type 1 receptor blockers (ARB), effective in cardiovascular diseases, were found to prevent and counteract acute lung injury in several experimental models by restoring the balance between these two opposing arms. The evidence of RAS arm disequilibrium in COVID-19 and the hypothesis of a beneficial role of RAS modulation supported by preclinical and clinical studies are the focus of the present review. Preclinical and clinical studies on drugs balancing RAS arms might be the right way to counter COVID-19.

Pharmacological Approach to Smoking Cessation: An Updated Review for Daily Clinical Practice

Abstract: Tobacco use is one of the major public health concerns and it is the most preventable cause of morbidity and mortality worldwide Smoking cessation reduces subsequent cardiovascular events and mortality Smoking is a real chronic disorder characterized by the development of an addiction status mainly due to nicotine This condition makes the smokers generally unable to quit smoking without help Different strategies are available to treat smoking dependence that include both non-pharmacological (behavioral counselling) and pharmacological therapies Currently, it is well accepted that smoking cessation drugs are effective and safe in real-world settings Nicotine replacement therapy (NRT), varenicline, bupropion and cytisine are the main pharmacological strategies available for smoking cessation Their efficacy and safety have been proved even in patients with chronic cardiovascular disease Each of these drugs has peculiar characteristics and the clinician should customize the smoking cessation strategy based on currently available scientific evidence and patient's preference, paying particular attention to those patients having specific cardiovascular and psychiatric comorbidities The present document aims to summarize the current viable pharmacological strategies for smoking cessation, also discussing the controversial issue regarding the use of alternative tobacco products, in order to provide useful practical indications to all physicians, mainly to those involved in cardiovascular prevention

A commentary on the Spanish hypertension studies MAPEC and HYGIA.

Abstract: The recently published chronotherapeutic Spanish papers MAPEC and HYGIA proposing that antihypertensive drug treatment should be given at bedtime suffers from obvious deficiencies in study design and are not a valid basis for drug treatment of hypertension.

Thoracic continuous spinal anesthesia for high-risk comorbid older patients undergoing major abdominal surgery: one-year experience of an Italian geriatric hospital.

Abstract: BACKGROUND General anesthesia is associated with high morbidity/mortality in comorbid older adults. Thoracic continuous spinal anesthesia/analgesia (TCSA) may be an alternative for major abdominal surgery. We report a one-year experience of the use of TCSA in an Italian geriatric center. METHODS Retrospective review of case notes of high-risk older patients (ASA class ≥III) who underwent TCSA for major abdominal surgery between May 2017-May 2018. TCSA was performed with a 21-gauge Tuohy-shaped spinal needle and a 24-gauge catheter (level of insertion between T6-7 and T10-11). Hyperbaric bupivacaine or levobupivacaine (two boluses of 2.5 mg) plus fentanyl (10-25 µg) were injected before incision, followed by additional doses if needed. Intrathecal levobupivacaine plus fentanyl were infused for 72 hours after surgery. We described the anesthesiologic management and evaluated the incidence of postoperative complications. RESULTS Ninety patients (age 84.4±6.9 years, 53.3% male) were enrolled. High comorbidity, according to the Geriatric Index of Comorbidity, was found in 64.4% of the patients. Mean Metabolic Equivalents were 2.58±0.99. Switching to general anesthesia was required in one case. Intraoperative noradrenaline (0.17±0.12 mcg/kg/min) was required in 70.6%. Additional intravenous paracetamol or weak opioids were required in 23% and 2.2% of patients, respectively. No direct complications of TCSA were reported. Cardiac, respiratory and surgical complications occurred in 15.6%, 13.3% and 13.3% of patients, respectively. Delirium occurred in 14.4%. Hospital mortality was 5.6%. CONCLUSIONS TCSA may be a valid alternative to general anesthesia in high-risk older patients undergoing major abdominal surgery. Further studies are needed to confirm its safety and benefits.

Inflammatory activation and endothelial dysfunction markers in patients with permanent atrial fibrillation: a cross-sectional study

Abstract: In recent years a growing body of evidence supported the role of inflammation in the initiation, maintenance and outcome of atrial fibrillation (AF). Nevertheless, despite a large amount of information, whether AF or the underlying structural heart disease (SHD) is the cause of the inflammatory process is still under debate. We, therefore, sought to determine if the inflammatory process reflect an underlying disease or the arrhythmia 'per se'. We evaluated plasma levels of soluble Interleukin 2 Receptor Alpha (sIL-2Rα), TNF-α and IL-18 in 100 consecutive patients with permanent AF, (43 with a SHD and 57 without a SHD) compared to 121 age and sex-matched controls which had normal sinus rhythm. We also evaluated the endothelial function in both groups of patients using reactive hyperemia index (RHI) values measured by Endo-PAT2000. Compared to controls, AF patients showed higher circulating levels of inflammatory markers and a lower mean value of RHI. At multiple logistic regression analysis, the inflammatory markers and RHI were significantly associated with AF presence, whereas ROC curve analysis had good sensitivity and specificity in inflammatory variables and RHI for AF presence. No significant association was observed in the group of permanent AF patients, between inflammatory markers and the presence of an underlying SHD. These findings could help to clarify the role of inflammation in subjects with AF and suggest that the markers of systemic inflammation are not associated with the underlying cardiovascular disease, rather with the atrial fibrillation 'per se'.

Statin therapy is associated with better ambulatory blood pressure control: a propensity score analysis.

Abstract: OBJECTIVE Statin therapy was associated with lower blood pressure (BP) in some but not all studies. We evaluated the association between statin therapy and ambulatory BP in a large hypertensive population using 'propensity score matching'. METHODS Retrospective observational study on 1827 consecutive essential hypertensive patients evaluated with 24-h ambulatory BP monitoring. Antihypertensive treatment intensity (ATI) was calculated to compare different drug associations. We used a propensity score matching to compare two equally-sized cohorts of patients with similar characteristics according to statin therapy. Matching was performed on log-transformed propensity score in a 1 : 1 fashion with a caliper of 0.1, in order to account for the different baseline characteristics between statin and no-statin group. RESULTS Mean age: 58.1 ± 13.8 years; male sex: 55%. Patients on statin therapy: 402 (22%). These patients showed lower 24-h BP (-2.8/-7.1 mmHg), daytime (-3.3/-7.6 mmHg) and night-time BP (-2.5/-6.0 mmHg, all P < 0.001). They also showed better ambulatory BP control, even after adjustment for confounding factors. The analyses on the groups derived from the 'propensity score matching' (369 patients in each group) confirmed these results (OR 1.8 for 24-h BP control; OR = 1.6 for daytime BP control; OR = 1.7 for night-time BP control, all P < 0.001). CONCLUSION Statin therapy is associated with better ambulatory BP control in essential hypertensive patients. This result is not affected by the intensity of the antihypertensive treatment or by the several cofactors analyzed.

Choroidal thickness is associated with renal hemodynamics in essential hypertension

Abstract: The choroid is the most vascularized structure of the eye and plays a central role in the development of the retinal vascular changes that occur in arterial hypertension. Changes of choroidal thickness (ChT) assessed by optical coherence tomography (OCT) technology could reflect the vascular complications of hypertension. Also, intrarenal hemodynamic damage, associated with endothelial dysfunction, demonstrated to be a good indicator of systemic morphofunctional arterial impairment. The aim of this study is to assess the relationship between ChT and renal hemodynamics in subjects with essential hypertension. Routine laboratory tests, clinical history, and physical examination, including blood pressure assessment, were performed in 90 subjects with essential hypertension. All patients underwent Doppler ultrasonographic evaluation of intra-renal hemodynamics and OCT imaging to assess ChT. When subjects were divided in two groups based on renal resistive index (RRI), group I (RRI ≥ 75% percentile) showed significantly lower values of ChT than group II (RRI < 75% percentile) (P < .001). When divided in two groups based on the ChT median values, patients with lower ChT had significantly higher RRI values than those with ChT above the median values (P < .05). In multivariate model including age, eGFR, and other variables as confounding factors, RRI ≥ 75% was independently associated with ChT. ChT was significantly correlated with renal resistive index in subjects with essential hypertension, confirmed in multivariate analyses. This result could be referred to changes in vascular elastic properties that occur in retinal and intrarenal vascular system probably due to oxidative stress and endothelial dysfunction commonly found in early complications of hypertension.

Sodium-glucose co-transporter-2 inhibitors: peculiar "hybrid" diuretics that protect from target organ damage and cardiovascular events.

Abstract: Aims Sodium-glucose co-transporter-2 inhibitors (SGLT2i) have been proven to lead to relevant cardiovascular benefits, regardless of glycemic control function. SGLT2i have on the one hand led to reduction in cardiovascular events such as heart failure and on the other hand to renal protection. Blood pressure reduction and kidney function play a central role in these outcomes. This focused review describes the main mechanisms and clinical aspects of SGLT2i. Data synthesis These drugs act on the proximal renal tubule and behave as diuretics with a “hybrid” mechanism, as they can favour both natriuresis and enhanced diuresis due to an osmotic effect dependent on glycosuria, resulting in blood pressure decrease. The exclusive peculiarity of these “diuretics”, which distinguishes them from loop and thiazide diuretics, lies also in the activation of the tubule-glomerular feedback. Conclusions This mechanism, resulting in modulation of arterioles’ tone and renin secretion, contributes to the favorable outcomes, suggesting a wider use of SGLT2i in internal medicine, nephrology and cardiology.

Antagonizing the renin-angiotensin-aldosterone system in the era of COVID-19.

Abstract: Patients with pre-existing cardiovascular (CV) disease, especially older subjects, are more likely to develop severe symptoms and have worse prognosis if infected with the severe acute respiratory syndrome coronavirus-2 (SARSCoV-2). Recently, some authors have raised concerns about the safety and potential effects of anti-hypertensive therapy with angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II type 1 receptor blockers (ARB) in patients with SARS-CoV-2 infection (COVID-19), given their capacity to increase ACE2 levels, which has been found to act as a functional receptor for SARS-CoV-2. This would be followed by a hypothetical greater susceptibility to SARSCoV-2 infection, as well as a possible greater severity of the disease, in patients already at higher risk of death due to their CV comorbidities. Although these concerns are currently not supported by any scientific evidence, such speculations increase the risk of discrediting pharmacological classes which have largely been shown to protect even older patients from CV and all-cause mortality, regardless of comorbidities [1]. Instead, based on the available evidence, the exact opposite may actually be more likely. The renin–angiotensin–aldosterone system (RAAS) blockers were found to protect against acute lung injury in several animal models, also due to their ability to increase ACE2 levels [2]. ACE2 plays a key role in counterbalancing the negative effects of a hyper-activated RAAS. Indeed, ACE2 cleaves angiotensin (Ang) I into a nonapeptide (Ang 1–9), which binds Ang II type 2 receptor (AT2R), and Ang II into Ang 1–7, which binds an endogenous orphan receptor (MasR). While the activation of ACE/Ang II/Ang II-type 1 receptor (AT1R) pathway induces vascular permeability, inflammation, and lung fibrosis, previous studies found that ACE2/Ang 1–7/MasR pathway can protect lungs from the development of acute respiratory distress syndrome (ARDS) in several animal models, through opposite mechanisms [3]. Moreover, ACE2 interacts with another branch of RAAS based on Ang peptides in which the aminoterminal aspartate is replaced by alanine (Alatensins), leading to the production of Ala-Ang 1–7 (Alamandine) that has been found to bind Mas-related G protein-coupled receptor D (MrgD) and may also protect against lung injury and fibrosis, improving vascular/endothelial dysfunction [4]. The down-regulation of ACE2 after the binding of the viral surface-spike protein and the consequent RAAS hyperactivation result in the worsening of acute lung injury. Moreover, ACE2 and the RAAS dysregulation may also play a key role in the myocardial involvement following the SARSCoV-2 infection. In fact, ACE2 is critical for heart function, preventing oxidative stress, inflammation, left ventricular remodeling, and dysfunction [4]. RAAS blockers, especially ARB, may attenuate these damage mechanisms (see Fig. 1), through the reduction of Ang II/AT1R stimulation, increase in Ang II substrate and increase in ACE2, leading to a larger increase in both Ang 1–7 and alamandine. ACE-I stop the conversion of Ang 1–9 to Ang 1–7 and may facilitate stimulation of AT2R by Ang 1–9, but may also reduce the pathway depending on Ang 1–7. Therefore, most experimental evidences are currently favoring the use of ARB in lung protection. Very recently, some clinical studies evaluated the effects of ACE-I and ARB on COVID-19 outcomes in hospitalized patients, although limited to observational * Riccardo Sarzani r.sarzani@univpm.it

Risk stratification in hypertension: NT-proBNP and R wave in aVL lead combination better than echocardiographic left ventricular mass.

Abstract: Objectives Plasma N-terminal pro brain natriuretic peptide (NT-proBNP) and R wave in aVL lead (RaVL) have been associated with mortality in hypertension. The aim of the current study was to compare the prognostic value of their combination to that of the left ventricular mass index (LVMI) assessed by echocardiography. Methods A total of 1104 hypertensive patients who had at baseline an assessment of plasma NT-proBNP, a 12-lead ECG, and echocardiography were included. LVMI was assessable in 921 patients. After a median (interquartile range) follow-up of 8.5 (5.4-13.3) years, 110 deaths occurred, 62 of which were from a cardiovascular cause. Results Optimal thresholds of RaVL and plasma NT-proBNP to predict mortality were 0.7 mV and 150 pg/ml, respectively. A three-modality variable based on RaVL and NT-proBNP was built: 0 when none were above the threshold, 1 or 2 when only one or both were above the threshold. After adjustment for all confounders including LVMI indexed to height raised to the allometric power of 2.7 in Cox regression analysis, we observed a significant increased risk for patients having one marker above the threshold for all-cause and cardiovascular mortality [hazard ratio: 1.76; 95% confidence interval (1.08-2.86); 2.18 (1.06-4.46)] and for those having two markers above the threshold [2.76 (1.51-5.03); 3.90 (1.69-9.00)]. The prognostic value of the combination had the highest C-index (0.772 and 0.839, respectively) in comparison with LVMI (0.746 and 0.806, respectively). Conclusion Risk stratification in hypertension using the combination of NT-proBNP and RaVL is a simple method that may be considered in first line screening.

Ambulatory blood pressure monitoring by a novel cuffless device: a pilot study.

Abstract: Purpose: Cuffless blood pressure (CL-BP) measurements are believed to be a potentially alternative to cuff-occlusion-based (C-BP) measurement. A new cuffless device was developed for ambulatory BP ...

A 95-year-old patient with unexpected coronavirus disease 2019 masked by aspiration pneumonia: a case report.

Abstract: Severe acute respiratory syndrome coronavirus-2 infection has become a pandemic disease (coronavirus disease 2019) The infection has moved from China to the rest of the world and Italy represents one of the most affected countries Older adults are more susceptible to develop complications with the consequent highest mortality rates We report a case of a 95-year-old Caucasian woman affected by pneumonia, initially defined as common aspiration pneumonia in a bedridden patient with vascular dementia, which later turned out to be coronavirus disease 2019 pneumonia during the initial spread of severe acute respiratory syndrome coronavirus-2 in our district Some features of a computed tomography scan of her chest and her clinical history with known dysphagia had led at first to a different diagnosis with a consequent exposure of health professionals to infectious risk in two distinct hospitals In this case report, we describe the clinical/imaging features of coronavirus disease 2019 pneumonia and the diagnostic process that led to a correct diagnosis in a nonagenarian with multiple comorbidities This case report highlights both the possible pitfalls in diagnosing coronavirus disease 2019 pneumonia in very old patients with comorbidities and the greater than expected spread of the infection, even in individuals with reduced interpersonal contacts and no defined epidemiological link

May Measurement Month 2018: an analysis of blood pressure screening results from Italy.

Abstract: Cardiovascular (CV) diseases are burdened by high mortality and morbidity, being responsible for half of the deaths in Europe. Although hypertension is recognized as the most important CV risk factor, hypertension awareness and blood pressure (BP) control are still unsatisfactory. In 2017, 30.6% of a >10 000 individual sample who took part in the May Measurement Month (MMM) campaign in Italy was found to have high BP. To raise awareness on the hypertension issue and to report BP data on a nation-wide scale in Italy. In the frame of the MMM campaign, an opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2018. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. Screenings were conducted in multiple sites by health care personnel. Among the 5554 people screened (females: 48.3%, mean age 58 ± 17 years) mean BP was 127/77 mmHg, and after imputations, 1462 (26.3%) participants were found to have high BP levels. Body mass index >25 was associated with higher systolic BP and diastolic BP (DBP), while diabetes was associated with high DBP only. Our data provide a nation-wide snapshot of BP control in a sample of individuals participating in a national health care campaign, and confirm the power of this kind of healthcare-related activities in reaching a significant number of people to raise awareness on health topics. The apparent positive trend in BP control compared to available data from other similar campaigns carried out during the past years needs to be confirmed with more methodologically robust studies.

Prevalence of Subclinical Carotid Atherosclerosis and Role of Cardiovascular Risk Factors in Older Adults: Atherosclerosis and Aging are Not Synonyms

Abstract: Age is traditionally considered a major cardiovascular (CV) risk factor, but its real weight in the absence of other modifiable risk factors is not clear. To compare the prevalence of subclinical carotid atherosclerosis, and its association with the main CV risk factors, between older adults and hypertensive adults. Cross-sectional study on 210 consecutive patients: 70 older adults (age ≥ 80 years), and 140 hypertensive adults having at least another CV risk factor. Patients had no history of peripheral artery disease or major CV events. Mean age was 54.2 ± 7.2 years in hypertensive adults and 88.5 ± 5.5 years in older adults with a female prevalence in the latter group. Dyslipidemia and smoking were more prevalent in hypertensive adults, while chronic kidney disease was more prevalent in older adults. Prevalence of carotid plaques did not differ between hypertensive adults and older adults (48.2% vs 55.6%, respectively, p = 0.311). Age ≥ 80 years was not associated with a higher risk of carotid plaques even after adjusting for other risk factors (p = 0.204). Hypertension and dyslipidemia were the risk factors more strongly associated with carotid plaques in older adults and hypertensive adults, respectively. When older adults with hypertension were excluded from the analysis, prevalence of carotid plaques was significantly higher in hypertensive adults (p = 0.042). Hypertension and dyslipidemia are the major determinant of atherosclerosis regardless of age in our study. Our findings support the concept that aging is not necessarily synonymous with atherosclerosis and highlight the key role played by superimposed CV risk factors on arterial ‘‘bad aging’’.

Insufficient reply by Hermida et al. to the critical comments to the MAPEC and HYGIA studies.

Abstract: The reply of Hermida et al. (2020) to our critical comments on the MAPEC and HYGIA Lemmer and Middeke (2020) studies in this Journal is insufficient and incomplete. Hermida does not address our fir...

The “Renocentric Theory” of Renal Resistive Index: Is It Time for a Copernican Revolution?

Abstract: Ultrasound (US) with duplex Doppler scanning has spread to the capillary level, becoming an irreplaceable tool in daily clinical practice thanks to its characteristics: low cost, repeatability, and noninvasiveness. Moreover, US has become over time more sensitive and accurate; it can be considered an extension of the clinician’s hand. For this reason, it currently represents the ideal tool for first-level diagnostic use in several fields, and is the simplest and most flexible instrument for obtaining morphological and functional information on different organs, including the kidneys. In this issue of The Journal , Gigante, et al 1 propose to assess renal involvement in patients with systemic sclerosis (SSc) through the evaluation of both structural and hemodynamic US measurements, paying particular attention to the Doppler-measured renal resistive index (RRI) and its clinical significance. This index has a relatively recent history and an unfortunate name: resistance index (or resistive index ). It was initially proposed by Gosling and King2 and Pourcelot3 in 1974 to identify the renal vascular diseases through the noninvasive measurement of intrarenal hemodynamics indirectly related to changes in arteriolar resistance. For a long time, the role of RRI has remained confined to renal damage, and it has been used as an important marker to predict the progression of renal function in patients with chronic kidney disease (CKD), diabetes mellitus, or hypertension (HTN). Its prognostic value has been studied only in the context of purely kidney diseases, with inconsistent results4. Over the years many authors have tried to find a correct interpretation of the RRI, and several studies have shown that it was minimally affected by intrarenal resistance: unexpectedly, the correlation between RRI values and changes in renal vascular impedance proved to be weak. Through in vitro studies, Tublin, et al observed that the RRI was dependent on … Address correspondence to Dr. G. Geraci, University of Palermo, Via del Vespro 141, 90127 Palermo, Italy. E-mail: giulio.geraci{at}unipa.it