Aggressive Blood Pressure Control Research Articles

Epidemiological Profile and Correlates for Left Ventricular Diastolic Dysfunction among Patients Attending a Tertiary Health Facility in India

Background: There is an increasing recognition that congestive heart failure (CHF), caused by diastolic dysfunction (DD) (diastolic heart failure), is common and causes significant morbidity and mortality. Methods: The institution-based cross-sectional study was conducted among 119 subjects to determine the epidemiological profile, and regression analysis was used to evaluate the association of clinico-social correlates with the likelihood of developing DD. Result: The mean age of subjects was 51.6(±17.7) years. The mean systolic (SBP) and diastolic blood pressures (DBP) were 130(±18.9) mm Hg and 82.1(±11.1) mm Hg, respectively. Thirty-three (27.7%) subjects were hypertensive. Twelve (10%) were diabetic and experienced heart failure. DD was present in 54 (45.4%) subjects. Age, diabetes, ejection fraction (EF), and interventricular septal thickness in diastole (IVSd) were significant (P < 0.05) correlates of DD. Mean values of age, body mass index (BMI), EF, IVSd, and left ventricular posterior wall thickness in diastole (LVPWD) were higher in subjects with DD. Hypertension contributed to 1.63 times greater odds of developing DD. Conclusion: The prevalence of DD increased with age among hypertensive and diabetic participants. Preventive strategies directed toward identifying subclinical signs of early stage and aggressive blood pressure and blood sugar control are likely to offer the greatest promise for reducing the incidence of DD.

Code-ICH: A New Paradigm for Emergency Intervention.

Intracerebral hemorrhage (ICH) is the most devastating type of stroke, causing widespread disability and mortality. Unfortunately, the acute care of ICH has lagged behind that of ischemic stroke. There is an increasing body of evidence supporting the importance of early interventions including aggressive control of blood pressure and reversal of anticoagulation in the initial minutes to hours of presentation. This review highlights scientific evidence behind a new paradigm to care for these patients called Code-ICH. While numerous trials aimed at decreasing hematoma expansion through single interventions had failed to show statistically significant effects on primary outcomes, time-sensitive, multifaceted, bundled care approaches have recently shown substantial promise in improving functional outcomes in patients with ICH. The concept of Code-ICH can serve as a structural platform for the practice of acute care neurology to continuously measure its performance, reflect on best practices, advance care, and address disparities.

Transfusion-Associated Reversible Cerebral Vasoconstriction Syndrome in Pediatrics: A Case Report and Review of Literature

Background Reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication of packed red blood cell (pRBC) transfusion primarily reported in adults with severe chronic anemia due to menorrhagia. It is characterized by a triad of rapidly changing and reversible segmental cerebral artery narrowing and dilatation, thunderclap headache, and benign cerebrospinal fluid findings. 1,2 More than 50% of patients experience blurring of vision or cortical vision loss, and a subset of patients develop hemiparesis or aphasia. 1 There are emerging case reports of RCVS in pediatric patients, however the literature examining this transfusion complication in children is limited. The rarity and potential severity of RCVS warrants better understanding by pediatric hematology and transfusion providers. Results We describe a previously healthy 4 year-old male who presented with pallor and laboratory parameters consistent with severe iron deficiency anemia. Chest x-ray showed cardiomegaly, and echocardiogram demonstrated pericardial effusion, moderate left ventricular dilation, and moderate coronary artery dilatation. His history was notable for an extremely selective diet and at least 50 ounces of cow's milk daily. The patient was admitted, and over the course of 3 days, he received a total of 43 mL/kg of pRBCs (602 mL total) in 8 aliquots, and his hemoglobin (Hgb) increased from 1.4 g/dL to 11.4 g/dL (Fig. 1). He then re-presented 5 days after discharge with altered mental status and malignant hypertension. Brain MRI/MRA was consistent with RCVS, with luminal irregularities in multiple anterior and posterior circulation intracranial arteries creating a beaded appearance. He was treated supportively with aggressive blood pressure control and made a complete neurologic recovery 8 days after presentation. At hematology clinic follow-up 2 months post-discharge, he remained at his typical neurologic baseline. Conclusions The connection between blood transfusion and RCVS is postulated to be due to a rapid increase in hematocrit and blood viscosity, which alters cerebral autoregulation and leads to hypertensive encephalopathy despite systemic normotension. 3 The increased viscosity may also lead to vasospasm. 3 When a patient with severe chronic anemia receives a pRBC transfusion, there is increased cerebral blood flow and viscosity, resulting in decreased vasodilation, increased vascular resistance, and cerebral vessel constriction. However, these are hypothesized mechanisms with little supportive experimental data. Vasculopathies and vasoconstrictive medications 2 are also risk factors for RCVS. There are 4 previous reported cases of pediatric RCVS associated with pRBC transfusion. 2 patients were acutely ill with complications of sickle cell anemia. 7,9 Another case occurred in a patient with systemic lupus erythematosus 8, and the fourth occurred in the setting of severe iron deficiency anemia. 5 Several features of our patient's clinical course are similar to the reported cases of transfusion-related RCVS 5 and warrant highlighting: 1) severe chronic anemia with cardiac dysfunction and 2) the large volume of transfused pRBCs over a short period resulting in a significant increase in Hgb. However, our patient developed symptoms of RCVS sooner than other published cases and did not have seizure or stroke. Pediatric guidelines recommend pRBC transfusion for Hgb levels between 5-10 g/dL, depending on the clinical scenario. 4 There are few data to guide Hgb targets for pediatric patients presenting with severe anemia. Over-transfusion does not offer physiological benefit and poses risk of transfusion-related adverse events. A case report from Dou et al 6 proposed that a >5 g/dL Hgb increase was associated with a greater likelihood of developing RCVS. For this patient with cardiac dysfunction and social concerns including lack of primary care, the potential benefits of achieving a higher Hgb with pRBC transfusions were prioritized. RCVS should be considered in pediatric and adult patients recently transfused for chronic severe anemia presenting with headaches or other neurological symptoms. Prompt recognition of RCVS may prevent unnecessary treatment and potentially limit risk of neurologic compromise. The role of the volume and rapidity of the pRBC transfusions in the development of RCVS warrants further study. Fig 1. Timeline of initial presentation, detailing blood transfusions

Class A ventral spinal epidural hematoma as a rare complication of hypertensive crisis

Spinal epidural hematoma is a rare but severe medical condition that can cause neurological deficits and disability. In this case report, a 53-year-old man with poorly controlled hypertension and end-stage renal disease presented with hypertensive crisis and a one-week history of symptoms including back pain, abdominal pain, and pain radiating down his legs. Despite aggressive blood pressure control, the patient was found to have a 21mm ventral epidural hematoma at T10 causing thoracic cord compression and paraplegia. The patient underwent surgical hematoma evacuation but remained paraplegic with minimal motor and sensory recovery. Spinal epidural hematoma as a complication of hypertensive crisis is rare. Clinicians should be aware of the potential development of spinal epidural hematoma in patients with hypertensive crisis, even in cases with no obvious risk factors. Prompt diagnosis and treatment are crucial for preventing permanent neurological damage and improving patient outcomes. Further research is needed to better understand the underlying mechanisms and risk factors for spinal epidural hematoma in patients with hypertensive crisis.

Abstract P475: Left Ventricular Hypertrophy Prevalence by Electrocardiogram in Patients Presenting With Cerebrovascular Accident

Background: A strong association has been previously suggested between left ventricular hypertrophy (LVH) and stroke. The prevalence of LVH and hypertension, however, differs depending on demographic variables. In light of the most recent hypertension guidelines, more aggressive blood pressure control is called for to achieve the lower goals set forth. This will hopefully translate into lower incidence of LVH and stroke. Objectives: To examine the prevalence of left ventricular hypertrophy in patients receiving an electrocardiogram (EKG) for a diagnosis of stroke, transient ischemic attack, or cerebrovascular accident; all of which will be referred to as CVA. Methods: An EKG database from a university cardiology noninvasive lab was examined for the diagnosis of CVA over a one year period. The EKGs were evaluated for the presence of LVH or atrial fibrillation/flutter. The results were analyzed using Chi square test. Results: There was a total of 14,798 EKGs performed over one year. There were 272 EKGs with a diagnosis of CVA (1.7%); 2364 EKGs (16%) with diagnosis of LVH, and 481 (3.2%) with diagnosis of atrial fibrillation/flutter. Out of the 272 EKGs in patients with CVA diagnosis, there were 174 EKGs in sinus rhythm without LVH (64%), 78 EKGs in sinus rhythm with LVH (29%, P < 0.05), and 20 EKGs in atrial fibrillation or atrial flutter (7.4%, P < 0.05). Discussion: Stroke is a major health problem associated with increased mortality and morbidity. While atrial fibrillation and atrial flutter are well-established causes of stroke and were nearly twice as frequent in CVA patients as the general population in our cohort, LVH by EKG, in the absence of atrial fibrillation/flutter, was also nearly twice as prevalent, underscoring its importance as a potential marker for CVA. Hypertension is a well established risk factor for stroke in addition to cardiovascular events, and is a major cause of LVH on EKG. In our cohort nearly one third of patients with stroke were in sinus rhythm, but had left ventricular hypertrophy by EKG, a prevalence that was nearly four times that of atrial fibrillation/flutter. Since hypertension is the most common cause of left ventricular hypertrophy in our population, this places further significance on hypertension as a major modifiable risk factor and predictor of CVA and cardiovascular disease in general. In light of the most recent hypertension guidelines, aggressive blood pressure management to achieve the newly defined lower limits for a diagnosis of hypertension, with monitoring for signs of left ventricular hypertrophy by EKG, should be emphasized in order to decrease the incidence of stroke and other cardiovascular events.

Posterior reversible encephalopathic syndrome in systemic lupus erythematous: A case report

Posterior reversible encephalopathy syndrome (PRES) implies to a reversible subcortical vasogenic brain edema, which leads to some acute neurological symptoms. PRES occurs usually in the setting of renal failure, blood pressure fluctuations, cytotoxic drugs, autoimmune disorders, and pre-eclampsia or eclampsia.This is a 40 year old female patient with history of systemic lupus erythematous (SLE) from twenty years ago, admitted to our neurology ward due to severe and refractory headache with multiple convulsive events.Brain MRI showed vasogenic brain edema in occipito-parieto-frontal lobes white matter compatible with PRES. Treatment is omitting of the etiology, but in these patients, discontinuation of immunosuppressive drugs is not possible and probably intravenous methylprednisolone pulse is a good treatment option especially in patient without response to aggressive control of blood pressure.

A computational study of aortic insufficiency in patients supported with continuous flow left ventricular assist devices: Is it time for a paradigm shift in management?

De novo aortic insufficiency (AI) following continuous flow left ventricular assist device (CF-LVAD) implantation is a common complication. Traditional early management utilizes speed augmentation to overcome the regurgitant flow in an attempt to augment net forward flow, but this strategy increases the aortic transvalvular gradient which predisposes the patient to progressive aortic valve pathology and may have deleterious effects on aortic shear stress and right ventricular (RV) function. We employed a closed-loop lumped-parameter mathematical model of the cardiovascular system including the four cardiac chambers with corresponding valves, pulmonary and systemic circulations, and the LVAD. The model is used to generate boundary conditions which are prescribed in blood flow simulations performed in a three-dimensional (3D) model of the ascending aorta, aortic arch, and thoracic descending aorta. Using the models, impact of various patient management strategies, including speed augmentation and pharmacological treatment on systemic and pulmonary (PA) vasculature, were investigated for four typical phenotypes of LVAD patients with varying degrees of RV to PA coupling and AI severity. The introduction of mild/moderate or severe AI to the coupled RV and pulmonary artery at a speed of 5,500 RPM led to a reduction in net flow from 5.4 L/min (no AI) to 4.5 L/min (mild/moderate) to 2.1 L/min (severe). RV coupling ratio (Ees/Ea) decreased from 1.01 (no AI) to 0.96 (mild/moderate) to 0.76 (severe). Increasing LVAD speed to 6,400 RPM in the severe AI and coupled scenario, led to a 42% increase in net flow and a 16% increase in regurgitant flow (RF) with a nominal decrease of 1.6% in RV myocardial oxygen consumption (MVO2). Blood pressure control with the coupled RV with severe AI at 5,500 RPM led to an 81% increase in net flow with a 15% reduction of RF and an 8% reduction in RV MVO2. With an uncoupled RV, the introduction of mild/moderate or severe AI at a speed of 5,500 RPM led to a reduction in net flow from 5.0 L/min (no AI) to 4.0 L/min (mild/moderate) to 1.8 L/min (severe). Increasing the speed to 6,400 RPM with severe AI and an uncoupled RV increased net flow by 45%, RF by 15% and reduced RV MVO2 by 1.1%. For the uncoupled RV with severe AI, blood pressure control alone led to a 22% increase in net flow, 4.2% reduction in RF, and 3.9% reduction in RV MVO2; pulmonary vasodilation alone led to a 18% increase in net flow, 7% reduction in RF, and 26% reduction in RV MVO2; whereas, combined BP control and pulmonary vasodilation led to a 113% increase in net flow, 20% reduction in RF and 31% reduction in RV MVO2. Compared to speed augmentation, blood pressure control consistently resulted in a reduction in WSS throughout the proximal regions of the arterial system. Speed augmentation to overcome AI in patients supported by CF-LVAD appears to augment flow but also increases RF and WSS in the aorta, and reduces RV MVO2. Aggressive blood pressure control and pulmonary vasodilation, particularly in those patients with an uncoupled RV can improve net flow with more advantageous effects on the RV and AI RF.

Blood pressure control in hypertensive disorders of pregnancy

Hypertension is a major cause of maternal morbidity and occurs as a complication in up to one in ten pregnancies. Hypertensive disorders of pregnancy encompass gestational hypertension, preeclampsia, chronic hypertension, and chronic hypertension with superimposed preeclampsia. However, the management of hypertensive disorders of pregnancy remains a matter of debate, particularly the blood pressure thresholds and targets for managing hypertension in pregnancy. Previously, there was no clear evidence of the effectiveness of aggressive blood pressure control in pregnancy due to the risk of fetal growth restriction. Recent clinical trials have shown that aggressive control of blood pressure in pregnant women is safe for both the mother and fetus. The purpose of this paper is to present a clinically oriented guide to the drugs of choice in patients with hypertension during pregnancy, present contrasts among different guidelines and recent clinical trials, and discuss the blood pressure thresholds and targets for hypertension during pregnancy based on recent studies.

Lobar intracerebral hemorrhage and risk of subsequent uncontrolled blood pressure.

Uncontrolled blood pressure (BP) in intracerebral hemorrhage (ICH) survivors is common and associated with adverse clinical outcomes. We investigated whether characteristics of the ICH itself were associated with uncontrolled BP at follow-up. Subjects were consecutive patients aged ⩾18 years with primary ICH enrolled in the prospective longitudinal ICH study at Massachusetts General Hospital between 1994 and 2015. We assessed the prevalence of uncontrolled BP (mean BP ⩾140/90 mmHg) 6 months after index event. We used multivariable logistic regression models to assess the effect of hematoma location, volume, and event year on uncontrolled BP. Among 1492 survivors, ICH was lobar in 624 (42%), deep in 749 (50%), cerebellar in 119 (8%). Lobar ICH location was associated with increased risk for uncontrolled BP after 6 months (OR 1.35; 95% CI [1.08-1.69]). On average, lobar ICH survivors were treated with fewer antihypertensive drugs compared to the rest of the cohort: 2.1 ± 1.1 vs 2.5 ± 1.2 (p < 0.001) at baseline and 1.8 ± 1.2 vs. 2.4 ± 1.2 (p < 0.001) after 6 months follow-up. After adjustment for the number of antihypertensive drugs prescribed, the association of lobar ICH location with risk of uncontrolled BP was eliminated. ICH survivors with lobar hemorrhage were more likely to have uncontrolled BP after 6 months follow-up. This appears to be a result of being prescribed fewer antihypertensive medications. Future treatment strategies should focus on aggressive BP control after ICH independent of hemorrhage location.

Drug utilization study of anti-hypertensive drugs and prescription pattern adherence with joint national committee-8 guideline

Background: Hypertension is a major and serious non-communicable disease. It is also a major risk factor for cerebrovascular strokes, coronary artery thrombosis, and renal failure. The overall prevalence of hypertension in India is 29.8%. Joint national committee-8 guidelines on prevention, detection, evaluation, and treatment of high blood pressure highlight that aggressive blood pressure control is essential for the reduction of hypertension-associated morbidity and mortality.Methods: It was a cross-sectional, observational study. Prescriptions were collected from four pharmacy stores located in four different areas of Ahmedabad over a period of 2 months. These were analysed along with relevant co-morbidities and, the level of prescription pattern adherence was assessed as per JNC 8 guidelines. Appropriate statistical tests were applied for analyses of collected data.Results: A total of 321 prescriptions were collected. Out of them, 186(57.9%) were prescribed to male patients while 135 (42.1%) were for female patients. Mean systolic and diastolic blood pressure was found to be 152 mmHg and 91 mmHg respectively. The mean age of the patients was found to be 44.63 years. A total of 209 (65.1%), 91 (28.34%), 21 (6.54%) prescriptions had monotherapy, dual therapy, and polytherapy for treating hypertension respectively. Amlodipine (CCBs) was found to be the most commonly prescribed medicine as a monotherapy. The overall adherence rate was found to be 77.88%.Conclusions: The present study demonstrated that medical professionals are not completely adhering to standard guidelines while prescribing antihypertensive drugs. There is substantial scope for improvement, particularly the utilization of antihypertensive agents in patients of the pre-hypertension category, where non-pharmacological measures play an important role to treat the condition.

A Computational Study of Aortic Insufficiency in Patients Supported with Left Ventricular Assist Devices

<h3>Purpose</h3> Aortic insufficiency (AI) following left ventricular assist device (LVAD) implantation is common. Speed augmentation to overcome the regurgitant flow (RF) is used but this leads to progressive AI and may have deleterious effects on shear stress (SS) and the right ventricle (RV). <h3>Methods</h3> We employed a closed-loop mathematical model of the cardiovascular system to generate boundary conditions for blood flow simulations performed in a three-dimensional (3D) model of the aortic arch. AI was introduced and the impact of speed augmentation and blood pressure control on SS and RV oxygen consumption (MVO2) were determined in a model with a coupled and uncoupled RV. <h3>Results</h3> Addition of severe AI to the coupled RV at 5500 RPM led to a reduction in net flow from 5.4 L/min (no AI) to 2.1 L/min (severe). Increasing speed to 6400 RPM in the severe AI and coupled RV, led to a 42% increase in net flow and a 16% increase in RF with a nominal decrease of 0.9% in RV MVO2. Blood pressure control with the coupled RV with severe AI at 5500 RPM led to an 81% increase in net flow with a 15% reduction RF and an 8% reduction in RV MVO2 (Fig A). With an uncoupled RV, addition of severe AI at 5500 RPM led to a reduction in net flow from 5.0 L/min (no AI) to 1.8 L/min (severe). Increasing speed to 6400 RPM with severe AI and uncoupled RV increased net flow by 45%, RF by 15% and RV MVO2 by 4.2%. For the uncoupled RV with severe AI, blood pressure control alone led to a 22% increase in net flow, 4.2% reduction in RF and 6.1% reduction in RV MVO2; whereas combined BP control and pulmonary vasodilation led to a 113% increase in net flow, 20% reduction in RF and 41% reduction in RV MVO2 (Fig B). Compared to speed augmentation, blood pressure control consistently resulted in a reduction in SS (Fig C). <h3>Conclusion</h3> Speed augmentation to overcome AI in patients supported by CF-LVAD will augment flow but at the expense of RV MVO2, RF and SS. Aggressive blood pressure control and pulmonary vasodilation can improve net flow with more advantageous effects on the RV and aortic valve integrity.

Abstract P116: Hypertension Severity As Quantified By Hypertension Daily Dose (HDD) And Blood Pressure And Risk Of Stroke In The REGARDS Study

Background: Hypertension is a modifiable stroke risk factor, but hypertension severity isn't completely captured by blood pressure (BP) alone. Prior studies have shown that among adults with similar systolic BP, those taking a greater number of antihypertensive medications have greater stroke risk. However, count of antihypertension medications does not consider relative dose across classes and incompletely characterizes hypertension medical therapy. The recently described Hypertension Daily Dose (HDD) metric quantifies total dose of BP-lowering medications across multiple classes. The association between HDD and BP with stroke risk is unknown. Objective: Determine stroke risk by HDD and BP levels. Methods: We included Black and White adults from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study without prevalent stroke at visit 2 (2013-2017; treated as baseline) with follow-up data and full BP assessment. We classified systolic BP using JNC7 groupings and HDD by no BP medications and tertiles among those on BP medications. Cox proportional hazards models estimated hazard ratios (HR) for incident stroke by HDD group and BP group. Results: Of 13,265 participants included (mean age 72 [SD 8.5], 36% Black race, 56% women), 344 incident stroke events occurred during a median follow-up of 5.5 years. The stroke rate was higher among Black than White participants (5.6 vs. 5.0/1000 person-years). Relative to no BP medications and normotension, those with systolic BP ≥140 mm Hg and HDD in tertiles ≥2 had a 2.3x to 3.7x greater risk of incident stroke ( Table ). Those with systolic BP &lt;140 mm Hg had similar stroke risk across HDD groupings. Conclusion: Among Black and White US adults without prevalent stroke, higher HDD was associated with greater risk of incident stroke in those with systolic BP ≥140 mm Hg, possibly reflecting greater disease severity and treatment resistance. These findings support aggressive BP control with antihypertensive medications to lower stroke risk among adults with hypertension.

Abstract TP191: Three-month Daily Blood Pressure Monitoring Predicts Incident Stroke In CADASIL

Introduction: CADASIL is a hereditary small vessel disease caused by NOTCH3 mutations. Whether superimposed hypertension had harmful effects on these populations was unknown. Methods: We recruited 100 participants in the prospective cohort of Taiwan CADASIL Registry with documented NOTCH3 mutations , as well as 18 age- and sex-matched controls. Daily blood pressure (BP) and heart rate (HR) were recorded by the participants with a standardized home-based sphygmomanometer for consecutive 90 days. Linear analysis of the variability parameters was done. Neuroimaging markers of small vessel disease on brain magnetic resonance imaging and any incident stroke was documented. Results: Participants with NOTCH3 mutations are more likely to have stroke history and use antithrombotic or antihypertensive medications than controls. However, the systolic, diastolic BP, and pulse pressure were comparable, except for higher mean HR (77.3±10.0 vs 70.7±8.3, P =0.01) in the NOTCH3 group. In participants with NOTCH3 mutations, higher 90-day mean systolic and diastolic BP correlated with more cerebral microbleeds, while the mean, standard deviation, coefficient of variation, and average real variability of 90-day HR positively correlated with number of lacunes. During median follow-up of 24 months, there were 8 stroke events (5 ischemic, 3 hemorrhagic). Participants with persistent hypertension (90-day mean systolic/diastolic BP &gt; 130/80 mmHg) were more likely to have incident stroke (log-rank P = 0.04), and the effects persisted (hazard ratio 5.29, 95% CI 1.12 - 25.1) after adjustment of number of cerebral microbleeds. Conclusions: In participants with NOTCH3 mutations, persistent hypertension had detrimental effects on the severity of cerebral microbleeds as well as incident stroke. Aggressive blood pressure control seems beneficial in hereditary small vessel disease.

The atrial fibrillation paradox -connecting hypertension to atrial disease and stroke

A “double paradox” exists in the understanding of racial differences in the association between traditional cardiovascular (CV) risk factors, the incidence and prevalence atrial fibrillation (AF), and the increased incidence of ischemic stroke. Simply stated, Black persons have an increased number of CV risk factors yet less AF. Despite lower incidence of AF, Black individuals have higher rates of stroke and systemic embolism. This important public health challenge is notable, given that, despite a significant decline in overall stroke mortality rates since the 1950s, age-adjusted stroke death rates have remained higher in Black versus White individuals through 2008.[2] The purpose of this review is to examine the risk of ischemic stroke in Black persons and provide a summary of options to improve the recognition of individual risk and reinforce preventive care. Consider the following concepts: • Black individuals have more traditional CV risk factors and higher rates of ischemic stroke, than their non-Hispanic White counterparts, yet a lower incidence and prevalence of AF. • The difference in the incidence of AF does not fully explain the differences in stroke risk • The explanation for these differences is likely complex and leads to the following questions. ○ Should researchers and clinicians reassess the way atrial disease and embolic risk are defined in specific populations? ○ Do traditional risk factors for AF account for increased stroke risk in select patient populations which also needs to be re-evaluated in the context of stroke reduction. As with prior work[1,17,18,19,21] which has addressed the “AF Paradox” this review supports the concept of atrial disease - including atrial fibrillation - as a continuum. There also appears to be a risk of stroke associated with this continuum in the absence of a diagnosis of AF.[1,18,21] These factors alone do not account for the differences in overall stroke rates in Black persons. In addition to a revision on the views of atrial disease, there should be a renewed emphasis early and aggressive blood pressure control – as well as other risk factor management – in Black individuals to affect the differences in stroke rates. The objective of this review is to re-examine the specific role of hypertension in atrial disease and perceptions on stroke risk, AF and possible differences between Black and White individuals.

747 A Case Report: Spontaneous Recovery of Type B Aortic Dissection

Abstract Introduction An aortic dissection occurs when there is a tear in the intimal and medial layer of the aorta, leading to a false lumen within the media. Type B aortic dissections (TBAD), according to the Stanford Classification are where the entry tear is located distally from the left subclavian artery. Resolution of a Type B aortic dissection (TBAD) by medical therapy is a very rare event. Case Presentation 58-year-old gentleman presented with sudden onset central chest pain. A CTPA was organised following a high d-dimer. This showed a TBAD extending from the origin of the left subclavian artery to the level of the diaphragm. His blood pressure was aggressively controlled with IV labetalol and IV isosorbide dinitrate and was monitored for 2 weeks. He was then discharged home on oral antihypertensive medication. A follow up CT aortogram was done 7 months later which showed that the false lumen of the TBAD has improved from 18mm to 2 mm. Discussion The anti-inotropic effect of beta blockers reduces the stress on the aortic wall and therefore prevents further dilatation. Aggressive control of blood pressure and heart rate comes with its own disadvantages. It had been shown, patients managed conservatively were more likely to develop renal failure (43%) compared to those having endovascular repair. About half of those patients required surgical treatment. There are not many cases in literature where a TBAD had resolved with medication. Conclusions As evident from this case, rigorous management of blood pressure may help with cases of Type B Dissection.

The role of brain natriuretic peptide in atrial fibrillation: a substudy of the Substrate Modification with Aggressive Blood Pressure Control for Atrial Fibrillation (SMAC-AF) trial

BackgroundCatheter ablation is an established therapy for atrial fibrillation but is limited by recurrence; efforts have been made to identify biomarkers that predict recurrence. We investigated the effect of baseline NT-proBNP on AF recurrence following catheter ablation in patients randomized to aggressive (< 120/80 mmHg) or standard blood pressure management (< 140/90 mmHg) in the Substrate Modification with Aggressive Blood Pressure Control trial (SMAC-AF).MethodsThe SMAC-AF study included 173 patients resistant or intolerant to at least one class I or III antiarrhythmic drug. We studied the effect of baseline NT-proBNP on the primary outcome of AF recurrence > 3 months post-ablation.ResultsOf the 173 patients, 88 were randomized to the aggressive cohort, and 85 into the standard group. The primary outcome occurred in 61.4% of those in the aggressive arm, versus 61.2% in the standard arm. In the aggressive group, logNT-proBNP predicted recurrence (HR 1.28, p = 0.04, adjusted HR 1.43, p = 0.03), while in the standard cohort, it did not (HR 0.94, p = 0.62, adjusted HR 0.83, p = 0.22). NT-proBNP ≥ 280 pg/mL also predicted occurrence in the aggressive (HR 1.98, p = 0.02) but not the standard cohort (HR 1.00, p = 1.00).ConclusionWe conclude that pre-ablation NT-proBNP may be useful in predicting recurrence in hypertensive patients and identifying patients who benefit from aggressive blood control and upstream therapies.Trial registration: NCT00438113, registered February 21, 2007.

Склеродермический почечный криз: вопросы патогенеза, клиника и современные подходы к лечению

Склеродермический почечный криз (СПК) является одним из самых тяжелых осложнений у пациентов с системной склеродермией (ССД). СПК возникает примерно у 5–25 % пациентов, страдающих склеродермией. Он характеризуется злокачественной гипертензией и олиго-/анурической острой почечной недостаточностью. Около 10 % случаев СПК могут сопровождаться нормальным артериальным давлением — это так называемый нормотензивный почечный кризис. Предполагается, что этиопатогенез СПК обусловлен повреждением почек, что приводит к поражению эндотелия, пролиферации интимы и сужению почечных артериол, вызывая снижение кровотока, гиперплазию юкстагломерулярного аппарата, гиперренинемию и развитие злокачественной артериальной гипертензии. Развитие СПК у пациентов с ССД часто провоцируется нефротоксичными препаратами или уменьшением внутрисосудистого объема крови. СПК наиболее часто встречается в первые годы развития склеродермии и при диффузной ее форме. Появление СПК чаще встречается у пациентов, получающих глюкокортикоиды, риск увеличивается с увеличением дозы. Характерные также такие клинические признаки, как левожелудочковая сердечная недостаточность и гипертоническая энцефалопатия. Тромботическая микроангиопатия появляется в 43 % случаев СПК. Антитела к РНК-полимеразе III присутствуют у одной трети больных, у которых развился СПК. При классическом течении СПК проведение нефробиопсии не рекомендуется. Однако этот метод исследования может помочь определить прогноз и методы лечения при нетипичных формах. Прогноз СПК резко улучшился с использованием ингибиторов ангиотензинпревращающего фермента. Однако выживаемость в течение 5 лет у пациентов с СПК остается низкой (65 %). Лечение СПК опирается на агрессивный контроль артериального давления с помощью ингибиторов ангиотензинпревращающего фермента, если необходимо сочетание с другими видами антигипертензивных препаратов. Довольно часто больные нуждаются в проведении гемодиализа, но при контроле артериального давления он может быть прекращен. Пациентам, которым необходим диализ более 2 лет, показана трансплантация почек. СПК остается важной причиной заболеваемости и смертности при склеродермии. Быстрая диагностика и лечение могут помочь предотвратить неблагоприятные последствия и улучшить выживание таких пациентов.

Influence of Hypertension on Open Aortic Repair Outcomes in Patients With Marfan Syndrome

Patients with Marfan syndrome are generally treated with aggressive blood pressure control in order to reduce aortic dilation and the risk of dissection. Optimal perioperative blood pressure management must balance the deleterious effects of relative hypotension and hypertension. This study aims to examine the effect of blood pressure and hypertensive history in patients undergoing open aortic repair.

Cushing Syndrome Complicated by Multiple Pathological Spinal Fractures and Posterior Reversible Encephalopathy Syndrome in the Post-delivery Phase

A 28-year-old female with central obesity, moon face and multiple sites of acne vulgaris began to experience generalized convulsions after complaining of severe back pain during hospitalization on post-first-delivery day 5. After an infusion of diazepam, she showed severe hypoxia and underwent tracheal intubation. She had a history of gestational diabetes mellitus (DM), acne vulgaris, osteoporosis and thoracolumbar fracture. She also felt severe back pain after falling down two weeks previously and underwent Caesarean section. Her blood pressure was remained 100–160 mmHg during the perinatal period. Whole body computed tomography revealed bilateral low density in the parieto-occipital white matter, bilateral aspirated lesions in her lungs, and enlargement of the right adrenal gland. The tentative diagnosis was posterior reversible encephalopathy syndrome (PRES) with convulsion, aspirated pneumonia and Cushing syndrome with DM and pathological fracture due to osteoporosis. She underwent an infusion of levetiracetam, sedatives, analgesics and a depressor were administered to control blood pressure strictly. She was extubated two days after her respiratory function showed improvement. After controlling her pain and treating osteoporosis, a blood test was compatible with Cushing syndrome. She finally underwent adenectomy in four months. Pathology was adenoma. This is a rare case of Cushing syndrome complicating pathological spinal fractures and PRES in the post-delivery phase. Aggressive control of pain and blood pressure in the perinatal period may be required to prevent the onset of PRES.

Carfilzomib-Induced Pneumotoxicity in a Lung Transplant Recipient

Introduction Development of de novo donor-specific antibodies (DSA) in lung transplant (LTx) recipients is a risk factor for antibody-mediated rejection (AMR). There is no consensus on treatment protocols for patients who develop de novo DSA, but strategies include plasmapheresis (PLEX), intravenous immunoglobulin (IVIG), and carfilzomib (CFZ), a second-generation proteasome inhibitor. Dyspnea is common in patients with multiple myeloma treated with CFZ; however, lung injury in LTx recipients has not been reported. We report a case of CFZ-related pneumotoxicity in a bilateral LTx recipient undergoing treatment for possible AMR. Case Report A 71-year-old bilateral LTx recipient (October 2011) with moderate mitral regurgitation was diagnosed with probable AMR in June 2018, characterized by de novo DSA (DQ7, MFI 20,634) and FEV1 decline, but no radiographic changes or capillaritis. He was treated with PLEX, IVIG, and rituximab and had monthly PLEX/IVIG until January 2020. He tolerated the treatment well and his FEV1 stabilized. After a 5-month moratorium of PLEX/IVIG, the patient's MFI increased from 4,337 in November 2019 to 15,444 in June 2020; however, FEV1 remained stable. PLEX was resumed and CFZ was administered in August 2020, which led to a hypertensive emergency, hypoxemic respiratory failure requiring mechanical ventilation, renal failure requiring continuous renal replacement therapy, and corticosteroid therapy for persistent hypoxemia and radiographic infiltrates despite a negative fluid balance. He was extubated, his renal function recovered, and he was discharged home on supplemental oxygen and a corticosteroid taper. On outpatient follow-up, he had a 600-ml drop in FEV1, complained of severe dyspnea on exertion with hypoxemia, appeared euvolemic on physical exam, and was readmitted with evidence of ongoing lung injury. Radiographic infiltrates and hypoxemia improved with additional steroid therapy. Summary A bilateral LTx recipient presented with hypoxemic respiratory failure immediately after a 5-day course of PLEX and an infusion of CFZ. Although volume overload was a factor, persistent lung injury despite aggressive diuresis and blood pressure control suggests CFZ pneumotoxicity. Although the mechanism of CFZ lung injury is not understood, it appears to be steroid responsive, both in our patient and in other cases of proteasome inhibitor-induced pneumotoxicity.