Aggressive Blood Pressure Control Research Articles

The Unsolved Conundrum of Optimal Blood Pressure Target During Acute Haemorrhagic Stroke: A Comprehensive Analysis.

Intracerebral haemorrhage (ICH) is a devastating cerebrovascular disease, which accounts to 15% of all strokes. Among modifiable risk factors for ICH, hypertension is the most frequent. High blood pressure (BP) is detected in more than 75-80% of patients with ICH. Extremely elevated BP has been associated with early hematoma growth, a relatively frequent occurrence and powerful predictor of poor outcome in patients with spontaneous ICH. On the other hand, excessively low BP might cause cerebral hypoperfusion and ultimately lead to poor outcome. This review will analyse the most important trials that have tried to establish how far should BP be lowered during acute ICH. These trials have demonstrated either a small non-significant benefit (INTERACT-2, INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial) or no benefit (ATACH-2, Antihypertensive treatment of acute cerebral haemorrhage II study) when intensive systolic BP reduction was compared with modest or standard BP reduction. The more recent meta-analyses including studies investigating this issue yielded similar conclusions: aggressive BP control in the acute phase of ICH is not beneficial. For these reasons the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the management of arterial hypertension, do not recommend treatment to immediately lowerBPin patients with acute ICH and systolic BP < 220mmHg. Careful lowering of SBP to less than 180mmHg via i.v. Infusion may be considered only in patients with SBP ≥ 220mmHg.

Remodeling of the Feeding Arterial System After Surgery for Resection of Brain Arteriovenous Malformations: An Observational Study.

Avoiding the risk of postoperative hemorrhage after brain arteriovenous malformation (AVM) resection involves aggressive blood pressure control. Remodeling of the feeding arterial system is critical in reducing this risk. To investigate factors predicting time to return to normal on digital subtraction angiography (DSA) after AVM resection. For AVM in which the largest feeding artery (FA) on DSA was in the anterior circulation, the preoperative and postoperative diameter of the FA were compared with the diameter of the internal carotid artery (IC) immediately proximal to the posterior communicating artery. The preoperative FA/IC ratio (FA/IC preAVM) was compared with the first postoperative FA/IC ratio (FA/IC postAVM). Normal FA/IC ratio (FA/IC normal) was established from matched arteries in the contralateral hemisphere to the AVM. Eighty-six patients were analyzed for postoperative DSA performed a median 4 d after resection. From the interval-censored proportional hazards regression analysis, FA/IC preAVM (hazard ratio of 0.0006; 95% confidence interval: 0.00-0.21; P=.013) and maximum AVM diameter (hazard ratio of 0.47; 95% confidence interval: 0.23-0.95; P=.036) were significant in time to return to normal. These 2 factors were poorly correlated with each other (r=0.41). AVMs with FA/IC preAVMs <0.57 combined with a diameter <3.0 cm normalize within 7 d in more than 50% of cases. Any other combination of ratio and size has fewer than 20% normalizing within 7 d (log rank P<.001). FA/IC preAVM and AVM size are both important in predicting the time taken for return to normal feeding arterial system on DSA after AVM resection.

Global Impact of the 2017 American College of Cardiology/American Heart Association Hypertension Guidelines.

Global Impact of the 2017 American College of Cardiology/American Heart Association Hypertension Guidelines.

Modifiable Predictors of Ventricular Ectopy in the Community.

BackgroundPremature ventricular contractions (PVCs) predict heart failure and death. Data regarding modifiable risk factors for PVCs are scarce.Methods and ResultsWe studied 1424 Cardiovascular Health Study participants randomly assigned to 24‐hour Holter monitoring. Demographics, comorbidities, habits, and echocardiographic measurements were examined as predictors of PVC frequency and, among 845 participants, change in PVC frequency 5 years later. Participants exhibited a median of 0.6 (interquartile range, 0.1–7.1) PVCs per hour. Of the more directly modifiable characteristics and after multivariable adjustment, every SD increase in systolic blood pressure was associated with 9% more PVCs (95% confidence interval [CI], 2%–17%; P=0.01), regularly performing no or low‐intensity exercise compared with more physical activity was associated with ≈15% more PVCs (95% CI, 3–25%; P=0.02), and those with a history of smoking exhibited an average of 18% more PVCs (95% CI, 3–36%; P=0.02) than did never smokers. After 5 years, PVC frequency increased from a median of 0.5 (IQR, 0.1–4.7) to 1.2 (IQR, 0.1–13.8) per hour (P<0.0001). Directly modifiable predictors of 5‐year increase in PVCs, described as the odds per each quintile increase in PVCs, included increased diastolic blood pressure (odds ratio per SD increase, 1.16; 95% CI, 1.02–1.31; P=0.02) and a history of smoking (OR, 1.31; 95% CI, 1.02–1.68; P=0.04).ConclusionsEnhancing physical activity, smoking cessation, and aggressive control of blood pressure may represent fruitful strategies to mitigate PVC frequency and PVC‐associated adverse outcomes.

Low Diastolic Blood Pressure Is Associated With Angina in Patients With Chronic Coronary Artery Disease

BackgroundIn patients with coronary artery disease (CAD), low diastolic blood pressure (DBP) is associated with increased risk of myocardial infarction, but its association with angina is unknown. ObjectivesThe goal of this study was to examine the association of low DBP and angina in patients with CAD. MethodsThe study assessed the frequency of angina (measured by using the Seattle Angina Questionnaire–Angina Frequency score) according to DBP in patients with known CAD from 25 U.S. cardiology clinics. Hierarchical logistic regression was used to test the association between DBP and angina, with a spline term for DBP to assess nonlinearity. ResultsAmong 1,259 outpatients with CAD, 411 (33%) reported angina in the prior month, with higher rates in the lowest DBP quartile (40 to 64 mm Hg: 37%). In the unadjusted model, DBP was associated with angina with a J-shaped relationship (p = 0.017, p for nonlinearity = 0.027), with a progressive increase in odds of angina as DBP decreased below ∼70 to 80 mm Hg. This association remained significant after sequential adjustment for demographic characteristics (p = 0.002), comorbidities (p = 0.002), heart rate (p = 0.002), systolic blood pressure (p = 0.046), and antihypertensive antianginal medications (p = 0.045). ConclusionsIn patients with chronic CAD, there seemed to be an association between lower DBP and increased odds of angina. If validated, these findings suggest that clinicians should consider less aggressive blood pressure control in patients with CAD and angina.

Thoracic endovascular aortic repair to treat uncomplicated Stanford type B aortic dissection: The surgeon's dilemma to preventing future complications.

Uncomplicated type B aortic dissections have traditionally been managed non-operatively with aggressive blood pressure control. However, the best medical treatment is associated with a considerable risk of disease progression to complicated dissection or aneurysmal degeneration of the affected aortic segment. Thoracic endovascular aortic repair could prevent long-term complications but, because the dissected aorta is vulnerable, it is a high-risk procedure performed in asymptomatic patient. Therefore, endovascular treatment is not a solution for all patients and it should be performed only in the subgroup prone to developing progression of the disease and future complications. A number of studies have suggested several prognostic factors of early or late adverse events such as the patency of the false lumen in the follow-up, an initial aortic diameter ≥4 cm with a patent false lumen, an initial false lumen diameter ≥22 mm in the proximal descending aorta, visceral involvement and recurrent or refractory pain or hypertension. Partial false lumen thrombosis and a proximal entry tear size >10 mm have also been suggested to be associated with an increased rate of aortic growth. We need randomised trials focused on these prognostic factors to reach level 1, class A recommendation for the optimal timing of intervention. Meanwhile, we have to discuss with the patient the pro and cons of this prophylactic, low-invasive but high-risk treatment to personalise medical care and provide the optimal risk-to-benefit ratio.

Abstract P182: Low Diastolic Blood Pressure is Associated With Subclinical Myocardial Disease and Cardiac Events in Patients With Coronary Artery Disease

Introduction: Clinical trials have shown increased survival at lower blood pressures, but low diastolic blood pressure (DBP) is associated with increased cardiovascular (CV) events and mortality. The suggested mechanism in patients with coronary artery disease (CAD) is limitation in coronary blood flow; however, evidence is lacking. We investigated the association between DBP, biomarkers of myocardial injury, and incident events in patients with CAD. Methods: We assessed 2448 individuals (aged 65±12 years, 68% male, median follow-up 4.5 years) with stable CAD undergoing cardiac catheterization. Those with acute coronary syndromes or heart failure with reduced ejection fraction were excluded. DBP was categorized into 10 mm Hg increments. Biomarkers of myocardial damage (high sensitivity cardiac troponin-I [hs-cTnI] and soluble urokinase plasminogen activating receptor [suPAR]) were dichotomized at their median values. DBP 80-89 mmHg was used as the referent group and individuals were followed for MACE (CV death or non-fatal myocardial infarction) and all-cause mortality. Results: After adjusting for relevant demographic and clinical covariates, individuals with DBP &lt; 60 mm Hg had increased odds of elevated hs-cTnI (OR = 1.75; 95% CI = 1.05, 2.90) and suPAR (OR = 1.73; 95% CI = 1.09, 2.76) compared to the referent group. Additionally, DBP &lt; 60 mm Hg was associated with increased risk of MACE (HR = 2.01; 95% CI = 1.24, 3.25) and all-cause mortality (HR = 2.18; 95% CI = 1.50, 3.19). Adding hs-cTnI and suPAR into the Cox proportional hazards model attenuated the association between DBP &lt; 60 mmHg and MACE (HR =1.63, 95% CI 0.91, 2.91), but not all-cause mortality (HR = 1.67, 95% CI = 1.06, 2.63). Conclusion: In patients with CAD, low DBP is associated with biomarkers of myocardial injury and incident events. Aggressive blood pressure control may be harmful in these patients, and further investigation is warranted to determine appropriate blood pressure targets in patients with CAD.

Posterior Reversible Encephalopathy associated with Eclampsia and HELLP Syndrome

Posterior reversible encephalopathy (PRES) is a rare clinical entity which presents with neurological signs and symptoms with characteristic findings on neuroimaging. Eclampsia is a common pre-disposing cause. We report a case of a 29-year-old lady presenting at 36 weeks of gestation with eclampsia evident by a very high blood pressure, generalized tonic clonic (GTC) seizures, albuminuria and clonus. She remained drowsy with a fluctuating Glasgow coma scale (GCS) post-delivery with features of HELLP syndrome, prompting the need for neuroimaging which confirmed PRES. Early normal vaginal delivery (NVD), with aggressive blood pressure and seizure control resulted in a complete recovery within 72 hours post-partum. In a pregnant patient with eclamptic seizures, a high degree of suspicion is needed, and neuroimaging should be utilized in order to diagnose PRES. This case highlights the fact that PRES is a reversible entity with favourable outcomes with timely recognition and aggressive management.

Posterior Reversible Encephalopathy Syndrome Secondary to Cyclophosphamide in the Treatment of Pulmonary Renal Syndrome

SESSION TITLE: Nervous System Disorders in the ICU 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is a clinical radiological syndrome, carrying a 15% mortality risk. It can lead to permanent neurological deficits and death if not identified and treated early. CASE PRESENTATION: A 22-year-old female with a history of Sjogren’s syndrome was admitted to the intensive care unit for acute respiratory failure. She was diagnosed with diffuse alveolar hemorrhage after bronchoalveolar lavage, along with concurrent acute glomerulonephritis. Labs were significant for creatinine of 1.47 mg/dL, as well as protein >500, large blood, and 54 RBCs/hpf on urinalysis. Urine protein to creatinine ratio was 8.3. Glomerulonephritis workup was significant for ANA 1:5120, positive anti-MPO IgG, but negative anti-dsDNA, negative anti-GBM, negative HIV and hepatitis serologies, as well as a negative syphilis screen. The patient was initially diagnosed with pulmonary renal syndrome due to MPO-associated vasculitis. She was treated with high dose pulse steroids, cyclophosphamide induction on day 2 of ICU, and 5 days of plasmapheresis with improvements in respiratory status, but not in renal function. On day 5 the patient developed acute nausea, vomiting, and tonic-clonic seizures. Her vital signs were significant for a blood pressure of 170/110 mmHg. Neurological exam was evident for lethargic appearance, and a right pronator drift. Based on documentation, a progressive increase in her blood pressure was observed since the start of cyclophosphamide. Non-contrast MRI of the brain confirmed posterior reversible encephalopathy syndrome (PRES), with evidence of vasogenic edema in the bilateral parietal, occipital lobes, and cerebellum. DISCUSSION: The most common signs and symptoms of PRES are acute hypertension, seizure, nausea and vomiting, and altered consciousness. The incidence of PRES is unknown but is reported in ages 2-90, and occurs more frequently in women. Reported risk factors associated with PRES are hypertension, renal disease, immunosuppressive therapy, eclampsia/preeclampsia, and autoimmune diseases. The pathogenesis is not fully understood, however current hypotheses suggest disruption of vascular autoregulation in the brain, leading to vascular leakage, vasogenic edema, and hemorrhage. Diagnosis involves a high degree of clinical suspicion, as there are no current guidelines available. Aggressive blood pressure control with rapid lowering of the diastolic pressure below 100 mmHg within 2-6 hours is the mainstay of therapy, along with removal of the inciting agent. CONCLUSIONS: It is important to recognize PRES early and initiate the appropriate management. Unlike its name, PRES is not always posterior, and may not always be reversible. If not treated, it can lead to permanant neurological disability and death. Reference #1: Pedraza, R. Posterior Reversible Encephalopathy Syndrome: A Review, Crit Care & Shock (2009) 12:135-143 DISCLOSURE: The following authors have nothing to disclose: Di Pan, Basera Sabharwal, Franco Vallejo No Product/Research Disclosure Information

PREDICTORS OF ATRIAL FIBRILLATION AFTER CATHETER ABLATION IN A HYPERTENSIVE POPULATION: A SUB-STUDY OF SMAC-AF

Radiofrequency ablation for atrial fibrillation (AF) has emerged as a valuable therapy option; however, high rates of AF recurrence after ablation remain a limitation of this procedure. The recent Substrate Modification with Aggressive Blood Pressure Control (SMAC-AF) randomized controlled trial enrolled hypertensive patients, defined as BP>130/80mmHg, who had either persistent or paroxysmal AF, resistant or intolerant to at least one class I or III antiarrhythmic drug, who were scheduled for catheter ablation. 173 patients were randomly assigned to standard-of-care blood pressure target, 140/90mmHg or aggressive target, 120/80mmHg; there was no reduction in recurrence (HR 0.94, 95% CI 0.65-1.38 for aggressive control). This post-hoc analysis of the SMAC-AF population aimed to compare the risk factors for AF recurrence in each of the two cohorts. Using the SMAC-AF cohorts, we investigated how baseline characteristics and serum NT-pro-brain-natriuretic-peptide measured after AF ablation were associated with AF recurrence, defined as >30s of AF, more than 3 months post-ablation. Univariate Cox regression analysis was used to determine association between variables and AF recurrence. Of the 173 patients, 88 were randomized to the aggressive cohort, and 85 into the standard group. 106 (61.3%) patients had AF recurrence and 67 (38.7%) patients did not. Table 1 shows variables associated with AF recurrence. In the standard group, age (HR 1.03, p=0.04), number of antihypertensive medications (HR 1.31, p=0.048), and use of a calcium channel blocker (HR 1.81, p=0.03) were associated with recurrence. Twelve month NT-proBNP ≥300pg/ml was associated with higher AF recurrence as well. In the aggressive cohort, baseline systolic blood pressure (SBP) (HR 1.03, p=0.02), baseline SBP ≥ 140mmHg (HR 2.14, p=0.01), complex ablation during initial procedure (HR 3.11, p=0.01) were associated with recurrence, while use of diuretic (HR 0.44, p=0.01) was associated with reduced recurrence. There was a trend towards a reduction in occurrence with more anti-hypertensive agents (HR 0.81, p=0.08). An elevated baseline NT-proBNP had a trend towards association with recurrent AF; there were too few patients with an NT-proBNP ≥300pg/ml at 12 months (n=7 in the aggressive group) to determine significance in this group. In this post-hoc analysis, variables associated with recurrent AF differed between the aggressive and standard groups. Although aggressive blood pressure lowering was not associated with an improvement in AF recurrence in the entire cohort, there may be benefit in patients with higher baseline NT-proBNP, and older age. These associations need to be further clarified in ongoing clinical studies.

Post-carotid Endarterectomy Hypertension. Part 2: Association with Peri-operative Clinical, Anaesthetic, and Transcranial Doppler Derived Parameters

The first paper in this series observed that pre-operative baroreceptor dysfunction and poorly controlled hypertension were independently predictive for identifying patients who went on to require treatment for post-endarterectomy hypertension (PEH). The second paper examines the influence of intra-operative patient, transcranial Doppler (TCD) ultrasound, and anaesthetic variables on the incidence of PEH. In total, 106 patients underwent carotid endarterectomy (CEA) under general anaesthesia. Systolic blood pressure (SBP) changes, anaesthetic and vasoactive agents, analgesia, and post-operative pain scores, as well as TCD derived changes in middle cerebral artery (MCA) velocity during surgery were recorded. Patients who met pre-existing unit criteria for treating PEH after CEA (SBP>170mmHg without symptoms or SBP>160mmHg with headache/seizure/neurological deficit) were treated according to an established and validated protocol. In total, 40/106 patients (38%) required treatment for PEH following CEA (26 in theatre recovery [25%], 27 back on the vascular surgery ward [25%]), whereas seven (7%) had SBP surges>200mmHg on the ward. Patients requiring treatment for PEH had significantly higher pre-induction SBP (174±21mmHg vs. 153±21mmHg; p<.001), the greatest decreases in SBP after induction of anaesthesia (median decrease 100±32mmHg vs. 83±24mmHg; p=.01) and were significantly more likely to experience moderate/severe pain scores post-operatively (p=.003). Logistic regression analysis of the pre- and intra-operative data revealed that higher pre-induction mean SBP and lower pre-operative (impaired) BRS were the only independent predictors of PEH. This analysis of intra-operative variables has demonstrated that patients with poorly controlled and/or labile hypertension at induction of general anaesthesia were those at greatest risk of requiring treatment for PEH in the post-operative period after CEA. No other variables, including use of vasopressors, treatment of hypotension, anaesthetic agents, or changes in MCA velocity after clamp release and restoration of flow were able to predict who might go on to require treatment for PEH. Identification of at-risk individuals and aggressive blood pressure control in the post-operative period remains the mainstay of treatment.

Abstract P226: Aggressive Blood Pressure Control Status Post-acute Aortic Dissection May be Associated With Acute Kidney Injury: A Pilot Study

Management of acute aortic dissection includes appropriate blood pressure control (120/80 mmHg per AHA guidelines) but this is not based on evidence. Excessive lowering of blood pressure may contribute to organ malperfusion. The kidneys are the most commonly affected organs, causing refractory hypertension and acute kidney injury (AKI). Recent landmark blood pressure trials with intensive pressure goals have a significant incidence of AKI. This pilot study tested the hypothesis that achieved systolic blood pressure less than 120 mmHg has a higher incidence of AKI than those treated systolic pressures &gt; 120 mmHg. Methods: Patients were identified via surgical log. Retrospective chart review was performed on patients in the acute setting following dissection. Daily average blood pressures were calculated. Patients were included if they underwent surgical repair of aortic dissection and survived the first 24 hours. Patients were excluded if they demonstrated shock physiology or required renal replacement therapy in the first 24 hours. Serum creatinine and clinical course (including anti-hypertensive regimen) were recorded. The primary endpoint was in-hospital occurrence of AKI (defined per KDIGO criteria) in the acute setting status post aortic dissection in patients receiving anti-hypertensive therapy. An unadjusted odds ratio was calculated. Data on potential confounders and covariates (baseline sCR, contrast exposure etc) were also collected. Results: From 2013-2017, 37 cases of surgically repaired aortic dissection were identified and 16 cases met inclusion/exclusion criteria. The incidence of AKI in patients treated to an average systolic blood pressure less than 120mmHg was 75% compared with 50% in those with pressure greater than 120 mmhg. OR =3.0 [95% CI 0.3612-24.9];p=0.3019. Covariates and potential confounders were balanced between groups but given the small numbers additional statistical adjustments were not performed. Conclusion: The incidence of AKI was numerically higher in the group of patients achieving more intensive blood pressure targets. Our study was limited by small sample size and selection bias. Both of these issues can be addressed if we apply similar methodologies to address the same question on a lager sample size.

Malignant hypertension as a rare cause of thrombotic microangiopathy

Malignant hypertension can occasionally be associated with microangiopathic haemolytic anaemia. A 38-year-old male presented with nausea, vomiting, loss of appetite and oliguria for 2 weeks. He was diagnosed with hypertensive...

Effect of Aggressive Blood Pressure Control on the Recurrence of Atrial Fibrillation After Catheter Ablation: A Randomized, Open-Label Clinical Trial (SMAC-AF [Substrate Modification With Aggressive Blood Pressure Control]).

Radiofrequency catheter ablation for atrial fibrillation has become an important therapy for AF; however, recurrence rates remain high. We proposed to determine whether aggressive blood pressure (BP) lowering prevents recurrent atrial fibrillation (AF) after catheter ablation in patients with AF and a high symptom burden. We randomly assigned 184 patients with AF and a BP >130/80 mm Hg to aggressive BP (target <120/80 mm Hg) or standard BP (target <140/90 mm Hg) treatment before their scheduled AF catheter ablation. The primary outcome was symptomatic recurrence of AF/atrial tachycardia/atrial flutter lasting >30 seconds, determined 3 months beyond catheter ablation by a blinded end-point evaluation. The median follow-up was 14 months. At 6 months, the mean systolic BP was 123.2±13.2 mm Hg in the aggressive BP treatment group versus 135.4±15.7 mm Hg (P<0.001) in the standard treatment group. The primary outcome occurred in 106 patients, 54 (61.4%) in the aggressive BP treatment group compared with 52 (61.2%) in the standard treatment group (hazard ratio=0.94; 95% confidence interval, 0.65-1.38; P=0.763). In the prespecified subgroup analysis of the influence of age, patients ≥61 years of age had a lower primary outcome event rate with aggressive BP (hazard ratio=0.58; 95% confidence interval, 0.34-0.97; P=0.013). There was a higher rate of hypotension requiring medication adjustment in the aggressive BP group (26% versus 0%). In this study, this duration of aggressive BP treatment did not reduce atrial arrhythmia recurrence after catheter ablation for AF but resulted in more hypotension. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00438113.

Clinical Trials in Pediatric Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease and is associated with concerning long-term implications for kidney function and cardiovascular health. Early intervention is needed in order to mitigate these long-term complications. Herein, we review important findings from recent clinical trials in ADPKD and their relevance to affected children and young adults and consider future directions for intervention. Recent clinical trials support aggressive control of blood pressure with blockade of the renin-angiotensin-aldosterone system as well as potential benefit of pravastatin therapy in children and young adults with ADPKD. There are several other candidate therapies, some of which have shown benefit in adult ADPKD, which require further investigation in affected children.

Adverse Effects of Aggressive Blood Pressure Control in Patients with Intracerebral Hemorrhage

Adverse Effects of Aggressive Blood Pressure Control in Patients with Intracerebral Hemorrhage

Left Ventricular Hypertrophy Regression During Antihypertensive Treatment in an Outpatient Clinic (the Campania Salute Network)

BackgroundRegression of left ventricular (LV) hypertrophy (LVH) has been a goal in clinical trials. This study tests the external validity of results of clinical trials on LVH regression using a large registry from a tertiary care center, to identify phenotypes less likely to achieve regression of LVH.Methods and ResultsPatients from the Campania Salute Network, free of prevalent cardiovascular disease, but with echocardiographic LVH (defined as LV mass index [LVMi] >47 g/m2.7 in women and >50 g/m2.7 in men) were included. During a median follow‐up of 67 months, clear‐cut regression of LVH was documented in 14% of patients (13±8% reduction of initial LVMi) or 23% when also considering those with a reduction of LVMi ≥5 g/m2.7. Patients with persistent LVH were older with longer duration of hypertension, suboptimal blood pressure (BP) control, larger body mass index, LV mass, and carotid intima‐media thickness and included more women and subjects with diabetes mellitus, isolated systolic hypertension, and metabolic syndrome (all P<0.05). Number and class of antihypertensive drugs during follow‐up did not differ between groups. In multiple logistic regression analysis, older age, female sex, obesity, higher baseline LVMi and carotid intima‐media thickness, and suboptimal BP control were significant covariates of persistent LVH (all P≤0.01), independent of diabetes, duration of hypertension, isolated systolic hypertension, follow‐up time and number and class of antihypertensive drugs.ConclusionsEarly initiation of antihypertensive treatment, aggressive BP control, and attention to metabolic aspects are critical to avoid irreversible LVH.

Abstract 77: Intensity of Blood Pressure Reduction and Secondary Stroke Prevention: A Systematic Review and Meta-regression Analysis of Randomized Clinical Trials

Background &amp; Purpose: Current recommendations do not specifically address the optimal blood pressure (BP) cut-off for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and meta-regression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized-controlled clinical trials (RCTs) of secondary stroke prevention. Methods: For all reported events during each eligible study period we calculated the corresponding risk ratios (RRs) to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. Based on the reported BP values, we performed univariate meta-regression analyses according to achieved BP values under the random-effects model (Method of Moments) for those outcome events reported in ≥10 total subgroups of included RCTs. Results: In pairwise meta-analyses of 14 RCTs comprising 42,736 patients antihypertensive treatment lowered the risk for recurrent stroke (RR=0.73, 95%CI: 0.62-0.87, p&lt;0.001), disabling or fatal stroke (RR=0.71, 95%CI: 0.59-0.85, p&lt;0.001) and cardiovascular death (RR=0.85, 95%CI: 0.75-0.96, p=0.010). In meta-regression analyses systolic BP reduction was linearly related to lower risk of recurrent stroke (p=0.049; Figure A), myocardial infarction (p=0.024), death from any cause (p=0.001) and cardiovascular death (p&lt;0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke (p=0.026; Figure B) and all-cause mortality (p=0.009). Funnel plot inspection and Egger’s statistical test revealed no evidence of publication bias. Conclusion: The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebro- and cardio-vascular events. Strict and aggressive BP control appears to be essential for effective secondary stroke prevention.

A case of eclampsia complicated by cerebral haemorrhage and iatrogenic hypopharyngeal oedema and haemathoma

Introduction. Eclampsia, serious complication of preeclampsia, can further be complicated by intracranial haemorrhage. Cesarean section under general anesthesia represents an additional risk factor. Case report. We present a case of 22 years old primipara in the 38th gestational week who after a sudden occurrence of a headache, within one hour developed eclampsia. Emergent Caesarean section was undertaken; she was intubated after several attempts. Severe tongue and hypopharyngeal edema and haemathoma made the extubation impossible; she remained intubated, sedated, mechanically ventilated, on antioedematous, anticonvulsive, antihypertensive therapy. On the third postoperative day, tracheostomy was performed. On the sixth day, she complained of a headache and visual disturbances. Neurological examination revealed left-sided hemiparesis. Multislice computed tomography showed intracranial hemorrhage. It was not until the closure of tracheostoma (eleventh day) that her blood pressure normalized and the headache ceased. Four days later she was dismissed from the hospital with improved clinical state. Conclusion. In order to avoid sudden and unexpected, but serious complications of preeclampsia/eclampsia, we emphasize the need of searching for more subtle signs of the disease, of prompt radiologic diagnosis and aggressive blood pressure control, with a prepared strategy for difficult airway management.

Blood Pressure Reduction and Secondary Stroke Prevention: A Systematic Review and Metaregression Analysis of Randomized Clinical Trials.

Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. On the basis of the reported BP values, we performed univariate metaregression analyses according to the achieved BP values under the random-effects model (Method of Moments) for those adverse events reported in ≥10 total subgroups of included randomized controlled clinical trials. In pairwise meta-analyses, antihypertensive treatment lowered the risk for recurrent stroke (risk ratio, 0.73; 95% confidence interval, 0.62-0.87; P<0.001), disabling or fatal stroke (risk ratio, 0.71; 95% confidence interval, 0.59-0.85; P<0.001), and cardiovascular death (risk ratio, 0.85; 95% confidence interval, 0.75-0.96; P=0.01). In metaregression analyses, systolic BP reduction was linearly related to the lower risk of recurrent stroke (P=0.049), myocardial infarction (P=0.024), death from any cause (P=0.001), and cardiovascular death (P<0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke (P=0.026) and all-cause mortality (P=0.009). Funnel plot inspection and Egger statistical test revealed no evidence of publication bias. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.