Aggressive Management Of Hypertension Research Articles

PREVALENCE AND CONTROL OF THE HYPERTENSION IN PATIENTS SUFFERING FROM RHEUMATOID ARTHRITIS

Hypertension or high blood pressure (BP) is a long-term ailment in which blood pressure in the arteries raises persistently. Blood pressure can be determined using two methods, systolic pressure which is the uppermost pressure and diastolic pressure which is the lowermost blood pressure in the arterial system. It is estimated that worldwide around 1.13 billion persons are suffering from hypertension. In addition, the World Health Organization (WHO) has reported that 13% of all deaths in the world are caused by hypertension. Furthermore, they set a target to reduce its frequency by 25% from the year 2010 to 2025.1,2 Rheumatoid arthritis (RA) is a systemic autoimmune disease that leads to inflammation of the joints and pain. Approximately 1% of the global population is diagnosed with this disease. Rheumatoid arthritis can be associated with multiple comorbidities that can reduce a patient's quality of life (QoL), upturn the economic burden of the disease, and may increase the rate of mortality. Cardiovascular comorbidities are quite common in patients with rheumatoid arthritis. Cardiovascular comorbidity is estimated to be about 1.5 times more frequent in patients with rheumatoid arthritis than in healthy people. Many studies have suggested that of all cardiovascular disorders, hypertension is the most important and changeable risk factor in subjects suffering from rheumatoid arthritis. Based on a pool of 115,867 insurance claims, about 76% of rheumatoid arthritis patients in America were diagnosed with hypertension. These results are similar to studies conducted in Europe and Canada that have shown a higher incidence of hypertension in patients with rheumatoid arthritis compared to the normal group. It is unknown why patients with rheumatoid arthritis pose such a high risk for hypertension. Reduced physical activity, obesity, systemic inflammation, and medications used to treat rheumatoid arthritis can increase the risk of high blood pressure.3 Around 0.55% of the urban population in northern Pakistan suffers from rheumatoid arthritis, while the incidence rate is close to 0.14% in southern Pakistan.4 There are many reasons why people with rheumatoid arthritis have high blood pressure. Chronic inflammation in rheumatoid arthritis results in increased rigidity of arteries leading to increase systolic blood pressure. The first presumed link between low-grade systemic inflammation and hypertension has been identified in previous studies conducted on the general population. In rheumatoid arthritis, elevated levels of C-reactive protein (CRP) increase the likelihood of developing high blood pressure. Several mechanisms may be implicated in the development of hypertension with a high concentration of C-reactive protein. For example, nitric oxide synthesis may be reduced because of the increased concentration of the C-reactive protein that will cause vasoconstriction, platelet activation and thrombosis. Additionally, increased expression of the type 1 angiotensin receptor and stimulation of the plasminogen activator inhibitor-1 (PAI-1) may contribute to the progression of hypertension. Occasionally, restriction on exercise due to the fear of worsening disease condition is recommended (unwarranted) by healthcare professionals, and it could be a reason for the inactive and sedentary lifestyle of patients with rheumatoid arthritis. In turn, physical idleness can lead to obesity, which may be linked independently to high blood pressure in rheumatoid arthritis. Obesity and familial history of hypertension are significant predictors of premature death. A study has also demonstrated that an increase in sodium (Na) intake and a decrease in potassium (K) intake can play a significant role in the pathogenesis of rheumatoid arthritis and high blood pressure. The urinary Na/K quotient may be useful as an important parameter of hypertension in patients suffering from rheumatoid arthritis and in normal subjects. Optimal cardiovascular risk management continues to be a major challenge. In this regard, increased awareness and management are needed to reduce the high risk of cardiovascular disorders in patients with rheumatoid arthritis. To date, only a few studies have investigated the potential relationship between high blood pressure and these factors in patients with rheumatoid arthritis. A lifestyle shift (i.e. exercise, smoking cessation, eating a balanced diet, reducing the use of ethanol and salt) is needed in patients suffering from rheumatoid arthritis to manage their high blood pressure and improve their quality of life (QoL). To treat rheumatoid arthritis, many medications are routinely prescribed, including cyclooxygenase, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, and disease-modifying anti-rheumatic drugs (DMARDs). The use of these drugs in rheumatoid arthritis should always be considered in conjunction with comorbid hypertension. Clinicians should closely monitor such patients for prior diagnosis and, where appropriate, aggressive management of hypertension. Systems for diagnosis, proper treatment, and continuous surveillance of these patients need to be in place in primary and secondary healthcare setups. Furthermore, specially designed clinical trials are required to determine the finest approaches to treat hypertension in patients of rheumatoid arthritis.5-8

Surgical management of cellular congenital mesoblastic nephroma in a neonate: a case report and review of literature

BackgroundCongenital mesoblastic nephroma (CMN) is the most common type of renal stromal tumor in neonates. It is classified into cellular, classical, and mixed types. The multidisciplinary management approach is the mainstay of management. We are reporting a case of neonatal congenital mesoblastic nephroma in a full-term boy with intrauterine growth restriction and hypertension managed effectively in our institution.Case presentationA full-term boy with intrauterine growth restriction (IUGR) with a birth weight of 2.3 kg, referred at birth with an abdominal mass. His antenatal scan at 35 weeks showed a cystic abdominal mass. On delivery, a huge visible abdominal mass of cystic consistency and smooth surface was noticed at the right side of the abdomen. blood pressure was 98/75 mmHg. It was responsive to hydralazine. Aldosterone and renin were significantly elevated at more than 100 and 500 ng/dl, respectively. Serum neurone-specific enolase (NSE) was 35 ng/ml while alfa feto protein was (AFP) 50,000 kIU/L. An abdominal ultrasound scan revealed an ill-defined large heterogeneous mass of 6.09 × 6.5 × 5.77 cm that arises from the right kidney. A computed tomography scan confirmed a right kidney mass with peripheral claw sign of the normal right renal tissue. It was crossing the midline and causing a mass effect on the adjacent structures. The right renal artery and vein were compressed and shifted posteriorly and inferomedially. Right radical nephrectomy was performed via a right lower transverse incision. The tumor was completely excised with a tumor weight of 270 g and a size of 10.5 × 8 × 5.5 cm. Histopathological diagnosis was mesoblastic nephroma of a cellular type which was confirmed by immunohistochemistry. Post-operatively, the blood pressure has significantly reduced and antihypertensive medications were eventually weaned off. The multidisciplinary team decided to preserve chemotherapy only in case of recurrence. At 3 months follow-up, no features of recurrence were noticed based on surveillance ultrasonography.ConclusionMesoblastic nephroma should be considered in any newborn with renal mass. The multidisciplinary team approach with aggressive management of hypertension, detailed radiological investigation, and complete tumor resection is fundamental for obtaining an excellent outcome for such entities.

The Diagnostic Yield of Routine Electrocardiography in Hypertension and Implications for Care in a Southwestern Nigerian Practice.

BackgroundNigeria, like other developing nations, has an increasing burden of hypertension. Electrocardiography is an integral part of the diagnostic work-up for the newly diagnosed hypertensive subjects. The aim of this study was to determine the diagnostic yield of electrocardiography in hypertensive patients of a southwestern Nigerian hospital.Patients and MethodsThis was a retrospective descriptive study of electrocardiographs of hypertensive patients over a six-year period. Electrographic variables of interest were cardiac rhythm and rate, left ventricular hypertrophy (LVH), left atrial enlargement (LAE), T wave abnormalities, cardiac axis, blocks, complexes, QT segment abnormalities, atrial fibrillation (AF)/flutter, supraventricular tachycardia and pre-excitation syndrome. The Pearson’s chi square was used to test for differences across age groups (15–44yrs, 45–64yrs and >65yrs) and between male and female subjects with the significance level set at 5% (p< 0.05).ResultsHypertension was the indication for 40% of electrocardiographs completed and comprised of 3713 electrocardiograms (ECG) over a six-year period. The commonest abnormalities were left axis deviation (LAD) (32.2%), LVH (20.7%), rhythm abnormalities (16.7%) and LAE (14.5%). The diagnostic yield (presence of at least one electrographic abnormality) was 51% in 15–44 yrs age group, 64% in middle aged and 76.5% in the >65 yrs age group. While the male subjects in this study had a slightly increased likelihood of having an abnormal finding (odds ratio 1.18: 95% CI 1.02–1.35), the odds ratio for an abnormal ECG in subjects younger than 45 years was 0.48 (95% CI 0.41–0.57).ConclusionThe diagnostic yield of electrocardiography in this study was considerable, although lowest in subjects younger than 45 years and increased with age. This may reflect an increased burden and earlier onset of hypertension and its complications. This should also engender prompt and aggressive management of hypertension, especially in the elderly in whom the cardiovascular complications from hypertension is most severe.

Association of Hypertension and Arterial Blood Pressure on Limb and Cardiovascular Outcomes in Symptomatic Peripheral Artery Disease: The EUCLID Trial.

Current guidelines recommend aggressive management of hypertension. Recent evidence suggested potential harm with low blood pressure targets in patients with peripheral artery disease. We investigated the association of a history of hypertension and office systolic blood pressure (SBP) with major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The EUCLID trial (Examining the Use of Ticagrelor in Peripheral Artery Disease) included 13 885 participants with symptomatic peripheral artery disease; median follow-up was 30 months. Cox proportional hazards regression was used to calculate hazard ratios (HRs) for any MACE, MALE, and MALE including lower extremity revascularization. A clinical history of arterial hypertension was present in 10 857 (78%) participants, and these participants were older and more likely to be female when compared with the 3026 (22%) patients without hypertension. In patients with a history of hypertension, the adjusted hazard ratio for MACE was 0.94, 95% CI, 0.82-1.08; P=0.39, and the adjusted hazard ratio for MALE was 1.08, 95% CI, 0.96-1.23; P=0.21. During follow-up, average SBP was 135 mm Hg (125-145). Every 10 mmHg increase in SBP>125 mmHg was associated with an increased risk of MACE (HR, 1.10 [95% CI, 1.06-1.14]; P<0.001), a marginally increased risk of MALE (HR, 1.07 [95% CI, 1.00-1.15]; P=0.062), and an increased risk of MALE/lower extremity revascularization (HR, 1.08 [95% CI, 1.04-1.11]; P<0.001). Every decrease in 10 mmHg SBP ≤125 mmHg was associated with an increased risk of MACE (HR, 1.19 [95% CI, 1.09-1.31]; P<0.001) but not MALE or MALE/lower extremity revascularization (HR, 1.02 [95% CI, 0.84-1.23], P=0.824; HR, 1.04 [95% CI, 0.95-1.13], P=0.392, respectively). History of hypertension was not associated with higher hazard for MACE or MALE in patients with peripheral artery disease. In contrast, there was a higher hazard of MACE in patients with out-of-target low and high SBP. High but not low SBP was associated with an increased risk of ischemic limb events. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01732822.

Hypertension is a Leading Cause of Nontraumatic Intracerebral Hemorrhage in Young Adults

Objective: To evaluate the etiology and discharge outcome of nontraumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center. Methods: A retrospective chart review was performed on patients with a discharge diagnosis of nontraumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome. Results: Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n = 25) or acute inpatient rehabilitation (n = 17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n = 6), hospice (n = 1) or died in the hospital (n = 14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (P < .0001) and use of DNR orders (P < .0001) were associated with bad outcome. All 11 patients with DNR orders died in the hospital. Location or etiology of hemorrhage were not associated with discharge outcome. Conclusions: Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. Aggressive management of hypertension is essential to halt the recent increased trends of ICH due to hypertension. Early DNR orders may need to be cautiously used in the hospital.

Treatment response and progression to end stage renal disease in adolescents and young adults with lupus nephritis: A follow up study in an Egyptian cohort

BackgroundLupus nephritis (LN) badly affects the outcome in adolescents and young adults with systemic lupus erythematosus (SLE). Many have renal disease at onset and the significance of remission and relapse in adolescents and young adults is poorly evaluated. Aim of workTo outline the clinical and laboratory characteristics of treatment resistance, renal relapse and progression to end-stage renal disease (ESRD) in adolescents and young adults with LN. Patients and methodsEighty-five biopsy-proven LN patients were examined; SLE disease activity and renal damage were evaluated at baseline and followed up at 6 and 12 months. Laboratory and immunology profiles were assessed. Patients were evaluated for predictors of treatment response, renal flares, and renal survival. ResultsThe patients mean age was 15.12 ± 4.53 years. Female/male ratio was 10.5:1. 12.9% had treatment resistance, 87.1% achieved remission: complete (CR 31.8%) and partial (PR 55.2%) within 1st year. 27 (31.8%) developed a relapse within the 1st year (9 after CR and 18 after PR). Nephrotic range proteinuria persisted in 24 (28.2%) patients (13 PR and the 11 non-responders). Baseline hypertension (p = 0.034), persistent nephrotic range proteinuria (<0.001) and PR (p < 0.001) were predictive for renal flares. Treatment resistance (p = 0.021), disease relapse (p < 0.001), persistent nephrotic range proteinuria (p < 0.001) were predictors of ESRD, especially in males (p = 0.035). Autoimmune profile and histopathology class showed insignificant differences among groups. ConclusionPrevention and aggressive management of hypertension, proteinuria and renal flares is expected to prevent progression to ESRD in lupus nephritis in adolescent and young adult SLE patients.

Monotherapy versus combination therapy for the initial treatment of hypertension

Objectives: There is a significant gap among hypertensive patients who are being treated and those who actually achieve blood pressure (BP) control. The main objective of this article is to determine if there are any differences in clinical outcomes and BP control with a combination treatment as compared to monotherapy as the initial treatment of hypertension. It also focuses on to compare the efficacy and compliance of fixed-dose combination (FDC) as compared to monotherapy and conventional multi-pill combination therapy as the initial treatment of hypertension. Methods: A search of literature was done using PubMed and Google scholar to prepare a review on this topic. Results: The main evidence supporting the use of combination therapy is focused on the use of combinations of renin–angiotensin System (RAS) blocker with calcium channel blockers (CCBs) and with thiazide diuretics. Several randomized clinical trials have proven the efficacy of combination therapy to be superior to monotherapy as initial treatment for timely and adequate BP control. Conclusion: Several benefits of achieving good BP control have been proven by several studies including the Systolic Blood Pressure Intervention Trial study, but only a few guidelines internationally recommend combination antihypertensives as a routine first-line treatment in all hypertensive patients. It is reasonable to go for aggressive management of hypertension involving the use of FDC antihypertensives from two different classes of drugs to achieve the recommended goals of BP of

Assessment of renal involvement in patients with systemic lupus erythematosus in a tertiary care hospital

Background: Renal involvement in SLE is common. Lupus Nephritis is the major cause of mortality in SLE patients. Renal involvement is a severe form of the disease and subsequent management is planned according to the histopathological class of lupus nephritis. Thus, this study was planned to assess the clinical profile and the extent of renal disease in SLE patients.Methods: A prospective observational study was conducted among SLE patients who got admitted in the Department of General Medicine and Nephrology in Thanjavur Medical College Hospital, Thanjavur from July 2012 to October 2013. Fifty SLE patients who had renal symptoms were included in this study.Results: SLE is Common among females. Common renal presentations were haematuria and proteinuria. 42% of the patients had Class IV lupus nephritis, followed by 24%, 16%, 16%, and 2% of Class III, II, Class V and Class I lupus nephritis respectively. No case of class VI lupus nephritis was reported in this study. ANA was positive among 66%, Anti ds DNA was positive in 64% and C3 level was found to be reduced in 50% of patients. Antiphospholipid antibodies were seen in 2% of the patients.Conclusions: Proteinuria, haematuria, a lower serum C3 level and need for aggressive hypertension management were prominently seen with a worse class of lupus nephritis. Patients with active and proliferative forms of lupus nephritis had a severe course of illness and required aggressive management with immunosuppressants.

Abstract 096: Comparing Strategies to Improve Systolic Blood Pressure Over 10 Years: A Simulation Study Using the Blood Pressure Control Model

Background: Uncontrolled hypertension increases patients’ risk for cardiovascular and kidney disease. This study compared strategies to improve systolic blood pressure (SBP) among 1000 simulated patients with uncontrolled hypertension (SBP &gt;=140 mmHg) from the National Health and Nutrition Examination Survey (NHANES). Methods: The Blood Pressure Control Model (BPCM) is a microsimulation, health state transition model that predicts the weekly SBP of patients receiving usual care. In the BPCM, patient SBPs are estimated using office visit frequency, measured SBP accuracy and variability, probability of treatment intensification with uncontrolled SBP, effect of antihypertensive medications, and adherence. BPCM inputs are derived from national survey data, meta-analyses, and other published literature. The effects of usual care on SBP were compared to 10% and 50% increases in global strategies for SBP control (i.e., visit frequency, treatment intensification, and/or adherence) over 10 years. SBP outcomes were validated against published literature values of 44-46% prior to implementation (i.e., usual care) and 74-80% 8-10 years after implementation of aggressive hypertension management programs in large health systems. Results: In the simulated NHANES population, the mean (SD) age was 61.1 (14.6), 52% were male, and mean baseline SBP was 153.2 (13.6) mmHg. Under usual care, the BPCM estimated a mean SBP of 140.1 (16.4) mmHg and 49% of patients achieving SBP &lt;140 mmHg after 10 years. Compared to usual care, 50% improvements in global strategies resulted in more rapid reductions in SBP and earlier achievement of SBP control. Simultaneously improving all global strategies by 50% resulted in an estimated mean SBP of 132.4 (15.5) mmHg with 71% achieving control after 10 years. Conclusions: Usual care and intervention BPCM predictions are consistent with hypertension control rates observed in contemporary national surveys and the observed results of recent systematic hypertension control improvement programs. These results show the BPCM may be used by health system planners to project the impact of implementing hypertension control strategies.

Recurrent Intracerebral Hemorrhage: Associations with Comorbidities and Medicine with Antithrombotic Effects.

BackgroundIntracerebral hemorrhage (ICH) is a disease with high mortality and a substantial risk of recurrence. However, the recurrence risk is poorly documented and the knowledge of potential predictors for recurrence among co-morbidities and medicine with antithrombotic effect is limited.Objectives1) To estimate the short- and long-term cumulative risks of recurrent intracerebral hemorrhage (ICH). 2) To investigate associations between typical comorbid diseases, surgical treatment, use of medicine with antithrombotic effects, including antithrombotic treatment (ATT), selective serotonin reuptake inhibitors (SSRI’s), and nonsteroidal anti-inflammatory drugs (NSAID’s) with recurrent ICH.MethodsThe cohort consisted of all individuals diagnosed with a primary ICH in Denmark 1996–2011. Information on comorbidities, surgical treatment for the primary ICH, and the use of ATT, SSRI’s and NSAID’s was retrieved from the Danish national health registers. The cumulative recurrence risk of ICH was estimated using the Aalen-Johansen estimator, thus taking into account the competing risk of death. Associations with potential predictors of recurrent ICH were estimated as rate ratios (RR’s) using Poisson regression. Propensity score matching was used for the analyses of medicine with antithrombotic effects.ResultsAmong 15,270 individuals diagnosed with a primary ICH, 2,053 recurrences were recorded, resulting in cumulative recurrence risk of 8.9% after one year and 13.7% after five years. Surgical treatment and renal insufficiency were associated with increased recurrence risks (RR 1.64, 95% CI 1.39–1.93 and RR 1.72, 95% CI 1.34–2.17, respectively), whereas anti-hypertensive treatment was associated with a reduced risk (RR 0.82, 95% CI 0.74–0.91). We observed non-significant associations between the use of any of the investigated medicines with antithrombotic effect (ATT, SSRI’s, NSAID’s) and recurrent ICH.ConclusionsThe substantial short-and long-term recurrence risks warrant aggressive management of hypertension following a primary ICH, particularly in patients treated surgically for the primary ICH, and patients with renal insufficiency.

Secondary prevention after coronary artery bypass graft surgery: a primer.

Despite the benefits of surgical coronary revascularization, patients continue to be at risk for ischemic events in the years that follow coronary artery bypass graft surgery (CABG), mandating the role for postoperative secondary preventive therapy. The purpose of this review was to present a summary on the subject of secondary prevention after CABG, including an overview of a recently published scientific statement, and highlight the newest studies in the field. Aspirin and statin therapy continue to be the mainstay of secondary prevention after CABG, although newer antiplatelet and lipid-lowering medicines are being actively studied for their potential benefits. Other important elements to secondary prevention after CABG include the aggressive management of hypertension, smoking cessation, and the initiation of cardiac rehabilitation. Secondary prevention is an essential component of postoperative care after CABG. Instituting preventive therapies after surgery optimizes graft patency and helps patients achieve the highest level of physical health and quality of life following CABG.

Prevalence and Predictors of Metabolic Syndrome After Liver Transplantation.

The development of metabolic syndrome (MS) after liver transplantation (LT) is a major source of mortality derived from cardiovascular events. The aim of the present study was to determine the prevalence and risk factors of MS after LT. One-hundred seventy-four consecutive LT patients from January 2004 to June 2010 surviving longer than 1 year after LT were included. Median follow-up after LT was 48 months. Independent predictors of MS were obtained by means of multivariate logistic regression. At 3 years after LT, 25.5% of patients reached a body mass index (BMI)≥30 kg/m2, 35.6% of patients developed arterial hypertension, 54.2% showed impaired fasting glucose, 22.5% had serum cholesterol >200 mg/dL, and 22.5% showed hypertriglyceridemia >150 mg/dL. The prevalence of MS ranged from 49% to 86% depending on the considered period. The pre-LT variables associated with MS were age at LT (odds ratio [OR], 1.08; P= .002), BMI of recipient before LT (OR, 1.23; P= .001), serum glucose (OR, 1.02; P= .005), and non-heart-beating donor (OR, 1.02; P= .046). The post-LT predictors of MS were body weight (OR, 1.04; P= .005), arterial hypertension (OR, 1.02; P= .047), and serum glucose (OR, 1.02; P= .011) at 6 months. LT patients develop MS in a high proportion and progressively despite current efforts (ie, lifestyle modifications and aggressive management of hypertension, diabetes, and hyperlipidemia). The associated risk factors include age, increased BMI, and pre- and post-LT glucose.

MP73-10 MODIFIABLE RISK FACTORS TO REDUCE RENAL CELL CARCINOMA CANCER INCIDENCE IN THE PLCO TRIAL

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging I1 Apr 2016MP73-10 MODIFIABLE RISK FACTORS TO REDUCE RENAL CELL CARCINOMA CANCER INCIDENCE IN THE PLCO TRIAL Aashish Kabra, Jonathan Gelfond, Steven Madson, Robert Svatek, Dharam Kaushik, and Michael Liss Aashish KabraAashish Kabra More articles by this author , Jonathan GelfondJonathan Gelfond More articles by this author , Steven MadsonSteven Madson More articles by this author , Robert SvatekRobert Svatek More articles by this author , Dharam KaushikDharam Kaushik More articles by this author , and Michael LissMichael Liss More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1665AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is good evidence that overweight and obesity cause increased incidence of renal cell carcinoma (RCC) Identifying modifiable factors might play a role in disease prevention and reducing healthcare costs. We investigated the PLCO trial to identify modifiable risk factors for RCC. METHODS The PLCO database was queried for the primary outcome of kidney cancer. Demographics were investigated, specifically focusing on modifiable risk factors, such as smoking, obesity, and hypertension. Statistical analysis includes the Student T test for continuous variables, chi-squared or Fisher’s Exact tests for dichotomous variables for univariable analysis. Multivariable analysis included cox proportional hazard models. Time to event analysis included log rank test and displayed as Kaplan-Meier graphs. RESULTS After IRB approval and request to the PLCO for data with data use agreement, we investigate existing data relating specifically to renal cancer. After missing data was excluded, we analyzed 149,683 subjects enrolled in the PLCO trial and noted 0.5% (n=748) subjects developed renal cancer. Age, male gender, body mass index (BMI), diabetes, and hypertension were all significant associations with renal cancer in univariate analysis (all <0.05). Men have a significant increased risk of kidney cancer over women (HR 1.85, 95% CI: 1.58, 2.16, p<0.0001). Non-modifiable risk factors that are associated with kidney cancer include age (HR 1.05, 95% CI: 1.01, 1.05, p=0.001). Modifiable risk factors include obesity measured by body mass index; (HR 1.05 95% CI: 1.02, 1.07, p<0.0001), hypertension (HR 1.32 95% CI: 1.13, 1.54, p=0.0004), and smoking in pack years (HR 1.04 95% CI: 1.02, 1.07, p=0.0002). CONCLUSIONS Reducing obesity, hypertension, and smoking are the three modifiable risk factors that could aggressively be targeted to reduce RCC. In particular, future investigation regarding aggressive management of hypertension with lower systolic and diastolic pressures than 140/90 set by the Joint National Committee and weight loss interventions, especially in at risk men, could prove to be the most beneficial prevention strategy. Further research is needed to elucidate mechanism of increased incidence of RCC in these patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e964 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Aashish Kabra More articles by this author Jonathan Gelfond More articles by this author Steven Madson More articles by this author Robert Svatek More articles by this author Dharam Kaushik More articles by this author Michael Liss More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Therapeutic inertia: underdiagnosed and undertreated hypertension in children participating in the T1D Exchange Clinic Registry.

Reduction of cardiovascular risk in children with type 1 diabetes requires aggressive management of hypertension (HTN). However, the frequency of diagnosing and effectively treating HTN in youth with type 1 diabetes has not been established. To address this question, we used the data collected in >9000 youth with type 1 diabetes who enrolled in the T1D Exchange Clinic Registry. This analysis included data from medical records of 9362 individuals with enrolment and 1-yr follow-up visits (age 3 to <18 yr, disease duration ≥ 1 yr at follow-up). Data included the prevalence of a documented diagnosis of HTN, elevated blood pressure (BP) (systolic or diastolic ≥95th percentile for age, gender, and height), and treatment with angiotensin converting enzyme (ACE)-receptor inhibitor (ACE-I)/angiotensin receptor blocker (ARB) therapy. HTN was diagnosed in only 1% (113/9362) of participants; yet, elevated BP was recorded at one of the two visits in 17% and at both visits in 4%. Among those with diagnosed HTN, only 52% (59/113) were receiving ACE-I/ARB therapy and only 32% (19 of 59) of those treated were at goal BP. Children with diagnosed HTN had higher HbA1c (adjusted p < 0.001) and higher BMI (p < 0.001) when compared with children without HTN. HTN is likely under diagnosed and undertreated even in pediatric diabetes clinics. The relatively low proportion of hypertensive children receiving ACE-I therapy and reaching BP goals probably identifies an important area for improving care in children with type 1 diabetes.

SECONDARY PREVENTION AFTER CORONARY ARTERY BYPASS GRAFT SURGERY: PRESENTATION OF A SCIENTIFIC STATEMENT

BackgroundA proven therapy for nearly 50 years, CABG is the most durable and complete treatment of ischemic heart disease. However, in the months and years that follow surgery, patients who have undergone CABG remain at risk for subsequent ischemic events as a result of native coronary artery disease progression and the development of graft atherosclerosis. Secondary therapies therefore play a key role in the maintenance of native and graft vessel patency and for the prevention of adverse cardiovascular outcomes.Methods and ResultsWe present a Scientific Statement prepared for the American Heart Association (AHA) to expand on two 2011 AHA and American College of Cardiology documents that provided a general overview of secondary prevention and briefly summarized the use of medical therapy after surgical coronary revascularization. Since the writing of those two statements, important evidence from clinical and observational trials has emerged that further supports and broadens the merits of intensive risk-reduction therapies for CABG patients. The present statement, specifically focused on the CABG population, thoroughly evaluates the current state of evidence regarding preventative therapies after surgery. Postoperative antiplatelet agents and lipid-lowering therapy continue to be the mainstay of secondary prevention following coronary surgical revascularization. Other opportunities for improving long-term clinical outcomes after CABG include the aggressive management of hypertension and diabetes mellitus, smoking cessation, weight loss, and cardiac rehabilitation. Select Class I and IIa recommendations are summarized in the Table below.Conclusion BackgroundA proven therapy for nearly 50 years, CABG is the most durable and complete treatment of ischemic heart disease. However, in the months and years that follow surgery, patients who have undergone CABG remain at risk for subsequent ischemic events as a result of native coronary artery disease progression and the development of graft atherosclerosis. Secondary therapies therefore play a key role in the maintenance of native and graft vessel patency and for the prevention of adverse cardiovascular outcomes. A proven therapy for nearly 50 years, CABG is the most durable and complete treatment of ischemic heart disease. However, in the months and years that follow surgery, patients who have undergone CABG remain at risk for subsequent ischemic events as a result of native coronary artery disease progression and the development of graft atherosclerosis. Secondary therapies therefore play a key role in the maintenance of native and graft vessel patency and for the prevention of adverse cardiovascular outcomes. Methods and ResultsWe present a Scientific Statement prepared for the American Heart Association (AHA) to expand on two 2011 AHA and American College of Cardiology documents that provided a general overview of secondary prevention and briefly summarized the use of medical therapy after surgical coronary revascularization. Since the writing of those two statements, important evidence from clinical and observational trials has emerged that further supports and broadens the merits of intensive risk-reduction therapies for CABG patients. The present statement, specifically focused on the CABG population, thoroughly evaluates the current state of evidence regarding preventative therapies after surgery. Postoperative antiplatelet agents and lipid-lowering therapy continue to be the mainstay of secondary prevention following coronary surgical revascularization. Other opportunities for improving long-term clinical outcomes after CABG include the aggressive management of hypertension and diabetes mellitus, smoking cessation, weight loss, and cardiac rehabilitation. Select Class I and IIa recommendations are summarized in the Table below. We present a Scientific Statement prepared for the American Heart Association (AHA) to expand on two 2011 AHA and American College of Cardiology documents that provided a general overview of secondary prevention and briefly summarized the use of medical therapy after surgical coronary revascularization. Since the writing of those two statements, important evidence from clinical and observational trials has emerged that further supports and broadens the merits of intensive risk-reduction therapies for CABG patients. The present statement, specifically focused on the CABG population, thoroughly evaluates the current state of evidence regarding preventative therapies after surgery. Postoperative antiplatelet agents and lipid-lowering therapy continue to be the mainstay of secondary prevention following coronary surgical revascularization. Other opportunities for improving long-term clinical outcomes after CABG include the aggressive management of hypertension and diabetes mellitus, smoking cessation, weight loss, and cardiac rehabilitation. Select Class I and IIa recommendations are summarized in the Table below. Conclusion

A Large Cohort Study Evaluating Risk Factors Associated With Uncontrolled Hypertension

Hypertension is the most common primary diagnosis in the United States. Risks for long-term consequences such as myocardial infarction, heart failure, stroke, and kidney disease continue to significantly increase as long as hypertension remains uncontrolled. This retrospective cohort study of 661,075 patients identified with uncontrolled hypertension, defined as systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg, from a large integrated healthcare organization was conducted to examine multiple patient characteristics to determine their association with uncontrolled hypertension. Multivariate analysis revealed that compared with Caucasians, African Americans (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16-1.20) were significantly associated with uncontrolled hypertension, as were unpartnered populations (OR, 1.15; 95% CI, 1.14-1.17), number of antihypertensive medications prescribed (OR, 1.37; 95% CI, 1.33-1.41), and adherence to most antihypertensive medications. A secondary analysis found an association between uncontrolled blood pressure and Patient Health Questionnaire-9 (PHQ-9) score (OR, 1.21; 95% CI, 1.16-1.26). Our findings suggest that the presence of these identified risk factors recommends a commitment to a more aggressive hypertension management program to prevent cardiovascular disease caused by uncontrolled hypertension.

Non-Invasive Characterization of Electrical Remodeling in a Risk Factor Modification Program

Introduction: Weight management in obese subjects is suggested to improve cardiac remodelling. Little is known about the atrial electrical changes that accompany weight reduction.Methods: In a randomized-controlled trial (ANZCTR: 12610000497000), 46 subjects with BMI >27 in sinus rhythm were randomized to a comprehensive risk factor management program or general lifestyle advice, and followed-up for 12-months. Metabolic profiles, pharmacotherapy, BMI, waist circumference (WC) and body surface area (BSA) were recorded. Digital analysis of 12-lead ECGs was used to assess P-wave duration (PWD) and area (PWA) and indexed to BSA (PWD-I and PWA-I), at baseline and at completion of the study.Results: Subjects were well matched for all baseline characteristics (25 active, 21 controls). Mean follow-up was 11.6±1.6 months. Using the paired-sample t-test, significant reduction was seen in all indices at 12-months (PWD; P<0.001, PWA; P=0.001, PWD-I; P=0.014, PWA-I; P=0.016) in the active group. No significant difference was seen in the control group. Using regression analysis with intention-to-treat, active group allocation was predictive of abbreviated P-wave indices (P=0.019). Controlling for age, gender, baseline respiratory disturbance index (RDI), ΔBMI, ΔWC and ΔBSA, significant correlation remained between shortening of PWD-I and number of anti-hypertensive medication used (P=0.026). Conclusion: A structured comprehensive risk factor management program, with aggressive hypertension management and weight reduction, is associated with a favourable improvement in ECG-derived indices of atrial electrical remodelling.

The Role of Vasodilating β-Blockers in Patients with Hypertension and the Cardiometabolic Syndrome

In the United States, a vast segment of the adult population is classified as having the cardiometabolic syndrome, and currently there are epidemic rates of both type 2 diabetes mellitus and obesity. Hypertension is closely linked with these metabolic disorders and is a strong independent predictor of incident type 2 diabetes. In addition, hypertension is an important contributor to increasing cardiovascular disease risk in patients with the cardiometabolic syndrome. Lowering elevated blood pressure in patients with the cardiometabolic syndrome or diabetes is a critical component of reducing global cardiovascular risk. However, aggressive management of hypertension in these patients is often challenging, and the presence of these conditions is associated with poor blood pressure control. The utility of β-blockers in patients with these conditions continues to be a subject of intense debate, given the adverse metabolic effects associated with conventional β-blockers. Data on vasodilating β-blockers, however, suggest that these agents have favorable or neutral metabolic effects and generally more favorable effects when compared with nonvasodilating members of this class. These agents may expand the utility of β-blockers to patient populations traditionally considered not to be optimal candidates for β-blocker therapy—a fact which has important clinical implications, because more antihypertensive agents are needed to diversify the therapeutic options available for clinicians treating hypertension in patients with the cardiometabolic syndrome or type 2 diabetes.

Glucose Control and Cardiovascular Disease

There is a substantial amount of clinical data showing the relationship between diabetes and atherosclerosis and its clinical complications (1,2). Cardiovascular disease (CVD) is more common in people with diabetes than in subjects without the disease, and when it is present, it also has a more aggressive course and a worse prognosis (3). The bulk of epidemiological data has firmly established that type 2 diabetes is associated with more than a twofold increased risk for cardiovascular (CV) death. In the case of subjects with type 1 diabetes, in spite of the fact that the CVD rate is significantly lower compared with the population with type 2 diabetes, their relative risk for coronary heart mortality is sevenfold higher than in matched counterparts without the disease (4). Despite all of these data concerning the association of diabetes and CVD, the exact mechanism by which diabetes, and its alterations, is linked to atherosclerosis remains incompletely elucidated. This is especially true in the case of hyperglycemia. The role of nonglycemic factors that accompany the vast majority of patients with type 2 diabetes, such as high blood pressure, dyslipidemia, and hemorreological abnormalities, among others, is much better understood and seems to be independent of glycemia. In addition to this, there have been studies demonstrating that interventions addressed to control these other factors in patients with diabetes effectively reduce CV risk. There also have been data including the use of statins, aspirin, the aggressive management of hypertension, and the use of ACE inhibitors (5,6). Therefore, the positive effects that the control of other factors beyond hyperglycemia exert on CVD are, nowadays, unquestionable. In contrast, to date, the positive effect of intensive glucose management in comparison to nonintensive glucose control on CVD outcomes is still far from proven and seems unlikely to change …

Macrovascular Complications of Diabetes Mellitus

Adults with diabetes mellitus frequently develop macrovascular complications. Vascular disease is a frequent cause of morbidity and mortality among patients with diabetes. Diabetes and vascular diseases remain among the most common causes of death in the United States. A number of clinical trials and practice guidelines have been published addressing the management of macrovascular complications. The cornerstone of preventing or delaying the progression of macrovascular complications of diabetes is aggressive management of hypertension and cholesterol. Angiotensin-converting enzyme inhibitors have proven effective in managing hypertension and avoiding other complications of diabetes. The body of evidence for angiotensin receptor blockers is growing in this area as well. Statins have been repeatedly proven to be the first-line agents in the management of dyslipidemia. Lifestyle modification strategies and antiplatelet therapy also remain essential. This review will focus on the role of newer diagnostic techniques, clinical trial evidence, and appropriate pharmacotherapy for macrovascular complications of diabetes.