Change In Antihypertensive Medication Research Articles

Cardiac Remodeling and Antihypertensive Medication Changes After Thoracic Endovascular Aortic Repair vs Open Surgical Repair

ObjectiveCardiovascular complications remain one of the major all-cause mortalities among patients who receive either thoracic endovascular aortic repair (TEVAR) or open surgical repair (OSR). Increased aortic stiffness after endograft deployment has been shown to induce left ventricular hypertrophy, diastolic dysfunction, and reduced coronary flow reserve. However, there is limited data on the hemodynamic effects after OR. The purpose of this study is to compare the cardiovascular and hemodynamic changes after TEVAR and OR. MethodsA retrospective analysis of 100 patients with thoracic aortic aneurysm or dissection who underwent open (n=50) or endovascular repair (n=50) was conducted. Information on demographics, medical and surgical history, and clinical outcomes were retrieved. Transthoracic echocardiographic (TTE) imaging results were collected to assess cardiac function. Changes to antihypertensive medication dosage and number were used as surrogate markers for hemodynamic changes and aortic stiffness. ResultsNo statistically significant differences were observed in antihypertensive medication number or dosage between the TEVAR and OSR group at 12 months, 24 months, and 36 months post-surgery. When adjusting for patient demographic factors of age, sex, and BSA in a multivariable generalized estimating equation model, patients who underwent TEVAR had a higher likelihood of receiving more antihypertensive medications (IRR = 1.131; P = .044). Patient characteristics such as BSA (IRR = 1.266; P = .001), HTN (IRR = 2.070; P ≤ .001), DM (IRR = 1.474; P ≤ .001), ESRD (IRR = 1.304; P = .011) were also associated with a higher number of antihypertensive medications. A significant increase in beta-blockers (P ≤ .001) and diuretics (P = .046) intake was observed post-TEVAR and post-OR. No significant differences in left ventricular ejection fraction and left ventricular hypertrophy were observed between the two groups. ConclusionsWe observed a greater likelihood of antihypertensive medications escalation following TEVAR, suggesting an increase in aortic stiffness post-operatively. No significant differences in cardiac remodeling were observed between the two groups. Our findings emphasize the need for an improved post-operative cardiac surveillance program in patients undergoing both TEVAR and OSR. Furthermore, additional innovation is needed to create aortic grafts that are more compatible with the native aorta in order to reduce long-term cardiovascular complications.

Blood pressure monitoring in elderly migraineurs starting an anti-CGRP monoclonal antibody: a real-world prospective study

BackgroundWhile monoclonal antibodies (mAbs) targeting the CGRP pathway have revolutionized migraine management due to their improved tolerance and adherence, concerns remain about their potential impact on blood pressure (BP), especially in older patients, due to CGRP-mediated vasodilation blockade. Given the growing use of these therapies in older populations, assessing their cardiovascular (CV) safety is of paramount importance.MethodsThis multicentric observational prospective study focused on migraine sufferers aged ≥ 60 who began erenumab, galcanezumab, or fremanezumab for prevention. Baseline, three-month, and twelve-month BP measurements were collected. Changes in antihypertensive medication and "Newly or Worsened Hypertensive" patients (NWHP) were assessed.ResultsAmong 155 patients receiving anti-CGRP mAbs (40 Erenumab, 47 Galcanezumab, 68 Fremanezumab), 42.5% had hypertension history and 39% were on antihypertensive treatment. No significant systolic or diastolic BP changes occurred at any time point compared to baseline (all p > 0.05), with no differences between the three groups. After one year, 20/155 (12.9%) patients were considered NWHP; 11/20 had prior hypertension, and 5/11 adjusted antihypertensive therapy. Among 9/20 newly hypertensive patients, 5/9 had a single measurement above the normal threshold with no requirement for new pharmacological therapy. A higher baseline BP value was associated with increased BP (p = 0.002).ConclusionsThe study concludes that treatment with anti-CGRP mAbs over one year does not significantly affect BP in patients aged ≥ 60, nor does it increase the incidence of hypertension compared to general population trends. Nonetheless, continuous monitoring and further long-term studies are necessary to fullya scertain the cardiovascular safety of these medications in the elderly.

Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards.

Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30days afterwards. A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS). At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge. Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.

Abstract P160: Orthostatic Hypotension During Hospitalization: A Retrospective Observational Study

Background: During hospital admissions, orthostatic hypotension (OH) is often considered a consequence of hypertension treatment, but the impact of reducing antihypertensive agents on OH response is unknown. Objective: To examine the association between inpatient antihypertensive medication changes and OH response. Methods: In this retrospective observational study, we reviewed electronic medical records of adult patients who experienced OH during their admission to Beth Israel Deaconess Medical Center between 2015 and 2021. Antihypertensive classes were categorized as not prescribed, no change, or decrease. OH improvement was assessed using vital sign flow sheets at presentation and discharge. We used logistic regression models adjusted for age, sex, and Black race to assess the association between antihypertensive categories and OH improvement. Results: Among 399 included patients (mean age: 69.9 years, 44% female, 10% Black), beta blockers (45%) were the most common antihypertensive class prescribed, followed by loop diuretics (23%), alpha blockers (21%), ACE inhibitors (20%), dihydropyridines (16%), ARBs (12%), thiazide diuretics (10%), and non-dihydropyridines (4%). Not being prescribed a dihydropyridine was associated with OH improvement (OR =2.37, 95% CI: 1.16-4.84), while decreasing a loop diuretic was associated with OH improvement (OR = 3.49, 95% CI: 1.46-8.36) (Table) . Changes to other classes were not associated with OH improvement. Conclusion: This study suggests that neither continuation nor reduction of most antihypertensives is associated with OH improvement. These findings should be tested in a prospective randomized trial.

Effect of Sodium Bicarbonate on Systolic Blood Pressure in CKD: A Systematic Review and Meta-Analysis.

Individuals with CKD are at a higher risk of cardiovascular morbidity and mortality. Acidosis is positively correlated with CKD progression and elevated systolic BP. Sodium bicarbonate is an efficacious treatment of acidosis, although this may also increase systolic BP. In this systematic review and meta-analysis, we summarize the evidence evaluating systolic BP and antihypertensive medication change (which may indicate systolic BP change) in response to sodium bicarbonate therapy in individuals with CKD. Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Cochrane Central Register of Controlled Trials, and World Health Organization (WHO) trials registry databases were searched for randomized control trials where sodium bicarbonate was compared with placebo/usual care in CKD stage G1-5 non-dialysis-dependent populations. Random effects meta-analyses were used to evaluate changes in systolic BP and BP-modifying drugs after sodium bicarbonate intervention. Fourteen randomized control trials (2110 individuals, median follow-up 27 [interquartile range 97] weeks, mean age 60 [SD 10] years, mean systolic BP 136 [SD 17] mm Hg, mean eGFR 38 [SD 10] ml/min, mean serum bicarbonate 22 [SD 4] mmol/L) were eligible for inclusion. Meta-analysis suggested that sodium bicarbonate did not influence systolic BP in individuals with CKD stage G1-5. Results were consistent when stratifying by dose of sodium bicarbonate or duration of intervention. Similarly, there was no significant increase in the use of antihypertensive medication or diuretics in individuals taking sodium bicarbonate, whereas there was a greater decrease in antihypertensive medication use in individuals taking sodium bicarbonate compared with controls. Our results suggest, with moderate certainty, that sodium bicarbonate supplementation does not adversely affect systolic BP in CKD or negatively influence antihypertensive medication requirements.

Remote physiologic monitoring for hypertension in primary care: a prospective pragmatic pilot study in electronic health records using propensity score matching.

Since 2019, the Centers for Medicare and Medicaid Services covers remote physiologic monitoring (RPM) for blood pressure (BP) per hypertension diagnosis and treatment guidelines. Here, we integrated Omron VitalSight RPM into the health system's electronic health record to transmit BP and pulse without manual entry, assessed feasibility, and used pragmatic prospective matched cohort studies to assess initial effects in (1) uncontrolled (last two office BP ≥140/90 mmHg) and (2) general (diagnosed hypertension or last office BP ≥140/90 mmHg) hypertension patient populations. Seventeen clinicians at two internal medicine practices were oriented. Eligible patients were aged 65-85 years had Medicare insurance with ≥1 office visit in the previous year. We prospectively identified matched controls (age, sex, BP, and number of office visits in previous year) from other primary care practices within the health system and estimated the association between RPM availability (clinic-level) and patient BP outcomes after 6 months. ClinicalTrials.gov: NCT04604925. Feasibility. Uptake was low at pilot clinics: 10 physicians prescribed RPM to 118 patients during the 6-month pilot. This included 7% (14/207) of the prespecified uncontrolled hypertension cohort and 3.3% (78/2356) of the general hypertension cohort. Surveyed clinicians (n = 4) reported changing their patients' medical treatment in response to RPM BPs, although they recommended having a dedicated RN or LPN to review BP readings. Effectiveness. At 6 months, BP control was greater at pilot practices than among matched controls (uncontrolled: 31.4% vs 22.8%; P = .007; general: 64.0% vs 59.7%; P < .001). Systolic BP at last office visit did not differ (mean [SD] 146.0 [15.7] vs 147.1 [15.6]; P = .48) in the uncontrolled population, and was lower in the general population (131.8 [15.7] vs 132.8 [15.9]; P = .04).The frequency of antihypertensive medication changes was similar in both groups (uncontrolled P = .986; general P = .218). Uptake notwithstanding, RPM may have improved BP control. A potential mechanism is increased physician awareness of and attention to uncontrolled hypertension. Barriers to RPM use among physicians require further study.

LIMITED CUTANEOUS SYSTEMIC SCLEROSIS MIMICKING HEREDITARY ANGIOEDEMA WITH NORMAL C1 INHIBITOR

<h3>Introduction</h3> Hereditary angioedema with normal C1 inhibitor (HAE-nl-C1INH) is often diagnosed when patients with antihistamine-resistant angioedema respond to bradykinin-targeted therapies. We present a patient with limited cutaneous scleroderma initially diagnosed as HAE-nl-C1INH, with variable response to HAE therapy. <h3>Case Description</h3> 56-year-old woman with hypertension presented with recurrent periorbital swelling while on ACE inhibitor therapy. After discontinuation, she continued to have episodes of angioedema for two months, responsive to recombinant C1 inhibitor therapy. Initial workup included normal C1 esterase inhibitor antigen and function, C4, C1q, SPEP, tryptase, and thyroid studies. After a six-month symptom-free period, angioedema recurred in the setting of stressful life events, viral infection, and antihypertensive medication changes. When on-demand therapy with recombinant C1 esterase inhibitor was observed to provide insufficient control, she started lanadelumab prophylaxis which stabilized her symptoms. She then developed episodic fluid retention with daily joint and subcutaneous swelling involving the hands, abdomen, and lower extremities coincident with additional changes to her antihypertensive regimen. Discontinuation of suspected culprit medications did not resolve the progression of her symptoms. Evaluation by rheumatology for joint symptoms and persistent hand swelling led to the diagnosis of limited cutaneous systemic sclerosis (scleroderma). Angioedema symptoms resolved after starting mycophenolate mofetil and she no longer required HAE therapy. <h3>Discussion</h3> Our case highlights the complicated and nuanced nature of diagnosing HAE-nl-C1INH, particularly in patients with partial response to HAE therapy. Limited cutaneous scleroderma either mimicked or triggered angioedema in our patient. Her partial response to C1 inhibitor infusions and lanadelumab may have represented off-target effects of HAE therapy.

Short-term Blood Pressure Variability and Incident CKD in Patients With Hypertension: Findings From the Cardiovascular and Metabolic Disease Etiology Research Center–High Risk (CMERC-HI) Study

The association between short-term blood pressure variability (BPV) and kidney outcomes is poorly understood. This study evaluated the association between short-term BPV and kidney disease outcomes in people with hypertension. Prospective observational cohort study. 1,173 hypertensive participants in the Cardiovascular and Metabolic Disease Etiology Research Center-High Risk (2013-2018) Study with estimated glomerular filtration rate (eGFR)≥60mL/min/1.73m2. Short-term BPV assessed by average real variability (ARV). Composite kidney disease outcome (30% decline in eGFR from baseline, new occurrence of eGFR<60mL/min/1.73m2, or onset of UACR >300mg/g). Multivariable Cox regression analyses to evaluate the association between systolic and diastolic BP ARV (SBP-ARV and DBP-ARV) and outcomes. During a median follow-up of 5.4 [4.1-6.5] years, 271 events of the composite kidney disease outcome occurred (46.5 per 1,000 person-years). Multivariable Cox analysis revealed that the highest SBP-ARV and DBP-ARV tertiles were associated with a higher risk of the composite kidney disease outcome than the lowest tertiles, independent of the 24-hour SBP or DBP levels (HR, 1.64 [95% CI, 1.16-2.33], and 1.60 [95% CI, 1.15-2.24] for SBP-ARV and DBP-ARV, respectively). These associations were consistent when SBP-ARV and DBP-ARV were treated as continuous variables (HR per 1.0-unit greater SBP-ARV, 1.03 [95% CI, 1.01-1.06]; HR per 1.0-unit greater DBP-ARV, 1.04 [95% CI, 1.01-1.08]). These associations were consistent, irrespective of subgroups (age, sex, 24-hour SBP or DBP, and moderate albuminuria). However, other measures of short-term BPV including SD, coefficient of variation, and dipping patterns were not associated with the composite kidney disease outcome. Observational study design, the use of single measurement of 24-hour BP, lack of information on changes in antihypertensive medication during the follow-up. Short-term BPV is associated with the development of a composite kidney disease outcome in hypertensive patients.

Factors affecting the changes in antihypertensive medications in patients with hypertension.

As frequent changes in anti-hypertensive (HTN) medications may reduce adherence to the treatments, identifying modifiable factors leading to changes in anti-HTN medications can help clinicians optimize treatment strategies for individual patients. We performed this study to explore the pattern of anti-HTN medications and to identify factors that are associated with the changes in anti-HTN medications. To this end, we used a clinical database of Seoul National University Hospital, extracted, transformed, and loaded by the observational medical outcomes partnership common data model. Demographic and all recorded clinical diagnoses, medications, and procedures data of eligible subjects were collected. Of 636 subjects who were eligible for this study, 297 subjects with a record of ≥1 anti-HTN medication changes and other 297 subjects without a record of medication change were selected for the study population. High diastolic blood pressure (adjusted odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.001–1.040, p = 0.040), arrhythmia (adjusted OR: 10.01, 95% CI: 1.86–185.57, p = 0.030), and angina pectoris with antianginal agents (adjusted OR: 4.85, CI: 1.05–23.89, p = 0.046) were associated with the changes in anti-HTN medications, indicating that any patients with these covariates require additional attention to reduce the likelihood of changing anti-HTN medications.

Changes in Antihypertensive Medication Following Bariatric Surgery.

Obesity is a leading cause of hypertension (i.e., high blood pressure [BP]). While hypertension can be managed with antihypertensive medication, substantial weight loss can also lower BP, reducing the need for antihypertensive medication. Articles in this review (n = 60) presented data on antihypertensive medication use among adults pre- and postoperatively. Roux-en-Y gastric bypass was the most studied surgical approach followed by Laparoscopic Sleeve Gastrectomy. Antihypertensive medication was discontinued in a large proportion of patients after surgery, and the mean number of antihypertensive medications decreased by approximately one. In almost a third of the studies, over 75% of participants experienced hypertension remission. All articles aside from two reported a decrease in systolic BP, with about 40% reporting a decrease of ≥ 10mm Hg.

Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

BackgroundA high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients’ home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation.MethodsOne hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients’ medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol.ResultsMean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients.ConclusionsThis mixed-methods process evaluation provided novel insights into practitioners’ decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients’ readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response.Trial registration(ISRCTN13790648). Registered 14 May 2015.

Impact of national valsartan recalls on Veterans' outcomes.

Background and Aims:Chemical impurities discovered in angiotensin receptor blocker (ARB) products in late 2018–2019 resulted in recalls of various products and has likely had downstream effects for patients and prescribers. The purpose of this study is to determine how the valsartan recall impacted clinical endpoints and prescribing of antihypertensives.Methods:This was a retrospective, single-center, cohort study including patients receiving recalled valsartan with essential hypertension who were mailed a recall letter on 12 March 2019. Mean blood pressure endpoints were collected 6 months before (pre-recall) and after the recall letter was mailed (post-recall). Antihypertensive medication changes and titrations were also characterized post-recall.Results:A total of 300 patients meeting eligibility criteria were included. There was no statistically significant difference in mean systolic blood pressure (SBP) or diastolic blood pressure (DBP) when pre- and post-recall blood pressures were compared (SBP: 137.2 mmHg versus 135.8 mmHg, p = 0.125; DBP: 78.6 mmHg versus 78.5 mmHg, p = 0.900). In addition, the percentage of patients with controlled blood pressure readings was similar in the pre- and post-recall timeframes (28% versus 27%, p = 0.72). A total of 33 medication changes involving valsartan occurred, with approximately one-third being changed to another ARB (n = 11) or drug class (n = 12). In total, 11 valsartan medication changes were specifically documented to be related to the valsartan recall.Conclusion:The results of this study indicate the valsartan recalls that occurred in 2019 did not significantly impact the clinical outcomes of the studied population.Plain Language SummaryImpact of a medication recall on Veterans’ outcomesBackground:Chemical impurities discovered in a class of blood pressure medications known as angiotensin receptor blockers (ARBs) occurred in late 2018–2019. This resulted in recalls of various products and has likely had downstream effects for patients and prescribers.Objective:The purpose of this study is to determine how the recall of valsartan, which is a medication in the ARB class, impacted clinical endpoints and prescribing of medications for blood pressure.Methods:This was a retrospective, single-center, cohort study including patients receiving recalled valsartan with high blood pressure who were mailed a recall letter on 12 March 2019. Blood pressure endpoints were collected 6 months before (pre-recall) and after the recall letter was mailed (post-recall). Medication changes and titrations were also characterized post-recall.Results:Three hundred patients meeting eligibility criteria were included. There was no difference found in systolic blood pressure (SBP) or diastolic blood pressure (DBP) when pre- and post-recall blood pressures were compared (SBP: 137.2 mmHg versus 135.8 mmHg; DBP: 78.6 mmHg versus 78.5 mmHg). In addition, the percent of patients with controlled blood pressure readings was similar in the pre- and post-recall timeframes (28% versus 27%). A total of 33 medication changes involving valsartan occurred, with approximately one-third being changed to another ARB (n = 11) or drug class (n = 12). Eleven valsartan medication changes were specifically documented to be related to the valsartan recall.Conclusions:The results of this study indicate the valsartan recalls that occurred in 2019 did not significantly impact the clinical outcomes of the studied population.

Optimizing a digital intervention for managing blood pressure in stroke patients using a diverse sample: Integrating the person-based approach and patient and public involvement.

BackgroundHaving a stroke or transient ischaemic attack increases the risk of a subsequent one, especially with high blood pressure (BP). Home‐based BP management can be effective at maintaining optimal BP.ObjectiveTo describe the optimization of a digital intervention for stroke patients and the value of participant diversity, using the person‐based approach (PBA) and integral patient and public involvement (PPI).Setting and participantsStroke patients recruited from primary care and community settings, and health‐care professionals in primary care, in England and Ireland.DesignThree linked qualitative studies conducted iteratively to develop an intervention using the PBA, with integral PPI.InterventionThe BP: Together intervention, adapted from existing BP self‐monitoring interventions, is delivered via mobile phone or web interface to support self‐monitoring of BP at home. It alerts patients and their clinicians when a change in antihypertensive medication is needed.FindingsFeedback from a diverse range of participants identified potential barriers, which were addressed to improve the intervention accessibility, feasibility and persuasiveness. Easy‐to‐read materials were developed to improve usability for patients with aphasia and lower literacy. The importance of including family members who support patient care was also highlighted. Feedback messages regarding medication change were refined to ensure usefulness for patients and clinicians.DiscussionInput from PPI alongside qualitative research with a diverse study sample allowed the creation of a simple and equitable BP management intervention for stroke patients.Patient involvementTwo PPI co‐investigators contributed to design, conduct of study, data interpretation and manuscript preparation; community PPI sessions informed early planning. Study participants were stroke patients and family members.

The effect of partial nephrectomy on blood pressure in patients with solitary kidney.

To determine the effect of partial nephrectomy (PN) in the solitary kidney on systolic and diastolic blood pressures (SBP and DBP, respectively), and use of antihypertensive medications. We performed a retrospective cohort study of solitary kidney patients who underwent PN for kidney cancer from 1999-2015. Primary outcomes evaluated were blood pressure (BP) and antihypertensive medication changes from baseline up to 5years postoperatively. Using a multivariable mixed-effects model to account for repeated measurements, we evaluated the effect of PN on the outcome measurements while controlling for baseline patient, pathologic, and perioperative characteristics. 292 patients who underwent PN on solitary kidneys met inclusion criteria (median [range] age, 63 [24-84] years; 179 men [61%]). SBP decreased immediately postoperatively (- 1.7mmHg [- 2.6, - 0.7], p < 0.001), and further decreased by 0.04mmHg per year (p = 0.01) postoperatively, for a total change of - 1.9 [- 3.9, 0.2] mmHg at 5years (p = 0.01). DBP decreased immediately postoperatively (- 2.2mmHg [- 2.7, - 1.7], p < 0.001), and then rebounded by 0.37mmHg per year (p = 0.003) postoperatively, for a total change of - 0.4 [- 1.5, 0.7] mmHg at 5years (p = 0.003). Antihypertensive medication use increased at 5years (0.35 more medications per patient, p < 0.001). Our results suggest a minimal change in BP after PN, although patients increased antihypertensive medication use. This data suggests damage to renal parenchyma or hilar nerves during PN did not significantly impact BP regulation in our cohort.

2220-PUB: Renal Outcomes Associated with Canagliflozin 100mg and with Intensification of SGLT2 Inhibitor Therapy Switching to Canagliflozin 300mg in Patients with Type 2 Diabetes Mellitus in a Real-World Setting: The Renal-WECAN Study

The aim of this multicentric retrospective study was to assess in a real-world setting kidney outcomes associated with canagliflozin 100 mg/d (CANA100), as add-on to the background antihyperglycemic therapy, and with the intensification of SGLT2 inhibitor (SGLT2i) therapy by switching to canagliflozin 300 mg/d (CANA300) in patients with T2DM. 583 patients were included, 279 with CANA100 (eGFR 86.5 ml/min, eGFR&amp;lt;60 12.3%, albuminuria &amp;gt;30 mg/g 25.7%) and 304 with CANA 300 (eGFR 84.9 ml/min, eGFR&amp;lt;60 9.1%, albuminuria &amp;gt;30 mg/g 20.7%). Median follow-up periods in both cohorts were 9.1 and 15.4 months respectively. The primary outcomes of the study were changes in eGFR, albuminuria and systolic BP (SBP) over the follow-up time. CANA100 was associated to significant reductions in eGFR (-2 ml/min) and SBP (-4.8 mmHg). In those patients with SBP&amp;gt;140 mmHg, CANA 100 lowered SBP levels by 14.9 mmHg. No significant changes in albuminuria were observed. However, in the subset of patients with baseline albuminuria &amp;gt;30 mg/gr, there was a significant decrease in median albuminuria. In the second cohort, patients with prior background SGLT2i therapy switched to CANA300. Significant reductions in eGFR (-1.8 ml/min), SBP (-3.2 mmHg), and median albuminuria (from 8.1 to 5.8 mg/g) were observed over the follow-up period. In those patients with SBP&amp;gt;140 mmHg, CANA 300 lowered SBP levels by 15.9 mmHg. In the subset with baseline albuminuria &amp;gt;30 mg/g, there was a significant decrease in median albuminuria. No significant changes in anti-hypertensive medications were observed over the follow-up. There was a low rate of adverse events related to volume depletion. In summary, CANA100 (as add-on therapy) and CANA300 (switching from CANA100 or other SGLT2i) significantly decreased SBP and modestly reduced eGFR. A significant reduction in albuminuria was observed with CANA300. Disclosure J.J. Gorgojo-Martinez: Advisory Panel; Self; Abbott, AstraZeneca, Grunenthal Group, Janssen Pharmaceuticals, Inc., Lilly Diabetes, Mundipharma International, Novo Nordisk Inc., Pfizer Inc. Research Support; Self; AstraZeneca, Novo Nordisk Inc. Speaker’s Bureau; Self; Abbott, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Celgene, Janssen Pharmaceuticals, Inc., Lilly Diabetes, Mundipharma International, Novo Nordisk Inc. M.A. Gargallo-Fernandez: Speaker’s Bureau; Self; Janssen Pharmaceuticals, Inc., Lilly Diabetes, Novo Nordisk Inc., Sanofi. A. Galdon: Speaker’s Bureau; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Mundipharma International, Novo Nordisk Inc. T. Antón-Bravo: Speaker’s Bureau; Self; AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Mundipharma International, Novo Nordisk Inc. M. Brito-Sanfiel: Advisory Panel; Self; Abbott, Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Sanofi-Aventis. Speaker’s Bureau; Self; Almirall, AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Esteve, Janssen Pharmaceuticals, Inc., Merck &amp; Co., Inc., Mylan, Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Sanofi-Aventis. J.E.M. Wong-Cruz: None.

Remote Management of Poststroke Patients With a Smartphone-Based Management System Integrated in Clinical Care: Prospective, Nonrandomized, Interventional Study.

BackgroundAdvances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases.ObjectiveWe developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients.MethodsWith a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3.ResultsThe study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0], P<.001; 12 weeks: 74.7 [SD 14.0], P<.001) and BDI score (baseline: 12.7 [SD 10.1]; 4 weeks: 11.2 [SD 10.2], P=.01; 12 weeks: 10.7 [SD 10.2], P<.001) showed gradual improvement; however, no significant differences were found in the mean EQ-5D score (baseline: 0.66 [SD 0.33]; 4 weeks: 0.69 [SD 0.34], P=.01; 12 weeks: 0.69 [SD 0.34], P<.001). Twenty-six patients who had uncontrolled BP at baseline had −13.92 mmHg (P=.001) and −6.19 mmHg (P<.001) reductions on average in systolic and diastolic BP, respectively, without any antihypertensive medication change. Medication compliance was better at visit 2-3 (60.9% [SD 37.2%]) than at visit 1-2 (47.8% [SD 38.7%], P<.001).ConclusionsAwareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost.

The efficacy of unilateral laparoscopic nephrectomy in the pediatric hypertensive patient

Secondary hypertension due to a poorly functioning or non-functional kidney may be refractory to medical management. In such cases, nephrectomy can improve or cure hypertension. With the routine use of laparoscopy, nephrectomy can be performed in a minimally invasive manner, but surgery still carries inherent risks and complications. The objective of this study is to evaluate the outcomes of laparoscopic nephrectomy performed for secondary hypertension and identify potential predictors of postoperative hypertension resolution. After obtaining approval from institutional review board, patients from January 2002 to March 2018 who underwent laparoscopic nephrectomy were identified using Current Procedural Technology codes. All charts were then manually reviewed to isolate those patients with secondary hypertension present preoperatively. Patient demographics, urologic history, and laboratory and imaging findings were recorded for all patients. Serial blood pressures were recorded at all renal visits along with any antihypertensive medication changes. Postoperative outcomes and complications were also noted for all patients. A total of 20 patients (7 girls, 13 boys) underwent laparoscopic nephrectomy to treat hypertension at an average age of 10.6 years (range 1.7-17.0 years). Etiology of a solitary non-functional kidney was vesicoureteral reflux in 10 of 20 patients, multicystic dysplastic kidney in 5 of 20, ureteropelvic junction obstruction in 2 of 20, ureteral obstruction in 1 of 20, and renal artery stenosis in 2 of 20 patients. At time of surgery, 3 of 20 patients were on two antihypertensives, 10 of 20 were on one antihypertensive, and 7 of 20 proceeded to surgery with no medical management. In the 30-day postoperative period, no complications were noted. Hypertension improved in 10 of 20 (50%) patients, all of whom were not on any antihypertensive medications after surgery. Hypertension persisted in 4 of 20 (20%) patients, requiring the same antihypertensive regimen and worsened in 6 of 20 (30%) patients, requiring increased doses and/or additional antihypertensives. Average follow-up time was 2.7 years. No significant predictors of postoperative hypertension result were identified when comparing the groups of responders and non-responders. While laparoscopic nephrectomy for a non-functioning kidney in the setting of hypertension is a safe procedure, the cure rate for hypertension in the cohort appears to be on the low side of what was previously reported. While the small sample size is a main limitation, it is amongthe largest sample sizes for pediatric hypertensive patients. Previously shown predictors were not predictive in the similar-sized cohort. Patients should be carefully counseled on the risks and benefits of nephrectomy to treat hypertension, the importance of continued follow-up after nephrectomy, and the possible need for chronic medical management with antihypertensives.

Effect of Radiofrequency-Based Renal Denervation: The Impact of Unplanned Medication Change from a Systematic Review and Meta-Analysis.

Catheter-based renal denervation (RDN) has emerged as a promising treatment option for hypertension. However, randomized controlled trials (RCTs) have reported conflicting results on blood pressure (BP) reduction. Patient- and procedure-related confounders have been implied as the potential sources of inconsistent BP responses. We aimed to investigated whether unplanned and frequent medication changes in RDN studies affected the BP response to RDN by conducting sensitivity and subgroup analyses, according to antihypertensive medication change rates in a meta-analysis of RCTs. We searched the PUBMED, EMBASE, and COCHRANE databases up to May 2018. RCTs that studied the effects of RDN on hypertensive patients were included. A meta-analysis was carried out using RevMan 5.3. A total of 12 studies were included, of which four fulfilled the inclusion criteria of < 10% medication change rate in our review. Subgroup meta-analyses of the four RCTs with < 10% medication change rates showed statistically significant reductions of 6.07 mmHg and 7.12 mmHg in 24-hour and office systolic BP, respectively. The 24-hour and office diastolic BP were also reduced (mean difference = -3.89 mmHg and -4.27 mmHg, respectively). These subgroup analyses had no heterogeneity (I2 = 0%). In contrast, the pooled analysis of the 12 studies and the subgroup analysis of eight studies with > 10% medication change rates both had a high level of heterogeneity and no significant BP reduction. The effectiveness of RDN was demonstrated across a broad range of antihypertensive medications used at baseline after removing the confounder of unplanned medication changes.

Hypoperfusion Symptoms Poorly Predict Hemodynamic Compromise and Stroke Risk in Vertebrobasilar Disease.

Background and Purpose- Cerebral hypoperfusion symptoms (defined as symptoms related to change in position, effort or exertion, or recent change in antihypertensive medication) have been used in stroke studies as a surrogate for detecting hemodynamic compromise. However, the validity of these symptoms in identifying flow compromise in patients has not been well established. We examined whether hypoperfusion symptoms correlated with quantitative measurements of flow compromise in the prospective, observational VERiTAS study (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke). Methods- VERiTAS enrolled patients with recent vertebrobasilar transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral or basilar arteries. Hemodynamic status using vertebrobasilar large vessel flow was measured using quantitative magnetic resonance angiography, and patients were designated as low, borderline, or normal flow based on distal territory regional flow, incorporating collateral capacity. The presence of qualifying event hypoperfusion symptoms was assessed relative to the quantitatively determined flow status (normal versus borderline/low) and also examined as a predictor of subsequent stroke risk. Results- Of the 72 enrolled subjects, 66 had data on hypoperfusion symptoms available. On initial quantitative magnetic resonance angiography designation, 43 subjects were designated as normal flow versus 23 subjects designated as low flow (n=16) or borderline flow (n=7). Of these, 5 (11.6%) normal flow and 3 (13.0%) low/borderline flow subjects reported at least one qualifying event hypoperfusion symptom ( P=0.99, Fisher exact test). Hypoperfusion symptoms had a positive predictive value of 37.5% and negative predictive value of 65.5% for low/borderline flow status. Compared with flow status, which strongly predicted subsequent stroke risk, hypoperfusion symptoms were not associated with stroke outcome ( P=0.87, log-rank test). Conclusions- These results suggest that hypoperfusion symptoms alone correlate poorly with actual hemodynamic compromise as assessed by quantitative magnetic resonance angiography and subsequent stroke risk in vertebrobasilar disease, and are not a reliable surrogate for flow measurement. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00590980.

Twenty-Four-Hour Blood Pressure-Lowering Effect of a Sodium-Glucose Cotransporter 2 Inhibitor in Patients With Diabetes and Uncontrolled Nocturnal Hypertension: Results From the Randomized, Placebo-Controlled SACRA Study.

The risk of cardiovascular disease and mortality in salt-sensitive patients with diabetes mellitus and uncontrolled nocturnal hypertension is high. The SACRA (Sodium-Glucose Cotransporter 2 [SGLT2] Inhibitor and Angiotensin Receptor Blocker [ARB] Combination Therapy in Patients With Diabetes and Uncontrolled Nocturnal Hypertension) study investigated changes in blood pressure (BP) with empagliflozin plus existing antihypertensive therapy. This multicenter, double-blind, parallel study was conducted in Japan. Adult patients with type 2 diabetes mellitus and uncontrolled nocturnal hypertension receiving stable antihypertensive therapy including angiotensin receptor blockers were randomized to 12 weeks' treatment with empagliflozin 10 mg once daily or placebo. Clinic BP was measured at baseline and weeks 4, 8, and 12; 24-hour ambulatory BP monitoring was performed at baseline and week 12; and morning home BP was determined for 5 days before each visit. The primary efficacy end point was change from baseline in nighttime BP (ambulatory BP monitoring). One hundred thirty-two nonobese, older patients with well-controlled blood glucose were randomized (mean age 70 years, mean body mass index 26 kg/m2). Empagliflozin, but not placebo, significantly reduced nighttime systolic BP versus baseline (-6.3 mm Hg; P=0.004); between-group difference in change from baseline was -4.3 mm Hg (P=0.159). Reductions in daytime, 24-hour, morning home, and clinic systolic BP at 12 weeks with empagliflozin were significantly greater than with placebo (-9.5, -7.7, -7.5, and -8.6 mm Hg, respectively; all P≤0.002). Between-group differences in body weight and glycosylated hemoglobin reductions were significant, but small (-1.3 kg and -0.33%; both P<0.001). At 4 weeks, N-terminal pro-B-type natriuretic peptide levels were reduced to a greater extent in the empagliflozin versus placebo group (-12.1%; P=0.013); atrial natriuretic peptide levels decreased with empagliflozin versus placebo at weeks 4 and 12 (-8.2% [P=0.008] and -9.7% [P=0.019]). Changes in antihypertensive medication during the study did not differ significantly between groups. Nonseverely obese older diabetes patients with uncontrolled nocturnal hypertension showed significant BP reductions without marked reductions in glucose with the addition of empagliflozin to existing antihypertensive and antidiabetic therapy. Use of sodium-glucose cotransporter 2 inhibitors in specific groups (eg, those with nocturnal hypertension, diabetes, and high salt sensitivity) could help reduce the risk of heart failure and cardiovascular mortality. URL: https://www. gov. Unique identifier: NCT03050229.