BP Goals Research Articles

Abstract 133: White Matter Hyperintensity and Cardiovascular Disease Outcomes: A Secondary Analysis of the SPRINT MIND Trial

Background: The Systolic Blood Pressure Intervention Trial (SPRINT) randomized patients to a goal SBP <120 mm Hg vs. <140 mm Hg . A subset of patients enrolled in SPRINT MIND, which performed a baseline MRI and measured white matter hyperintensity volume (WMHv). We evaluated the association between WMHv and cardiovascular events. Methods: The primary outcome was a composite of stroke, MI, ACS, decompensated CHF, or CVD death. The secondary outcome was stroke. The WMHv was divided into quartiles. We fit Cox models to the outcomes and report adjusted hazard ratios for the quartiles of WMHv, and stratified by SPRINT treatment arm. Results: Among 719 included patients, the mean WMHv in the quartiles was 0.34, 1.09, 2.61, and 10.8 mL. The primary outcome occurred in 51/719 (7.1%) and the secondary outcome in 10/719 (1.4%). The WMHv was associated with both outcomes (Table 1, Figure 1). After stratifying by treatment arm, we found the association persisted in the standard, but not intensive, treatment arm (Table 2). However, the interaction term between WMHv and treatment arm was not significant. Conclusions: We observed that degree of WMH was associated with CVD and stroke risk in SPRINT MIND. The risk may be attenuated in patients randomized to intensive BP lowering. Trials are needed to determine if intensive BP lowering can prospectively reduce the high cardiovascular risk in patients with WMH.

Hypertension: evolving from standardized to individualized care.

: The hypertension paradigm has contributed to a dramatic reduction in CVD mortality. This has been achieved by applying average results of population studies to identify a target population and design a common intervention to achieve a BP goal. Progressive lowering of the BP threshold has expanded the fraction of persons at risk who have access to treatment. Meanwhile, falling risk reduces potential benefit, while treatment-induced adverse events increase - making further expansion of the treatment pool no longer tenable. Still, CVD remains the leading cause of death. Fortunately, new science reveals opportunities to enhance CVD prevention when BP management is based upon individual characteristics. Treatment can be directed at those most likely to benefit, while sparing others the hazards of unnecessary therapy. Treatment can be designed to achieve a variety of physiological objectives that influence cardiovascular outcomes. This new strategy should improve both the efficacy and efficiency of BP-related CVD prevention.

Is There a Role for Device Therapies in Resistant Hypertension?: The CON Side.

In this piece, I will argue that device-based therapies for resistant hypertension (RH), although interesting and meritorious of further study, do not yet deserve a prominent role in the management of patients with RH. This argument is on the basis of the limited availability of controlled studies using devices, the cost and uncertain long-term effectiveness of device modalities, and the successful track record of medical therapy. First, let me define the demand for advanced therapies in RH. RH is defined as the BP of a hypertensive patient that remains above goal despite the concurrent use of three antihypertensive agents of different classes, preferably including a blocker of the renin-angiotensin system, a calcium channel blocker, and a thiazide-type diuretic (1). The prevalence of RH in the general hypertensive population is 12%–18%, on the basis of office BP measurements >140/90 mm Hg (1), an estimate that is expected to increase by approximately 2% when the 130/80 mm Hg threshold is applied to high-risk patients (2). Approximately one third of these patients have normal 24-hour BP (1), and a sizable portion is nonadherent to prescribed medications; therefore, approximately 5%–10% of hypertensive patients would ultimately qualify as having true RH. The current approach to the treatment of RH calls for adequate dosing of complementary medications, preferential use of long-acting thiazide diuretics ( e.g ., chlorthalidone), and the addition of a mineralocorticoid antagonist ( e.g ., spironolactone) (1). When such a strategy is used, BP goal is achieved in up to 90% of patients (3). Hence, about 0.5%–1% of hypertensive patients (approximately 750,000–1.5 million adults in the United States) would benefit from alternative approaches to treatment, such as referral to hypertension specialists for more advanced drug combinations or the use of device therapies. I acknowledge the importance of treatment nonadherence and medication intolerance in RH. Nonadherence is …

Achievement of Metabolic Goals among Different Health Insurance Schemes in Thai Patients with Type 2 Diabetes Mellitus: a Nationwide Study

Objective: Thailand has three healthcare insurance schemes, including: Universal Health Coverage (UHC), Social Health Insurance (SHI), and Civil Servant Medical Benefit (CSMB). UHC has the narrowest drug coverage, SHI uses its own list, and CSMB offers the greatest drug coverage. The aim of this study was to investigate metabolic goal achievement in patients with type 2 diabetes mellitus (T2DM) compared among the three healthcare schemes in Thailand. Methods: Data were obtained from a nationwide survey administered by MedResNet during 2011 to 2012. A cross-sectional survey was conducted in patients with T2DM aged >35 years who were treated for at least 12 months. The data were retrospectively collected from medical records. Results: Of 49,303 T2DM patients that were recruited, 69.8% were female. CSMB patients were the oldest and had the longest diabetes duration. Achievement of BP, HbA 1c , and LDL goals was 32.8%, 33.3%, and 42.5%, respectively. UHC patients had the highest percentage of BP control achievement (<130/80 mmHg; 33.1%), while CSMB patients had the highest percentage of HbA 1c (<7%; 40.4%) and LDL (<100 mg/dL; 49%) achievement. CSMB patients had the highest prevalence of 2-goal (16.8% for T2DM without HT) and 3-goal achievement (8.2% for T2DM with HT). Multivariate analysis revealed the CSMB scheme to be significantly associated with 3-goal achievement compared to the UHC scheme (odds ratio: 1.48, 95% confidence interval: 1.30-1.67; p <0.01). Conclusion: The prevalence of metabolic goal achievement in patients with T2DM in Thailand is low. CSMB patients have the highest prevalence of 2-goal and 3-goal achievement.

Target BP Goals in Children/Adolescents

Target BP Goals in Children/Adolescents

P1679Blood pressure and LDL-cholesterol control in patients with primary hypertension is far from optimal: results from a large observational, multicentric, prospective study

Abstract Background Blood pressure (BP) and LDL-cholesterol control worldwide is still suboptimal. New European and American guidelines have introduced more strict recommendations regarding BP and LDL-cholesterol goals, but data of how difficult is to reach them in routine clinical practice is missing. Triple combination (preferably in a single pill) has been recommended as the 2nd step for the BP control, but data on its efficacy and treatment adherence is limited. Purpose To assess BP control at baseline, and after 6 months of optimized treatment with a single pill triple combination (of perindopril, amlodipine, and indapamide), and to assess associated risk factors control and treatment adherence. Methods In an observational, multicentric, prospective study, involving 209 investigators, we included 2077 patients (62±10 years; 49% men) with primary hypertension, in sinus rhythm, on current treatment with a single pill triple combination for at least one month prior to inclusion. General characteristics, cardiovascular risk factors, concomitant diseases, concomitant medications, fixed triple combination dosage, and adherence score were collected at baseline (V1), one month (V2), and 6 months (V3). Standardized office BP was measured with a single type sphygmomanometer, at each visit. Lipid profile was collected, if available. At V1 and V2, non-pharmacological and pharmacological treatment was optimized, according to the current guidelines. Results At baseline, BP control was suboptimal: only 37% of patients (38% of non-diabetic and 33% of diabetic patients) had optimal BP control as per ESC guidelines 2013, whereas only 10% of patients (11% of non-diabetic and 10% of diabetic patients) had optimal BP control as per ESC guidelines 2018. However, after 6 months of optimized treatment, 75% of patients (78% of non-diabetic and 67% of diabetic patients) had optimal BP control as per ESC guidelines 2013, while 33% of patients (33% of non-diabetic and 33% of diabetic patients) had optimal BP control as per ESC guidelines 2018. At baseline, despite that 52% of patients were on a statin, only 12% of patients at very high cardiovascular risk had an LDL-cholesterol<70 mg/dl, while only 25% of patients at high cardiovascular risk had a LDL-cholesterol<100 mg/dl; at 6 months, 13% of patients at very high cardiovascular risk had an LDL-cholesterol<70 mg/dl, while 30% of patients at high cardiovascular risk had a LDL-cholesterol<100 mg/dl. Single pill triple combination dose was increased at V1 in 29% of patients, and at V2 in 7% of patients. Adherence score increased from 7.0±1.6 at V1 to 7.4±1.1 at V3 (p<0.001). Conclusion BP control and LDL-cholesterol control, according to the new guidelines, is far from optimal. However, by optimizing non-pharmacological treatment and increasing dosing and adherence of a single pill triple combination, BP control can be markedly improved. Acknowledgement/Funding Servier Pharma

Abstract 103: The Effects of s Lower Blood Pressure Treatment Goal on Orthostatic Hypotension in Adults With Recent Stroke

Background: Lower systolic blood pressure (SBP) treatment goals reduce risk of orthostatic hypotension (OH). Whether a lower goal also reduces orthostatic symptoms is unknown. Methods: We examined the effect of SBP goal on OH in SPS3-BP (Secondary Prevention of Small Subcortical Strokes - Blood Pressure), an open label, randomized trial. Adults with a recent stroke (<6 months) were assigned to either a SBP goal of 130-149 mm Hg or <130 mm Hg. During follow-up, BP was measured 3 times in a seated position and once after 2 minutes of standing. OH was defined as a drop in SBP ≥20 mm Hg or DBP ≥10 mm Hg. We also examined extreme standing BP values (SBP ≥190 mm Hg or ≤90 mm Hg; DBP ≥110 mm Hg or ≤40 mm Hg). Participants were asked about dizziness and lightheadedness in the process of standing up. We used generalized estimating equations to account for repeat measurements. Results: During 36,342 visits, involving 2,876 participants (mean age 62.8 ± 10.7 yrs, 37% women, 16% black) with a mean of 15 follow-up visits, OH was present 2,591 times in 1,165 participants. Similarly, dizziness was present 1,343 times (in 592 participants) and lightheadedness was present 941 times (in 893 participants). A lower SBP goal (compared to standard) was associated with a lower risk of OH (OR 0.86; 95% CI: 0.75, 0.99), a higher risk of SBP ≤90 mm Hg (3.79; 2.35, 6.11) or DBP ≤40 mm Hg (2.42; 1.41, 4.15), and a lower risk of SBP ≥190 mm Hg (0.40; 0.27, 0.60) or DBP ≥110 mm Hg (0.31; 0.19, 0.50) ( Table ). BP goal did not affect dizziness or lightheadedness. Conclusions: A lower SBP goal decreased OH without affecting orthostatic symptoms. These findings support recent observations that more intensive SBP treatment does not increase risk of falls.

Abstract 001: Hypertension Control to Systolic Blood Pressure <140 and <130. Implications for Hypertension Guidelines and Performance Metrics Based on Sprint Pop Data

Background: Value-based healthcare rewards quality, e.g. 90 th percentile performance, which requires more than 77% of eligible adults 18 - 85 years with hypertension have BP below 140/90 on the last visit of 2019. Systolic (S)BP (mmHg) below140 on most visits leads to fewer cardiovascular events (CVE) than less consistent control. Goal SBP was lowered to below 130 in the 2017 ACC / AHA Hypertension Guideline as treated patient groups with mean SBP 120-124 had fewer CVE than groups with higher mean SBP. Stricter treatment targets and incentives for excellent performance may lead to group mean SBP less than 120, i.e., below the evidence. Methods: SPRINT POP Year 2 data were analyzed given more treatment adjustments in Year 01 and fewer patients active in Year 3 and later. The % of patients controlled on various % of visits and mean SBP on the last visit for each group are provided (Table). SEM for SBP less than 0.5 mmHg. Results: Standard and intensive therapy, respectively, consistently controlled (more than 75% visits) SBP to less than 140 in 29.9% and 78.0% (mean 128.4, 117.6) and SBP to less than 130 in 5.1% and 53.8% (mean 118.5, 114.8) of SPRINT participants. Discussion: Group mean SBP falls as the (% visits and patients at goal rise. Consistent control to SBP less than 140 likely requires group mean SBP 118-128 on the last yearly visit. Consistent control to SBP less than 130 likely requires group mean SBP 115-119, which is below the evidence of 120-124. BP variability, the impact of single point assessment, and incentives for excellent control are items to consider in hypertension guideline and performance metrics as mean SBP below the evidence may be attained.

SUN-273 ASSOCIATION BETWEEN BLOOD PRESSURE AND THE PROGRESSION OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH GLOMERULAR DISEASES

The KDIGO guideline recommends target BP < 130/80 mmHg in proteinuric patients with CKD. The guideline is largely based on many clinical studies in diabetic and hypertensive patients. However, there is lack of evidence that this BP goal can also be applied to patients with glomerular diseases. Here, we studied the relationship between BP and CKD progression in patients with glomerular diseases. We performed a multicenter retrospective cohort study from 4 university hospitals in Korea. A total of 1179 patients diagnosed with 3 primary glomerular diseases such as IgAN (n=298, 67.6%), MGN (n=210, 17.8%), and FSGS (n=171, 14.5%) between 2005 and 2017 were enrolled. Patients were categorized as <120 (n=405, 34.4%), 120-129 (reference; n=304, 25.8%), 130-139 (n=221, 18.7%), and ≥140 (n=249, 21.1%) mmHg by SBP. Primary outcome was a composite of a ≥ 30% decline in eGFR or the onset of ESRD The mean age was 43.6±12.3 years and 597 patients (50.6%) were male. Baseline GFR was 79.2±32.1 ml/min/1.73 m2 and 699 (59.3%) patients had hypertension. During a mean follow-up of 43.6 months, primary outcome occurred in 107 (26.4%), 72 (23.7%), 66 (29.9%), and 79 (31.7%) patients in the categories of <120, 120-129, 130-139, and ≥140 mmHg, respectively. In baseline BP-based model, after adjustment of confounding factors, HRs for CKD progression were 1.37 (95% CI 0.98-1.93; p=0.067), 1.17 (95% CI 0.98-1.93; p=0.415), and 1.60 (95% CI 1.12-2.29; p=0.010), respectively. Time-varying BP-based model confirmed the significant association between SBP and CKD progression; HRs were 1.39 (95% CI 0.97-1.99; p=0.070), 1.50 (95% CI 1.02-2.22; p=0.039), and 1.62 (95% CI 1.10-2.38; p=0.014) in each SBP category. Among patients with glomerular diseases, SBP of 120-129 mmHg was significantly associated with decreased risk of CKD progression. Further well-designed randomized controlled studies are warranted to determine optimal BP goal in these patients

Analysis of blood pressure control in outpatients with non-dialysis chronic kidney disease referred by primary care physicians: a study from the centre of nephrology care

Background. Patients with chronic kidney disease (CKD) have increased all-cause mortality, especially cardiovascular. The majority of patients with CKD have stages 1–3 and are treated by primary care physicians and nephrologists. Arterial hypertension (HTN) is highly prevalent comorbidity among CKD population, but its control remains poor. Material and methods. This retrospective non-interventional cross-sectional study was conducted in the Centre of Nephrology Care in Dnipropetrovsk Mechnikov Regional Hospital, Dnipro, Ukraine. We aimed to select patients who are supposed to be followed-up by primary care practitioners but due to certain reasons required nephrologist’s consultation. From 4540 patients who received medical care in the Centre of Nephrology Care 365 patients fulfilled inclusion criteria. They were subdivided by presence of HTN, CKD stage, presence of proteinuria and achieving blood pressure targets according to different standards. All patients were examined and followed-up according to local and European standards. Results. Forty-nine percent of patients had known HTN, and 21% had HTN de novo. Advance of CKD stage was significantly associated with increase in the most of laboratory findings, age and BP values. Non-proteinuric patients achieved BP goals significantly more often, than proteinuric ones. Females achieved BP targets more often, than males. Monotherapy was the most common treatment regimen. Conclusions. HTN occurs in 70% of patients with CKD and it is controlled in up to 34% of cases. HTN is important factor of CKD progression and it is closely connected with GFR and proteinuria.

SUN-228 ACC/AHA BLOOD PRESSURE THRESHOLD AND BURDEN OF HYPERTENSION, AND PREVENTING CHRONIC KIDNEY DISEASE

The diagnosis and treatment of hypertension with the appropriate agents to the desirable BP goal is arguably one of the most cost effective interventions in modern medicine. What constitutes the appropriate BP treatment goal is based on the available evidence that the attainment of such BP levels should limit or altogether prevent the complications such as CKD due to hypertensive nephrosclerosis. Recently the AHA/ACA recommended a downward review of the BP threshold compared to the JNC 7 recommendations for diagnosis of hypertension. In this cross sectional survey of the general population in the Northeast, Nigeria, we recruited all the adults who responded to our invitation for medical check in clusters of residential areas in the Maiduguri and its environs. Besides the documentation of the demographic characteristics, we recorded three consecutive blood pressure measurements of all adults aged 18 and above and determined the average of both the systolic (SBP) and diastolic (DBP) blood pressures. We further categorized the study population into BPs groups according to the JNC7 cut off value of SBP >/=140 and or DBP of >/=90mmHg for stage 1 hypertension and by the 2017 ACC/AHA threshold of >/=130 and/or >/=80 mmHg. Nigeria in 2017 had a median age of 18.4 years and an estimated population of 197.7 million people. 1010 adults aged 18 to 79 (mean 36.7) years made up of 544 males and 466 females (M:F = 1.2:1) were studied. The prevalence of hypertension by the JNC 7 threshold was 344/1010 (34%) plus an additional 138 (13.6%) individuals classified as having hypertension by the AHA/ACA threshold. Therefore 47.6% of the adult population are at risk of developing complications of hypertension in Nigeria. The mean eGFR for the general study population was 100.5ml/min/1.73M2. The SBP categories 130-139mmHg and the >/= 140mmHg had eGFRs of 98.6 and 98.5 ml/min/1.73M2 respectively. On the other hand SBP categories less than 120mmHg and the 120-9 mmHg had eGFRs of 103 and 102.0ml/min/1.73M2 respectively. Those eGFR values were higher than eGFRs of the study population as a whole and those of the individuals with higher SBPs than 130mmHg. The individuals with DBP categories < 80 and 80 - 89mmHg had eGFRs of 101.5 and 101.6 which were higher than the 97.4ml/mi/1.74M2 for the individuals with DBP greater than 90mmHg. Based on the ACC/AHA guideline on hypertension, close to half of the adults in the general population amounting to about 50 million Nigerians are at the risk of developing the consequences of hypertension. Moreover the blood pressure categories of SBP less than 130mmHg and/or DBP less than 90mmHg had kidney functions which were better than the average for the study population and those of individuals with higher BP measurements. Our study lends support to the ACC/AHA report that some health risk including the possible loss of kidney function maybe associated with SBP greater than 130mmHg in the general population.

THE IMPACT OF LONG-TERM TREATMENT WITH SYMPATHETIC NERVOUS SYSTEM BLOCKERS ON BLOOD PRESSURE VALUES IN PATIENTS WITH RESISTANT HYPERTENSION

Objective: Comparative evaluation of influence of sympathetic nervous system blockers on blood pressure values for the long-term treatment in patients with resistant hypertension. Design and method: 100 patients with essential HTN gr.3 without comorbidities after a 3-week treatment with standardized treatment with Losartan, Amlodipine and Indapamide and confirmation of their resistance were randomized in two groups, depending on the medication supplemented to the previously administered: group I – selective I1-imidazoline agonist Moxonidine and group II – cardioselective beta-blocker Bisoprolol. All patients were evaluated by ambulatory blood pressure monitoring (ABPM) and office measurement of blood pressure at baseline, three, six and twelve months follow up. Results: At baseline office SBP and DBP values constituted 188,0 ± 3,1 mmHg and 111,2 ± 2,4 mmHg in group I versus 193,3 ± 3,2 mmHg and 114,6 ± 1,7 mmHg in group II, without differences between groups (p > 0,005). Both treatment regimens demonstrated a statistically significant comparable antihypertensive effect already after the third month of continuous medication, the benefit being maintained until the end of the study (Tab. 1). Similar dynamics were noted in the analyses of the mean SBP and DBP on ABPM measurement: statistical authenticity occurs in both groups at 3 months of medication without differences in the comparative analysis between batches. At 12 months of follow-up, Moxonidine exhibits superior antihypertensive effect over Bisoprolol, resulting in statistically significant differences in mean SBP / 24-hour reductions between groups (Tab.2).Conclusions: Medication with SNS blockers Moxonidine and Bisoprolol resulted in a statistically significant reduction in SBP and DBP values assessed in office and by ABPM starting with the 3rd month of medication, the beneficial effect being maintained until the end of the monitoring period, but without achievement of BP goal values. The Moxonidine treatment group demonstrates a superior net potency in ameliorating these parameters. Thus, Moxonidine can be recommended as an effective remedy in the treatment of resistant HTN.

1270-P: Improving ABC Targets through a Quality Improvement Initiative in China

Strong scientific evidence supports the benefits of ABC control (A1c &amp;lt;7%, blood pressure &amp;lt;140/80 mmHg, and LDL cholesterol &amp;lt;100 mg/dL) in reducing complications. A recent national multicenter study in China showed that the percentage of Chinese patients with type 2 diabetes who met recommended targets for A1c, BP and LDL in 2010 was 5.4%. A diabetes clinic in a Chinese tertiary hospital conducted a pilot quality improvement project from January to November 2018 to enhance ABC outcomes. Doctors and nurses from the clinic participated in biweekly video case conferences with Joslin Diabetes Center clinicians (endocrinologist and a certified diabetes educator). They also received bi-monthly on-site training, each lasting 10 days, from visiting U.S. clinicians. A1c, blood pressure and cholesterol levels collected from patients receiving routine care in the diabetes clinic from the first half of 2018 were compared with those collected in the second half of 2018. There were 1,036 patients who had at least one visit at each of these periods, and 683 patients of them (65.9%) had A1c, BP and LDL measured during these two periods. Paired comparisons were done by paired t-test (continuous variables) or McNemar’s test (dichotomous variables) using SAS version 9.4. The mean age of the patients was 54.7±11.9 years, with 53.8% female, and 95.3% with T2DM. There was a significant increase in the patients who achieved composite A1c, BP and LDL goal from 6.8 to 10.0% (p=0.048). The percentage of patients attaining the BP goal increased from 54.6 to 63.5% (p=0.0016). The systolic pressure decreased from 137.8 ± 20.2 to 133.3 ± 19.4 mmHg (p&amp;lt;0.0001). The LDL cholesterol decreased from 107.5 ± 34.0 to 97.5 ± 34.4 mg/dL (p&amp;lt;0.0001), and resulted in an increase in the percentage of individuals meeting the LDL goal, from 24.5% to 32.9% (p=0.0012). Interventions through regular case-based video conferences, complemented by live coaching from diabetes specialists, have the potential to improve clinical outcomes for patients with diabetes in China. Disclosure K. Lau: None. L. Yunxia: None. L. Yi: None. C. Li: None. Y. Zhengguo: None. D.M. Pober: None. L. Zhang: None. R.A. Gabbay: Advisory Panel; Self; HealthReveal, Hygieia, Lark, Onduo LLC. Consultant; Self; Sanofi. W.C. Hsu: Consultant; Self; Onduo LLC.

Hypertension control among euvolemic hypertensive hemodialysis patients in Malaysia: a prospective follow-up study

ObjectivesExisting literature does not provide enough information on evaluation of factors associated with pre-dialysis controlled hypertension among euvolemic hemodialysis (HD) patients. We conducted a study to evaluate the rate and factors influencing pre-dialysis controlled hypertension among euvolemic HD patients.DesignA multicenter prospective follow-up study.SettingTertiary care teaching hospital and its associated private dialysis centers.ParticipantsThis study included 145 euvolemic eligible hypertensive patients. Various sociodemographic, clinical factors and drugs were investigated and analyzed by using appropriate statistical methods to determine the factors influencing hypertension control among the study participants.ResultsOn baseline visit, the mean pre-dialysis systolic and diastolic BP (mmHg) of study participants was 161.2 ± 24. and 79.21 ± 11.8 retrospectively, and 30 (20.6%) patients were on pre-dialysis goal BP. At the end of the 6-months follow-up, the mean pre-dialysis systolic BP and diastolic BP (mmHg) of the patients was 154.6 ± 18.3 and 79.2 ± 11.8 respectively, and 42 (28.9%) were on pre-dialysis goal BP. In multivariate analysis, the use of calcium channel blockers (CCBs) was the only variable which had statistically significant association with pre-dialysis controlled hypertension at baseline (OR = 7.530, p-value = 0.001) and final (OR = 8.988, p-value < 0.001) visits.ConclusionsIn present study, the positive association observed between CCBs and controlled hypertension suggests that CCBs are effective antihypertensive drugs in the management of hypertension among euvolemic HD patients.Strengths and limitations of this studyThis study involved a group of patients from tertiary-level teaching hospital and its associated private dialysis centers of Malaysia.To the best of the authors’ knowledge, this is the first study to assess the factors influencing pre-dialysis controlled hypertension in a cohort of 145 euvolemic HD patients in a Malaysian setting.For determining the factors influencing hypertenion control multivariate analysis was conducted.Being a prospective follow-up study, the findings of the present study need to be interpreted with caution since it is limited to only 6 months follow up.Nevertheless, a multicenter study with a large sample size and longer follow up time is needed to confirm the findings of the current study.

Successful Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Octogenarian Trauma Patient

- Background: To demonstrate how to perform successful REBOA/ABO in extreme elderly patient&#x0D; - Materials and methods: A case report&#x0D; - Results:&#x0D; A 86-year old male, he was struck by car and transferred to Level I Trauma center at Siriraj hospital after injury for 30 minutes. Arrival clinical signs were coma and hypotension, lowest SBP was 50 mmHg. Primary survey found unstable pelvic fracture and severe head injury. We did REBOA at Zone I via left common femoral artery which aim to do partial balloon technique by inflation with 15-18 mL and arterial line monitoring for goal SBP around 100-120 mmHg due to his extreme age and associated traumatic brain injury. After CT scan showed no intra-abdominal injury, we did reposition the balloon to zone III under fluoroscopy. Unexpectedly, during deflation the balloon before removal, we found fresh blood through the balloon port, then ruptured balloon was suspected and confirmed with aortography. We immediately converted to remove by open technique due to balloon was failed to shrinkage through 7-Fr sheath. We reviewed the CT scan was shown calcified plaque along aorta and arteries which could be the cause of ruptured balloon. Throughout all procedures to stop bleeding which are pelvic external fixation, preperitoneal pelvic packing and embolization at right internal iliac artery, patient was given PRC only 4 units and no inotropic support to stabilizing patient. Total inflation time was 167 minutes with partial and intermittent REBOA technique. ICU Admission lab showed normal renal and liver function.&#x0D; - Conclusion :&#x0D; To perform ABO/REBOA in extreme elderly trauma patient, the partial balloon technique with goal SBP to balance between associated injury in polytrauma patient is very essential. The specific concern in this group would be related with reserve function and the changing of vascular access. Techniques for detection and solving the uneventful conditions should be prepared and learnt to successfully save the elderly patient.

Blood pressure control in treated hypertensive Nigerians in South-South Nigeria: Experience from Benin City

Background: Systemic hypertension is the most common noncommunicable disease in Nigeria with a plethora of associated clinical conditions and target organ damage. Adequate blood pressure (Bp) reduction with antihypertensive medication is expected to reduce mortality and morbidity. However, although Bp is easy to measure and hypertension responds well to therapy, a significant number of hypertensive patients on medication are not well controlled and hence remain at risk for the complications of hypertension, since a significant number of patients do not reach the goal Bp of ≤140/90 mmHg. Methods: Case notes of 826 hypertensive patients seen over the past 5 years, who have had a minimum period of treatment of 6 months at the Medical Outpatient Department of the University of Benin Teaching Hospital, were retrospectively evaluated. All had antihypertensive medication prescribed and subjectively reported compliance with medications. Adequate Bp control was defined as a systolic Bp of

Effects of the strict control of blood pressure in pediatric renal transplant recipients-ESCORT trial.

Strict BP control can retard progression of CKD in children. This prospective 3-year randomized controlled trial is aimed to investigate whether strict BP control can retard progression of chronic allograft dysfunction. Twenty-three pediatric patients were randomly selected to the standard BP group (STAND, target 24-hour MAP 50-95th percentile, n=11) or the intensified BP group (INTENS, target 24-hour MAP <50th percentile, n=12). The primary endpoint was an annual reduction in eGFR (Schwartz formula, mL/min/1.73m2 /y), secondary graft survival, BP, proteinuria, and safety. A total of 21 children (age at entry 11.2 (range 6.2-16.8) years) completed the study, with 73% of children in INTENS and 70% of children in STAND group reached their goal BP. Ambulatory indexed 24-hour MAP decreased significantly in INTENS group (from 0.94 (range 0.86-1.17) to 0.85 (range 0.79-1.01, P<0.01)) but not in STAND group (from 0.93 (range 0.85-1.07) to 0.90 (range 0.84-1.01)). Proteinuria did not change significantly in either group (22.1mg/mmol creatinine to 15.3 in STAND group vs 25.7 to 11.8 in INTENS group). The annual reduction in eGFR did not differ between the INTENS and STAND groups (-1.9mL/min/1.73m2 /y (range +6.4 to -14.3) vs -0.9 (range +4.0 to -8.5)). This first randomized controlled trial on strict BP control has demonstrated that strict BP control is feasible in 73% of children but the strict BP control does not lead to retardation of graft function decline in comparison with standard BP control. However, the results need to be interpreted with caution keeping the major limitation of the study, that is, small sample size in mind.

Blood Pressure Goals in Patients with CKD: A Review of Evidence and Guidelines.

Hypertension affects the vast majority of patients with CKD and increases the risk of cardiovascular disease, ESKD, and death. Over the past decade, a number of hypertension guidelines have been published with varying recommendations for BP goals in patients with CKD. Most recently, the American College of Cardiology/American Heart Association 2017 hypertension guidelines set a BP goal of <130/80 mm Hg for patients with CKD and others at elevated cardiovascular risk. These guidelines were heavily influenced by the landmark Systolic Blood Pressure Intervention Trial (SPRINT), which documented that an intensive BP goal to a systolic BP <120 mm Hg decreased the risk of cardiovascular disease and mortality in nondiabetic adults at high cardiovascular risk, many of whom had CKD; the intensive BP goal did not retard CKD progression. It is noteworthy that SPRINT measured BP with automated devices (5-minute wait period, average of three readings) often without observers, a technique that potentially results in BP values that are lower than what is typically measured in the office. Still, results from SPRINT along with long-term follow-up data from the Modification of Diet in Renal Disease and the African American Study of Kidney Disease and Hypertension suggest that a BP goal <130/80 mm Hg will reduce mortality in patients with CKD. Unfortunately, data are more limited in patients with diabetes or stage 4-5 CKD. Increased adverse events, including electrolyte abnormalities and decreased eGFR, necessitate careful laboratory monitoring. In conclusion, a BP goal of <130/80 is a reasonable, evidence-based BP goal in patients with CKD. Implementation of this intensive BP target will require increased attention to measuring BP accurately, assessing patient preferences and concurrent medical conditions, and monitoring for adverse effects of therapy.

Abstract 294: Alterations in Cerebral Mitochondrial Dynamics and Mitochondrial Mass After Successful Cardiopulmonary Resuscitation in a Porcine Model of Pediatric Cardiac Arrest

Introduction: A critical convergence point for neurologic injury following cardiac arrest is cerebral mitochondrial (Mt) dysfunction, regulated by Mt dynamics (balance of fusion and fission). Both fusion and fission are important to Mt homeostasis under normal conditions; however, under stress fission can decrease Mt mass and signal apoptosis, while fusion promotes oxidative phosphorylation efficiency. Our group has previously shown hemodynamic directed CPR (HD-CPR) improves Mt bioenergetics compared to AHA depth-guided CPR (DG-CPR), which correlated with better neurologic function. Hypothesis: Compared to DG-CPR, HD-CPR will result in cerebral cortical protein expression consistent with Mt fusion and preservation of mitochondrial mass 24 hours post-ROSC. Methods: One-month-old piglets were designated into three groups: 1) DG-CPR (n=5); 2) HD-CPR (n=5; goal SBP 90 mmHg, goal coronary perfusion pressure 20mmHg); 3) Shams (n=7). Groups 1 and 2 underwent 7 minutes of asphyxia, VF, 10-20 min of CPR, and post-ROSC therapies to maintain hemodynamic, oxygenation and ventilation goals. The primary outcomes were immunoblot quantification of cortical proteins for fusion (Opa-1, Opa-1 long to short chain ratio, MFN-2), fission (DRP-1), and citrate synthase activity for Mt mass. Groups shown as median and IQR and analyzed by Kruskal-Wallis, then Dunn’s multiple comparisons. Results: HD-CPR subjects had increased total Opa-1 expression compared to sham (1.52 [1.02,1.69] vs. 0.47 [0.34,0.51], p=0.001). Opa-1 long to short chain ratio was higher in HD-CPR than both sham (0.64 [0.46,0.92] vs. 0.28 [0.25,0.36], p=0.025) and DG-CPR (0.26 [0.26,0.31], p=0.018). There were no differences in MFN-2 or DRP-1 expression between groups. Mt mass was lower in DG-CPR than sham (11.02 [10.15,12.29] vs. 13.9 [12.35,15.63], p=0.029), but preserved in HD-CPR. Discussion: Piglets treated with HD-CPR exhibited protein expression consistent with Mt fusion, as evidenced by upregulation of total Opa-1, elevated Opa-1 long to short chain ratio, and preservation of Mt mass compared to standard AHA depth guided CPR strategy. We speculate that neurotherapeutics that target Mt dynamics could further improve brain Mt bioenergetics and neurologic function after pediatric CA.

Review: In hypertension, intensive BP goals reduce CV events; self vs office BP measures do not improve BP at 12 mo

Source Citation Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and ...