BP Goals Research Articles

6457 You Are Never Too Old For Pheo

Abstract Disclosure: M. Masumy: None. B. McAdams: None. P. Mikkilineni: None. Introduction: Pheochromocytomas (PCC) are a rare neuroendocrine tumor derived from chromaffin cells. The incidence is estimated at 8 in 1 million individuals with no sex or ethnic predilection. It is estimated that 0.05-0.2% of hypertensives may have PCC. Its incidence generally peaks between the third and fifth decades of life. The classic PCC symptoms are headaches, hypertension, palpitations, pallor and tachycardia. However, most patients may not present with these symptoms, and may go undiagnosed. Untreated PCC can have significant morbidity and mortality such as MI, CVA, and hypertensive crises. The current standard of evaluation for PCC includes obtaining serum metanephrines, then if significantly elevated, obtaining CT imaging. Oftentimes, surgical resection is the treatment of choice, but PCC may recur, thus regular follow up is needed. We present a case of PCC in an elderly patient who developed symptoms over a year. Case presentation: A 72-year-old Caucasian female with diabetes presented to the emergency department with palpitations, severe headache, flushing and hypertension. She began experiencing these spells several months earlier with increasingly difficult to manage hypertension. She also had a CVA and NSTEMI earlier in the year. Her blood pressure regimen included amlodipine 20 mg, valsartan 160 mg, and carvedilol 12.5 mg bid. Despite this her blood pressure was uncontrolled. She also had palpitations and unease up to an hour after taking valsartan. Due to her symptoms; PCC was suspected. Serum metanephrines were obtained with her normetanephrines measured at 3334.7 pg/ml and metanephrines were 475.6 pg/ml, these were significantly elevated and thus an abdominal CT scan was done. On CT, she was found to have a 4.9 cm x 4.4 cm left adrenal mass with a density of 31 Hounsfield units. Her symptoms, labs and imaging were strongly indicative of PCC and she was referred to surgery. Her previous blood pressure medications were discontinued, and doxazosin was titrated to a goal SBP of 120 mmHg. Then metoprolol was added to attain a goal heart rate below 70 bpm. She then underwent a successful laparoscopic left adrenalectomy. She is now on 5mg of amlodipine for her blood pressure and metformin for her diabetes. She will be having regular follow ups to monitor for pheochromocytoma recurrence. Conclusion: Though pheochromocytoma is a rare entity that affects individuals primarily in the third and fourth decade of life, it may also occur in elderly patients. In patients with difficult hypertension, screening with metanephrines may be indicated if these are significantly elevated CT imaging should be obtained. When obtaining CT imaging, Hounsfield units are important in characterizing PCC. Achieving adequate alpha blockade before beta blockade is also essential pre-surgery for the best outcome. Even after surgery, patients will require lifelong follow up to monitor for recurrence. Presentation: 6/1/2024

Original Moxonidine and Generics: Where is the Edge of Difference?

To compare the efficacy of adding original moxonidine and its generics to previous ineffective antihypertensive therapy in patients with poorly controlled arterial hypertension (AH). This observational prospective non-randomized study included 120 patients with poorly controlled blood pressure on the previous antihypertensive therapy. All patients underwent clinical evaluation, including anthropometric and laboratory indexes, and 24-hour blood pressure monitoring (24-h BPM) at baseline and after 12 weeks of observation. Office systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) were recorded after 4 and 12 weeks of treatment. During the observation period, 4 equal groups were formed: group 1, Physiotens was added to the treatment; group 2, Moxonitex; group 3, Moxonidine SZ; and group 4, Moxonidine Canon. Statistical analysis was performed with the StatTech v.4.2.7 software (© OOO StatTech, Russia). After 4 weeks of therapy, the BP target was achieved significantly more frequently in group 1 (63% of patients) compared to groups 2 (36.7% of patients), 3 (16.7% of patients), and 4 (16.7% of patients) (p<0.05). At 12 weeks, office SBP, DBP, and HR were significantly decreased in all groups, but the decrease was significantly greater in group 1. The therapy was associated with a more pronounced decrease in all studied 24-h BPM parameters in the Physiotens group than in other groups, as well as with a significantly more frequent normalization of the 24-h BP profile, in 66.7% of patients vs. 46.7%, 33.4%, and 23.2% of patients in groups 2, 3, and 4, respectively. The treatment with original moxonidine demonstrated advantages over generic drugs in terms of achieving the BP goal, reducing office BP and HR, and improving 24-h BPM parameters.

Mean Arterial Pressure and Neonatal Outcomes in Pregnancies Complicated by Mild Chronic Hypertension.

To estimate the association between mean arterial pressure during pregnancy and neonatal outcomes in participants with chronic hypertension using data from the CHAP (Chronic Hypertension and Pregnancy) trial. A secondary analysis of the CHAP trial, an open-label, multicenter randomized trial of antihypertensive treatment in pregnancy, was conducted. The CHAP trial enrolled participants with mild chronic hypertension (blood pressure [BP] 140-159/90-104 mm Hg) and singleton pregnancies less than 23 weeks of gestation, randomizing them to active treatment (maintained on antihypertensive therapy with a goal BP below 140/90 mm Hg) or standard treatment (control; antihypertensives withheld unless BP reached 160 mm Hg systolic BP or higher or 105 mm Hg diastolic BP or higher). We used logistic regression to measure the strength of association between mean arterial pressure (average and highest across study visits) and to select neonatal outcomes. Unadjusted and adjusted odds ratios (per 1-unit increase in millimeters of mercury) of the primary neonatal composite outcome (bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, or intraventricular hemorrhage grade 3 or 4) and individual secondary outcomes (neonatal intensive care unit admission [NICU], low birth weight [LBW] below 2,500 g, and small for gestational age [SGA]) were calculated. A total of 2,284 participants were included: 1,155 active and 1,129 control. Adjusted models controlling for randomization group demonstrated that increasing average mean arterial pressure per millimeter of mercury was associated with an increase in each neonatal outcome examined except NEC, specifically neonatal composite (adjusted odds ratio [aOR] 1.12, 95% CI, 1.09-1.16), NICU admission (aOR 1.07, 95% CI, 1.06-1.08), LBW (aOR 1.12, 95% CI, 1.11-1.14), SGA below the fifth percentile (aOR 1.03, 95% CI, 1.01-1.06), and SGA below the 10th percentile (aOR 1.02, 95% CI, 1.01-1.04). Models using the highest mean arterial pressure as opposed to average mean arterial pressure also demonstrated consistent associations. Increasing mean arterial pressure was positively associated with most adverse neonatal outcomes except NEC. Given that the relationship between mean arterial pressure and adverse pregnancy outcomes may not be consistent at all mean arterial pressure levels, future work should attempt to further elucidate whether there is an absolute threshold or relative change in mean arterial pressure at which fetal benefits are optimized along with maternal benefits. ClinicalTrials.gov , NCT02299414.

Russian medical society expert consensus on arterial hypertension: use of fixed combinations in the treatment of patients with arterial hypertension

Despite the large arsenal of antihypertensive agents, BP control, both in Europe and in Russia, remains at a low level, more than 50% patients do not reach the goal BP levels. At the same time, data from the results of RCTs demonstrate that the achievement of goal BP values is possible in most patients, no more than 5-10% of patients have resistance to antihypertensive therapy. Sufficient evidence has been accumulated that low adherence to treatment remains afundamental contributing factor to insufficient BP control. There is evidence that adherence to treatment closely correlates with the complex dosing regimen of the drugs and the number of tablets taken. Low adherence has been shown to be associated with an increased risk of cardiovascular complications. Furthermore, evidence suggests that medical inertia contributes to treatment failure in patients remaining on monotherapy or receiving inadequate suboptimal therapy. The use of combination therapy, including the use of fixed combinations in most patients, can help to solve both problems. This consensus focuses on various issues related to the prescription of combination therapy in the form of fixed combinations and polypill.

Role of Home Blood Pressure Monitoring in Treatment Follow-up by Hypertensive Patients Cohort

Background: The main benefit of home-based blood pressure monitoring (HBPM) is the potential approach to reduce the risk of white-coat hypertension (HTN) and to encourage patients to take ownership of their condition. This study was conducted to assess the role of HBPM in treatment follow-up in a cohort of hypertensive patients. Materials and methods: This was a prospective observational study conducted from December 2017 to May 2018. A total of 100 patients fulfilling the inclusion and exclusion criteria were selected by purposive sampling from Medicine Outdoor of Dhaka Medical College Hospital (DMCH). In total, 100 hypertensive patients were enrolled, and informed consent was obtained. Subsequently, the study subjects received information and training on BP self-management and performed 2 resting measurements per day for 4 days per week for 3 months. All measurements were performed using validated BP monitors.The study endpoints included patient awareness, attainment of BP goals, adherence to antihypertensive treatment, lifestyle modification, assessment of discrepancy between office and HBPM, and white coat HTN or masked HTN at 3 months. SPSS version 22.0 was used for data analysis and reporting. Results: Overall, the mean age was 57.76 ±12.60 years with a range of 34 – 80 years. Males were more prevalent than females, and the ratio was 1.17:1. The majority of cases (76.0%) had established HTN with a history of taking medication, whereas others were non-compliant with medications. Among them 47% had obesity, and 24% had diabetes mellitus. Of the patients, 91% adherence to HBP monitoring, 84.0% adherence to medication, and 75.0% achieved their target BP. The achievement of target blood pressure was significantly higher among the study subjects who adhered to HBP monitoring, and the p-value was < 0.04 (Fisher’s Exact test). Conclusion: In a cohort of patients with arterial hypertension, information, and training on BP self-measurement and direct involvement of patients using HBPM led to improvement in BP control and could be an effective method by incorporating it into the usual care of hypertensive patients in the hypertension management center of the community. J MEDICINE 2024; 25: 17-23

Clinical characteristics, treatment, and blood pressure control in patients with hypertension seen by primary care physicians in Spain: the IBERICAN study.

To determine the clinical profile, according to the history of hypertension, the risk of developing hypertension, current antihypertensive treatment and BP control rates in patients with hypertension from the IBERICAN cohort. IBERICAN is an ongoing prospective cohort study, whose primary objective is to determine the frequency, incidence, and distribution of CVRF in the adult Spanish population seen in primary care settings. This analysis shows the baseline clinical characteristics of patients with hypertension. Adequate BP control was defined as BP <140/90 mmHg according to 2013 ESH/ESC guidelines. A total of 8,066 patients were consecutively included, of whom 3,860 (48.0%) had hypertension. These patients were older (65.8 ± 10.9 vs. 51.6 ± 14.7 years; p < 0.001), had more cardiovascular risk factors, target organ damage and cardiovascular disease (CVD) in comparison with those without hypertension. The risk of hypertension increased with the presence of associated CV risk factors and comorbidities, particularly diabetes, obesity and the metabolic syndrome, and decreased with the intensity of physical activity. Regarding antihypertensive treatments, 6.1% of patients did not take any medication, 38.8% were taking one antihypertensive drug, 35.5% two drugs, and 19.6% three or more antihypertensive drugs. Overall, 58.3% achieved BP goals <140/90 mmHg. A greater probability of BP control was observed with increasing age of patients and the greater number of antihypertensive drugs. Blood pressure control was lower in hypertensive patients with diabetes, obesity, the metabolic syndrome, increased urinary albumin excretion, higher pulse pressure, and lack of antihypertensive treatment. About half of patients attended in primary care settings have hypertension in Spain. Patients with hypertension have a worse CV clinical profile than non-hypertensive patients, with greater association of CVRF and CVD. Around four out of ten patients do not achieve the recommended BP goals, and higher use of combination therapies is associated with a better BP control.

Juridical Analysis of the Obligations Batam Free Trade Zone and Free Port Enterprise Agency (BP BATAM) to Problematic Land Allocation Recipients

BP Batam has very broad authority to manage Batam Island in order to attract investors to invest their capital in Batam Island. Land problems that occur in the city of Batam must be resolved by BP Batam as the authority holder for management rights in Batam in accordance with Head of BP Batam Regulation No. 26 of 2021 concerning Implementation of Land Management. The study's goal is to find out how BP Batam's duties to people who receive land allocations for problematic land are carried out and what factors affect those duties. This research uses empirical juridical qualitative methods, using one legal action against problematic land as a sample. Findings from the study show that BP Batam's duties and goals have been met in how they handled their responsibilities to people who were given problematic land. The obstacles faced so far are due to the lack of communication between BP Batam and the communities that receive problematic land allocations in the city of Batam. BP Batam's obligations are stated to be limited to planning the allocation and use of land and exploiting or using land for purposes of carrying out its duties. Implementation is proven by monitoring and taking action against problematic land, which is the authority of BP Batam.

Abstract 13836: Percentage of Patients Achieving Blood Pressure Goals With Aprocitentan, a Dual Endothelin Receptor Antagonist: Results From a Randomized, Controlled Phase 3 Study (PRECISION)

Background: In the phase 3 PRECISION trial, aprocitentan (APRO) lowered BP in patients with resistant hypertension. Research Question: How effective is APRO for achieving the following BP goals over 4 weeks: mean 24-hour ambulatory BP monitoring (ABPM) measurements &lt;130/80 mmHg, daytime ABPM &lt;135/85 mmHg, nighttime ABPM &lt;120/70 mmHg, reduction in 24-hour ABPM ≥5 mmHg, mean trough unattended automated office BP &lt;130/80 mmHg, and reduction in office systolic BP (SBP) ≥10 mmHg? Aim: To evaluate percentages of patients achieving BP goals with APRO or placebo (PBO) after 4 weeks of treatment. Methods: Patients had sitting unattended automated office SBP ≥140 mmHg despite prescription of ≥3 antihypertensives of different classes in the year prior to enrollment. After 4 weeks of standardized triple therapy (amlodipine, valsartan, hydrochlorothiazide), those still hypertensive could enter a 4-week single-blind placebo (PBO) run-in period, followed by a 4-week double-blind period wherein patients were randomized 1:1:1 to APRO 12.5 mg, 25 mg, or PBO added to background therapy. We evaluated percentages of patients achieving BP goals during the double-blind period. Results: The APRO 12.5 mg, APRO 25 mg, and PBO groups comprised 243, 243, and 244 patients, respectively. Among 633 patients with ABPM data, 41.1%, 51.6%, and 29.6% in the APRO 12.5 mg, APRO 25 mg, and PBO groups had 24-hour mean ABPM &lt;130/80 mmHg. Similarly, 47.4%, 52.7%, and 35.8% in the APRO 12.5 mg, APRO 25 mg, and PBO groups had daytime ABPM &lt;135/85 mmHg; 37.9%, 44.0%, and 22.9%, respectively, had nighttime ABPM &lt;120/70 mmHg. In the APRO 12.5 mg, APRO 25 mg, and PBO groups, 61.7%, 64.8%, and 39.7% had reductions in ABPM of ≥5 mmHg. Overall, 25.1%, 24.2%, and 16.5% in the APRO 12.5 mg, APRO 25 mg, and PBO groups achieved mean office BP &lt;130/80 mmHg; 65.0%, 65.8%, and 55.8%, respectively, had reductions in office SBP of ≥10 mmHg. APRO was generally well tolerated. Edema or fluid retention occurred in 9%, 18%, and 2% of patients in the APRO 12.5 mg, 25 mg, and PBO groups, respectively, during the 4-week double-blind period. Conclusion: Greater proportions of patients receiving APRO versus PBO achieved BP goals at 4 weeks. Based on ABPM, treatment benefits with APRO showed dose-dependency, with a larger effect for APRO 25 mg.

FRI207 Challenges Of Pheochromocytoma Management In A Heart Failure Patient

Abstract Disclosure: M. Novitskaya: None. M. Sonbol: None. S. Jafri: None. J. Monye: None. E. Japp: None. Introduction: Successful management of pheochromocytoma in patients with heart failure requires a careful balance between blood pressure control and appropriate perioperative volume resuscitation. Clinical Case: A 38-year-old male with heart failure with reduced ejection fraction (EF 15-20%), HTN, and polysubstance use disorder presented with dyspnea and subsequent in-house PEA arrest. Whole body CT showed an incidental 7.3 cm left adrenal mass. Laboratory work-up was notable for elevated plasma free metanephrines 47.30 nmol/L (n&amp;lt;0.89) and normetanephrines 39.8 nmol/L (n&amp;lt;0.49). Medical management of presumed pheochromocytoma was initiated with doxazosin. Left and right heart catheterization showed elevated intracardiac filling pressures (mmHg): RA 10, RV 66/5 (12), PA 55/29 (43), PCWP 35. Subsequent coronary angiogram was aborted due to hypertensive emergency and flash pulmonary edema for which he required IV hydralazine 20 mg, furosemide 80 mg, labetalol 30 mg, verapamil 5 mg, nitroglycerin 800 mg bolus then gtt at 100 mcg/min to achieve hemodynamic stability. He reached the preoperative BP goal after up titration of doxazosin to 12 mg daily and carvedilol to 25 mg twice daily. He subsequently underwent left adrenalectomy. Intraoperatively, the patient’s abdomen was insufflated to 13 mmHg given his reduced EF, and he received 2 L crystalloid prior to adrenal vein division. After a left adrenalectomy, he developed hypotension despite receiving an additional 3 L crystalloid, and was started on norepinephrine, epinephrine, and vasopressin gtt. Postoperatively, he remained intubated for two days due to distributive shock. With continued diuresis, mean arterial pressure recovered to &amp;gt;65 mmHg and he was extubated. He was successfully discharged on metoprolol succinate 25 mg, spironolactone 25 mg and losartan 25 mg daily. Clinical Lessons: Preoperative management of pheochromocytoma involves alpha-adrenergic blockade followed by beta-adrenergic blockade to target a BP of &amp;lt;130/80. A high sodium diet is recommended after adequate alpha-adrenergic blockade, and volume resuscitation is started preoperatively due to vasodilation after adrenalectomy. Successful management of patients with pheochromocytoma and heart failure requires extra attention to BP and volume status. Our patient’s case was complicated by severe HTN during cardiac catheterization resulting in flash pulmonary edema, and postoperative hypotension requiring vasopressor support due to loss of circulating catecholamines. His estimated risk of morbidity/mortality from adrenalectomy was &amp;gt;25% due to these factors. Multidisciplinary collaboration among endocrinologists, cardiologists, anesthesiologists, surgeons, and perfusionists is crucial to optimize patient outcomes. This patient case adds to the literature in presenting a positive adrenalectomy outcome in a patient with heart failure. Presentation: Friday, June 16, 2023

Hypertension in Type 2 Diabetes and Its Association with Glycemic Control: A Hospital-Based Study from Pakistan

Objective: To determine the frequency of type 2 diabetic-hypertensive patients who fail to achieve target blood pressure goals despite treatment and to find the association between uncontrolled hypertension and poor glycemic control. Study Design: Descriptive, cross-sectional. Place and Duration: The study was conducted in the Department of Medicine, Pakistan Railways Hospital, Islamic International Medical College/Riphah International University, from 1st August 2022 to 31st January 2023. Methodology: A total of 200 diabetic patients were included. Study variables included age, gender, duration of diabetes/hypertension, glycemic/blood pressure control, target organ damage, compliance to treatment and life style modification, regular follow ups and awareness of target blood pressure goals. Data was recorded on a self-developed proforma. Diabetic patients with hypertension were classified into those with optimally controlled blood pressure (&lt; 140/90 mmHg) and those with uncontrolled hypertension despite treatment (BP &gt; 140/90 mm Hg). Results: Prevalence of hypertension in our diabetic population was 68.5%. Blood pressure was optimally controlled in 50.4%. Poor glycemic control was observed in 56.5% patients. Patients with sub-optimal glycemic control were more likely to be hypertensive (77.8%) as compared to their normoglycemic counterparts (56.3%). There was a significant correlation between uncontrolled hypertension and poor glycemic control (p-Value 0.202). Older age, female gender, duration of hypertension, lack of awareness of target BP goals and non-adherence to pharmacological and non-pharmacological measures were independent predictors for uncontrolled hypertension. Conclusion: Blood pressure is not optimally controlled in half of the diabetic hypertensive patients despite treatment. Uncontrolled hypertension correlates significantly with poor glycemic control. Keywords: Frequency; Diabetes; Blood Pressure; Goals; Association; Hypertension How to Cite This: Burney S, Asad M, Fazal M, Zulfiqar A. Hypertension in Type 2 Diabetes and Its Association with Glycemic Control: A Hospital-Based Study from Pakistan. Isra Med J. 2023; 15(1): 30-34. DOI: https://doi.org/10.55282/imj.oa1392. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Hypertension in Type 2 Diabetes and Its Association with Glycemic Control: A Hospital-Based Study from Pakistan

Objective: To determine the frequency of type 2 diabetic-hypertensive patients who fail to achieve target blood pressure goals despite treatment and to find the association between uncontrolled hypertension and poor glycemic control. Study Design: Descriptive, cross-sectional. Place and Duration: The study was conducted in the Department of Medicine, Pakistan Railways Hospital, Islamic International Medical College/Riphah International University, from 1st August 2022 to 31st January 2023. Methodology: A total of 200 diabetic patients were included. Study variables included age, gender, duration of diabetes/hypertension, glycemic/blood pressure control, target organ damage, compliance to treatment and life style modification, regular follow ups and awareness of target blood pressure goals. Data was recorded on a self-developed proforma. Diabetic patients with hypertension were classified into those with optimally controlled blood pressure (&lt; 140/90 mmHg) and those with uncontrolled hypertension despite treatment (BP &gt; 140/90 mm Hg). Results: Prevalence of hypertension in our diabetic population was 68.5%. Blood pressure was optimally controlled in 50.4%. Poor glycemic control was observed in 56.5% patients. Patients with sub-optimal glycemic control were more likely to be hypertensive (77.8%) as compared to their normoglycemic counterparts (56.3%). There was a significant correlation between uncontrolled hypertension and poor glycemic control (p-Value 0.202). Older age, female gender, duration of hypertension, lack of awareness of target BP goals and non-adherence to pharmacological and non-pharmacological measures were independent predictors for uncontrolled hypertension. Conclusion: Blood pressure is not optimally controlled in half of the diabetic hypertensive patients despite treatment. Uncontrolled hypertension correlates significantly with poor glycemic control. Keywords: Frequency; Diabetes; Blood Pressure; Goals; Association; Hypertension How to Cite This: Burney S, Asad M, Fazal M, Zulfiqar A. Hypertension in Type 2 Diabetes and Its Association with Glycemic Control: A Hospital-Based Study from Pakistan. Isra Med J. 2023; 15(1): 30-34. DOI: https://doi.org/10.55282/imj.oa1392. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

COMPARISON OF FIRST RESULTS OF RADIOFREQUENCY RENAL DENERVATIONS WITH FIRST AND SECOND GENERATION TECHNIQUES

Objective: A form of renal denervation, when using radiofrequency technique, thermal energy destroys the nerve-fibres around the renal artery. The Symplicity FlexTM was the first such catheter, an improved new generation version of it is the Symplicity SpyralTM catheter. In the Albert Szent-Györgyi Health Center of the University of Szeged, renal denervations were performed with both devices in hypertensive patients whose blood pressure could not be reduced to the goal range with multiple antihypertensive combinations. Design and method: With the first generation catheter, only the main branch was ablated at 4-5 points per side, and with the Symplicity SpyralTM catheter, even the segmental small branches together with the main branches were ablated at a total of at least 16-18 points per side. Results: With the old method after RDN, SBP decreased by 40 mmHg and DBP by 20 mmHg. The reduction was greatest 1 month after the intervention, 45 and 35 mm Hg. But did not reach the goal values. With new method after RDN, SBP decreased by 38 mmHg and DBP by 27 mmHg. The reduction was greatest 1 month after the intervention, 49 and 37 mm Hg. With the new the SBP was already in the target range after the intervention and remained there for 6 months. In addition, the number of antihypertensives could be significantly reduced. With the old method the goal BP value could not be achieved. Vascular complications did not occur in either case of interventions. Conclusions: Our first result with the Symplicity SpyralTM catheter according to the new concepts supports the view that more accurate ablation and preferably distal ablation can lead to more effective blood pressure reduction.

Effectiveness of Amlodipine in the Control of 24-Hour Blood Pressure in Mild-to-Moderate Essential Hypertension: A Prospective, Multicenter, Observational Real-World Study from India.

Background Calcium-channel blockers (CCB) are a mainstay in the management of hypertension (HTN), and amlodipine is the preferred CCB due to its longer half-life and better safety. Patients and methods This practice-based, observational, real-world evidence study assessed the 24-hour ambulatory blood pressure (ABP) control in mild-to-moderate essential hypertensive patients (treatment naïve receiving amlodipine monotherapy, or as add-on therapy) in inadequately controlled blood pressure (BP goal not met after one month of existing therapy). One hundred four (62M/42F) patients between 18 and 65 years of age who received amlodipine 5/10 mg/day for >8 weeks were included after obtaining informed written consent. The primary outcome was a change from baseline in the mean 24-hSBP and DBP on ABP monitoring at eight (±1) weeks. Secondary outcomes were different from baseline in the mean morning, day-time, night-time, and last six-hour dosing interval period. Other outcomes assessed BP variability (dippers and non-dippers), and responder rates based on ABP monitoring and in-clinic trough cuff measurements. Safety outcomes included adverse effects reported, electrocardiogram, and laboratory abnormalities (hepatic and renal function). Changes in BP parameters in different sub-groups (age, gender, BMI, physical activity, occupation, duration of hypertension, the total daily dose of amlodipine, type of amlodipine therapy, and hypertension severity at baseline) were estimated. Results Of the 104 patients, 49 patients (completed eightweeks) were included in the per-protocol (PP) data for efficacy analysis. Safety analysis was done on the intent-to-treat (ITT) dataset. Significant reductions (p<0.0001) from baseline in all BP measurements on ABPM were observed at the end of eight weeks. Similar improvements were observed in office BP recordings. There was a marginal but non-significant (p>0.05) increase in the proportion of dippers and extreme dippers with amlodipine at the end of the eight-week treatment period. Conclusions Amlodipine 5/10 mg/day therapy used as monotherapy or adjuvant therapy provided significant reductions in both office BP and ambulatory BP over eight weeks.

369 Depressive Symptoms and Achieving BP Goals in the Systolic Blood Pressure Intervention Trial (SPRINT)

369 Depressive Symptoms and Achieving BP Goals in the Systolic Blood Pressure Intervention Trial (SPRINT)

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An algorithm helps reverse anticoagulation for intracranial hemorrhageFigure: An Algorithm for Reversing Anticoagulation for Intracranial HemorrhageA 65-year-old man with a history of hypertension, diabetes mellitus, and atrial fibrillation presented with a posterior scalp hematoma and altered mental status after a mechanical fall. The patient's family reported that he was taking apixaban, and his last dose had been four hours before arrival. A physical examination revealed a GCS of 13, a blood pressure of 175/99 mm Hg, and asymmetric pupils. The patient was taken to CT, where head imaging revealed a left-sided subdural hematoma with a midline shift and developing uncal herniation. A nicardipine infusion was initiated and the head of the bed was elevated. Andexanet alfa was not available, so an infusion of 4-factor prothrombin complex concentrate was initiated. The patient was taken emergently to the operating room by neurosurgery for a craniotomy and hematoma evacuation. Discontinue Anticoagulation Patients may require blood pressure control including antihypertensive infusions (goal SBP <140). Avoid reversal for intracranial hemorrhage associated with cerebral venous thrombosis. Use cautiously in patients with concomitant life-threatening ischemia, thrombosis, or severe DIC. Vitamin K Antagonists (Ex. Warfarin) Initial Dose: A fixed dose of 4F-PCC 1500 to 2000 units can be given as an initial dose with repeat dosing based on INR measurement 15 minutes after completion of the infusion. Follow local institution guidelines if available. Monitoring and Repeat Dosing: Give vitamin K if the INR is ≥1.4 at 12 hours (Chest. 2008;133[6 Suppl]:160S.) Consider repeat PCC dosing based on INR, though with increased DIC and thrombotic risk, it is recommended to correct further with FFP if INR remains ≥1.4. (J Thromb Haemost. 2008;6[4]:622; https://bit.ly/3ZDvpdU.) Direct Factor Xa Inhibitors (Ex. Rivaroxaban, Apixaban) Activated charcoal may be effective for up to six hours for apixaban (https://bit.ly/41PvXPJ) and eight hours for rivaroxaban (https://bit.ly/3L2mQFm). Andexanet Alfa Regimens (Stroke. 2021;52[6]:2096; https://bit.ly/3STy01c; J Am Coll Emerg Physicians Open. 2022;3[2]:e12655; https://bit.ly/3IYilZH.) Low-dose: rivaroxaban <10 mg, apixaban <5 mg, edoxaban <30 mg or eight or more hours since last dose High-dose: If greater than the thresholds above or dose/timing unknown Pentasaccharides (Ex. Fondaparinux) Use high-dose Andexanet alfa regimen (Nat Med. 2013;19[4]:446). Direct Thrombin Inhibitors (Ex. Dabigatran) Monitoring and Repeat Dosing: If the patient has ongoing significant bleeding after treatment, consider redosing idarucizumab or hemodialysis. Alternative Regimens: If idarucizumab is not available, aPCC (50-80 units/kg), 4F-PCC, or 3F-PCC (50 units/kg) can be used in order of preference. Unfractionated Heparin Dosing: Heparin units are based on estimated active agent (half-life 1-2 hours). Protamine sulfate 1 mg/100 units IV, maximum dose 50 mg Alternatively, give fixed dose of 25 to 50 mg. Monitoring and Repeat Dosing: If aPTT is persistently elevated, repeat 0.5 mg/100 units. Low-Molecular Weight Heparin (Clin Pharmacokinet. 2003;42[12]:1043.) Reversal is not indicated if more than three to five half-lives have passed since administration: Enoxaparin mean half-life: Four to five hours Dalteparin mean half-life: 2.8 hours Nadroparin mean half-life: 3.7 hours If bleeding persists or the patient has or renal insufficiency, repeat dose 0.5 mg/1 mg enoxaparin or 0.5 mg/100 anti-Xa units. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

Efficacy and Safety of Fixed-Dose Combination of Efonidipine and Telmisartan in Stage II Hypertensive Patients: Results from Randomized Clinical Trial

Aim: The aim of this study was to evaluate the anti-hypertensive efficacy of a fixed-dose combination (FDC) of Efonidipine 40 mg and Telmisartan 40 mg in Stage II hypertensive patients.&#x0D; Study Design: Multicentric, randomized, double-blind, parallel, comparative Phase III clinical trial.&#x0D; Methodology: This clinical trial was conducted at six geographically distributed sites across India and enrolled 240 Stage II hypertensive patients. They were randomized into two groups in a ratio of 1:1 using computer-generated block randomization to receive E+T (FDC of Efonidipine 40 mg + Telmisartan 40mg) or C+T (FDC of Cilnidipine 10 mg + Telmisartan 40 mg) group intervention once daily for a period of 90 days. The study site staff, investigator and patients were blinded to the treatment allocation. The primary endpoint of the study evaluated the mean reduction in sitting systolic BP (SBP) and diastolic BP (DBP) from baseline to day 90 whereas the secondary endpoints assessed were mean reduction in BP from baseline to day 30 &amp; 60, patients achieving target BP (&lt;140/90 mmHg) and the safety and tolerability of the investigational products based on the incidences of adverse events (AEs) reported.&#x0D; Results: A total of 118 subjects were randomized to the E+T group wherein the mean (±SD) SBP and DBP at baseline was 167.25 ± 4.68/107.26 ± 5.19 mmHg. After 30 days of treatment with the E+T group, the mean reduction in SBP/DBP of 29.37/18.06 mmHg was observed whereas at Day 60 reduction of 38.55/22.69 mmHg was seen from the baseline. At Day 90, SBP/DBP decreased to 119.41±14.99/81.67±4.29 mmHg with a mean reduction of 47.94/25.89 mmHg in the E+T group. During the study period, the difference in systolic blood pressure between the treatments with E+T and C+T was -0.48 mmHg, with the two-sided 95% confidence interval (CI) ranging from -4.54 to 3.58 mmHg. The corresponding difference in diastolic blood pressure was -0.77 (95% CI: -2.60 to 1.06) mm Hg. The upper boundary of the 95% CI was below the margin of 10 mmHg, confirming the non-inferiority of E+T to C+T. A total of 92% of patients who had been assigned to E+T treatment achieved their target BP goal. Only one patient reported an adverse event with E+T treatment. No unexpected AEs were reported in the E+T group suggesting its good safety and tolerability. Overall, the E+T treatment was effective, safe and well-tolerated by the patients for 90 days.&#x0D; Conclusion: It was concluded that the FDC of Efonidipine 40 mg and Telmisartan 40 mg was efficacious in the management of Stage II hypertension.

Abstract 203: Exploratory Study Of The Time Course Of Post-arrest Neurologic Injury In A Porcine Model Of Pediatric Cardiac Arrest

Introduction: In preclinical models, hemodynamic-directed CPR (HD-CPR) mitigates post-arrest neurofunctional impairment and cerebral mitochondrial dysfunction. We aimed to explore the temporal evolution of markers of neurologic injury over five days following cardiac arrest treated with HD-CPR. Methods: Pigs (1-month-old) underwent 7min asphyxia, induction of ventricular fibrillation, 10-20min of HD-CPR (goal SBP 90 mmHg, coronary perfusion pressure 20mmHg), randomization to post-ROSC survival duration (24, 48, 72, 96, 120h; n=3 per group) with standardized post-resuscitation care. Plasma neurofilament light (NFL) and glial fibrillary acidic protein (GFAP) were collected at 0, 6, 24, 48, 72, 96, 120h and compared by mixed effects analysis. At terminal endpoints, cerebral cortical tissue was assessed for: mitochondrial electron transport system function; citrate synthase quantification (mitochondrial mass); immunoblot quantification of mitochondrial dynamic proteins (Opa-1, MFN-2, DRP-1, FIS-1); ELISA for 4-HNE and protein carbonyls (oxidative injury); and neuropathologic examination for IBA-1 (microglial activation) and GFAP (reactive astrocytes), all compared via ANOVA. Results: All animals had swine cerebral performance category score of 1 (grossly normal) by 24h after injury. Plasma NFL was significantly elevated at 24, 48, 72, 96 (p&lt;0.001) and 120h (p=0.009) compared to baseline. No significant differences were identified between time points for GFAP, mitochondrial measures, or neuropathological outcomes. Discussion: Despite grossly normal neurofunctional status, plasma NFL was elevated from baseline at multiple timepoints. No significant temporal differences were identified in other markers of neurologic injury. NFL may be a sensitive marker of mild neurologic injury post-arrest.

Prevalence of Apparent Treatment-Resistant Hypertension in Chronic Kidney Disease in Two Large US Health Care Systems.

More intensive BP goals have been recommended for patients with CKD. We estimated the prevalence of apparent treatment-resistant hypertension among patients with CKD according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA; BP goal <130/80 mm Hg) and 2021 Kidney Disease Improving Global Outcomes (KDIGO; systolic BP <120 mm Hg) guidelines in two US health care systems. We included adults with CKD (an eGFR <60 ml/min per 1.73 m2) and treated hypertension from Kaiser Permanente Southern California and the Veterans Health Administration. Using electronic health records, we identified apparent treatment-resistant hypertension on the basis of (1) BP above the goal while prescribed three or more classes of antihypertensive medications or (2) prescribed four or more classes of antihypertensive medications regardless of BP. In a sensitivity analysis, we required diuretic use to be classified as apparent treatment-resistant hypertension. We estimated the prevalence of apparent treatment-resistant hypertension per clinical guideline and by CKD stage. Among 44,543 Kaiser Permanente Southern California and 241,465 Veterans Health Administration patients with CKD and treated hypertension, the prevalence rates of apparent treatment-resistant hypertension were 39% (Kaiser Permanente Southern California) and 35% (Veterans Health Administration) per the 2017 ACC/AHA guideline and 48% (Kaiser Permanente Southern California) and 55% (Veterans Health Administration) per the 2021 KDIGO guideline. By requiring a diuretic as a criterion for apparent treatment-resistant hypertension, the prevalence rates of apparent treatment-resistant hypertension were lowered to 31% (Kaiser Permanente Southern California) and 23% (Veterans Health Administration) per the 2017 ACC/AHA guideline. The prevalence rates of apparent treatment-resistant hypertension were progressively higher at more advanced stages of CKD (34%/33%, 42%/36%, 52%/41%, and 60%/37% for Kaiser Permanente Southern California/Veterans Health Administration eGFR 45-59, 30-44, 15-29, and <15 ml/min per 1.73 m2, respectively) per the 2017 ACC/AHA guideline. Depending on the CKD stage, up to a half of patients with CKD met apparent treatment-resistant hypertension criteria.

Nicardipine versus Labetalol for Hypertension during Acute Stroke: A Systematic Review and Meta-Analysis.

Current recommendations prescribe either nicardipine or labetalol as the first-line treatment for acute hypertension due to ease of use, availability, and low price. However, it is unclear if these drugs have different effectiveness and safety profiles. This systematic review and meta-analysis aimed to compare the efficacy and safety of labetalol and nicardipine in patients with acute stroke. MEDLINE via PubMed, Scopus, Embase, and Google Scholar databases were electronically searched for the eligible publications from inception until March 2022. All full-text journal papers in English which compared the efficacy of nicardipine with that of labetalol on lowering blood pressure (BP; or treating hypertension) in all subtypes of acute stroke were included. The Cochrane Collaboration tool was used to assess the risk of bias. Data were analyzed using specific statistical methods. Following the abstract and full-text screening, this meta-analysis included five retrospective cohorts and one prospective pseudorandomized cohort. Nicardipine's effect on time at goal BP was significantly superior to that of labetalol in patients with acute stroke (0.275 standardized mean difference [SMD], 95% confidence interval [CI]: 0.112-0.438, P = 0.001). The incidence of adverse events was significantly higher in the nicardipine group than that in the labetalol group. The pooled odds ratio (OR) was 1.509 (95% CI: 1.077-2.113, I2 = 0.00%, P = 0.757). The quality of included studies was found to be low. More prospective, comparative trials are needed to investigate the efficacy of BP management as well as clinical outcomes in acute stroke patients receiving continuous labetalol and nicardipine infusions.

Postmenopausal Hypertension and Blood Pressure Target Achievements using Monotherapy in a Tertiary Care Teaching Hospital, South India

Background: Prevalence of hypertension and scanty of evidences related to the clinical efficacy and safety of antihypertensive regimens among post menopausal women were almost negligible in India. So, the aim of the present study was aimed to evaluate the efficacy of antihypertensive as monotherapy in hypertensive postmenopausal women. Materials and Methods : A prospective observational study was conducted in Department of General Medicine at Karuna Medical College Hospital, Palakkad, Kerala for a period of November 2019 to October 2020. The patients were divided in to four groups according to the class (Angitensin Receptor Blockers (ARBs) or Calcium Channel Blockers (CCBs) or Diuretics or Beta Blockers) as monotherapy and their BP values were noted. Results: A total of 250 post menopausal hypertensive women were enrolled in this study. The patients achieved the goal on ARBs with 78% and CCBs with 69.5% was higher compared than BB (54.3%) and Diuretics (45.7%). ARBs and CCBs treated patients showed statistically significant differences in reduction of systolic blood pressure, Diastolic blood pressure, Pulse Pressure and Mean Arterial Pressure in hypertensive women. Conclusion: The twothirds of hypertensive post menopausal women are not being achieved the BP goal; those have more risk for cardiovascular disease and stroke.