Hypertension Clinic Research Articles

Evaluating an integrated clinical pharmacy service model in an ambulatory cardiac clinic- a single centre study

Abstract Background Evidence suggests that multidisciplinary cardiology clinics improve patient outcomes. Currently, there is limited data on the type of pharmacist-led interventions occurring in cardiac ambulatory clinics in the Australian setting. Purpose The primary aim of this pilot audit is to examine the frequency and type of pharmacist-led interventions in the ambulatory clinics of this specialist hospital. The secondary aim is to assess factors associated with hospital readmissions within 30 days of Pharmacists' reviews. Methods A retrospective pilot audit was conducted for patients who attended an integrated multidisciplinary Heart Failure (HF) and Hypertension (HTN) clinic from April 2023 to February 2024. Patients’ demographics, Charlson comorbidity index (CCI), and the number and types of pharmacist interventions and readmission data 30 days post clinic review were recorded. Descriptive statistics were used to evaluate patient characteristics and logistic regression for hospital readmissions. Results A total of 398 patients were reviewed by pharmacists, with 300 (75%) from the HF clinics and 98 (25%) from the HTN clinics. Patients’ median age was 63± 14.8 years and median CCI was 4± 3.7. Pharmacists documented medication histories for all patients (100%) and provided 355 recommendations, of which 213 (60%) were actioned by the cardiologist. Pharmacists had a face-to-face consultation and provided education and counselling to 175 (44%) patients. The most common types of interventions were related to guideline-directed prescribing and deprescribing (68, 39%), followed by up-titration of current therapies (61, 35%). Pharmacists also provided education on medication adherence and lifestyle modifications (28, 16%) as well as optimizing medications related to other comorbidities (18, 10%). A total of 8 patients (2%) were re-admitted l within 30 days of clinic review from either heart failure exacerbation or hypertensive crisis. Patients who had a face-to-face consultation and education with a pharmacist were less likely to be readmitted within 30 days (P=0.048). However, none of the other predictors tested for readmission such as age (P= 0.572), gender (0.296), history of non-compliance (0.834), CCI (0.984) or a diagnosis of HF or HTN (0.473) were predictors for readmission within 30 days of clinic review. Conclusion Pharmacists play an integral role in the cardiac ambulatory setting by providing expert medication advice and patient education to optimize patients’ outcomes. This study demonstrates that the activities performed by pharmacists working in Australian cardiac clinics are consistent with other international ambulatory clinics. The study also identified opportunities to develop a similar service for other ambulatory clinics at this hospital such as lipid and atrial fibrillation clinics. Additionally, further research is required to assess long term benefit of pharmacist led interventions on cardiac patients.

Prolonged dual antiplatelet therapy in an extended Phase 3 Cardiac Rehabilitation Program following myocardial infarction

Abstract Background Prolonged dual antiplatelet therapy (P-DAPT) is recommended in selected patients beyond 12 months after myocardial infarction (MI). Several risk scores have been developed to estimate the ischemic and bleeding risk and individualize the decision-making process. Purpose We aim to analyse the factors, including ischemic and bleeding scores, associated with P-DAPT prescription in MI patients submitted to a Cardiac Rehabilitation Program (CRP). Methods Patients with ST-segment elevation MI (STEMI) or occlusion MI (OMI) who were submitted to our CRP underwent Phase 2 CRP and were prospectively included. Patients were followed in an extended Phase 3 CRP, and a follow-up visit was scheduled 12 months after hospital discharge. Baseline and follow-up clinical characteristics and treatment after the 12-months visit were registered, specifically P-DAPT. Ischemic (DAPT score) and bleeding (PRECISE-DAPT and CRUSADE scores) risk scores were retrospectively computed. Predictors of P-DAPT were studied by univariate analysis and multivariable binary logistic regression. The model was tested by area under the curve (AUC) analysis in receiver operating characteristic curves. A p<0.05 was considered statistically significant. Results The cohort comprised 78 patients (mean age 61±11 years, 84.6% male). Anterior and inferior STEMI were the most common presentations (43.6% and 47.4%, respectively). The most prevalent cardiovascular risks factors were hypercholesterolemia (85.9%), hypertension (53.8%), smoking habit (46.2%) and diabetes mellitus (23.1%). P-DAPT was prescribed in 39 (50%) patients beyond 12 months after MI, primarily combining aspirin 100mg o.d. and ticagrelor 60mg b.i.d. (n=33, 84.6%). On multivariate analysis, variables associated with P-DAPT prescription were hypertension (HR 4.92 [1.37-17.68], p=0.02), diabetes mellitus (HR 5.13 [1.09-24.09], p=0.04), multivessel disease (HR 5.54 [1.55-19.79], p=0.008), and stent diameter <3mm (HR 5.46 [1.25-23.78], p=0.02). The predictive power of the model was excellent (AUC 0.88 [0.8-0.96], p<0.001). Ischemic (DAPT score) and bleeding (PRECISE-DAPT and CRUSADE) risk scores were not associated with P-DAPT neither in continuous form nor by using their standard cutoffs (≥2, <25 and >40 points, respectively). Conclusions In a real-life cohort of MI patients undergoing extended Phase 3 Cardiac Rehabilitation, P-DAPT was prescribed in half of the population. Clinical (hypertension and diabetes mellitus) and angiographic (multivessel disease and stent diameter <3mm) variables straightforwardly predict the likelihood of receiving P-DAPT, unlike ischemic and bleeding risk scores. The clinical consequences of this management should be further explored.Prolonged DAPT in Cardiac Rehabilitation

Automated quantification of cerebral microbleeds in susceptibility-weighted MRI: association with vascular risk factors, white matter hyperintensity burden, and cognitive function.

To train and validate a deep learning (DL)-based segmentation model for cerebral microbleeds (CMB) on susceptibility-weighted MRI; and to find associations between CMB, cognitive impairment, and vascular risk factors. Participants in this single-institution retrospective study underwent brain MRI to evaluate cognitive impairment between January-September 2023. For training the DL model, the nnU-Net framework was used without modifications. The DL model's performance was evaluated on independent internal and external validation datasets. Linear regression analysis was used to find associations between log-transformed CMB numbers, cognitive function (mini-mental status examination [MMSE]), white matter hyperintensity (WMH) burden, and clinical vascular risk factors (age, sex, hypertension, diabetes, lipid profiles, and body mass index). Training of the DL model (n = 287) resulted in a robust segmentation performance with an average dice score of 0.73 (95% CI, 0.67-0.79) in an internal validation set, (n = 67) and modest performance in an external validation set (dice score = 0.46, 95% CI, 0.33-0.59, n = 68). In a temporally independent clinical dataset (n = 448), older age, hypertension, and WMH burden were significantly associated with CMB numbers in all distributions (total, lobar, deep, and cerebellar; all P <.01). MMSE was significantly associated with hyperlipidemia (β = 1.88, 95% CI, 0.96-2.81, P <.001), WMH burden (β = -0.17 per 1% WMH burden, 95% CI, -0.27-0.08, P <.001), and total CMB number (β = -0.01 per 1 CMB, 95% CI, -0.02-0.001, P = .04) after adjusting for age and sex. The DL model showed a robust segmentation performance for CMB. In all distributions, CMB had significant positive associations with WMH burden. Increased WMH burden and CMB numbers were associated with decreased cognitive function. CMB = cerebral microbleed; DL = deep learning, DSC = dice similarity coefficient; MMSE = mini-mental status examination; SVD = small vessel disease; SWI = susceptibility-weighted image; WMH = white matter hyperintensity.

8356 Total Hypophysectomy in Cushing’s Disease: Results from a Terciary Center

Abstract Disclosure: M.V. Lopes: None. M.D. Severino: None. J. Rocha: None. C.R. Peixe: None. M.I. Alexandre: None. A. Gomes: None. M.J. Bugalho: None. Introduction: Transsphenoidal surgery (TSS) is the first line treatment for Cushing’s disease (CD), leading to remission in 70-80% of cases. Though selective adenomectomy is the preferred approach, total hypophysectomy may be needed. Objective: To describe 3 CD patients in which total hypophysectomy was performed. Clinical cases 1. A 58-year-old man with a history of type 2 diabetes (T2D) and obesity, was referred to the Endocrinology Clinic due to abdominal purple striae and facial plethora. Laboratory tests suggested ACTH dependent hypercortisolism, with normal serum ACTH, high 24h urinary cortisol and no cortisol suppression in the overnight 1mg dexamethasone suppression test (DST). The CRH test was suggestive of CD but no adenoma was found on pituitary MRI. Inferior petrosal sinus sampling (IPSS) was compatible with CD with right-sided lateralization. Right hypophysectomy was performed but no CD remission was achieved, so the patient underwent total hypophysectomy. Corticotroph hyperplasia was identified in histology. After 9 months of follow-up, he mantains CD remission. 2.A 37-year-old woman was diagnosed with ACTH dependent hypercortisolism after referral to the Endocrinology Clinic for alopecia, amenorrhea, hypertension and hirsutism. Laboratory tests showed severe hypokalemia, high plasma ACTH and 24h urinary cortisol and the MRI showed a right-sided macroadenoma. Nonetheless, considering the clinical severity, an IPSS was performed and definitely excluded an ectopic Cushing’s syndrome (CS) thus confirming the diagnosis of CD with right-sided lateralization. The patient underwent selective TSS, however, for lack of CD remission, total hypophysectomy was performed. Histology revealed an adenocorticotrophic adenoma. Yet, a year later, she maintains persistence of CD, although less severe, and is under treatment with metyrapone. 3.A 58-year-old woman with a history of T2D and class 3 obesity, was evaluated in our Endocrinology Clinic due to obesity. Her physical examination suggested CS, so this hypothesis was investigated. Laboratory tests suggested ACTH dependent hypercortisolism, with normal serum ACTH, elevated 24h urinary cortisol and no cortisol suppression in the overnight 1mg DST. The high dose DST was suggestive of CD but the pituitary MRI didn’t show an adenoma. IPSS was compatible with CD but it was not possible to determine lateralization. So, total hypophysectomy was performed. An adenocorticotrophic adenoma was identified in histology. Postoperative CD remission was achieved and persists 3 months later. Conclusions: These 3 cases highlight the challenge of treating CD and suggest that in certain cases total hypophysectomy may be the treatment of choice to cure or at least improve CD. Although it is associated with more complications than selective TSS, our patients had no complications, only developed panhypopituitarism and diabetes insipidus. Presentation: 6/1/2024

7236 Long Term Extension of Osilodrostat Therapy in Canadian Patients with Cushing’s Disease Benefiting from the LINC 3 and LINC 4 Studies

Abstract Disclosure: L.M. Martel: Other; Self; LMD receives partial fellowship salary support though educational grants from Recordati Rare Disease Canada Inc and Pfizer Canada. G. Houde: Other; Self; GH served as a consultant for Novartis. C. Chik: Other; Self; grants and/or consulting fees from Pfizer, Ipsen, Novartis and Novo Nordisk Canada. S.A. Imran: Other; Self; consulting fees from Pfizer, Recordati and Novartis. E. Paron: Other; Self; employees of Recordati Rare Disease Canada Inc. F. Lebel: Other; Self; employees of Recordati Rare Disease Canada Inc. A. Lacroix: Other; Self; reports grants and personal consulting fees from Novartis, Recordati and Pfizer. Introduction: Osilodrostat, a potent oral 11β-hydroxylase inhibitor, provided rapid, sustained cortisol normalization in Cushing’s disease (CD) patients in two Phase III trials (LINC 3, NCT02180217; LINC 4, NCT02697734); persistent biochemical and clinical improvement of CD were reported after 72 and 96 weeks of therapy, respectively (10.1530/EJE-22-0317; 10.3389/fendo.2023.1236465). After study completion and continued clinical benefit with osilodrostat, patients could transition in a roll-over study (CLCI699C2X01B , NCT03606408). As osilodrostat is now approved for therapy of CS in Europe and CD in USA, but not in Canada, seven Canadian patients who had benefited from osilodrostat were transitioned to an investigator initiated study ((ISS-CA-2023, NCT06131580). Objective: To analyze the course of therapy with osilodrostat which allowed long-term biochemical and clinical control of CD since initiation of LINC 3 and LINC 4 core studies for up to 105 months. Methods: Retrospective review of clinical, biochemical and imaging data were collected through chart review of 11patients enrolled in four Canadian centers in LINC 3 and 4 in LINC 4 parent studies. Seven patients remained in the roll-over study until termination and initiation of the Canadian study on October 24 2023. Data from initiation of therapy until October 24 2023 were analyzed. Results: Of the eleven enrolled patients, four discontinued treatment due to muscle cramps, repeat transsphenoidal surgery (TSS) for corticotroph adenoma progression in 2 cases, and hyperandrogenism and opting for bilateral adrenalectomy in one case. Seven cases (5 LINC 3 and 2 LINC 4) pursued therapy in the extension study: 2 men and 5 women, mean age 46 y.o. (range 28-72). All but one had previous TSS, one Gamma Knife and 4 received previous medical therapy. The median 24 hour urinary free cortisol (UFC) before starting osilodrostat was 334 nnmol/d (2.4 x ULN; range 133-414). The median treatment duration was 82 months (range 67-105) and median time to normalize UFC was 36 days. The median maximal dose required to normalize UFC was 10 mg/day (4-60); dose was frequently reduced because of symptoms of relative cortisol withdrawal or adrenal insufficiency (n: 5) to 6.5 mg/day (range: 1 mg every 6 days to 30 mg/d) currently. Last median UFC was 60 nmol/d (range 22-154; 6/7 in normal range &amp;lt; 138nmol/d). Tumor growth occurred in 1 patient (2mm). All patients presented partial to complete improvement of CD features, whereas one patient developed moderate clinical hyperandrogenism, hypertension and borderline prolongation of QTc that normalized after a dose reduction. Conclusions: Osilodrostat can provide sustained biochemical and clinical control of hypercortisolism in patients with CD for up to 9 years; however drug efficacy and dose requirement varies greatly between patients and must be adjusted carefully and regularly during course of therapy. Presentation: 6/3/2024

8401 Genetic Characterization of a Case of Primary Aldosteronism in an 11-Year-Old Girl carrying a Germline VUS of CACNA1H and a Somatic Mutation of CTNNB1

Abstract Disclosure: S. Parisien-La Salle: None. G. Van Vliet: None. G. Corbeil: None. M. Labrecque: None. M. Tétreault: None. I. Bourdeau: None. Introduction: Primary aldosteronism is a frequent cause of secondary hypertension in adults but is rare in children. We report the case and genetic studies of an 11 yo girl presenting with primary aldosteronism at puberty. Case presentation: An 11-year-old female patient was referred to the pediatric endocrinology clinic for hypertension (166/118). Her past medical history and family history were unremarkable. She reported polyuria, polydipsia and occasional headaches and abdominal pain. Her Tanner stage indicated that puberty was initiated (P2M2). An abdominal CT revealed a 9x10x11cm right adrenal mass with calcifications and a necrotic zone. On [1]8F-FDG PET/CT, the mass had an uptake of 2.9 SUVmax. Laboratory results revealed hypokalemia (K: 2.6 mmol/L [N: 3.5-4.5]) and elevated aldosterone (1712.8 pmol/L [N: 110-1330]) with suppressed renin (0.2 ng/ml/h [N: &amp;lt;5.3]). Her urinary aldosterone level was elevated (114 nmol/day [N: &amp;lt;67]). The rest of the biochemical adrenal panel was normal. Patient underwent a right adrenalectomy by laparotomy. The pathology report showed an adrenal tumor without capsular or vascular invasion. The only malignancy criterion was an area of necrosis and the ki-67% proliferation index was &amp;lt; 1%. Genetic investigations: After informed consent, the patient underwent germline analysis for the chimeric gene CYP11B2/CYP11B1 (Ruhr University Bochum, Germany) and a multigene panel including KCNJ5, CACNA1D, CACNA1H and CLCN2 genes (Fulgent, CA), which were both negative except for a variant of unknown significance (VUS) that was identified in CACNA1H (c.3868G&amp;gt;A, p.Val1290Ile) with a minor allele frequency of 3.291E-5 (GnomAD). Tumor DNA was extracted after adrenalectomy from fresh frozen tissues. Somatic genetic analysis of GNAS, CTNNB1, KCNJ5, ATP1A1, ATP2B3 and CACNA1D was performed using direct Sanger Sequencing (Genome Quebec Innovation Centre) and revealed a heterozygous missence pathogenic variant in the CTNNB1 gene (c.121 A&amp;gt;G p.Thr41Ala). This mutation was absent in leukocyte DNA of the patient. Immunohistochemistry of the adrenal tumor disclosed strong cytoplasmic β-catenin staining in most tumor cells (monoclonal anti-β-catenin antibody; BD Transduction Laboratories). RNA-sequencing of patient tumor RNA was performed (Research Center CHU Québec) and compared to human adrenal total RNA (Clontech, Mountain View, CA). Pathway enrichment analysis showed activation of the Wnt signaling pathway. No variant was identified in GNAQ or GNA11 genes. However, GNRHR was upregulated compared to the control sample with a log2 fold change of 3.96 (p=0.000074). Conclusion: We present a rare pediatric case of an aldosterone producing adenoma harbouring a somatic β-catenin pathogenic variant with upregulation of GNRHR. The implication of the germline CACNA1H VUS still needs to be clarified. Presentation: 6/3/2024

Impact of a Disease-Focused Electronic Health Record Dashboard on Clinical Staff Efficiency in Previsit Patient Review in an Ambulatory Pulmonary Hypertension Care Clinic.

We aimed to improve the operational efficiency of clinical staff, including physicians and allied health professionals, in the previsit review of patients by implementing a disease-focused dashboard within the electronic health record system. The dashboard was tailored to the unique requirements of the clinic and patient population. A prospective quality improvement study was conducted at an accredited pulmonary hypertension (PH) clinic within a large academic center, staffed by two full time physicians and two allied health professionals. Physicians' review time before and after implementation of the PH dashboard was measured using activity log data derived from an EHR database. The review time for clinic staff was measured through direct observation, with review method-either conventional or newly implemented dashboard-randomly assigned. Over the study period, the median number of patients reviewed by physicians per day increased slightly from 5.50 (interquartile range [IQR]: 1.35) before to 5.95 (IQR: 0.85) after the implementation of the PH dashboard (p = 0.535). The median review time for the physicians decreased with the use of the dashboard, from 7.0 minutes (IQR: 1.55) to 4.95 minutes (IQR: 1.35; p < 0.001). Based on the observed timing of 70 patient encounters among allied clinical staff, no significant difference was found for experienced members (4.65 minutes [IQR: 2.02] vs. 4.43 minutes [IQR: 0.69], p = 0.752), while inexperienced staff saw a significant reduction in review time after familiarization with the dashboard (5.06 minutes [IQR: 1.51] vs. 4.12 minutes [IQR: 1.99], p = 0.034). Subjective feedback highlighted the need for further optimization of the dashboard to align with the workflow of allied health staff to achieve similar efficiency benefits. A disease-focused dashboard significantly reduced physician previsit review time while that for clinic staff remained unchanged. Validation studies are necessary with our patient populations to explore further qualitative impacts on patient care efficiency and long-term benefits on workflow.

Correction to “An audit of the initial 12 months of a multi‐disciplinary pulmonary hypertension clinic in South Western Sydney (Campbelltown Hospital)”

Correction to “An audit of the initial 12 months of a multi‐disciplinary pulmonary hypertension clinic in South Western Sydney (Campbelltown Hospital)”

In vivo safety assessment of a polyherbal formulation (Stress WIN) proposed for clinical hypertension management

Herbal treatments are nowadays considered dietary supplements and nutraceuticals for health maintenance and alternative/complementary therapy. A large range of herbal medications worldwide can easily be accessible in the local market. The polyherbal formulation (Stress WIN) containing Ashwagandha (Withania somnifera L. Dunal), Pushkarmoola (Inula racemosa Hook. F.), and Jatamansi (Nardostachys jatamansi (D. Don) DC.) root has been used empirically in the management of hypertension. However, toxicity data for the StressWIN is not available yet. The present study aims to evaluate the StressWIN’s safety profile by 28 days of repeated dose oral toxicity in Wistar rats. Rats received different doses (500 mg/kg/day, 1000 mg/kg/day, and 2000 mg/kg/day) of StressWIN, for 28 days. The study was conducted in compliance with the OECD guideline 423. No significant differences were observed in hematological and biochemical parameters as compared to the control group (p > 0.05). Histopathological studies revealed no significant alterations in the macroscopic and microscopic architecture of the liver, kidney, heart, and spleen of the StressWIN treated groups in comparison to the control group (p > 0.05). Findings from the present study suggest that StressWIN supplementation has not shown any side effects in terms of sub-acute toxicity in both male and female rats. These findings indicated no observed adverse effect level (NOAEL) of StressWIN was higher than 2000 mg/kg/day.

Patient-Related Factors Influencing Drug Non-Compliance among Hypertensive Patients in Selected State Hospitals in Lagos, Nigeria

Drug non-compliance for some time has remained a major health-related issue among chronic diseases, especially among hypertensive patients. Drug non-compliance in middle and low-income countries including Nigeria is attributed to many factors but aggravated by economic recession. There have not been sufficient studies, particularly theory-based, which explored drug non-compliance among hypertensive patients at the secondary health facilities. Understanding major factors that could influence drug non-compliance is a key step in controlling hypertension. Thus, this study aims to explore patient-related factors influencing drug non-compliance among hypertensive patients in selected state hospitals in Lagos State, Nigeria. The study adopted quantitative and qualitative research designs using descriptive surveys and Key Informant Interviews (KII) with a sample size of 349 participants among patients with hypertension in cardiac outpatient clinics of the selected general hospitals. Responses were also collected from purposively selected healthcare providers through oral interviews and their responses were analyzed qualitatively. Survey data were analyzed using Statistical Package for Social Science (SPSS) version 25.0. The study revealed that both old and young patients are ignorant of the disease thus, they tend to forget their drug prescriptions. The study further discovered that poverty and inability to procure their drugs regularly often make them turn to unorthodox medicine, and these were responsible for drug non-compliance. The study recommended that government and healthcare-providing institutions should intensify efforts to educate patients on drug compliance so as to prevent complications resulting from drug non-compliance.

Porto-Sinusoidal Vascular Disease: A New Nomenclature Different from Idiopathic Non-Cirrhotic Portal Hypertension.

Porto-sinusoidal vascular disease (PSVD) as a novel clinical conception was modified on the basis of idiopathic non-cirrhotic portal hypertension (INCPH). This study aimed to compare the clinical, biochemical histological features and prognosis between the diagnostic criteria for PSVD and that of INCPH. A total of 65 patients who underwent liver biopsies were analyzed retrospectively. The clinical, pathological and prognosis date were reviewed and screened according to the latest diagnostic criteria of PSVD and INCPH. A total of 65 patients were diagnosed with PSVD, of which 31 (47.69%) also fulfilled INCPH criteria. Specific histological and specific clinical portal hypertension (PH) signs were found in 34 (52.31%) and 30 (46.15%) of the patients, respectively. PSVD patients showed higher LSM levels (11.45 (6.38, 18.08) vs. 7.90 (6.70, 13.00), p = 0.039) than the INCPH patients. INCPH patients had a higher cumulative incidence of liver-related complications than the PSVD patients (86.95% vs. 35.71%, log-rank p < 0.001). Novel PSVD criteria facilitate early diagnosis. PSVD patients with other liver diseases may have higher LSM values. Disease progression and survival outcomes are correlated with PH in PSVD patients.

Non-adherence to appointment follow-up and its associated factors among hypertensive patients in follow-up clinics in South Gondar hospitals

Hypertension is a persistent systemic Blood Pressure reading of 140/90 mm Hg or greater which is a preventable cause of cardiovascular disease morbidity and mortality. To assess non-adherence to appointment follow-up and its associated factors among Hypertensive patients in the follow-up clinics in South Gondar Hospitals 2023. Institutional-based cross-sectional study design was employed in hospitals in South Gondar from January to February to assess missed appointment follow-up and its associated factors among Hypertensive patients in follow-up clinics. There is one comprehensive specialized hospital and 9 primary hospitals in this zone. Using simple random methods four hospitals were selected by lottery method. The sample was calculated by using the single population proportion formula. The collected data was entered into Epi data version 3.1 and exported to Statistical Package for Social Sciences version 26 for analysis. Bivariate and multivariable logistic regression analysis was performed to determine the association factors. A total of 401 hypertensive patients on hypertensive follow-up were involved with a response rate of 95.02%. Age ranged from 25 to 86 years with a median age of 58.47 years. Of the total of participants, 211 (52.6.) were rural residents. Among the total hypertensive patients in the hypertensive follow-up clinic, 39.2% were non-adherent for their appointment follow-up. Living far from follow-up health facility (AOR: 2.53; 95% CI 1.349–4.743), absence of perceived symptoms (AOR: 4.98; 95% CI 2.888–8.590), patient complaints Pill burdens (AOR: 3.50; 95% CI 2.108–5.825), and poor Awareness about complication of hypertension (AOR: 2.62; 95% CI 1.471–4.673) were significantly associated with missing of their appointment follow-up for the most hypertensive patients. The prevalence of non-adherence to medical follow-up in hypertension is high as compared to different national health policy recommendations. Distance from the health facility, absence of perceived symptoms, Pill burdens, and lack of knowledge about complications of hypertension were significantly associated with Missed appointment follow-up in Hypertensive patient.

Obstructive sleep apnea comorbid with insomnia symptoms and objective short sleep duration is associated with clinical and preclinical cardiometabolic risk factors: Clinical implications

BackgroundInsomnia with objective short sleep duration (ISSD) but not insomnia with normal sleep duration (INSD) is associated with cardiometabolic morbidity. It has been reported that sleep apnea comorbid with insomnia (COMISA) confers higher cardiovascular risk than each condition alone. We hypothesize that the association of COMISA with clinical (hypertension) and preclinical (inflammatory and metabolic) biomarkers is driven by the ISSD phenotype. MethodsA clinical sample of 101 adults with mild-to-moderate OSA (mmOSA) (5 ≤ AHI <30) and insomnia symptoms underwent polysomnography or home sleep apnea testing, blood pressure measures (BP), fasting blood glucose, insulin, CRP and IL-6 plasma levels. Insomnia was based on PSQI. Objective short sleep duration was based on the median total sleep time of the sample. Participants were classified into 2 groups based on objective sleep duration: mmOSA with ISSD vs. mmOSA with INSD. Analysis of covariance and logistic regression analysis were conducted controlling for confounders. ResultsSystolic and diastolic BP were elevated in the ISSD group compared to INSD group (p = 0.039 and p = 0.004, respectively). Also, the risk of hypertension was significantly higher in the ISSD (OR = 3.88, 95%CI = 1.26–11.95, p < 0.05) compared to INSD group. Plasma IL-6 concentrations and insulin resistance as indexed by glucose/insulin ratio were significantly higher in the ISSD group compared to INSD group (both p < 0.05). CRP levels were not different between the two groups. ConclusionIt appears that the additive adverse effects of COMISA on cardiometabolic risks are driven by the ISSD phenotype, a finding with potential implications for further phenotyping COMISA.

Innovations in blood pressure measurement and reporting technology: International Society of Hypertension position paper endorsed by the World Hypertension League, European Society of Hypertension, Asian Pacific Society of Hypertension, and Latin American Society of Hypertension.

Blood pressure (BP) is a key contributor to the lifetime risk of preclinical organ damage and cardiovascular disease. Traditional clinic-based BP readings are typically measured infrequently and under standardized/resting conditions and therefore do not capture BP values during normal everyday activity. Therefore, current hypertension guidelines emphasize the importance of incorporating out-of-office BP measurement into strategies for hypertension diagnosis and management. However, conventional home and ambulatory BP monitoring devices use the upper-arm cuff oscillometric method and only provide intermittent BP readings under static conditions or in a limited number of situations. New innovations include technologies for BP estimation based on processing of sensor signals supported by artificial intelligence tools, technologies for remote monitoring, reporting and storage of BP data, and technologies for BP data interpretation and patient interaction designed to improve hypertension management ("digital therapeutics"). The number and volume of data relating to new devices/technologies is increasing rapidly and will continue to grow. This International Society of Hypertension position paper describes the new devices/technologies, presents evidence relating to new BP measurement techniques and related indices, highlights standard for the validation of new devices/technologies, discusses the reliability and utility of novel BP monitoring devices, the association of these metrics with clinical outcomes, and the use of digital therapeutics. It also highlights the challenges and evidence gaps that need to be overcome before these new technologies can be considered as a user-friendly and accurate source of novel BP data to inform clinical hypertension management strategies.

P018 IMPLEMENTATION CONSIDERATIONS FOR SMS REMINDERS TO IMPROVE ANTIHYPERTENSIVE MEDICATION ADHERENCE IN BANGLADESH AND ETHIOPIA: A QUALITATIVE EVALUATION

Background: Poor medication adherence remains a significant barrier to hypertension control, particularly in resource-limited settings. Objective: To qualitatively explore the feasibility and acceptability of SMS reminders to support antihypertensive medication adherence and identify local nuances of barriers, facilitators, and implementation considerations in resource-limited settings. Methods: Patients with hypertension and providers in primary care clinics in Ethiopia and Bangladesh were interviewed to assess perceptions and experiences with SMS reminders. Interviews were transcribed and translated, an inductive codebook was developed, thematic content analysis was used to identify key implementation considerations. The Consolidated Framework for Implementation Research (CFIR) constructs of innovation, outer, inner settings, individual-level factors were used to synthesize findings. Results: Fifty patients (mean age 53.1±13.1 years, 28(56%) female, 28(56%) from Ethiopia) and 50 providers (mean age 32±7.5 years, 24(48%) female, 27(54%) from Ethiopia) were interviewed. Facilitators included the perceived value of SMS reminders for adherence (patients) and improved patient-provider communication (providers). Patients and providers generally viewed SMS reminders as valuable for supporting adherence (innovation). However, concerns were raised about the timing of message delivery and the potential for missed messages. Unreliable network infrastructure was identified as a potential barrier, particularly in rural areas (outer setting). The absence of electronic medical and pharmacy records in many clinics was a reported challenge for automating reminders; providers highlighted the need for dedicated IT support and staff (inner setting). Focusing on the highest-need patients was suggested as a practical approach to begin implementation. Patient's access to mobile phones, literacy levels, and receptiveness to reminders were key individual-level factors that could influence engagement with SMS reminders. Providers emphasized that reminders may not be effective for all patients (Table). Conclusions: SMS reminders can potentially improve antihypertensive medication adherence in resource-limited settings, but several implementation barriers need to be addressed. Tailoring SMS reminders to patient needs, strengthening infrastructure, and providing adequate IT and staff support are essential for successful implementation.

Post-Pulmonary Embolism Phenotypes Described by Invasive Cardiopulmonary Exercise Testing

BackgroundPost pulmonary embolism (PE) dyspnea is common. Existing non-invasive studies have demonstrated that post PE dyspnea is associated with elevations in right ventricular afterload, dead space ventilation, and deconditioning. We aimed to use invasive cardiopulmonary exercise testing (iCPET) parameters in patients with post PE dyspnea to identify unique physiologic phenotypes. Research QuestionAre there distinct post pulmonary embolism dyspnea physiologic phenotypes described with iCPET? Study Design and MethodsPatients were enrolled at the time of acute PE and through our pulmonary hypertension and dyspnea clinic. ICPET was performed if there was high suspicion for pulmonary hypertension or if there was unexplained dyspnea. A hierarchical cluster analysis was performed to identify dyspnea phenotypes. ICPET parameters assessing pulmonary hemodynamics, ventilation, and peripheral oxygen utilization were then compared within and across each cluster and with iCPET controls against peak oxygen consumption (Peak VO2). Results173 patients were enrolled. Sixty-seven patients underwent iCPET. All patients had reductions in Peak VO2 and peak cardiac index relative to controls. Three clusters were identified. Cluster one was defined by having elevated RV afterload and impaired ventilatory efficiency. Cluster two had elevated RV afterload with reductions in respiratory mechanics. Cluster three had mild derangement in RV afterload with mild reductions in peak cardiac output. InterpretationiCPET reveals significant heterogeneity in post PE dyspnea. Three phenotypes are characterized by differences in RV afterload, ventilatory efficiency, respiratory mechanics, and peripheral oxygen utilization.

Abstract 22: Evaluation of the effects of CD8 knock-out on cognitive decline in the TAC-induced hypertension mouse model

Hypertension is one of the main risk factors for cognitive impairment and dementia. We and others demonstrated the role of immunoinflammatory challenges in the establishment of cerebral injury following hypertension, highlighting a major role of inflammatory cytokines as interferon-gamma (IFN-γ) and finding increased parenchymal infiltration of CD8+ T cells. To establish the mechanistic role of these cells in cognitive impairment we subjected mice lacking CD8 cells (CD8 KO) and matched controls to aortic coarctation (TAC) and performed advanced neuroimaging analyses with a dedicated 7T small animal MRI, evaluating perfusion, brain volumes, and white matter microstructural integrity. Cognitive performance was evaluated at 4 weeks using the Morris Water Maze (MWM) test. Brain perfusion analyses shown protection from cerebral hypoperfusion in TAC CD8 KO mice compared to TAC WT mice (TAC WT vs TAC KO: 108 vs 148 ml/100g/min, p=0.0298) (Figure A). CD8 KO show preserved microstructural structure at DTI MRI, a typical trait of cerebral injury in clinical and experimental hypertension (Fimbria Fractional Anisotropy, TAC WT vs TAC KO: 0.45 vs 0.54, p=0.0210) , and show no a preserved cognition at MWM (Figure B), with a preserved learning curve at acquisition trial and a preserved memory retention capability evidenced at the probe trial (TAC WT vs TAC KO: 16,4 vs 32.2 seconds spent in platform quadrant, p=0.0014). The rescue from cerebral injury evidenced at MRI and the absence of cognitive impairment in CD8 KO mice demonstrate the pivotal role of CD8+ lymphocytes in the pathogenesis of hypertension-induced cognitive impairment.

P130 TO ASSESS THE SENSITIVITY OF ANKLE BRACHIAL INDEX, WAIST TO THIGH RATIO AND HEIGHT TO WAIST RATIO AS A PREDICTOR OF HYPERTENSION

Materials and Methods: This cross-sectional study included 1000 subjects and spanned from August 2021 to December 2023. It compared Height to Waist Ratio (HtWR), Ankle Brachial Index (ABI), Waist to Thigh Ratio (WTR), and Wrist to Arm Ratio (WAR) against established markers like Waist to Height Ratio (WHtR), Waist to Hip Ratio (WHR), and Body Mass Index (BMI) to assess their effectiveness in measuring body composition. Results: Out of 750 participants, 40% (n=400) were males and 60% (n=600) were females. Among them, 44% (n=440) were non-hypertensive, while 56% (n=560) were hypertensive. For males, HtWR (AUROC: 0.677) and Inverse ABI (AUROC: 0.611) showed superior predictive capability for hypertension compared to other measures. Conversely, among females, Waist to Thigh Ratio (AUROC: 0.669) was the most effective predictor. Cut-off values for WTR in females were 1.55, while for males, HtWR and Inverse ABI were 2.3 and 2.84, respectively. Conclusion: Among males, height to waist ratio and inverse ABI proved more reliable for predicting hypertension, while in females, waist to thigh ratio was more sensitive. Among males, HtWR (AUROC: 0.677) and Inverse ABI (AUROC: 0.611) were superior predictors of hypertension, while females showed a higher predictive capability with Waist to Thigh Ratio (AUROC: 0.669). Specific cut-off values were established: 1.55 for WTR in females, and 2.3 for HtWR and 2.84 for Inverse ABI in males. These gender-specific findings inform tailored hypertension risk assessment strategies. This study suggests incorporating inverse ABI into both clinical and community-based hypertension screenings to enable earlier detection.

P210 ASSOCIATION BETWEEN FOLLOW-UP BLOOD PRESSURE AND BLOOD PRESSURE CONTROL: A META-REGRESSION ANALYSIS

Background: Blood pressure (BP) control is typically defined as BP values under certain thresholds, most commonly &lt;140/90 mmHg – but there is widespread uncertainty about how mean BP is related to BP control, and what mean BP is required to achieve BP control in 80% of patients. Objective: To assess the association between follow-up mean systolic BP (SBP) and BP control from randomised clinical trials (RCTs). Methods: We systematically searched multiple databases for relevant RCTs. We included double-blind individual RCTs (iRCTs) of adults with hypertension, randomised to BP-lowering drugs from five major antihypertensive classes for ≥2 to ≤ 26 weeks, and which reported data for follow-up mean SBP and BP control (clinic BP &lt;140/90 mmHg) at the last follow-up visit. We also included cluster RCTs (cRCTs), of adults with hypertension, randomised to any BP-lowering intervention, for any duration. The association between follow-up mean SBP and BP control at the last follow-up visit was assessed using a linear regression model. The coefficient was interpreted as the increase in percentage of patients with BP control for every 1 mmHg decrease in follow-up mean SBP. Results: Seventy iRCTs (45,836 participants) and 36 cRCTs (28,154 participants) were included. Each 1 mmHg decrease in follow-up mean SBP was associated with about 2% improvement in BP control in both iRCTs and cRCTs (R2= 78% and 76%, respectively). This finding was broadly consistent in the subgroups of BP-lowering drug classes, baseline SBP categories, and pre-trial BP-lowering treatment status in iRCTs, and country income and baseline SBP categories in cRCTs. Mean SBP levels of 125, 130, and 135 mmHg were associated with BP control rates of 78%, 67%, and 55%, respectively, in iRCTs and 80%, 68%, and 56% in cRCTs. Conclusion: Mean SBP levels of 125 mmHg are required for achieving BP control of &lt;140/90 mmHg in about 80% of the patients. These findings should inform clinical care, guideline recommendations and hypertension control programs.

P044 TEAM-BASED CARE TO MANAGE COMPLEX CASES OF HYPERTENSION

Background and Objectives: Team-based care that uses home blood pressure (BP) telemonitoring to facilitate hypertension management is safe and effective in lowering BP in routine primary care. However, its usefulness to manage more complex cases of hypertension is uncertain. This 6-month study explores its use in such patients attending a hypertension clinic. Methods: BP telemonitoring consisted of smartphone with BP app paired with wireless home BP device to transmit BP readings to a central server, accessible to patients and clinic staff. Patients were asked to contact the clinic about worrisome home BP readings, treatment problems and technical issues. Home readings were integrated into clinical decision-making. Outcomes were patients’ experience and clinical measures. Results: Of 90 enrolled patients, 38% had grade 3 or 4 chronic kidney disease, 23% diabetes, 31% heart disease, 12% stroke and 12% aortic dissection. Mean number (standard deviation) of co-morbid conditions was 4.2 (2.0). Most patients were at very high (30%) or high risk (50%) for a cardiovascular event. During follow-up, one patient died and one dropped-out of care. Mean number of in-person and virtual assessments by a physician were 1.6 (0.6) and 2.0 (1.8), respectively. Eighty-three percent (n=75) contacted clinic staff. Mean number of contacts for technical reasons was 1.2 (1.8), treatment-related issues 0.5 (1.0) and personal support 4.2 (5.9). From baseline to exit mean automated office BP fell (p&lt;0.001), BP control improved (p&lt;0.001) and mean number of antihypertensive drug classes increased (p=0.049). Most patients, 91% (80/88), felt BP telemonitoring to be a valuable tool for managing their hypertension. Nonetheless, 38% also considered cost to be potentially a barrier to long-term use. Only 6% had data security concerns. Conclusions: Team-based care was highly rated by patients to manage their hypertension and may account for the low drop-out rate, high number of patient-provider contacts, good patient acceptance of more intensified pharmacological treatment and better BP control. However, cost potentially may be a barrier for long-term use.