High-risk Hypertensive Patients Research Articles

Construction of OSA-related hypertension prediction model based on nomogram

Objective:This study aimed to construct a risk prediction model for obstructive sleep apnea（OSA） related hypertension based on the nomogram, and to explore the independent risk factors for OSA-related hypertension, so as to provide reference for clinical treatment decision-making. Methods:The clinical data of OSA patients diagnosed by polysomnography from October 2019 to December 2021 were collected retrospectively and randomly divided into training sets and validation sets. A total of 1 493 OSA patients with 27 variables were included. The least absolute shrinkage and selection operator（Lasso） logistic regression model was used to select potentially relevant features and establish a nomogram for OSA-related hypertension.The performance and clinical benefits of this nomogram were verified in terms of discrimination, calibration ability and clinical net benefit. Results:Multivariate logistic regression showed that body mass index（BMI）, family history of hypertension, lowest oxygen saturation（LSaO2）, age and cumulative percentage of total sleep time with oxygen saturation below 90% were independent risk factors for OSA-related hypertension. Lasso logistic regression identified BMI, family history of hypertension, LSaO2 and age as predictive factors for inclusion in the nomogram. The nomogram provided a favorable discrimination, with a C-indexes of 0.835（95% confidence interval[CI ]0.806-0.863） 0.865（95%CI 0.829-0.900） for the training and validation cohort, respectively, and well calibrated. The clinical decision curve analysis displayed that the nomogram was clinically useful. Conclusion:Compared with cumulative percentage of total sleep time with blood oxygen saturation below 90%, LSaO2 may have a greater impact on the incidence of OSA-related hypertension, and the effects of different times and degrees of hypoxia on OSA-related hypertension should be further explored in the future. Apnea hypopnea index involvement is weak in predicting OSA-related hypertension, and the blood oxygen index may be a better predictor variable. Furthermore, we established a risk prediction model for OSA-related hypertension patients using nomogram, and demonstrated that this prediction model was helpful to identify high-risk OSA-related hypertension patients. This model can provide early and individualized diagnosis and treatment plans, protect patients from the serious.

Elderly men are underscreened for primary aldosteronism even in Hypertension Excellence Centre

Purpose The Endocrine Society (ES) guidelines recommend screening for primary aldosteronism (PA) in high risk hypertensive patients presenting with at least one of seven criteria (resistant HTN, hypokalaemia, adrenal nodule, etc.) Although guidelines are clear and screening is simple, compliance rates among clinicians are extremely low. This results in underdiagnosis of early disease, leading to cadiovasculaer complications and the extra-burden of advanced chronic kidney disease. We aimed to evaluate the screening rates in our Nephrology and Hypertension clinics, as an example of a dedicated Hypertension Excellence Centre. Materials and methods Data on adult hypertensive patients was retrieved from January 2018 to December 2020. Included in the study were hypertensive patients who had at least one of the ES criteria for PA screening. Of all suitable patients, we compared those who were screened for PA to patients who were not screened. Univariate and multivariate cox regression analyses were used for comparison between groups. Results Of 661 patients with HTN, 218 patients (33%) met the ES guidelines for PA screening. Forty-six of them (21.1%) were referred for screening. Advanced age and male gender were associated with lower screening referral rates. Odds ratio for age was 0.945 for every year (95% CI 0.915 − 0.975). There was a trend towards decreased referral rate in advanced kidney disease. Conclusions A 21% screening rate, suggests that many cases of PA are likely missed, more often in older patients. We therefore advocate for PA screening of all hypertensive patients, especially elderly patients with CKD, in whom clinicians’ awareness is low but the absolute risk is high.

A Comparative Study Between Ultrasound-Guided Ilioingunial/Iliohypogastric Nerve Block versus Transverse Abdominis Plane Block in Patients Undergoing Oblique Inguinal Hernia Repair

Abstract Background Poorly controlled acute pain after abdominal surgery is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted post-operative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia and prolonged hospital stay. Objective Regional anesthesia by (Ultrasound guided (US) Transversus abdominis plane block (TAP) or Ultrasound guided ilioinguinal and iliohypogastric nerves (IIN+IHN) block may be used as components of multimodal anesthesia with a comparable effect. In the present study, Bupivacaine is used to compare between them following inguinal hernia repair. Patients and Methods The study was conducted on 60 randomly chosen patients aged above 18 years, American Society of Anesthesiologists (ASA) class I or II scheduled for elective unilateral open inguinal hernia repair under general anesthesia, in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups. TAP block Group: received general anesthesia and (0.2 mL/kg of 0.25% bupivacaine per side), by midaxillary approach, under ultrasound guidance, the probe was placed transversely between the iliac crest and costal margin. Ilioinguinal/ iliohypogastric nerves block group: received general anesthesia, with (0.2 mL/kg of 0.25% bupivacaine per side). The inferior portion of linear ultrasound transducer will be placed over the anterior superior iliac spine with the superior margin of the transducer pointed directly in an oblique plane toward the umbilicus. The superior margin of the ultrasound transducer was slowly rotated superiorly and inferiorly until the fascial plane between the internal oblique and transverse abdominis muscle is identified. Results The results of the study revealed that patients received IIN+IHN block had significantly lower pain scores at 8, 12, 16, 20, and 24 hrs after operation, delayed time for rescue analgesia and decreased total need of analgesic in the first 24hrs post-operative compared to patients who received TAP nerves block. Conclusion IIN+IHN block was effective in reducing postoperative pain scores for 4-6 hours, lowering total 24-h postoperative opioid and analgesic consumption and delaying the need for rescue analgesia after inguinal hernia repair under general anesthesia, compared to TAP nerves block. It will be more useful to study in high-risk hypertensive and cardiac patients and to correlate with plasma catecholamine levels, which reflect the stress response and it is necessary to evaluate postoperative pain on movement in farther studies.

Hypertension and Heart Failure: From Pathophysiology to Treatment.

Hypertension represents one of the primary and most common risk factors leading to the development of heart failure (HF) across the entire spectrum of left ventricular ejection fraction. A large body of evidence has demonstrated that adequate blood pressure (BP) control can reduce cardiovascular events, including the development of HF. Although the pathophysiological and epidemiological role of hypertension in the development of HF is well and largely known, some critical issues still deserve to be clarified, including BP targets, particularly in HF patients. Indeed, the management of hypertension in HF relies on the extrapolation of findings from high-risk hypertensive patients in the general population and not from specifically designed studies in HF populations. In patients with hypertension and HF with reduced ejection fraction (HFrEF), it is recommended to combine drugs with documented outcome benefits and BP-lowering effects. In patients with HF with preserved EF (HFpEF), a therapeutic strategy with all major antihypertensive drug classes is recommended. Besides commonly used antihypertensive drugs, different evidence suggests that other drugs recommended in HF for the beneficial effect on cardiovascular outcomes exert advantageous blood pressure-lowering actions. In this regard, type 2 sodium glucose transporter inhibitors (SGLT2i) have been shown to induce BP-lowering actions that favorably affect cardiac afterload, ventricular arterial coupling, cardiac efficiency, and cardiac reverse remodeling. More recently, it has been demonstrated that finerenone, a non-steroidal mineralocorticoid receptor antagonist, reduces new-onset HF and improves other HF outcomes in patients with chronic kidney disease and type 2 diabetes, irrespective of a history of HF. Other proposed agents, such as endothelin receptor antagonists, have provided contrasting results in the management of hypertension and HF. A novel, promising strategy could be represented by small interfering RNA, whose actions are under investigation in ongoing clinical trials.

ACHIEVED SYSTOLIC BLOOD PRESSURE BELOW 130 MMHG PRESERVES KIDNEY FUNCTION IN DIABETIC AND NON-DIABETIC HYPERTENSIVE PATIENTS WITHOUT CARDIAC HYPERTROPHY

Objective: Kidney function is preserved by achieving systolic blood pressure (SBP) primarily <140mmHg and possibly <130mmHg in hypertensive patients. We aimed to investigate kidney function when achieving SBP 130-139 and <130mmHg in type-2 diabetic and non-diabetic hypertensive patients without cardiac hypertrophy who participated in a major prospective hypertension outcome trial. Design and method: Of the 15,245 study participants, 13,803 patients were without cardiovascular events during the first six months after randomization with roll-over from previous medications to blinded study drugs and had a minimum of 3 subsequent BP visits during 4-6 years. Of these, 2,458 patients with cardiac left ventricular hypertrophy (LVH) by ECG were not included in the present analysis because, as previously reported, they had increased cardiac and all-cause mortality at average achieved SBP <130mmHg. Of the remaining 11,345 patients, 3932 had diabetes. Cox analyzes adjusted for baseline covariates compared the pre-specified kidney endpoints 50% rise of se-creatinine (worsening kidney function, WKF) and end-stage renal disease (ESRD, dialysis and/or transplantation) for patients who achieved average SBP 130-139 and <130mmHg with those who remained with SBP >=140mmHg. Results: Patients with diabetes had less WKF at SBP 130-139mmHg (HR=0.50, 95% CIs 0.34-0.72, n=1605, p<0.001) and at SBP <130mmHg (HR=0.43, CIs 0.23-0.80, n=599, p=0.008). They also had less ESRD at SBP 130-139mmHg (HR=0.32, CIs 0.12-0.88, p=0.03) with similar trend at SBP <130mmHg (HR=0.21, CIs 0.03-1.65) which was significant for the 3rd quartile of SBP (135mmHg) (HR=0.09, CIs 0.01-0.71, p=0.02) and for the 4th quartile of SBP (126mmHg) (HR=0.12, CIs 0.02-0.92, p=0.04). Patients without diabetes (n=7413) also had less WKF at SBP 130-139mmHg (HR=0.58, CIs 0.40-0.83, n=3258, p=0.003) and at SBP <130mmHg (HR=0.38, CIs 0.21-0.68, n=1542, p<0.001). For ESRD the trend was similar as for diabetes at 3rd quartile of SBP (135mmHg) (HR=0.37, CIs 0.14-1.00, p=0.05) and at 4th quartile of SBP (126mmHg) (HR=0.23, CIs 0.07-0.75, p=0.02). Conclusions: In high-risk hypertensive patients above 50 years, with and without type-2 diabetes, but without cardiac hypertrophy, we found stepwise less worsening of kidney function and end-stage renal disease with lower average achieved systolic BP from >=140mmHg to 130-139mmHg to <130mmHg.

Testing for Primary Hyperaldosteronism in Resistant Essential Hypertensive Patients

Background: Hypertension is a common condition that affects many people all over the world. It could be associated with several complications especially in cases of resistant hypertension. Many clinical practice guidelines recommend screening for primary aldosteronism especially in persons with resistant hypertension owing to the worse prognosis when compared with blood pressure-matched essential hypertension. Objective: The study aimed to screen for primary aldosteronism in high-risk hypertensive Egyptian patients, and to determine the challenges faced in the diagnosis. Material and methods: 50 high-risk hypertensive patients were recruited from the Outpatient Endocrinology Clinic out of 200 hypertensive patients in the period from February 2019 and April 2021. Creatinine, Glycosylated hemoglobin (HBA1c), lipid profile, potassium level, sodium level, Plasma Aldosterone Concentration (PAC), Active Renin Concentration (ARC), and aldosterone/ Renin Ratio (ARR) were assessed in all patients. Results: A series of 50 hypertensive patients screened for PA (26 females and 24 males) with a mean age of 41.88±11.91 SD. We found that 41(82%) patients were receiving antihypertensive medications and 9(18%) patients didn’t receive treatment for hypertension previously. 9(18%) patients kept on no treatment, 6(12%) patients were kept on the same anti-hypertensive medications, and 35(70%) of them were shifted to other anti-hypertensive drugs. 4 patients out of total 50 patients had a positive ARR (>46), while 13(26%) patients out of total 50 hypertensive patients had low renin levels. There was a statistically significant relation between serum Aldosterone/ Renin Ratio (ARR) and serum Potassium (K) with P-value=0.001 (Figure 4), also a statistically significant relation between serum aldosterone/ renin ratio (ARR) and (systolic blood pressure, diastolic blood pressure) with P-value=0.001 was found. Conclusion: We recommend routine screening for PA in high-risk hypertensive patients that could offer targeted treatment before adverse cardiovascular consequences develop.

Association of Periodontitis with Ambulatory Blood Pressure, Salt Intake, and Neutrophil-Lymphocyte Ratio in High-Risk Hypertensive Patients

<i>Objective</i>: Periodontitis and cardiovascular disease are prevalent entities that often coexist, with a common pro-inflammatory pathway. The objective of this study was to evaluate the association between periodontitis and cardiovascular pro-inflammatory parameters rarely considered within risk factors. <i>Methods</i>: Forty-three participants aged between 38-82 years were examined. An association between mean probing depth (MPD), mean attachment loss (MAL), bleeding on probing (BOP), and periodontal inflamed surface area (PISA) was correlated with the following cardiovascular disease factors and inflammatory promoters: neutrophil-to-lymphocyte ratio (NLR), 24h ambulatory blood pressure, global cardiovascular risk, daily salt intake, night-time systolic blood pressure (nSBP), and pulse wave velocity (PWV). A two-way ANOVA and multiple comparison tests were performed using SPSS statistics software. <i>Results</i>: A highly significant correlation (p<0.05) was found between BOP, MPD, and MAL with high salt intake, global cardiovascular risk estimation, nSBP, and PISA. Also, significantly statistical correlation (p<0.05) was found between BOP, NLR, and PWV while PISA was only associated with NLR. Logistic regression analysis identified absolute values of nSBP, salt intake and NLR as possible independent contributors to the increase in the <i>log</i> odds of developing BOP. <i>Conclusions</i>: Several periodontal disease parameters are linked to cardiovascular risk factors such as hypertension, neutrophil-to-lymphocyte ratio, daily salt intake and night-time systolic blood pressure.

High Risk of Obstructive Sleep Apnea Among Hypertensive Patients at a Selected Tertiary Care Hospital

Introduction: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by partial or complete obstruction of the upper airway, which causes desaturations and arousal. Various studies have shown that OSA is a major modifiable risk factor for hypertension. Untreated OSA is increasingly associated with cardiovascular and neurocognitive sequela. Thus, our study aims to determine the high-risk of obstructive sleep apnea among hypertensive patients at a tertiary care hospital in Malaysia. Methods: A cross-sectional study was conducted among hypertensive patients at a tertiary hospital in Malaysia. A validated Malay version of the Berlin Questionnaire was utilized along with other questions on sociodemographic characteristics and diabetes mellitus. Results: A total of 161 respondents were involved in the study. The mean age was 48.35 years and among these 75% were males and 25 % were females. The majority of respondents were of Malay ethnicity (78%), followed by Chinese (11%) and Indians (10%). Of these,18 % comprised of obese patients and 29.8% had diabetes mellitus. The prevalence of high-risk OSA among hypertensive patients was 18.0% (95% CI). High risk of OSA was found to be prevalent in the elderly age group (p<0.001), female gender (p<0.001), Indian ethnicity (p<0.001) and among diabetes mellitus patients (p<0.001). Conclusion: The study results illustrate the high risk of OSA among hypertensive patients with advancing age and diabetes mellitus. This study finding mandates these high-risk hypertensive patients should be screened for early diagnosis and timely treatment of OSA to prevent further cardiovascular risk, morbidity and mortality.

High versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: a study protocol for the HISTAP randomized clinical trial

BackgroundThe intraoperative period is often characterized by hemodynamic instability, and intraoperative hypotension is a common complication. The optimal mean arterial pressure (MAP) target in hypertensive patients is still not clear. We hereby describe the protocol and detailed statistical analysis plan for the high versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP randomized clinical trial. The HISTAP trial aims at addressing whether the use of a higher intraoperative MAP target in high-risk hypertensive surgical patients scheduled for elective abdominal surgery would improve postoperative outcomes, as compared to the standard and recommended perioperative MAP, by using a composite outcome including a 30-day mortality from surgical intervention and at least one major organ dysfunction or new onset of sepsis and septic shock occurring 7 days after surgery.MethodsThe HISTAP trial is an investigator-initiated, pragmatic, parallel-grouped, randomized, stratified, analyst-blinded trial with adequate allocation sequence generation, and allocation concealment. We will allocate 636 patients to a MAP target ≥ 80 mmHg (treatment group) or to a MAP target ≥65 mmHg (control group). The primary outcome is a composite outcome including a 30-day mortality from the operation and major organ complications. Secondary outcomes are mortality at 30 days, intensive care unit (ICU) length of stay, ICU readmission, Sequential Organ Failure Assessment (SOFA) scores recorded up to postoperative day 7, overall intraoperative fluid balance, vasopressors use, and the need for reoperation. An unadjusted χ2 test will be used for the primary outcome analysis. A Cox proportional hazards model will be used to adjust the association between the primary outcome and baseline covariates.ConclusionsThe HISTAP trial results will provide important evidence to guide clinicians’ choice regarding the intraoperative MAP target in high-risk hypertensive patients scheduled for elective abdominal surgery.

A Federated Learning Approach to Support the Decision-Making Process for ICU Patients in a European Telemedicine Network

A result of the pandemic is an urgent need for data collaborations that empower the clinical and scientific communities in responding to rapidly evolving global challenges. The ICU4Covid project joined research institutions, medical centers, and hospitals all around Europe in a telemedicine network for sharing capabilities, knowledge, and expertise distributed within the network. However, healthcare data sharing has ethical, regulatory, and legal complexities that pose several restrictions on their access and use. To mitigate this issue, the ICU4Covid project integrates a federated learning architecture, allowing distributed machine learning within a cross-institutional healthcare system without the data being transported or exposed outside their original location. This paper presents the federated learning approach to support the decision-making process for ICU patients in a European telemedicine network. The proposed approach was applied to the early identification of high-risk hypertensive patients. Experimental results show how the knowledge of every single node is spread within the federation, improving the ability of each node to make an early prediction of high-risk hypertensive patients. Moreover, a performance evaluation shows an accuracy and precision of over 90%, confirming a good performance of the FL approach as a prediction test. The FL approach can significantly support the decision-making process for ICU patients in distributed networks of federated healthcare organizations.

Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas

ObjectivesTo assess the impact of student telephone motivational interviewing intervention on angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARBs) adherence trajectories and identify predictors of each trajectory. MethodsThe intervention group included continuously enrolled Medicare Advantage Plan patients non-adherent to ACEI/ARBs vs the control group (1:2 ratio). The intervention was tailored by pre-intervention trajectories and included an initial and five follow-up calls. Adherence was measured 6 months after initial calls using the proportion of days covered (PDC). Monthly PDCs were integrated into a group-based trajectory model and categorized patients into 4-groups. A multinomial logistic regression model was used to evaluate trajectory predictors. ResultsThe study comprised 240 intervention patients and 480 controls with four trajectories: adherent trajectory 44.2%, gradual improvement in adherence 13.4%, slow decline in adherence 24.1%, and discontinuation 18.3%. Patients with the intervention were less likely to experience a slow decline in adherence than controls (OR: 0.627 [0.401–0.981]). Patients with specialty prescribers’ visits, ≥ 1 previous hospitalization, rapid decline in adherence as pre-intervention trajectory, and higher CMS risk score were associated with discontinuation trajectory. ConclusionIntervention patients vs controls had a lower likelihood of following a slow decline in adherence pattern. Practice implicationsThis study underscores the importance of individualized interventions and the association between past adherence patterns and post-intervention trajectories.

Comparing Triple Combination Drug Therapy and Traditional Monotherapy for Better Survival in Patients With High-Risk Hypertension: A Systematic Review.

High-risk hypertension patients are more susceptible to cardiovascular disease, stroke, and mortality.Monotherapy and triple combination drug therapy are two different approaches to treating hypertension. Monotherapy involves using a single medication to manage hypertension, whereas triple combination therapy involves the simultaneous use of three different antihypertensive medications from different drug classes. Making a fast switch from monotherapy to combination medication is one method to regulate blood pressure (BP) better. It is widely recognized that a significant proportion of individuals with hypertension require combination therapy to manage their condition effectively. This review aims to evaluate the mortality rates across monotherapy and triple combination drug therapy in high-risk hypertension patients. A systematic literature review was conducted across multiple scientific literature repositories. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for systematic reviews and meta-analyses. Based on the end outcome of each published journal on the effectiveness of triple combination drug therapy as a treatment option for high-risk hypertension patients, there was a notable difference in overall survival, mortality rates, BP reduction, and adherence datasets. Triple combination drug use correlated with increased timeframes for multiple patient survival parameters within the articles shortlisted in this investigation. However, it is crucial for healthcare providers to weigh the risks and benefits of triple combination drug therapy when deciding which treatment approach is best for their patients.

SCREENING RATES FOR PRIMARY ALDOSTERONISM ARE UNSATISFACTORY EVEN IN HYPERTENSION EXCELLENCE CENTERS. A CALL FOR COMPULSORY SCREENING FOR ALL HYPERTENSIVE PATIENTS

Objective: The Endocrine Society guidelines recommend screening for primary aldosteronism (PA) in high risk hypertensive patients. These include patients with sustained blood pressure (BP) above 150/100 mmHg, patients with resistant hypertension (HTN), hypertensive patients with spontaneous or diuretic-induced hypokalemia, adrenal incidentaloma, sleep apnea, family history of early onset HTN or cerebrovascular accident at a young age and all hypertensive first-degree relatives of patients with PA. Even though guidelines are clear and screening is simple, compliance rates among clinicians are extremely low ranging between 0.1% to 2.7%. This results in underdiagnosis of early disease, leading to an enormous extra-burden of advanced chronic kidney disease, heart failure, atrial fibrillation, and stroke. We aimed to examine the screening rate, according to the abovementioned guidelines, at our recently recognized Hypertension Excellence Center in Assuta Ashdod University Hospital. Design and method: A retrospective cohort study. We analyzed all hypertensive patients, eligible for screening between 01/18 and 12/20. We calculated screening rates and in univariate and multivariate regression analyses, looked at parameters that influence screening. Results: Of 661 patients over 18 years of age with HTN, 218 patients (33%) met the Endocrine Society guidelines for PA screening. However only 46 of them (21.1%), were referred for screening. A multivariate regression analysis, demonstrated that advanced age and male gender were associated with lower rates of screening referral. Odds ratio for age was 0.945 for every year (95% CI 0.915-0.975). Conclusions: A 21% screening rate in a Hypertension Excellence Center, although higher than prior published studies, suggests that many cases of PA are likely missed, more often in elderly population in whom adrenal micro as well as macronodular-hyperplasia is extremely common and can be the cause of secondary HTN. We therefore advocate for PA screening at least once of all hypertensive patients, preferably before the patient is started on multiple anti-hypertensive medications. This should be done regardless of patients’ age and gender, as the absolute risk for cardiovascular events in both hypertensive and PA patients increases with rising age, and treatment with mineralocorticoid receptor antagonists can be lifesaving.

AVERAGE ACHIEVED BP <130/80 MMHG IN HIGH-RISK MIDDLE-AGED AND OLDER HYPERTENSIVE PATIENTS PROVIDES STRONG CARDIOVASCULAR PROTECTION EXCEPT IN LEFT VENTRICULAR HYPERTROPHY

Objective: Evidence that reducing blood pressure (BP) to <130/80 mmHg rather than to <140/90 mmHg by antihypertensive treatment in hypertensive patients is conflicting. Left ventricular hypertrophy (LVH) is common in hypertension, and low perfusion pressure may result in ischemia in patients with LVH. We investigated whether average achieved BP <130/80 mmHg implied cardiovascular benefits in high-risk middle-aged and older hypertensive patients who participated in the VALUE Trial. Considering a previous report of excess mortality in LVH patients with in-treatment systolic BP (SBP) <130 mmHg, we paid special attention to whether the average achieved SBP <130 mmHg may cause harm in similar patients with LVH. Design and method: Of the 15,245 participants, we identified 13,803 patients without cardiovascular events during the first six months after randomization during which previous medications were discontinued and study drugs up-titrated. Of these, 2,458 patients had LVH on an electrocardiogram (ECG). Cox analyses adjusted for age, gender, and baseline variables compared cardiac and all-cause mortality and other pre-specified endpoints for patients who achieved average SBP 130 - 139 mmHg (No LVH group n = 4,863, ECG LVH group n = 929) and <130 mmHg (No LVH group n = 2,107, ECG LVH group n = 305). Reference groups were patients who achieved an average SBP > = 140 mmHg following the first excluded six months (No LVH group n = 4,375, ECG LVH group n = 1,224). Results: The No LVH group with average achieved BP <130/80 mmHg had a significantly lower incidence of all endpoints except for myocardial infarction. The ECG LVH group with average achieved SBP <130 mmHg had increased cardiac mortality (HR = 1.98, p = 0.032) and all-cause mortality (HR = 1.74, p = 0.007), and SBP <130 mmHg was not associated with a reduction in any endpoint. However, as in those without LVH, the ECG-LVH group had fewer strokes and heart failure with an average achieved diastolic BP <80 mmHg. Conclusions: Our data suggest that target SBP <130 mmHg may cause harm and needs further investigation in middle-aged and older patients with LVH detected by ECG. Otherwise, the average achieved BP <130/80 mmHg prevents most cardiovascular endpoints in middle-aged and older hypertensive patients with high cardiovascular risk but without LVH.

S-09-2: POLYPILLS FOR HYPERTENSION CONTROL IN ASIANS

The number of cardiovascular disease (CVD) cases and deaths have continued to rise in Asian population. These unfavorable trends are expected to continue, particularly in low-income and middle-income countries.Raised blood pressure and LDL-cholesterol are among the leading modifiable risk factors for this problem. From the year 1990–2019, the prevalence of hypertension in many low-income and middle-income countries in Asia remained unchanged or increased. Most of the increase was in those without a previous diagnosis. However, the hypertension treatment and control were not improved in many countries since 1990. A meta-analysis concluded that combination anti-hypertensive therapies results in a greater reduction in blood pressure compared with increasing the dose of a single drug, regardless of the class of drugs used in combination. In term of safety, two-drug combinations have been shown to be safe and well tolerated with only a small increase in the risk of hypotension. The 2019 Thai hypertension Guidelines recommend using statin in high risk hypertensive patients. Adding a statin together with a combination of antihypertensive drug can further reduce the risk of future CVD. Such Polypill may offer many advantages and potential to solve many challenges and barriers in management of hypertension and CVD control in many, if not all, Asian Countries.

PS-C09-11: THE EFFICACY OF SACUBITRIL/VALSARTAN FOR NONDIPPER AND EXTREME DIPPER HYPERTENSION USING 24 AMBULATORY BP MEASUREMENT

Sacubitril/Valsartan increases natriuresis and diuresis and makes superior blood pressure control compared with usual RAS inhibitors. In Japanese clinical cicumstances,ideal blood pressure control to attain BP < 130/80mmHg is difficult for next reasons. 1, Japanese predisposition towards high sodium intake. 2, Salt sensitivity due to Gene Polymorphism. 3, Increasing morbidity of obesity and Metabolic syndrome. 4, Clinical inertia to attain ideal blood pressure control especially in high risk hypertension patients ex. CKD and DM. These high risk patients often suggest nocturnal hypertension by 24 hour ambulatory blood pressure monitoring,24Hr ABPM. Nocturnal hypertension consists of non-dipper pattern, riser pattern, and often associated with cardiovascular event. On the contrary, extreme dipper pattern is sometimes found by24 Hr ABPM and it suggests high systolic BP during daytime in spite of night systolic BP decline. iIt sometimes results in stroke. Therefore antihypertensive therapies to these high risk patients by monitoring only clinic BP are surely insufficient to prevent CVD. Furthermore checking Home BP immediately after wake up is off course necessary, but still inadequate. Without monitoring by 24hr ABPM during nighttime,it is impossible to distinguish between non-dipper pattern, riser pattern and morning surge pattern. Quoting from literature, superiority of Ambulatory over Clinic Blood pressure measurement is proved in predicting mortality,The Dublin Outcome Study. It is essential to check 24hr ABPM to high risk patients. These high risk CKD or DM patients are accompanied by the diminished renal capacity to excrete sodium during daytime and compensate sodium excretion by elevating night blood pressure. This mechanism could be a component of the non dipper or riser pattern. Sacubitril/Valsartan `s effect of natriuresis and diuresis effect could be effective to excrete sodium excretion at daytime and Np makes vasodilatory effect and prohibits of aldosterone production.,and valsartan is anAT1 receptor blockade and prohibits of angiotensin2 effect. Sacubitril/Valsartan is very effective for characteristic “salt sensitive hypertension” Japanese patients. In our clinic, we prescribed 250 patients,120 patients are RAS inhibitor naive, and the rest of130 patients are switched from RAS inhibitor. We present 2 clinical cases prescribing Sacubitril/Valsartan 400 mg every morning and monitored 24hrABPM before and after prescription. 1st case is 48yrs old male, HT, DM and CKD showing non dipper-pattern. 2nd case is 86 yrs female, HT and old cerebral lacuna and left common iliac aneurysma showing extreme dipper pattern. 2 weeks after administration of Sacubitril/Valsartan, 24hr ABPM were checked and non dipper pattern disappeared in Ist patients and extreme dipper pattern disappeared in 2nd case,. Normal circadian rhythms are attained in both patients.

Prediction model of obstructive sleep apnea-related hypertension: Machine learning-based development and interpretation study.

Obstructive sleep apnea (OSA) is a globally prevalent disease closely associated with hypertension. To date, no predictive model for OSA-related hypertension has been established. We aimed to use machine learning (ML) to construct a model to analyze risk factors and predict OSA-related hypertension. We retrospectively collected the clinical data of OSA patients diagnosed by polysomnography from October 2019 to December 2021 and randomly divided them into training and validation sets. A total of 1,493 OSA patients with 27 variables were included. Independent risk factors for the risk of OSA-related hypertension were screened by the multifactorial logistic regression models. Six ML algorithms, including the logistic regression (LR), the gradient boosting machine (GBM), the extreme gradient boosting (XGBoost), adaptive boosting (AdaBoost), bootstrapped aggregating (Bagging), and the multilayer perceptron (MLP), were used to develop the model on the training set. The validation set was used to tune the model hyperparameters to determine the final prediction model. We compared the accuracy and discrimination of the models to identify the best machine learning algorithm for predicting OSA-related hypertension. In addition, a web-based tool was developed to promote its clinical application. We used permutation importance and Shapley additive explanations (SHAP) to determine the importance of the selected features and interpret the ML models. A total of 18 variables were selected for the models. The GBM model achieved the most extraordinary discriminatory ability (area under the receiver operating characteristic curve = 0.873, accuracy = 0.885, sensitivity = 0.713), and on the basis of this model, an online tool was built to help clinicians optimize OSA-related hypertension patient diagnosis. Finally, age, family history of hypertension, minimum arterial oxygen saturation, body mass index, and percentage of time of SaO2 < 90% were revealed by the SHAP method as the top five critical variables contributing to the diagnosis of OSA-related hypertension. We established a risk prediction model for OSA-related hypertension patients using the ML method and demonstrated that among the six ML models, the gradient boosting machine model performs best. This prediction model could help to identify high-risk OSA-related hypertension patients, provide early and individualized diagnoses and treatment plans, protect patients from the serious consequences of OSA-related hypertension, and minimize the burden on society.

Abstract P308: Comparative Cost-effectiveness Of Hypertension Treatment Guidelines In US Adults

Introduction: The 2017 ACC/AHA guidelines lowered blood pressure (BP) thresholds for hypertension diagnosis and treatment compared to the 2003 JNC7. We compared cost-effectiveness of treating to ACC/AHA and JNC7 over 10 years in untreated hypertensive adults 35-84 years of age. Methods: The Cardiovascular Disease (CVD) Policy Model simulates CVD events, deaths, and costs in US adults. Inputs are estimated from national datasets, cohort studies, and literature. We simulated three treatment strategies: (1) no pharmacological treatment; (2) full JNC7; or (3) full ACC/AHA. Base-case analyses targeted all treatment-eligible adults. Secondary analyses stratified treatment by baseline BP (130-139/80-89 vs. ≥140/90 mmHg) and indicators of high CVD risk (diabetes, CKD, CVD, or 10-yr risk ≥10%). Results: Twenty-four million untreated adults could be treated under JNC7 and 29 million under ACC/AHA, preventing 1.2 million and 1.5 million CVD events at 10 years, respectively. Treating to JNC7 compared to no treatment and ACC/AHA compared to JNC7 was cost-effective (&lt;$50,000 per quality-adjusted life year gained) (Table). JNC7 or ACC/AHA was cost-saving for high-risk adults with BP ≥140/90 mmHg and cost-effective for high-risk adults with BP 130-139/80-89 mmHg (JNC7: $103,000/QALY; ACC/AHA: $90,000/QALY). Both JNC7 and ACC/AHA cost &gt;$150,000 per QALY gained for treating lower risk adults. Conclusion: Treating according to either JNC7 or ACC/AHA guidelines is a cost-effective way to prevent CVD. At ten years, regardless of guideline, treating high-risk hypertensive patients is either cost-saving or cost-effective; treating lower-risk patients is relatively low value.

Management of hypertension in advanced kidney disease.

The aim of this study was to present recent developments in pharmacotherapy of hypertension in patients with advanced chronic kidney disease (CKD). In the AMBER trial, compared with placebo, the potassium-binder patiromer mitigated the risk of hyperkalaemia and enabled more patients with uncontrolled resistant hypertension and stage 3b/4 CKD to tolerate and continue spironolactone treatment; add-on therapy with spironolactone provoked a clinically meaningful reduction of 11-12 mmHg in unattended automated office SBP over 12 weeks of follow-up. In the BLOCK-CKD trial, the investigational nonsteroidal mineralocorticoid-receptor-antagonist (MRA) KBP-5074 lowered office SBP by 7-10 mmHg relative to placebo at 84 days with a minimal risk of hyperkalaemia in patients with advanced CKD and uncontrolled hypertension. The CLICK trial showed that the thiazide-like diuretic chlorthalidone provoked a placebo-subtracted reduction of 10.5 mmHg in 24-h ambulatory SBP at 12 weeks in patients with stage 4 CKD and poorly controlled hypertension. Enablement of more persistent spironolactone use with newer potassium-binding agents, the clinical development of novel nonsteroidal MRAs with a more favourable benefit-risk profile and the recently proven blood pressure lowering action of chlorthalidone are three therapeutic opportunities for more effective management of hypertension in high-risk patients with advanced CKD.

Prevalence and factors associated with psychological distress among adult patients with hypertension in a primary care clinic: A cross-sectional study.

Psychological distress worsens the control of hypertension. This study aims to fill the knowledge gap and evaluate the prevalence and factors associated with depression, anxiety, and stress among patients with hypertension in a primary care clinic. A cross-sectional study was conducted at Klinik Kesihatan Bandar Jerantut on hypertensive patients using a systematic random sampling method. Data were collected from 391 hypertensive patients using a self-administered questionnaire. Multiple logistic regression analysis was performed to identify the associated factors. The response rate was 99.5% (389/391). The mean age of respondents was 60.1 years and 44.7% were male. The prevalence of psychological distress was the highest at 28.8%, followed by anxiety (21.3%), depressive (16.2%), and stress symptoms (13.9%). Uncontrolled blood pressure was significantly associated with depressive (OR: 6.4; 95% CI: 3.32-12.28), anxiety (OR: 4.9; 95% CI: 2.75-8.82), and stress symptoms (OR: 6.3; 95% CI: 3.06-12.98). Worry about the complications of hypertension was significantly associated with depressive (OR: 4.5; 95% CI: 2.08-9.94), anxiety (OR: 10.8; 95% CI: 4.15-28.17), and stress symptoms (OR: 5.3; 95% CI: 2.14-13.22). Other associated factors were physical inactivity, employment, lack of formal education, and low household income. A quarter of hypertensive patients experienced psychological distress in terms of depressive, anxiety, or stress symptoms. We recommend screening for psychological distress among high-risk hypertensive patients, especially those cannot achieve adequate blood pressure control or those who are worried about the complications of hypertension.