Higher Baseline Systolic Blood Pressure Research Articles

Predictors of early versus delayed neurological deterioration after thrombolysis for ischemic stroke: ENCHANTED study.

We aimed to determine predictors of early (END) and delayed neurological deterioration (DND) and their association with functional outcome in patients with acute ischemic stroke (AIS) who participated in the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). END and DND were defined as scores of a ≥2 point increase on the National Institutes of Health Stroke Scale (NIHSS) or ≥1 point decrease on Glasgow coma scale, or death, from baseline to 24 hours and 24 hours to 72 hours, respectively. Multivariable logistic regression models were used to determine independent predictors of END and DND and their association with 90-day outcomes (dichotomous scores on the modified Rankin scale [mRS] of 2-6 vs 0-1 and 3-6 vs 0-2, and death). Of 4496 patients, 871 (19.4%) and 302 (8.4%) patients experienced END and DND, respectively. Higher baseline NIHSS score, older age, large artery occlusion due to significant atheroma, cardioembolic stroke subtype, hemorrhagic infarction and parenchymatous hematoma within 24 hours, were all independent predictors for both END (all P ≤0.01) and DND (all P ≤0.024). Moreover, higher baseline systolic blood pressure (BP) (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12), higher diastolic BP variability within 24 hours (OR 1.07, 95% CI 1.04-1.09), patients from Asia (OR 1.25, 95% CI 1.03-1.52) were the only independent predictors for END. However, Asian ethnicity was negatively associated with DND (OR 0.64, 95% CI 0.47-0.86). Hemorrhagic infarction and parenchymatous hematoma within 24 hours were the key predictor of END across all stroke subtypes. END and DND were all associated with a poor functional outcome at 90 days (all P<0.001). We identified overlapping and unique demographic and clinical predictors of END and DND after thrombolysis for acute ischemic stroke. Both END and DND predict unfavorable outcomes at 90 days.

Association of Sacubitril/Valsartan versus Valsartan with Blood Pressure Changes, and Symptomatic Hypotension: The PARAGLIDE-HF Trial

In PARAGLIDE-HF, among patients with ejection fraction (EF) >40%, stabilized after worsening heart failure (WHF), sacubitril/valsartan led to greater reduction in plasma NT-proBNP levels and was associated with clinical benefit compared to valsartan alone, despite more symptomatic hypotension (SH). Concern over SH may be limiting use of sacubitril/valsartan in appropriate patients. We characterized patients by the occurrence of SH (investigator-reported) after randomization to either sacubitril/valsartan or valsartan. A key trial inclusion criterion was systolic blood pressure (SBP) ≥100 mmHg for the preceding 6 hours and no SH. We also compared outcomes based on baseline SBP stratified by the median blood pressure. The primary endpoint was time-averaged proportional change in NT-proBNP from baseline through Weeks 4 and 8. A secondary hierarchical outcome (win ratio) consisted of: a) cardiovascular death, b) HF hospitalizations, c) urgent HF visits, and d) change in NT-proBNP. Among 466 randomized patients, 92 (19.7%) experienced SH (sacubitril/valsartan, N=56 [24.0%]; valsartan, N=36 [15.5%], p=0.020). The median time to the first SH event was similar between treatment arms (18 days vs. 15 days, respectively, p=0.42) as was the proportion of first SH events classified as "serious" by investigators. Patients who experienced SH with sacubitril/valsartan were more likely to be White (OR 1.87 [95%CI: 0.31, 11.15]), to have a lower baseline SBP (per 10mmHg increase OR 0.68 [95%CI: 0.55, 0.85]), or to have a left ventricular ejection fraction (LVEF) of >60% (OR 2.21 [95%CI: 1.05, 4.65]). Time-averaged change in NT-proBNP did not differ between patients with baseline SBP ≥128 mmHg vs. SBP<128mmHg (interaction p=0.43). The composite hierarchical outcome for sacubitril/valsartan in patients with baseline SBP≥128mmHg had a win ratio of 1.34 ([95%CI: 0.91, 1.99], p=0.096) vs SBP<128mmHg with a win ratio of 1.09 ([95%CI: 0.73, 1.66], p=0.62; interaction p value=0.42). Among patients with LVEF>40% stabilized after WHF, incident SH was more common with sacubitril/valsartan compared with valsartan. SH was associated with lower baseline SBP, White race, and higher LVEF. Treatment benefits with sacubitril/valsartan may be more pronounced in patients with higher baseline SBP and lower LVEF (≤ 60%). (Funded by Novartis Pharmaceutical Corporation; ClinicalTrials.gov number, NCT03988634.) ABBREVIATIONS: : HFpEF, heart failure with preserved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; NT-proBNP, amino terminal-pro b-type natriuretic peptide; SBP, systolic blood pressure; WHF, worsening heart failure.

Abstract 17851: Prevalence and Predictors of Early Left Ventricular Functional Recovery After Transcatheter Aortic Valve Implantation: The TAVI-NOR Study

Introduction: Pre-intervention left ventricular (LV) ejection fraction (LVEF) in aortic stenosis (AS) patients has prognostic value. However, the hemodynamic changes early after TAVI (transcatheter aortic valve implantation) is not fully explored. Hypothesis: To what extent early functional recovery by a clinically significant increase (≥10%) in LVEF is achievable following TAVI, how it differs from baseline patient characteristics, and its potential prognostic impact. Methods: Between 2012 and 2019, 600 consecutive patients (age 81±6years, 49.3% females) with clinically significant AS underwent TAVI. Echocardiography was performed before and within 8 weeks after TAVI. Variables associated with &lt;10% LVEF improvement were identified. End-points were ≥10% LVEF improvement and all-cause mortality. Results: From baseline to follow-up; 28% of patients achieved ≥10% LVEF improvement. A ≥10% LVEF improvement was observed in 25% of patients with normal baseline flow (indexed stroke volume ≥35ml/m 2 ) versus 38% in low-flow (p=0.002). Impaired kidney function, higher blood pressure (BP), higher baseline LVEF and indexed stroke volume, and lower LV mass was more likely in patients with &lt;10% LVEF. In a multivariate logistic regression analysis, higher baseline systolic BP (OR 1.02; 95% CI 1.01-1.03, p=0.004) and lower LV mass (OR 1.25; 95% CI 1.02-1.54, p=0.031), and new pacemaker implantation (OR 1.55; 95% CI 0.99-2.42, p=0.055) were associated with a higher risk, and baseline LVEF &lt;50% with a lower risk (OR: 0.15; 95% CI: 0.09-0.25) for &lt;10% LVEF improvement following TAVI, independent of CKD, baseline troponin T and NT-proBNP. In a univariate Cox regression model, &lt;10% increase in LVEF in early phase after TAVI was not a significant predictor of mortality (HR 1.16; 95% CI 0.90-1.50, p=0.258). Conclusions: Clinically significant early LV functional recovery was evident in nearly one-third of severe AS patients, especially patients with reduced LVEF and more symptoms at baseline. Higher systolic BP, lower LV mass, and the need for new permanent pacemaker, were independently associated with a higher risk of not achieving early LV function recovery after TAVI. In long-term follow-up early LV functional recovery was not associated with all-cause mortality.

Abstract P337: Blood Pressure And Retina Responses Of Malignant Hypertension Patients In The Rice Diet Program

Introduction: The residential Rice Diet Program at Duke (RDP) has been shown to be effective in treating patients with malignant hypertension (MH) using a low salt (5 meq/d), low protein (5% kcal), and low fat (5% kcal) diet with no anti-hypertensive medications. Our team examined the RDP medical records and further clarified the identification of 710 MH patients by limiting the criteria of an averaged systolic blood pressure (SBP)&gt;170 mmHg to be met ±7 and a documented non-diabetic hemorrhrage and/or papilledema to be met ± 30 days of starting RDP, respectively. Methods: Wilcoxon ranked-sum was used to compare baseline and week-4 blood pressures (BPs), weight, and urine chloride (uCl, a measure of low-salt diet adherence). Linear regression was used to examine the association between baseline age, gender, SBP, last weight measure and uCl change with SBP change at week-4. Retina evaluation were compared between baseline and last measure using Chi-Square and Fisher’s Exact tests. Results: Male patients (p=.048) and those with a greater change in uCl (p=.001) had a greater reduction in SBP at week-4 ( Table ). Those with a higher baseline SBP had a lower reduction in SBP (p&lt;.001), while baseline age and last weight measure had no effect. The proportion of MH patients with either hemorrhage alone, papilledema alone or both, reduced during RDP participation (p&lt;.001). Conclusion: The RDP significantly lowered BPs, weight and uCl in MH patients within 4-week of starting RDP. The proportion of patients with documented retinal hemorrhage and/or papilledema also reduced significantly during participation in RDP. The mechanisms of the diet’s impact merit further investigation.

The Relationship between Metabolic Comorbidities and Post-Surgical Weight Loss Outcomes in Adolescents Undergoing Laparoscopic Sleeve Gastrectomy

Introduction: Little is known about the relationship between metabolic factors and weight loss success in adolescents undergoing bariatric surgery. Methods: The objective of this study was to assess if baseline metabolic characteristics associate with weight loss in adolescents undergoing laparoscopic sleeve gastrectomy. A retrospective study was conducted in a comprehensive adolescent bariatric surgery center of 151 subjects (34 male, 117 female). Anthropometric measurements and metabolic factors including blood pressure, fasting glucose, hemoglobin A1c (HbA1c), metabolic syndrome (MeS), liver function, triglycerides, and waist circumference were collected at one pre-surgical visit and at 6- and/or 12-month post-laparoscopic sleeve gastrectomy. Weight loss was compared between subjects with normal or abnormal baseline metabolic factors. Absolute BMI change was used to measure successful weight loss. Results: Higher baseline systolic blood pressure (SBP) was associated with greater weight loss as measured by body mass index (BMI) change and BMI standard deviation score (BMI-SDS) change at 6 and 12 months. Those patients in the 6-month follow-up group with an abnormal HbA1c at baseline had significantly more weight loss as measured by BMI-SDS. None of the other parameters, including fasting glucose, MeS, liver function, triglycerides, and waist circumference showed a predictive relationship. Conclusion: Elevated SBP and HbA1c in adolescents with morbid obesity may reflect a population more likely to achieve successful weight loss and, thus, may be a good target for bariatric surgery, specifically laparoscopic sleeve gastrectomy, as an intervention for severe obesity. An assessment of behavioral differences in patients with and without elevated BP and HbA1c might explain the mechanism for the improved weight loss.

Blood Pressure, Incident Cognitive Impairment, and Severity of CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

Hypertension is a known risk factor for dementia and cognitive impairment. There are limited data on the relation of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with incident cognitive impairment in adults with chronic kidney disease. We sought to identify and characterize the relationship among blood pressure, cognitive impairment, and severity of decreased kidney function in adults with chronic kidney disease. Longitudinal cohort study. 3,768 participants in the Chronic Renal Insufficiency Cohort (CRIC) Study. Baseline SBP and DBP were examined as exposure variables, using continuous (linear, per 10-mm Hg higher), categorical (SBP<120 [reference], 120 to 140,>140mm Hg; DBP<70 (reference), 70 to 80, > 80mm Hg) and nonlinear terms (splines). Incident cognitive impairment defined as a decline in Modified Mini-Mental State Examination (3MS) score to greater than 1 standard deviation below the cohort mean. Cox proportional hazard models adjusted for demographics as well as kidney disease and cardiovascular disease risk factors. The mean age of participants was 58±11 (SD) years, estimated glomerular filtration rate (eGFR) was 44mL/min/1.73m2 ± 15 (SD), and the median follow-up time was 11 (IQR, 7-13) years. In 3,048 participants without cognitive impairment at baseline and with at least 1 follow-up 3MS test, a higher baseline SBP was significantly associated with incident cognitive impairment only in the eGFR>45mL/min/1.73m2 subgroup (adjusted hazard ratio [AHR], 1.13 [95% CI, 1.05-1.22] per 10mm Hg higher SBP]. Spline analyses, aimed at exploring nonlinearity, showed that the relationship between baseline SBP and incident cognitive impairment was J-shaped and significant only in the eGFR>45mL/min/1.73m2 subgroup (P=0.02). Baseline DBP was not associated with incident cognitive impairment in any analyses. 3MS test as the primary measure of cognitive function. Among patients with chronic kidney disease, higher baseline SBP was associated with higher risk of incident cognitive impairment specifically in those individuals with eGFR>45mL/min/1.73m2. High blood pressure is a strong risk factor for dementia and cognitive impairment in studies of adults without kidney disease. High blood pressure and cognitive impairment are common in adults with chronic kidney disease (CKD). The impact of blood pressure on the development of future cognitive impairment in patients with CKD remains unclear. We identified the relationship between blood pressure and cognitive impairment in 3,076 adults with CKD. Baseline blood pressure was measured, after which serial cognitive testing was performed over 11 years. Fourteen percent of participants developed cognitive impairment. We found that a higher baseline systolic blood pressure was associated with an increased risk of cognitive impairment. We found that this association was stronger in adults with mild-to-moderate CKD compared with those with advanced CKD.

Elevated Blood Pressure and Worsening Cardiac Damage During Adolescence

To examine the longitudinal course for the development of elevated blood pressure (BP)/hypertension and cardiac damage in adolescents. From the Avon Longitudinal Study of Parents and Children, UK birth cohort, 1856 (1011 female) 17-year-old adolescents were followed up for 7years. BP and echocardiography were assessed at ages 17 and 24years. Elevated/hypertensive BP was defined as ≥130mm Hg systolic and ≥85mm Hg diastolic. Left ventricular (LV) mass indexed for height2.7 (LVMI2.7) ≥51g/m2.7 was defined as LV hypertrophy (LVH) and LV diastolic function (LVDF) E/A <1.5 as LVD dysfunction (LVDD). Data were analyzed with generalized logit mixed-effect models and cross-lagged structural equation temporal path models adjusting for cardiometabolic and lifestyle factors. Over follow-up, the prevalence of elevated systolic BP/hypertension increased from 6.4% to 12.2%, LVH from 3.6% to 7.2%, and LVDD from 11.1% to 16.3%. Cumulative elevated systolic BP/hypertension was associated with worsening LVH in female participants (OR 1.61, CI 1.43-1.80 P<.001) but not in male participants. Elevated systolic BP/hypertension was associated with worsening LVDD in male and female participants. Elevated diastolic BP/hypertension was associated with worsening LVH in male and female participants. In cross-lagged temporal path models, higher baseline systolic BP was associated with LVDF (β=0.09, SE=0.002, P=.029) but not LVMI2.7 at follow-up. Higher baseline cardiac indices were not associated with follow-up systolic BP. Higher baseline diastolic BP was associated with follow-up higher cardiac indices except LVDF. Baseline LVMI2.7 was not associated with follow-up diastolic BP. Elevated BP/hypertension may temporally precede premature cardiac damage in youth.

New-Onset Post-Operative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting Surgery - A Retrospective Case-Control Study.

New-onset postoperative atrial fibrillation (POAF) is a common complication following coronary artery bypass grafting (CABG) surgery. To explore predictive factors and potential mechanisms of new-onset POAF in isolated off-pump CABG patients. Retrospective observational case-control study of 233 patients undergoing isolated off-pump CABG surgery between August 2018 and July 2020 at the Department of Thoracic and Cardiovascular Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School. Associations between predictor variables and new-onset POAF were identified. The main outcome was new-onset POAF after CABG surgery. A total of 75 (32.19%) patients developed new-onset POAF after CABG surgery. The new-onset POAF patients had advanced age, higher baseline systolic blood pressure, more preoperative use of diuretic drug, more transfusion of blood products, atrial dilation and postoperative positive inotropic drug treatment. Nineteen variates entered the multivariable logistic regression model with a Hosmer-Lemeshow test score of 7.565 (P=0.477). Postoperative left atrial enlargement, postoperative drainage in the first 24 hours and total length of hospital stay were statistically significant, while postoperative right atrial enlargement (OR and 95% CI, 7.797 [0.200, 304.294], P=0.272) and left atrial enlargement (3.524 [1.141, 10.886], P=0.029) assessed by echocardiography had the largest OR value. Atrial enlargement is strongly associated with new-onset POAF in patients with isolated off-pump CABG, thus it highlights the advantage of echocardiography as a useful tool for predicting new-onset POAF. Careful monitoring and timely intervention should be considered for these patients.

1055 MALMÖ POTS SYMPTOM SCORE: ASSESSING SYMPTOM BURDEN IN POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME

Abstract Background Postural orthostatic tachycardia syndrome (POTS) is a common cardiovascular autonomic disorder characterized by excessive heart rate increase on standing and symptoms of orthostatic intolerance, posing significant limitations on functional capacity. No objective tool exists to classify symptom burden in POTS. Methods We conducted a case-control study in 62 POTS patients and 50 healthy controls to compare symptom burden between groups using the newly developed, self-rating, 12-item, Malmö POTS Score (MAPS; 0-10 per item, total range 0-120) based on patients’ own perception of symptoms through visual analogue scale assessment. We have also explored correlations between symptom severity assessed by MAPS, basic clinical parameters and postural haemodynamic changes. Results POTS patients showed significantly higher total MAPS score (78±20 vs. 14±12, p&amp;lt;0.001), higher baseline systolic blood pressure (BP), diastolic BP and heart rate (HR)(p&amp;lt;0.001) compared with healthy controls. The most prominent symptoms in POTS were palpitations, fatigue, and concentration difficulties. Haemodynamic parameters on standing were significantly correlated with palpitations in POTS after adjustment for age and sex (lower systolic and diastolic BP, and higher HR) (p&amp;lt;0.001 for all). Orthostatic HR was significantly associated with concentration difficulties and total MAPS score. The optimal cut-point value of MAPS to differentiate POTS and healthy controls was ≥42 (sensitivity, 97%; specificity, 98%). Conclusions Symptom severity, as assessed by MAPS score, is 5-fold higher in POTS compared with healthy individuals. The new MAPS score can be useful as a semi-quantitative system to assess symptom burden, monitor disease progression and evaluate pre-test likelihood of disease.

Malmö POTS symptom score: Assessing symptom burden in postural orthostatic tachycardia syndrome.

Postural orthostatic tachycardia syndrome (POTS) is a common cardiovascular autonomic disorder characterized by excessive heart rate (HR) increase on standing and symptoms of orthostatic intolerance, posing significant limitations on functional capacity. No objective tool exists to classify symptom burden in POTS. We conducted a case-control study in 62 POTS patients and 50 healthy controls to compare symptom burden between groups using the newly developed, self-rating, 12-item, Malmö POTS Score (MAPS; 0-10 per item, total range 0-120) based on patients own perception of symptoms through visual analogue scale assessment. We have also explored correlations between symptom severity assessed by MAPS, basic clinical parameters and postural haemodynamic changes. POTS patients showed significantly higher total MAPS score (78 ± 20 vs. 14 ± 12, p < 0.001), higher baseline systolic blood pressure (BP), diastolic BP and HR (p < 0.001) compared with healthy controls. The most prominent symptoms in POTS were palpitations, fatigue and concentration difficulties. Haemodynamic parameters on standing were significantly correlated with palpitations in POTS after adjustment for age and sex (lower systolic and diastolic BP, and higher HR) (p < 0.001 for all). Orthostatic HR was significantly associated with concentration difficulties and total MAPS score. The optimal cut-point value of MAPS to differentiate POTS and healthy controls was ≥42 (sensitivity, 97%; specificity, 98%). Symptom severity, as assessed by MAPS score, is fivefold higher in POTS compared with healthy individuals. The new MAPS score can be useful as a semiquantitative system to assess symptom burden, monitor disease progression and evaluate pre-test likelihood of disease.

Early drop in systolic blood pressure is associated with poor diuretic response and prognosis in patients with acute heart failure.

Although an excessive drop in systolic blood pressure (SBP) during acute heart failure (AHF) negatively impacts prognosis, the association between changes in SBP and the diuretic response (DR) is unclear. We aimed to clarify the association between an early drop in SBP and DR/prognosis in patients with AHF. This was a sub-analysis of the REALITY-AHF study, which registered patients with AHF admitted through emergency departments (EDs). An early SBP drop was defined as the difference between baseline SBP and the lowest value during the first 48 h of hospitalization. DR was defined as the urine output achieved per 40 mg of intravenous furosemide administered. SBP was measured on admission, at 90 min, and 6, 24, and 48 h after admission. Patients were divided into four groups according to their median SBP drop and DR: greater SBP drop/poor DR (n = 322), smaller SBP drop/poor DR (n = 409), greater SBP drop/good DR (n = 419), and smaller SBP drop/good DR (n = 314). The study included 1,464 patients. A greater SBP drop/poor DR was associated with higher baseline SBP and vasodilator use. Multivariable linear regression analysis showed that a greater drop in SBP was associated with poorer DR following adjustment for potential covariates. Cox proportional hazards analysis demonstrated that a greater SBP drop/poor DR was independently associated with 1-year mortality. Both SBP and DR changes were independently associated with prognosis. An early drop in SBP during the first 48 h of hospitalization was associated with poor DR and 1-year mortality in patients with AHF. URL: http://www.umin.ac.jp/ctr/Unique identifier: UMIN000014105.

CARDIOVASCULAR AND KIDNEY OUTCOMES IN TREATED RESISTANT HYPERTENSIVE PATIENTS

Objective: To evaluate the incidence of cardiovascular (CV) and kidney outcomes and its predictors in treated resistant hypertensive (rHTN) patients. Design and method: We studied 117 rHTN patients and 114 controlled hypertensives (cHTN) patients on a triple fixed-dose combination of RAAS blockers / CCB / thiazide or thiazide-like diuretic. Patients with rHTN treated with the same type of triple fixed-dose combination in maximally tolerated doses plus the individually defined most effective fourth-line agent (spironolactone/eplerenone 56.1%, torasemide 26.8%, nebivolol 14.6%, moxonidine 2.5%); the fifth class of antihypertensive drug was added for 35.2 % of patients. A composite CV (CV death, myocardial infarction and/or revascularization, stroke, atrial fibrillation, and peripheral arterial disease) and kidney outcome (dialysis or GFR decline by 40% or greater) were estimated after five years (a mean follow-up 5.1 ± 0.1). The combined endpoint was defined as total CV and renal outcome events. Results: The goal office and 24-h BP were achieved at 49.6 and 34.2 % rHTN patients by the end of 5-year follow-up. During follow-up the incidence of all outcomes were higher at rHTN patients compared to cHTN pts: composite CV events (26.5 % vs 7 %, P = 0.001), kidney outcomes (4.3 % vs 0.9 %, P = 0.01), and diabetes (3.4 % vs 0.9 %, P = 0.02). The independent predictors of combined end point identified by multivariant logistic regression analysis were initial 24-h systolic BP ( = 0.099; OR = 1.10; 95 % CI 1.03 – 1.18; P = 0.008), blood concentration of endothelial progenitor cells (CD45+/CD34+) ( = - 0.89; OR = 0.41; 95 % CI: 0.21 – 0.79), P = 0.007) and citrulline ( = - 0.89; OR = 1.13; 95 % CI: 1.07 – 1.20; P &lt; 0.001). Conclusions: Despite significant improvement in BP control the incidence of CV and renal outcomes in rHTN patients were higher than in cHTN patients. The independent predictors of combined CV and renal events were higher baseline systolic blood pressure, citrulline plasma level, and low concentration of endothelial progenitor cells.

Risk Factors for Intravenous Propacetamol-Induced Blood Pressure Drop in the Neurointensive Care Unit: A Retrospective Observational Study.

Intravenous propacetamol is commonly used to control fever and pain in neurocritically ill patients in whom oral administration is often difficult. However, several studies reported that intravenous propacetamol may cause blood pressure drop. Thus, we aimed to investigate the occurrence and risk factors for intravenous propacetamol-induced blood pressure drop in neurocritically ill patients. This retrospective study included consecutive patients who were administered intravenous propacetamol in a neurointensive care unit at a single tertiary academic hospital between April 2013 and June 2020. The exact timing of intravenous propacetamol administration was collected from a database of the electronic barcode medication administration system. Blood pressure drop was defined as a systolic blood pressure below 90mm Hg or a decrease by 30mm Hg or more. Blood pressure, pulse rate, and body temperature were collected at baseline and within 2h after intravenous propacetamol administration. The incidence of blood pressure drop was evaluated, and multivariable logistic regression analysis was performed to identify risk factors for blood pressure drop events. A total of 16,586 instances of intravenous propacetamol administration in 4916 patients were eligible for this study. Intravenous propacetamol resulted in a significant decrease in systolic blood pressure (baseline 131.1 ± 17.8mm Hg; within 1h 124.6 ± 17.3mm Hg; between 1 and 2h 123.4 ± 17.4mm Hg; P < 0.01). The incidence of blood pressure drop events was 13.5% within 2h after intravenous propacetamol. Older age, lower or higher baseline systolic blood pressure, fever, higher Acute Physiology and Chronic Health Evaluation II score, and concomitant administration of vasopressors/inotropes or analgesics/sedatives were significant factors associated with the occurrence of blood pressure drop events after intravenous propacetamol administration. Intravenous propacetamol can induce hemodynamic changes and blood pressure drop events in neurocritically ill patients. This study identified the risk factors for blood pressure drop events. On the basis of our results, judicious use of intravenous propacetamol is warranted for neurocritically ill patients with risk factors that make them more susceptible to hemodynamic changes.

Abstract 11613: Prognostic Implication of Early Drop in Systolic Blood Pressure During the First 48 Hours in Patients with Acute Heart Failure from REALITY-AHF Registry

Background: Although it has been suggested that excessive drop in systolic blood pressure (SBP) in the acute phase of acute heart failure potentially has a negative impact on prognosis, the association between changes in SBP during acute phase and prognosis has yet to be clarified. Methods and Results: This is the sub-analysis of REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) study, which was a prospective, multicenter, observational registry which registered patients with acute heart failure admitted through emergency department (ED). Peak drop in SBP was defined as the difference between the baseline SBP values and the lowest values during the first 48 hours of hospitalization. After ED arrival, SBP was measured at the time of admission, 90 minutes, 6 hours, 24 hours, and 48 hours of ED admission. Patients were divided into three groups according to the value of peak SBP drop . A total of 1,656 patients were included in our study. Patients with greater peak SBP drop group was associated with higher baseline SBP and vasodilator use after admission. Cox proportional hazard analysis demonstrated greater peak SBP drop (per 10mmHg decrease) was independently associated with 180-day (hazard ratio, 1.12; 95% confidence interval, 1.01–1.23; P=0.027) and 1-year (hazard ratio, 1.12; 95% confidence interval, 1.03–1.21; P=0.006) mortality even after adjustment for confounding factors including baseline SBP (Figure). Conclusions: Early drop in SBP during first 48 hours of hospitalization was associated with all-cause mortality in patients with acute heart failure.

Effect of the Mediterranean diet on blood pressure in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials

Abstract Background It is unclear whether the Mediterranean diet (MedDiet) has a favorable effect on blood pressure (BP) levels because among randomized controlled trials (RCTs) investigating the MedDiet-mediated BP reduction there are significant methodological and clinical differences. Purpose The purpose of this study was to comprehensively assess the MedDiet BP-effect compared to the usual diet or another dietary intervention (e.g. low-fat diet) in adults with and without hypertension, accounting for different confounders. Methods We systematically searched Medline and the Cochrane Collaboration Library databases and identified 35 RCTs (13,943 participants). Random-effects model was used to calculate the mean attained systolic BP (SBP) and diastolic BP (DBP) differences during follow-up. Subgroup and meta-regression analyses were also conducted. Results Compared to the usual diet and all other active intervention diets the MedDiet reduced SBP and DBP (difference in means: −1.5 mm Hg; 95% CI: −2.8, −0.1; P=0.035, and −0.9 mm Hg; 95% CI: −1.5, −0.3; P=0.002, respectively). Compared only to the usual diet the MedDiet reduced SBP and DBP, while compared to all other active intervention diets or only to the low-fat diet the MedDiet did not reduce SBP and DBP. The MedDiet reduced DBP levels to a higher extent in trials with a mean baseline SBP ≥130 mm Hg, while both SBP and DBP were reduced more in trials with a mean follow-up period ≥16 weeks. The quality of evidence was rated as moderate for both outcomes according to the grading of recommendations, assessment, development and evaluation (GRADE) approach. Conclusions The adoption of the MedDiet was accompanied by a relatively small, but yet significant BP reduction, while higher baseline SBP levels and longer follow-up duration enhanced the BP-lowering effect of the intervention Funding Acknowledgement Type of funding sources: None.

Predictors of futile recanalization in patients undergoing endovascular treatment in the DIRECT-MT trial

BackgroundFutile recanalization—when patients have a successful recanalization but fail to achieve a satisfactory functional outcome— is a common phenomenon of endovascular treatment of acute ischemic stroke (AIS). The present study...

Evaluation of Systolic Blood Pressure, Use of Aspirin and Clopidogrel, and Stroke Recurrence in the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke Trial

Elevated systolic blood pressure (SBP) after acute ischemic stroke and transient ischemic attack (TIA) is associated with future stroke risk. To explore the association of dual antiplatelet therapy (DAPT) with stroke recurrence among patients with acute ischemic stroke and TIA with or without elevated baseline SBP. This cohort study performed a post hoc subgroup analysis of the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, which was a multicenter trial conducted from 2010 to 2018 at 269 sites in 10 countries in North America, Europe, Australia, and New Zealand. Patients enrolled in POINT with available blood pressure and outcome data were included in this cohort. Statistical analysis was performed from November 2020 to January 2021. Baseline SBP less than 140 mm Hg vs greater than or equal to 140 mm Hg and the interaction term of SBP (<140 mm Hg vs ≥140 mm Hg) × treatment group (aspirin vs DAPT). The primary outcome was ischemic stroke during 90 days of follow-up. The statistical analysis fit Cox proportional hazards models adjusted for patient age, race, premorbid hypertension, diabetes, and final diagnosis of the qualifying event (stroke vs TIA). Among 4781 patients in the cohort, the mean (SD) age was 64.6 (13.1) years; 2142 (44.8%) were male individuals, 3487 (72.9%) were White individuals, and 266 (5.6%) had a primary outcome of ischemic stroke during follow-up. There were 946 patients (19.8%) with baseline SBP less than 140 mm Hg and 3835 (80.2%) with SBP greater than or equal to 140 mm Hg. The interaction term (SBP × treatment) was significant (P for interaction = .03). In the subgroup of patients with SBP less than 140 mm Hg, the hazard ratio (HR) of DAPT vs aspirin alone for ischemic stroke was 0.36 (95% CI, 0.18-0.72; P = .004), whereas the HR in the subgroup with SBP greater than or equal to 140 mm Hg was 0.79 (95% CI, 0.60-1.02; P = .08). When evaluating the outcome of ischemic stroke within 7 days of randomization, the interaction term was significant (P for interaction = .02), and the HR for patients with DAPT with SBP less than 140 mm Hg was 0.19 (95% CI, 0.07-0.55; P = .002). In the POINT trial, patients with SBP less than 140 mm Hg at presentation received a greater benefit from 90 days of DAPT than those with higher baseline SBP, particularly for reduction of early ischemic stroke recurrence. Additional research is needed to replicate these findings and potentially test whether mild SBP reduction and DAPT within 12 hours of stroke onset lowers early risk of stroke recurrence.

NON-INTERVENTIONAL WEIGHT CHANGES AFFECT SYSTOLIC BLOOD PRESSURE IN NORMOTENSIVE INDIVIDUALS

Objective: The association between obesity and hypertension is well established. Weight loss has been shown to reduce blood pressure (BP) among hypertensive patients. Nevertheless, the effect of weight changes on BP in normotensive individuals is less clear. We explored the association between non-interventional weight alterations and BP changes in a large cohort of normotensive adults. Design and method: a retrospective analysis of normotensive individuals, between 2010–2018. All weight changes were non-interventional. Body mass index (BMI) and BP were measured annually. Patients were divided according to the change in BMI between visits: reduction of more than 5% (’large reduction’), between 2.5–5% (’moderate reduction’), reduction of less than 2.5% or elevation of less than 2.5% (’unchanged’), elevation between 2.5–5% (’moderate increase’) and elevation of more than 5% (’large increase’). The primary outcome was the change in systolic BP (SBP) between the visits. Results: The final analysis included 8,723 individuals. 20% of the subjects reduced their BMI by at least 2.5% and 24.5% increased their BMI by more than 2.5%. ’High reduction’ inferred an absolute decrease of 3.6 mmHg in SBP, while ’large increase’ resulted in an absolute increase of 1.9 mmHg in SBP. The proportion of individuals with at least 10 mmHg decrease in SBP progressively declined according to the relative decrease in BMI, and the proportion of patients with at least 10 mmHg increase in SBP progressively increased. This effect was more pronounced in individuals with higher baseline SBP. Conclusions: Among normotensive adults, modest non-interventional weight changes may have significant effects on SBP.

Non-interventional weight changes affect systolic blood pressure in normotensive individuals.

The association between obesity and hypertension is well established. Weight loss has been shown to reduce blood pressure (BP) among hypertensive patients. Nevertheless, the effect of weight changes on BP in normotensive individuals is less clear. The author explored the association between non‐interventional weight alterations and BP changes in a large cohort of normotensive adults. This is a retrospective analysis of normotensive individuals, between 2010 and 2018. All weight changes were non‐interventional. Body mass index (BMI) and BP were measured annually. Patients were divided according to the change in BMI between visits: reduction of more than 5% ("large reduction"), between 2.5% and 5% ("moderate reduction"), reduction of <2.5% or elevation of <2.5% ("unchanged"), elevation between 2.5% and 5% ("moderate increase"), and elevation of more than 5% ("large increase"). The primary outcome was the change in systolic BP (SBP) between the visits. The final analysis included 8723 individuals. 20% of the patients reduced their BMI by at least 2.5% and 24.5% increased their BMI by more than 2.5%. "High reduction" inferred an absolute decrease of 3.6 mmHg in SBP, while "large increase" resulted in an absolute increase of 1.9 mmHg in SBP. The proportion of individuals with at least 10 mmHg decrease in SBP progressively declined according to the relative decrease in BMI, and the proportion of patients with at least 10 mmHg increase in SBP progressively increased. This effect was more pronounced in individuals with higher baseline SBP. Among normotensive adults, modest non‐interventional weight changes may have significant effects on SBP.

Incidence and factors associated with prescribing renin-angiotensin-system inhibitors in adult idiopathic nephrotic syndrome: A nationwide cohort study.

Angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are prescribed as conservative or adjunctive therapies for adult idiopathic nephrotic syndrome. However, studies on real‐world practice patterns are scarce. This study aimed to examine the prevalence and incidence of ACEI/ARB prescription and their associated factors. This nationwide cohort study included adult Japanese patients with idiopathic nephrotic syndrome including minimal change disease (MCD), membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), and others. The outcomes were the prevalence of ACEI/ARB prescription at baseline (date of renal biopsy or date of immunosuppressant initiation) and at 2 months after baseline. Of the 326 eligible patients, 122 (37.4%) had already been prescribed ACEIs/ARBs. Of the remaining 204 patients, 67 (32.7%) were newly prescribed within the 2‐month period. MN/FSGS (vs. MCD, adjusted odds ratio [AOR]: 4.96 [95% confidence interval {CI} 2.53–9.72] and 3.95 [95% CI 1.61–9.66], respectively), higher age (per 1‐yr increase, AOR: 1.02 [95% CI 1.00–1.04]), other hypertensive agents (AOR: 2.18 [95% CI 1.21–3.92]), antidiabetic drug (AOR: 6.57 [95% CI 1.77–24.4]) were associated with a higher prevalence of ACEI/ARB prescription. MN (vs. MCD, AOR: 6.00 [95% CI 2.57–14.0]) and higher baseline systolic blood pressure (SBP) (per 10‐mmHg increase, AOR: 1.36 [95% CI 1.09–1.70]) were associated with a higher incidence of ACEI/ARB prescription. On average, incidence of ACEI/ARB prescription increased from 19.2% to 40.8% as baseline SBP increased from 100 to 140 mmHg. Thus, Japanese nephrologists are likely to prescribe ACEIs/ARBs for nephrotic patients with MN or high baseline SBP, even below the hypertensive range.