History Of Major Cardiovascular Events Research Articles

#3094 Prevalence and risk factors for progression and mortality in patients with advanced chronic kidney disease

Abstract Background and Aims Chronic kidney disease (CKD) is a growing health concern worldwide. Prevalence and risk factors for its progression are highly relevant, given that Portugal has the highest incidence and prevalence rates of dialysis in Europe. With this study, we aimed to estimate the prevalence of patients with CKD stage 4 and 5 in a tertiary center in Portugal, as well as to evaluate risk factors for progression and mortality. Method We evaluated all patients followed in the Nephrology outpatient clinic at a tertiary center in Portugal during the year 2021, and selected those with CKD stage 4 and stage 5, based on estimated glomerular filtration rate (eGFR) using CKD-EPI formula. Primary endpoints were CKD progression or mortality after 1 year of follow-up. Progression was defined as initiating renal replacement therapy (RRT) or transition from stage 4 to stage 5 CKD. Results We evaluated 4381 patients, of which 1083 (24.7%) were included with CKD stage 4 (n = 856) and CKD stage 5 (n = 227). There was a predominance of males (52.7%), with a mean age of 74.6 ± 12.5 years. We observed a high prevalence of hypertension (94%), diabetes mellitus (46.2%), dyslipidemia (81%), heart failure (34%) and past history of major cardiovascular events (21%). At one year follow-up 108 patients died, 116 lost follow-up, and 256 (26.5%) had CKD progression, of which 179 (18.5%) initiated renal replacement therapy. 33.5% of patients initiating dialysis had a definitive access, mostly in stage 5 CKD (40 vs. 25%, p < 0.05). Risk factors for progression (versus stability) in univariate analysis were male gender (64.5 vs. 50.1, p < 0.001), younger age (68 vs. 75 years, p < 0.001) and lower eGFR (16 vs. 22 mL/min). Progression occurred in 51% of stage 5 CKD vs. 26.5% stage 4. Worse laboratory control of anemia, hyperparathyroidism, acidosis, and albuminuria (urinary albumin/creatinine ratio 1242 vs. 302 mg/g, p < 0.01) were identified risk factors for progression. In multivariate analysis, predictors for CKD progression were younger age (OR: 0.97, CI: 0.95-0.99, p = 0.02), male gender (OR: 2.82, CI: 1.43-5.57, p = 0.003), lower eGFR (OR: 0.80, CI: 0.74-0.86, p < 0.001), lower hemoglobin levels (OR: 0.62, CI: 0.48-0.79, p < 0.001), and proteinuria (OR: 1.44, CI: 1.22-1.53, p 0.003). Regarding mortality, no statically significant differences were observed between CKD stage 4 and 5, and in multivariate analysis the only independent risk factors for death were older age and heart failure, which increased 3.4 times mortality risk (OR: 3.40, CI: 1.48-7.83, p = 0.04). Conclusion Our data show a high prevalence of CKD and traditional risk factors, with an annual progression rate of 26.5%. Anemia and proteinuria were identified as modifiable risk factors for progression. In older patients with heart failure, the mortality risk was found to be higher than progression risk, highlighting the importance of cardiovascular protection and consideration of conservative management in this particular subset of patients.

Diabetes mellitus and the progression of non-alcoholic fatty liver disease to decompensated cirrhosis: a retrospective cohort study.

To determine the incidence of decompensated cirrhosis and associated risk factors in people hospitalised with non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) with or without cirrhosis. Retrospective cohort study; analysis of linked Queensland Hospital Admitted Patient Data Collection, Queensland Registry of Births, Deaths and Marriages, and Queensland Cancer Register data. Queensland residents aged 20 years or older admitted to Queensland hospitals with NAFLD/NASH during 1 July 2009 - 31 December 2018. Progression to decompensated cirrhosis (ascites, hepatic encephalopathy, or oesophageal variceal bleeding). We included data for 8006 patients in our analysis (10 082 admissions), including 4632 women (58%) and 2514 people with diabetes mellitus (31%); median follow-up time was 4.6 years (interquartile range, 2.7-7.2 years). Three hundred and fifty-one people (4.4%) experienced decompensated cirrhosis during the follow-up period. Of the 6900 people without cirrhosis, 4.5% (95% confidence interval [CI], 3.6-5.7%) experienced decompensated cirrhosis within ten years (mean, 0.5% per year; 95% CI, 0.4-0.6% per year); risk of progression was greater for people aged 70 years or older (v 20-39 years: adjusted hazard ratio [aHR], 4.7; 95% CI, 2.0-11.0) and those who had extrahepatic cancers (aHR, 5.0; 95% CI, 3.0-8.2), history of major cardiovascular events (aHR, 1.9; 95% CI, 1.2-3.1), or diabetes mellitus (aHR, 2.8; 95% CI, 2.0-3.9). Of the 1106 people with cirrhosis, 32.4% (95% CI, 27.2-38.3%) experienced decompensated cirrhosis within ten years (mean, 5.5% per year; 95% CI, 4.8-6.3% per year); risk of progression was greater for those with portal hypertension (aHR, 1.8; 95% CI, 1.3-2.7), extrahepatic cancer (aHR, 1.8; 95% CI, 1.1-2.9), or diabetes mellitus (aHR, 1.5; 95% CI, 1.1-2.0). Compared with people who had neither cirrhosis nor diabetes mellitus, the risk of decompensation was greater for people with cirrhosis (aHR, 10.7; 95% CI, 7.6-15.0) or cirrhosis and diabetes mellitus (aHR, 14.4; 95% CI, 10.1-20.6). Given the greater risk of progression to cirrhosis decompensation in people with diabetes mellitus, a disorder common in people with NAFLD/NASH, identifying advanced fibrosis and providing appropriate treatment for averting disease progression is vital.

#2667 CARDIOVASCULAR AND MORTALITY RISKS IN YOUNG HEALTH SCREENING EXAMINEES WITH MARGINAL ESTIMATED GLOMERULAR FILTRATION RATE

Abstract Background and Aims Additional evidence is necessary to interpret the kidney function parameters in young adults, particularly in those with marginal eGFR values. We aimed to study the clinical significance of marginal eGFR values in large-scale general health screening examinees of young age (20-39 years). Method We performed a nationwide retrospective cohort study using the health screening database of South Korea. We included young adults aged 20-39 years without a history of major cardiovascular events (MACE) or end-stage kidney disease who underwent a nationwide health screening in 2012. The study exposure was eGFR categorized into 15 mL/min/1.73 m2 intervals, with a reference group and a main group of interest: < 30, 30-45, 45-60, 60-75, 75-90 (reference), 90-105, 105-120, and ≥ 120 mL/min/1.73 m2. The risks of all-cause mortality and MACE were calculated using Cox regression analysis adjusted for various clinicodemographic characteristics. Results In total, 3,132,409 young adults were included in this study. During a median follow-up of 7.3 years, marginal eGFR (60-75 mL/min/1.73 m2) was not significantly associated with a higher risk of all-cause mortality [adjusted HR 0.92 (0.86-0.99)]. The results were similarly identified for the MACE outcome [adjusted HR 1.01 (0.94-1.07)]. On the other hand, those with presence of albuminuria, even the marginal eGFR range was significantly associated with higher risks of all-cause mortality [adjusted HR 1.52 (1.01-1.29)] and ischemic stroke [adjusted HR 1.73 (1.10-2.74)]. Conclusion Marginal eGFR alone was not associated with higher risks of all-cause mortality and MACE in general young adults. However, in those with albuminuria, the mortality risk was higher even in eGFR of 60-75 mL/min/1.73 m2.

Patterns of care of subjects with type 1 and type 2 diabetes according to their cardiovascular risk

AIM OF THE STUDY To explore the distribution by cardiovascular risk groups according to the classification promoted by the ESC (European Society of Cardiology) of subjects with type 1 (T1D) and type 2 (T2D) diabetes cared for by Italian diabetologists and to describe the quality indicators of care, with particular regard to cardiovascular risk factors. DESIGN AND METHODS The study is based on data extracted from electronic medical records of patients treated at the 258 diabetes centers participating in the Annals AMD initiative and active in the year 2018. Patients with T1D or T2D were stratified by cardiovascular risk, in accordance with the recent ESC guidelines. General descriptive indicators and measures of intermediate outcomes, intensity/appropriateness of pharmacological treatment for diabetes and cardiovascular risk factors, presence of other complications and overall quality of care were evaluated. RESULTS Overall, 29,368 adults with T1D and 473,740 subjects with T2D were evaluated. Among subjects with T1D: 64.7% were at very high cardiovascular risk, 28.5% at high risk and the remaining 6.8% at moderate risk. Among subjects with T1D at very high-risk: 54.7% had retinopathy, 29.0% had albuminuria, 7.3% had a history of major cardiovascular event, 47.3% had organ damage, 48.9% had three or more risk factors, and 70.6% had a diabetes duration of over 20 years. Among subjects with T2D: 78.5% were at very high cardiovascular risk, 20.9% at high risk and the remaining 0.6% at moderate risk. Among those with T2D at very high risk: 39.0% had organ damage, 89.1% had three or more risk factors, 18.7% had a previous major cardiovascular event, 26,4% had retinopathy, 39.5% had albuminuria. With regard to the glucose-lowering drugs: the use of DPPIV-i increased markedly as cardiovascular risk increased; the use of secretagogues also increased and, although within low percentages, also the use of GLP1-RA tended to increase. The use of SGLT2-i is also still limited, and only slightly higher in subjects with very high cardiovascular risk. In both types of diabetes, the overall quality of care, as summarized by the Q score values, tended to be lower as the level of cardiovascular riskincreased. CONCLUSIONS The analysis of a large population such as that of the AMD Annals database allowed to highlight the characteristics and quality indicators of care of subjects with T1D and T2D in relation to cardiovascular risk classes. A large proportion of subjects appear to be at high or very high risk. Glucose-lowering drug therapies seem not to be adequately used with respect to the potential advantages in terms of reduction of cardiovascular risk of some drug categories (GLP1-RA and SGLT2-i) and, conversely, with respect to the potential risks related to the use of other pharmacological classes (sulfonylureas). Several actions are necessary to optimize care and improve the quality of care for both subjects with T1D and T2D. KEY WORDS type 1 diabetes; type 2 diabetes; cardiovascular risk; quality indicators of care.

Predictive Factors for Pre-operative Recurrence of Cerebrovascular Symptoms in Symptomatic Carotid Stenosis

Across stroke subtypes, carotid artery stroke carries the highest risk of recurrence. Despite initiation of best medical therapy (BMT), some patients suffer recurrent neurological events before undergoing carotid endarterectomy (CEA). The aim was to identify clinical predictors of early recurrent events in patients with symptomatic carotid stenosis (sCS) awaiting CEA on modern BMT. The Helsinki Carotid Endarterectomy Study 2 (HeCES2) is a cross sectional, longitudinal, prospective, and consecutive cohort study, which enrolled 500 symptomatic or asymptomatic patients with carotid stenosis scheduled for CEA in a tertiary stroke centre. Symptomatic patients were included for this analysis (n=324). Of all 324 patients with sCS, 39 (12%) had a recurrent cerebrovascular event at a median of six days after the index symptom: four had an ischaemic stroke (1.2%), 16 a hemispheric transient ischaemic attack (TIA; 4.9%), and 19 amaurosis fugax (AFX; 5.9%). The recurrence rate was 4.0 % (n=13) within 48h and 9.9% (n=32) within two weeks. None of the patients (n=108) presenting with ocular symptoms (AFX or retinal artery occlusion) suffered recurrent hemispheric TIA or stroke. In Cox regression analysis, comorbid hypertension (hazard ratio [HR] 6.58, 95% confidence interval [CI] 1.33-32.47), hemispheric TIA as the index symptom (HR 3.42, 95% CI 1.70-6.90), the number of prior attacks (HR 1.12, 95% CI 1.08-1.15), and high low density lipoprotein/high density lipoprotein ratio (HR 1.51, 95% CI 1.09-2.11) were independently associated with an increased risk of recurrent event, while a history of major cardiovascular event (HR 0.33, 95% CI 0.11-0.96) and high serum fibrinogen level (HR 0.59, 95% CI 0.41-0.86) were associated with a decreased risk. More than every tenth patient with sCS experienced an early recurrent cerebrovascular event prior to scheduled CEA, despite optimal medication. However, stroke recurrence was lower than in earlier observational studies, which could be explained by improved care pathways, more aggressive medication, and expedited CEA. All recurrent strokes occurred in patients initially presenting with minor stroke.

Factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events

BackgroundThe World Health Organization recommends consumption of a minimum of 400 g of fruits and vegetables per day for prevention of cardiovascular disease. Low fruit and vegetable intake is associated with an increased risk of stroke by 11% and ischemic heart disease by 31%. The present study aims to explore factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events (myocardial infarction and stroke).MethodData for this cross-sectional study were collected as part of the study “Community Based Management of Hypertension in Nepal” initiated in the Lekhnath Municipality in 2013. Demographic and nutrition information were collected using the WHO STEPwise approach to a surveillance tool. Descriptive statistics identified the frequency and percentage of fruit and vegetable intake. A Chi-square test examined the association between fruit and vegetable intake and history of self-reported cardiovascular events, socio-demographic and cardiovascular risk factors. Binary logistic regression analysis identified odds ratio with 95% confidence intervals between fruit and vegetable intake and history of self-reported cardiovascular events.ResultsThe mean and median intake of fruits and vegetables were 3.3 ± 0.79 and 3 servings respectively. Of the 2815 respondents, 2% (59) reported having a history of major cardiovascular events. The adjusted odds of having a history of major cardiovascular events was 2.22 (95%CI, 1.06–4.66) for those who consumed < 3 servings compared to those who consumed ≥3 servings of fruits and vegetables a day.ConclusionThe respondents who consumed < 3 servings of fruits and vegetables a day had higher odds of a history of major cardiovascular events in comparison to those who consumed ≥3 servings. This finding may carry a policy recommendation for those settings where the current recommendation of having ≥5 servings of fruits and vegetables a day is not possible. Our findings also suggest that surviving a major cardiovascular event was not enough in itself to modify nutritional intake. As many Nepali consumes low amount of fruits and vegetables, appropriate measures should be taken to increase this consumption to prevent cardiovascular morbidity and mortality.

Salivary Biomarkers of Oral Inflammation Are Associated With Cardiovascular Events and Death Among Kidney Transplant Patients

BackgroundTriggering receptors expressed on myeloid cells (TREMs) and their ligand, peptidoglycan recognition protein 1 (PGLYRP-1), have been detected in secretions from patients with inflammatory diseases, which may lead to the formation of atherosclerotic plaques. Here, we aimed to analyze the association between salivary concentrations of soluble (s)TREM-1 and PGLYRP-1 with death and cardiovascular disease before and after kidney transplantation. Materials and MethodsSaliva samples from 53 patients on dialysis were collected during their regular dental evaluation before treatment and after kidney transplantation. Oral inflammatory burden was assessed from panoramic radiographs and full-mouth dental examination. Demographic data, graft function, patient survival, and history of major cardiovascular events (MACEs) were retrieved from hospital records. ResultsSalivary sTREM-1 before transplantation increased the odds for death and MACE. In addition, PGLYRP-1 increased the odds for MACE before transplantation. After transplantation, neither salivary sTREM-1 nor PGLYRP-1 increased the odds for death or MACE, probably because of the previous eradication of oral inflammatory foci. None of the studied biomarkers correlated with kidney transplant function. ConclusionsSalivary sTREM-1 and PGLYRP-1 before transplantation were associated with MACE and death. The utility of salivary proinflammatory biomarkers for risk stratification in kidney transplant candidates requires further investigation.

Reduced risk for chronic kidney disease after recovery from metabolic syndrome: A nationwide population-based study.

BackgroundMetabolic syndrome (MetS) is linked to various chronic comorbidities, including chronic kidney disease (CKD). However, few large studies have addressed whether recovery from MetS is associated with reduction in the risks of such comorbidities.MethodsThis nationwide population-based study in Korea screened 10,664,268 people who received national health screening ≥ 3 times between 2012 and 2016. Those with a history of major cardiovascular events or preexisting CKD were excluded. We classified study groups into four, according to the course of MetS state, as defined by the harmonizing criteria. The main study outcome was incidental CKD (estimated glomerular filtration rate < 60 mL/min/1.73 m2 which was persistent until the last health exams). The study outcomes were investigated using multivariable logistic regression analysis, which was adjusted for clinical variables and the previous severity of MetS.ResultsFour study groups included 6,315,301 subjects: 4,537,869 people without MetS, 1,034,605 with chronic MetS, 438,287 who developed MetS, and 304,540 who recovered from preexisting MetS. Those who developed MetS demonstrated higher risk of CKD (adjusted odds ratio [OR], 1.26 [1.23-1.29]) than did those who did not develop MetS. In contrast, MetS-recovery was associated with decreased risk of CKD (adjusted OR, 0.84 [0.82-0.86]) than that in people with chronic MetS. Among the MetS components, change in hypertension was associated with the largest difference in CKD risk.ConclusionReducing or preventing MetS may reduce the burden of CKD on a population-scale. Clinicians should consider the clinical importance of altering MetS status for risk of CKD.

Same-day discharge on laparoscopic Roux-en-Y gastric bypass patients: an outcomes review.

The objective of this research was to study safety and outcomes in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) on an ambulatory outpatient basis. As the prevalence of morbid obesity increases, more patients are opting for surgical weight loss as a means to combat their chronic disease. There are several studies demonstrating the safety and feasibility of select patients undergoing LRYGB on a 23-h outpatient basis, but few studies exist regarding the safety and efficacy of these procedures being performed on an ambulatory outpatient basis. A retrospective review was completed on all patients who underwent a laparoscopic gastric bypass procedure from 2008 to 2018 at a single outpatient ambulatory surgery center. Median BMI was 46.7kg/m2. Inclusion criteria included age > 18 and < 65, ASA class less than 3, completion of a bariatric surgery preparation program, no history of major cardiovascular events, and no prior major open abdominal operations. Exclusion criteria included males > 55years, BMI > 55 for men, and BMI > 60 for women. Operations included primary LRYGB procedures. We determined 30-day post-operative morbidity and mortality for all patients. There were 398 patients who underwent a LRYGB on an ambulatory basis. After thorough chart review, a total of 362 patients were included. The majority were women (315, 87%). The median age was 42 (range 19-65). Seven (1.93%) patients were directly admitted to the hospital, while 13 (3.59%) patients were admitted to the hospital after initial discharge. There were 3 (0.83%) leaks, 4 (1.11%) bleeds requiring transfusion, no wound infections, 1 (0.28%) obstruction, one (0.28%) venous thrombotic event and/or pulmonary embolism, and 9 (2.49%) reoperations. There were zero deaths. This study demonstrates that laparoscopic Roux-en-Y gastric bypass is both feasible and safe when performed on select patients on an ambulatory outpatient basis.

Predicting of the risk of major cardiovascular events developing in patients with chronic obstructive pulmonary disease in combination with renal dysfunction

Aim.To identify the independent predictors of major cardiovascular events (MCVE) in patients with chronic obstructive pulmonary disease (COPD) in combination with the early stages of chronic kidney disease (CKD).Material and methods.The study included 279 patients with GOLD 2014 2-4 severity COPD. At the first stage, we surveyed the potential risk factors for MCVE and the level of 25-OH vitamin D. After 12 months, all patients had a history of MCVE. Patients were divided into 2 groups: those who had MCVE during the previous 12 months, and without them. The risk factors for the development of MCVE, significantly differing between the two groups according to the results of a univariate analysis, were included in the logistic regression to determine reliable independent predictors of MCVE. We also studied ROC curve to identify the prognostic cut-off point.Results.The group of patients who had MCVE consisted of 37 people with 40 MCVE cases. In patients with COPD in combination with the early stage of CKD, the level of vitamin D, the frequency of exacerbations in the preceding 12 months, the glomerular filtration rate (GFR), the score of PROCAM scale significantly influence to the development of MCVE. For the constructed regression equation, the determination coefficient is defined as R2=0,76, Hosmer-Lemeshov criterion =0,8. The area under the curve for the model =0,95. According to the results of the ROC analysis, it was found that independent predictors of MCVE in a 12-month period in patients with COPD and CKD (early stages) are: the sum of PROCAM scale points &gt;56, the frequency of COPD exacerbations for the previous 12 months &gt;2, GFR &lt;80 ml/min/1,73 m2, the level of vitamin D &lt;34,3 ng/ml.Conclusion.Independent predictors of MCVE in a 12-month period in patients with COPD and the early stages of CKD are: the score of the PROCAM scale &gt;56, the frequency of exacerbations of COPD in the preceding 12 months &gt;2, GFR &lt;80 ml/min/1,73 m2, the level of vitamin D &lt;34,3 ng/ml.

Improved oral hygiene care attenuates the cardiovascular risk of oral health disease: a population-based study from Korea.

Oral health problems such as periodontal disease, dental caries, and tooth loss have been suggested to have associations with cardiovascular disease. This study aimed to evaluate whether oral hygiene behaviour can alleviate cardiovascular risk associated with oral health status using a nationwide population-based cohort. The data of 247696 healthy adults aged 40 years or older who underwent an oral health screening programme and had no history of major cardiovascular events were extracted from the National Health Insurance System-National Health Screening Cohort. After a median follow-up of 9.5 years, 14893 major cardiovascular events occurred including cardiac death, myocardial infarction, stroke, and heart failure. The risk of cardiovascular events was higher when a subject had periodontal disease, a higher number of dental caries, or more tooth loss. Performing one more tooth brushing a day was associated with a 9% significantly lower risk of cardiovascular events after multivariable adjustment. Regular dental visits (once a year or more) for professional cleaning were also shown to reduce cardiovascular risk by 14%. Improved oral hygiene behaviours were shown to attenuate the cardiovascular risk originating from periodontal disease, dental caries, and tooth loss. Oral hygiene care such as frequent tooth brushing and regular dental visits for professional cleaning reduced the risk of future cardiovascular events in healthy adults. This study also suggests that improved oral hygiene behaviour may modify the association between oral health and cardiovascular diseases.

A REAL WORLD MANAGEMENT OF OSTEOARTHRITIS (OA) KNEE PATIENTS WHO UNDERGO TOTAL KNEE REPLACEMENT – A RETROSPECTIVE STUDY IN THAILAND. (ARMOR STUDY)

Background: In Thailand. Total knee replacement (TKA) is a common clinical intervention to manage patients with OA (osteoarthritis). Public and private hospitals tend to exhibit different patients of TKA use. Hence, knowledge with regard to TKA practice patterns, use and treatment outcomes in different hospitals in Thailand will improve the understanding of clinical management of OA and patient care. Objectives: The primary objective of the study was to examine the patterns of pain management during pre-operative, hospital admission for TKA, and postoperative periods (surgery to 3 months after discharge) for patients receiving TKA in public and private hospitals. The data were collected from various hospitals and subjected to analysis. Methods: This retrospective observational multi-center chart review study was conducted in public (n=2) and private (n=2) hospital in Thailand. A total of 220 patients diagnosed with knee OA (ICD-10 code, M17.0 and 17.1) who had undergone TKA were included in the study. The estimated ratio of patients from public and private hospitals was 1:1. Patient medical charts were accessed with the Ethics Committee’s approval. De-identified patient data were extracted from the chart and entered into a paper Case Report Form (CRF). Patients with history of major cardiovascular events and bilateral total knee replacement were excluded from the study. Results: At clinical baseline, cyclooxygenase-II (COX-II) inhibitors followed by traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) were the preferred drug classes for pain management irrespective of hospital type or age group. At operation, use of pain control drugs was comparable between public and private hospitals. The use of concomitant drugs such as antithrombotic agents was observed to be frequent in both the hospital types and different age groups. After surgery, use of opioids was the highest among other drug classes followed by COX-II inhibitors and tNSAIDs; however, the use of opioids decreased faster daily compared with COX-II inhibitors which remained constant until 4 days after surgery. Among discharge pain control medications, analgesics and opiods were used extensively followed by COX-II inhibitors; however, the use of NSAIDs was very limited because of associated complications. During the follow-up period, opiods were the most commonly prescriped drug class in both hospital types; use of COX-II inhibitors was significantly higher in private hospitals The same trend of drug use was observed by age group (both &gt; 70 and &lt; 70 years of age). The proportion of patients with complications was observed more in public hospitals as compared with private settings. In the present study, patients receiving COX-II-inhibitors combined with other pain control medications reported lower pain scored than average after surgery. The clinical outcome distribution among patients receiving multiple pain control drugs during discharge was observed to be better compared with other combined regimens or analgesics alone. Conclusion: Pain management is one of the most important and challenging aspects of TKA. The patterns of pain management during pre-operative, during operation and postoperative stages differed. The use of COX-II inhibitors followed by NSAIDs was observed to be higher in the pre-operative stage, while use of opioids was higher after surgery and follow-up period compared with COX-II inhibitors

FACTORS ASSOCIATED WITH AN INCREASED SYSTOLIC BLOOD PRESSURE VISIT- TO-VISIT VARIABILITY IN A TERTIARY HEALTH CARE CENTER

Objective: Identify factors associated with an increased systolic blood pressure visit to visit variability in a “real-life” setting. Design and method: The study was observational, and retrospective. We included 2436 hypertensive outpatients, followed at our tertiary health care center, who had at least 8 visits with blood pressure readings. Epidemiological, clinical and therapeutic data were extracted and analyzed. Systolic blood pressure visit to visit variability was defined as the standard deviation around the mean systolic blood pressure of the 8 recordings. Results: The mean age of the population was 63.7 ± 10.9 years, and 55.7% of the patients were men. The proportions of diabetes, smoking, dyslipidemia and history of major cardiovascular events were 32.4%, 28.6%, 39.9% and 22.6% respectively. The mean blood pressure was 157.2 ± 11.7 / 90.8 ± 8.3 mmHg. The proportions of patients receiving one, two, three or more antihypertensive drugs at time of inclusion were 19.6%, 59.4% and 21% respectively. We found that age, systolic blood pressure, left ventricular hypertrophy, low eGFR, use of diuretics and use of beta-blockers were significantly associated with an increased systolic blood pressure variability. In a multiple regression analysis, the remaining independent factors were: age (p = 0.001), low eGFR (p = 0.003), use of diuretics (p = 0.0001) and treatment with beta-blockers (p = 0.0001). Conclusions: Among factors affecting blood pressure visit to visit variability in our hypertension unit, the most deleterious are related to the type of drug prescribed, suggesting that limiting the use of these medications, at least in the first step, could result in a risk reduction of cardiovascular events linked to blood pressure visit to visit variability.

PP.21.05] PREVALENCE OF ASYMMETRICAL BLOOD PRESSURE AND ITS ASSOCIATION WITH CARDIOVASCULAR EVENTS IN UNCONTROLLED HYPERTENSIVE PATIENTS

Objective: Estimate the prevalence of asymmetrical blood pressure (BP) in uncontrolled hypertensive patients in daily community medical practice, and analyze its association with the occurrence of cardiovascular events. Design and method: Observational and descriptive cross sectional study conducted among 68 liberal and hospital cardiologists in the first term of 2016 in Tizi-ouzou and Bejaia areas (Algeria). The investigation focused on hypertensive patients treated with a combination of 2 or 3 antihypertensive drugs at a stable dose for at least 3 months. Uncontrolled hypertension was defined as BP superior or equal to 140 /90 mmHg under treatment. Asymmetrical BP was defined as a between-arm difference in systolic BP superior or equal to 15 mm Hg. Results: uncontrolled patients were included. The mean age of the population was 64 ± 11 years, with 56.4% of men. The proportions of diabetes, Dyslipidemia, persistent smoking, or history of major cardiovascular events were 34.5%, 41.7%, 16.2% and 23.6% respectively. Asymmetrical BP was present in 21.4% of the patients, and in a multiple regression analysis, was significantly associated with subclinical target organ damage [OR: 1.7 (1.3–1.9)], stroke [OR: 1.8 (1.2–2.3) and acute coronary syndrome [OR: 1.7 (1.4–2.5)]. Conclusions: asymmetrical BP is frequent in uncontrolled hypertensive patients and could help to identify patients at high cardiovascular risk.

PP.21.12

Objective: To estimate the frequency of beta-blockers use in the treatment of hypertensive patients receiving 2 or 3 drugs, and to identify the factors encouraging physicians to prescribe this pharmacological class. Design and method: The study was prospective, observational and descriptive, conducted among 60 liberal and hospital cardiologists in the year 2013 in Tizi-ouzou and Bejaia areas (Algeria). The investigation focused on hypertensive patients treated with a combination of 2 or 3 antihypertensive medications (angiotensin-converting enzyme inhibitor, antagonist of the angiotensin 2 receptor, diuretics, beta-blockers and central antihypertensive agents) at a stable dose for at least 3 months. Results: 772 patients were included. The mean age of the population was 66 ± 11 years and the sex ratio was 1.3. The diagnosis of hypertension was established, on average, since 10 ± 7.2 years. The proportions of diabetes, dyslipidemia, persistant smoking, and history of major cardiovascular events (acute coronary syndromes, stroke or peripheral arterial disease) were 37.5%, 41.7%, 13.3% and 27.6%, repectively. Beta-blockers were part of the combination of antihypertensive drugs in 376 patients (48.7%). Physicians reported prescribing this class due to ischemic heart disease in 31.6% of cases, atrial or ventricular rythm disorder in 20.7% of cases, and heart failure in 6.4% of cases. In the remaining cases (41.3%), none of these reasons has been mentionned. Conclusions: The frequency of beta-blockers use in the combination of antihypertensive drugs remains high in our population as it concerns a half of the patients. The presence of ischemic heart disease, heart rythm disorder and heart failure explains only 50% of these prescriptions.

Severe androgenetic alopecia as a proxy of metabolic syndrome in male psoriatic patients older than 59 years.

Whereas several studies have underlined the association between severe psoriasis and metabolic syndrome (MetS), the association of androgenetic alopecia (AGA) and MetS have yielded inconsistent results. To investigate the relationship between AGA and the components of MetS in a population of psoriatic male patients. A non-interventional, cross-sectional, multicenter study was conducted in France. A standardized questionnaire was completed, including information on components of MetS and other possible risk factors. MetS was defined in this study as a combination of three or more of the four components of MetS: waist circumference, hyperlipidemia, diabetes mellitus and hypertension. In addition, a standardized simplified Norwood classification limited into 5 grades (0-4) was used. In a total of 1073 male patients, hypertension, high waist circumference, diabetes mellitus and hyperlipidemia were observed in 28%, 59%, 11%, and 31%, respectively. In age-adjusted multivariate analysis, severe AGA (grade 3-4 versus grade 0) was associated with the presence of at least one component of MetS. By groups of age, a statistically significant association of severe AGA and MetS was demonstrated in patients over 59 years. Severe AGA was also associated with a first degree familial history of major cardiovascular event in patients older than 59 years. Our study, based on a simplified but stringent definition of MetS, confirmed the link between severe AGA and individual components of MetS in psoriatic patients. This argues for careful follow-up with regular screening in male psoriatic patients with severe AGA in order to early detect determinants of MetS.

Bariatric Surgery is Associated with a Reduced Risk of Mortality in Morbidly Obese Patients with a History of Major Cardiovascular Events

Although the safety of bariatric surgery in patients with established cardiovascular disease has been demonstrated, little is known about the mid- to long-term survival of these patients after surgery. We conducted a retrospective cohort study of bariatric surgical patients (n = 349) compared with morbidly obese surgical controls (n = 903). Data were obtained on all patients 40 to 79 years of age, from 1996 to 2008, with a diagnosis code of morbid obesity, a primary surgical procedure of interest, and a cardiovascular event history. Data sources were the statewide South Carolina UB92 inpatient hospitalization database and death records. The primary outcome was all-cause mortality. A total of 349 bariatric and 903 control patients with cardiovascular event histories were identified. Among bariatric patients, 19 deaths occurred in 986 person-years of follow-up versus 150 deaths among controls in 3138 person-years of follow-up. Unadjusted all-cause mortality was estimated at 7 ± 2 per cent at 5 years in bariatric patients compared with 19 ± 2 per cent (P < 0.001) in controls. Adjusting for age, comorbidities, and event history, the relative risk of mortality was reduced by 40 per cent in bariatric patients compared with controls [hazard ratios (95% confidence interval): 0.60 (0.36, 0.99)]. In patients with a history of cardiovascular events, bariatric surgery is associated with a significantly decreased risk of all-cause mortality.

Circulating Adiponectin: Associations with Risk Factors and the Reynolds Risk Score in Women without Prior Major Cardiovascular Events

Objective: Adiponectin may play an important role in the interplay between metabolic changes and cardiovascular risks. Our aim was to establish if plasma adiponectin can be used to detect the metabolic syndrome (MetS) in women without a history of major cardiovascular events and to evaluate its correlation with the global cardiovascular risk expressed by the Reynolds risk score (RRS). Methods: 148 consecutive women without a history of cardiovascular events with or without MetS have been investigated. Clinical risks factors as well as plasma levels of lipids, fasting glucose and adiponectin were determined. Results: As expected, circulating adiponectin was lower in women with MetS: 26.8 ± 20.4 versus 44.3 ± 26.7 μg/ml (p < 0.001) and inversely related to the number of MetS features (r = –0.33, p < 0.001). The latter was further associated with the total cardiovascular risk calculated using RRS (r = 0.49, p < 0.001). However, there was no relationship between circulating adiponectin and this score (r = –0.14, p = NS). Conclusions: Plasma adiponectin levels are significantly lower in women with MetS, but as a stand-alone tool plasma adiponectin may be of little value in the diagnosis MetS. Circulating adiponectin levels are not associated with the global cardiovascular risk calculated using RRS.

Improvement of cardiovascular risk factors in patients with type 2 diabetes after long‐term continuous subcutaneous insulin infusion

The effects of long-term continuous subcutaneous insulin infusion (CSII) on cardiovascular risk factors such as hyperglycaemia, dyslipidaemia, and proinflammatory cytokine levels have not been assessed so far in type 2 diabetes. We analysed the levels of HbA(1c), serum lipids, tumor necrosis factor alpha (TNF-alpha), and interleukin 6 (IL-6) at 0, 2, and 30 weeks after CSII in 15 patients with type 2 diabetes (mean age, 53.3+/-10.1 years; disease duration, 9.4+/-5.3 years) without previous history of major cardiovascular events. At week 30, CSII significantly lowered HbA(1c) by 5.0+/-0.9% compared to baseline (7.9+/-1.9%, p<0.001) and improved high-density lipoprotein cholesterol (HDLc; 1.09+/-0.16 at baseline vs 1.25+/-0.15 mmol/L at week 30; p<0.05) and low-density lipoprotein cholesterol (LDLc)/HDLc ratios (2.8+/-1.4 at baseline vs 2.2+/-0.9 at week 30; p<0.05). CSII also decreased the proportion of patients with dyslipidaemia at week 30. At baseline, TNF-alpha and IL-6 levels were up-regulated (2.65+/-4.04 and 2.82+/-1.81 pg/mL, respectively) compared to the normal control (p<0.01 and p<0.05, respectively); however, cytokine levels decreased significantly at week 30 (1.44+/-2.25 and 1.99+/-1.05 pg/mL, respectively; p=NS vs control). Long-term CSII alone decreased cardiovascular risk factors in poorly controlled type 2 diabetes, suggesting that the synchronization of sufficient insulin peaks with meal ingestion and continuous pulsatile infusion of basal insulin corrects metabolic derangements.