Outpatient Hypertension Clinic Research Articles

Factors associated with chronic kidney disease knowledge and preventive practices: An analytical cross-sectional study among patients with hypertension at Amana Regional Referral Hospital in Dar es Salaam, Tanzania.

Globally, Chronic kidney Disease (CKD) has become a significant public health concern, with sub-Saharan Africa being among the populations experiencing the highest rates. Managing CKD poses a significant challenge due to its health complications and associated high cost of care. Hypertension is one of the leading causes of CKD, responsible for the decline in kidney function in patients. Knowledge and lifestyle modifications are pivotal to the prevention and progression of CKD. In Tanzania, little is known regarding CKD knowledge and preventive practices among patients with hypertension. Therefore, this study aimed to assess context-specific factors associated with CKD knowledge and preventive practices among patients with hypertension at Amana Regional Referral Hospital in Dar es Salaam. An analytical cross-sectional study involving 184 patients was conducted at Amana Regional Referral Hospital. Patient were recruited at the outpatient hypertension clinic using simple random sampling in June and July 2022. Data analysis was conducted using IBM-SPSS Statistics version 25. Bivariate and multiple logistic regression analyses were performed to identify factors associated with knowledge and preventive practices related to CKD, with statistical significance set at a p-value < 0.05. The median CKD knowledge score was 13 (IQR: 9-16). Of the 184 respondents, 104 (56.5%) demonstrated high CKD knowledge. None of the sociodemographic factors were significantly associated with CKD knowledge. The median score for CKD preventive practices was 9 (IQR: 8-9), and 111 respondents (60.3%) had good practices. High CKD knowledge was significantly associated with good CKD preventive practices (AOR: 1.98; 95% CI: 1.08, 3.62; p = 0.027). A significant proportion of hypertensive patients in this study exhibited both high CKD knowledge and good preventive practices. The positive correlation between CKD knowledge and improved preventive practices highlights the importance of educational interventions to further enhance CKD knowledge among patients with hypertension.

Characteristics of the Basel Postpartum Hypertension Cohort (Basel-PPHT Cohort): An Interim Analysis.

Postpartum hypertension (PPHT) is hypertension that persists or develops after delivery and is a frequent cause of readmission, affecting 10% of pregnancies. This interim analysis aims to describe the cohort and to determine the feasibility and acceptance of a home-based telemonitoring management strategy (HBTMS) in PPHT patients. Enrollment at the University Hospital Basel began during the 2020 SARS-CoV-2 pandemic. Maternity-ward patients were screened for preexisting hypertension, hypertensive disorders of pregnancy, and de novo PPHT. In this pragmatic non-randomized prospective trial, the participants chose the HBTMS or standard of care (SOC), which consisted of outpatient hypertension clinic appointments. The HBTMS was a smartphone application or a programmed spreadsheet to report blood pressure (BP), followed by telephone consultations. Three months postpartum, the participants underwent a 24 h BP measurement and a blood, biomarker, and urine analysis. A total of 311 participants were enrolled between 06/20 and 08/23. The mean age was 34 (±5.3) years. The current pregnancy history demonstrated the following (≥1 diagnosis possible): 10% had preexisting hypertension, 27.3% gestational hypertension, 53% preeclampsia (PE), 0.3% eclampsia, 6% HELLP (hemolysis, elevated liver enzymes, and low platelets), and 18.3% de novo PPHT. A family history of cardiovascular disease and PE was reported in 49.5% and 7.5%, respectively. In total, 23.3% were high-risk for PE. A total of 68.5% delivered via c-section, the mean hospitalization was 6.3 days (±3.9), and newborn intrauterine growth restriction occurred in 21%. A total of 99% of the participants chose the HBTMS. This analysis demonstrated that the HBTMS was accepted. This is vital in the immediate postpartum period and pertinent when the exposure of hospital visits should be avoided.

SINGLE-PILL, TRIPLE ANTIHYPERTENSIVE THERAPY IN RURAL SUB-SAHARAN AFRICA: PRELIMINARY EXPERIENCE

Objective: Arterial hypertension is worldwide the leading modifiable cardiovascular risk factor. Beside life-style changes, strong evidence supports the efficacy of pharmacological treatment in reducing the complications of hypertension. International guidelines have recommended single-pill, low-dose combinations as initial treatment strategy. We investigated whether management of hypertension through this approach is feasible and effective in a rural sub-Saharan Africa setting. Design and method: Diagnosis of hypertension was established over three sets of blood pressure measurements: during a community-based, house-to-house screening in 2020 and in 2022, and at the hypertension outpatient clinic. Blood pressure measurements were performed according to the ESH recommendations by trained personnel, using a validated, oscillometric device OMRON M7 IT-HEM-7322-E. In 98 individuals diagnosed to have arterial hypertension, once-daily, single-pill combination of olmesartan, amlodipine, and hydrochlorothiazide was prescribed at a dose suitable to their blood pressure values and clinical characteristics. They were instructed on its administration and potential side effects and encouraged towards lifestyle modifications. Treatment regimen was adjusted, if needed, at each outpatient clinic visit scheduled after 4, 8, 12, and 16 weeks Results: 79 patients (aged 61 [53-70] years; median and interquartile range) strictly adhered to the treatment schedule, while overall 19 individuals dropped-out (aged 70 [65-80] years) because of different reasons. About 20% were tobacco smokers and nearly all consumed alcohol. Blood pressure was &lt;140/90 mm Hg after 4 weeks in 44 (56%), after 8 weeks in 62 (78%), after 12 weeks in 69 (87%), and after 16 weeks in 74 (94%) participants. Excellent tolerance was widely reported. Conclusions: Management of hypertension with once-daily, single-pill combination of olmesartan, amlodipine, and hydrochlorothiazide as initial treatment was feasible and effective also in a rural sub-Saharan setting, with very high rate of hypertension control in patients adherent to treatment. Our results provide real life evidence in favor of extensive implementation of single-pill combination therapy also in low- and middle-income countries where local Health Care Systems should include recommendation on their usage in national guidelines and should make them available also in rural and remote areas at low or no cost as reliable first-line treatment strategy

Body Mass Index (BMI) Is the Strongest Predictor of Systemic Hypertension and Cardiac Mass in a Cohort of Children.

Hypertension (HTN) is a well-established cardiovascular (CV) risk factor in adults. The presence of HTN in children appears to predict its persistence into adulthood. Early diagnosis of HTN is crucial to reduce CV morbidity before the onset of organ damage. The aim of this study is to investigate cardiac damage in HTN, its risk factors (RFs), and evolution. We conducted a prospective/retrospective study involving children referred to the Childhood Hypertension Outpatient Clinic. This study included clinical and echocardiographic assessments of cardiac morphology and function at three time points: enrollment (T0) and follow-up (T1 and T2). Ninety-two patients (mean age 11.4 ± 3 years) were enrolled. Cardiac eccentric and concentric hypertrophy were present in 17.9% and 9%, respectively, with remodeling in 10.5%. Overweight/obese subjects exhibited significantly higher systolic blood pressure (SBP), frequency of HTN, and body mass index (BMI) at T0 compared with patients with chronic kidney disease (CKD). SBP and BMI persisted more during follow-up. Normal-weight vs. overweight/obese patients were significantly more likely to have normal geometry. Positive correlations were found between BMI and left ventricular (LV) mass at T0, BMI and SBP at T0 and T1. Gender, BMI, SBP, and diastolic blood pressure (DBP) significantly predicted LV mass index (LVMI), but only BMI added significance to the prediction. During follow-up, the variation of BMI positively correlated with the variation of SBP, but not with LVMI. In our cohort, body weight is strongly associated with HTN and cardiac mass. Importantly, the variation in body weight has a more significant impact on the consensual variation of cardiac mass than blood pressure (BP) values. A strict intervention on weight control through diet and a healthy lifestyle from early ages might reduce the burden of CV morbidity in later years.

Systematic review/meta-analysis and a cross-sectional study to assess effects of potassium supplementation on the renin-angiotensin-aldosterone system (RAAS) and blood pressure

Abstract Introduction Nutritional medicine plays a key role in disease prevention and treatment, and we pharmacists must consider our contribution beyond our role in dispensing. Apart from the Dietary Approaches to Stop Hypertension (DASH) diet1, there is a paucity of data on the benefits of nutritional interventions in hypertension with no clear recommendation on potassium in the NICE guidelines. Potassium has been an area of interest in clinical medicine over the decades because of its effect on cardiovascular disease. However, its mechanism of action is poorly understood, and it is unclear it differs between different ethnic groups. Dietary potassium decreases blood pressure (BP) but can also stimulate aldosterone production2. However, the magnitude of potassium-dependent regulation of aldosterone secretion in humans is not fully characterised and it is not clear whether this is mediated by activation of the renin-angiotensin-aldosterone system (RAAS) as a result of a reduction in BP or other mechanisms. Aim To perform a (1) systematic review and meta-analysis of clinical trials assessing effects of potassium on plasma aldosterone and renin in adult individuals alongside a (2) cross-sectional multi-ethnic study to explore the relationship between potassium intake and aldosterone in hypertension. Methods (1) This study was carried out in accordance with PRISMA guidelines3. The full protocol can be found on the PROSPERO database. (2) Self-defined black or white hypertensives were recruited from the hypertension outpatient clinic at St. Thomas’ Hospital and had aldosterone, renin and a 24-hour urinary potassium collected. The systematic review and meta-analysis on already approved clinical trials and did not require ethnical approval. The cross-sectional study was approved by the local Research Ethics Committee in the UK and written informed consent was obtained from all patients. Results 6395 articles were retrieved, and 124 full-text articles were assessed for eligibility. 36 met the prespecified inclusion/exclusion criteria. Potassium supplementation caused a significant decrease in systolic BP (- 3.69 mmHg [-4.91, -2.46], P&amp;lt;0.001) and increase in serum potassium (+0.37 [0.23, 0.52] mmol/L, P&amp;lt;0.001). There was an increase in plasma aldosterone (standardised difference 0.414 [0.291, 0.537], P&amp;lt;0.001) but no effect on plasma renin activity (+0.033 [-0.07, 0.14], P=0.538]. Meta-regression showed a significant positive correlation between change in plasma aldosterone and change in serum potassium (P&amp;lt;0.001). (2) In 469 subjects (72% black), there was a positive association between the measured 24-hour potassium excretion and aldosterone in black (β = 0.200, P = 0.014) but not in white individuals (P = 0.531). Discussion/Conclusion Potassium supplementation increases plasma aldosterone but not renin. The increase in aldosterone correlates with the raise in serum potassium. In subjects with hypertension, potassium intake is related with aldosterone concentration only in black subjects. Overall, the data supports a RAAS-independent potassium regulation of aldosterone which could be particularly relevant in African origin subjects. Limitations: 1. the systematic review results could not be stratified by ethnicity because most of the studies were performed in Caucasian subjects, 2. Use of background therapy in some studies, variable doses of potassium supplementation and duration of supplementation.

POST HOC ERGO PROPTER HOC? NOT EVERYTHING THAT HAPPENS AFTER COVID-19 IS LONG COVID. OR, THE MANY MASQUERADES OF PHEOCHROMOCYTOMA

Objective: A seemingly endless list of symptoms and conditions are being labeled as long COVID or post-COVID syndrome, but not everything that happens after a COVID-19 episode can be attributed to it. We hereby present a clinical case in which pheochromocytoma was masquerading as long COVID. Design and method: Review of the patient's clinical record and the relevant literature. Results: A previously healthy, non-smoker, 57-year-old woman was admitted in October 2020 with fever, dyspnea and asthenia. She was diagnosed with SARS-CoV-2 bilateral bronchopneumonia and required oxygen therapy but not assisted ventilation or intensive care. Three months after discharge the patient was asymptomatic but in the two following years she progressively developed symptoms of confusion, dizziness, inability to concentrate, gait instability, tachycardia, palpitations, anxiety and insomnia. The syndrome was labeled as post-COVID and in March 2022 began treatment with alprazolam and propranolol. Subsequently she complained of severe non-pulsatile holocranial headache accompanied by vertigo, nausea and skin pallor. In October 2022 she was admitted in Emergency Care with a BP reading of 226/118 mmHg, HR 132 bpm, ECG: sinus rhythm without repolarization anomalies. She was referred to our Outpatient Hypertension Clinic for workup of suspected secondary hypertension. Physical exam: BMI 27.3 kg/m2, BP 156/94 mmHg, FC 112 lpm, normal cardiopulmonary auscultation, no murmurs or oedema. Lab: Plasma glucose, ionogram, lipid profile, blood count, free T4, TSH, aldosterone, renin, ARR, NT-pro-BNP: normal, metanephrines 876/1238 pg/mL, albuminuria 56 mg/g Cr. Echocardiography: slight LVH (13 mm septum and posterior wall) with preserved function. Abdominal CT: Left adrenal mass, 54 mm, hyperdense, heterogeneous. MIBG scintigraphy: hyperintense left adrenal uptake without additional anomalies. After standard presurgical conditioning the patient underwent laparoscopic adrenalectomy, uneventfully. Pheochromocytoma was pathologically confirmed, without suggestion of malignancy (Ki-67 &lt;2%). Three months afterwards the patient is normotensive and asymptomatic without medication, with normal plasma metanephrines. Conclusions: The clinical presentation of pheochromocytoma may be atypical and sometimes bizarre. Sustained hypertension may be absent, but the paradoxical hypertensive response to beta-adrenergic blockade is highly suggestive. Anyhow, a ‘post-COVID syndrome’ label may be masking unrelated and solvable serious diseases.

ARTERIAL STIFFNESS ASSESSED BY SYSTEMIC VERSUS REGIONAL INDICES: DETERMINANTS AND DIAGNOSTIC AGREEMENT

Objective: Arterial stiffness is closely associated with aging and hypertension and may improve the stratification of cardiovascular risk in patients with hypertension. This study investigated the determinants and the diagnostic agreement of systemic (brachial-ankle pulse wave velocity [baPWV]) and regional (carotid distensibility coefficient [DC]) arterial stiffness indices. Design and method: Adults referred to a hypertension outpatient clinic were subjected to: (i) triplicate office blood pressure (BP) measurement using a validated professional oscillometric upper-arm cuff device Microlife WatchBP Office, (ii) baPWV measurements using an automated oscillometric device Microlife WatchBP Office Vascular, and (iii) DC and carotid intima-media thickness (cIMT) measurements with carotid ultrasound. Results: Data from 136 participants were analyzed (mean age 60±12 [SD] years, 71% males, body mass index 28±4 kg/m2, 83% hypertensives, 12% diabetics, 16% smokers, baPWV 14±2 m/sec, DC 24±9 10-3/kPa). There was a moderate negative association between baPWV and DC (r = -0.37, p&lt;0.01). baPWV was positively correlated with age (r = 0.64, p&lt;0.01), systolic office BP (r = 0.27, p&lt;0.01) and cIMT (r = 0.29, p&lt;0.01), while DC was inversely associated with age (r = -0.37, p&lt;0.01), systolic office BP (r = -0.48, p&lt;0.01), and cIMT (r = -0.29, p&lt;0.01). In multivariable linear regression models (independent variables: age, sex, systolic office BP, cIMT, diabetes), age and systolic office BP appeared to be significant determinants of baPWV (beta = 0.12/0.05, respectively) and DC (beta = -0.32/-0.27, respectively). The agreement between the two methods in identifying individuals with increased arterial stiffness (1st quartile of DC distribution and 4th quartile of baPWV distribution) was fair (agreement 71%, kappa = 0.22, p&lt;0.05). Conclusions: These results suggest that although these two methods for assessing arterial stiffness are correlated and determined by similar variables, their agreement in identifying individuals with increased arterial stiffness is fair, implying that they may provide complementary information.

HOW DOES THE ANTIHYPERTENSIVE THERAPY OF EVERYDAY PATIENTS FOLLOW THE DIFFERENT GUIDELINES?

Objective: The different guidelines have got therapeutic recommendations for different conditions with hypertension. It sounds perfect. But what is the situation in the real life? How does the antihypertensive therapy of everyday patients follow the different guidelines? Design and method: Medications of alltogether 453 patients were analysed retrospectively from case reports. The selection of the patients was not based on specific criteria, but they arrived for their next visit at one of the Hypertension Outpatient Clinics of the Nephrology-Hypertension Center of the University of Szeged between 06/01/2021 and 31/12/2021. The authors used the guidelines valid in 2021 of the European Hypertension Society, the Hungarian Hypertension Society, the American Heart Association, the Hypertension Canada and the NICE as a base. Diabetes mellitus, angina pectoris, acute myocardial infarction, atrial fibrillation, congestive heart failure, chronic kidney disease without proteinuria, renal failure with proteinuria and stroke/TIA were the analysed conditions. Results: The rates of recommendation follow-up are summarized in the table. Conclusions: The antihypertensive medication of the patients proved to follow recommendations well. There were only non-significant differences between the following recommendations. In cardiovascular conditions, which can be considered more serious, it was completely the same.

EFFECT OF THE PERIOD OF THE COVID-19 PANDEMIC ON HYPERTENSIVE PEOPLE: A PROSPECTIVE COHORT STUDY

Objective: To analyze the influence of the COVID-19 pandemic period on habits and lifestyles, adherence to antihypertensive treatment, control of blood pressure and comorbidities, in hypertensive patients followed in a specialized outpatient clinic of high complexity. Design and method: Prospective longitudinal study that evaluated hypertensive patients treated at the hypertension outpatient clinic of a tertiary teaching hospital, in São Paulo - SP, Brazil before and during the covid-19 pandemic. The following were included: older than 18 years old and being followed up for at least six months. Pregnant women were excluded. In the pre-pandemic period, the interview and assessments were carried out between March and May 2019, in person (face to face). During the pandemic, assessments were carried out between March and August 2020, by telephone. Biosocial data, habits and lifestyles and disease history were evaluated. The study was approved by the Research Ethics Committee. Values of p less or equal 0.05 were considered significant. Results: 111 hypertensive patients were evaluated, the majority (61.3%) women, with a mean age of 66.0 (SD = 12.6) years, 66.7% white, 56.8% married, with an average schooling of 10.5 (SD = 4.2) years. When comparing before and during the pandemic, statistically significant differences (p less or equal 0.05) were observed, respectively, for the variables: monthly income (R$2,362.98 vs R$1,924.88); in the number of widowed (16.2% vs 19.8%) and divorced people (8.1% vs 22.5%), smoking habits (8.1% vs 7.2%), alcoholism (45.0% vs 21.8%) and physical inactivity (97.3% vs 89.2%); glycemia [116.1 (SD = 33.2) vs 129.6 (SD = 57.3) mg/dL] adherence to antihypertensive drug treatment (89.2% vs 54.9%), increase in diabetics ( 48.6% vs 52.2%) and chronic kidney patients (18.9% vs 28.8%). Despite the decrease in blood pressure control, there was no significant difference (67.6% vs 56.9%). Conclusions: The findings indicate that there were favorable influences for habits and lifestyles in hypertensive people in the period of the COVID-19 pandemic, but there was a compromise in income, comorbidities, and especially in adherence to antihypertensive treatment.

Multiple drug intolerance in patients with arterial hypertension: prevalence and determining factors.

One of the reasons for poor medication compliance among patients is the occurrence of adverse drug reactions. The aim of this study was to determine the prevalence of multiple drug intolerance syndrome (MDIS), defined as adverse reactions to 3 or more classes of drugs, among patients with arterial hypertension, and to assess the predisposing factors. The study population included hospitalized patients diagnosed with arterial hypertension as well as patients undergoing chronic treatment in an outpatient hypertension clinic. The authors used a structured proprietary questionnaire, which focused on demographic and clinical data, including current or past history of adverse drug reactions. The study population comprised 1000 patients, including 560 women. The mean (SD) age was 62.8 (14.9) years. Eighty patients (8%) suffered from MDIS. There were more women in this group, as compared with the entire study population (71% vs 55%; P = 0.01). The patients with MDIS had a longer history of hypertension (median 15 vs 10 years; P = 0.01), and were more likely to suffer from respiratory (P = 0.01), gastrointestinal (P = 0.003), rheumatoid (P <0.001), and endocrine (P = 0.01) disorders. The risk of MDIS was the highest with the concomitant use of analgesics, followed by β‑blockers, antiplatelet drugs, and antibiotics. MDIS in patients with hypertension is common and more frequently affects women and patients with a longer known disease duration. Comorbidities increase the risk of MDIS. Its risk is strongly associated with the use of analgesics, β‑blockers, antiplatelet drugs, and antibiotics.

Asymptomatic Bacteriuria in Patients with Type 2 Diabetes Mellitus.

Objectives: Asymptomatic bacteriuria (ASB) is a common finding in patients with diabetes. Moreover, patients with diabetes and ASB have a greater risk for symptomatic urinary tract infections and associated severe complications. The aim of this study was to estimate the prevalence of ASB, as well as to identify independent risk factors and related pathogens associated with ASB in female and male patients with type 2 diabetes mellitus (T2D). Methods: This prospective case-control study was performed at the University hospital, and the Venezeleion General Hospital, Heraklion, Greece between 2012 and 2019. All patients with T2D attending the diabetes and hypertension outpatient clinics at both hospitals were enrolled, and data regarding their medical history and clinical and laboratory profiles were recorded. Asymptomatic patients with positive urine cultures were assigned as cases while those with negative urine cultures were designated as controls. Results: A total of 437 adult patients of which 61% were female and 39% were male patients with a mean age of 70.5 ± 9.6 years, were enrolled. The prevalence of ASB was 20.1%, in total. ASB was noted in 27% of female participants and 9.4% of male participants. Higher glycated hemoglobin (OR = 3.921, 95%CI: 1.521−10.109, p < 0.001) and urinary tract infection within the previous year (OR = 13.254, 95%CI: 2.245−78.241, p < 0.001) were independently positively associated with ASB, while higher levels of vitamin B12 were independently negatively associated with ASB (OR = 0.994 per ng/mL, 95%CI: 0.989−0.999, p < 0.001). Conclusions: Development of ASB was associated with specific factors, some of which may be modifiable. Interestingly, high B12 was found to be negatively associated with ASB.

PS-BPC07-9: BLOOD PRESSURE LOWERING EFFICACY OF THE HYPERTENSION EDUCATION PROGRAM OF THE GERMAN SOCIETY OF HYPERTENSION AND PREVENTION

Objective: In 2013 the German Society of Hypertension and Prevention initiated a hypertension education program (HEP) - Mein Blutdruck - OK! (https://www.hochdruckliga.de/hypertonie-schulung-fuer-patienten.html). The objective of this study was to evaluate the blood pressure lowering efficacy of the HEP. Design and method: The HEP consists of 5 modules (blood pressure regulation, non-pharmacological treatment 1 and 2, pharmacological treatment, adherence) of group (4–6 patients) teaching, held by trained physicians and medical staff who underwent a specially designed train the trainer program. Each module consisted of 90 minutes training and patients underwent all 5 modules within 4 weeks. The validation study was performed in 8 hypertension outpatient clinics. Patients with mild (stage 1) hypertension, treated or untreated were included, and pharmacologic antihypertensive treatment was not altered during 6 months. The clinics were randomized to HEP or standard care. Blood pressure was monitored at baseline and after 6 months by standardized office measurements, home measurements (automatic oscillometric device, patients training) and 24 h ABPM. Primary endpoint was an at least 5 mmHg greater reduction of systolic office blood pressure by HEP compared to usual care. Results: 4 hypertension outpatient clinics were randomized to HEP, including 35 patients, 4 hypertension outpatient clinics were randomized to usual care, including 53 patients in the study. ABPM data were available in only 71 out of 88 patients. Data are presented in tables 1 and 2. Conclusion: The HEP resulted in significantly greater reductions of office and home blood pressure values as compared to usual care. The primary endpoint was met. Changes in ABPM daytime means did not differ significantly between groups, possibly due to insufficient available data. These results were obtained in patients with mild hypertension, either treated or untreated, and may differ in patients with severe or resistant hypertension.

PS-R01-9: THE PERILS OF GRAPEFRUIT: A POTENTIALLY LETHAL INTERACTION WITH VERAPAMIL

Objective: Hereby we describe a case of severe toxicity induced by a standard dose of slow-release verapamil Design and Methods: Review of the patient's records and of the relevant literature. Results (Case Description): A 57-year old woman had been diagnosed with hypertension by her family physician, but her management had been complicated with intolerance to multiple antihypertensive drugs. On the occasion of a family conflict, she developed a hypertensive crisis, with a holocranial headache, tremor and palpitations, but no symptoms of ischemia on the EKG. After discharge from the Emergency Room she was referred to our Outpatient Hypertension Clinic in order to rule out secondary hypertension. For the workup, and in order to avoid interference with the renin-angiotensin-aldosterone system she was switched to slow-release verapamil 120 mg twice a day. One month afterwards the workup was completed: primary aldosteronism, pheochromocytoma/paraganglioma, renovascular hypertension and Cushing's syndrome had been ruled out. Her BP was adequately controlled with verapamil, with ABPM confirmation, and her tolerance was good. Considering her multiple drug intolerances, we decided to keep her on verapamil. Four months afterwards, the patient was brought back to the Emergency Room with severe hypotension and bradycardia, extreme asthenia, generalized rubor and diaphoresis, with normal lab tests except for mild creatinine elevation in the context of dehydration. Her SBP was 74 mmHg, with DBP not measurable, and HR 39 lpm; the EKG showed Wenckebach 2:1 AV block. After 48 hr in the Emergency Room with saline infusion and basic support measures the patient was discharged and referred again to our Clinic for reevaluation. A verapamil overdose was suspected, but the patient was adamant that she had always taken verapamil exactly as prescribed. A detailed anamnesis revealed that the patient had put on some weight the previous month and decided to lose it with a novelty diet based on the intake of about 2 liters of grapefruit fruit daily plus protein. She was switched to indapamide 2.5 mg daily with good tolerance and adequate BP control. Conclusions: Grapefruit juice contains 6’-7’dihydrohybergamottin, a powerful inhibitor of the key drug metabolizing enzyme CYP3A4, potentially causing accumulation of many common drugs such as verapamil, statins, ticagrelor, sildenafil, amiodarone or cisapride, and related toxicity. We need to remember that prescription drugs do not only interact among themselves but also with herbal remedies and common foodstuffs such as grapefruit.

PS-C33-9: PSYCHOLOGICAL ABNORMALITIES IN PATIENTS WITH RESISTANT HYPERTENSION FOUND NON-ADHERENT BY DIRECTLY OBSERVED TREATMENT INTAKE

Introduction &amp; aim: We intend to assess the underlying psychological and behavioural factors in patients with resistant hypertension (HTres) confirmed as non-adherents by directly observed treatment intake (DOTI). Methods: We studied with DOTI 68 patients with HTres in outpatient hypertension clinic. 24-h ambulatory BP (ABP) was evaluated before the procedure. In DOTI patients took all medications in the morning for 5 days under the supervision of a technician and performing on the fifth day a second ABP. In some patients a third ABP measurement was repeated 3–6 months after DOTI. All patients responded to appropriate questionnaires evaluating their psychological and behavioural profiles Results: Out of the 68 patients 76% were female and 21% diabetics in average ageing 62 years and BMI 30 Kg/m2. Average antihypertensive agents was 4.6 ± 1.2 drugs/day. After DOTI casual, daytime and night-time BP decreased significantly (24 h from 149/82 + 13/13 to 131/74 + 13/9 mm Hg, p &lt; 0.01). Pts (n = 36, i.e. 52.9%) were classified as non-adherents (false HTres) since after DOTI vs previous 24-h ABP there was a significant reduction of mean 24 h BP to &lt; 130/80 mm Hg or a reduction of both 24 h SBP and 24 h DBP by &gt; 10%). Non-adherents i.e false HTres showed significant worse values of disbelief in the potential benefits of treatment, expression of emotions, hostility, anxiety, paranoid ideation, self-blame, physical mobility, smoking habits and social isolation. Conclusions: DOTI can be a valuable tool to identify the non-adherence to therapy as a cause of HRes. Non-adherence was associate with worse psychological and behaviour profiles.

PS-BPC06-9: THE EFFECT OF COMMON SURGICAL MASKS ON UNATTENDED BLOOD PRESSURE CHANGES IN DRUG TREATED HYPERTENSIVE PATIENTS

Objective: While there are several studies that have focused on the role of face masks in preventing airborne transmission of SARS-CoV-2, few data are available on their effects on physiological measures, and no study has examined their effects on blood pressure (BP). The purpose of our study was to investigate the effect of surgical masks on BP in drug-treated hypertensive patients who had a routine follow-up visit to a university hospital outpatient hypertension clinic. Design and method: The study included already treated hypertensive patients aged &gt; 18 years, while the exclusion criteria were atrial fibrillation or any other arrhythmia affecting the BP measurement, an arm circumference &gt; 42 cm, mental disorders, Parkinson disease, pregnancy, intolerance to the BP measurement method, or unwillingness to participate. A new surgical mask was provided to all participants to replace the face mask that was already in use. After the routine mask-on office BP measurement, patients were left alone and randomized to automated office BP measurement, with measurements taken after first wearing a mask for 10 min, then without wearing the mask for 10 min, and vice versa. Results: A total number of 265 patients were included in the study. Among the participants, 115 were women (43.4%), the mean age was 62 ± 12 years, and the mean office BP was 134 ± 15 / 81 ± 12 mmHg. There was no significant difference between mask-on unattended systolic BP (133 ± 15 mmHg) and mask-off unattended systolic BP (132 ± 15 mmHg) (P = 0.13) or between mask-on unattended diastolic BP (77 ± 13 mmHg) and mask-off unattended diastolic BP (76 ± 13 mmHg) (P = 0.32). Moreover, there was no difference in the heart rate (mask-on first, 69 ± 11 bpm; mask-off first, 69 ± 11 bpm, P = 0.7). Conclusions: Common surgical masks do not affect systolic/diastolic BP levels during unattended BP measurements in treated hypertensive patients.

PS-BPC06-8: FACTORS ASSOCIATED WITH POTENTIAL COGNITIVE FUNCTIONAL CHANGES IN OLDER PATIENTS WITH HYPERTENSION

Objective: There are many cases of potentially impaired cognitive function in older patients with hypertension. Therefore, we investigated factors associated with one-year changes in cognitive function in older hypertensive patients during outpatient visits. Design and method: We included 223 hypertensive patients (age 76.3 ± 6.3 years, 106 males) aged 65 years or older who attended outpatient hypertension clinics at six specialized institutions nationwide and had no prior diagnosis of dementia. We obtained the mini-mental state examination (MMSE) from all participants. We defined the impaired cognitive function as an MMSE score of 27 or less. At baseline and one year later, the participants were evaluated for comprehensive geriatric assessment, including MMSE, and muscle strength, with the converted group defined as having new cognitive decline at one year and the reverted group as having cognitive improvement one year after the cognitive decline. All participants gave informed consent, and our institutional review board approved the study protocol. Results: At baseline, 81 of 223 elderly hypertensive patients had impaired cognitive function. At one-year follow-up, 40 of 142 patients in the maintained cognitive function group were classified as converted, and 33 of 81 patients in the impaired cognitive function group were classified as converted. The converted group was older than the cognitively intact group (76.8 vs. 73.9 years, p &lt; 0.05), had higher home blood pressure, and had more significant grip strength loss over the year. Multivariate analysis identified age (odds ratio 1.1, 95% CI 1.0–1.2) and change in grip strength (odds ratio 0.84, 95% CI 0.72–0.99) as factors associated with the converted group. The reverted group was younger, had a higher percentage of males, and had weaker grip strength than the group with persistent cognitive decline. In multivariate analysis, grip strength (odds ratio 0.80, 95%CI 0.68–0.94) was extracted as a factor associated with the revert group. Conclusions: Potential cognitive decline was observed in 36% of older patients with hypertension. Furthermore, we examined a high rate of cases of cognitive function change over one year. Age and grip strength decline was considered responsible for cognitive conversion and baseline grip strength for revert, respectively.

PS-R02-7: PAROXYSMAL ATRIAL FIBRILLATION IN A PATIENT WITH HYPERTENSION: A CASE REPORT

Objective: To present the association between arterial hypertension and concomitant arrhythmias. Summary: The report examines a case of a 74-year-old female patient with known arterial hypertension. She presented with wide blood pressure (BP) fluctuations, with surges of very high BP during the last three months. She also experienced palpitations, dyspnea and chest pain. BP measurements ranged from 116/67 mmHg in the office to 235/103 mmHg at home. She had been taking telmisartan 40 mg once-daily (OD), lercanidipine 10 mg OD and bisoprolol 5 mg OD regularly for several years and her BP was previously well controlled. Considering the discrepancy between BP measurements in the office and at home, we decided against changing her regular therapy. Therefore, the patient was advised to continue current antihypertensive treatment and additionally take captopril 25 mg and/or sublingual nitroglycerin when systolic BP was above 150 mmHg. Further diagnostics was performed. Transthoracic echocardiogram was normal, except for moderately enlarged left atrium. Pulmonary embolism and obstructive coronary artery disease were excluded. 24-hour Holter ECG revealed that the patient had symptomatic paroxysmal AF with rapid ventricular response (Figure 1a). There were also some sinus pauses and short periods of sinus bradycardia immediately after the cessation of AF paroxysm (Figure 1b). To reduce AF-related symptoms and improve the quality of life, the patient was referred to catheter ablation. Pulmonary vein isolation was successfully achieved with no periprocedural complications. Due to borderline sinus bradycardia, bisoprolol was temporarily discontinued and later reintroduced in a lower dose. After the procedure, she was regularly taking telmisartan 40 mg OD, lercanidipine 10 mg OD, bisoprolol 1.25 mg OD, a direct oral anticoagulant and a statin. 24-hour ambulatory blood pressure monitoring was performed. A 24-hour mean BP was 112/66 mmHg, mean day-time BP was 115/69 and mean night-time BP was 108/62 mm Hg (Figure 1c). There was no excessive fluctuation in BP. Furthermore, no increases in HR were noted that would suggest recurrence of AF paroxysms. Conclusion: The patient, who was referred to our outpatient hypertension clinic due to uncontrolled hypertension, was diagnosed with symptomatic paroxysmal AF. By means of a successful AF catheter ablation, we eliminated the excessive BP fluctuations. AF and hypertension are closely related, and the appearance of AF can lead to poor BP control. An appropriate treatment for AF in patients with hypertension contributes to better control of the hypertension itself.

PS-P15-5: EFFECT OF SODIUM RESTRICTION ON LARGE ARTERY STIFFNESS AND DISTENSIBILITY OF SMALL ARTERIES IN HYPERTENSIVE PATIENTS: A RANDOMIZED TRIAL

Objective: Arterial stiffness is characterized by a decrease in arterial distensibility, resulting from the interaction between the extracellular matrix and cellular elements. Large and small arteries can be differently influenced by extrinsic factors, such as excessive sodium intake. This study aim to evaluate the impact of sodium restriction on large artery stiffness and distensibility of small arteries in young adults diagnosed with arterial hypertension. Methods: Randomized controlled clinical trial, including 20 hypertensive patients, aged between 30 and 59 years, followed up at the hypertension outpatient clinic of a tertiary hospital. Subjects were randomized into two groups: group 1 - low-sodium diet (2 g sodium/day); group 2 - usual diet. To analyze the stiffness and distensibility of the arteries, it was measured aortic pulse wave velocity by Complior®, elasticity of small arteries and vascular resistance by HDI®, and also through the measurement of metalloproteinase-9. For nutritional assessment it were considered blood glucose levels, 24-h urinary sodium, body mass index (BMI) and other anthropometric measurements. For nutritional intake we analized the 24-hour dietary recall. Results and Discussion: In comparison with group 2, it was observed a significant (p &lt; 0.05) reduction in office blood pressure (p = 0,037) and pulse wave velocity (p = 0,010) in group 1 subjects. Also, in group 1 it occurred reduction in blood glucose levels, BMI, waist and neck circumference. Sodium intake was significantly reduced in group 1, taking into account 24 hs urinary sodium and evaluated by dietary recall. It is worth mentioning that excessive sodium intake linked to arterial hypertension causes a remodeling process, increased oxidative stress, inflammation and fibrosis of the arteries, contributing to arterial stiffness. Regarding the distensibility of small arteries, no significant differences were found between the two groups, but the intervention period and the number of individuals in the study should be taken into account, since these factors may have influenced the results. Conclusion: Sodium restriction for a short period of time promoted reduction of arterial stiffness, in parallel to reduction in obesity parameters and blood pressure in adults diagnosed with systemic arterial hypertension.

JS-AHA: AHA SESSION CLINICAL CASE; CLINICAL-PATHOLOGICAL CONFERENCE (CPC) IN COOPERATION WITH HYPERTENSION, AN AMERICAN HEART ASSOCIATION JOURNAL

A 35-year-old woman, with a known history of right renal artery FMD, presented at the Hypertension Outpatient Clinic for evaluation of resistant hypertension. The patient was an active smoker and had a single kidney after left nephrectomy for kidney malformation during childhood. The diagnosis of FMD had been made on the occasion of a previous pregnancy at 23 years, complicated by preeclampsia and an angioplasty had been performed. Work-up disclosed a recurrence of right renal artery stenosis, and a new renal angioplasty was performed. Blood pressure normalized after the procedure. At 36 years, the patient had another pregnancy, also complicated by preeclampsia and preterm delivery. An Echo-Doppler performed during pregnancy and an Angio-CT after delivery, allowed ruling out recurrence of renal artery stenosis. At 43 years, she was admitted to the emergency room for thoracic pain. The coronarography was in favour of a coronary spasm. There was no coronary stenosis or image suggestive of a Spontaneous Coronary Artery Dissection. At 54 years, the patient was again admitted in emergency for malignant hypertension associated with severe acute renal failure. She also reported a history of lower limbs claudication since several months. An abdominal CT disclosed dissection complicated by occlusion of the right renal artery, dissection of both iliac arteries as well as a severe stenosis of the infra-renal aorta. An angioplasty with insertion of stents in the right renal artery and the aorta was performed. After the procedure, a partial normalization of renal function was observed, and blood pressure control was achieved on 3 medications. During the recovery, the patient presented a skin rash associated with a general feeling of discomfort, with spontaneous resolution after a few days. One year later, following a control Angio-CT of the abdomen, an anaphylaxis episode occurred, requiring Adrenaline administration. Iodine contrast allergy was suspected, but milder hypersensitivity symptoms occurred in the following months, without exposition to a clear trigger. An allergology work-up was performed with final diagnosis of secondary Mast Cell Activation Syndrome. B-Blockers and ACE-inhibitors were contra-indicated and cautious premedication before further exposure to iodine contrast was recommended.

Bendopnea Predicts Right Ventricular Energy Failure in Patients with Pulmonary Hypertension.

The development of right ventricular failure has a significant adverse prognostic impact on the course of pulmonary hypertension. Right ventricular energy failure has been shown to double the mortality of pulmonary hypertension even after correction for many established risk predictors. We hypothesize that bendopnea may indicate right ventricular energy failure in patients with pulmonary hypertension. We prospectively enrolled patients with pulmonary hypertension who were admitted to our pulmonary hypertension outpatient clinic between January 2021 and June 2021. Bendopnea was assessed by asking patients to bend forward and report any shortness of breath within 30 seconds. Routine physical examination, laboratory tests, echocardiography, and right heart catheterization parameters were collected. A total of 167 patients were enrolled into the study. Bendopnea and right ventricular energy failure was present in 79 (47.3%) and 43 (25.7%) patients, respectively. Bendopnea accurately predicted the presence of right ventricular energy failure (area under the curve, 0.667; 95% CI, 0.574-0.760; P < 0.001) and had a significantly superior diagnostic power compared with many other symptoms and signs. Our study shows that bendopnea predicts right ventricular energy failure in patients with pulmonary hypertension and can be added to our physical examination armamentarium as an easy, rapid, and noninvasive prognostic tool.