Hypertension Specialist Research Articles

EXPRESS: Intimacy, Contraception, and Pregnancy Prevention in Patients with Pulmonary Arterial Hypertension: Are We Counseling Our Patients?

Pulmonary arterial hypertension (PAH) is a serious, life-altering condition. Patients who are diagnosed are often of childbearing potential. Given the well-documented risks associated with this condition during pregnancy, as well as risks to the fetus from medications used to treat this disorder, patients should be strongly advised against pregnancy. Despite this, patients still become pregnant, leading to the question of whether care providers are counseling patients and their partners about the risks of pregnancy, methods of contraception, and issues of intimacy on a regular basis. We have conducted a survey of pulmonary hypertension specialist physicians and allied healthcare professionals on their practice patterns related to counseling on intimacy, contraception, and pregnancy prevention. Most respondents indicated they are counseling on these issues to varying degrees, but our survey pointed to several areas where improvements can be made. The most significant barrier to counseling for all respondents was lack of time. Survey respondents reported that a large percentage of the pregnancies seen in their practices were either intentional or due to contraceptive non-compliance. We review specific practical approaches to initiate reproductive health counseling as well as ways to integrate this important aspect of PAH care into regular practice routines and documentation. Protocols regarding pregnancy avoidance and PAH should be developed and become standard procedure.

Prevalence and clinical correlates of ambulatory blood pressure phenotypes in a Saudi hypertensive population.

International Guidelines recommend ambulatory blood pressure monitoring (ABPM) for the management of hypertension. ABPM phenotypes predict outcomes independent of office blood pressure (BP). The authors explored the prevalence and clinical correlates of ABPM phenotypes and relationship with office BP in Saudi patients (n=428, mean age 53.5±14.6, 55% male) referred to a Specialist Hypertension clinic in Riyadh, Saudi Arabia. ABPM phenotypes included sustained normotension (27%), masked hypertension, MHT(32%), sustained hypertension, SHT(52%), and white coat hypertension(2.6%). MHT was more prevalent using asleep than 24-hours (26.4% vs 12.9%, P<.01) or awake BP (26.4% vs 8.5%, P<.001) and observed in 85% of pre-hypertensive patients. Isolated nocturnal hypertension was more prevalent in MHT vs SHT (70% vs 30%, P<.001). Office BP overestimated control rates compared with ABPM (48% vs 12.9%, P<.001). Our study shows that one in three Saudi patients will be managed inappropriately if office BP alone was relied upon for management of hypertension.

Differences in patient and physician perspectives on pharmaceutical therapy and renal denervation for the management of hypertension.

Objective:To study patient and physician attitudes to pharmaceutical therapy and renal denervation for the management of hypertension.Methods:Data were analyzed from 19 market research studies in Western Europe and the United States conducted between 2010 and 2019 to obtain quantitative and qualitative perspectives. The analysis incorporated insights from 2768 patients and the experiences of 1902 physicians either actively performing or interested to perform device procedures, or hypertension specialists who would refer patients for a device-based intervention.Results:Referring cardiologists and proceduralists were more likely to recommend the renal denervation procedure to patients with higher BP levels and a greater number of antihypertensive medications. Physicians perceived patient reluctance towards a procedure as an important obstacle to recommending renal denervation as a treatment option for uncontrolled hypertension. Patient interest in the renal denervation procedure did not correlate with BP severity (P = NS), and the highest preference for the procedure was in patients diagnosed with hypertension but not receiving treatment (P < 0.001). Patients who perceived high BP as a major problem (P = 0.029) and those who experienced side effects attributed to their BP medications (P = 0.006) had a higher preference for renal denervation.Conclusion:Patients with hypertension often regard the choice of renal denervation to lower BP differently from physicians. A considerable proportion of hypertensive patients, especially those not taking medications, may prefer a device-based approach to reduce their BP.

Pregnancy hypertension diagnosis and care in COVID-19 era and beyond.

Pregnancy hypertension diagnosis and care in COVID-19 era and beyond.

Novel Insight into How Nurses Working at PH Specialist Clinics in Sweden Perceive Their Work.

Outpatient pulmonary hypertension (PH) specialist centers have an important role in the optimal management of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). The aim of the present study was to gain an understanding of the work facing nurses at the outpatient PH specialist centers in Sweden. All nurses (n = 14) working at the outpatient PH specialist centers in Sweden were included. Qualitative content analysis was employed to analyze the interviews, wherein an overarching theme emerged: “Build and maintain a relationship with the patient”. Three categories described the nurses’ experiences: “Ambiguous satisfaction regarding information and communication”, “Acting as a coordinator” and “Professional and personal development”. To provide good patient care, the nurses described the key components as the ability to give information on all aspects of the disease and their availability by phone for patients, their relatives, and other healthcare resources. This requires evidence-based, specialist knowledge about the disease, its care, and treatments as well as experience. In conclusion, working as a nurse at the outpatient PH specialist centers highlight the advantages, expectations, and difficulties in working with patients with a rare and life-threatening illness. The overall knowledge and skills were high, but the nurses expressed a need for in-depth and continued training.

Hypertension, renin–angiotensin–aldosterone system inhibition, and COVID-19

Hypertension, renin–angiotensin–aldosterone system inhibition, and COVID-19

Rationale and Best Practices for Pediatric Cardiology Prevention Programs

Atherosclerotic cardiovascular diseases are the most common cause of death in North America, and a significant number of children have conditions such as inherited dyslipidemias, overweight/obesity, and hypertension, placing them at increased risk for future cardiovascular events and other comorbidities. Training in cardiovascular prevention is an important tool to help pediatric cardiologists address these issues in children. We describe a model for training pediatric cardiologists in primary and secondary prevention strategies. A multidisciplinary team approach is needed for robust training in dyslipidemias, hypertension, insulin resistance and type 2 diabetes mellitus, and other obesity-related comorbidities. Research is a significant component of training and necessary for translating science into practice. Ongoing education is also necessary, and certification is available through associations such as the National Lipid Association, the American Diabetes Association, The Obesity Society, and the American Hypertension Specialist Certification Program. Knowledge of primordial, primary, and secondary cardiovascular prevention strategies is essential for pediatric cardiologists to accomplish the goal of helping children lead healthier lives long into adulthood.

Update of the position paper on arterial hypertension and erectile dysfunction.

: Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.

Is There a Role for Device Therapies in Resistant Hypertension?: The CON Side.

In this piece, I will argue that device-based therapies for resistant hypertension (RH), although interesting and meritorious of further study, do not yet deserve a prominent role in the management of patients with RH. This argument is on the basis of the limited availability of controlled studies using devices, the cost and uncertain long-term effectiveness of device modalities, and the successful track record of medical therapy. First, let me define the demand for advanced therapies in RH. RH is defined as the BP of a hypertensive patient that remains above goal despite the concurrent use of three antihypertensive agents of different classes, preferably including a blocker of the renin-angiotensin system, a calcium channel blocker, and a thiazide-type diuretic (1). The prevalence of RH in the general hypertensive population is 12%–18%, on the basis of office BP measurements >140/90 mm Hg (1), an estimate that is expected to increase by approximately 2% when the 130/80 mm Hg threshold is applied to high-risk patients (2). Approximately one third of these patients have normal 24-hour BP (1), and a sizable portion is nonadherent to prescribed medications; therefore, approximately 5%–10% of hypertensive patients would ultimately qualify as having true RH. The current approach to the treatment of RH calls for adequate dosing of complementary medications, preferential use of long-acting thiazide diuretics ( e.g ., chlorthalidone), and the addition of a mineralocorticoid antagonist ( e.g ., spironolactone) (1). When such a strategy is used, BP goal is achieved in up to 90% of patients (3). Hence, about 0.5%–1% of hypertensive patients (approximately 750,000–1.5 million adults in the United States) would benefit from alternative approaches to treatment, such as referral to hypertension specialists for more advanced drug combinations or the use of device therapies. I acknowledge the importance of treatment nonadherence and medication intolerance in RH. Nonadherence is …

The effectiveness of a specialist Hypertension Clinic in reducing blood pressure: Factors determining blood pressure response.

ObjectivesWe retrospectively assessed both blood pressure response to management in a specialist Hypertension Clinic and the predictors of response.DesignRetrospective data audit.SettingHypertension Clinic at Guy’s and St Thomas’ Hospitals, London, UK.ParticipantsOne hundred and twenty-two sequential patients attending the clinic between January 2017 and October 2018. Patients were excluded if they had previously been seen in the clinic, failed to attend their initial appointment or did not return after their initial appointment.Outcome measureChange in blood pressure readings between first and last recorded appointments.ResultsSystolic blood pressure decreased from 149 ± 20 mmHg to 140 ± 17 mmHg, and diastolic blood pressure from 92 ± 13 to 86 ± 1 mmHg, between the first and last recorded appointments (P < 0.05 for each). Those patients who reached target blood pressure were significantly younger than those who did not (age 45 ± 14 versus 52 ± 17 years, P = 0.0171); however, the degree of blood pressure reduction was independent of age, and younger subjects had a baseline blood pressure significantly lower than older subjects. Sex, body mass index and lifestyle interventions had an important effect on blood pressure reduction; however, these were not associated with attainment of target blood pressure.ConclusionSpecialist hypertension input is effective in helping patients to achieve target blood pressure, especially so in younger as compared to older hypertensive patients, but this appears to be related to the fact that blood pressure in younger patients is already closer to target at baseline. Blood pressure reduction is greater in women, those with higher body mass index and those who receive lifestyle interventions.

Practical application of ABPM in the pediatric nephrology clinic.

The use of 24-h ABPM has become commonplace when diagnosing and managing hypertension in the pediatric population. Multiple clinical guidelines recommend ABPM as the preferred method for identifying white-coat hypertension, masked hypertension, and determining degree of blood pressure (BP) control. Accurate, timely diagnosis and optimal management are particularly important in certain populations, such as children with chronic kidney disease (CKD), diabetes, and other conditions with increased risk for cardiovascular disease. Understanding how best to utilize ABPM to achieve these goals is important for pediatric nephrologists and other hypertension specialists. This review will provide practical information on the equipment, application, interpretation, and documentation of ABPM in the specialty clinic.

Diagnosis and treatment of hypertensive emergencies and urgencies among Italian emergency and intensive care departments. Results from an Italian survey: Progetto GEAR (Gestione dell'Emergenza e urgenza in ARea critica)

Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Emergency Department (ED) and the approach may be different according to local clinical practice. Our aim was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of an on-line survey. The young investigator research group of the Italian Society of Hypertension developed a 23-item questionnaire spread by e-mail invitation to the members of Italian Scientific societies in the field of Hypertension. 665 questionnaires were collected from EDs, Emergency and Urgency Medicine, Cardiology or Coronary Units, Internal Medicines, Intensive care, Stroke units. Symptoms considered suspicious of acute organ damage were: chest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%) and epistaxis (34.4%). Exams more frequent prescribed were: electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). The use of intravenous or oral medications to treat HEs was 94.7% and 3.5%, while for HUs 24.4% and 70.8% respectively. Of note, a surprisingly high percentage of physicians (22 % overall, 24.5% in North Italy) used to prescribe sublingual nifedipine. After discharge, home blood pressure monitoring and general practitioner re-evaluation were more frequently suggested, while ambulatory blood pressure monitoring and hypertension specialist examination were less prescribed. The differences observed across the different macro-areas, regarded prescription of diagnostic test and drug administration. This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy.

P1822Pocket-size mobile echocardiographic device screening for thoracic aortic aneurysm in asymptomatic hypertensive patients

Abstract Background Patients with hypertension may develop thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients and define the effectiveness of a TAA point-of-care screening program using pocket-size mobile echocardiographic (PME) devices. Methods We prospectively performed transthoracic echocardiography for TAA screening using a PME device on 1529 hypertensive patients (age, 62y [30y to 85y], 824 men) who attended our hypertension specialist clinic between June 2016 and July 2018. Measurement of the dimensions of the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta were obtained through multiple standard echo views. Results The prevalence of TAA (defined as maximum aortic diameter of ≥4.5cm and/or &gt;50% diameter of the adjacent aorta) in our study population was 7.3% (111/1529), with distal ascending aorta as the most frequent location (Figure). Multiple logistic regression analysis identified male gender, older age, and presence of heart valve disease as independent factors associated with TAA (all p&lt;0.05). Figure 1 Conclusions Asymptomatic TAA is common among asymptomatic hypertensive patients. Point-of-care use of PME device is effective in detecting TAA in a clinic setting. Such approach may be useful for early detection of TAA among at-risk patients allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications such as aortic dissection or rupture. Acknowledgement/Funding Health and Medical Research Fund of the Hong Kong Government

Abstract 108: Prevalence and Characteristics of Cardiac Rehabilitation Participants With Resistant Hypertension

Introduction: The prevalence of apparent treatment resistant hypertension (RH) varies based on the population studied. We sought to determine the prevalence and characteristics associated with RH among patients enrolling in cardiac rehabilitation (CR). Methods: Between 2012 and 2017, 504 consecutive individuals at initial intake for entry into phase II CR were evaluated for RH. RH was defined as a participant taking 3 antihypertensive medications including a diuretic, with a resting systolic BP &gt;130 mm Hg, or 4+ antihypertensive medications, regardless of BP. Participants with RH were compared to all other participants using student’s t-test or Fisher’s exact test as appropriate. Results: Sixty-three percent (320/504) of all CR participants carry a diagnosis of hypertension. Of those, 11% were classified as having RH (7% of all participants.) RH patients were more likely to be older, African-American, have higher SBP and higher pulse pressure. They also demonstrated an increased prevalence of co-morbid diagnoses, including heart failure with reduced ejection fraction, peripheral arterial disease, and type 2 diabetes mellitus (Table 1.) Only 3% of participants (1/36) with RH were prescribed a mineralocorticoid receptor antagonist, and only 14% (5/36) visited a hypertension specialist for consultation within a year of the initial CR appointment. Conclusions: The prevalence of RH amongst CR participants is 7%. RH participants have more co-morbidities than normotensive or non-resistant hypertensive counterparts. Given that CR participants are a high cardiovascular risk population, greater efforts to identify patients with RH, and refer for appropriate care are needed.

HTA essentielle résistante : place de la spironolactone

Resistant hypertension is defined as uncontrolled blood pressure (BP) despite three antihypertensive agents including a diuretic (thiazide diuretic if renal function is normal or loop diuretic in case of chronic kidney disease with eGFR<30mL/min), a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, at optimal doses. Resistance must be confirmed by out-of-office measurements (ambulatory blood pressure monitoring or home blood pressure monitoring) and patients should be asked about treatment compliance and excessive salt or alcohol intake. If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for secondary causes of hypertension as they are frequent in this context. If essential resistant hypertension is confirmed, the mineralocorticoid receptor antagonist, spironolactone, should be added (25 to 50mg daily). In the event of a contraindication to spironolactone, or if adverse effects occur, a beta-blocker, an alpha-blocker, or a centrally acting antihypertensive drug should be prescribed.

LOW AWARENESS OF GENERAL PRACTITIONERS ON KIDNEY FUNCTION AND CHRONIC KIDNEY DISEASE IN HYPERTENSIVE PATIENTS. PRELIMINARY REPORT FOR NORTH-WEST PART OF CROATIA

Objective: The prevalence of hypertension (HT) in general Croatian population is 37%. We are still lacking data on prevalence of HT in Zagorje County, North West part of Croatia and characteristics of this population (prevalence of associated risk facotrs and co-morbidity). Our aim was to analyse characteristics of consecutive sample of patients who were referred from GPs and examined in nephrology unit in local hospital. Design and method: Data on subjects who were examined in nephrology outpatient unit in GH Zabok from November 2018 till January 2019 were analyzed. Blood pressure was measured using Omron M6 device and ABPM using Moil-O-Graph during regular working day. Fasting blood sample and urine were collected after clinical exam and BP measurements. Chronic kidney disease (CKD) was defined as eGFR (CKD Epi) <60 ml/min/1.73 m2. Results: In a consecutive sample of patients 54% of them have CKD (mostly CKD stage 3b 63%), suggesting a late referral of hypertensive patients to a nephrologist. In the whole group we found 28% of them to have diabetes type 2. However, in none of them, albuminuria was determined. Arterial hypertension was treated either with monotherapy or using fixed dose combination therapy which was utilized in only 51% of patients. Heart rate, an independent cardiovascular risk factor more than 80 was present in 47% of patients. Conclusions: Analyzing data of this sample of patients from real life we found that general practitioners, at least in this part of Croatia, are unaware that determination of kidney function is important part of regular exam and that CKD is important independent prognostic factor in hypertensive patients. GPs should more closely collaborate with hypertension specialist/ nephrologist and should be regular partners in multidisciplinary team.

IMPACT OF SYSTEMATIC AND MULTIDISCIPLINARY EVALUATION OF FMD PATIENTS ON NUMBER OF NEWLY REVEALED FMD LESIONS AND COMPLICATIONS -POLISH ARCADIA-POL STUDY

Objective: Analysis of large cohorts of FMD patients allowed to reevaluate fibromuscular dysplasia (FMD) as a systemic arteriopathy. The aim of this analysis is to evaluate to what extent systematic and multidisciplinary evaluation of FMD patients results in novel FMD findings and reveals newly diagnosed vascular complications Design and method: Out of 272 patients enrolled into ARCADIA-POL study since January 2015 (instituted on the basis of Polish-French collaboration) we present 192 patients with confirmed FMD in at least one vascular bed.. All patients underwent detailed clinical evaluation including ABPM, biochemical evaluation, biobanking, duplex Doppler of carotid and abdominal arteries and whole body angio-CT. All patients included in the study were evaluated by the multidisciplinary team including specialists in cardiology and hypertension, interventional cardiology, radiology, interventional radiology, neuroradiology and vascular surgery. Results: Systematic evaluation of all 192 FMD patients included into the study revealed new FMD lesions in 61 (31.9 %) patients. Newly diagnosed vascular complications were found in 46 (24.0%) patients and in 2 patients more than one new vascular complications were revealed. Newly diagnosed aneurysms were found in 45 (32.4%) of patients and in 13 (6.8%) patients more than one aneurysms were found (Table). In 35 (18.2 %) FMD patients significant RAS was diagnosed.(Table).Conclusions: Systematic and multidisciplinary evaluation of FMD patients reveals a high incidence of previously unknown FMD lesions and newly diagnosed vascular complications.

DIAGNOSIS AND TREATMENT OF HYPERTENSIVE EMERGENCIES AND URGENCIES IN ITALY. THE GEAR (GESTIONE DELL’EMERGENZA E URGENZA IN AREA CRITICA) SURVEY

Objective: Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Italian Emergency Department (ED), however the diagnostic and therapeutic approach may differ across the Italian country. The aim of the study GEAR (Gestione delle Emergenze e urgenze in ARea critica) was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of on-line survey. Design and method: The young investigator research group of the Italian Society of Hypertension developed a 23-items questionnaire spread by e-mail invitation to the members of Italian Scientific societies involved in the field of Emergency Medicine and Hypertension. Results: 665 questionnaires were collected: 59.7% from EDs, 22% from Emergency and Urgency Medicine wards, 8.7% from Cardiology or Coronary Units, 5.7% from Internal Medicines and 3.9% from Intensive care or Stroke units. The definition of HE and HU was correctly identified by 81.2% and 89.3% of the responders respectively. The symptoms considered suspicious of acute organ damage were: chest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%), epistaxis (34.4%). Appropriate cuffs, for different arm sizes, were not widely available in all units: 94% had standard cuffs, 57% small and 75.6 % large cuffs, extra-large only 38.5%. The exams more frequent prescribed to evaluate target organ damage were electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). HEs were treated by 94.7% of the physicians by intravenous medications and by 3.5% by oral drugs, while HUs were treated by intravenous drugs in 24.4% of the cases and by oral drugs in 70.8%. When patients were discharged from ED, 87.5 % of the responders recommended home blood pressure monitoring, 87.5% general practitioner re-evaluation, while ambulatory blood pressure monitoring and hypertension specialist examination were less frequently recommended. Conclusions: This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy. Strong unmet needs clearly emerged, especially for educational initiatives, standardized treatment protocols and interrelationship with the chronic care system.

The Kidney in Congenital Cyanotic Heart Disease.

This column is supplied by Benjamin J. Lee, MD, MAS, an assistant professor of clinical medicine at both the Houston Methodist Institute for Academic Medicine and Weill Cornell Medical College. After earning his medical degree at Harvard Medical School, Dr. Lee completed a residency in internal medicine at the University of California, San Francisco (UCSF). He subsequently completed a nephrology fellowship at UCSF while simultaneously obtaining a Master of Advanced Study in clinical research from the UCSF Department of Epidemiology and Biostatistics. Dr. Lee is a Fellow of the American Society of Nephrology, a Certified Hypertension Specialist through the American Hypertension Specialist Certification Program, and a member of the American Society of Transplantation. He maintains his clinical practice with the Houston Kidney Consultants.

Challenges in the Patient With Pulmonary Hypertension and Atrial Septal Defect: Understanding When and How to Close the Defect

Atrial septal defects (ASDs) are common congenital heart defects in children and adults. Pulmonary arterial hypertension (PAH) is found in subsets of both pediatric and adult patients with atrial defects under varied clinical contexts. The pulmonary hypertension specialist is often faced with questions surrounding timing and method of defect closure, which may have significant impact on procedural and long-term morbidity and survival. This review highlights important differences in management between children and adults with ASDs associated with PAH, highlighting indications for closure, operability, types of closure, and long-term outcomes.