Hypertension Specialist Research Articles

HYPERTENSIVE URGENCIES AND EMERGENCIES. A QUESTIONNAIRE AMONG EXCELLENCE CENTERS OF THE EUROPEAN SOCIETY OF HYPERTENSION

Objective: The diagnostic approach as well as drug treatment algorithms for hypertensive urgencies(HU), hypertensive emergencies(HE) and malignant hypertension(MH)may be different across Europe,which may also be true for the knowledge of recently updated scientific information. We aimed to explore these items in the Excellence Center(EC)network of the European Society of Hypertension. Design and method: We conducted an anonymized electronic survey among our ECs Results: Overall, 65 ECs from 17 European and 5 non-European countries participated, mostly residents, clinical specialty was mainly Internal Medicine, Cardiology and Nephrology. The definition of HU was correctly identified by 46.1%, the definition of MH was correctly identified in 27.7%. The use of COX-1 antagonists, COX-2 antagonists, steroids and illicit drugs (cocaine, meth) is regularly investigated in 63.1, 69.2, 87.7 and 89.2%, respectively. Small, standard, large and extra large cuffs are available in 73.8, 93.8, 95.4 and 63.1 %, respectively. BP is measured more than once in almost all centers. Common measures/investigations of organ damage performed are renal function(96.9%), electrocardiogram (95.4%), urinary protein(89.2%), echocardiography(80%), fundoscopy(69.2%), myocardial injury markers (64.6%), and chest radiography(53.8%). Dedicated protocols for management of HU/HE are available in 70.8% of centers. HUs are treated with oral antihypertensives in 70.8%, with i.v. antihypertensives in 20%, and combinations of both in the remainder. HEs are treated with i.v. antihypertensives in 84.6%, with oral antihypertensives in 4.6%, and combinations of both in the remainder. Commonly used antihypertensives in HE are i.v. nitrates(73.8%), i.v. furosemide (64.6%), i.v. labetalol(61.5%), i.v. nitroprusside(41.5%), i.v. urapidil (38.5%), i.v./i.m. clonidine (27.7%), i.v. nicardipine(24.6%), oral captopril(26.2%) and s.l. nifedipine (24.6%), while some of these drugs are not available in up to one quarter of ECs. BP reduction goals in HE have a tendency to depend on the clinical presentation in 44.6%, while achieving less than 25% of BP decrease in 36.9%. Reasons to admit patients to hospital include signs of acute organ damage(90.8%), and inability to decrease BP inspite of i.v. medications(47.7%), whereas a hypertension specialist is consulted in 10.8%. Conclusions: This survey higlights the need to further spread the updated scientific information on the management and treatment of HE and HU.

MANAGING ANXIETY AND STRESS IN HYPERTENSION: DEVELOPMENT OF HEART RATE VARIABILITY BIOFEEDBACK WITH PSYCHOLOGICAL SUPPORT

Objective: How can digital wearable Heart Rate Variability (HRV) biofeedback and psychological support be used to improve the management of anxiety and stress in hypertension? Design and method: A mixed methods study was used to develop and evaluate initial outcomes from a HRV biofeedback intervention for the management of anxiety and stress in hypertension. We used systematic review evidence to guide a series of patient and stakeholder consultations to co-design a HRV biofeedback intervention to assess and treat anxiety and cardiovascular stress reactivity in a hypertension specialist outpatient's service. We evaluated initial outcomes from case studies of 15 patients who attended 2-5 x 1 hour face to face sessions with a Health Psychologist. Sessions involved: 1) assessment of anxiety and stress responses; 2) resonance frequency breathing training with HRV biofeedback with a respiration rate (between 6.5 and 4.5 breaths/minute) to produce optimal baroreflex stimulation and blood pressure regulation; 3) psychological skills development for dealing with anxiety and stress. Results: At 8 weeks follow up, 45% patients reported a 5-10 mmHg systolic reduction in blood pressure and 55% reported a reduction of 10-20 mmHg. 85% of patients reported increased morning HRV readiness scores and improvements in patient reported psychological outcomes (e.g. improvements in BP, anxiety reduction and increase in valued activities). 11 patients reported improved health behaviour change (increased physical activity, improved diet, reduction in alcohol intake). Whitecoat hypertension was improved in 70% of patients. Conclusions: Biofeedback with psychological support can help improve anxiety and stress symptoms, as well as improvements in systolic blood pressure within an integrated specialist hypertension team.

Pseudopheochromocytoma — an epidemic of the modern world? Case series and review of literature

Background: Pseudopheochromocytoma is a condition that occurs more frequently than other diseases presenting with similar symptoms such as: paroxysmal hypertension, diaphoresis, pallor, palpitations. However, due to the lack of specific guidelines and awareness among physicians, it is widely underdiagnosed. Conventional antihypertensive treatment is ineffective in controlling symptoms which leads to decreased quality of life in patients affected by this disorder. Case presentation: In our paper, we present three female patients with paroxysmal hypertension who were admitted to the Department of Endocrinology for an investigation of suspected pheochromocytoma. The biochemical findings and imaging carried out at the hospital ruled out the diagnosis of an adrenal tumor in all three of the patients. Given the proposed criteria the clinical features of the patients were suggestive of pseudopheochromocytoma. In all three cases, the anxiolytic or SSRI treatment was applied with satisfactory symptom control. Conclusions: After ruling out pheochromocytoma in patients presenting with paroxysmal hypertension, physicians should consider a diagnosis of pseudopheochromocytoma. Management of the disorder should include anxiolytic, antidepressant, α-adrenoceptor blockers, and β-adrenoceptor blockers treatment, with close cooperation between hypertension specialist and psychiatrist or psychologist. Early proper diagnosis can reduce emotional distress related to an extensive diagnostic process as well as the overall cost of healthcare in patients with pseudopheochromocytoma.

In Memoriam: Richard H. Grimm, Jr, MD, MPH, PhD (August 22, 1946-September 8, 2022).

In Memoriam: Richard H. Grimm, Jr, MD, MPH, PhD (August 22, 1946-September 8, 2022).

Cancer Therapy-Related Hypertension: A Scientific Statement From the American Heart Association.

Contemporary anticancer drugs have significantly improved cancer survival at the expense of cardiovascular toxicities, including heart disease, thromboembolic disease, and hypertension. One of the most common side effects of these drugs is hypertension, especially in patients treated with vascular endothelial growth factor inhibitors, as well as tyrosine kinase inhibitors and proteasome inhibitors. Adjunctive therapy, including corticosteroids, calcineurin inhibitors, and nonsteroidal anti-inflammatories, as well as anti-androgen hormone therapy for prostate cancer, may further increase blood pressure in these patients. Cancer therapy-induced hypertension is often dose limiting, increases cardiovascular mortality in cancer survivors, and is usually reversible after interruption or discontinuation of treatment. The exact molecular mechanisms underlying hypertension are unclear, but recent discoveries indicate an important role for reduced nitric oxide generation, oxidative stress, endothelin-1, prostaglandins, endothelial dysfunction, increased sympathetic outflow, and microvascular rarefaction. In addition, genetic polymorphisms in vascular endothelial growth factor receptors are implicated in vascular endothelial growth factor inhibitor-induced hypertension. Diagnosis, management, and follow-up of cancer therapy-induced hypertension follow national hypertension guidelines because evidence-based clinical trials specifically addressing patients who develop hypertension as a result of cancer therapy are currently lacking. Rigorous baseline assessment of patients before therapy is started requires particular emphasis on assessing and treating cardiovascular risk factors. Hypertension management follows guidelines for the general population, although special attention should be given to rebound hypotension after termination of cancer therapy. Management of these complex patients requires collaborative care involving oncologists, cardiologists, hypertension specialists, primary care professionals, and pharmacists to ensure the optimal therapeutic effect from cancer treatment while minimizing competing cardiovascular toxicities.

PS-C36-1: CLINICAL INERTIA IN THE HYPERTENSIVE PATIENTS TREATED BY HYPERTENSION SPECIALISTS

Background: Only about 30% of hypertensive patients in Japan is reported to have properly controlled blood pressure (BP). The clinical inertia (Inertia) seems to be one of the factors behind the inadequate BP control. Purpose: We investigate the achievement rate of the BP lowering target in 2020 for outpatients in the division of hypertension, and confirm the prevalence of inertia as a possible factor for the failure to achieve their BP targets. Methods: Subjects were 517 outpatients (mean age 68.6 ± 13.2 years, 54% of women) who regularly visited the division of hypertension from March to September 2020 and took antihypertensive drugs prescribed by hypertension specialists. We calculated the average of office BP (OBP) in the two visits during the same period, and the average of home BP (HBP) for the three days before each two visits. In addition, we investigated the antihypertensive drugs taken during that period and complications such as diabetes and chronic kidney disease, and collected blood chemistry and urine test data. From these data, as of December 2021, the attending doctors determined whether each patient achieved the BP target according to the Japanese Society of Hypertension 2019 (JSH2019), and chose one reason from the options in the patients who failed to achieve target BP. Results: The target for OBP in all subjects was < 130/80 (48%), < 140/90 (140 group, 15%), < 140/90 mandatory, and < 130/80 if tolerable (37%). The percentage of those who achieved each OBP target was 48% (OBP achievers, N = 246). As a result of investigating the reason for the OBP non-achievement (N = 273) by the attending doctors, 20% answered “judged to be the optimal BP level (Optimal)”, 20% answered “due to the white coat effect ”, and then “Inertia” was the next highest at 14%. Regarding the achievement rate of HBP for OBP achievers, 36% did not measure HBP, 38% achieved < 135/85 or < 130/80 (HBP 135), and 26% (N = 65) did not achieve it. Among the HBP 135 other than the 140 group (N = 66), the unachieved rate of < 125/75 was 58% (N = 38). The reasons for non-achievement of HBP (N = 103 in total), “Optimal” was the most common answer (42%), followed by “Inertia” (27%). Conclusion: Inertia existed as a factor explaining insufficient BP control even in the patients treated by hypertension specialists. From now on, in order to increase the rate of achieving the BP target, we should make an effort to overcome inertia.

S-24-3: CURRENT TREND OF HYPERTENSION PRACTICE BY SPECIALISTS AND NON-SPECIALISTS IN THE JAPANESE PRIMARY CARE SETTINGS - J-DOME STUDY

Objective: Measuring the quality of primary care practice in Japan is difficult due to insufficient clinical data. To change the situation, the first nationwide primary care registry trial in Japan called J-DOME was launched for type 2 diabetes mellitus in 2018, and expanded to assess hypertension by 2020. In this cross-sectional analysis, we compare the patients with hypertension managed by hypertension specialists with those by non-specialists in the primary care settings. Design and Method: A total of 2,161 patients with hypertension were registered in 2021 (1,583 by non-specialists and 578 by specialists). Data were registered to the web-based registry system directly by the participating doctors or their staff. Clinic office blood pressure (BP) captured at the last visit (mandatory item), and the most recent self-measured home BP (not mandatory) were registered. The registered data were analyzed and compared between the two groups classified by whether the physicians were hypertension specialists or not. Results: Average age, body mass index (BMI), and duration of hypertension were 69.7 years, 25.3 kg/m2, and 12.8 years in the non-specialist group and 70.5 years, 25.2 kg/m2, and 13.2 years in the specialist group, respectively. The average systolic/diastolic office BP was 134.9/75.2 mmHg in the non-specialist group and 134.9/75.7 mmHg in the specialist group, and patients with systolic BP > = 140 mmHg consisted of 34.2% and 35.8%, respectively. The average home BP was 127.9/75.7 mmHg in the non-specialist group (n = 722, 45.6% of this group registered home BP) and 125.9/74.9 mmHg in the specialist group (n = 419, 72.5%). The HbA1c in the hypertension non-specialist group averaged 6.6% compared with 6.2% in the specialist group (p < 0.001). The ratio of prescribed antihypertensive medications was significantly different between the non-specialist and specialist groups (Figure). As for education on sodium intake, 80.7% of the patients with non-specialists received the education compared to 91.8% of those with specialists, and the average daily sodium consumption was 9.0 g (n = 426) and 8.7 g (n = 365), respectively. Conclusions: Although the office BP and essential characteristics were similar, the evident differences between the specialist and non-specialist groups were identified in hypertensive medications and education on sodium intake. Furthermore, the number of home BP data registered in the non-specialist group was limited, which urges further promotion of home BP measurement. The J-DOME study will continue to call for far more registration to provide the benchmark of practice quality in Japanese primary care settings.

S-24-4: SIGNIFICANCE OF THE JAPAN MEDICAL ASSOCIATION DATABASE OF CLINICAL MEDICINE (J-DOME) IN THE TREATMENT OF HYPERTENSION IN JAPAN

The Japan medical association Database Of clinical MEdicine (J-DOME) was started with the aim of understanding the actual status of real-world diabetes care at the general practitioner level. The Japan Society of Hypertension and the Japan Medical Association have signed an agreement to register hypertension cases in addition to diabetes cases. Hypertension in Japan is a national disease with an estimated 43 million patients. While the average blood pressure is gradually decreasing, and only 27% of patients achieve their antihypertensive goals, a situation also known as the Hypertension Paradox continues. Although the majority of hypertension care in Japan is provided by general practitioners, information on hypertension care to date has been limited to large-scale studies and epidemiological studies conducted mainly at university hospitals and core hospitals, and the information collected by J-DOME is expected to be important in reflecting real-world blood pressure control, antihypertensive drug use, frequency of complications, etc. The information collected by J-DOME is expected to be important in reflecting real-world blood pressure control, antihypertensive drug use, and frequency of complications. J-DOME registers three types of cases: hypertension alone, diabetes alone, and combined hypertension and diabetes, and also allows comparison between specialists and non-specialists, so it is possible to understand what specific cases hypertension specialists are treating, from medication use to control status. In fact, hypertension specialists administer more types of antihypertensive medications to cases with slightly elevated blood pressure, with the result that they achieved the target of blood pressure. In addition, some information on daily salt intake estimated from urinary Na and Cr levels is also collected, which provides valuable information on the average salt intake. The Japan Society of Hypertension has spontaneously established an organization called the Practitioner Subcommittee, which has formed a working group and is conducting various promotional activities to increase the number of cases in conjunction with the society's task force. Specifically, the subcommittee has been promoting J-DOME at various lecture meetings, and reaching out to local medical associations, in order to increase case registration throughout Japan. At this meeting, we would like to discuss the significance of hypertension case registration in J-DOME from various angles, taking into account the contents of the third report published in August 2021.

S-55-1: PRIMARY ALDOSTERONISM – WHERE TO FROM HER E?

Over the past decade there have been remarkable advances in the pathophysiology of primary aldosteronism (PA); in contrast, there has been little if any change in the clinical management of PA for over 20 years. A patient suspected of PA is referred to an expert center, and their medications withdrawn for 4–6 weeks, with CCBs/alpha blockers used if needed to control blood pressure (BP).They undergo a single blood draw for plasma aldosterone concentration (PAC) and plasma renin activity or concentration (PRA/PRC), to establish the aldosterone to renin ratio (ARR). If the ARR 'suggests’ PA, the patient then undergoes confirmatory testing by one of at least five different procedures – to ensure no patient who does not have PA ever slips through the net. There are multiple reasons for change. First, in no country are more than 1% of hypertensives ever screened for PA. Secondly, a single blood draw for PAC is a very imperfect index of a patient’s actual aldosterone status; among those referred many are excluded on the basis of their PAC who in fact have PA. Third, the current work up – in addition to being exclusionary - is demanding and clunky. Fourth, the prevailing attitude among those treating hypertension is that if the BP is controlled all will be well, when in fact patients with PA have a three-fold higher risk profile than matched essential hypertensives with the same BP. What we are thus facing is a major public health crisis. There is finally increasing recognition that the current estimate of PA prevalence (5% - 10% of hypertensives) is far too low, and the actual prevalence in hypertensives is of the order of at least 30% (and of 10% in normotensives). The current protocols are useless facing figures such as these; what is needed are much simpler and inclusive measures to diagnose probable PA – rather than excluding all but the most obvious cases. This will require input not only from endocrinologists, but also from hypertension specialists, internists, primary care and public health physicians. It is important to distinguish newly presenting and established hypertension. When a patient is newly diagnosed with an elevated BP eschew immediate antihypertensive(s) and order a PRA/PRC assay. If renin is not suppressed, onto antihypertensives. If the renin is suppressed coach the patient to provide a 24 h urine collection for Na, K, and urinary excretion of aldosterone (UEA). If the UEA is < 6 mcg/24 h the patient does not have PA; if the UEA is 6–12, the patient may have PA; if the UEA is > 12 the patient has PA. For these two latter categories order 25 mg/d spironolactone and review at four weeks. If BP falls by < 10mmHg onto antihypertensives; if BP falls by > 10 mmHg continue spironolactone. Established hypertension is rather simpler. Add spironolactone 25 mg/d to current medication and review at 4 weeks. If BP falls < 10mmHg, discontinue; if BP falls > 10mmHg order a UEA. If UEA and BP are moderately elevated continue spironolactone, as such patients very probably have bilateral hyperaldosteonism; if UEA and BP are high, refer to an expert center. What this is calling for is a radical reassessment of how physicians should address hypertensive patients. The rationale is to save them from the double jeopardy of hypertension and PA, and the attendant increased morbidity and premature mortality. The time is now.

DB-2-3: ANTIHYPERTENSIVE STRATEGIES IN END-OF LIFE OLD PATIENTS (PRO/CON SESSION)

High blood pressure (BP) especially systolic BP is very common in older persons and is associated with considerable morbidity and mortality. Evidence from a limited number of clinical studies indicates that people 80+ y.o. can get significant benefits from BP lowering treatments and that targeting SBP < 140 mmHg reduces morbidity and mortality. However, these clinical studies excluded patients with high frailty and severe alteration of functionality/autonomy. Indeed, in subjects with this clinical profiles, observational data indicate that low SBP is associated with higher morbidity and mortality particularly in those with antihypertensive medication and multiple other drug regimens. These observations made in very altered or end-of-life patients by several clinical research groups should be taken into account by the clinicians, and therefore deprescription i.e. reduction of the antihypertensive treatment, should be considered in presence of very low SBP levels (<130mmHg). However, this approach should be viewed with great caution: firstly, observational studies provide weak evidence and therefore further data are needed from controlled clinical trials in very old patients with the health condition and of autonomy status described above, i.e. people who have been systematically excluded from clinical trials so far. Second, deprescribing should be done gradually, taking into account comorbidities and patient preferences. Finally, in these patients, emphasis should be given to the quality of life and symptoms relief when choosing therapeutic strategies. Collaboration between hypertension specialists, geriatricians and clinical pharmacists is a key issue in this perspective.

S-21-1: IMPLEMENTING HEARTS HYPERTENSION CONTROL PROJECT IN CHINA

Hypertension is the leading cause of death and disability worldwide, due to its high prevalence and severe complications (stroke, heart attack, etc). Control of hypertension could prevent most unnecessary outcomes. However, detecting hundreds of millions of hypertensive patients globally and controlling BP to target for the rest of their lives could be a huge burden to all health care systems. The HEARTS technical package developed by WHO provides tools for governments and professional organizations to support primary care services (PCS) to apply evidence-based strategies to control and prevent cardiovascular diseases. The HEARTS China hypertension control project was initiated in 2017. It is owned by governments, technically supported by a hypertension specialist committee and managed by the secretariat. The standard protocol with screening for all adult visitors, and stepwise treatment with calcium channel blockers + ARB + thiazide-like diuretic was selected by the advisory committee. The supply of selected medications was supported by governments. The HEARTS monitoring system, with ID card-driven automatic BP measurement and data transfer to the doctors web page (no data entry), records screening, registration and prescriptions during daily practice. The information helps physicians with decision making in diagnosis and treatment and provides regular quality and progress reports to PSCs and health authorities. Up to December 2021, a cumulative total of 894 PSCs participated in the project. They screened more than 620,000 adults, registered over 268,000 and treated 190,000 hypertensive patients. A total of 86,523 patients achieved the goal of BP control at their last visit. The awareness, treatment and control rates improved continuously in the project-involved areas. Consequently, the episodes of hospitalization for cardiovascular disease among all-cause hospitalizations reduced by 13%. It reduced more in the service areas that screened and treated more hypertensive patients, than in those that screened and treated fewer patients (-15% vs -6%). However, the data recorded in the monitoring system indicated serious clinical inertia in the implementation of the HEARTS protocol: screening does not yet involve all visitors; nearly 30% of diagnosed patients were untreated, 70% of treated patients were not regularly followed-up; only 19% of patients with BP> = 160/100 initiated treatment with combined medications; 64% of revisited patients with uncontrolled BP failed to intensify treatment. More training courses and incentive mechanisms may help PSCs to improve the quality of care. Implementing HEARTS has improved quality and coverage for hypertension control. Overcoming clinical inertia should be able to accelerate this progress.

«SGLT2 INHIBITORS: RATIONALE FOR THE USE IN HEART FAILURE», RESOLUTION ON THE RESULTS OF THE PANEL OF EXPERTS WITH INTERNATIONAL PARTICIPATION, ALMATY

Patients with heart failure have a high risk of developing cardiovascular complications, and prevention of thereof requires timely medical care and diagnostic assessment. An expert meeting was held with the participation of the NGO "Society of Specialists in Arterial Hypertension and Cardiovascular Prevention", NGO "Evidence-Based Cardiology", NGO "Association of Endocrinologists of Kazakhstan". On April 29, 2022 a panel of experts discussed the rationale for the use of SGLT2 inhibitors in heart failure. The EMPEROR-Reduced and EMPEROR-Preserved trials analyzed cardiovascular and renal outcomes in empagliflozin treatment in patients with and without type 2 diabetes mellitus (T2DM). Several proposals and recommendations have been adopted for further research on the cardiovascular and renal effects of empagliflozin and its use in clinical practice in patients with chronic heart failure, regardless of the presence of type 2 diabetes.At the experts meeting, issues were considered on the creation of heart failure rooms in outpatient settings and the possibility of studying the concentration of brain natriuretic peptides and performing echocardiography, including the assessment of left ventricular deformity and electrocardiography (ECG).

Does the Naked Emperor Parable Apply to Current Perceptions of the Contribution of Renin Angiotensin System Inhibition in Hypertension?

To address contemporary hypertension challenges, a critical reexamination of therapeutic accomplishments using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, anda greater appreciation of evidence-based shortcomings from randomized clinical trials are fundamental in accelerating future progress. Medications targeting angiotensin II mechanism of action are essential for managing primary hypertension, type 2 diabetes, heart failure, and chronic kidney disease. While the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to control blood pressure is undisputed, practitioners, hypertension specialists, and researchers hold low awareness of these drugs' limitations in preventing or reducing the risk of cardiovascular events. Biases in interpreting gained knowledge from data obtained in randomized clinical trials include a pervasive emphasis on using relative risk reduction over absolute risk reduction. Furthermore, recommendations for clinical practice in international hypertension guidelines fail to address the significance of a residual risk several orders of magnitude greater than the benefits. We analyze the limitations of the clinical trials that have led to current recommended treatment guidelines. We define and quantify the magnitude of the residual risk in published hypertension trials and explore how activation of alternate compensatory bioprocessing components within the renin angiotensin system bypass the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to achieve a significant reduction in total and cardiovascular deaths. We complete this presentation by outlining the current incipient but promising potential of immunotherapy to block angiotensin II pathology alone or possibly in combination with other antihypertensive drugs. A full appreciation of the magnitude of the residual risk associated with current renin angiotensin system-based therapies constitutes a vital underpinning for seeking new molecular approaches to halt or even reverse the cardiovascular complications of primary hypertension and encourage investigating a new generation of ACE inhibitors and ARBs with increased capacity to reach the intracellular compartments at which Ang II can be generated.

Spontaneous, independent, single-center renal denervation registry of a resistant hypertension multidisciplinary team

Abstract Background Uncontrolled resistant hypertension (URH) is defined as PAS ≥140mmHg despite the adherence to at least 3 maximally tolerated doses of antihypertensive medications. In the adult population URH is a common condition with a prevalence that ranges between 10–15% and is related with poor prognosis and higher risk of major adverse cardiovascular events. Renal sympathetic denervation (RDN) has recently proved efficacy in different hypertensive subsets of patients. However, patients with chronic kidney disease (CKD) IIIB-V stages (i.e. glomerular filtrate rate <45 ml/min) have been systematically excluded from randomized clinical trials (RCT). Purpose To evaluate the safety and the efficacy of RDN in a daily practice population of patients with URH on top of medical therapy, including patients with renal function impairment (GFR<45ml/min). Methods Consecutive unselected patients with URH undergoing RDN were enrolled. Indication of RDN was assessed in a multidisciplinary team involving cardiologist, nephrologist and hypertension specialists, after secondary forms of hypertension had been excluded. Efficacy was defined as the inter-individual change of office (OBP) and ambulatory blood pressure monitoring (ABPM) at 3, 6 and 12 months after RDN. Safety as the absence of any device-related major complication (BARC classification), end-stage renal disease, stroke, acute myocardial infarction and any cause of death within 1 month of the procedure. Safety and efficacy profile was assessed in patients with an estimated GFR below 45 ml/min/1.73 m2. Results Seventy-two patients underwent RDN for URH from 2012 to 2022. The population presented with multiple comorbidities and target organ damage: almost 50% were smoker, 43% diabetic, 33% PAD, 25% CAD and 60% CKD. Isolated systolic hypertension prevalence was 53%. The average number of antihypertensive medications at baseline was 5.3±1.1. Baseline OBP and ABPM were 158.8/86.6±23.4/15.3 mmHg and 151.4/87.6±18.8/14.2 mmHg, respectively. The vast majority of the procedures were performed with tetrapolar radio-frequency catheter (91.7%), with 37.3±14.3 number of ablations per procedure. The average amount of contrast medium was 72.1±38.1 ml. At 12-month follow-up a significant reduction of office and ambulatory systolic BP, respectively by −15.66±29.73 mmHg (P<0.01) and by −11.3±23.1mmHg (P<0.05), was noticed. BP reduction at 12-month follow-up among patients with eGFR <45 ml/min was similar to that obtained in patients with higher eGFR. No major complications were observed and renal function was stable up to 12 months, even in patients with lowest eGFR at baseline. Conclusion(s) RDN is safe and feasible in patients with URH on top of medical therapy, even in a high-risk CKD population with multiple comorbidities. Our experience underlines the central role of multidisciplinary team evaluation for the targeted management of uncontrolled resistant hypertension. Funding Acknowledgement Type of funding sources: None.

Primary Aldosteronism: State-of-the-Art Review.

We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.

Quality of life following renal sympathetic denervation in treatment-resistant hypertensive patients: a two-year follow-up study

Objective. Hypertension is a significant health burden. In the last 10 years, renal sympathetic denervation has been tested as a potential treatment option for a select group of patients with treatment-resistant hypertension. The aim of this study was to broadly assess the quality of life in patients undergoing renal sympathetic denervation with two years’ follow-up. Materials and methods. Patients with treatment-resistant hypertension being treated by hypertension specialists were eligible for inclusion in this study. Bilateral renal sympathetic denervation was performed with the Symplicity Catheter System. Quality of life was measured using standardised questionnaires (Short Form 36, 15 D and a single-item question) and an open question before denervation, after six months and after two years. Results. A total of 23 patients were included. The typical participant was male, 53 years, had a mean office blood pressure of 162/108 mmHg, body mass index of 32 kg/m2, and was prescribed 4.8 blood pressure lowering drug classes. At baseline, both physical and mental aspects of quality of life were affected negatively by the treatment-resistant hypertension. Over time, there were modest improvements in quality of life. The largest improvements were seen at six months. Simultaneously, the mean number of blood pressure lowering drug classes was reduced to 4.2. Conclusion. Following renal sympathetic denervation treatment, some aspects of health related quality of life showed an improved trend during follow-up. The observed improvement may reflect the impact of a reduced number of blood pressure lowering drug classes. Clinical Trial Number registered: NCT01630928

EVALUATION OF A DIGITAL THERAPY FOR UNCONTROLLED HYPERTENSIVE PATIENTS FOLLOWED BY GENERAL PRACTITIONERS IN FRANCE

Objective: The digital therapy was designed by hypertension specialists and included - a touch-sensitive tablet (Vodafon smart tab 3G) and an automatic blood pressure, connected via Bluetooth to the tablet (ihealth, BKN-550BT), a web portal developed specifically for the study with access reserved for health professionals involved in the follow-up of hypertensive patients. The health data were hosted on an accredited server. Design and method: The digital therapy was designed by hypertension specialists and included - a touch-sensitive tablet (Vodafon smart tab 3G) and an automatic blood pressure, connected via Bluetooth to the tablet (ihealth, BKN-550BT), a web portal developed specifically for the study with access reserved for health professionals involved in the follow-up of hypertensive patients. The health data were hosted on an accredited server. - as software for the patient, several applications specifically developed to 1) perform home blood pressure monitoring over 3 days 2) monitor treatment compliance (GIRERD questionnaire) 3) detect excessive salt consumption (ExSel questionnaire) for the physician a web interface specifically developed to 1) know the results of the remote monitoring of each patient 2) help to follow the recommendations of the ESH for the associations of antihypertensive drugs 3) obtain if necessary the opinion of a Hypertension specialist after a request written by e-mail. 77 patients treated for uncontrolled primary hypertension at office visit despite the prescription of bi-therapy were randomized into 2 groups: a group in which the physician had access to functions 2 and 3 of the website, and a control group in which the physician did not have access to functions 2 and 3 of the website. All patients were instructed to use the 1 2 3 applications once every 3 weeks for a total of 3 months. Results: The patients included were 63 ± 7 years old. 32.5% of patients used the entire program and completed 4 HBPM and visited the physician again at the final visit. The table shows the main results by randomization group: Conclusions: A digital therapy developed by hypertension specialists is effective in improving hypertension control in patients followed by general practitioners in France.

ADVANTAGES AND LIMITATIONS OF USING THE AKTIIA CUFFLESS BRACELET FOR A HYPERTENSION SPECIALIST

Objective: The AKTIIA bracelet was the first cuffless blood pressure monitor available in Europe over the counter. While published medical data show the validity of the measurement system compared to traditional blood pressure measurements, the objective of this preliminary study was to assess the value of the AKTIIA bracelet in the care of treated hypertensive patients. Design and method: Two bracelets were provided by the manufacturer to university cardiologist, specialist in hypertension. They were assigned to two hypertensive patients treated with antihypertensive drugs: one 62 years old treated with nebivolol 5 mg for 1 month and then with nebivolol 5 mg + candesartan 4 mg for the following 2 months, the other 52 years old treated with irbesartan 150 mg for 3 months. They were instructed to wear the bracelet for 3 consecutive months and following the manufacturer’s instructions to perform a calibration on 3 occasions. The patients performed also home blood pressure monitoring for 3 days with 6 measures per day once a month while wearing the bracelet on the other arm. Results: Over the same time periods, SYS/DIA values were accurately comparable between the AKTIIA bracelet and HBPM Conclusions: The AKTIIA bracelet, the first cuffless blood pressure monitor available in Europe over the counter, is currently proposed for blood pressure monitoring in healthy subjects. Its technological properties make it possible to use it for the follow-up of patients treated for hypertension. Some evolutions are desirable to facilitate its use by hypertension specialists. The cuffless method which allows blood pressure measurements without disturbing sleep constitutes a breakthrough in the management of hypertensive patients.

URINARY ALBUMIN EXCRETION CHANGES AFTER ADRENALECTOMY IN PATIENTS WITH PRIMARY ALDOSTERONISM

Objective: We aimed to evaluate changes in urinary albumin excretion (UAE) in patients with primary aldosteronism (PA) after adrenalectomy compared with those who remained with non-surgical treatment. Design and method: We evaluated 28 patients with PA diagnosed by adrenal venous sampling (AVS), attended by hypertension specialists or endocrinologists in Hospital del Mar, Barcelona. Office blood pressure (BP), body weight and laboratory parameters (estimated glomerular filtration rate by CKD-EPI equation (eGFR), plasma potassium (K) and UAE) were analyzed before and at 6 months after adrenalectomy (Adx group) or before and 6 months after AVS (non-Adx group). Results: Most patients (66.7%) were male and the mean age was 55.8 ± 9.6 years. Twelve patients (42.8%) underwent adrenalectomy and 16 (57.1%) remained on pharmacological treatment alone. Spironolactone was the principal antihypertensive treatment in the non-Adx group (84.6% of patients). The proportion of diabetes mellitus was similar in both groups (12.5% in Adx group vs 16.2% in non-Adx group, p = 0.6). The decrease in BP was statistically significant in both groups (table 1). Adx group patients showed a statistically significant reduction in the UAE (-7.7 [-33.2 to -4.0] mg/g, p = 0.002) compared to patients in non-Adx group (+0.1 [-6.5 to + 24.9], p = 0.8). After six months, the mean reduction in UAE (log-transformed) was significantly superior in the Adx group than in the non-Adx group. After adjusting by variation of systolic-BP and variation of body weight, a mean difference between the two groups of -0.966 mmHg (95% CI -1.746 to -1.182); p = 0.018 was observed. Conclusions: Patients with PA who underwent adrenalectomy presented a higher reduction in UAE than patients who remained on pharmacological treatment alone.

Ophthalmic artery peak systolic velocity ratio distinguishes pre-eclampsia from chronic and gestational hypertension: Aprospective cohort study.

To examine whether the ophthalmic artery peak systolic velocity ratio (OA PSV-ratio) is higher in women with pre-eclampsia compared with gestational hypertension (GH) and chronic hypertension (CH), after controlling for confounding variables. Prospective cohort. Specialist hypertension clinic in a tertiary referral centre. Singleton pregnancies presenting between 32+0 and 36+6 weeks of gestation with pre-eclampsia (n=50), GH (n=54) and CH (n=56). Paired measurements of maternal mean arterial pressure (MAP) and OA PSV-ratio were performed by trained sonographers. Multiple linear regression was fitted to the OA PSV-ratio, including maternal characteristics and medical history, GH, pre-eclampsia and MAP and use of antihypertensive medication. Whether pre-eclampsia is independently associated with higher OA PSV-ratio. MAP was significantly higher in both GH (p=0.0015) and pre-eclampsia (p=0.008) than in CH pregnancies. There was no significant difference between pre-eclampsia and GH (0.670). The OA PSV-ratio was significantly higher in pre-eclampsia than CH (p=0.0008) and GH (p=0.015). There was no significant difference between the OA PSV-ratio in CH and GH (p=0.352). Multiple linear regression modelling showed that the OA PSV-ratio was influenced by maternal weight (p=0.005), maternal age (p=0.014), antihypertensive medications (p=0.007) and MAP (p<0.0001). After controlling for these variables, the OA PSV-ratio was still significantly higher in those with pre-eclampsia (p=0.0002). The OA PSV-ratio is influenced by maternal weight, age, antihypertensive medications and MAP. Pre-eclampsia is an independent predictor of OA PSV-ratio, which therefore may be a useful point-of-care test when assessing women presenting with hypertension.