Lower Baseline Systolic Blood Pressure Research Articles

Association of Sacubitril/Valsartan vs Valsartan With Blood Pressure Changes and Symptomatic Hypotension: the PARAGLIDE-HF Trial

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

Hypotension in heart failure is less harmful if associated with high or increasing doses of heart failure medication: Insights from the Swedish Heart Failure Registry.

Heart failure (HF) medication may reduce blood pressure (BP). Low BP is associated with worse outcomes but how this association is modified by HF medication has not been studied. We evaluated the association between BP and outcomes according to HF medication dose in HF with reduced ejection fraction (HFrEF). We studied HFrEF patients from the Swedish HF registry (2000-2018). Associations between systolic BP (SBP) and cardiovascular death (CVD) and/or HF hospitalization (HFH) were analysed according to doses of renin-angiotensin system (RAS) inhibitors, beta-blockers and mineralocorticoid receptor antagonists (MRA). Among 42 040 patients (median age 74.0), lower baseline SBP was associated with higher risk of CVD/HFH (adjusted hazard ratio [HR] per 10 mmHg higher SBP: 0.92, 95% confidence interval [CI] 0.92-0.93), which was less high risk under optimized RAS inhibitor and beta-blocker doses (10% decrease in event rates per 10 mmHg SBP increase in untreated patients vs. 7% decrease in patients at maximum dose, both adjusted p < 0.02). Among the 13 761 patients with repeated measurements, 9.9% reported a SBP decrease >10 mmHg when HF medication doses were increased, whereas 24.6% reported a SBP decrease >10 mmHg with stable/decreasing doses. Decreasing SBP was associated with higher risk of CVD/HFH in patients with stable (HR 1.10, 95% CI 1.04-1.17) or decreasing (HR 1.29, 95% CI 1.18-1.42) HF medication dose but not in patients with an increase in doses (HR 0.94, 95% CI 0.86-1.02). The association of lower SBP with higher risk of CVD/HFH is attenuated in patients with optimized HF medication. These results suggest that low or declining SBP should not limit HF medication optimization.

Parkinson´s disease cardiovascular symptoms: A new complex functional and structural insight.

The known impairments of the cardiovascular system in Parkinson´s disease (PD) are caused by autonomic dysfunction and manifested mainly in postural hypotension, chronotropic insufficiency, and reduced heart rate variability. Other dysfunctions, mainly stress response, arrhythmia occurrence, and heart morphology changes, are still the subject of research. To assess the heart rate and blood pressure reaction during exercise, advanced measurements of heart volumes and mass using cardiac magnetic resonance (CMR), and occurrence of arrhythmias in PD patients. Thirty PD patients (19 men, mean age 57.5 years) without known cardiac comorbidities underwent bicycle ergometry, electrocardiogram Holter monitoring and CMR. Exercise and CMR parameters were compared with controls (24 subjects for ergometry, 20 for CMR). PD patients had lower baseline systolic blood pressure (SBP) (117.8 vs. 128.3 mmHg, p < 0.01), peak SBP (155.8 vs. 170.8 mmHg, p < 0.05), and lower heart rate increase (49.7 vs. 64.3 beats per minute, p < 0.01). PD patients had higher indexed left and right ventricular end-diastolic volumes (68.5 vs. 57.3, p = 0.003 and 73.5 vs. 61.0 mL/m2 , respectively) and also indexed left and right ventricular end-systolic volumes (44.1 vs. 39.0, p = 0.013 and 29.0 vs. 22.0 mL/m2 , p = 0.013, respectively). A high prevalence of atrial fibrillation (8 subjects, 26.7%) was found. This novel study combining functional and structural approaches showed that PD is linked with weaker blood pressure and heart rate reaction during exercise, increased myocardial mass and heart volumes compared to controls, and a high prevalence of atrial fibrillation.

Effect of Telehealth Services on Mitral and Tricuspid Regurgitation Progression: Retrospective Study.

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are common cardiac conditions with high mortality risks, which can be improved through early intervention. Telehealth services, which allow for remote monitoring of patient conditions, have been proven to improve the health management of chronic diseases, but the effects on MR and TR progression are unknown. This study aimed to explore whether patients receiving telehealth services have less MR and TR progression compared with a control group. We also aimed to identify the determinants of MR and TR progression. This single-center retrospective study conducted at the National Taiwan University Hospital compared MR and TR progression (defined as either progression to moderate or greater MR and TR or MR and TR progression by ≥2 grades during the study period) between the telehealth and control groups. Patients had a minimum of 2 transthoracic echocardiograms at least 6 months apart; baseline mild-moderate MR and TR or lower; and no prior surgeries on the mitral or tricuspid valve. Telehealth patients were defined as those who received telehealth services for at least 28 days within 3 months of baseline. Basic demographics, baseline blood pressure measurements, prescribed medication, and Charlson Comorbidity Index components were obtained for all patients. A total of 1081 patients (n=226 in the telehealth group and n=855 in the control group) were included in the study analyses. The telehealth group showed significantly lower baseline systolic blood pressure (P<.001), higher Charlson Comorbidity Index (P=.02), higher prevalence of prior myocardial infarction (P=.01) and heart failure (P<.001), higher beta-blocker (P=.03) and diuretic (P=.04) use, and lower nitrate use (P=.04). Both groups showed similar cardiac remodeling conditions at baseline. Telehealth was found to be neutral for both MR (hazard ratio 1.10, 95% CI 0.80-1.52; P=.52) and TR (hazard ratio 1.27, 95% CI 0.92-1.74; P=.14) progression. Determinants for moderate or greater MR progression included older age, female sex, diuretic use, larger left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction. Determinants of moderate or greater TR progression included older age, female sex, diuretic use, presence of atrial fibrillation, LA dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction; statin use was found to be protective. This is the first study to assess the association between telehealth services and the progression of MR and TR. Telehealth patients, who had more comorbidities, displayed similar MR and TR progression versus control patients, indicating that telehealth may slow MR and TR progression. Determinants of MR and TR progression included easy-to-measure traditional echo parameters of cardiac function, older age, female sex, and atrial fibrillation, which can be incorporated into a telehealth platform and advanced alert system, improving patient outcomes through personalized care.

Blood Pressure and Body Composition During First Year of Antiretroviral Therapy in People With HIV Compared With HIV-Uninfected Community Controls.

Body composition changes may explain the rapid increase in blood pressure (BP) in people with HIV (PWH) during the first year of antiretroviral therapy. We analyzed data from a cohort of PWH and HIV-uninfected adults from the same communities in Mwanza, Tanzania. Blood pressure (BP, mm Hg) and body composition data were collected at baseline and 12-month follow-up. We used multivariable linear regression to compare BP changes in PWH and HIV-uninfected adults, and the relationship between changes in body composition and changes in BP. BP data were available for 640 PWH and 299 HIV-uninfected adults. Sixty-four percent were women and the mean age was 38 years. In PWH, systolic BP (SBP) increased (114-118) whereas SBP decreased (125-123) in HIV-uninfected participants. Fat mass increased by 1.6 kg on average in PWH and was strongly associated with the change in BP (P < 0.001). The greater increase in SBP in PWH was partly explained by the lower baseline SBP but PWH still experienced a 2.2 (95% CI: 0.3-4.2) greater increase in SBP after adjustment. Weight gain partially mediated the relationship between HIV and SBP increase in PWH; a 1-kg increase in fat mass accounted for 0.8 (95% CI: 0.6-1.1) increase in SBP. Weight and fat mass increase rapidly in PWH during the first 12 months of antiretroviral therapy and contribute to a rapid increase in SBP. Interventions to prevent excessive increase in fat mass are needed for PWH.

Utility of PREDICT-HF score in high-risk Asian heart failure patients receiving sacubitril/valsartan.

ObjectiveThe aim of this study was to investigate the application of sacubitril/valsartan in clinical practice and the utility of PREDICT-HF score for outcome prediction in Asian heart failure patients with difference risk profiles.MethodsThe TAROT-HF study was a multicenter, single-arm, observational study. Totally 1,187 outpatients with HFrEF treated with sacubitril/valsartan were enrolled and categorized by: (1) high-risk group with ≥1 of the following three risk factors: old age (≥80 years), low baseline systolic blood pressure (<100 mmHg), and renal impairment (eGFR <30 ml/min/1.73 m2), and (2) standard-risk group, those who did not have any risk factors. Clinical outcomes were assessed using the PREDICT-HF risk model.ResultsA total of 305 (25.7%) patients matched the criteria for the high-risk group. The event rates of cardiovascular death or first unplanned heart failure hospitalization (HFH) among the overall population, high-risk, and standard-risk groups were 13.7, 24.9, and 10.8 events per 100 patient-years, respectively. The C statistics for the PREDICT-HF model in the overall cohort and high-risk group for cardiovascular death or first unplanned HFH at 2 years were 0.73 (95% CI 0.70–0.76) and 0.71 (95% CI 0.65–0.76), respectively. The permanent discontinuation rate among the high-risk patients was significantly higher than that among the standard-risk patients (8.3 vs. 2.5 per 100 patient-years, p < 0.001).ConclusionsReal-world outcomes of the TAROT-HF study demonstrated that the PREDICT-HF model performed well in Asian HFrEF patients. Three easily detected clinical profiles of age, renal function, and systolic BP could help to identify patients at risk before initiating sacubitril/valsartan.

Abstract 12257: The Utility of PREDICT-HF Score in High-Risk Asian Heart Failure Patients Receiving Sacubitril/Valsartan Treatment

Introduction: Although the efficacy and safety of sacubitril/valsartan (Sac/val) for treating patients with heart failure and reduced ejection fraction (HFrEF) have been shown in global clinical trials, long-term tolerability and effectiveness data from Asian patients are limited. Hypothesis: The aim of this study was to investigate the effectiveness and tolerability of Sac/val in clinical practice and the utility of PREDICT-HF score for outcome prediction in Asian heart failure patients with difference risk profiles. Methods: The TAROT-HF study was a multicenter, single-arm, observational study. Totally 1,187 outpatients with HFrEF treated with Sac/val were enrolled and categorized by: (1) high-risk group with one or more of the following three risk factors: old age (≥80 years), low baseline systolic blood pressure (&lt;100mmHg), and renal impairment (eGFR &lt;30ml/min/1.73 m2), and (2) standard-risk group, those who did not have any risk factors. Clinical outcomes were assessed using the PREDICT-HF risk model. Results: A total of 305 (25.7%) patients matched the criteria for the high-risk group. The event rates of cardiovascular death or first unplanned heart failure hospitalization (HFH) among the overall population, high-risk, and standard-risk groups were 13.7, 24.9, and 10.8 events per 100 patient-years, respectively. The C statistics for the PREDICT-HF model in the overall cohort and high-risk group for cardiovascular death or first unplanned HFH at 2 years were 0.73 (95% CI 0.70-0.76) and 0.71 (95% CI 0.65-0.76), respectively. Conclusions: Real-world outcomes of the TAROT-HF study showed good tolerability of Sac/val. Although the current study enrolled high-risk patients not included in the PARADIGM-HF trial, the PREDICT-HF model performed well in real-world Asian HFrEF patients. Three easily detected clinical profiles of age, renal function, and systolic BP could help to identify patients at risk before initiating Sac/val therapy.

Abstract 9931: Baseline Characteristics of Patients with Peripartum Cardiomyopathy; Mortality versus Left Ventricular Ejection Fraction Recovery Groups

Introduction: Data about long term outcomes among patients with peripartum cardiomyopathy (PPCM) is limited. According to the 2018 ESC guideline for the management of cardiovascular disease during pregnancy, three factors are associated with adverse outcomes including baseline LVEF &lt; 30%, LVEDD ≥ 60 mm, and right ventricular involvement. Purpose: To identify the baseline characteristics between two groups of patients with PPCM; patients with LVEF recovery within first year after diagnosis and patients who died within the same period after diagnosis. Also to identify the specific outcomes of the two groups. Methods: Retrospectively data were analyzed including patients with PPCM who had LVEF recovery within first year of diagnosis versus patients who died within one year after diagnosis. Data collected at cardio-obstetric clinic between January 2015 - November 2020. Results: Total number of patients who died within the first years were six patients while the total number of patients who had LVEF recovery within 1 year was 14 patients. Their clinical characteristics and outcomes are shown in table 1. Conclusions: Mortality group had less hypertension co-morbid disease, lower baseline systolic blood pressure, higher heart rate, lower LVEF, more right ventricular dysfunction, and less to be diagnosed in the postpartum period compared with LVEF recovered group. Use of spironolactone and bromocriptine were limited among both groups and light should be focus on this gap to be bridged. Lower rate of ACE-inhibitor use among mortality group may be explained by lower systolic blood pressure in this cohort. Most of the patients had LVEF recovery within the first 6-month and most of the patients in the other group died within the same period with sudden cardiac death as the leading cause of mortality.

Blood Pressure and Safety Events With Vericiguat in the VICTORIA Trial.

BackgroundAlthough safety and tolerability of vericiguat were established in the VICTORIA (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) trial in patients with heart failure with reduced ejection fraction, some subgroups may be more susceptible to symptomatic hypotension, such as older patients, those with lower baseline systolic blood pressure (SBP), or those concurrently taking angiotensin receptor neprilysin inhibitors. We described the SBP trajectories over time and compared the occurrence of symptomatic hypotension or syncope by treatment arm in potentially vulnerable subgroups in VICTORIA. We also evaluated the relation between the efficacy of vericiguat and baseline SBP.Methods and ResultsAmong patients receiving at least 1 dose of the study drug (n=5034), potentially vulnerable subgroups were those >75 years old (n=1395), those with baseline SBP 100–110 mm Hg (n=1344), and those taking angiotensin receptor neprilysin inhibitors (n=730). SBP trajectory was plotted as mean change from baseline over time. The treatment effect on time to symptomatic hypotension or syncope was evaluated overall and by subgroup, and the primary efficacy composite outcome (heart failure hospitalization or cardiovascular death) across baseline SBP was examined using Cox proportional hazards models. SBP trajectories showed a small initial decline in SBP with vericiguat in those >75 years old (versus younger patients), as well as those receiving angiotensin receptor neprilysin inhibitors (versus none), with SBP returning to baseline thereafter. Patients with SBP <110 mm Hg at baseline showed a trend to increasing SBP over time, which was similar in both treatment arms. Safety event rates were generally low and similar between treatment arms within each subgroup. In Cox proportional hazards analysis, there were similar numbers of safety events with vericiguat versus placebo (adjusted hazard ratio [HR], 1.18; 95% CI, 0.99–1.39; P=0.059).No difference existed between treatment arms in landmark analysis beginning after the titration phase (ie, post 4 weeks) (adjusted HR, 1.14; 95% CI, 0.93–1.38; P=0.20). The benefit of vericiguat compared with placebo on the primary composite efficacy outcome was similar across the spectrum of baseline SBP (P for interaction=0.32).ConclusionsThese data demonstrate the safety of vericiguat in a broad population of patients with worsening heart failure with reduced ejection fraction, even among those predisposed to hypotension. Vericiguat’s efficacy persisted regardless of baseline SBP.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02861534.

Systolic Blood Pressure Time in Target Range and Cardiovascular Outcomes in Patients With Hypertension

BackgroundStandard blood pressure control metrics may not account for fluctuations in blood pressure over time. ObjectivesThis study sought to estimate the independent association between time in systolic blood pressure target range and major adverse cardiovascular events among adults with hypertension. MethodsThis study was a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial), a randomized clinical trial that compared intensive (<120 mm Hg) and standard (<140 mm Hg) systolic blood pressure treatment interventions in adults with hypertension and high cardiovascular risk. Target range was defined as 110 to 130 mm Hg and 120 to 140 mm Hg for the intensive and standard arms, respectively. Time in target range was estimated over the first 3 months of follow-up using linear interpolation. The association between time in target range with major adverse cardiovascular events was estimated using adjusted Cox proportional hazards regression models. ResultsParticipants with greater time in target range were younger, had lower 10-year cardiovascular risk and lower baseline systolic blood pressure, and were more likely women and statin users. Each 1-SD increase in time in target range was significantly associated with a decreased risk of first major adverse cardiovascular event in fully adjusted models. Time in target range remained significantly associated with major adverse cardiovascular events despite adjustment for mean systolic blood pressure or systolic blood pressure variability. Among participants with mean systolic blood pressure at or below target, time in target range remained associated with major adverse cardiovascular events. ConclusionsTime in systolic blood pressure target range independently predicts major adverse cardiovascular event risk.

Nonresponse to Acute Vasodilator Challenge and Prognosis in Heart Failure With Pulmonary Hypertension

BackgroundAn acute vasodilator challenge is recommended in patients with heart failure and pulmonary hypertension during heart transplant evaluation. The aim of the study was to assess which hemodynamic parameters are associated with nonresponsiveness to the challenge. Methods and ResultsThis study is a retrospective analysis of 402 patients with heart failure with pulmonary hypertension who underwent right heart catheterization and a pulmonary vasodilator challenge. Among the 140 who fulfilled the transplant guidelines eligibility criteria for the vasodilator challenge, 38 were responders and 102 nonresponders. At multivariable analysis, a diastolic blood pressure of <70 mm Hg, pulmonary vascular resistance of >5 Woods units, and pulmonary artery compliance of <1.2 mL/mm Hg were independently associated with poor response to vasodilator challenge (all P < .001). The presence of any 2 of these 3 conditions was associated with a 90% probability of being a nonresponder. The covariate-adjusted hemodynamic predictors of death in the entire population were a low baseline systolic blood pressure (P = .0017) and a low baseline right ventricular stroke work index (P = .0395). ConclusionsIn patients with heart failure and pulmonary hypertension, low pulmonary arterial compliance, high pulmonary vascular resistance, and low diastolic blood pressure predict the nonresponsiveness to acute vasodilator challenge whilst a poor right ventricular function predicts a dismal prognosis.

Progression of coronary atherosclerosis in patients without standard modifiable risk factors

Background and aimsThe outcome of patients with clinical coronary artery disease despite traditional risk factors is poorly understood. MethodsClinical characteristics and plaque burden on serial intravascular ultrasonography were compared in patients without (n ​= ​165) and with (n ​= ​492) standard modifiable risk factors after matching on age, sex and use of statins from a database of 5823 patients participating in clinical trials of anti-atherosclerotic therapies. ResultsPatients without standard modifiable risk factors had lower baseline systolic blood pressure (118 ​± ​12 vs. 129 ​± ​17 ​mmHg, p ​< ​0.001), low-density lipoprotein cholesterol (87 ​± ​21 vs. 104 ​± ​34 ​mg/dl, p ​< ​0.001), triglycerides [106 vs. 136 ​mg/dl, p ​< ​0.001)] and C-reactive protein [1.5 vs. 2.1 ​mg/l, p ​= ​0.001]. At baseline, patients without modifiable risk factors had a lower percent atheroma volume (35.7 ​± ​8.6 vs. 38 ​± ​8.8%, p ​= ​0.004) and total atheroma volume (174.7 ​± ​80 vs. 190.9 ​± ​84 ​mm3, p ​= ​0.03) and less images with calcification (22.2 vs. 26.5%, p ​= ​0.025). The use of aspirin and statin prior to and during the trials was similar. The use of ACE inhibitors and beta blockers was lower in the no risk factor group prior to and during the trials. The change in percent atheroma volume (−0.2 ​± ​2.8 vs. −0.1 ​± ​3.6%, p ​= ​0.71), total atheroma volume (−5.5 ​± ​23.4 vs. −3.8 ​± ​22.7 ​mm3, p ​= ​0.42), and the percentage of patients demonstrating any degree of progression (50.9% vs 45.1%, p ​= ​0.20) were similar in those without and with standard modifiable risk factors, respectively. ConclusionPatients who develop clinical coronary atherosclerosis without standard modifiable risk factors have similar rates of plaque progression to those with traditional risk factors.

Hypertension, hypotension, longevity and dementia.

High blood pressure at midlife has been consistently identified as a risk factor for dementia in late life, while dementia onset is typically associated with a subsequent decline of blood pressure values. A previous meta-analysis of randomized controlled studies of anti-hypertensive treatment in old age has shown a borderline effect of active treatment in reducing the risk of dementia. The cognitive sub-studies of SPRINT (SPRINT-MIND) and of HOPE-3, published in 2019, were aimed at assessing the cognitive effect of aggressive antihypertensive treatment. In SRINT-MIND, that included subjects with high vascular risk, the risk of dementia (primary outcome) did not differ between groups, but the risk of mild cognitive impairment was significantly reduced in the treatment group. Conversely in HOPE-3, that included subjects with intermediate vascular risk, no significant cognitive effect was observed, with a trend for a better outcome in the placebo arm in the subgroup with lower baseline systolic blood pressure. These data add to observational studies showing detrimental cognitive effect of lower blood pressure values in very old subjects, with cognitive impairment, disability, and complex health problems. Regarding longevity, observational studies confirm protective effects of lower blood pressure values, although systolic blood pressure <130 mmHg are associated with greater mortality risk in subjects with cognitive and/or motor impairment. On the whole antihypertensive treatment might decrease the risk of cognitive impairment in older, robust, high vascular risk subjects. Yet the presence of cognitive impairment might modify the prognostic effect of antihypertensive treatment and advise against aggressive blood pressure lowering.

Assessment of Risk Factor for Developing Acute Kidney Injury in the Setting of Acute ST Elevation Myocardial Infarction

Background: An acute kidney injury (AKI) is a recognized complication in patients with ST elevation myocardial infarction (STEMI) by several mechanisms and it adversely affects morbidity and mortality on long-term bases (1, 2, and 3). Few studies have investigated which patients with STEMI are at risk of developing AKI (6), and this study is aiming to do this assessment. Patients and Methods: We enrolled patients with STEMI who were admitted to the CCU. KDIGO definitions was utilized to search for development of AKI in these patients throughout their stay in the CCU (their baseline serum creatinine was measured and traced daily thereafter; and their urine output was monitored). Common epidemiological and some relevant medical parameters were recorded for all patients. Results and conclusion: low baseline systolic blood pressure, ejection fraction % and estimated glomerular filtration rate (eGFR); in addition to use of diuretics; are the major risk factors for the development of AKI in the setting of STEMI.

Determinants of aortic root dilatation over time in patients with essential hypertension: The Campania Salute Network.

Determinants of changes of aortic root dimension over time are not well defined. We investigated whether specific phenotype and treatment exist predicting changes in aortic root dimension in hypertensive patients from the Campania Salute Network. N = 4856 participants (age 53 ± 11 years, 44% women) were included. At first and last available echocardiograms, we measured aortic root and a z-score of aortic root (AOz) was generated as the difference between measured and predicted aortic root, derived from a healthy reference population. Aortic root dilatation (ARD) was defined as AOz >75th percentile of distribution. At baseline, 3642 patients (75%) exhibited normal aortic root, and 1214 (25%) ARD. After a follow-up of 6.1 years (interquartile range 3.0-8.8 years), 366 (11%) patients with initial normal aortic root exhibited ARD, whereas 457(38%) with initial ARD exhibited normal aortic root. At multivariate analysis patients with incident ARD were most likely to be women, obese, with left ventricular hypertrophy, lower systolic but higher diastolic blood pressure and stroke volume index at baseline, and higher average value of diastolic blood pressure during follow-up (p < 0.05); whereas patients normalizing their ARD were non-obese women with lower baseline systolic blood pressure, stroke volume index, average diastolic blood pressure during follow-up and longer follow-up time (p < 0.05). Anti-renin-angiotensin system (anti-RAS) was associated with 45% greater probability to normalize aortic root dimension. Volume (stroke volume index) and pressure loads (diastolic blood pressure) influence aortic root dimension over time. Aortic root normalization, reflecting a more favourable haemodynamic load, is predictable in non-obese women with lower diastolic blood pressure, taking more anti-RAS therapy. This suggest that sex elicits a different response in aortic walls to pathological stimuli.

Effects of Baseline Systolic Blood Pressure on Outcome in Ischemic Stroke Patients With Intravenous Thrombolysis Therapy: A Systematic Review and Meta-Analysis.

Baseline systolic blood pressure (SBP) is an important parameter that can significantly influence the outcome in ischemic stroke patients who received intravenous thrombolysis, but the target baseline SBP for optimal outcome is uncertain. This study aimed to assess the relationship between baseline SBP and outcome. Studies that evaluated the association between the baseline SBP and the outcome of patients undergoing thrombolytic therapy were sought. Data were extracted according to a predefined data extraction form and then analyzed by STATA 12.0 software. The primary endpoint was the occurrence of good outcomes measured by a modified Rankin Scale score at 3 months, while the secondary endpoint was the occurrence of intracranial hemorrhage and death. Eleven studies involving a total of 33,263 patients were included. Pooled data suggested that the odds of good outcome was decreased by 7% per 10 mm Hg increase in baseline SBP (odds ratio=0.93; 95% confidence interval: 0.91-0.94; P<0.001). Patients with higher baseline SBP were more likely to have intracranial hemorrhage (odds ratio=1.12 per 10 mm Hg increase; 95% confidence interval: 1.08-1.16, P<0.001). This study suggested that lower baseline SBP may be positively associated with a greater chance of good outcome and less chance of intracranial hemorrhage. However, this effect was reliable only when the baseline SBP was within a certain range, which has not been explicitly stated. Therefore, more well-designed studies are needed to define the optimal baseline SBP.

Impact of Patient and Model of Care Factors on Titration and Tolerability of Sacubitril/Valsartan: An Early Australian Real-World Experience

Sacubitril/valsartan was shown to be superior to enalapril in the Prospective Comparison of angiotensin receptor neprilysin inhibitor with an angiotensin converting enzyme inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) study. However, the study design raised uncertainty about the potential real-world tolerability amongst less well selected cohorts. We aimed to examine the real-world tolerability and factors associated with successful titration of sacubitril/valsartan. We performed a retrospective single centre analysis in a tertiary referral centre of 235 consecutive patients prescribed sacubitril/valsartan between August 2016 and January2018. At baseline, our patients were younger, had lower baseline systolic blood pressure (SBP), reduced ischaemic aetiology and a higher rate of mineralocorticoids receptor antagonist compared to PARADIGM-HF. At last assessment, 120 patients (51%) reached target dose (97/103 mg bi-daily [BD]), 67 patients (29%) were stable on a mid-range dose (≥49/51 mg BD), 22 patients (9%) tolerated the low dose (24/26 mg BD) and 26 patients (11%) discontinued, comparable to PARADIGM-HF. Adverse effects were similar to PARADIGM-HF and hypotension remained the primary reason of sub-maximal titration. Several baseline characteristics were associated with successful titration to target dose including; higher baseline body mass index, systolic blood pressure (SBP) and sodium, male gender and treatment coordinated by multidisciplinary heart failure (HF) clinic. Comparable results to PARADIGM-HF in attaining target dose of sacubitril/valsartan and tolerability profile can be achieved in a real-world setting. Several baseline characteristics involving patient factors, markers of disease severity and systems of care predict successful titration to the target dose 97/103 mg BD.

Effects of benzodiazepines on orthostatic blood pressure in older people

BackgroundOlder people taking benzodiazepines (BDZs) have higher risk of falling, which is mainly attributed to cognitive and psychomotor effects. BDZs may also have hypotensive effects. We investigated the association between BDZs and orthostatic blood pressure behaviour in older people. MethodsWe retrospectively analysed data from an outpatient clinic where people aged 60 or older underwent a geriatric assessment. Non-invasive beat-to-beat orthostatic systolic blood pressure (SBP) was assessed at regular time intervals before and after an active stand test. We compared clinical characteristics between BDZs users and non-users and also investigated if BDZs use was an independent predictor of baseline SBP. Factors associated with SBP change were investigated using a repeated measures general linear model. ResultsOf 538 participants (67.7% female, mean age 72.7), 33 (6.1%) reported regular BDZs use. BDZ users had lower baseline SBP (149 versus 161 mmHg, P < 0.05). Multiple linear regression confirmed BDZs use as independent predictor of baseline SBP in N = =538. At 10 s post-stand, the SBP difference between BDZs use groups became maximum (21 mmHg); at this point, SBP still seemed to be decreasing in BDZ-users, whereas in controls it seemed to be recovering. After adjustment (age, sex, hypertension, frailty, comorbidity, antihypertensives), BDZs were associated with greater SBP reduction between baseline and 10 s post-stand (P < 0.05). ConclusionOlder people taking BDZs may have a higher risk of orthostatic hypotension, perhaps due to an exaggerated immediate BP drop. This adds to other BDZ-related falls risks. BDZs should be avoided in older people at risk of falling.

Sex Differences in Vasovagal Syncope: A Post Hoc Analysis of the Prevention of Syncope Trials (POST) I and II

BackgroundVasovagal syncope (VVS) occurs in > 40% of individuals at least once in their lifetime. Sex-dependent differences in presentation and outcomes are not understood. We sought to determine differences in clinical presentation, treatment modalities, and outcomes of VVS between men and women. MethodsData were collected as part of the Prevention of Syncope Trials (POST) I and II, 2 multicenter, placebo-controlled, randomized trials testing the effectiveness of metoprolol and fludrocortisone, respectively. Data regarding clinical presentation, outcomes, and time to first syncope event after randomization were compared. ResultsOf the 418 patients (280 women and 138 men), women were younger at the time of first syncope event (21 vs 26 years P = 0.002) and had a lower baseline systolic blood pressure (117 vs 124 mm Hg, P < 0.001). Response to heat as a trigger for syncope was more common in women (68% vs 48%, P = 0.011). Clinical presentation in women consisted more commonly of feeling warm, having seizures, and experiencing more postsyncope fatigue (68% vs 54%, P = 0.048; 10% vs 2.7%, P = 0.045; 75% vs 59%, P = 0.017, respectively). Women were more likely to experience recurrent syncope after adjustment for prerandomization syncope burden and randomization assignment (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P = 0.012). ConclusionClinical presentation and provocative factors of VVS differ between men and women, as do recurrent events. Recognition of these differences may help target therapy specifically in men and women.

4879Is intensive blood pressure strategy effective and safe in patients with cardiovascular disease? The two sides of the coin

Abstract Background/Lntroduction Recent data advocate the adoption of a more intensive treatment strategy for the management of blood pressure (BP). Purpose We sought to investigate whether the overall effects of the Systolic Blood Pressure Intervention Trial (SPRINT) are applicable to cardiovascular disease (CVD) patients. Methods In the present post-hoc analysis we analyzed data from SPRINT that randomly assigned 9361 individuals to systolic blood pressure (SBP) target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). 1562 patients had clinically evident CVD (age=70.3±9.3 years, 24% females) at study entry and were followed for 3.1 years. Further, we assessed the effect of low (&lt;150 mm Hg) baseline SBP on clinical endpoints. Results In CVD patients, there was no benefit from the intensive treatment regarding all endpoints, except for a marginally significant benefit on all-cause mortality (hazard ratio [HR]: 0.67; 95% confidence interval [CI], 0.45 to 1.00; P=0.0509) (Figure). Further, while there was no increase in serious adverse events (SAE) in the intensive group, there was an increased HR for study-related SAE in the intensive management group (HR: 2.00; 95% CI: 1.22 to 3.26; p=0.006), a greater incidence of acute renal failure (HR: 1.57; 95% CI: 1.01 to 2.44; P=0.044), electrolyte abnormalities (HR: 1.77; 95% CI: 1.03 to 3.02; P=0.038) and specifically hyponatremia (HR: 2.24; 95% CI: 1.13 to 4.46; p=0.021). In patients with low baseline SBP there was a beneficial effect on all-cause mortality (HR: 0.56; 95% CI: 0.33 to 0.96; P=0.033), but with greater stroke incidence (HR: 2.94; 95% CI: 1.04 to 8.29; P=0.042). As far as adverse events are concerned, patients with SBP&lt;150 mm Hg had increased risk only for study-related SAE and electrolyte abnormalities. Survival curves for the main endpoints Conclusions We confirm the beneficial effect of the intensive strategy in SPRINT study on all-cause mortality and the harmful effect on other than serious adverse outcomes in patients with CVD. However, in patients with low baseline SBP stroke increases. Acknowledgement/Funding This manuscript was prepared using SPRINT_POP Research Materials obtained from the National Heart, Lung, and Blood Institute