Hypotension Research Articles

Association between Dietary Vitamin E Intake and the Risk of Hypertension in US Adults.

Many studies have shown that Vitamin E (VitE) intake has beneficial effects on human health, but the relationship between VitE intake and Blood Pressure (BP) is not well understood. Thus, our present study aimed to assess the relationship between VitE intake and hypertension, systolic and diastolic BP in US (United States) adults. We used data from the 2003-2018 National Health and Nutrition Examination Survey (NHANES). Weighted multivariate regression analysis, subgroup analysis, and Restricted Cubic Splines (RCS) were used to explore the independent associations between VitE intake and hypertension, systolic and diastolic BP. A total of 32,371 participants were included in this study. The mean VitE intake of participants was 8.50 ± 0.08 mg/d. The prevalence of hypertension in subjects was 37.76% and it decreased with increasing VitE intake quartiles (quartile 1: 40.97%, quartile 2: 37.60%, quartile 3: 37.47%, quartile 4: 35.66%). A significant negative correlation was found between VitE intake and hypertension. We also observed a significant negative association between VitE intake and systolic BP (model 1: β = -0.11, 95% CI: -0.15 ~ -0.07; model 2: β = -0.09, 95% CI: -0.12 ~ -0.05; and model 3: β = -0.05, 95% CI: -0.10 ~ -0.01). Quartile 2 of dietary VitE intake significantly correlated to a lower diastolic BP compared to the lowest quartile of VitE intake (model 3: β = -0.72, 95%CI: -1.26~-0.18). In US adults, VitE intake has not been significantly found to be associated with hypertension, but it has been found to exhibit a negative association with both systolic and diastolic BP in US adults.

Age and blood pressure stratified healthy vascular aging, organ damage and prognosis in the community-dwelling elderly: insights from the North Shanghai Study

BackgroundThis study aimed to investigate the prognostic value of age and blood pressure stratified healthy vascular aging (HVA) defined in the North Shanghai Study (NSS), and illustrate its relationship with organ damage (OD).MethodsThis study enrolled 3590 community-dwelling elderly Chinese aged over 65 years and finally 3234 participants were included. 3230 individuals were included in the final analysis, with 4 participants lost to follow-up. NSS HVA was defined as low carotid-femoral pulse wave velocity (PWV) which had a higher cutoff value with advanced age and level of blood pressure. OD was thoroughly assessed and classified into vascular, cardiac and renal OD. Primary endpoints were major adverse cerebrocardiovascular events (MACCE) and all-cause mortality.ResultsNine hundred seventy-eight participants out of 3234 participants (43.1%) were identified as having NSS HVA. The NSS HVA group exhibited a younger age, lower blood pressure levels, lower body mass index, and milder OD compared to the non-NSS HVA group. Over follow-up of 5.7 ± 1.8 years, 332 MACCE (1.82 per 100 person-year) and 212 all-cause deaths (1.14 per 100 person -year) occurred. NSS HVA was associated with a reduced risk of MACCE (HR [95% CI] = 0.585, 0.454–0.754) and all-cause death (HR [95%CI] = 0.608 [0.445, 0.832]), especially in those subgroups without clinical diagnosed cardiovascular disease (CVD) or diabetes mellitus but with at least one type of OD. Moreover, NSS HVA exhibited improved prognostic value for MACCE, all-cause death and CVD death compared to other definitions of HVA.ConclusionsAge and blood pressure stratified NSS HVA could serve as an improved indicator against serious adverse events in the community-dwelling elderly Chinese.Trial registrationPrognosis in the Elderly Chinese: The Northern Shanghai Study (NSS), NCT02368938, https://clinicaltrials.gov/study/NCT02368938?cond=NCT02368938&rank=1.

Differences in the effects of exercise on blood pressure depending on the physical condition of the subject and the type of exercise: a systematic review and meta-analysis.

Although hypertension is a major cause of cardiovascular disease, the control of blood pressure (BP) is insufficient worldwide. Exercise is an effective treatment for reducing BP, but the differences in the blood pressure lowering effects of exercise according to the underlying pathophysiological condition, the type of exercise, and the geographic region are not fully understood. An umbrella review with a meta-analysis of 435 randomized controlled trials that investigated the BP-lowering effects of exercise was performed using Ovid MEDLINE and the Cochrane Library, covering the period from inception to August 1, 2023. A random effects model meta-analysis was performed to estimate the effect size across multiple studies. Exercise significantly reduced systolic BP in healthy subjects (-3.51 mmHg, 95% confidence interval: -3.90, -3.11; p < 0.001) and in those with lifestyle-related diseases including hypertension (-5.48 mmHg, -6.51, -4.45; p < 0.001), but not in those with cardiovascular diseases (-1.16 mmHg, -4.08, 1.76; p = 0.44). According to the type of exercise, all types significantly reduced systolic BP in healthy subjects and in those with lifestyle-related diseases, but not in those with cardiovascular diseases. According to the region, in Oceania, there were no reductions in systolic BP. In Asia, systolic BP was reduced in patients with cardiovascular diseases. In conclusion, any type of exercise reduced BP in healthy subjects and in those with lifestyle-related diseases, but not in those with cardiovascular diseases, and the region affected the effect of exercise. When using exercise to reduce hypertension, it is important to consider the patient's pathophysiological condition and the region.

Efficacy and Safety of Sotagliflozin in Patients with Type 1 Diabetes and CKD.

This analysis evaluated the efficacy and safety of sotagliflozin, a dual SGLT1&2 inhibitor, added to insulin in patients with type 1 diabetes and chronic kidney disease (CKD). We used data from the 52-week pooled inTandem1&2 trials and the 24-week inTandem3 trial to assess the effects of sotagliflozin (200mg [inTandem 1&2 only] or 400mg daily) versus placebo on glycated hemoglobin (HbA1c; primary endpoint), body weight, systolic blood pressure (BP), insulin dose, and safety endpoints including adjudicated severe hypoglycemia and diabetic ketoacidosis (DKA), stratified by CKD. CKD was identified in 237/1575 of inTandem1&2 participants and 228/1402 of inTandem3 participants. At week-24, significant, placebo-adjusted reductions in HbA1c were observed - inTandem1&2: Non-CKD subgroup (sotagliflozin 200mg: -0.4%, 95% CI -0.4 to -0.3; 400mg: -0.4%, 95% CI -0.5 to -0.3) and CKD subgroup (sotagliflozin 200mg: -0.4%, 95% CI -0.6 to -0.1; 400mg: -0.3%, 95% CI -0.5 to -0.1). For systolic BP, there was a significant reduction at week-24 with sotagliflozin in the non-CKD subgroup but no effect in the CKD subgroup in inTandem1&2. At week-52, the incidence of severe hypoglycemia was lower with sotagliflozin (7% on 200 mg and 4% on 400 mg) compared to placebo (17%) in the CKD subgroup of inTandem1&2, whereas the incidence of severe hypoglycemia was 5-6% across non-CKD subgroups. The incidence of adjudicated DKA at week-52 was 1%, 5%, and 3% for placebo, 200 mg, and 400 mg in the CKD subgroup compared to 0%, 3%, and 4% in the non-CKD subgroup. Results were generally similar in inTandem3 except systolic BP was significantly reduced with sotagliflozin versus placebo in CKD and non-CKD subgroups. In participants with type 1 diabetes and CKD, sotagliflozin treatment had similar HbA1c, body weight, and systolic BP lowering effects as in participants with type 1 diabetes without CKD. Additionaly, sotagliflozin was associated with a lower to neutral risk of severe hypoglycemia and did not significantly increase the risk of DKA among a small number of DKA events.

The Effectiveness of Cupping Therapy in Reducing Blood Pressure in Hypertensive Patients at Citra Medika 3 Limau Manis Clinic

Hypertension, a medical condition characterized by chronically elevated blood pressure, is one of the most prevalent cardiovascular diseases. Although asymptomatic in its early stages, hypertension can lead to serious complications in the cardiovascular system and other vital organs. Cupping therapy is a complementary treatment modality that has been used as an alternative approach to manage hypertension. This study aims to evaluate the effectiveness of wet cupping therapy in lowering blood pressure. The method employed involves the application of wet cupping therapy on patients with hypertension. The study results indicate that cupping therapy significantly lowers blood pressure in hypertensive patients, as evidenced by the Wilcoxon test showing a significant difference before and after the intervention. Based on the effectiveness of wet cupping therapy in lowering blood pressure, it shows potential for development as an alternative treatment for hypertension.

Disentangling the phenotypic patterns of hypertension and chronic hypotension

Objective2017 blood pressure (BP) categories focus on cardiac risk. We hypothesize that studying the balance between mechanisms that increase or decrease BP across the medical phenome will lead to new insights. We devised a classifier that uses BP measures to assign individuals to mutually exclusive categories centered in the upper (Htn), lower (Hotn) and middle (Naf) zones of the BP spectrum; and examined the epidemiologic and phenotypic patterns of these BP-categories. MethodsWe classified a cohort of 832,560 deidentified electronic health records by BP-category; compared the frequency of BP-categories and four subtypes of Htn and Hotn by sex and age-decade; visualized the distributions of systolic, diastolic, mean arterial and pulse pressures stratified by BP-category; and ran Phenome-wide Association Studies (PheWAS) for Htn and Hotn. We paired knowledgebases for hypertension and hypotension and computed aggregate knowledgebase status (KB-status) indicating known associations. We assessed alignment of PheWAS results with KB-status for phecodes in the knowledgebase, and paired PheWAS correlations with KB-status to surface phenotypic patterns. ResultsBP-categories represent distinct distributions within the multimodal distributions of systolic and diastolic pressure. They are centered in the upper, lower, and middle zones of mean arterial pressure and provide a different signal than pulse pressure. For phecodes in the knowledgebase, 85% of positive correlations align with KB-status. Phenotypic patterns for Htn and Hotn overlap for several phecodes and are separate for others. Our analysis suggests five candidates for hypothesis testing research, two where the prevalence of the association with Htn or Hotn may be under appreciated, three where mechanisms that increase and decrease blood pressure may be affecting one another’s expression. ConclusionPairedPheWAS methods may open a phenome-wide path to disentangling hypertension and chronic hypotension. Our classifier provides a starting point for assigning individuals to BP-categories representing the upper, lower, and middle zones of the BP spectrum. 4.7 % of individuals matching 2017 BP categories for normal, elevated BP or isolated hypertension, have diastolic pressure < 60. Research is needed to fine-tune the classifier, provide external validation, evaluate the clinical significance of diastolic pressure < 60, and test the candidate hypotheses.

The Role of Animal Assisted Therapy in the Rehabilitation of Mental Health Disorders: A Systematic Literature Review

Mental health disorders like depression, anxiety, post-traumatic stress disorder (PTSD), and schizophrenia significantly reduce the daily functioning and quality of life of individuals. Traditional treatments often fall short, thus opening interest in complementary therapies like animal assisted therapy (AAT) which encourages the human-animal bond and gives emotional and psychological support. This review evaluated the efficacy of AAT in treating mental health disorders, and understanding its mechanisms and benefits. A comprehensive literature review was conducted (using databases such as PubMed, Google Scholar, and ResearchGate) focused on peer-reviewed articles, systematic reviews and meta-analyses published in the last 2 decades. Studies indicated that AAT improved mental health outcomes for people with depression, anxiety, PTSD, and schizophrenia. Interaction with therapy animals reduced cortisol levels, increased oxytocin, lowered blood pressure, and increased social engagement and emotional regulation. Benefits included reduced symptoms of depression, anxiety, PTSD, and improved social functioning and quality of life. AAT offered a complementary treatment for mental health disorders, providing emotional comfort, improving mood, and serving as a nonpharmacological option for individuals. However, challenges such as individual preferences, allergies, ethical concerns for therapy animals, and logistical issues must be addressed. Future research should focus on the long-term effects and mechanisms involved to optimize the application of AAT in the clinical setting, and alternatives like robotic companion pets could also be explored.

Clinical Characteristics and Risk Factors for Severe Japanese Spotted Fever: A Retrospective Multicenter Study in Nagasaki Prefecture, Western Japan.

Japanese spotted fever (JSF) is a tick-borne rickettsial disease prevalent in western Japan, with an increasing incidence and geographical distribution. This retrospective study aimed to describe the clinical features of JSF and identify factors associated with its severe form. We included adult patients with laboratory confirmed JSF in Nagasaki prefecture from 2010 to 2021. Severe JSF was defined by the presence of altered mental status, low blood pressure, or low oxygen saturation. In total, 65 JSF cases were diagnosed. Common symptoms were fever (87%), rash (48%), and fatigue (48%) with eschars detected in 50 (79.4%) of patients. Thirty-eight (60.3%) patients were initially diagnosed with non-JSF conditions. Twenty-one (33.3%) cases were categorized as severe JSF, including one death. Pre-hospital factors associated with severe JSF included age ≥75 (adjusted odds ratio [aOR] 37.53, 95% confidence interval [CI] 3.03-465.38), male sex (aOR 26.5, 95% CI 4.23-166.00), and a treatment delay ≥4 days from onset (aOR 5.96, 95% CI 1.13-31.60). This study highlights diagnostic challenges of JSF due to its non-organ-specific clinical presentation. Delayed initial treatment, advanced age, and male sex significantly increase the risk of severity. It is crucial to further raise awareness of JSF among clinicians and residents in endemic areas.

Efficacy of Beetroot Juice Supplementation on Lowering Blood Pressure in Hypertensive Patients – A Single Centre Study

I Background : Quasi -interventional pretest posttest research design was adopted to investigate beetroot juice supplementation on reduction of blood pressure and serum cholesterol levels among 60 hypertensive clients with hyperlipidemia using non probability purposive sampling technique Methodology: On Day-1: The demographic and clinical information was gathered by using a self-structured questionnaire . On Day -2, the pretest level of hyperlipidemia was estimated and also, the pretest blood pressure level was assessed using sphygmomanometer. From Day-3, 200ml of beetroot juice was administered once a day for 30 days. On Day- 34 study participants were re-assessed to estimate the levels hyperlipidemia and blood pressure. Results: The study results concluded that, the pretest and posttest mean score with mean difference score of SBP and DBP in the Interventional Group was141.46±10.43,88.60±5.48 and 128.40±7.13 ,83.20±4.65 with mean difference score was13.06, 5.40 The calculated paired ‘t’ test value of SDP and DBP t =12.558 , 5.964 was statistically significant at p&lt;0.001 Level. The pretest and posttest with mean difference score of total cholesterol,LDL,HDL, triglyceride , cholesterol/HDLratio in the interventional group was 176.86±14.26,103.60±9.68,36.96±4.73,156.53±32.48, 4.45±0.82 and 170.10±15.37,92.96±9.20,41.96±6.08,138.83±26.48,4.00±0.75with mean difference score was 6.76,10.64,5.0,17.70, 0.45.The calculated Paired ‘t’ test value of t =10.329,15.804, 7.816,10.652,14.879 was statistically significant at p&lt;0.001 level.this clearly shows that after administered beetroot juice the blood pressure and serum cholesterol levels was significantly reduced in the Interventional group. Conclusion: administered Beetroot juice proved to be an effective intervention in reducing the blood pressure and serum cholesterol level among hypertensive patients with hyperlipidemia

KENDALIKAN TEKANAN DARAH PADA LANSIA DENGAN TERAPI KOMPLEMENTER

Non-Communicable Diseases (NCDs) often referred to as NCDs have become a considerable public health problem in Indonesia, this is marked by a shift in epidemiological disease patterns from infectious diseases to NCDs which globally continues to increase, one of which is hypertension. The purpose of this study is to determine the effect of complementary therapy on lowering blood pressure in the elderly with hypertension. This research method is pre-experimental with a one-group pre-post test design. The population in this study is 152 people with a sample of 18 respondents, Sampling with non-probability sampling techniques, The instrument that will be used in this study is a data processing questionnaire using the wilcoxon test. The results showed that the Sig (2-tailed) value for systolic blood pressure before and after the administration of complementary therapy was 0.000 &lt; 0.05 its means that Ha is accepted and Ho is rejected. In conclusion, there is an effect of providing complementary therapy on reducing blood pressure in the elderly with hypertension

Initial blood pressure and adverse cardiac events following acute ischaemic stroke: An individual patient data pooled analysis from the VISTA database.

Adverse cardiac events following ischaemic stroke (stroke-heart syndrome, SHS) pose a clinical challenge. We investigated the association between initial blood pressure at stroke presentation and the risk of SHS. We utilised data from the Virtual International Stroke Trials Archive (VISTA). We defined SHS as the incidence of cardiac complications within 30 days post-ischaemic stroke. These presentations included acute coronary syndrome encompassing myocardial injury, heart failure/left ventricular dysfunction, atrial fibrillation/flutter, other arrhythmia/electrocardiogram abnormalities, and cardiorespiratory arrest. Using Cox proportional hazards models, we assessed the risk trajectories for developing SHS and its presentations associated with initial blood pressure. We also explored the risk trajectories for 90-day mortality related to initial blood pressure. From 16,095 patients with acute ischaemic stroke, 14,965 (mean age 69 ± 12 years; 55% male) were analysed. Of these, 1774 (11.8%) developed SHS. The risk of SHS and initial blood pressure showed a U-shaped relationship. The lowest blood pressures (⩽130 mmHg systolic and ⩽55 mmHg diastolic) were associated with the highest risks (adjusted hazard ratio [95%confidence interval]: 1.40 [1.21-1.63]; p < 0.001, 1.71 [1.39-2.10]; p < 0.001, respectively, compared to referential blood pressure range).Cardiorespiratory arrest posed the greatest risk at higher blood pressure levels (2.34 [1.16-4.73]; p = 0.017 for systolic blood pressure >190 mmHg), whereas other presentations exhibited the highest risk at lower pressures. The 90-day mortality risk also followed a U-shaped distribution, with greater risks observed at high blood pressure thresholds. There is a U-shaped relationship between initial blood pressure at ischaemic stroke presentation and the risk of subsequent SHS.

SPICT tool among intubated elderly patients at emergency department

BackgroundThe global rise in the aging population necessitates a proactive approach to palliative care, with a substantial gap between the demand for and access to such care. The Supportive and Palliative Care Indicators Tool (SPICT) has emerged as a valuable instrument for identifying patients at risk of deterioration and death, enhancing the timely initiation of palliative care. This study aimed to investigate the characteristics and outcomes of patients aged 60 and above who got intubated in the emergency department (ED), with and without fulfilling SPICT criteria. MethodsThis retrospective single-center study was conducted at a tertiary care teaching hospital in Thailand. The research involved 408 adults aged 60 and older who underwent ED intubation and subsequent admission. Baseline characteristics and follow-up data were collected, encompassing vital signs, comorbidities, and SPICT criteria. Mortality rates between SPICT criteria-fulfilled and non-fulfilled groups were compared. ResultsOut of 408 analyzed patients, SPICT criteria were met by 39.7 % of patients, exhibiting distinctive features such as a higher respiratory rate and lower diastolic blood pressure. Hypertension and diabetes mellitus were most prevalent comorbidities. Respiratory and neurological disorders were the leading final diagnoses. The overall in-hospital mortality rate was 28 %, significantly higher in the SPICT criteria-fulfilled group compared to the non-fulfilled group (34.0 % vs 23.6 %, P = 0.022). SPICT criteria demonstrated moderate sensitivity (48.7 %) and specificity (63.7 %) for predicting mortality. ConclusionSPICT criteria identified elderly patients at an elevated mortality risk following intubation in the emergency setting. The early implementation of SPICT as a screening tool for identifying palliative care candidates is advocated for more effective advance care planning.

Isometric handgrip versus aerobic exercise: a randomized trial evaluating central and ambulatory blood pressure outcomes in older hypertensive participants.

It remains unclear whether the hemodynamic effects of isometric handgrip exercise (IHG) are comparable to those of aerobic exercise (AE). This study investigated the efficacy of IHG in reducing central and ambulatory blood pressure in older hypertensive participants and compared its effects with AE. In a three-arm randomized controlled trial, 54 older hypertensive participants (age range: ≥60; mean age: 69 years) underwent 12 weeks of either IHG training (n = 17), AE training (n = 19), or were part of a no-exercise control group (n = 18). IHG participants engaged in bilateral handgrips using a digital device, four times for 2 min each at 30% of maximal voluntary contraction. AE participants undertook brisk walking and cycling exercises at moderate intensity for 30 min, thrice weekly. Baseline and postintervention measurements included resting office, central, and 24-h ambulatory blood pressures. Both IHG and AE interventions led to significant reductions in office and ambulatory systolic blood pressure compared to control group (P < 0.05 for both), with no marked difference in the magnitude of systolic blood pressure reductions between the two groups. Notably, the IHG group exhibited greater reductions in office, central, and ambulatory diastolic blood pressure compared to the AE group and control group. While both IHG and AE effectively lowered ambulatory systolic blood pressure, IHG demonstrated superior efficacy in reducing central and ambulatory diastolic blood pressure. Consequently, IHG training presents a promising alternative antihypertensive therapy for hypertensive participants over the age of 60.

Nyctanthes arbor-tristis Improves Blood Pressure via Endothelial Pathway: In Silico, Ex Vivo, and In Vivo Evidence.

Systemic hypertension, a common metabolic disorder, poses significant health risks despite the availability of antihypertensive drugs. Nyctanthes arbor-tristis has garnered increasing attention for its perceived efficacy and safety, though its mechanisms of action and the bioactive compounds responsible for its antihypertensive effects remain elusive. Therefore, this study aims to elucidate the antihypertensive activity of N. arbor-tristis leaves in rats and explore associated mechanism through in silico, in vitro, ex vivo, and in vivo studies. The methanolic extract of N. arbor-tristis leaves (MENAT) was fractionated and subjected to qualitative and quantitative phytochemical screening, including total phenolic content (Folin-Ciocalteu method), total flavonoid content (Aluminum chloride method), and total alkaloid content (spectrometric method). Antioxidant studies were conducted using DPPH, FRAP, and H2O2 assays. The most promising fraction (WNAT) was analyzed using LC-MS, and the identified compounds were used for molecular docking studies against cGMP and eNOS. Further, aortic ring assays were conducted to assess ex vivo vasorelaxant activity (rat aortic strip assay) and the underlying mechanisms of WNAT. Later, in vivo studies using a DOCA-salt-induced hypertension model in Wistar rats, along with molecular analyses (RT-PCR), were performed to validate the antihypertensive claims of N. arbor-tristis. In vitro studies demonstrated that the water extract of N. arbor-tristis leaves (WNAT) exhibited strong antioxidant activity and contained key phytochemicals. LC-MS analysis revealed the presence of 19 major compounds, including betulinic acid and arbortristosides. Molecular docking studies indicated that arborside C exhibited a strong affinity for both eNOS and cGMP. Ex vivo studies involving rat aortic strips showed that WNAT induced vasodilatory activity, which is associated with parasympathetic and nitric oxide-related pathways. In vivo experiments further supported WNAT's antihypertensive properties through improvements via amelioration of rat blood pressure and histological features, biochemical markers, morphometric parameters, and gene expression in hypertensive rats. In conclusion, WNAT effectively lowers blood pressure through modulation of the endothelial pathway and warrants further studies to attain its clinical utility in hypertensive subjects.

Psychophysiological profile of ischemic patients according to their resting heart rate variability: one step closer to training individualization

Ischemic heart disease continues to be a major cause of morbidity and mortality around the world. Nowadays, research is focusing on the role of the brain-heart axis in autonomic nervous system balance. Resting heart rate variability (HRV) could help to identify the readiness of ischemic patients to achieve cardiac rehabilitation exercise stimulus in a safer manner. The objectives of the study were i) to analyze the resting HRV in ischemic cardiopathy, determining whether it was below or within its normal range, and ii) to identify the effect of the psychophysiological parameters of age, body mass index (BMI), blood pressure, cardiorespiratory fitness, and quality of life. This was a cross-sectional study of patients affected by ischemic cardiopathy. The patients were divided into the nonNormal-HRV or Normal-HRV group according to their normal resting HRV. The HRV temporal and frequency domains were recorded along with heart rate and blood pressure, BMI, cardiorespiratory fitness and auto-perception. The sample comprised men with an average age of 58.64±9.54 years. In total, 43.92% were below their normal resting-HRV range. They were older (P&lt;.001, d=.856), had worse auto-perception (P&lt;.001, d=.473), and higher systolic and lower diastolic blood pressure (P&lt;.001, d=.446; P=.007, d=.29). HRV domains correlated directly (P&lt;.05) with diastolic blood pressure and inversely with heart rate and age. The percentage of low resting-HRV scores in ischemic patients was higher than expected and was conditioned by age, blood pressure and heart rate. Moreover, the patients had worse auto-perception. All these factors should be considered to optimize cardiac rehabilitation programs.

National dispensing of evidence-based treatment for New Zealand patients before and after peripheral arterial or percutaneous coronary procedures; undertreatment in plain sight

Abstract Background/Introduction Cardiovascular management guidelines recommend that those undergoing arterial procedures for atherosclerotic disease should be on a long-term antithrombotic agent, statin and blood pressure (BP) lowering (triple therapy) to prevent or delay future ischaemic events or death. Internationally, treatment gaps have been reported for people having peripheral arterial disease (PAD) procedures. Purpose We aimed to investigate national rates of triple therapy dispensing before and after admission for a percutaneous coronary intervention (PCI) compared to a PAD procedure. Methods All people aged 18-84 years admitted for a publicly-funded PCI or PAD procedure in New Zealand between 1 January 2015 and 30 June 2020 were identified. Data were linked to national community dispensing records for antithrombotic agents, statins and BP lowering and the adjusted relative risk (adjRR) of dispensing individual medication classes and triple therapy investigated 6 months prior-procedure and 0-6 months and 7-12 months post-procedure. Analyses were controlled for age, sex, prioritised ethnicity, socioeconomic deprivation index, diabetes and prior cardiovascular disease. Results During the study period, 26,383 people were admitted for a PCI procedure and 10,938 people for PAD. Compared to PCI, those with PAD were more likely to be women, older (median age 69 vs 66 years), of Māori or Pacific ethnicity, living in more deprived communities, more likely to have diabetes (33% vs 24%) and a prior admission for cardiovascular disease (63% vs 52%). Triple therapy in the 6 months prior to procedure was 48% for PAD compared to 37% for PCI (adjRR 1.04; 1.03-1.05); however, in the 6 months post-discharge, improved for PCI more than PAD (PAD 58% vs PCI 91%, [adjRR 0.82; 0.81-0,83]) with decreased dispensing in both cohorts by 7-12 months post procedure (PAD 55% vs PCI 83%, [adjRR 0.84; 0.83-0,84]). Conclusions Patients undergoing atherosclerotic arterial procedures are at high risk of future fatal and nonfatal cardiovascular events. Less than half the patients who were admitted for a PCI or PAD procedure had been dispensed triple therapy in the 6 months prior to admission. Post procedure, 91% of PCI patients were on triple therapy but this substantial increase did not occur for PAD patients. The risk management gap for those who have peripheral arterial compared to coronary procedures indicates clear clinical and system-related deficiencies and a national quality improvement approach is required to address these issues. Figure 1. Adjusted relative risk of being dispensed preventive medications for patients who had a PAD procedure, compared to patients who had a PCI procedure [after adjusting for age, sex, ethnicity, NZDep, history of CHD (including prior PCI and CABG), stroke/TIA, haemorrhagic stroke, heart failure, PVD, and diabetes]

Blood pressure-lowering and risk of cancer: an individual participant-level data meta-analysis and mendelian randomisation studies

Abstract Background The current body of randomised evidence concerning the effect of blood pressure lowering on the risk of cancer remains limited. Purpose We leveraged the strengths of both randomised controlled trials (RCTs) and genomic information to examine this question. Methods Individual-level data from 314,016 participants from 42 RCTs were pooled to investigate the effect of blood pressure lowering on the risk of cancer through one-stage individual participant data (IPD) meta-analysis. The primary outcome was incident cancer, defined as the first occurrence of any cancer diagnosed after randomisation. Pre-specified subgroup analyses were conducted to assess heterogeneity in effect by follow-up time and baseline age groups, sex, body mass index categories, smoking status and previous use of antihypertensive drugs. Secondary outcomes were cause-specific cancer death and site-specific cancer risk comprising breast, colorectal, kidney, lung, prostate, and skin. Cox proportional hazard regression, stratified by trials, were used for statistical analyses. For site-specific cancers, analyses were complemented with Mendelian randomisation analyses using naturally randomised genetic variants associated with blood pressure lowering, retrieved from genome-wide association studies involving participants of European ancestry. Results Over a median of 4 years (interquartile range 2), 17,954 participants in RCTs were diagnosed with cancer of any type and 4,878 participants were reported to have died with cancer as the cause of death. In the IPD meta-analysis that compared the treatment arm with the comparator, no associations were identified between reductions in either systolic or diastolic blood pressure and the risk of incident cancer (hazard ratios [HRs] per 5 mmHg reduction in systolic and per 3 mmHg diastolic blood pressure were 1.03 (95% confidence interval [CI] 0.99-1.06) and 1.03 [0.98-1.07], respectively). We also found no pattern of increasing or decreasing relative risk for incident cancer during the follow-up period, nor was there evidence of heterogeneity in treatment effects across baseline subgroups. No effect on the risk of cause-specific cancer death was identified for either systolic or diastolic blood pressure lowering. Considering site-specific cancers, we also found no evidence of effect, except for a possible link with lung cancer risk, with HRs of 1.17 [99.5% CI 1.02-1.32] for systolic blood pressure and 1.17 [99.5% CI 0.98-1.36] for diastolic blood pressure lowering. In Mendelian randomisation studies, no association was observed for genetically determined systolic and diastolic blood pressure and all the considered site-specific cancers, including overall lung cancer and its subtypes. Conclusion We found no consistent randomised evidence to suggest that blood pressure-lowering has a substantial effect, whether increasing or decreasing, on incident cancer, cause-specific cancer death, or selected site-specific cancers.

The safety of in-hospital initiation of SGLT2 inhibitor with MRA therapy in patients hospitalized for heart failure with a reduced left ventricular ejection fraction and chronic kidney disease

Abstract Deferring in-hospital initiation of guideline-recommended medications in HFrEF has a few chances they will be initiated ambulatory, especially in the case of coexisting HFrEF and chronic kidney disease (CKD). The aim was to investigate the safety of in-hospital initiation of SGLT2i with MRA therapy for patients hospitalized for HFrEF and CKD 3. Methods 88 patients with HFrEF (on top of standard therapy ACE-I/ARB, B-blockers) and CKD (baseline eGFR between 30 and 60 ml/min) were included in the study. The potassium (K), creatinine (C), uric acid (UA) levels were estimated at baseline and week 12. After biochemical evaluation, patients started on spironolactone (SP) treatment with a median dose of 20 mg daily (titrated) and dapagliflozin (D) with a dose of 10 mg daily (D+SP). Blood pressure (BP), K, and renal function (RF) were checked at weeks 1 (in-hospital), 2, 4, 6, 8, 12 (ambulatory), and more frequently as necessary. Results After the start of therapy D+SP mean eGFR decreased significantly at week 1 from 51.14±9.18 to 46.26±7.91 ml/min/1.73m2 (P&amp;lt;.0001) and at week 2 to 44.18±6.51 ml/min/1.73m2 (-2.08±1.2; P&amp;lt;.001). At week 4 mean eGFR decreased to 42.73±6.86 ml/min/1.73m2 (-1.45±1.1; P&amp;lt;.05). So, a significant decrease in eGFR was observed only during the first month with no significant decrease at 6 and 12 weeks after the start of therapy. Six patients (8%) experienced a significant decline in RF resulting in temporary withdrawal of SP. At week 2 mean K level increased significantly from 4.56±0.63 to 5.07±0.57 mmol/L (P&amp;lt;.001). At weeks 4, 6, 8 K levels remain stable. At week 12 mean K level decreased significantly compared with week 2 (to 4.92±0.57 mmol/L, P&amp;lt;.05). The incidences of severe hyperkalemia (HK) (K+≥6.0mmol/L) were in three patients &amp;lt; 2 %, and moderate HK (K 5.5–5.9 mmol/L) occurred in ten patients (11 %). Patients who experienced inpatient hyperkalemia had a significantly lower eGFR than patients without episodes of HK (38.70 vs. 55.21 mL/min/1.73 m2; P&amp;lt;.0001). Episodes of HK were predicted by baseline K≥5.0 mmol/L and eGFR≤40 ml/min/1.73m2. Additionally, there was a significant improvement in blood UA (-1,53±0.49 mg/dL, P&amp;lt;.01). By multivariate analysis older age, diabetes, low diastolic BP (&amp;lt;60 mm Hg), eGFR≤40 ml/min/1.73m2 at baseline were associated with decreased RF (0.378, P&amp;lt;.01; 0.632, P&amp;lt;.001; 0.771, P&amp;lt;.0001; 0.397, P&amp;lt;.01; respectively), whereas episodes of HK were predicted by baseline K≥5.0 mmol/L and eGFR≤40 ml/min/1.73m2 (0.785, P&amp;lt;.0001; 0.542, P&amp;lt;.001; respectively). Conclusion Initiation of SGLT2i with MRA in patients hospitalized for HFrEF and CKD 3 was mainly safe although it caused an early drop in eGFR. Importantly, a fall in eGFR was observed during the first month. Concern about the reduction in eGFR should be in older diabetic patients with eGFR≤40 and low diastolic blood pressure. Although hyperkalemia was common, the occurrence of it was predicted by baseline potassium level and eGFR.

Long term outcomes of patients with decompensated aortic stenosis undergoing urgent transcatheter aortic valve implantation: a TAVI-NOR subs-study

Abstract Background Aortic stenosis (AS) is a progressive disease, which untreated leads to irreversible myocardial damage and potentially death. Patients with AS may present with acute decompensation (ADAS) even during active surveillance. Purpose In this TAVI-NOR sub-study, we investigate the clinical profile, risk factors, epidemiology and long-term outcomes of patients treated with TAVI after presenting with ADAS compared to stable patients who underwent elective TAVI (no ADAS). Method A total of 600 patients with severe AS consecutively treated with TAVI between January 2012 and July 2019 were enrolled in TAVI-NOR study. Predictors and long-term clinical outcomes were explored in binary logistic and Cox regression models. Results A total of 68 patients (11.3%) received urgent TAVI due to acute hospitalization with ADAS. Age (80±8.0 years vs 81±6.0 years, p=0.662), gender (56% males vs 50% males, p=0.361) and other comorbidities at baseline such as cardiovascular disease, chronic lung disease and atrial fibrillation (AF) were comparable in patients with ADAS and no ADAS (n=532) (p&amp;gt;0.05 for all). However, patients with ADAS had greater symptom burden (NYHA III-IV 81% vs 51%, p&amp;lt;0.001), lower blood pressure, higher heart rate and lower estimated glomeruli filtration rate (52.0±10.8 vs 54.6±9.8 mL/min/1.73m2, p&amp;lt;0.045). They had also higher prevalence of ECG left ventricular (LV) hypertrophy (40% vs 27%, p=0.027), more often reduced LV ejection fraction (&amp;lt;50%) (41% vs 16%, p&amp;lt;0.001), lower stroke volume (39±11 ml/m2 vs 42±11 ml/m2 vs, p=0.030) a trend of abnormal ECG (p=0.055) and longer hospital stay (11.5 ±8.7 days 6.6± 4.9 days, p&amp;lt;0.001). Patients with ADAS were comparable with no ADAS in terms of early short-term (&amp;lt;30 days) all-cause mortality (p&amp;gt;0.05). Although 1-year mortality was comparable (1.5% in ADAS vs 2.1% in no ADAS, p&amp;gt;0.99), mid- to late-term mortality rates were significantly higher in patient with ADAS receiving urgent TAVI, with 3-, 5- and 7 years mortality of 22% vs 11%, p=0.008; 46% vs 29%, p=0.005; 53% vs 39%, p=0.033, respectively. In a Kaplan-Meier analysis, event-free survival was significantly reduced for patients with ADAS undergoing urgent TAVI compared with stable patients undergoing elective TAVI HR 1.63, 95% CI 1.15-2.31, p=0.006), confirmed by a multivariable-adjusted model (HR 1.54; 95% CI 1.05-2.25, p=0.026) independent of age, gender, AF, LV ejection fraction and time from diagnosis to TAVI (Fig). Conclusion Patients with AS presenting with acute decompensation and treated with urgent TAVI had excellent short-term survival. This was irrespective of increased symptom burden, adversely remodeled and functionally reduced LV at baseline. These findings might explain the observed higher mid- and long-term mortality compared with stable patients undergoing elective TAVI. It is essential to identify patients at risk of acute decompensation and treat them timely before irreversible myocardial damage occur.

Blood pressure and renal function changes in patients with severe chronic kidney disease undergoing radiofrequency renal denervation: 12 months outcomes from the Global SYMPLICITY Registry DEFINE

Abstract Background Radiofrequency renal denervation (RF RDN) lowers blood pressure (BP) in patients with uncontrolled hypertension (HTN). The impact of renal function on safety and efficacy of RDN is unknown. Purpose To assess BP and renal function in patients with HTN following RDN. Methods All patients treated with RF RDN (n=3332) from the observational Global SYMPLICITY Registry Denervation Findings in Real World (GSR DEFINE) were included. Patients were categorized into CKD stages by the corresponding estimated glomerular filtration rate (eGFR; mL/min/1.73m2): &amp;lt;45 (CKD stage 3b and higher; n=339), 45-59 (CKD stage 3a; n=467), ≥60 (CKD stage 2 and lower; n=2334). BP (office, 24h ambulatory BP), eGFR changes from baseline through 12 months were compared between groups. Comparisons between groups were made after adjusting for baseline BP and change in number of antihypertensive drug classes from baseline. Results At baseline, office systolic SBP (OSBP) in eGFR groups &amp;lt;45, 45-59, and ≥60 ml/min/1.73 m2 was: 164±25, 163±26 and 165±25 mmHg, respectively (p=0.083). 24-h ambulatory systolic BP (ASBP) was: 156±19, 153±20 and 154±19 mmHg, respectively (p=0.082). Mean eGFR was: 32.5±11.2, 53.6±4.4, and 86.8±18.6 ml/min/1.73 m2, respectively. A total of 1.1% of patients were on dialysis. Patients in eGFR group &amp;lt;45 ml/min/1.73 m2 were significantly older, had higher rates of ischemic heart disease, heart failure, diabetes, on more antihypertensive drug classes compared to higher eGFR groups. Patients were on 5.0±1.3, 4.6±1.3, and 4.5±1.4 antihypertensive drugs in eGFR &amp;lt;45, 45-59 and ≥60 ml/min/1.73 m2 groups, respectively (p&amp;lt;0.001). At 12 months, all had significant OSBP drop from baseline within the different eGFR groups (p&amp;lt;0.001). OSBP changed by -10.8±27.8, -10.5±25.9 and -14.7±26.6 mmHg in eGFR &amp;lt;45, 45-59 and ≥60 ml/min/1.73 m2 groups, respectively (adjusted p=0.095; Figure 1A). Similarly at 12 months, all patients had significant ASBP reductions from baseline across the eGFR groups (p&amp;lt;0.01). ASBP changed by -5.2±18.0, -6.9±18.8, and -8.5±18.8 mmHg in eGFR &amp;lt;45, 45-59 and ≥60 ml/min/1.73 m2 subgroups, respectively (adjusted p=0.16). At 12 months, eGFR did not significantly change from baseline in eGFR &amp;lt;45 and 45-59 ml/min/1.73 m2 groups (Figure 1B): 0.1±14.6 (p=0.92) and -0.6±12.8 ml/min/1.73 m2 (p=0.45), respectively. Estimated GFR changed from baseline by -5.6±15.5 ml/min/1.73 m2 in eGFR ≥60 ml/min/1.73 m2 group (p&amp;lt;0.001). Between group differences in eGFR changes were statistically significant (adjusted p&amp;lt;0.001), but by a numerically small difference. The no. of antihypertensive drug classes changed by -0.2±1.3, -0.1±1.0 and -0.1±1.0 in eGFR &amp;lt;45 and 45-59 ml/min/1.73 m2 groups, respectively. Conclusion Patients with uncontrolled HTN with different CKD severity including those with eGFR &amp;lt;45 ml/min/1.73 m2 had significant SBP reductions from baseline through 12 months, whilst renal function was preserved.Figure 1