Lower Systolic Blood Pressure Research Articles

Nurse-Led Intervention Lowers Cardiovascular Risk Factors in People with HIV.

According to this study: A nurse-led, multicomponent intervention significantly reduced systolic blood pressure and non-high-density lipoprotein (HDL) cholesterol levels in people with HIV.At 12 months, participants in the intervention group had a significant 4.2-mmHg lower systolic blood pressure and a 16.9-mg/dL lower non-HDL cholesterol level than those in the control group.

Renal effects and safety between Asian and non-Asian chronic kidney disease and type 2 diabetes treated with nonsteroidal mineralocorticoid antagonists.

Asians bear a heavier burden of chronic kidney disease (CKD), a common comorbidity of type 2 diabetes mellitus (T2DM), than non-Asians. Nonsteroidal mineralocorticoid receptor antagonists (MRAs) have garnered attention for their potential advantages in renal outcomes. Nevertheless, the impact on diverse ethnic groups remains unknown. The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang database, and clinical trial registries were searched through August 2023 with the following keywords: nonsteroidal MRAs (finerenone, apararenone, esaxerenone, AZD9977, KBP-5074), CKD, T2DM, and randomized controlled trial (RCT). A random effects model was used to calculate overall effect sizes. Seven RCTs with 14 997 participants were enrolled. Nonsteroidal MRAs reduced urinary albumin to creatinine ratio (UACR) significantly more in Asians than non-Asians: (weighted mean difference [WMD], -0.59, 95% CI, -0.73 to -0.45, p < .01) vs (WMD, -0.29, 95% CI, -0.32 to -0.27, p < .01), respectively. The average decline of estimated glomerular filtration rate (eGFR) was similar in Asians and non-Asians (p > .05). Regarding systolic blood pressure (SBP), nonsteroidal MRAs had a better antihypertension performance in Asians (WMD, -5.12, 95% CI, -5.84 to -4.41, p < .01) compared to non-Asians (WMD, -3.64, 95% CI, -4.38 to -2.89, p < .01). A higher incidence of hyperkalemia and eGFR decrease ≥30% was found in Asians than non-Asians (p < .01). Nonsteroidal MRAs exhibited significant renal benefits by decreasing UACR and lowering SBP in Asian than that of non-Asian patients with CKD and T2DM, without increase of adverse events except hyperkalemia and eGFR decrease ≥30%.

Serum 25-Hydroxyvitamin D Level Is Positively Associated with Vascular Reactivity Index in Patients with Type 2 Diabetes Mellitus

Circulating 25-hydroxyvitamin D (25(OH)D) significantly influences endothelial function. This study assessed the correlation between serum 25(OH)D and endothelial function using the vascular reactivity index (VRI) in patients with type 2 diabetes mellitus (T2DM). Fasting blood samples from 102 T2DM participants and VRI were assessed. Patients were divided into three categories based on VRI: low (VRI &lt; 1.0), intermediate (1.0 ≤ VRI &lt; 2.0), and good (VRI ≥ 2.0). Among these patients, 30 (29.4%) had poor, 39 (38.2%) had intermediate, and 33 (32.4%) exhibited good vascular reactivity. Higher serum fasting glucose (p = 0.019), glycated hemoglobin (p = 0.009), and urinary albumin-to-creatinine ratio (p = 0.006) were associated, while lower prevalence of hypertension (p = 0.029), lower systolic blood pressure (p = 0.027), lower diastolic blood pressure (p &lt; 0.001), and lower circulation 25(OH)D levels (p &lt; 0.001) were associated with poor vascular reactivity. Significant independent associations between diastolic blood pressure (p = 0.002) and serum 25(OH)D level (p &lt; 0.001) and VRI were seen in T2DM patients according to multivariable forward stepwise linear regression analysis. Serum 25(OH)D positively correlated with VRI values, and lower levels of serum 25(OH)D were linked to endothelial dysfunction in T2DM patients.

Association of Diabetes with Changes in Blood Pressure during Hemodialysis: A Secondary Analysis of the Frequent Hemodialysis Network Daily Trial.

Introduction Diabetes mellitus is a common cause of kidney failure and is often complicated by autonomic neuropathy, which may have implications for blood pressure (BP) homeostasis during hemodialysis (HD). Methods In this post hoc analysis of the Frequent Hemodialysis Network (FHN) Daily Trial, we used random effects Poisson and linear regression models to estimate the association of diabetes (versus not) with intra-dialytic hypotension (IDH) and peri-dialytic BP parameters, respectively. We tested for differential associations according to the randomized treatment (6/week vs 3/week HD) and pre-HD systolic BP. Results Of the 244 patients with intra-dialytic BP data, 100 (41%) had diabetes at baseline. The mean age was 51 ± 14 years; 39% were female. In adjusted models, diabetes (vs. not) was associated with a 93% higher risk of developing IDH (IRR 1.93; 95% CI 1.26, 2.95). There was no evidence that the randomized treatment assignment modified the association between diabetes and IDH (P-interaction=0.32), but more potent associations were noted among those with higher pre-HD systolic BP (P-interaction &lt;0.001). Diabetes (vs. not) was associated with a lower adjusted nadir intra-HD BP (-4.2; 95%CI -8.3, -0.2 mmHg), but not with the pre- or post-HD systolic BP. Conclusions Among participants of the FHN Daily trial, patients with diabetes had a higher risk of intra-dialytic hypotension and lower nadir intra-HD systolic BP than patients without diabetes, even when undergoing HD up to 6 times per week.

#2682 Evaluation of clinical, pathological findings and treatment outcomes of patients diagnosed with lupus nephritis: a single center experience

Abstract Background and Aim Renal involvement of systemic lupus erythematosus (SLE) is known as lupus nephritis (LN). The prognosis of lupus patients with LN is worse than those without kidney involvement. Renal survival can be improved in patients with lupus nephritis with appropriate and timely treatment. The aim of our study is to compare the clinical and pathological findings of patients diagnosed with LN in our clinic by renal biopsy, the results of the treatment applied in our center, and renal survival with the literature. Method The local ethical committee approved the study design (date: 04/10/2021; reference number: 121/07) and all procedures were conducted in accordance with the Declaration of Helsinki. Forty-four patients diagnosed with lupus nephritis between January 2012 and January 2021 in the Nephrology Department of Ankara Dıskapı Yıldırım Beyazıt Education and Research Hospital were enrolled in this study. Patient data were analyzed retrospectively. Exclusion criteria were as follows: 1) Patients under 18 years of age, 2) patients with follow-up of period less than 6 months and who did not attend regular follow-ups, 3) patients with connective tissue diseases other than SLE. Results The mean age of the study population was 36.0 ± 10.8, and the majority were female. All patients had proteinuria at diagnosis. Class IV LN was the most common (36.4%). Majority of the patients were in the proliferative LN group (65.9%). A significant difference was found between patients diagnosed with proliferative LN (n = 29) and non-proliferative LN (n = 15) in terms of high serum creatinine levels, low serum complement, presence of anti-dsDNA antibodies and active urinary sediment with proliferative LN (p = 0.021, p = 0.024, p = 0.008, p = 0.008). Treatment responses at 6 and 12 months are shown in Table 1. A significant difference was found between the patients who were in complete remission (n = 16) at 12 months and those who were not in remission (n = 27) in terms of low systolic blood pressure and the estimated glomerular filtration rate (eGFR) at the time of diagnosis (p = 0.008, p = 0.016). It was observed that most of the patients who were not in complete remission at 12 months were in the proliferative LN group (p = 0.024). There was no significant difference in the partial and complete remission rates at 6 and 12 months between the group receiving steroids + cyclophosphamide (n = 14) and the group receiving steroid + mycophenolate mofetil (MMF) (n = 15) in the initial treatment of proliferative LN (p&amp;gt;0.05). In the group taking MMF treatment (n = 15) had a shorter time to reach complete remission than the group taking cyclophosphamide treatment, and it was statistically significant (Table 2) (p = 0.048). It was found that end-stage renal disease (ESRD) developed in 9% of the patients and 2 patients died during followed up period. Recurrence was detected in 8 patients, and it was observed that more than half of the patients with relapse could not achieve complete remission at 12 months. Patients with relapse had higher systolic blood pressure and serum total cholesterol level at the time of diagnosis compared to patients without recurrence (p = 0.013, p = 0.045). In addition, patients with relapse were found to have a higher level of proteinuria at the time of diagnosis (p = 0.036). Conclusion Lupus nephritis remains an important source of morbidity and mortality for SLE patients. SLE patients should be regularly examined for renal involvement. About 10-20% of patients diagnosed with lupus nephritis develop ESRD. Early diagnosis of LN and initiating appropriate treatment when diagnosed without delay is important for renal and patient survival. Although there were some different results, most of the statistically significant data in our study were found to be compatible with the existing literature. However, these data need to be confirmed by studies with high patient participation.

Accelerometer-Measured Physical Activity, Fitness and Indicators of Cardiometabolic Risk among Rural Adolescents: A Cross-Sectional Study at 15-Year Follow-up of the MINIMat Cohort.

Little is known about the relationship of physical activity (PA) and fitness with cardiometabolic risk among rural adolescents in low- and middle-income countries. Thus, we examined the associations of PA and fitness with selected cardiometabolic indicators along with potential gender-based differences in a birth cohort of rural adolescents from southeast Bangladesh. We utilized data from the 15-year follow-up of Maternal and Infant Nutrition Interventions in Matlab (MINIMat) cohort (n = 2253). Wrist-worn ActiGraph wGT3x-BT accelerometers were used to estimate sedentary time (ST) and PA. Fitness was assessed using: handgrip strength, standing long jump, and Chester Step Test. Anthropometric parameters, systolic blood pressure (SBP), and fasting lipid, insulin and glucose levels were measured. We calculated insulin resistance using the Homeostasis Model Assessment equation (HOMA-IR). Linear regression and isotemporal substitution models were fitted. The adolescents spent 64min/day (inter-quartile range: 50-81) in moderate-to-vigorous physical activity (MVPA). A 10-minute-per-day higher vigorous PA (VPA) was associated with: 4.9% (95% confidence interval (CI): 2.9-6.8%) lower waist circumference (WC), 3.2 mmHg (95% CI: 1.5-4.8) lower SBP, 10.4% (95% CI: 2.9-17.3%) lower TG, and 24.4% (95% CI: 11.3-34.9%) lower HOMA-IR. MVPA showed similar associations of notably smaller magnitude. Except for WC, the associations were more pronounced among the boys. Substituting ST with VPA of equal duration was associated with lower WC, SBP, triglyceride and HOMA-IR. Grip strength was favorably associated with all indicators, displaying considerably large effect sizes. Our findings indicated beneficial roles of PA- particularly VPA- and muscular fitness in shaping cardiometabolic profile in mid-adolescence. VPA and grip strength may represent potential targets for preventive strategies tailored to adolescents in resource-limited settings.

Effectiveness of medication self-management, self-monitoring and a lifestyle intervention on hypertension in poorly controlled patients: The MEDICHY randomized trial

BackgroundUncontrolled hypertension is a common problem worldwide, despite the availability of many effective antihypertensive drugs and lifestyle interventions. We assessed the efficacy of a multi-component intervention in individuals with uncontrolled hypertension in a primary care setting.MethodsThis study was a randomized, multicenter, parallel, two-arm, single-blind controlled trial performed in primary healthcare centers in Mallorca (Spain). All participants were 35 to 75-years-old and had poorly controlled hypertension. Patients were randomly assigned in a 1:1 ratio to a control group (usual care) or an intervention group (self-monitoring of blood pressure, self-titration of hypertensive medications, dietary interventions, and physical activity interventions). The primary outcome was decrease in the mean SBP at 6 months relative to baseline.ResultsA total of 153 participants were randomized to an intervention group (77) or a control group (76). After 6 months, the intervention group had a significantly lower systolic blood pressure (135.1 mmHg [±14.8] vs. 142.7 mmHg [±15.0], adjusted mean difference: 8.7 mmHg [95% CI: 3.4, 13.9], p &amp;lt; 0.001) and a significantly lower diastolic blood pressure (83.5 mmHg [±8.8] vs. 87.00 mmHg [±9.0], adjusted mean difference: 5.4 [95% CI: 2.9, 7.8], p &amp;lt; 0.0001). The intervention group also had significantly more patients who achieved successful blood pressure control (&amp;lt;140/90 mmHg; 54.4% vs. 32.9%, p = 0.011).DiscussionSelf-monitoring of blood pressure in combination with self-management of hypertensive medications, diet, and physical activity in a primary care setting leads to significantly lower blood pressure in patients with poorly controlled hypertension.Clinical Trial Registration:ClinicalTrials.gov, identifier ISRCTN14433778.

Association of genetic variants related to combined lipid-lowering and antihypertensive therapies with risk of cardiovascular disease: 2 × 2 factorial Mendelian randomization analyses.

Lipid-lowering drugs and antihypertensive drugs are commonly combined for cardiovascular disease (CVD). However, the relationship of combined medications with CVD remains controversial. We aimed to explore the associations of genetically proxied medications of lipid-lowering and antihypertensive drugs, either alone or both, with risk of CVD, other clinical and safety outcomes. We divided 423,821 individuals in the UK Biobank into 4 groups via median genetic scores for targets of lipid-lowering drugs and antihypertensive drugs: lower low-density lipoprotein cholesterol (LDL-C) mediated by targets of statins or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, lower systolic blood pressure (SBP) mediated by targets of β-blockers (BBs) or calcium channel blockers (CCBs), combined genetically lower LDL-C and SBP, and reference (genetically both higher LDL-C and SBP). Associations with risk of CVD and other clinical outcomes were explored among each group in factorial Mendelian randomization. Independent and additive effects were observed between genetically proxied medications of lipid-lowering and antihypertensive drugs with CVD (including coronary artery disease, stroke, and peripheral artery diseases) and other clinical outcomes (ischemic stroke, hemorrhagic stroke, heart failure, diabetes mellitus, chronic kidney disease, and dementia) (P > 0.05 for interaction in all outcomes). Take the effect of PCSK9 inhibitors and BBs on CVD for instance: compared with the reference, PCSK9 group had a 4% lower risk of CVD (odds ratio [OR], 0.96; 95%CI, 0.94-0.99), and a 3% lower risk was observed in BBs group (OR, 0.97; 95%CI, 0.94-0.99), while combined both were associated with a 6% additively lower risk (OR, 0.94; 95%CI, 0.92-0.97; P = 0.87 for interaction). Genetically proxied medications of combined lipid-lowering and antihypertensive drugs have an independent and additive effects on CVD, other clinical and safety outcomes, with implications for CVD clinical practice, subsequent trials as well as drug development of polypills.

Systolic blood pressure and risk of cardiovascular disease in normotensive diabetic adults: a prospective cohort study.

Currently, the special blood pressure (BP) target for normotensive diabetic patients has not been recommended. We investigated the optimal systolic blood pressure (SBP) for lower cardiovascular disease (CVD) risk in normotensive diabetic patients. In this 12-year follow-up study using the participants of the Kailuan Study, we mainly compared which SBP, 90-119 mmHg or 120-129 mmHg, had a lower risk of occurrence of CVD (stroke and myocardial infarction) in the 3072 normotensive diabetic participants and 21,532 normotensive and non-diabetic participants, respectively. The SBP was expressed as a mean time-weighted cumulative (MTWC) SBP, calculated from the multiple measurements of SBP during the follow-up. Multivariate competing risk regression analyses were used for the analysis. We found that in normotensive diabetic participants, MTWC SBP of 120-129 mmHg was associated with a lower risk of CVD (HR = 0.69 [0.50-0.95]), myocardial infarction (HR = 0.48 [0.24-0.96]), and trending towards lower risk of stroke (HR = 0.80 [0.55-1.16]), compared to MTWC SBP of 90-119 mmHg. Sensitivity analyses confirmed the relationship between low SBP and increased CVD risk. Whereas, in the normotensive and non-diabetic participants, MTWC SBP of 90-119 mmHg vs 120-129 mmHg did not exhibit any difference in the risk of CVD occurrence (HR = 0.99 [0.83-1.18]). The higher level of SBP in normotensive diabetic patients is especially associated with a lower risk of CVD occurrence.

Sex difference in the associations among risk factors with gastroesophageal reflux disease in a large Taiwanese population study

BackgroundGastroesophageal reflux disease (GERD) is a common global health issue. Previous studies have revealed a higher prevalence of GERD in females than in males, however few studies have investigated sex differences in the risk factors associated with GERD. Therefore, the aim of this population-based study was to examine sex differences in the risk factors for GERD in a large cohort of over 120,000 Taiwanese participants.MethodsWe enrolled 121,583 participants (male: 43,698; female: 77,885; mean age 49.9 ± 11.0 years) from the Taiwan Biobank. The presence of GERD was ascertained using self-reported questionnaires. Sex differences in the risk factors associated with GERD were examined using multivariable logistic regression analysis.ResultsThe overall prevalence of GERD was 13.7%, including 13.0% in the male participants and 14.1% in the female participants (p < 0.001). Multivariable analysis showed that older age, hypertension, smoking history, alcohol history, low fasting glucose, and low uric acid were significantly associated with GERD in the male participants. In the female participants, older age, diabetes, hypertension, smoking history, alcohol history, low systolic blood pressure, low fasting glucose, high hemoglobin, high total cholesterol, low high-density lipoprotein cholesterol (HDL-C), low low-density lipoprotein cholesterol, and low uric acid were significantly associated with GERD. Significant interactions were found between sex and age (p < 0.001), diabetes (p < 0.001), smoking history (p < 0.001), fasting glucose (p = 0.002), triglycerides (p = 0.001), HDL-C (p = 0.001), and estimated glomerular filtration rate (p = 0.002) on GERD.ConclusionsOur results showed a higher prevalence of GERD among females compared to males. Furthermore, sex differences were identified in the risk factors associated with GERD, and older age, diabetes, smoking history, and low HDL-C were more closely related to GERD in females than in males.

Blood Pressure, Readmission, and Mortality Among Patients Hospitalized With Acute Kidney Injury

Acute kidney injury (AKI) complicates 20% to 25% of hospital admissions and is associated with long-term mortality, especially from cardiovascular disease. Lower systolic blood pressure (SBP) following AKI may be associated with lower mortality, but potentially at the cost of higher short-term complications. To determine associations of SBP with mortality and hospital readmissions following AKI, and to determine whether time from discharge affects these associations. This retrospective cohort study of adults with AKI during a hospitalization in Veteran Healthcare Association (VHA) hospitals was conducted between January 2013 and December 2018. Patients with 1 year or less of data within the VA system prior to admission, severe or end-stage liver disease, stage 4 or 5 chronic kidney disease, end-stage kidney disease, metastatic cancer, and no blood pressure values within 30 days of discharge were excluded. Data analysis was conducted from May 2022 to February 2024. SBP was treated as time-dependent (categorized as <120 mm Hg, 120-129 mm Hg, 130-139 mm Hg, 140-149 mm Hg, 150-159 mm Hg, and ≥160 mm Hg [comparator]). Time spent in each SBP category was accumulated over time and represented in 30-day increments. Primary outcomes were time to mortality and time to all-cause hospital readmission. Cox proportional hazards regression was adjusted for demographics, comorbidities, and laboratory values. To evaluate associations over time, hazard ratios (HRs) were calculated at 60 days, 90 days, 120 days, 180 days, 270 days, and 365 days from discharge. Of 237 409 admissions with AKI, 80 960 (57 242 aged 65 years or older [70.7%]; 77 965 male [96.3%] and 2995 female [3.7%]) were included. The cohort had high rates of diabetes (16 060 patients [20.0%]), congestive heart failure (22 516 patients [28.1%]), and chronic lung disease (27 682 patients [34.2%]), and 1-year mortality was 15.9% (12 876 patients). Overall, patients with SBP between 130 and 139 mm Hg had the most favorable risk level for mortality and readmission. There were clear, time-dependent mediations on associations in all groups. Compared with patients with SBP of 160 mm Hg or greater, the risk of mortality for patients with SBP between 130 and 139 mm Hg decreased between 60 days (adjusted HR, 1.20; 99% CI, 1.00-1.44) and 365 days (adjusted HR, 0.58; 99% CI, 0.45-0.76). SBP less than 120 mm Hg was associated with increased risk of mortality at all time points. In this retrospective cohort study of post-AKI patients, there were important time-dependent mediations of the association of blood pressure with mortality and readmission. These findings may inform timing of post-AKI blood pressure treatment.

Near hanging with Multiple Tentative Cuts: A Case Series

Suicide is one of the major global health issues specially in countries having low to medium socioeconomic condition. Hanging is method of choice for adults to commit suicide. Near hanging defined as person who survive a hanging injury for enough time to reach hospital. Tentative cut or self-inflicted injury is an intentional and direct injury to own’s body part. It is also known as self-harm, self-wounding, moderate self-mutilation and parasuicide. Various factors responsible for high mortality in near hanging are low systolic blood pressure (&lt;90), injury severity score (ISS) &gt;15, Glassgow coma scale (GCS) &lt;8, hypoxic brain injury on CT scan. Immediate arrival to hospital and aggressive management of near hanging and its complication can improve the final outcome.

Exercise as an anti-inflammatory Therapy in Axial Spondyloarthritis Therapeutic Intervention (EXTASI study): a randomised control trial

Abstract Objectives Axial Spondyloarthritis (AxSpA) is a chronic inflammatory disease, yet despite known anti-inflammatory effects of exercise, the effect of exercise on inflammatory immune cell populations and associated inflammatory profiles in AxSpA is unknown. This randomised-control trial investigated the effect of 12-weeks of walking on symptom severity, cardiometabolic health, inflammatory biomarkers, and immune cell populations. Methods Twenty people (60% male) living with AxSpA who were on stable dose non-steroidal anti-inflammatory (NSAIDs) medication participated. Participants were randomly assigned to control or exercise (30 min of walking five x per week). Participants were invited back every four-weeks for assessment. Results There was a 0% drop out and no adverse events in the exercise group showing walking exercise was well tolerated. Home-based walking for 12-weeks lowered the proportion of pro-inflammatory monocytes, whereas they increased in the control group. Changes were associated with lower interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations, lower spinal pain, and lower systolic blood pressure in the exercise group, whereas these markers increased in the control group. Reductions in IL-6 and pro-inflammatory monocytes with exercise were independent of lower body fat percentage. Conclusion Supplementing NSAID therapy with walking exercise can improve inflammatory immune profiles in people with AxSpA coinciding with reductions in spinal pain. Importantly, the exercise was well tolerated, suggesting walking exercise can be used as an adjuvant anti-inflammatory therapy for NSAID treatments. This should now be explored in people living with AxSpA who have had high enough disease activity to necessitate the prescription of biologic or synthetic DMARD treatments. Clinical trials registration ClinicalTrials.Gov, NCT04368494

2-(4-Methylthiazol-5-yl) Ethyl Nitrate Hydrochloride Ameliorates Cognitive Impairment via Modulation of Oxidative Stress and Nuclear Factor Kappa B (NF-κB) Signaling Pathway in Chronic Cerebral Hypoperfusion-Associated Spontaneously Hypertensive Rats.

Hypertension reduces the bioavailability of vascular nitric oxide (NO) and contributes to the onset of vascular dementia (VaD). A loss of NO bioavailability increases inflammation and oxidative stress. 2-(4-Methylthiazol-5-yl) ethyl nitrate hydrochloride (W1302) is a novel nitric oxide donor (NOD) which is undergoing phase I clinical trials in China for the treatment of VaD. In this study, we investigated the protective effects of W1302 in VaD rats induced by the permanent occlusion of a bilateral common carotid arteries model related to spontaneous hypertension (SHR-2VO), and we further explored the underlying mechanisms. Nimodipine was used as a positive control. Our results showed that W1302 treatment for 4 weeks (10 mg/Kg/day) exhibited stronger improvement in the spatial learning and memory deficits in SHR-2VO rats compared with nimodipine with slightly lower systolic blood pressure (SBP). Meanwhile, W1302 treatment significantly increased NO and cGMP production, restored mitochondrial membrane potential and attenuated oxidative stress as evidenced by increasing ATP production and reducing malondialdehyde (MDA) levels in the brain. Furthermore, W1302 treatment markedly inhibited the iNOS activity and decreased TNF-α expression via inhibiting the nuclear factor kappa B (NF-κB) signaling pathway. Nimodipine treatment also restored these aberrant changes, but its ATP production was weaker than that of W1302, and there was no significant effect on NO release. Taken together, W1302 exhibited beneficial effects on complications in VaD with hypertension, which is involved in suppressing oxidative damage, and the inflammatory reaction might be mediated by an increase in NO release. Therefore, W1302 has therapeutic potential for the treatment of VaD caused by chronic cerebral hypoperfusion-associated spontaneous hypertension.

Low left ventricular outflow tract velocity time integral predicts normotensive shock in patients with acute pulmonary embolism

Abstract Funding Acknowledgements None. Introduction In patients with intermediate-risk acute pulmonary embolism (PE) outcomes vary widely, with mortality rates ranging from 3-15% and rates of normotensive shock up to 30%.1-3 Current risk models don't fully capture those at higher risk and identify patients who may benefit from advanced therapies. The left ventricular outflow tract (LVOT) velocity time integral (VTI), a surrogate marker of cardiac output, has been associated with increased mortality in acute PE.4 Our objective was to determine the association between LVOT VTI and its predictive value in identifying normotensive shock in this patient population. Methods Patients who underwent percutaneous mechanical thrombectomy (MT) between August 2020 and March 2023 at a large academic public hospital were considered for the study. Inclusion criteria comprised of normotensive patients (SBP ≥ 90 mmHg) with invasive measures of cardiac index (CI). VTI was obtained by pulsed wave doppler at the LVOT in either the apical 3 or apical 5 chamber view. The primary outcome was the association between LVOT VTI and normotensive shock and a cut off of 15 cm was used to examine this association based on prior studies.4 Results A total of 49 patients with intermediate-risk PE underwent MT, 16 patients had incomplete data, resulting in a final cohort of 33 patients (mean age: 57 ± 13yrs; 38% female). Patients with LVOT VTI of &amp;lt;15 cm were younger (53 vs 62 years p=0.02), had lower systolic blood pressure at presentation (122 vs 134 mmHg, p=0.047), higher heart rate (112.6 vs 96.2 beats/min, p=0.008), a higher composite shock score (CPES) (5 vs 3, p=0.012), lower cardiac index (1.9 vs 3.1 L/min/m2, p&amp;lt;0.001), a higher PASP (61.4 vs 48.9 mmHg, p=0.018), and higher rates of elevated lactate (90% vs 42%, p=0.027). LVOT VTI threshold of &amp;lt;15cm effectively identified patients with normotensive shock (90% vs 8% p&amp;lt;0.001). There was no statistically significant difference in the rates of saddle emboli, left ventricular ejection fraction, sPESI and BOVA scores in patients with VTI above or below 15cm. In patients with normotensive shock, 19/20 (95%) had LVOT VTI ≤ 15cm with a median of 13 cm (IQR 12, 14) (Figure). In patients without normotensive shock, 11/13 (84%) had LVOT VTI &amp;gt;15 with a median of 18 (IQR 17, 21). The area under the curve for LVOT VTI ≤ 15 cm in predicting normotensive shock was 0.89. The sensitivity and specificity of LVOT VTI ≤ 15 cm in predicting normotensive shock was 91.6% and 90.4% respectively. Conclusion Our study suggests that LVOT VTI is a reliable surrogate for cardiac output in patients with acute PE and can effectively identify those in the intermediate-risk group who are at risk for normotensive shock. A LVOT VTI &amp;lt;15cm may identify intermediate-risk patients at higher risk for hemodynamic decompensation and further studies are needed to evaluate whether these patients would benefit from upfront catheter-based therapies.

Acute-on-chronic heart failure leading to cardiogenic shock: any role for intra-aortic balloon pump? Results from a multicenter retrospective data collection

Abstract Funding Acknowledgements None. Background Intra-aortic balloon pump (IABP) implantation has been significantly reduced since IABP-SHOCK II trial did not show any clinical benefit in acute myocardial infarction (AMI)-related cardiogenic shock (CS)(1). For a long time, AMI has been recognized as the first cause of CS; however, in the last years, acute-on-chronic heart failure (HF)-CS has become predominant. We hypothesized that in HF-CS population the IABP may decrease mortality having a role in decreasing left ventricular afterload and improving peripheral perfusion(2). Purpose To investigate whether, in this phenotypical category of cardiogenic shock, IABP could improve 28-days mortality. Methods Multicenter retrospective observational study including adult HF-CS patients admitted in cardiac or general intensive care units in 3rd level centers. Hemodynamic variables before (T0) and after IABP implantation (T1), pharmacological support and outcome data were collected. Independent samples t-test was applied to assess any difference between IABP and non-IABP group; Kaplan-Meier and Cox’s regression (forward stepwise method) were performed as survival analysis on 28-days mortality. Results 160 patients (35.6% female, 61 [47-74] years-old) were included from three centers; overall mortality was 42.5%. 50% received IABP support; amongst IABP patients, 24 received further MCS with VA-ECMO (p &amp;lt;0.001) and 4 with Impella (p 0.120). Patients’ baseline characteristics are shown in Figure 1-A. IABP patients had lower 28-days mortality. Patients who received IABP were younger, had lower systolic blood pressure (SBP), pulse pressure (PP) and lactate levels at T0. In reference to catecholaminergic drugs, patients supported with IABP had lower norepinephrine doses and vasoactive inotropic score (VIS) at baseline. After IABP implantation, no significant difference between the two groups in the time variation of these parameters was observed (Figure 1-B). Survival analysis graphs are shown in Figure 2. At Cox’s regression, a significant effect on 28-days mortality was found for IABP (HR 0.510 [0.293-0.887], p 0.017), SCAI classification-stage D (HR 2.582 [1.315-5.072], p 0.006), VIS-T0 above 15 (HR 2.348 [1.407-3.921], p 0.001) and SBP-T0 above 95 mmHg (HR 1.361 [1.016-1.823], p 0.039); no significant association was found for age above 61 years (overall median value) (p 0.091), mechanical ventilation (p 0.367), PP-T0 (0 0.081) and lactate-T0 (p 0.227). Conclusions Considering the specific pathophysiology of HF-CS, IABP may have a role in reducing mortality. These retrospective data need to be validated and compared with those deriving from ongoing randomized controlled trials(3).

Sex disparities in mid-term outcomes of ST-segment elevation myocardial infarction across age

Abstract Funding Acknowledgements None. Background Women with ST-segment elevation myocardial infarction (STEMI) have been reported to have higher short-term mortality than men, especially in younger patients. However, data on long-term outcomes did not corroborate this association. Purpose We aimed to evaluate if sex was an independent predictor of major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up. A sub-analysis across different age subgroups was performed. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. Cox proportional hazard models were used to identify predictors of MACCE at 1-year follow-up (death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization). Patients were divided into four age groups, according to quartiles, for subgroup analysis (≤50, 51-60, 61-70, &amp;gt;71 years). Results Of the 1131 patients included in the study, 291 (25.7%) were women. Women were older [68.2 (±14.2) vs 60.6 (±12.2) years, p&amp;lt;0.001], more often non-smokers (21.5% vs 60.2%, p&amp;lt;0.001), and had a higher prevalence of diabetes (34,8% vs 20.9%, p&amp;lt;0.001) and hypertension (71.6% vs 50.2%, p&amp;lt;0.001). They also had lower haemoglobin [12.8 (±1.6) vs 14.5 (±1.7) g/dl, p&amp;lt;0.001] and lower creatinine clearance at admission [73.8 (±35.3) vs 92.6 (±35.2) ml/min, p&amp;lt;0.001], as well as longer door-to-balloon times [90 (60-166) vs 75(50-120) min, p=0.005]. However, total ischemic time was not significantly different between groups [250(175-480) vs 224(150-440) min, p=0.054]. Overall, women had a higher occurrence of MACCE (22.1% vs 15.4%; log-rank P = 0.008, Figure 1). On multivariate analysis, sex was not found to be an independent predictor of MACCE (HR 1.12; 95% CI, 0.77–1.65; P = 0.547). The risk of unfavourable outcomes was mainly driven by other comorbidities (namely, age, presence of peripheral arterial disease, lower haemoglobin concentration, lower systolic blood pressure on admission, a higher peak CK activity, and the utilization of a femoral approach). When MACCE was stratified by age, sex was not an independent predictor of MACCE in any age group (Figure 2). Conclusion Women with STEMI submitted to PCI had a higher rate of MACCE at 1-year follow-up compared with men, however, sex was not an independent predictor of these events on multivariate analysis, regardless of the age subgroups considered.

Management and outcome of high-risk pulmonary embolism in intensive care units: results from a retrospective single-center analysis

Abstract Funding Acknowledgements None. Background High-risk pulmonary embolism (PE) patients are exposed to hemodynamic/multiorgan compromise including hypotension, cardiogenic shock and/or cardiac arrest (CA). Few data exist on management and outcome in patients admitted to intensive care units (ICU) with high-risk PE. Purpose We sought to analyse the epidemiology, management and outcome of patients admitted to ICU due to high-risk PE. Methods Retrospective monocentric analysis of adult patients with high-risk PE admitted from 2017 to 2023; COVID-19 patients were excluded. Demographic, clinical presentation, management and outcome data have been collected. Descriptive analysis comparing means adjusted for organ involvement severity and Cox regression were performed. Results 85 patients (55 male, 63±12 years old, BMI 29.06± 6) were included in the analysis. All patients received the diagnosis through the computed tomography angiography except 4 of them who underwent extra-corporeal cardiopulmonary resuscitation (eCPR) and the diagnosis was made with trans-oesophageal echocardiography. Overall mortality was 32%, eCPR rate was 9%. 92% were treated with adrenergic drugs (norepinephrine 78%, dobutamine 65%, epinephrine 35%); 7 patients required VA-ECMO due to CA. 42 patients received mechanical ventilation (MV) during the first 12 hours; those patients had higher rate of CS (p &amp;lt;0.001), higher lactates (mean difference 1.45±3.2; p &amp;lt;0.001), higher SOFA and SAPS II scores (respectively, mean difference 12.5±0.49 and 7.9±3.4; p 0.004). 75 patients underwent systemic thrombolysis. 10 patients with contraindication to systemic thrombolysis, underwent catheter directed thrombolysis (CDT); in 6 cases CDT was preceded by mechanical suction thrombectomy. Patients undertaking CDT had higher SOFA score at admission (mean difference 2.45±1.6; p 0.04), worsen creatinine (p &amp;lt;0.001), lower PaCO2 (mean difference -0.54±5.3; p 0.01), higher PaO2 (mean difference 28.7±6.5; p 0.009), higher bilirubin (mean difference 3.2±1.6; p &amp;lt;0.001) and lower systolic blood pressure (mean difference -6.8±3.36; p 0.01). At the Cox regression, higher lactates (HR 1.45 [0.40-0.99], p 0.004, panel A), lower glomerular filtration rate (HR 1.1 [1.02-1.09], p 0.001, panel B), higher bilirubin (HR 2.6 [1.20-6.03,] p 0.016), higher ALT (HR 1.07 [0.95-0.99], p 0.04), lower PaO2/FiO2 ratio (HR 1.1 [0.97-0.99], p 0.024, panel C), MV (HR 1.1 [0.78-7.58], p 0.04, panel D) and VA-ECMO (HR 2.5 [1.25-3.54], p 0.002) were associated with increased mortality; CDT was associated with lower mortality (HR 0.82 [0.68-1.89], p 0.04). Conclusions High-risk PE was burdened by high mortality. Signs of worsen organ failure and respiratory and mechanical support are associated with increased mortality. In this monocentric population the use of CDT was performed when systemic thrombolysis contraindicated and it was associated with favourable outcome, although the small sample (10%) should warn contextualization in results’ interpretation.

Influence of age on the incidence of acute complete atrioventricular block in right coronary artery infarction

Abstract Funding Acknowledgements None. Introduction Bezold-Jarisch is a cardioinhibitory reflex originating in cardiac vagal receptors, more concentrated in the inferoposterior wall of left ventricle, whose stimulation produces bradycardia and hypotension. The limited evidence suggests that vagal tone would predominate in younger individuals, whereas sympathetic tone would predominate in the elderly, resulting in a more striking Bezold-Jarisch reflex response among younger patients. Its maximum expression would be the occurrence of acute complete atrioventricular block (cAVB). Methods Observational, retrospective, single-centre analysis of consecutive patients hospitalised in the CCCU for STEACS with RCA or ADA as culprit artery (CA) between July 2011 and September 2022. We analysed the influence of age on the incidence of acute cAVB. Linear trend analysis and multivariate analysis were performed. Results A total of 723 patients with RCA as CA were included, with the baseline characteristics listed in Table1. Patients were divided into 4 groups: under 60 years (n=316 43.7%), 60-69 (n=223 30.8%), 70-79 (n=122 16.9%) and 80 or older (n=62 8.6%). The incidence of acute cAVB was 10.4%, 14.3%, 16.4% and 25.8% respectively (Fig1). A Cochran-Armitage analysis was performed, showing a significant linear trend between age and the incidence of acute cAVB (p=0.001). A multivariate analysis was performed using stepwise regression including age, sex, diabetes, hypertension, obesity, peripheral arterial disease, systolic blood pressure (SBP) at admission, renal failure, COPD, Killip-Kimbal (KK) score at admission and treatment with ticagrelor (for its described adenosine-like effect). Age (p=0.011), KK score (p&amp;lt;0.001) and lower SBP (p&amp;lt;0.001) were associated with a higher incidence of acute cAVB. Regarding the need for transient pacemaker, 6.2% of patients under 60, 7.7% aged 60-69, 10.1% aged 70-79, and 22.0% aged 80 and over required its implantation. As with cAVB, there was a significant linear trend between age and device implantation (p&amp;lt;0.001). Permanent pacemaker was implanted in only 6 patients. In-hospital mortality was significantly higher in patients with acute cAVB than all other patients with RCA infarction (7.9% vs 2.1%; p=0.001). Finally, as controls, acute cAVB data were analysed in patients with STEACS with ADA as CA (N=837). 366 patients (43.7%) were under 60 years, 204 (24.4%) 60-69, 155 (18.5%) 70-79 and 112 (13.4%) 80 or older. Only 10 patients presented with cAVB (1.2%), with no differences between those younger and older than 75 years (1.0% vs 2.3% respectively; p=0.13). Given the low incidence of cAVB in this group no further analysis was performed. Conclusion In RCA STEACS patients, there is a significant trend towards a higher incidence of acute cAVB with increasing age. These data suggest that older patients do not have a mitigated response to Bezold-Jarisch reflex. The inverse relationship between SBP and occurrence of cAVB supports the reflex nature of the mechanism.Table 1.Baseline characteristics.Fig 1.cAVB incidence among age groups.

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review.

Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.