Mm Hg In Patients Research Articles

Achieving low target intraocular pressures in severe glaucoma.

This study aimed to assess details of therapy required to achieve an intraocular pressure (IOP) of ⩽12 mmHg in patients with severe glaucoma of different etiologies. Patients with a follow-up of at least 1 year, who fulfilled inclusion criteria were selected, and data analyzed with respect to baseline IOP, number of medications, and/or surgeries required to achieve an IOP of ⩽12 mmHg and ⩾6 mmHg. Final IOP, visual field status and medications/surgery required were noted. About 127 eyes of 85 patients met all criteria. There were 48 eyes having primary angle closure glaucoma (PACG), 16 eyes with primary open angle glaucoma (POAG), 17 eyes of juvenile open angle glaucoma (JOAG), and 46 eyes of secondary glaucoma. The mean baseline IOP was 33.14 ± 11.07 mmHg and final IOP 10.25 ± 1.81 mmHg. In the age group >40 years, 29.63% of patients were controlled on medication as compared to 9.09% and 5.71% in the age group of <20 years and 20-40 years (p = 0.007). With a baseline IOP of <25 mmHg, 48.65% required a trabeculectomy, whereas for 25-30, and >30 mmHg, 62.5% and 97.29% respectively, required surgery (p < 0.001).66.67% of patients having mean deviation of -12 to -16 dB (decibels) on Humphrey field analyzer (HFA) underwent surgery to achieve target IOP in comparison to 83.52% who had mean deviation greater than -16 dB (p = 0.036). Only 21.26% of severe glaucoma eyes could be controlled on medications alone. A baseline IOP of >25 mmHg, age <40 years and mean deviation worse than -16 dB, had a higher frequency of trabeculectomies to achieve an IOP of ⩽12 mmHg.

Compression Therapy Is Not Contraindicated in Diabetic Patients with Venous or Mixed Leg Ulcer.

The aim of this study was to investigate if compression therapy (CT) can be safely applied in diabetic patients with Venous Leg Ulcers (VLU), even when a moderate arterial impairment (defined by an Ankle-Brachial Pressure Index 0.5–0.8) occurs as in mixed leg ulcers (MLU). Materials and methods: in one of our previous publications we compared the outcomes of two groups of patients with recalcitrant leg ulcers. Seventy-one patients were affected by mixed venous and arterial impairment and 109 by isolated venous disease. Both groups were treated by tailored inelastic CT (with compression pressure <40 mm Hg in patients with MLU and >60 mm Hg in patients with VLU) and ultrasound guided foam sclerotherapy (UGFS) of the superficial incompetent veins with the reflux directed to the ulcer bed. In the present sub analysis of the same patients we compared the healing time of 107 non-diabetic patients (NDP), 69 with VLU and 38 with MLU) with the healing time of 73 diabetic patients (DP), 40 with VLU and 33 with MLU. Results: Twenty-five patients were lost at follow up. The results refer to 155 patients who completed the treatment protocol. In the VLU group median healing time was 25 weeks for NDP and 28 weeks in DP (p = 0.09). In the MLU group median healing time was 27 weeks for NDP and 29 weeks for DP (p = −0.19). Conclusions: when providing leg ulcer treatment by means of tailored compression regimen and foam sclerotherapy for superficial venous refluxes, diabetes has only a minor or no effect on the healing time of recalcitrant VLU or MLU.

Impact of right ventricular systolic pressure in elderly patients admitted to intensive care unit after femur fracture surgery: A retrospective observational study.

The number of femoral fractures is expected to continue to increase as the size of the older population rapidly grows. However, old age is accompanied by various comorbidities and is an important postoperative risk factor in itself, meaning that patients who undergo surgery for a femur fracture may require admission to an ICU. We investigated pulmonary complications in patients over the age of 65 admitted to the ICU after femur fracture surgery.In this single-center retrospective observational study, 289 patients over 65 years who admitted to the ICU after femur fracture surgery between June 2008 and December 2016 were investigated.Pulmonary complications occurred in 97 of these patients (33.6%) after surgery. Mean hospitalization days (34.1 ± 25.7 vs 23.1 ± 15.7, P < .001) and mean ICU length of stay (8.4 ± 16.1 vs 2.5 ± 1.1, P = .001) were significantly longer for patients with pulmonary complications than for patients without pulmonary complications after femur fracture surgery. Patients with pulmonary complications were significantly more likely to have pulmonary disease (19.6% vs 8.9%, P = .009) and exhibit sequelae on preoperative chest X-rays (9.3% vs 3.6%, P = .048) than were patients without pulmonary complications. In addition, significant differences were observed in the right ventricular systolic pressure (RVSP) measured during preoperative echocardiography (37.4 ± 10.9 mm Hg vs 40.7 ± 9.3 mm Hg for patients without and with pulmonary complications, P = .010) and in the proportion of each group that had an RVSP of >35 mm Hg, which is a marker for pulmonary hypertension (55.2% vs 76.3% for patients without and with pulmonary complications, P < .001). In multivariate analysis, an RVSP of >35 mm Hg during preoperative echocardiography was associated with pulmonary complications after femur fracture surgery (OR, 2.6; 95% CI, 1.45-4.53).In conclusion, Pulmonary complications in older patients admitted to the ICU after femur fracture surgery was associated with longer hospitalization and ICU stays. Preoperative RVSP measurement could identify those older patients with a high risk of pulmonary complications following transferal to the ICU after femur fracture surgery.

Left Atrial Size May Predict Blood Pressure Improvement After Ganglionated Plexi Ablation in Addition to Pulmonary Vein Isolation.

Hypertension (HTN) and atrial fibrillation (AF) commonly co-exist. An improvement in control of HTN in a subset of patients undergoing AF ablation was previously demonstrated by our group. In the present study, we aimed to assess whether left atrial (LA) size based on transthoracic echocardiography may predict the patients who demonstratebetter HTN improvement after ganglionated plexus ablation (GPA) in addition to pulmonary vein isolation (PVI). This was a retrospective chart review of patients with AF and HTN who underwent GPA+PVI. Patients were divided into 2 groupsbased on LA size: Patients with normal LA size and patients with LA enlargement. Systolic blood pressure (SBP) levelswere compared at baseline, and 3, 6, and 12 months post-ablation. The primary endpoints of the study weremean systolic blood pressure change compared between groups from baseline to 12-months, as well as the absolute difference in systolic blood pressure at 12 months follow-up.Medical therapy for HTN was also assessed before the procedure, and at 12 months post-procedure. 53 patients (37 with LA enlargement, 16 with normal LA size) met inclusion criteria. At 12 months follow-up, SBP was 136.46 ± 22.38 mmHg in patients with LA enlargementand 118.25 ± 9.81 mmHg in patients with normal LA size (estimated difference of 19.04 ± 6.98 mmHg, p = 0.01). Patients with normal LA size were on significantly fewer anti-hypertensive agents at 12 months (2.33 ± 1.49 vs. 1.44 ± 1.21, p < 0.05). In patients undergoing PVI+GP ablation, normal LA size may predict HTN improvement at 12 months post-procedure. Normal LA size may identify hypertensive AF patients for whom autonomic modulation could be an effective therapy.

Carbon dioxide elimination pattern in assessing the risk of an unfavorable outcome in cardiac surgery

Aim. To assess the influence of resting partial pressure of end-tidal carbon dioxide (PetCO2) levels on the long-term results of cardiac surgery.Materials and methods. This prospective cohort study included 454 patients with coronary artery disease who underwent elective coronary artery bypass graft surgery. Before surgery, all patients underwent pulmonary function tests, including body plethysmography, lung diffusion capacity assessment and cardiopulmonary exercise testing with the determination of ventilatory and gas exchange parameters, including PetCO2 at rest. The endpoint was the 2-year survival rate after surgery.Results. Parameters characterizing the obstructive breathing pattern, the lung diffusion capacity, and resting PetCO2 levels had a significant predictor value in relation to long-term survival after cardiac surgery. Among the baseline clinical and functional characteristics, a significant influence on long-term results was shown by the EuroSCORE II (OR 1,69 (1,26-2,27), p=0,001). The highest sensitivity and specificity in relation to long-term mortality risk after coronary artery bypass grafting was shown by resting PetCO2 value equal to 31 mm Hg (area under the ROC curve 0,74 (0,64-0,86), p&lt;0,001).Conclusion. The resting PetCO2 level below 31 mm Hg in patients with coronary artery disease showed a significant effect on the increased long-term mortality risk after cardiac surgery, which is important for patients with exercise intolerance.

Aortic Valve Neocuspidization (Ozaki Procedure) in Patients with Small Aortic Annulus (≤21 mm): A Multicenter Study

ABSTRACT Background Patients with aortic stenosis (AS) and small aortic annulus (SAA) who undergo surgical aortic valve replacement (SAVR) are more likely to receive smaller prostheses, predisposing them to prosthesis patient-mismatch (PPM). Since the Ozaki Procedure (aortic valve neocuspidization – AVNeo) has proved promising, we aimed to assess its immediate results in this scenario. Methods AVNeo was performed in 106 consecutive patients from January 2017 to March 2019 at three centers. The records were prospectively collected and reviewed retrospectively. Most of the patients were older than 60 years and 97.2% had AS. Preoperative echocardiography showed an average peak pressure gradient of 64.9 ± 20.7 mmHg and a mean pressure gradient of 46.0 ± 12.2 mm Hg for patients with AS and an annular diameter of 19.8 ± 1.1 mm for all patients. EOA and indexed EOA (iEOA) averaged 0.7 ± 0.2 cm2 and 0.4 ± 0.2 cm2/m2 before surgery, respectively. Results There was no conversion to SAVR. Four patients needed reoperation for bleeding, but none needed reoperation due to early infective endocarditis. Median intensive care unit and hospital length of stay were 1.5 ± 1.2 and 13.7 ± 5.1 days, respectively. There were two in-hospital deaths due to non-cardiac causes. Postoperative peak pressure gradient averaged 11.8 ± 5.9 mmHg and mean pressure gradient averaged 7.3 ± 3.5 mmHg, which means statistically significant average decreases of 58.1 and 38.7 mmHg, respectively. Postoperative EOA and iEOA averaged 2.5 ± 0.4 cm2 and 1.3 ± 0.3 cm2/m2, which means statistically significant average increases of 1.8 cm2 and 0.9 cm2/m2, respectively. Conclusions AVNeo is feasible and reproducible with good immediate results. Our findings show that AVNeo produces immediate postoperative low-pressure gradients, larger EOA, and minimal regurgitation of the aortic valve.

B-Cell Lymphoma 2 (Bcl-2) Gene Is Associated with Intracranial Hypertension after Severe Traumatic Brain Injury.

Severe traumatic brain injury (TBI) activates the apoptotic cascade in neurons and glia as part of secondary cellular injury. B-cell lymphoma 2 (Bcl-2) gene encodes a pro-survival protein to suppress programmed cell death, and variation in this gene has potential to affect intracranial pressure (ICP). Participants were recruited from a single clinical center using a prospective observational study design. Inclusion criteria were: age 16-80 years; Glasgow Coma Scale (GCS) score 4-8; and at least 24 h of ICP monitoring treated between 2000-2014. Outcomes were mean ICP, spikes >20 and >25 mm Hg, edema, and surgical intervention. Odds ratios (OR), mean increases/decreases (B), and 95% confidence intervals (CIs) were reported. In 264 patients, average age was 39.2 years old and 78% of patients were male. Mean ICPs were 11.4 ± 0.4 mm Hg for patients with homozygous wild-type (AA), 12.8 ± 0.6 mm Hg for heterozygous (AG), and 14.3 ± 1.2 mm Hg for homozygous variant (GG; p = 0.023). Rs17759659 GG genotype was associated with more ICP spikes >20 mm Hg (p = 0.017) and >25 mm Hg (p = 0.048). Multi-variate analysis showed that GG relative to AA genotype had higher ICP (B = 2.7 mm Hg, 95% CI [0.5,4.9], p = 0.015), edema (OR = 2.5 [1.0, 6.0], p = 0.049) and need for decompression (OR = 3.7 [1.5-9.3], p = 0.004). In this prospective severe TBI cohort, Bcl-2 rs17759659 was associated with increased risk of intracranial hypertension, cerebral edema, and need for surgical intervention. The variant allele may impact programmed cell death of injured neurons, resulting in elevated ICP and post-traumatic secondary insults. Further risk stratification and targeted genotype-based therapies could improve outcomes after severe TBI.

Echocardiography to estimate high filling pressure in patients with heart failure and reduced ejection fraction.

AimsEchocardiographic assessment of left ventricular filling pressures is performed using a multi‐parametric algorithm. Unselected sample of patients with heart failure with reduced ejection fraction (HFrEF) patients may demonstrate an indeterminate status of diastolic indices making interpretation challenging. We sought to test improvement in the diagnostic accuracy of standard and strain echocardiography of the left ventricle and left atrium (LA) to estimate a pulmonary capillary wedge pressure (PCWP) > 15 mmHg in patients with HFrEF.Methods and resultsOut of 82 consecutive patients, 78 patients were included in the final analysis and right heat catheterization, and echocardiogram was performed simultaneously. According to the univariable analysis, E wave velocity, the ratio between E‐wave/A‐wave (E/A, area under the curve [AUC] = 0.81, respectively), isovolumic relaxation time (AUC = 0.83), pulmonary vein D wave (AUC = 0.84), pulmonary vein S/D Ratio (AUC = 0.85), early pulmonary regurgitation velocity (AUC = 0.80), and accelerationa time at right ventricular out‐flow tract (RVOT AT, AUC = 0.84) identified with the highest accuracy PCWP > 15 mmHg. They were all tested in multivariate analysis, and they were not independently correlated with PCWP. Tricuspid regurgitation (TR) velocity was measurement with the highest predictive value in identifying PCWP > 15 mmHg (AUC = 0.89), compared with other established parameters such as the ratio between e‐wave velocity divided by mitral annular e' velocity (E/e'), deceleration time, or LA indexed volume (LAVi), which all reached a lower accuracy level (AUC = 0.75; 0.78; 0.76). Among strain measures, global longitudinal strain in four chamber view (GLS 4ch), the ratio between e‐wave velocity divided by mitral annular e' strain rate (E/e'sr), and LA longitudinal strain at the reservoir phase were helpful in estimating elevated PCWP (AUC = 0.77; 0.76; 0.75). According to multivariable analysis, the following two models had the greatest accuracy in detecting PCWP > 15 mmHg: (i) TR velocity, LAVi, and E wave velocity (receiver operating characteristic [ROC]‐AUC = 0.98), (ii) AT RVOT, LAVi and GLS 4ch (ROC‐AUC = 0.96). Neither E/A (ROC‐AUC = 0.81) nor E/e' (ROC‐AUC = 0.75) was an independent predictor when included in the model. The two MODELS were applicable to the entire population and demonstrated better agreement with the invasive reference (91% and 88%) than the guidelines algorithm (77%) regardless of the type of rhythm.ConclusionsOur suggested echocardiographic approach could be used to potentially reduce the frequency of “doubtful” classification and increase the accuracy in predicting elevated left ventricular filling pressure leading to a decrease in the number of invasive assessment made by right heart catheterization.

SO033PATIROMER TO ENABLE SPIRONOLACTONE IN PATIENTS WITH RESISTANT HYPERTENSION AND CHRONIC KIDNEY DISEASE (AMBER): PRESPECIFIED RESULTS BY BASELINE SERUM POTASSIUM

Abstract Background and Aims Spironolactone (SPIRO) is effective at reducing blood pressure in patients with resistant hypertension (RHTN); however, its use in patients with advanced chronic kidney disease (CKD) is often limited by hyperkalaemia. In AMBER, patiromer (PAT) enabled more persistent use of SPIRO in patients with RHTN and eGFR 25 to ≤45 mL/min/1.73 m2. Patients were required to be normokalaemic at baseline, with serum potassium (sK+) 4.3 to 5.1 mmol/L. Since higher baseline sK+ may increase the risk for developing hyperkalaemia on SPIRO, we evaluated AMBER results in prespecified subgroups by baseline sK+. Methods This was a randomised, double-blind, placebo (PBO)-controlled trial in adults with eGFR 25 to ≤45 mL/min/1.73 m2, uncontrolled RHTN, and sK+ 4.3 to 5.1 mmol/L. Patients were assigned (1:1) to receive PBO or PAT, and SPIRO 25 mg QD, with dose titrations permitted after 1 week (PAT) and 3 weeks (SPIRO). The primary endpoint was the between-group difference at Week 12 in the percentage of patients on SPIRO. The secondary endpoint was the difference between treatment groups in the change in systolic automated office blood pressure (AOBP) from baseline to Week 12 (or to the last available measurement before the addition of any new antihypertensive medications or increase in any of the baseline antihypertensive medications). The primary and secondary endpoints were assessed in prespecified subgroups by baseline sK+ stratum: 4.3 to &amp;lt;4.7 mmol/L and 4.7 to 5.1 mmol/L. Results 295 patients were randomised, 129 (44%) and 166 (56%) with baseline sK+ 4.3 to &amp;lt;4.7 mmol/L and sK+ 4.7 to 5.1 mmol/L, respectively. Baseline mean (SD) systolic AOBP (mmHg) was 144.0 (7.3) and 144.1 (6.4), and eGFR (mL/min/1.73 m2) was 36.4 (7.6) and 35.2 (7.2), respectively. Significantly more patients treated with PAT than with PBO remained on SPIRO at Week 12 in both subgroups (between treatment difference of 16.2% [P=0.0167] for patients with sK+ 4.3 to &amp;lt;4.7 mmol/L and 22.4% [P=0.0016] for patients with sK+ 4.7 to 5.1 mmol/L) with P=0.45 for interaction between subgroups (Figure). In patients with sK+ 4.3 to &amp;lt;4.7 mmol/L, LS mean (SE) systolic AOBP change from baseline was –10.7 (1.9) mmHg in patients receiving PBO and –13.0 (1.9) mmHg in patients receiving PAT; systolic AOBP change from baseline was –10.5 (1.6) (PBO) and –10.5 (1.6) mmHg (PAT) in patients with sK+ 4.7 to 5.1 mmol/L (P&amp;lt;0.001 for all changes from baseline and P=NS for all differences between treatment groups). LS mean (SE) cumulative SPIRO dose was higher with PAT than PBO by 373.2 (157.0) mg and 392.3 (185.0) mg in patients with sK+ 4.3 to &amp;lt;4.7 mmol/L and sK+ 4.7 to 5.1 mmol/L, respectively. Adverse events occurred in 52% (PBO) and 56% (PAT) of patients with sK+ 4.3 to &amp;lt;4.7 mmol/L and in 55% (PBO) and 56% (PAT) of patients with sK+ 4.7 to 5.1 mmol/L. Adverse events of hyperkalaemia or blood K+ increased occurred in 2 (PBO) and 4 (PAT) patients with sK+ 4.3 to &amp;lt;4.7 mmol/L and in 12 (PBO) and 5 (PAT) patients with sK+ 4.7 to 5.1 mmol/L. One PBO and 2 PAT patients (sK+ 4.3 to &amp;lt;4.7 subgroup) and 1 PAT patient (sK+ 4.7 to 5.1 subgroup) had serum Mg 0.49 to &amp;lt;0.58 mmol/L; none had serum Mg &amp;lt;0.49 mmol/L. Conclusion PAT enabled more patients with advanced CKD and RHTN to continue treatment with SPIRO, regardless of baseline sK+ stratum.

Renal Denervation in High-Risk Patients With Hypertension

BackgroundRenal denervation (RDN) is under investigation for treatment of uncontrolled hypertension and might represent an attractive treatment for patients with high cardiovascular (CV) risk. It is important to determine whether baseline CV risk affects the efficacy of RDN. ObjectivesThe purpose of this study was to assess blood pressure (BP) reduction and event rates after RDN in patients with various comorbidities, testing the hypothesis that RDN is effective and durable in these high-risk populations. MethodsBP reduction and adverse events over 3 years were evaluated for several high-risk subgroups in the GSR (Global proSpective registrY for syMPathetic renaL denervatIon in seleCted IndicatIons Through 3 Years Registry), an international registry of RDN in patients with uncontrolled hypertension (n = 2,652). Comparisons were made for patients age ≥65 years versus age <65 years, with versus without isolated systolic hypertension, with versus without atrial fibrillation, and with versus without diabetes mellitus. Baseline cardiovascular risk was estimated using the American Heart Association (AHA)/American College of Cardiology (ACC) atherosclerosis cardiovascular disease (ASCVD) risk score. ResultsReduction in 24-h systolic BP at 3 years was −8.9 ± 20.1 mm Hg for the overall cohort, and for high-risk subgroups, BP reduction was −10.4 ± 21.0 mm Hg for resistant hypertension, −8.7 ± 17.4 mm Hg in patients age ≥65 years, −10.2 ± 17.9 mm Hg in patients with diabetes, −8.6 ± 18.7 mm Hg in isolated systolic hypertension, −10.1 ± 20.3 mm Hg in chronic kidney disease, and −10.0 ± 19.1 mm Hg in atrial fibrillation (p < 0.0001 compared with baseline for all). BP reduction in patients with measurements at 6, 12, 24, and 36 months showed similar reductions in office and 24-h BP for patients with varying baseline ASCVD risk scores, which was sustained to 3 years. Adverse event rates at 3 years were higher for patients with higher baseline CV risk. ConclusionsBP reduction after RDN was similar for patients with varying high-risk comorbidities and across the range of ASCVD risk scores. The impact of baseline risk on clinical event reduction by RDN-induced BP changes could be evaluated in further studies. (Global proSpective registrY for syMPathetic renaL denervatIon in seleCted IndicatIons Through 3 Years Registry; NCT01534299)

Clinical Decompensation and Outcomes in Patients With Compensated Cirrhosis and a Hepatic Venous Pressure Gradient ≥20 mm Hg.

Hepatic venous pressure gradient (HVPG) of ≥10 mm Hg predicts clinical decompensation (CD) in compensated cirrhosis. A proportion of cirrhotic patients at presentation have high HVPG (≥20 mm Hg) and are compensated. The natural history, spectrum of CD, and mortality in this group is largely unknown. Consecutive compensated cirrhotic patients with HVPG ≥6 mm Hg (n = 741) were followed up for 3-6 months for the development of any CD. Patients were classified based on the baseline HVPG (6 to <12 mm Hg [low HVPG, Gr.A, n = 163], 12 to <20 mm Hg [intermediate HVPG, Gr.B, n = 437] and ≥20 mm Hg [high HVPG, Gr.C, n = 141]). We analyzed the predictors of first CD, HVPG response to carvedilol, and mortality in these groups. CD developed in 217 (29.3%) patients during a mean follow-up of 1.6 ± 0.4 years, and those who developed CD had higher baseline HVPG (17.02 ± 4.79 vs 14.28 ± 4.86; P < 0.001). First CD was seen earlier (1.3 ± 0.7 years vs 1.5 ± 0.6 years and 1.6 ± 0.5 years, P = 0.02) and more frequently (44.7% vs 11% and 31.1%, P < 0.01) in high HVPG groups compared with low and intermediate HVPG groups, with higher mortality rates. Patients in the high HVPG group compared with the low HVPG group more often had NASH-cirrhosis (35.5% vs 19.6%; P 0.001), higher liver stiffness values (45.06 ± 20.46 vs 20.09 ± 5.47 kPa, P < 0.001), and lower platelet counts (113.37 ± 72.57 vs 151.7 ± 87.30/cmm, P < 0.001). Patients with HVPG ≥12 mm Hg received carvedilol, and a repeat HVPG performed in a proportion after 9.3 ± 2.4 months showed response (≥20% reduction in HVPG or <12 mm Hg) in 31.6% patients (Gr. B, 44.9% > Gr. C, 22.2%, P < 0.05). Baseline HVPG (HVPG ≥12 to <20 mm Hg [Hazard ratio: 2.73] and HVPG ≥20 mm Hg [Hazard ratio: 4.48], P < 0.001) independently predicted CD. HVPG ≥20 mm Hg in patients with compensated cirrhosis independently predicts early and more frequent CD and poor outcomes. These patients should be labeled as "high-risk compensated cirrhosis," and early and effective interventions to reduce portal pressure should be initiated to improve long-term outcomes.

Effect of Intensive Blood Pressure Lowering on the Risk of Atrial Fibrillation.

It remains uncertain whether intensive control of blood pressure (BP) results in a lower risk of atrial fibrillation (AF) in patients with hypertension. Using data from SPRINT (Systolic Blood Pressure Intervention Trial), which enrolled participants with hypertension at increased risk of cardiovascular disease, we examined whether intensive BP lowering (target systolic BP [SBP] <120 mm Hg), compared with standard BP lowering (target SBP<140 mm Hg), results in a lower risk of AF. This analysis included 8022 participants (4003 randomized to the intensive arm and 4019 to standard BP arm) who were free of AF at the time of enrollment and with available baseline and follow-up electrocardiographic data. AF was ascertained from standard 12-lead electrocardiograms recorded at biannual study examinations and an exit visit. During up to 5.2 years of follow-up and a total of 28 322 person-years, 206 incident AF cases occurred; 88 in the intensive BP-lowering arm and 118 in the standard BP-lowering arm. Intensive BP lowering was associated with a 26% lower risk of developing new AF (hazard ratio, 0.74 [95% CI, 0.56-0.98]; P=0.037). This effect was consistent among prespecified subgroups of SPRINT participants stratified by age, sex, race, SBP tertiles, prior cardiovascular disease, and prior chronic kidney disease when interactions between treatment effect and these subgroups were assessed using Hommel adjusted P values. In conclusion, intensive treatment to a target of SBP <120 mm Hg in patients with hypertension at high risk of cardiovascular disease has the potential to reduce the risk of AF. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.

Use of Tourniquet During Knee Arthroplasty in Patients With Radiographic Arterial Calcifications

BackgroundUse of tourniquet during total knee arthroplasty (TKA) in patients with radiographic arterial calcifications is controversial. Intimal arterial calcifications are feared to be associated with ischemic complications such as delayed wound healing and arterial thrombosis, whereas medial calcifications stiffen the arterial wall, possibly leading to tourniquet failure and increased blood loss. MethodsWe conducted a prospective cohort study to determine the incidence of tourniquet failure (inflated up to 300 mm Hg), blood transfusions, wound healing, and ischemic complications in thighs with and without arterial calcifications on preoperative radiographs, in 2548 consecutive primary TKAs conducted in our unit over a 5-year period. Eighty-six thighs showed vascular calcifications: 58 medial and 28 intimal. ResultsThighs with vascular calcifications had higher risk of tourniquet failure as compared to those without calcifications (P < .001), but with no significant increase in incidence of blood transfusions. All cases of tourniquet failure in the calcification group occurred in thighs with medial calcifications, whereas all cases of tourniquet failure in the control group occurred in obese patients. There was no difference in wound healing and ischemic complications in limbs with and without arterial calcifications. ConclusionThe presence of arterial calcifications on preoperative radiographs increases the risk of tourniquet failure at 300 mm Hg in patients undergoing TKA, with no significant increase in rate of blood transfusions, wound healing or ischemic complications.

Impact de l’exposition à la fumée de cigarette sur la réponse hémodynamique à l’exercice de patients sous traitement spécifique de l’HTAP

Pulmonary hypertension (PH) is a life-threatening haemodynamic condition associated with many disorders. In pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension, several treatments acting against pulmonary endothelial dysfunction have been shown to be effective. Exposure to cigarette smoke leads to endothelial dysfunction which is comparable to that observed in patients with PAH. The main objective was to investigate the difference in the haemodynamic changes during exercise in patients under specific treatment, from diagnosis (T0) to the first reassessment visit with a right heart catheterisation (T1), between those exposed or not exposed to cigarette smoke. Between January 2002 and December 2018, all patients under specific treatment for PAH or chronic thromboembolic PH who underwent supine submaximal exercise assessment at T0 and T1 in our institution were asked specific questions about tobacco smoking. Overall (n=109), difference in mean isoflow mPAP was 19.0±15.4mmHg in patients exposed to tobacco smoke versus 21.3±16.6mmHg in unexposed patients (P=0.59). Median survival in exposed group was 83 months while in the unexposed group, median survival was 100 months (P=0.099). Our study did not show any significant difference in terms of haemodynamic changes during exercise between a group of patients under specific PH treatment exposed to cigarette smoke and a group unexposed. Endothelial dysfunction induced by smoke exposure does not appear to have a major impact on the response to the specific PH treatment.

Differences in right ventricular dysfunction in patients with idiopathic pulmonary hypertension versus secondary pulmonary hypertension.

Right ventricular (RV) function in the setting of pulmonary hypertension based on different etiologies has not been well studied. In this study, we evaluated the RV function in patients with idiopathic pulmonary hypertension (IPH) versus secon-dary pulmonary hypertension (SPH) due to congestive heart failure. Forty-five patients with pulmonary hypertension and New York Heart Association (NYHA) functional class II or III were enrolled. Of these, 22 were diagnosed with IPH and 23 with SPH. Echocardiographic data, including Doppler and Doppler based strain, were assessed according to the American Society of Echocardiography (ASE) guidelines for detailed evaluation of RV function in these two groups. Mean PAP was 60 ± 14.5 mm Hg in patients with IPH versus 43 ± 11.5 mm Hg in patients with SPH (p = 0.001). Considering conventional indexes of RV function, only Sm and dp/dt were significantly better in the first group compared with the second group (p-value for Sm = 0.042 and for dp/dt = 0.039). RV end diastolic dimension was significantly higher in the IPH group (p = 0.013). Using deformation indexes of RV function, the basal and mid portion of RV free wall strain and basal RV strain rates were significantly worse in the chronic systolic heart failure (PH-HF) group in comparison to the IPH group (p < 0.001 in basal RV strain, p = 0.034 in mid RV strain and p = 0.046 in basal RV strain rate respectively). IPH has less impact on RV function in comparison to PH-HF. Considering both entities are in the category of RV pressure overload, we conclude that the etiology of pulmonary hypertension also plays an important role in RV function in addition to pressure overload.

Low blood pressure and cardiovascular events in diabetic patients with coronary artery disease after revascularization: the CREDO-Kyoto registry cohort-1.

The current American, European, and Japanese guidelines for hypertension treatment have lowered blood pressure (BP) targets to <130/80 mmHg in patients with diabetes mellitus (DM) and patients with coronary artery disease (CAD). However, there is concern that low BP may increase cardiovascular events in diabetic CAD patients. Currently, coronary revascularization has become widespread in diabetic CAD patients. Thus, whether low BP is an independent risk factor for cardiovascular events in diabetic CAD patients after revascularization was investigated. We examined 2718 stable CAD patients with DM in the CREDO-Kyoto cohort-1 registry enrolling 9877 patients who underwent their first percutaneous coronary intervention or coronary bypass grafting. There were no cutoff points for systolic BP (SBP) below which the age- and sex-adjusted hazard ratios for cardiovascular death, nonfatal myocardial infarction (MI), and nonfatal stroke increased. The cutoff diastolic BP (DBP) for increasing cardiovascular death was 70 mmHg (P = 0.014), whereas there was no cutoff DBP for increasing nonfatal MI and nonfatal stroke. However, on stepwise Cox hazard proportional regression analysis, the independent factors increasing cardiovascular death were hypertension, low creatinine clearance, wide pulse pressure, prior MI, and nonuse of statins, but DBP < 70 mmHg was not a significant factor. In conclusion, in diabetic CAD patients after coronary revascularization, low SBP and DBP were not significant factors that increased cardiovascular events. Careful attention should be paid to vascular lesions and organ damage that have already progressed.

Abstract TMP54: A VA Observational Study Examining the Benefit of Various Post-Ischemic Stroke/Tia Hypertension Goals in Preventing Recurrent Vascular Events

Introduction: Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of &lt; 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of &lt; 130/80 mmHg for patients with ischemic stroke/TIA. Understanding the potential benefit in preventing recurrent vascular events for patients reaching ACC/AHA BP goals is necessary to inform clinical care. Methods: This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up. Vascular events were defined as cerebrovascular-only, cardiovascular-only, and the composite of each. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and &gt;140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to recurrent event 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year recurrent vascular event rates. Results: A total of 12,337 eligible patients were included in the final analysis. Compared to those with SBP &gt; 140 mmHg, patients reaching ACC/AHA BP goal had significant lower risk of cerebrovascular recurrent events (HR=0.77, 95% CI=0.60-0.99) but not cardiovascular recurrence or both combined. Conclusions: In considering BP reached by 90-days, ACC/AHA BP guidelines showed protective effects on cerebrovascular event recurrence only.

Abstract TMP51: A VA Observational Study Examining the Mortality Benefit of Various Post-ischemic Stroke/tia Hypertension Goals - Is There a Too Low?

Introduction: Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of &lt; 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of &lt; 130/80 mmHg for patients with ischemic stroke/TIA. Understanding potential mortality benefit for patients reaching ACC/AHA goal is needed. Hypothesis: Stroke/TIA patients reaching ACC/AHA goal BP will experience lower 1-year all-cause mortality compared to those reaching JNC-8 BP goals. Methods: This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up for analysis of 1-year mortality. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and &gt;140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to mortality 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year mortality. Results: A total of 12,337 eligible patients were included in the final analysis. COX proportional regression demonstrated a statistically significant higher risk of death among patients with SBP lower than 105 mmHg as compared to those with &gt; 140 mmHg (HR = 1.79, 95% CI= 1.37-2.34), but no statistical differences were found in other SBP groups. Predicted probability of 1-year mortality generated from the logistic regression was plotted and showed a “U” shaped relationship between SBP and mortality, whereas SBP ranges encompassing both AHA/ACC and JNC-8 goal BP recommendations are found on the “flat” part of the curve. Conclusions: In considering BP reached by 90-days, there was no differential 1-year all-cause mortality benefit between JNC-8 and ACC/AHA BP recommendations, whereas patients experiencing low SBPs were at increased risk for higher mortality. Providers should be aware of the association between lower SBP and higher mortality when treating BP.

Abstract TMP53: Post Stroke Blood Pressure, It Ain't Over and Reload

Introduction: Even high blood pressure (BP) is regarded as an important target for the secondary prevention of ischemic stroke, there is limited information how it is controlled and what effect is on the prognosis. Methods: This study was a nation-wide, multicenter, prospective study to observe 3-month BP and long-term outcomes in patients with acute ischemic stroke. For all enrolled subjects, 3-month BP after index stroke event were collected and classified into good and poor controlled hypertension (SBP &lt; 130 mmHg versus ≤ 130 mmHg) and normotensive state. The association of 3-month BP with a composite outcome of stroke recurrence, myocardial infarction and vascular death was investigated using Cox proportional hazard model with predetermined adjusting variables. Results: Of enrolled 17976 subjects (age; 67.8 ± 13.1 years-old, male proportion: 57.9%), hypertension was estimated in 64.1% (n = 10459) at index event. After 3-month, SBP was mean 130.1 ± 1.3 mmHg in patients with hypertension, of which 67.8% showed poor controlled hypertension. In the Kaplan-Meier survival curve, a hypertension-controlled state showed significant association with the composite outcome (Figure). As referenced with normotensive state, poor controlled hypertension independently increased the hazards for composite event (adjusted odds ratio, 1.32; 95% confidence interval, 1.04 - 1.66), but not good controlled hypertension (1.20; 0.91 - 1.59) with adjustments for age, sex, diabetes mellitus, dyslipidemia, atrial fibrillation, stroke severity and stroke subtypes. Conclusion: This study clarified the clinical impact to monitor and control the BP after ischemic stroke.

Assessing the correlation between sublingual varices and hypertension among the adults of Satara district, Maharashtra: An observational study

Aim: In most of the times, sublingual varices (SLV) are noticed during aging process, cardiovascular disease, and smoking. The aim of this study was to find the relation of SLV and the presence of hypertension. Materials and Methods: A total of 215 dental patients were enrolled for the study, of which 14 were dropped, and the status of tongue and blood pressure of a total of 201 study subjects was recorded. The patients with an average blood pressure (at home) of ≥85 mm Hg (diastolic) and ≥135 mm Hg (systolic) were reported to the hospital, where three hypertension measurements were recorded with an interval of 1 week. Student t test and Pearson chi-square test were used for the analysis. Results: An association was found between hypertension and SLV (odds ratio = 2.16, P < 0.001). The systolic blood pressure was found to be 121.2 mm Hg and 138.1 mm Hg in subjects with grade 0 and grade 1 SLV, respectively (P < 0.001). The mean diastolic blood pressure was found to be 81.2 mm Hg and 85.2 mm Hg in patients with grade 0 and grade 1 SLV, respectively (P < 0.05). Conclusion: An association was observed between SLV and hypertension. Examination of lateral borders of tongue can be performed easily, and causes no harm to the patients, and can be considered as an important diagnosis method for the dentists to take an active role in preventive and primary health care.