Optimal Blood Pressure Targets Research Articles

Disability level’s impact on blood pressure-mortality association in older long-term care adults: evidence from a large Chinese cohort study

BackgroundEvidence of the optimal blood pressure (BP) target for older adults with disability in long-term care is limited. We aim to analyze the associations of BP with mortality in older adults in long-term care setting with different levels of disability.MethodsThis prospective cohort study was based on the government-led long-term care programme in Chengdu, China, including 41,004 consecutive disabled adults aged ≥ 60 years. BP was measured during the baseline survey by trained medical personnel using electronic sphygmomanometers. Disability profile was assessed using the Barthel index. The association between blood pressure and mortality was analyzed with doubly robust estimation, which combined exposure model by inverse probability weighting and outcome model fitted with Cox regression. The non-linearity was examined by restricted cubic spline. The primary endpoint was all-cause mortality, and the secondary endpoints were cardiovascular and non-cardiovascular mortality.ResultsThe associations between systolic blood pressure (SBP) and all-cause mortality were close to a U-shaped curve in mild-moderate disability group (Barthel index ≥ 40), and a reversed J-shaped in severe disability group (Barthel index < 40). In mild-moderate disability group, SBP < 135 mmHg was associated with elevated all-cause mortality risks (HR 1.21, 95% CI, 1.10–1.33), compared to SBP between 135 and 150 mmHg. In severe disability group, SBP < 150 mmHg increased all-cause mortality risks (HR 1.21, 95% CI, 1.16–1.27), compared to SBP between 150 and 170 mmHg. The associations were robust in subgroup analyses in terms of age, gender, cardiovascular comorbidity and antihypertensive treatment. Diastolic blood pressure (DBP) < 67 mmHg (HR 1.29, 95% CI, 1.18–1.42) in mild-moderate disability group and < 79 mmHg (HR 1.15, 95% CI, 1.11–1.20) in severe disability group both demonstrated an increased all-cause mortality risk.ConclusionThe optimal SBP range was found to be higher in older individuals in long-term care with severe disability (150-170mmHg) compared to those with mild to moderate disability (135-150mmHg). This study provides new evidence that antihypertensive treatment should be administered cautiously in severe disability group in long-term care setting. Additionally, assessment of disability using the Barthel index can serve as a valuable tool in customizing the optimal BP management strategy.Trial registrationChinese Clinical Trial Registry (Registration Number: ChiCTR2100049973).

#783 Individualized net benefit of intensive blood pressure lowering among older adults in SPRINT

Abstract Background and Aims The optimal blood pressure (BP) target for older adults remains controversial. This study aimed to determine whether results from the Systolic Blood Pressure Intervention Trial (SPRINT) could be tailored to individual trial participants using risk estimates and simulated preferences about the relative importance of multiple outcomes related to BP lowering. Method This analysis included 4,850 SPRINT participants age ≥65 years. Parsimonious Cox models were internally validated to predict the absolute difference in risk between intensive versus standard BP lowering in each SPRINT participant for all-cause death, cardiovascular outcomes, cognitive outcomes, and serious adverse events. Treatment effects were combined using simulated preference weights into an individualized net benefit, which represents the weighted sum of risk differences across outcomes. Individualized net benefits among older SPRINT participants were compared across categories of age (65-74 years vs. ≥ 75 years), frailty (fit, less fit, and frail), and polypharmacy status. Results When simulating preferences for older adults who view death, cardiovascular events, and cognitive impairment as much more important than the harms of BP lowering, the median (IQR) individualized net benefit was 5% (3%, 7%), and 100% had a net benefit that favoured intensive BP lowering. When simulating benefits and harms to have similar importance, the median (IQR) individualized net benefit was 2% (1%, 3%), and 95.4% had a positive net benefit. In subgroup analyses, the predicted net benefit of intensive BP lowering was significantly greater among those with advanced age, frailty, and polypharmacy compared with lower risk individuals (P&amp;lt;0.001 for all comparisons). Conclusion Almost all older participants in SPRINT had a predicted net benefit that favoured intensive BP control, but the degree of net benefit varied considerably. Personalizing BP targets for older adults according to each person's estimated risks and preferences may provide more refined BP target recommendations.

Changing Concepts About Optimal Target Blood Pressure and the Therapeutic Advantages of Azilsartan for Achieving it

The article discusses current issues of the treatment of arterial hypertension. According to presented data, so-called therapeutic nihilism is becoming one of the main barriers to achieving target blood pressure (BP). This nihilism is that despite evidence of the effectiveness of achieving lower BP values, practitioners do not intensify antihypertensive therapy sufficiently to achieve such values. The article specially addresses new criteria for the effectiveness of antihypertensive therapy, which reflect the therapy sustainability. The most commonly used indicator is the duration of the period, during which systolic BP remains in the therapeutic range. The prognostic significance of such indicators is discussed. In these conditions, it is very important to use the most effective antihypertensive drugs for initial antihypertensive therapy, including as a part of combination therapy. This tactic provides more frequent achievement of BP goals without the need for dose adjustment. In this regard, a systematic review was performed, which included sufficiently large randomized studies of the antihypertensive effectiveness of azilsartan medoxomil. This systematic review will provide comprehensive information on a possible role of using the angiotensin II receptor blocker azilsartan as a basic drug for the treatment of a wide range of patients with high BP. Most of the studies included in the systematic review assessed the effectiveness of combination therapy including azilsartan.

Cerebral Perfusion Unveiled: A Comprehensive Review of Blood Pressure Management in Neurosurgical and Endovascular Aneurysm Interventions.

This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain's susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.

Blood pressure levels and adverse cardiovascular outcomes in heart failure: A systematic review and meta-analysis.

Existing data on the association between blood pressure levels and adverse cardiovascular outcomes in patients with heart failure (HF) are inconsistent. The optimal blood pressure targets for patients with HF remain uncertain. This study sought to assess the associations between blood pressure (systolic and diastolic blood pressure, SBP and DBP) levels and adverse cardiovascular disease (CVD) outcomes in patients with HF. A systematic review and meta-analysis were conducted using MEDLINE, Embase, the Cochrane Library, and Web of Science databases up to 5 May 2023. The outcomes of interest included adverse cardiovascular events and all-cause mortality. Pooled relative risks (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Forty-three unique observational cohort studies, comprising 120 643 participants with HF, were included. The pooled RRs (95% CIs) for SBP thresholds of ≥140 mmHg vs <140 mmHg were 0.92 (0.83-1.01) for all-cause mortality, 0.83 (0.67-1.04) for CVD death, and 0.98 (0.80-1.21) for HF hospitalization. The pooled RR (95% CI) for SBP thresholds of ≥160 mmHg vs <160 mmHg and all-cause mortality was 0.67 (0.62-0.74). SBP levels below <130, <120, and < 110 mmHg were each associated with an increased risk of various cardiovascular endpoints and all-cause mortality. The pooled RR (95% CI) for DBP thresholds of ≥80 mmHg vs <80 mmHg and all-cause mortality was 0.86 (0.67-1.10). A 10 mmHg increase in SBP or DBP was associated with a reduction in all-cause mortality and other cardiovascular endpoints. The findings suggest that lower and normal baseline SBP levels (<130, <120, and < 110 mmHg) may be associated with future risk of worse outcomes in patients with HF. Optimal baseline blood pressure levels for these patients may lie within the range of ≥140 mmHg for SBP. In the absence of observational studies with repeated blood pressure measurements or definitive trials evaluating optimal blood pressure targets, individualized blood pressure targets based on patients' unique circumstances are warranted in HF management.

Preventing cognitive decline by reducing BP target (PCOT): A randomized, pragmatic, multi-health systems clinical trial

BackgroundGrowing evidence suggests that intensive lowering of systolic blood pressure (BP) may prevent mild cognitive impairment (MCI) and dementia. However, current guidelines provide inconsistent recommendations regarding optimal BP targets, citing safety concerns of excessive BP lowering in the diverse population of older adults. We are conducting a pragmatic trial to determine if an implementation strategy to reduce systolic BP to <130 and diastolic BP to <80 mmHg will safely slow cognitive decline in older adults with hypertension when compared to patients receiving usual care. MethodsThe Preventing Cognitive Decline by Reducing BP Target Trial (PCOT) is an embedded randomized pragmatic clinical trial in 4000 patients from two diverse health-systems who are age ≥ 70 years with BP >130/80 mmHg. Participants are randomized to the intervention arm or usual care using a permuted block randomization within each health system. The intervention is a combination of team-based care with clinical decision support to lower home BP to <130/80 mmHg. The primary outcome is cognitive decline as determined by the change in the modified Telephone Interview for Cognitive Status (TICS-m) scores from baseline. As a secondary outcome, patients who decline ≥3 points on the TICS-m will complete additional cognitive assessments and this information will be reviewed by an expert panel to determine if they meet criteria for MCI or dementia. ConclusionThe PCOT trial will address the effectiveness and safety of hypertension treatment in two large health systems to lower BP targets to reduce risk of cognitive decline in real-world settings.

Hypertension in frail older adults: current perspectives.

Hypertension is one of the most common chronic diseases in older people, and the prevalence is on the rise as the global population ages. Hypertension is closely associated with many adverse health outcomes, including cardiovascular disease, chronic kidney disease and mortality, which poses a substantial threat to global public health. Reasonable blood pressure (BP) management is very important for reducing the occurrence of adverse events. Frailty is an age-related geriatric syndrome, characterized by decreased physiological reserves of multiple organs and systems and increased sensitivity to stressors, which increases the risk of falls, hospitalization, fractures, and mortality in older people. With the aging of the global population and the important impact of frailty on clinical practice, frailty has attracted increasing attention in recent years. In older people, frailty and hypertension often coexist. Frailty has a negative impact on BP management and the prognosis of older hypertensive patients, while hypertension may increase the risk of frailty in older people. However, the causal relationship between frailty and hypertension remains unclear, and there is a paucity of research regarding the efficacious management of hypertension in frail elderly patients. The management of hypertension in frail elderly patients still faces significant challenges. The benefits of treatment, the optimal BP target, and the choice of antihypertensive drugs for older hypertensive patients with frailty remain subjects of ongoing debate. This review provides a brief overview of hypertension in frail older adults, especially for the management of BP in this population, which may help in offering valuable ideas for future research in this field.

Effects of intensive blood pressure control on left ventricular hypertrophy in aortic valve disease

Hypertension adds to the pressure overload on the left ventricle (LV) in combination with aortic valve (AV) disease, but the optimal blood pressure (BP) targets for patients with AV disease remain unclear. We tried to investigate whether intensive BP control reduces LV hypertrophy in asymptomatic patients with aortic stenosis (AS) or aortic regurgitation (AR). A total of 128 hypertensive patients with mild to moderate AS (n=93) or AR (n=35) were randomly assigned to intensive therapy, targeting a systolic BP <130 mm Hg, or standard therapy, targeting a systolic BP <140 mm Hg. The primary end point was the change in LV mass from baseline to the 24-month follow-up. Secondary end points included changes in severity of AV disease, LV volumes, ejection fraction and global longitudinal strain (GLS). The treatment groups were generally well balanced regarding the baseline characteristics. The mean (±SD) age of the patients was 68 ± 8 years and 48% were men. The mean BP was 145 ± 12/81 ± 10 mm Hg at baseline. Medication at baseline was similar between the 2 groups. The 2 treatment strategies resulted in a rapid and sustained difference in systolic BP (P < .05). At 24-month, the mean systolic BP was 129 ± 12 mm Hg in the intensive therapy group and 135 ± 14 mm Hg in the standard therapy group. No patient died or underwent AV surgery during follow-up in either of the groups. LV mass was changed from 189.5 ± 41.3 to 185.6 ± 41.5 g in the intensive therapy group (P=.19) and from 183.8 ± 38.3 to 194.0 ± 46.4 g in the standard therapy group (P < .01). The primary end point of change in LV mass was significantly different between the intensive therapy and the standard therapy group (-3.9 ± 20.2 g vs 10.3 ± 20.4 g; P=.0007). The increase in LV mass index was also significantly greater in the standard therapy group (P=.01). No significant differences in secondary end points (changes in severity of AV disease, LV volumes, ejection fraction and GLS) were observed between the treatment groups. Among hypertensive patients with AV disease, intensive hypertensive therapy resulted in a significant reduction in LV hypertrophy, although progression of AV disease was similar between the treatment groups. http://ClinicalTrials.gov (Number NCT03666351).

HUBUNGAN DRUG RELATED PROBLEMS (DRPs) KATEGORI DOSIS OBAT AMLODIPIN DAN KAPTOPRIL TERHADAP KONDISI TEKANAN DARAH PADA PASIEN HIPERTENSI

The incidence of drug-related problems (DRPs) in the dose category on the use of antihypertensive drugs has been associated with the failure of the patient's optimal blood pressure target. The study aims to analyze the relationship between drug-related problems (DRPs) on administering amlodipine and captopril drugs to the blood pressure conditions of elderly hypertensive patients in Puskesmas. This research is observational research with a cross-sectional design of analytical nature—purposive sampling techniques. The total number of samples meeting the inclusion and exclusion criteria was 435 patients. Analysis of DRPs dose category relationship data on administration of amlodipine and captopril against blood pressure conditions using a chi-square test. The results of the study showed that the characteristics of patients visited tended to be aged 65-69 years (53.33%), female (68,51%), stage II hypertensive (62.1%), amlodipine (80.92%). The incidence of the DRP dose category in stage II hypertensive (7.6%). Statistically known DRPs of amlodipine and captopril dosing categories showed different significance in each patient's condition of prehypertension (p=0.260), hypertension stage I (p = &lt;0,001), hypertensive stage II (p&lt;0,001). This study concludes, there is a relationship between the incidence of DRPs in the dose category in patients with stage I and stage II hypertension.

Optimal target blood pressure for the primary prevention of hemorrhagic stroke: a nationwide observational study.

There are few reports on the preventative value of intensive blood pressure (BP) management for stroke, especially hemorrhagic stroke (HS), after new criteria for hypertension (HTN) were announced by the American College of Cardiology/American Heart Association in 2017. This study aimed to identify the optimal BP for the primary prevention of HS in a healthy population aged between 20 and 65 years. We conducted a 10-year observational study on the risk of HS, subclassified as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) according to BP categories (e.g., low normal BP, high normal BP, elevated BP, stage 1 HTN, and stage 2 HTN) using the National Health Insurance Service Database. Out of 8,327,751 participants who underwent a health checkup in 2008, 949,550 were included in this study and observed from 2009 to 2018. The risk of ICH was significantly increased in men with stage 2 HTN {adjusted hazard ratio [aHR] 2.002 [95% confidence interval (CI) 1.203-3.332]} and in women with stage 1 HTN [aHR 2.021 (95% CI, 1.251-3.263)]. The risk of SAH was significantly increased in both men [aHR 1.637 (95% CI, 1.066-2.514)] and women [aHR 4.217 (95% CI, 2.648-6.715)] with stage 1 HTN. Additionally, the risk of HS was significantly increased in men with stage 2 HTN [aHR 3.034 (95% CI, 2.161-4.260)] and in women with stage 1 HTN [aHR 2.976 (95% CI, 2.222-3.986)]. To prevent primary HS, including ICH and SAH, BP management is recommended for adults under the age of 65 years with stage 1 HTN.

Tissue perfusion pressure enables continuous hemodynamic evaluation and risk prediction in the intensive care unit.

Treatment of circulatory shock in critically ill patients requires management of blood pressure using invasive monitoring, but uncertainty remains as to optimal individual blood pressure targets. Critical closing pressure, which refers to the arterial pressure when blood flow stops, can provide a fundamental measure of vascular tone in response to disease and therapy, but it has not previously been possible to measure this parameter routinely in clinical care. Here we describe a method to continuously measure critical closing pressure in the systemic circulation using readily available blood pressure monitors and then show that tissue perfusion pressure (TPP), defined as the difference between mean arterial pressure and critical closing pressure, provides unique information compared to other hemodynamic parameters. Using analyses of 5,988 admissions to a modern cardiac intensive care unit, and externally validated with 864 admissions to another institution, we show that TPP can predict the risk of mortality, length of hospital stay and peak blood lactate levels. These results indicate that TPP may provide an additional target for blood pressure optimization in patients with circulatory shock.

Blood pressure control and treatment burden from comorbidities

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the National Research Foundation of Korea grants funded by the Korea government (MEST) Background Achieving the optimal target blood pressure is important for patients with hypertension to prevent cardiovascular complications. Adhering to recommended therapeutic regimens is crucial to control the blood pressure. However, patients with non-cardiovascular comorbid conditions along with hypertension may experience difficulty performing adequate self-care of hypertension and achieving the optimal target blood pressure because they need to simultaneously manage hypertension and comorbidities. Treatment burden refers to workloads to manage chronic conditions and their impact. Thus, it is possible that the burden of treatment associated with managing multiple conditions adversely affects blood pressure control. Purpose To examine whether treatment burden was associated with achieving the optimal target blood pressure in patients with hypertension and non-cardiovascular comorbidities. Methods Patients with hypertension and non-cardiovascular comorbidities were recruited and asked to complete the questionnaires via online survey. Treatment burden was measured with the Multimorbidity Treatment Burden Questionnaire. Comorbid conditions that were diagnosed and/or treated were measured with the list developed to document self-reported chronic conditions in primary care. Patients were asked to report their blood pressure readings that were measured most recently within three months. Based on their blood pressure readings, patients were classified into two groups: controlled group with the blood pressure readings of &amp;lt; 140/90 mmHg and uncontrolled group with the blood pressure readings of 140/90 mmHg or above. To determine whether treatment burden was associated with blood pressure group assignment, multivariable logistic regression was used after adjusting for covariates (i.e., age, gender, education levels, employment status, periods since hypertension diagnosis, the number of non-cardiovascular comorbidities, and self-care maintenance of hypertension). Results A total of 280 patients with hypertension and non-cardiovascular comorbidities (52 years old, 33.2% female) were included in this study. Patients had an average of 3 comorbidities (SD 1.3). Of 280 patients, 153 (54.6%) had the blood pressure readings of &amp;lt;140/90 mmHg (i.e., controlled group). The multivariate logistic regression model shows that patients with greater levels of treatment burden were less likely to be in the controlled group after adjusting for covariates (adjusted odds ratio: 0.98, 95% confidence interval: 0.971-0.997). Conclusion We found that treatment burden was negatively associated with achieving the optimal target blood pressure in patients with hypertension and non-cardiovascular comorbidities. It is important for clinicians to assess patients’ burden of treatment associated with managing hypertension and comorbidities when discussing blood pressure management.

Pediatric Moyamoya Revascularization Perioperative Care: A Modified Delphi Study.

Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4h before and 24h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24h, hourly neurologic assessments for at least 12h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.

Association of Blood Pressure With Cardio-Renal Events and Mortality in Type 2 DM: A National Health Insurance Database.

The relationship of blood pressure (BP) with cardio-renal events and all-cause mortality in type 2 diabetes mellitus (T2DM) is still controversial. To investigate the optimal BP target in Korean individuals with T2DM. Using the Korean National Health Insurance System database, data of individuals with T2DM who underwent regular health checks from January 1, 2007, to December 31, 2007, were extracted (N = 1 800 073). Among them, a total of 326 593 individuals were included in the final study. The study population was divided into 7 groups according to their observed systolic blood pressure (SBP) (<110, 110-119, 120-129, 130-139, 140-149, 150-159, 160-169, and ≥170 mmHg) and diastolic blood pressure (DBP) (<65, 65-69, 70-74, 75-79, 80-84, 85-89, and ≥90 mmHg). Hazard ratios (HRs) of cardio-renal events and all-cause mortality according to BP categories were analyzed. Compared with SBP of 120-129 mmHg and DBP of 75-79 mmHg, SBP of ≥130 mmHg and DBP of ≥ 80 mmHg were associated with an increase in HR of major cardiovascular adverse events (MACEs). SBP of 120-129 mmHg and DBP 75-79 mmHg were associated with the lowest HR of all-cause mortality. Both lower BP (SBP/DBP <120/70 mm) and higher BP (SBP/DBP ≥130/80 mmHg) were associated with an increased HR of all-cause mortality. Contrary to MACE, the lower the SBP, the lower the HR of renal events. In patients with T2DM, the optimal cutoff value of BP associated with a lower incidence of MACE and mortality may be 120-129 mmHg for SBP and 75-79 mmHg for DBP. However, lower SBP may be helpful for T2DM patients with a high risk of renal disease.

Applications of near-infrared spectroscopy in neurocritical care.

Acute brain injuries are commonly encountered in the intensive care unit. Alterations in cerebrovascular physiology triggered by the initial insult can lead to neurological worsening, further brain injury, and poor outcomes. Robust methods for assessing cerebrovascular physiology continuously at the bedside are limited. In this review, we aim to assess the potential of near-infrared spectroscopy (NIRS) as a bedside tool to monitor cerebrovascular physiology in critically ill patients with acute brain injury as well as those who are at high risk for developing brain injury. We first review basic principles of cerebral blood flow regulation and how these are altered after brain injury. We then discuss the potential role for NIRS in different acute brain injuries. We pay specific attention to the potential for NIRS to (1)identify new brain injuries and clinical worsening, (2)non-invasively measure intracranial pressure (ICP) and cerebral autoregulation, and (3)identify optimal blood pressure (BP) targets that may improve patient outcomes. A growing body of work supports the use of NIRS in the care of brain injured patients. NIRS is routinely used during cardiac surgeries to identify acute neurologic events, and there is some evidence that treatment algorithms using cerebral oximetry may result in improved outcomes. In acute brain injury, NIRS can be used to measure autoregulation to identify an "optimum" BP where autoregulation status is best preserved. Finally, NIRS has been utilized to identify oximetry thresholds that correlate with poor outcome as well as identify new focal intracranial hemorrhages. NIRS is emerging as a tool that can non-invasively measure brain function in critically ill patients. Future work will be aimed at technical refinements to improve diagnostic accuracy, as well as larger scale clinical trials that can establish a definitive impact on patient outcomes.

#4674 CLINICAL PROFILE OF PATIENTS WITH DIABETIC KIDNEY DISEASE ATTENDING NEPHROLOGY CLINICS IN A LOW-MIDDLE INCOME COUNTRY

Abstract Background and Aims Chronic kidney disease secondary to diabetes is a significant contributor to the global burden of disease, both financially and through a marked deterioration in the quality of life. Diabetic kidney disease (DKD) increases the likelihood of adverse outcomes such as infirmity, cardiovascular events, progressive multi-organ damage, impaired quality of life and reduced life expectancy. Pakistan, a low-middle income country, is ranked among the top 10 countries for absolute diabetes prevalence. Over 19 million Pakistani adults have diabetes, which amounts to 17.1% of the adult population in the country. There is a dearth of literature examining the quality of care of diabetic kidney disease (DKD) patients in Pakistan. The aim of the current study is to evaluate the clinical profile and the quality of care delivered to patients with DKD attending nephrology clinics at a large tertiary care hospital in Karachi, Pakistan. Method It was a cross-sectional observational study at Aga Khan University Hospital (AKUH), a private tertiary-care facility located in Karachi, Pakistan. The data used in the study was acquired from the Diabetic Kidney Disease outpatient-database, a registry of patients managed by AKUH. It was used to identify a cohort of patients, with DKD presenting to the nephrology clinic at AKUH from December 2018-January 2021 (n = 553). Results Mean age of the study participants was 61.7 + 11.0 years and 60.9% of the study participants were male. 80.5% (n = 445) were non-smokers and over three-quarters (n = 400) had a body mass index (BMI) &amp;gt; 25 which according to the Asian-Pacific BMI cut-offs classified them as obese. These patients had been living with diabetes for an average of 15 years (median IQR = 10-21) and 99% had type 2 diabetes mellitus. A total of 519 study participants (93.9%) had hypertension while 34.2% and 30.9% had dyslipidemia and ischemic heart disease (IHD), respectively. Almost two third of the participants (68.4%) had advanced CKD (stages 3b, 4and 5) at the time of presentation. Less than half of the study population (43.6%) had HbA1c &amp;lt; 7.0 percentage and only 34.9% attained systolic blood pressure (BP) target &amp;lt;130mm Hg while optimal diastolic BP (&amp;lt;80 mmHg) targets were achieved in 72.7%. Almost 70% of the study population were on insulin while 49.7% were receiving oral anti-diabetics. The most prescribed oral anti-diabetic was DPP4 followed by metformin and two thirds were on statins. Calcium channel blockers and beta-blockers were the most used antihypertensive drugs 53.5% and 52.6% respectively; half of the population was on diuretics, while 47.4% were taking Renin-angiotensin system (RAAS) blockers. Those who had eGFR&amp;gt; 60, only 60% of them were receiving RAAS blockade therapy. Women were more likely to be obese and to have higher systolic BP compared to men. Diastolic BP and HbA1c were similar in men and women. The use of statins was higher in men and use of calcium channel blockers and RAAS blockers was significantly higher in women. Conclusion The basis for DKD management is multifactorial risk factor reduction which is achieved by optimizing care through modifiable risk factors. In our study we identified potential gaps in the quality of care related to risk factor control, optimal glycemic and/or blood pressure targets and pharmacotherapy to delay the progression of DKD and minimize cardiovascular events. This highlights a major treatment gap in DKD prevention and management calling for greater quality improvement effort in Pakistan, which now has the third highest number of people living with diabetes in the world.

Associations of blood pressure with all-cause and cause-specific mortality within different multimorbidity patterns among patients with type 2 diabetes

Abstract Funding Acknowledgements Type of funding sources: None. Background Achieving blood pressure targets is a key component of type 2 diabetes (T2D) management and is considered important in reducing mortality risk. However, little is known about whether different multimorbidity patterns would modify the associations between blood pressure and mortality among patients with T2D. Method In the prospective population-based UK Biobank cohort, prevalent T2D was defined as fasting blood glucose ≥7.0 mmol/L (126 mg/dL), non-fasting blood glucose ≥11.1 mmol/L (200 mg/dL), HbA1c level ≥47.5 mmol/mol (6.5%), self-reported physician-diagnosed diabetes, current use of blood glucose-lowering medication, or having hospital inpatient records occurring before the baseline study assessment. We qualitatively assessed multimorbidity (defined as the presence of the 39 self-reported long-term health conditions [in addition to T2D]) in three ways: total, concordant, and discordant condition, and calculated disease counts for each multimorbidity type. Cox regression models were used to estimate the associations of blood pressure and all-cause/cause-specific mortality within different multimorbidity patterns. Results 24,647 participants with prevalent T2D at baseline were included (mean age 59.8 years, 36.9% women). During a median follow-up time of 11.8 years (interquartile range: 11.0-12.6), 4114 (16.7%) individuals died, of whom 1189 (4.8%) died of cardiovascular disease. A U-shaped association was found between systolic blood pressure (SBP) and risk of mortality among T2D patients across total, concordant, and discordant multimorbidity patterns, and the related effect estimations increased with accumulating multimorbidity counts; whereas a reverse J-shaped association was indicated for diastolic blood pressure (DBP) in specific multimorbidity patterns. Notably, the lowest risk of death was consistently observed around 130~140 mmHg for SBP and 80~90 mmHg for DBP within different multimorbidity patterns. Among participants with none, one, two, and more than two total multimorbidity counts, respectively, those having SBP &amp;lt;120 mmHg, compared to having SBP around 130~139 mmHg, had a higher risk of all-cause mortality with a hazard ratio (HR) 1.08 (95 %CI: 0.81, 1.43), 1.36 (1.11, 1.67), 1.33 (1.04, 1.69), and 1.43 (1.09, 1.87), respectively; and those with DBP &amp;lt;70 mmHg, compared to having DBP 80~89 mmHg, had an HR (95%CI) of 1.21 (0.99, 1.48), 1.52 (1.30, 1.79), 1.35 (1.10, 1.65), and 1.34 (1.08, 1.67) for all-cause mortality, and 1.75 (1.20, 2.56), 2.03 (1.52, 2.70), 1.41 (1.00, 1.99), and 1.71 (1.17, 2.50) for cardiovascular mortality. Conclusion Low and high SBP and low DBP were related to a higher risk of all-cause and cardiovascular mortality in individuals with T2D, regardless of their multimorbidity patterns. This implies that different multimorbidity counts or types should not affect optimal blood pressure target in diabetes management.

Consensus Statements from the Diabetologists & Endocrinologists Alliance for the Management of People with Hypertension and Type 2 Diabetes Mellitus.

Hypertension and type 2 diabetes mellitus (T2DM) are important, intertwined public health issues. People with both conditions face significantly elevated risks of cardiovascular (CV) and renal complications. To optimize patient care, a multidisciplinary expert panel met to review recent evidence on optimal blood pressure (BP) targets, implications of albuminuria, and treatment regimens for hypertensive patients with T2DM, with the aim of providing recommendations for physicians in Hong Kong. The panel reviewed the relevant literature, obtained by searching PubMed for the publication period from January 2015 to June 2021, to address five discussion areas: (i) BP targets based on CV/renal benefits; (ii) management of isolated systolic or diastolic hypertension; (iii) roles of angiotensin II receptor blockers; (iv) implications of albuminuria for CV/renal events and treatment choices; and (v) roles and tools of screening for microalbuminuria. The panel held three virtual meetings using a modified Delphi method to address the discussion areas. After each meeting, consensus statements were derived and anonymously voted on by every panelist. A total of 17 consensus statements were formulated based on recent evidence and expert insights regarding cardioprotection and renoprotection for hypertensive patients with T2DM.

Relevance of age and hypertension for blood pressure targets in comatose survivors of cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation. Background Baseline arterial blood pressure (BP) is influenced by age. Therefore, age and previous hypertension may alter the appropriate BP target after out-of-hospital cardiac arrest (OHCA). Purpose To examine whether the optimal BP target after OHCA is affected by age and a history of arterial hypertension. Methods The Blood Pressure and Oxygenation Targets in Post Resuscitation Care (BOX) trial was a randomized, controlled, double-blind trial comprising 789 comatose patients ≥18 years of age, resuscitated after OHCA of presumed cardiac cause. Patients were randomized to a mean arterial BP target of either 63 mm Hg (low BP target group) or 77 mm Hg (high BP target group). The primary outcome was a composite of death from any cause or hospital discharge with severe cerebral disability within one year. The relationship between age or prevalent hypertension and clinical outcomes was evaluated using Cox proportional-hazards regression. Age was stratified into quartiles. We further determined if the effects of BP target varied across the age spectrum (and according to prevalent hypertension). Results Three-hundred and ninety-three patients were assigned to the high BP target group and 396 to the low BP target group. In all, 204 (25.9%), 201 (25.5%), 186 (23.6%), and 198 (25.1%) were ≤54, 55-64, 65-72, and ≥73 years. Mean age was similar between the two study groups (high BP target 63 ± 13 years versus low BP target 62 ± 14 years; P = 0.60). A total of 176 (45%) patients in the high BP target group and 186 (47%) patients in the low BP target group had known hypertension. At 90 days, 133 patients (34%) in the high BP target group and 127 patients (32%) in the low BP target group had experienced the primary outcome. The risk of the primary outcome increased with higher age (Figure 1). Hazard ratios of the primary outcome according to BP targets within each age quartile (with low BP target as reference) were as follows: ≤54: 1.71; 95% confidence interval [CI], 0.99 to 2.95; P = 0.054, 55-64: 0.92; 95% CI, 0.57 to 1.49; P = 0.73, 65-72: 1.12; 95% CI, 0.73 to 1.74; P = 0.59 and ≥73: 0.88; 95% CI, 0.60 to 1.27; P = 0.48 (Figure 2). The hazard ratio of the primary outcome was 0.99; 95% CI, 0.72 to 1.37; P = 0.97 in patients without prevalent hypertension, and 1.14; 95% CI, 0.83 to 1.54; P = 0.42 in patients with prevalent hypertension. Conclusions In patients resuscitated after OHCA, there was a significant association between age and the primary composite outcome of death, severe disability, or coma. The effect of BP target on the primary outcome did not appear to differ according to age groups or prevalent hypertension. Therefore, age and prevalent hypertension should not influence the choice of BP targets after OHCA.

Hypertension in pediatric kidney transplantation.

Arterial hypertension (HTN) in children after kidney transplantation is an important risk factor not only for graft loss but also for cardiovascular morbidity and mortality. The prevalence of posttransplant HTN ranges between 60% and 90%. The etiology of posttransplant HTN is multifactorial and includes residual chronic native kidney disease, immunosuppressive therapy, and chronic allograft dysfunction among other causes. Clinic blood pressure (BP) should be measured at each outpatient visit. However, ambulatory blood pressure monitoring (ABPM) is the gold standard method for BP evaluation in children after kidney transplantation, as it often reveals masked and nocturnal HTN; given this, it should be regularly performed in each transplanted child. All classes of antihypertensive drugs are used in the treatment of posttransplant HTN because it has never been proven that one class is better than another. However, in several retrospective studies, the use of calcium channel blockers is associated with better graft function. The optimal target BP for transplanted children is still a matter of debate; it is recommended to target the same BP as for healthy children, that is, <95th percentile. Control of HTN in transplanted children remains poor - only 20%-50% of treated children have normal BP. There is a great potential for improvement of antihypertensive treatment that could potentially result in improvement of both graft and patient survival in children after kidney transplantation.