Previous Cardiovascular Events Research Articles

Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project)

Hypertension is common in China and its prevalence is rising, yet it remains inadequately controlled. Few studies have the capacity to characterise the epidemiology and management of hypertension across many heterogeneous subgroups. We did a study of the prevalence, awareness, treatment, and control of hypertension in China and assessed their variations across many subpopulations. We made use of data generated in the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Million Persons Project from Sept 15, 2014, to June 20, 2017, a population-based screening project that enrolled around 1·7 million community-dwelling adults aged 35-75 years from all 31 provinces in mainland China. In this population, we defined hypertension as systolic blood pressure of at least 140 mm Hg, or diastolic blood pressure of at least 90 mm Hg, or self-reported antihypertensive medication use in the previous 2 weeks. Hypertension awareness, treatment, and control were defined, respectively, among hypertensive adults as a self-reported diagnosis of hypertension, current use of antihypertensive medication, and blood pressure of less than 140/90 mm Hg. We assessed awareness, treatment, and control in 264 475 population subgroups-defined a priori by all possible combinations of 11 demographic and clinical factors (age [35-44, 45-54, 55-64, and 65-75 years], sex [men and women], geographical region [western, central, and eastern China], urbanity [urban vs rural], ethnic origin [Han and non-Han], occupation [farmer and non-farmer], annual household income [< ¥10 000, ¥10 000-50 000, and ≥¥50 000], education [primary school and below, middle school, high school, and college and above], previous cardiovascular events [yes or no], current smoker [yes or no], and diabetes [yes or no]), and their associations with individual and primary health-care site characteristics, using mixed models. The sample contained 1 738 886 participants with a mean age of 55·6 years (SD 9·7), 59·5% of whom were women. 44·7% (95% CI 44·6-44·8) of the sample had hypertension, of whom 44·7% (44·6-44·8) were aware of their diagnosis, 30·1% (30·0-30·2) were taking prescribed antihypertensive medications, and 7·2% (7·1-7·2) had achieved control. The age-standardised and sex-standardised rates of hypertension prevalence, awareness, treatment, and control were 37·2% (37·1-37·3), 36·0% (35·8-36·2), 22·9% (22·7-23·0), and 5·7% (5·6-5·7), respectively. The most commonly used medication class was calcium-channel blockers (55·2%, 55·0-55·4). Among individuals whose hypertension was treated but not controlled, 81·5% (81·3-81·6) were using only one medication. The proportion of participants who were aware of their hypertension and were receiving treatment varied significantly across subpopulations; lower likelihoods of awareness and treatment were associated with male sex, younger age, lower income, and an absence of previous cardiovascular events, diabetes, obesity, or alcohol use (all p<0·01). By contrast, control rate was universally low across all subgroups (<30·0%). Among Chinese adults aged 35-75 years, nearly half have hypertension, fewer than a third are being treated, and fewer than one in twelve are in control of their blood pressure. The low number of people in control is ubiquitous in all subgroups of the Chinese population and warrants broad-based, global strategy, such as greater efforts in prevention, as well as better screening and more effective and affordable treatment. Ministry of Finance and National Health and Family Planning Commission, China.

Effects on the incidence of cardiovascular events of the addition of pioglitazone versus sulfonylureas in patients with type 2 diabetes inadequately controlled with metformin (TOSCA.IT): a randomised, multicentre trial

The best treatment option for patients with type 2 diabetes in whom treatment with metformin alone fails to achieve adequate glycaemic control is debated. We aimed to compare the long-term effects of pioglitazone versus sulfonylureas, given in addition to metformin, on cardiovascular events in patients with type 2 diabetes. TOSCA.IT was a multicentre, randomised, pragmatic clinical trial, in which patients aged 50-75 years with type 2 diabetes inadequately controlled with metformin monotherapy (2-3 g per day) were recruited from 57 diabetes clinics in Italy. Patients were randomly assigned (1:1), by permuted blocks randomisation (block size 10), stratified by site and previous cardiovascular events, to add-on pioglitazone (15-45 mg) or a sulfonylurea (5-15 mg glibenclamide, 2-6 mg glimepiride, or 30-120 mg gliclazide, in accordance with local practice). The trial was unblinded, but event adjudicators were unaware of treatment assignment. The primary outcome, assessed with a Cox proportional-hazards model, was a composite of first occurrence of all-cause death, non-fatal myocardial infarction, non-fatal stroke, or urgent coronary revascularisation, assessed in the modified intention-to-treat population (all randomly assigned participants with baseline data available and without any protocol violations in relation to inclusion or exclusion criteria). This study is registered with ClinicalTrials.gov, number NCT00700856. Between Sept 18, 2008, and Jan 15, 2014, 3028 patients were randomly assigned and included in the analyses. 1535 were assigned to pioglitazone and 1493 to sulfonylureas (glibenclamide 24 [2%], glimepiride 723 [48%], gliclazide 745 [50%]). At baseline, 335 (11%) participants had a previous cardiovascular event. The study was stopped early on the basis of a futility analysis after a median follow-up of 57·3 months. The primary outcome occurred in 105 patients (1·5 per 100 person-years) who were given pioglitazone and 108 (1·5 per 100 person-years) who were given sulfonylureas (hazard ratio 0·96, 95% CI 0·74-1·26, p=0·79). Fewer patients had hypoglycaemias in the pioglitazone group than in the sulfonylureas group (148 [10%] vs 508 [34%], p<0·0001). Moderate weight gain (less than 2 kg, on average) occurred in both groups. Rates of heart failure, bladder cancer, and fractures were not significantly different between treatment groups. In this long-term, pragmatic trial, incidence of cardiovascular events was similar with sulfonylureas (mostly glimepiride and gliclazide) and pioglitazone as add-on treatments to metformin. Both of these widely available and affordable treatments are suitable options with respect to efficacy and adverse events, although pioglitazone was associated with fewer hypoglycaemia events. Italian Medicines Agency, Diabete Ricerca, and Italian Diabetes Society.

OP.6A.02] 24-HOUR SYSTOLIC BLOOD PRESSURE LOAD REPRESENTS AN IMPORTANT VARIABLE IN DETERMINING THE CARDIOVASCULAR RIK PROFILE OF WHITE-COAT HYPERTENSION

Objective: White-coat hypertension (WCH) displays an increased cardiovascular (CV) risk. Scanty are the data available on the impact of 24-hour average blood pressure (BP) load on the increased CV risk in this condition. Design and method: 2051 subjects randomly selected from the general population of Monza (Italy), aged 25 to 74 years, stratified for sex and decades of age, underwent measurement of systolic (S) and diastolic (D) office BP and average 24-hour ambulatory SBP and DBP. Anthropometric variables, serum cholesterol, blood glucose were also measured. During a median follow-up of 156 months hospital admissions for coronary and stroke events were collected. Fatal events were also collected, among which those related to CV causes (ICD-10 from I-0 to I-99) were identified. In the whole population sample, the subjects with both normal office BP (<140/90 mmHg) and normal 24-hour BP (<125/79 mmHg) were defined as normotensives (NT, n. 1001). Among the 356 subjects with high office BP and normal 24-hour BP (WCH), those with 24-hour SBP above and under the median value (118 mmHg) were classified as WCHH and WCHL, respectively. Results: The analysis was carried out on the 1001 NT and on the 356 WCH subjects. During the follow-up 112 deaths and 73 fatal and non fatal CV events. Total mortality was 5.7%, 20.8% and 10.1% in NT, WCHH and WCHL, respectively. Incidence of CV events was 3.4%, 14.6% and 7.3%, in NT, WCHH and WCHL, respectively. Adjusting the data for age, sex, hypercholesterolemia, diabetes mellitus, smoking, obesity, previous CV events and antihypertensive therapy, the risk of all cause death and CV events in WCHH was significantly higher than that of NT (HR 1.8, CI 1.2–2.8, and HR 2.7, CI 1.6–4.7, respectively; p < 0.01 for both). No significant difference was found in the CV risk between WCHL and NT. Conclusions: Although by definition in the normal range, the level of 24-hour ambulatory SBP load is a relevant factor in determining the enhanced CV risk in WCH. Indeed, when the 24-hour SBP values are low, the CV risk of WCH is not different from that displayed by NT.

OP.1A.01] MORE CARDIOVASCULAR EVENTS AMONG WOMEN WITH UTERINE FIBROIDS

Objective: We recently showed that women with uterine fibroids have a higher hypertension risk compared to women without fibroids, independent of age, body mass index and ethnicity. Whether this translates into more cardiovascular events is unknown. Therefore, we assessed the risk of cardiovascular events in women with fibroids. Design and method: Data of the multi-ethnic, cross-sectional National Health and Nutrition Examination Surveys (NHANES) 1999–2006 were analyzed including 11,858 women, aged 18–85 years. Presence of uterine fibroids and previous cardiovascular events (i.e. any cardiovascular event, congestive heart failure, coronary heart disease or stroke) were self-reported. Physical examination included assessment for obesity (BMI >=30.0 kg/m2), hypertension (SBP/DBP >=140/90 mmHg, or antihypertensive treatment), diabetes (fasting glucose >6.9 mmol/L, or antidiabetic medication), and hypercholesterolemia (cholesterol >6.1 mmol/L, or receiving cholesterol-lowering medication). The primary outcome was the independent odds ratio of cardiovascular events in women with and without uterine fibroids. Results: We included 700 women with and 11,158 women without self-reported fibroids. Women with fibroids were younger (43.6 (SD 7.4) vs 46.4 (21.4) years, p < 0.001) and more often African (38.0 vs 19.8%, p < 0.001). In the different age groups, the prevalence of obesity, hypertension and cardiovascular disease was significantly higher in women with fibroids (Figure 1).As expected, women with fibroids had more hypertension (adjusted OR 1.49, 95%CI 1.13–1.97) and obesity (adjusted OR 1.49, 95%CI 1.17–1.89). Importantly, women with fibroids had more stroke (OR 2.25, 95%CI 1.10–4.57), and total cardiovascular disease (OR 2.27, 95%CI 1.42–3.62), adjusted for age, BMI, ancestry, use of hormones, educational level, SBP, fasting glucose and cholesterol. Diabetes and hypercholesterolemia did not differ significantly between women with and without fibroids. Conclusions: We found that women with fibroids have more cardiovascular events than women without fibroids. Further research regarding the underlying pathophysiology is needed. In addition, currently uterine fibroids are classified as a benign condition. However, these data indicate that fibroids may be considered as a marker for cardiovascular risk, warranting early screening and monitoring of the cardiovascular risk profile in women with fibroids.

PP.01.08] SINGLE-PILL VERSUS FREE ANTIHYPERTENSIVE COMBINATION USE BY GENERAL PRACTITIONERS IN IN BELGIUM AND LUXEMBURG

Objective: Studies suggest that the use of single-pill combinations could improve therapeutic adherence and blood pressure (BP) control in hypertensive patients. We examined the use of single-pill or free antihypertensive drug combinations, BP control, and attitude towards prescription of single-pill combinations in current general practice. Design and method: Between January 2015 and September 2016, 742 general practitioners in Belgium and Luxemburg retrospectively collected data from 8006 consecutive hypertensive patients recently seen in their routine practice and taking at least two antihypertensive drugs. Results: Patients (mean age 67 ± 22 years [SD], 54% men, 37% with diabetes mellitus, 37% with a previous cardiovascular event) were treated with two (n = 4549), three (n = 2470) or more than three (n = 987) antihypertensive drugs. Combinations were free (n = 3089), single-pill (n = 2713) or mixed (n = 2204) (93 missing data). Blood pressure was 141/82 ± 21/11 mm Hg (mean ± SD). According to the 2013 ESH/ESC Guidelines, control rates were: systolic BP 47%, diastolic BP 70%, and both systolic and diastolic BP 42%. Estimation by the GPs of both systolic and diastolic BP control rate was 61%. Actual control rates were comparable whatever the type of combination. Blood pressure control was better in patients with low cardiovascular risk compared to patients with high risk (respectively 43% vs 33% for systolic BP control and 63% vs 47% for diastolic BP control). Patients treated with single-pill combinations were younger and had a low cardiovascular risk. In 54% (n = 4361) of the patients, physicians considered to prescribe a single-pill combination. In 1452 (18%) patients, they were willing to switch to a single-pill 2-drug combination, and in 2508 (31%) patients, they were willing to switch to a single-pill 3-drug combination. Reasons were improved adherence (71%) and better BP control (69%). Conclusions: In patients requiring at least two antihypertensive drugs, BP control rate remains low and is overestimated by GPs. Free combinations remain largely used although many GPs seem prone to switch free to single-pill combinations. Treatment simplification could improve adherence and BP control rate, which has in turn been shown to lead to reduced morbidity and mortality.

OP.5B.03] TIME TO IMPLEMENT SERUM URIC ACID FOR RISK STRATIFICATION IN HYPERTENSIVE WOMEN? LONG-TERM FOLLOW-UP DATA IN THE OLD-HTA COHORT

Objective: Albeit controversial, serum uric acid (SUA) seems to convey a prognostic significance in women. Yet data over the long run are limited in hypertension. The aim of the present study was to confirm the prognostic significance over the long-term particularly in hypertensive women. Design and method: 1897 hypertensive patients with an assessment of SUA at baseline during their work-up for hypertension were followed according to tertile of SUA: < 339, 339 to 428 and >428 micromol/L. All-cause and cardiovascular mortalities were assessed after a 20 year-follow-up period. Results: Baseline characteristics were age 45.1 ± 13.4 years, systolic/diastolic blood pressure 180 ± 32/104 ± 20 mmHg, women 39.1% and eDFG 83.3 ± 29.5 mL/min. SUA was independently correlated with age, gender, BMI, previous cardiovascular events, eGFR, thiazide diuretics and beta-blockers use, and diabetes. At 20 years of follow-up, 748 deaths were observed, 442 of which were from cardiovascular causes. As shown in Kaplan-Meier curves, tertiles of SUA were predictor of all-cause and cardiovascular death in the whole cohort (p < 0.001 for both, Figure). In multivariate Cox regression analysis, patients in the third tertile have an increased risk of all-cause death (HR 1.34 (1.09–1.65) vs. tertile 1, HR 1.30 (1.09–1.55) vs. tertile 2) but only a trend was observed for cardiovascular death (HR 1.33 (1.00–1.76) vs. tertile 1, HR 1.16 (0.92–1.53) vs. tertile 2). A strong interaction with gender was observed for all-cause and cardiovascular mortality (p = 0.006 and p = 0.013 respectively). In subgroup analysis with the same Cox regression analysis, tertile 3 predicts mortality only in women: all-cause death HR 1.86 (1.34–2.58) vs. tertile 1, HR 1.76 (1.25–2.48) vs. tertile 2; cardiovascular death HR 1.77 (1.13–2.79) vs. tertile 1, HR 1.52 (0.96–2.38) vs. tertile 2. The information gain after addition of tertiles of SUA was significant in the multivariable Cox regression model (likelihood ratio test p = 0.009 and p = 0.025 for all-cause and cardiovascular mortality, respectively) with an increment of the C-index of 0.003 for the two different endpoints.Conclusions: After a long-term follow-up period, SUA improves death stratification in hypertensive women on top of traditional risk factors and target organ damages.

Abstract P173: Target Blood Pressure in Elderly Hypertensive Patients: A Korean National Health Insurance Service Health Examinee Cohort Study

Background: We aimed to investigate the benefits of strict blood pressure control and determine the optimal blood pressure in elderly hypertensive subjects. Methods: This study used the National Health Insurance Service Health examinee Sample Cohort. We selected subjects who were over the age of 60 years and who had received a newly diagnosis of hypertension (Korean Classification of Disease [KCD] codes I10–I13) from 2003 to 2006. Subjects who had previous major cardiovascular (CV) events, such as heart failure, ischemic heart disease, stroke, or end stage renal disease (ESRD) were excluded. The remaining 25,858 individuals were divided into three groups; 1) mean systolic blood pressure (SBP) &lt; 130mmHg (N = 7,494), 2) mean SBP 130 to 140 mmHg (N = 9,272), 3) mean SBP above 140mmHg (N = 9,092). The primary outcome of the study was to compare all-cause mortality and CV mortality in each group. Results: Compared to mean SBP ≥140 mmHg group, mean SBP 130 to 140 mmHg group had significantly lower rate of all-cause mortality (HR=0.63, 95% CI= 0.58-0.69, p&lt;0.001) and CV mortality (HR=0.58, 95% CI= 0.48-0.69, p&lt;0.001). The diastolic blood pressure (DBP) between 80 to 90 mmHg group also had lower risk of all-cause death (HR=0.51, 95% CI= 0.47-0.56, p&lt;0.001) and CV death (HR=0.44, 95% CI= 0.37-0.53, p&lt;0.001) in comparison with DBP ≥90 mmHg group. However, the SBP below 130 mmHg subjects and the DBP below 80 mmHg subjects did not have significant lower rate of all-cause and CV mortality compared to SBP 130 to 140 mmHg and DBP 80 to 90mmHg subjects, respectively. In subgroup analysis, mean SBP &lt;120 mmHg subjects were associated with higher risk of all-cause death (HR=1.47, 95% CI= 1.27-1.72, p&lt;0.001) and CV death (HR=1.57, 95% CI= 1.15-2.14, p=0.004) than SBP 130 to 140 mmHg subjects. Conclusion: Mean SBP between 130 to 140 mmHg and mean DBP below 90 mmHg for elderly hypertensives without previous major CV disease was beneficial in reducing all-cause and CV mortality. However, mean SBP below 120mmHg was associated with a raised risk of all-cause mortality and CV mortality.

OP.3C.09] RECURRENT ROTATIONAL VERTIGO IS A PREDICTOR OF STROKE IN HYPERTENSIVE PATIENTS

Objective: Vertigo is associated with hypertension but also with numerous other aetiologies. The aims of the present study were 1) to describe the characteristics and the clinical correlates of vertigo in a large cohort of hypertensive patients and 2) to test the prognostic value of this symptom for all-cause, cardiovascular, and stroke mortality. Design and method: 1716 hypertensive individuals were questioned at baseline with a standardized questionnaire. They were categorized first, according to the absence or the presence of at least twice vertigo during the past year. When the symptom was present, patients were classified according to 4 subgroups: rotational, hypotension-like, seasickness and other vertigo. Results: Baseline characteristics of our cohort were: mean age 45 years, 61% of men, mean office blood pressure 175/104 mmHg, 13% of diabetes, mean eGFR 82.4 mL/min and 20% of previous cardiovascular event. 33.9% (N = 581) of patients experienced frequent episodes of vertigo. Multiple regression analysis demonstrated that vertigo was predicted by age, gender (women) and coronary artery disease. After 30 years of follow-up, we observed 956 deaths of whom 508 from cardiovascular cause (including strokes) and 114 acute strokes. As shown by Kaplan-Meier curves (Figure), frequent vertigos were predictor of stroke mortality (p = 0.001) but not both for all-cause and cardiovascular mortality (p = 0.371 and p = 0.233, respectively). In the multivariate Cox regression model adjusted for cardiovascular risk factors, secondary prevention and treatment, patients with vertigo have a similar risk for stroke mortality than those without (hazard ratio 1.19; 95% CI [0.81–1.77]). Analyzing in turn, the different subgroups of vertigo, rotational vertigo predicted stroke death after adjustment (hazard ratio 2.08; 95% CI [1.22–3.55]), while the association was not observed with hypotension-like vertigo (hazard ratio 1.00; 95% CI [0.55–1.83]), seasickness vertigo (hazard ratio 1.12; 95% CI [0.72–1.76]) and other vertigo (hazard ratio 0.88; 95% CI [0.48–1.61]).Conclusions: Recurrent vertigos in hypertensive patients are associated at baseline with gender, age and coronary artery disease. Hypertensive patients complaining with frequent rotational vertigos must be carefully followed over years because of their increase risk of stroke mortality.

A policy model of cardiovascular disease in moderate-to-advanced chronic kidney disease

ObjectiveTo present a long-term policy model of cardiovascular disease (CVD) in moderate-to-advanced chronic kidney disease (CKD).MethodsA Markov model with transitions between CKD stages (3B, 4, 5, on dialysis, with kidney...

P4427Oxidative stress is closely associated with increased arterial stiffness, especially in male smokers without previous cardiovascular events

P4427Oxidative stress is closely associated with increased arterial stiffness, especially in male smokers without previous cardiovascular events

Design and baseline characteristics of participants in the Researching cardiovascular Events with a Weekly INcretin in Diabetes (REWIND) trial on the cardiovascular effects of dulaglutide.

The aim was to determine the effects of dulaglutide, a synthetic once-weekly, injectable human glucagon-like peptide 1 analogue that lowers blood glucose, body weight, appetite and blood pressure, on cardiovascular outcomes. People with type 2 diabetes, aged ≥50 years, with glycated haemoglobin (HbA1c) ≤9.5%, and either a previous cardiovascular event, evidence of cardiovascular disease or ≥2 cardiovascular risk factors were randomly allocated to a weekly subcutaneous injection of either dulaglutide (1.5 mg) or placebo and followed within the ongoing Researching cardiovascular Events with a Weekly INcretin in Diabetes (REWIND) trial every 3 to 6 months. The primary cardiovascular outcome is the first occurrence of the composite of cardiovascular death or non-fatal myocardial infarction or non-fatal stroke. Secondary outcomes include each component of the primary composite cardiovascular outcome, a composite clinical microvascular outcome comprising retinal or renal disease, hospitalization for unstable angina, heart failure requiring hospitalization or an urgent heart failure visit, and all-cause mortality. Follow-up will continue until the accrual of 1200 confirmed primary outcomes. Recruitment of 9901 participants (mean age 66 years, 46% women) occurred in 370 sites located in 24 countries over a period of 2 years. The mean duration of diabetes was 10 years, mean baseline HbA1c was 7.3%, and 31% had prior cardiovascular disease. The REWIND trial's international scope, high proportion of women, high proportion of people without prior cardiovascular disease and inclusion of participants whose mean baseline HbA1c was 7.3% suggests that its cardiovascular and safety findings will be directly relevant to the typical middle-aged patient seen in general practice throughout the world.

Single and multiple cardiovascular biomarkers in subjects without a previous cardiovascular event.

Aims To assess the incremental value of biomarkers, including N-terminal prohormone of brain natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), growth differentiation factor 15 (GDF-15), and procollagen type 1 N-terminal propeptide (P1NP), in predicting incident cardiovascular events and mortality among asymptomatic individuals from the general population, beyond traditional risk factors, including fasting glucose and renal function (cystatin C), medication use, and echocardiographic measures. Methods and results Prospective population-based cohort study of 1324 subjects without a previous cardiovascular event, who underwent baseline echocardiography and biomarker assessment between 2002 and 2006. The clinical endpoint was the composite of myocardial infarction, invasively treated stable/unstable ischemic heart disease, heart failure, stroke, or all-cause mortality. Predictive capabilities were evaluated using Cox proportional-hazards regression, Harrell's concordance index (C-index), and net reclassification improvement. Median age was 66 (interquartile range: 60-70) years, and 413 (31%) were female. During median 8.6 (interquartile range: 8.1-9.2) follow-up years, 368 (28%) composite events occurred. NT-proBNP, hs-TnT, GDF-15, and IL-6 were significantly associated with outcome, independently of traditional risk factors, medications, and echocardiography ( p < 0.05 for all). Separate addition of NT-proBNP and GDF-15 to traditional risk factors, medications, and echocardiographic measurements provided significant improvements in discriminative ability (NT-proBNP: C-index 0.714 vs. 0.703, p = 0.03; GDF-15: C-index 0.721 vs. 0.703, p = 0.02). Both biomarkers remained significant predictors of outcome upon inclusion in the same model ( p < 0.05 for both). Conclusions NT-proBNP and GDF-15 each enhance prognostication beyond traditional risk factors, glucose levels, renal function, and echocardiography in individuals without known cardiovascular disease.

The prevalence and correlates of low sexual functioning in women on hemodialysis: A multinational, cross-sectional study.

Sexual dysfunction may affect 80% of women in hemodialysis. However the specific patterns and clinical correlates of sexual functioning remain poorly described. The aim of this study was to assess prevalence and correlates of the individual domains of sexual functioning in women treated with hemodialysis. We recruited, into this multinational cross-sectional study, women treated with long-term hemodialysis (Collaborative Working Group on Depression and Sexual dysfunction in Hemodialysis study). Self-reported domains of sexual functioning were assessed by the Female Sexual Function Index, which is routinely administered within the network of dialysis patients followed by the working group. Lower scores represented lower sexual functioning. Socio-demographic and clinical correlates of each domain of sexual functioning were identified by stepwise multivariable linear regression. Sensitivity analyses were restricted to women who reported being sexually active. We found that of 1309 enrolled women, 659 (50.3%) provided complete responses to FSFI survey questions and 232 (35%) reported being sexually active. Overall, most respondents reported either no sexual activity or low sexual functioning in all measured domains (orgasm 75.1%; arousal 64.0%; lubrication 63.3%; pain 60.7%; satisfaction 60.1%; sexual desire 58.0%). Respondents who were waitlisted for a kidney transplant reported scores with higher sexual functioning, while older respondents reported scores with lower functioning. The presence of depression was associated with worse lubrication and pain scores [mean difference for depressed versus non-depressed women (95% CI) -0.42 (-0.73 to -0.11), -0.53 (-0.89 to -0.16), respectively] while women who had experienced a previous cardiovascular event reported higher pain scores [-0.77 (-1.40- to -0.13)]. In conclusion, women in hemodialysis reported scores consistent with marked low sexual functioning across a range of domains; the low functioning appeared to be associated with comorbidity.

Model for Risk-Based Screening of Diabetic Retinopathy in People With Newly-Diagnosed Type 2 Diabetes Mellitus.

The purpose of this study was to evaluate the role of inflammatory/lipid markers and potential risk factors for diabetic retinopathy (DR) development in newly diagnosed patients with type 2 diabetes mellitus (T2DM). Participants in this study were 1062 patients with newly diagnosed T2DM. Demographic and clinical data of patients were collected. Assessment of DR status was performed using digital two-field photography. In addition, HbA1c (%), lipid profile, and urinary albumin were measured at recruitment. The following inflammatory markers were also measured: serum C-reactive protein, white blood cells, platelet, adiponectin, IL-4, IL-6, IL-10, vascular endothelial growth factor, tumor necrosis factor-α (TNF-α), IL-1b, IL-1 receptor antagonist (IL-1RA), and monocyte chemotactic protein-1. Univariate and multivariate analyses of the association of various potential risk factors and DR were conducted. Univariate analysis showed that male sex, any cardiovascular event, and HbA1c were positively associated with DR, while IL-1RA, IL-1b, IL-6, and TNF-α were significantly negatively associated with presence of DR in the cohort. Risk factors that remained significantly associated with DR presence at the multivariate analysis were male sex, any cardiovascular event, HbA1c, and IL-1RA. Our study demonstrated that HbA1c levels, male sex, and previous cardiovascular events were risk factors for presence of DR in people with newly diagnosed T2DM, while IL-1RA seemed to have a protective role. The prevalence of DR in our population was 20.2%, reflecting current practice. Our findings may contribute to future risk-based modelling of screening for DR.

Two-year outcome and risk factors for mortality in patients with coronary artery disease and renal failure: The prospective, observational CAD-REF Registry

BackgroundChronic kidney disease (CKD) and coronary artery disease (CAD) are strongly associated. CAD is the most frequent cause of cardiovascular death in patients with CKD. MethodsThe prospective observational nationwide multicenter Coronary Artery Disease and REnal Failure (CAD-REF) Registry enrolled 3352 patients with angiographically documented CAD classified according to their baseline estimated glomerular filtration rate (eGFR) into 5 groups according to the K/DOQI-guidelines. Patients were followed for two years. The aim of this study was the analysis of outcome and the identification of risk factors for two-year mortality in patients with both CKD and CAD. ResultsWith decreasing renal function, patients had more often diabetes mellitus, hypertension, peripheral artery disease, and previous cardiovascular events and interventions. The amount of diseased vessels increased with decreasing renal function. For the whole cohort, two-year mortality was 6.5%. Kaplan-Meier-curves showed highest mortality in patients with CKD stages 4 and 5 (22.4%). In multivariate Cox-regression analyses, significant risk factors for two-year all-cause mortality were lower eGFR, current smoking, left ventricular ejection fraction, diabetes mellitus treated with oral medication or insulin, age, and peripheral artery disease. Coronary status missed the level of statistical significance as a risk factor for mortality in multivariable regression analysis. An eGFR reduction of 10ml/min/1.73m2 increased the risk of mortality by 19% regardless of other risk factors. ConclusionsTwo-year morbidity and mortality increased with the degree of renal impairment. To improve survival of patients with CAD and CKD, nephroprotection is urgently needed especially for patients with atherosclerotic burden. Clinical trial registration numberNCT00679419, http://clinicaltrials.gov/.

Predicción del riesgo cardiovascular en pacientes con enfermedad renal crónica

IntroductionScores underestimate the prediction of cardiovascular risk (CVR) as they are not validated in patients with chronic kidney disease (CKD). Two of the most commonly used scores are the Framingham Risk Score (FRS-CVD) and the ASCVD (AHA/ACC 2013). The aim of this study is to evaluate the predictive ability of experiencing a cardiovascular event (CVE) via these 2scores in the CKD population. Material and methodsProspective, observational study of 400 prevalent patients with CKD (stages 4 and 5 according the KDOQI; not on dialysis). Cardiovascular risk was calculated according to the 2scores and the predictive capacity of cardiovascular events (atherosclerotic events: myocardial infarction, ischaemic and haemorrhagic stroke, peripheral vascular disease; and non-atherosclerotic events: heart failure) was analysed. ResultsForty-nine atherosclerotic cardiovascular events occurred in 40.3±6.6 months of follow-up. Most of the patients were classified as high CVR by both scores (59% by the FRS-CVD and 75% by the ASCVD). All cardiovascular events occurred in the high CVR patients and both scores (FRS-CVD log-rank 12.2, P<.001, HR 3.1 [95% CI: 1.3–7.1] P: 0.006 and ASCVD log-rank 8.5 P<.001, HR 3.2 [95% CI: 1.1–9.4] P: 0.03) were independent predictors adjusted to renal function, albuminuria and previous cardiovascular events. ConclusionThe cardiovascular risk scores (FRS-CVD and ASCVD [AHA/ACC 2013]) can estimate the probability of atherosclerotic cardiovascular events in patients with CKD regardless of renal function, albuminuria and previous cardiovascular events.

Sleep-Time Ambulatory BP Is an Independent Prognostic Marker of CKD.

The prognostic value of clinic and ambulatory BP in predicting incident CKD and whether CKD risk reduction associates with progressive treatment-induced decrease of clinic, awake, or asleep BP are unknown. We prospectively evaluated 2763 individuals without CKD, 1343 men and 1420 women (mean±SD age: 51.5±14.3 years old), with baseline ambulatory BP ranging from normotension to hypertension. On recruitment and annually thereafter (more frequently if hypertension treatment was adjusted on the basis of ambulatory BP), we simultaneously monitored BP and physical activity (wrist actigraphy) for 48 hours to accurately derive individualized mean awake and asleep BP. During a median 5.9-year follow-up, 404 participants developed CKD. Mean asleep systolic BP was the most significant predictor of CKD in a Cox proportional hazard model adjusted for age, diabetes, serum creatinine concentration, urinary albumin concentration, previous cardiovascular event, and hypertension treatment time (on awakening versus at bedtime; per 1-SD elevation: hazard ratio, 1.44; 95% confidence interval, 1.31 to 1.56; P<0.001). The predictive values of mean clinic BP and mean awake or 48-hour ambulatory BP was not significant when corrected by mean asleep BP. Analyses of BP changes during follow-up revealed 27% reduction in the risk of CKD per 1-SD decrease in mean asleep systolic BP, independent of changes in mean clinic BP or awake ambulatory BP. In conclusion, sleep-time BP is a highly significant independent prognostic marker for CKD. Furthermore, progressive treatment-induced decrease of asleep BP, a potential therapeutic target requiring ambulatory BP evaluation, might be a significant method for reducing CKD risk.

Cardiovascular risk prediction in chronic kidney disease patients

IntroductionScores underestimate the prediction of cardiovascular risk (CVR) as they are not validated in patients with chronic kidney disease (CKD). Two of the most commonly used scores are the Framingham Risk Score (FRS-CVD) and the ASCVD (AHA/ACC 2013). The aim of this study is to evaluate the predictive ability of experiencing a cardiovascular event (CVE) via these 2 scores in the CKD population. Material and methodsProspective, observational study of 400 prevalent patients with CKD (stages 1–4 according the KDOQI; not on dialysis). Cardiovascular risk was calculated according to the 2 scores and the predictive capacity of cardiovascular events (atherosclerotic events:myocardial infarction, ischaemic and haemorrhagic stroke, peripheral vascular disease; and non-atherosclerotic events: heart failure) was analysed. ResultsForty-nine atherosclerotic cardiovascular events occurred in 40.3±6.6 months of follow-up. Most of the patients were classified as high CVR by both scores (59% by the FRS-CVD and 75% by the ASCVD). All cardiovascular events occurred in the high CVR patients and both scores (FRS-CVD log-rank 12.2, P<0.001, HR 3.1 [95% CI: 1.3–7.1] P: 0.006 and ASCVD log-rank 8.5 P<0.001, HR 3.2 [95% CI: 1.1–9.4] P: 0.03) were independent predictors adjusted to renal function, albuminuria and previous cardiovascular events. ConclusionThe cardiovascular risk scores (FRS-CVD and ASCVD [AHA/ACC 2013]) can estimate the probability of atherosclerotic cardiovascular events in patients with CKD regardless of renal function, albuminuria and previous cardiovascular events.

Effect of statins on hospitalization risk of bacterial infections in patients with or without diabetes.

To investigate whether statins reduce the risk to first hospitalization of bacterial infections, in patients with or without diabetes taking into account prior or incident comorbidities. By using administrative databases, the effect of current statin use was measured on the risk of first hospitalizations due to bacterial infections in people living in Tuscany, Italy, in the period January 1, 2011-December 31, 2015, after excluding those with previous statins use. Population was stratified as with (n=128,207) or without diabetes (n=3,304,906), and the hospitalization risk was analyzed by a Cox proportional hazards regression analysis after adjusting for age, gender, previous comorbidities, chronic renal failure, and prior or incident cardiovascular diseases. During the 5-year follow-up, 31,543 hospitalizations for bacterial infections were observed: 2.08(2.06-2.10) per 1000 person-year in non-diabetic and 5679: 9.13(8.94-9.32) per 1000 person-year in diabetic population. Diabetes conferred a greater risk of hospitalizations, independently from confounders [adjusted HR (95% CI) 2.04 (1.97-2.10); P<0.0001]. Statin use decreased the risk by about 2.5% for each one month of therapy, at the same extent in subjects with or without diabetes, after adjusting for all covariates. In this population, diabetes was associated by a twofold increase in the 5-year risk of hospitalizations for bacterial infections. Statin use decreased this risk to a same extent in subjects without or with diabetes, after adjusting for main confounders including comorbidities, and previous or incident cardiovascular events.

Association of blood pressure with anxiety and depression in a sample of primary care patients

IntroductionAccording to international scientific literature, and as summarized in the guidelines of the International Society of Hypertension, lowering of blood pressure can prevent cardiovascular accidents. Some studies suggest that hypertension, anxiety, and depression might be inversely correlated.ObjectiveTo investigate whether blood pressure is associated with anxiety and depression.MethodsCross-sectional design. Male and female primary care patients were enrolled, aged 40–80. Criteria of exclusion adopted: use of antidepressants or antipsychotics; previous major cardiovascular event; psychosis or major depression; Type 1-DM; pregnancy and hereditary disease associated to obesity. Anxiety and depression symptoms were assessed using HADS. Waist circumference, hip circumference, blood pressure, HDL, triglycerides, blood sugar, hypertension, albumin concentrations and serum iron were also assessed.ResultsOf the 210 subjects, 84 were men (40%), mean age was 60.88 (SD ± 10.88). Hypertension was found to correlate significantly to anxiety (OR = 0.38; 95% CI = 0.17–0.84), older age (OR = 3.96; 95% CI = 1.88–8.32), cigarette smoking (OR = 0.35; 95%CI = 0.13–0.94), high Body Mass Index (OR = 2.50; 95% CI = 1.24–5.01), Waist-hip ratio (OR = 0.09; 95% CI = 0.02–0.46) and the Index of comorbidity (OR = 16.93; 95% CI = 3.71–77.29).ConclusionsAn inverse association was found between anxiety and hypertension, suggesting the need to clinically manage these two dimensions in a coordinated way. Other findings are well known and already included in prevention campaigns. Further research is needed, also to better understand and explain the causative pathways of this correlation.Disclosure of interestThe authors have not supplied their declaration of competing interest.