Prior History Of Hypertension Research Articles

Characteristics and Outcomes of Cardiac Rehabilitation Patients With and Without Cancer: Insights From Western Sydney

Increased cardiovascular events are common in cancer survivors and contribute to an emerging cardio-oncology patient group requiring secondary prevention strategies including cardiac rehabilitation (CR). This study aimed to compare characteristics and outcomes for patients participating in CR with and without an existing cancer diagnosis. Observational cohort study including consecutive patients enrolled in a single-centre outpatient CR program in Western Sydney between 2018-2022. Clinical history, demographics and CR outcome data were collected as part of standard care at program enrolment and completion. Patients with and without a cancer diagnosis were compared at enrolment and outcomes were analysed in both groups. A total of 1,792 patients enrolled in CR, 191 (11%) had a documented history of cancer; prostate (18%), skin (12%), colon (9%) and breast (8%) malignancies were most prevalent. The most common treatments were surgical resection (80%) and chemotherapy or radiotherapy (37%). Cardio-oncology patients were older (68.8±10.6 vs 59.8±13.7yrs, p<0.001), more likely female (33% vs 21%, p<0.001), born in Australia (46% vs 35%, p=0.004), non-partnered (34% vs 25%, p=0.002) and had a prior history of hypertension (65% vs 56%, p=0.010) or stroke (8% vs 5%, p=0.045). After adjusting for age and sex, the overall cohort improved their mean peak exercise capacity and waist circumference after CR, however there were no differences between groups. There were also no between-group differences for adherence and completion of CR program or any other cardiovascular risk factors. Sub-analyses revealed a clinically meaningful improvement in waist circumference for cancer patients with a history of radiation therapy and a blunted peak exercise capacity adaptation for those with a history of chemotherapy treatment. Despite differences in demographic and clinical characteristics of CR patients with and without cancer, all patients showed significant and clinically relevant improvements in peak exercise capacity and waist circumference after CR. Results also highlighted potential associations between specific cancer treatments and changes in fitness outcomes, which warrants further evaluation.

Age-related difference in acute type B aortic dissection.

The objective is to compare the characteristics of clinical data, imaging data, and treatment methods of young and old patients with acute type B aortic dissection (ABAD). ABAD patients admitted to the Department of Vascular Surgery of the First Affiliated Hospital of Anhui Medical University from January 2012 to December 2018 were retrospectively reviewed. Patient demographics, such as gender, age, diabetes, hypertension, presenting symptoms, imaging characteristics, laboratory data on admission, hemodynamics on admission and in-hospital management, and mortality of different age groups were compared and analyzed. Categorical variables were compared using χ2 tests or Fisher's exact test. Continuous variables were compared using Student's t-test or Mann-Whitney U-test. A total of 141 ABAD patients were included in this study. Old ABAD patients were more likely to have a prior history of hypertension (88.6% vs 70.4%, p = 0.037) and atherosclerosis (29.8% vs 7.4%, p = 0.016). In the young group, Marfan syndrome was significantly higher (14.8% vs 0.9%; p = 0.005). Compared with the old group, the number of distal tears in the young group was significantly higher (62.3% vs 39.5%, p = 0.027). The proportion of patients with malperfusion of lower limbs in the young group was significantly higher than that in the old group (22.2% vs 6.1%, p = 0.026). There was no significant difference in the treatment methods and in-hospital mortality between the two groups. Compared with old ABAD patients, young ABAD patients had more distal tears and a higher proportion of lower limbs malperfusion.

Longitudinal Safety of Luspatercept in the Treatment of Anemia in Patients with Myelofibrosis: Results from the ACE-536-MF-001 Study

Introduction Luspatercept (LUSPA) is approved for the treatment of anemia in some adults with β-thalassemia or myelodysplastic syndrome who require red blood cell transfusion and has a well characterized safety profile for these indications. The primary readout from the phase 2 ACE-536-MF-001 study (NCT03194542) demonstrated manageable safety and promising efficacy of LUSPA for treatment of myelofibrosis (MF)-related anemia with 19.0%-31.6% of patients (pts) achieving transfusion independence (defined as 84 consecutive days transfusion free), and 18.2%-21.4% of non-transfusion-dependent (NTD) pts achieving anemia response (defined as 84 consecutive days ≥ 1.5 g/dL hemoglobin increase from baseline without transfusion) in the entire treatment period (Gerds ASCO 2023 7016). To characterize further the safety profile of LUSPA in MF and provide data on adverse event (AE) management, we present a detailed longitudinal safety analysis of the MF-001 study. Methods Pts were enrolled into 4 cohorts based on transfusion dependence (TD) and stable ruxolitinib (RUX) treatment - cohort 1: NTD, no RUX; cohort 2: TD, no RUX; cohort 3A: NTD, RUX; cohort 3B: TD, RUX. All pts received LUSPA 1.0 mg/kg subcutaneously with titration up to 1.75 mg/kg in 21-day cycles; the starting dose was 1.33 mg/kg in the cohort 3B expansion group. Response was assessed at day 169 (24 weeks), with treatment extended for pts showing clinical benefit. The primary endpoint was anemia response; AEs alongside LUSPA and RUX dosing were also assessed. On dosing days, seated blood pressure was assessed prior to LUSPA administration. In the case of ≥ grade 3 hypertension (systolic ≥ 160 mmHg, diastolic ≥ 100 mmHg), dosing was delayed until hypertension had resolved to ≤ grade 1 or baseline, followed by dose reduction by 1 dose level. If ≥ 2 dose reductions were implemented due to any suspected treatment-related AE (TRAE), LUSPA was discontinued. Results In the safety population (N = 95; cohort 1, n = 22; cohort 2, n = 14; cohort 3A, n = 21; cohort 3B, n = 38), the most frequently used prior medications for anemia treatment were erythropoiesis-stimulating agents (23.2%, most frequently epoetin alfa [14.7%]), followed by danazol (11.6%), lenalidomide (2.1%), and thalidomide (1.1%). Prior history of hypertension was recorded in 50.5% of pts. Median follow-up duration was 546 days. A total of 47.4% of pts had ≥ 1 TRAE; the most common were hypertension (17.9%), bone pain (7.4%), and diarrhea (6.3%). Incidence of treatment-related grade ≥ 3 diarrhea was low (2.1%). Overall, 13.7% of pts received concomitant antidiarrheals. LUSPA was discontinued in 9 pts due to AEs; 1 event of cerebral toxoplasmosis was considered treatment related by the investigator. Among pts receiving RUX (cohorts 3A/3B), hypertension was the most frequently occurring grade ≥ 3 TRAE ( Table 1) and 5 pts had LUSPA dose modifications related to hypertension events; considered related to LUSPA in 4 pts ( Table 2). In contrast, among pts not receiving RUX (cohorts 1/2), no pts experienced grade ≥ 3 hypertension events. Hypertension was manageable with clinical intervention; during the study the most frequent concomitant medications for hypertension were angiotensin-converting enzyme inhibitors (26.3%), beta-blocking agents (selective, 23.2%; non-selective, 3.2%), and angiotensin II receptor blockers (alone, 20.0%; plus diuretics, 5.3%). Among NTD pts (cohort 3A), there were no changes in RUX dose. Among TD pts (cohort 3B), 25 (65.8%) pts maintained their RUX dose and 6 (15.8%) pts had ≥ 1 dose increase. Overall, 9 deaths occurred during treatment; none were considered treatment related. Causes of death were pneumonia, septic shock, intracranial hemorrhage, ischemic stroke, organ dysfunction, post-procedural hemorrhage, myelofibrosis, renal failure, and pneumonitis (n = 1 each). Conclusions The safety profile of LUSPA in the ACE-536-MF-001 study was consistent with previous studies in other indications, and AEs were mostly low grade. In addition to benefits in anemia, the safety profile of LUSPA allowed most pts receiving RUX to maintain or increase their RUX dose, supporting maintenance of Janus kinase inhibitor therapy for adequate disease control of MF. Study support: Bristol Myers Squibb.

Missed opportunities in aspirin prescribing for preeclampsia prevention

BackgroundHypertensive disorders of pregnancy, including preeclampsia, are a leading cause of perinatal morbidity and mortality in the United States, particularly among low-income and historically marginalized populations. Evidence suggests low-dose aspirin prophylaxis may help prevent preeclampsia in individuals at increased risk of developing the disease. This study examines associations between preeclampsia risk factors and aspirin prescribing practices among patients receiving prenatal care at a network of federally qualified health centers (FQHC).MethodsResearchers conducted retrospective chart reviews (n = 523) of pregnant individuals ages 18–50 who completed two or more prenatal visits at the FQHC between January 1, 2019 and December 31, 2020. Prescription patterns for patients at moderate and high risk for preeclampsia were analyzed using unadjusted and adjusted logistic regression models to identify the patients with the greatest risk of not receiving the recommended prophylactic treatment.ResultsOf 249 total patients considered at risk for preeclampsia, only 39% received an aspirin prescription. 57.89% of patients with any high-risk factor were appropriately prescribed aspirin, but only 27.27% of patients with two or more moderate-risk factors without high-risk factors received a prescription. Clinicians most frequently prescribed aspirin for patients with a history of preeclampsia and history of hypertension. However, aspirin was prescribed a maximum of 78.79% of the time for patients with a prior history of hypertension. Among moderate-risk factors, patients with advanced maternal age, Black race, or nulliparity were significantly more likely in adjusted models to be prescribed aspirin.ConclusionsDespite the documented benefits of aspirin prescribing and support from professional societies, there are still many missed opportunities for aspirin prophylaxis to prevent preeclampsia. Future interventions should focus on identifying patients who qualify for aspirin prophylaxis on the basis of having multiple moderate-risk factors without comorbid high-risk factors.

Targeting Hypertensive Response To Exercise And The Association Of Masked Hypertension With Subclinical Organ Damage : A Mini-Review And Meta-Analysis.

Emerging evidence suggests that a hypertensive response to exercise (HRE) during dynamic or isometric stress tests assessing cardiac function is predictive of hypertension and cardiovascular events such coronary artery disease, heart failure and stroke. Whether HRE represents a marker of masked hypertension (MH) in individuals with no prior history of hypertension is still unclear. This is also the case for the association between MH and hypertension-mediated organ damage (HMOD) in the HRE setting. We addressed this issue through a review and a meta-analysis of studies providing data on this topic in normotensive individuals undergone both to dynamic or static exercise and to 24-hour blood pressure monitoring (ABPM). A systematic search was performed using Pub-Med, OVID, EMBASE and Cochrane library databases from inception up to February 28 th 2023. Six studies including a total of 1155 untreated clinically normotensive individuals were considered for the review. Data provided by the selected studies can be summarized as follows: I) HRE is a BP phenotype linked to a high prevalence of MH (27.3% in the pooled population ); II) MH is, in turn, associated with a greater, consistent likelihood of echocardiographic left ventricular hypertrophy (OR: 4.93, CI: 2.16-12.2, p < 0.0001) and vascular organ damage, as assessed by pulse wave velocity, (SMD: 0.34±0.11, CI: 0.12-0.56, p=0002). On the basis of this, albeit limited, evidence, the diagnostic work-up in individuals with HRE should primarily be addressed to look for MH as well as for markers of HMOD, a highly prevalent alteration in MH.

Masked Hypertension and Exaggerated Blood Pressure Response to Exercise: A Review and Meta-Analysis

Whether exaggerated blood pressure response (EBPR) to exercise represents a marker of masked hypertension (MH) in individuals with no prior history of hypertension is still unclear. We investigated this issue through a review and a meta-analysis of studies providing data on this association in normotensive individuals undergone both to dynamic or static exercise and to 24 h blood pressure monitoring (ABPM). A systematic search was performed using Pub-Med, OVID, EMBASE, and Cochrane library databases from inception up to 31 December 2022. Studies were identified by using the following search terms: "masked hypertension", "out-of-office hypertension", "exercise blood pressure", "exaggerated blood pressure exercise", "exercise hypertension". Nine studies including a total of 387 participants with MH and 406 true normotensive controls were considered. Systolic BP (SBP) and diastolic BP (DBP) at rest were significantly higher in MH individuals than in sustained normotensives: 126.4 ± 1.4/78.5 ± 1.8 versus 124.0 ± 1.4/76.3 ± 1.3 mmHg (SMD: 0.21 ± 0.08, CI: 0.06-0.37, p = 0.007 for SBP; 0.24 ± 0.07, CI: 0.08-0.39, p = 0.002 for DBP). The same was true for BP values at peak exercise: 190.0 ± 9.5/96.8 ± 3.7 versus 173.3 ± 11.0/88.5 ± 1.8 mmHg (SMD 1.02 ± 0.32, CI: 0.39-1.65, p = 0.002 for SBP and 0.97 ± 0.25, CI: 0.47-1.96, p < 0.0001 for DBP). The likelihood of having an EBPR was significantly greater in MH than in their normotensive counterparts (OR: 3.33, CI: 1.83-6.03, p < 0.0001). Our meta-analysis suggests that EBPR reflects an increased risk of MH and that BP measurement during physical exercise aimed to assess cardiovascular health may unmask the presence of MH. This underscores the importance of BP measured in the medical setting at rest and in dynamic conditions in order to identify individuals at high cardiovascular risk due to unrecognized hypertension.

Medication non-adherence patterns and profiles for patients with incident myocardial infarction: Observations from a large multi-morbid US population.

Consistent adherence levels to multiple long-term medications for patients with cardiovascular conditions are typically advocated in the range of 50% or higher, although very likely to be much lower in some populations. We investigated this issue in a large cohort covering a broad age and geographical spectrum, with a wide range of socio-economic disability status. The patients were drawn from three different health plans with a varied mix of socio-economic/disability levels. Adherence patterns were examined on a monthly basis for up to 12 months past the index date for myocardial infarction (MI) using longitudinal analyses of group-based trajectory modelling. Each of the non-adherent patterns was profiled from comorbid history, demographic and health plan factors using main effect logistic regression modelling. Four medication classes were examined for MI: betablockers, statin, ACE inhibitors and anti-platelets. The participant population for the MI/non-MI cohorts was 1,987,605 (MI cohort: mean age 62 years, 45.9% female; non-MI cohort: mean age 45 years, 55.3% females). Cohorts characterized by medication non-adherence dominated the majority of MI population with values ranging from 74% to 82%. There were four types of consistent non-adherence patterns as a function of time for each medication class: fast decline, slow decline, occasional users and early gap followed by increased adherence. The characteristics of non-adherence profiles eligible for improvement included patients with a prior history of hypertension, diabetes mellitus and stroke as co-morbidities, and Medicare plan. We found consistent patterns of intermediate non-adherence for each of four drug classes for MI cohorts in the order of 56% who are eligible for interventions aimed at improving cardiovascular medication adherence levels. These insights may help improve cardiovascular medication adherence using large medication non-adherence improvement programs.

Hepatotoxicity from high-dose methotrexate in primary central nervous system lymphoma.

High-dose methotrexate (HDMTX) is a mainstay of primary central nervous system lymphoma (PCNSL) treatment. Transient hepatotoxicity from HDMTX has been characterized in pediatric patients but not in adults. We sought to characterize hepatotoxicity in adult PCNSL patients undergoing HDMTX treatment. Retrospective study of 65 PCNSL patients treated at the University of Virginia from 02/01/2002 to 04/01/2020 was performed. Hepatotoxicity was defined using National Cancer Institute Common Toxicity Criteria (CTC) for adverse events, fifth version. High-grade hepatotoxicity was defined as a bilirubin or aminotransferase CTC grade of 3 or 4. Relationships between clinical factors and hepatotoxicity were assessed with logistic regression. Most patients (90.8%) had a rise of at least one aminotransferase CTC grade during HDMTX treatment. 46.2% had high-grade hepatotoxicity based on aminotransferase CTC grade. No patients developed high-grade bilirubin CTC grades during chemotherapy. Liver enzyme test values decreased to low CTC grade or normal in 93.8% of patients after the conclusion of HDMTX treatment without treatment regimen changes. Prior ALT elevation (P = .0120) was a statistically significant predictor of high-grade hepatotoxicity during treatment. Prior history of hypertension was associated with increased risk of toxic serum methotrexate levels during any cycle (P = .0036). Hepatotoxicity develops in the majority of HDMTX-treated PCNSL patients. Transaminase values decreased to low or normal CTC grades in almost all patients after treatment, without modification of MTX dosage. Prior ALT elevation may predict patients' increased hepatotoxicity risk, and hypertension history may be a risk factor for delayed MTX excretion.

Spontaneous Intracerebral Hemorrhage in the Young: An Institutional Registry Analysis

Abstract Background: Spontaneous intracerebral hemorrhage (SICH) accounts for about 10–15% of all strokes. Generally, it is a disease of the elderly; worldwide, the incidence of SICH in the young is showing an increasing trend, especially in India and the Asian continent. An attempt is also made to analyze the presence of factors, which may predict the risk of SICH among young hypertensives. Methods: A six-year retrospective review of patients aged below 50 years who presented with SICH was included in the study. Patients with bleeds secondary to an identifiable cause such as tumor, trauma, vascular malformations, and coagulopathy-induced bleeds were excluded from the study. The outcome was measured at 90 days using the modified ranking scale, and predictors of outcome (good outcome modified ranking score (mRS): 0–3; poor outcome mRS: 4–6) were analyzed. Results: SICH in the young accounted for 28.4% of all intracerebral hemorrhage (ICH) patients admitted during the study period (344/1210). The mean age of our male-dominant (78.5%) cohort was 42.9 ± 6.24 years, and the median Glasgow coma score (GCS) on presentation was 11 (IQR: 8–14). A prior history of hypertension (HTN) was obtained in 51.2% (176), and left ventricular hypertrophy (LVH) was documented in 237 (68.9%) patients. The basal ganglia was the most common location of the bleed (62.2%). At 90 days, 200 patients (58.1%) had good outcome and 144 (41.9%) had poor outcome with an overall mortality of 75 (21.8%). Independent predictors of poor outcome were poor GCS, larger volume, and high serum creatinine values. Conclusion: The incidence of SICH among the young accounts for nearly 30% of admitted ICH. Poor outcome and mortality are high with HTN being the single most important modifiable risk factor in the cohort.

Combined Arterial Hypertension and Ischemic Stroke Exaggerate Anesthesia-Related Hypotension and Cerebral Oxygenation Deficits: A Preclinical Study.

Intraoperative arterial hypotension (IOH) is a common side effect of general anesthesia (GA), associated with poor outcomes in ischemic stroke. While IOH is more prevalent with hypertension, it is unknown whether IOH may differ when GA is induced during ischemic stroke, versus other clinical settings. This is important given that many stroke patients receive GA for endovascular thrombectomy. We evaluate the cardiovascular responses to volatile GA (isoflurane in 100% o2 ) before and during middle cerebral artery occlusion stroke in rats instrumented to record blood pressure (BP) and cerebral tissue oxygenation (p o2 ) in the projected penumbra, in clinically relevant cohorts of normotensive (Wistar rat, n = 10), treated hypertensive (spontaneously hypertensive [SH] + enalapril, n = 12), and untreated hypertensive (SH rat, n = 12). During baseline induction of GA, IOH was similar in normotensive, treated hypertensive, and untreated hypertensive rats during the induction phase (first 10 minutes) (-24 ± 15 vs -28 ± 22 vs -48 ± 24 mm Hg; P > .05) and across the procedure (-24 ± 13 vs -30 ± 35 vs -39 ± 27 mm Hg; P > .05). Despite the BP reduction, cerebral p o2 increased by ~50% in all groups during the procedure. When inducing GA after 2 hours, all stroke groups showed a greater magnitude IOH compared to baseline GA induction, with larger falls in treated (-79 ± 24 mm Hg; P = .0202) and untreated(-105 ± 43 mm Hg; P < .001) hypertensive rats versus normotensives (-49 ± 21 mm Hg). This was accompanied by smaller increases in cerebral p o2 in normotensive rats (19% ± 32%; P = .0144 versus no-stroke); but a decrease in cerebral p o2 in treated (-11% ± 19%; P = .0048) and untreated (-12% ± 15%; P = .0003) hypertensive rats. Sham animals (normotensive and hypertensive) showed similar magnitude and pattern of IOH when induced with GA before and after sham procedure. Our findings are the first demonstration that ischemic stroke per se increases the severity of IOH, particularly when combined with a prior history of hypertension; this combination appears to compromise penumbral perfusion.

Prolonged ICU Stay in Severe and Critically-Ill COVID-19 Patients Who Received Convalescent Plasma Therapy.

Background Convalescent plasma administration in severe and critically-ill COVID-19 patients have been proven to not provide improvement in patients' outcome, yet it is still widely used in countries with limited resources due to its high availability and safety. This study aims to investigate its effects on ICU mortality, ICU length of stay (LoS), and improvement of oxygen support requirements. Methods Data of all severe and critically-ill patients in our COVID-19 ICU was collected retrospectively between May and November 2020. We dichotomized the variables and compared outcome data of 48 patients, who received convalescent plasma to 131 patients, receiving standard of care. Data were analyzed using multiple logistic regression to make prediction models of mortality, length of stay, and oxygen support device requirement. Result Overall mortality rate in our COVID-19 ICU was 55.3%, with a median overall length of stay of 8 (4–11) days. Less patients that received convalescent plasma presented with the need for mechanical ventilation on ICU admission (p < 0.001), but with comparable PaO2 to FiO2 (P/F) ratio (p=0.95). Factors that confounded mortality were obesity (aOR = 14.1; 95% CI (1.25, 166.7); p=0.032), mechanical ventilation (aOR = 333; 95% CI (4.5,1,000); p < 0.001), higher neutrophil-to-lymphocyte ratio (NLR) (aOR = 7.32; 95% CI (1.82, 29.4); p=0.005), and lower P/F ratio (aOR = 7.70; 95% CI (2.04, 29.4); p=0.003). ICU LoS was longer in patients, who had prior history of hypertension (aOR = 2.14; 95% CI (1.05, 4.35); p=0.036) and received convalescent plasma (aOR = 3.88; 95% CI (1.77, 8.05); p < 0.001). Deceased patients, who received convalescent plasma, stayed longer in the ICU with a mean length of stay of 12.87 ± 5.7 days versus 8.13 ± 4.8 days with a significant difference (U = 434; p < 0.000). The chance of improved oxygen support requirements was lower in obese patients (aOR = 9.18; 95%CI (2.0, 42.1); p < 0.004), mechanically ventilated patients (aOR = 13.15; 95% CI (3.75, 46.09); p < 0.001), patients with higher NLR (aOR = 2.5; 95% CI (1.07, 5.85); p=0.034), and lower P/F ratio (aOR = 2.76; 95% CI (1.1, 6.91); p=0.031). Conclusion The length of stay of patients in the convalescent plasma group was significantly longer than the control group. There was no effect of convalescent plasma in ICU mortality and no improvement was observed in terms of oxygen support requirements.

342.9: Factors Associated With a Higher Need for Antihypertensive Medications at 12- Months Post Renal Transplantation

Background: Hypertension (HTN) after renal transplantation can be difficult to control and often requires multiple blood pressure (BP) medications. In this study we examined the incidence and risk factors of “difficult to treat HTN” at one year post kidney transplantation at our center. Method: A single center retrospective study of renal transplant recipients who underwent kidney transplantation between January 2017 and May 2020 with 12 months follow up. We reviewed patients’ demographics, results of pretransplant cardiovascular imaging, and the change of cardiovascular risk factors during the first-year post kidney transplantation. We divided patients according to the number of their blood pressure medications at one year into two groups; those who required none or one, and those who required two or more medications. We labeled those who required ≥2 as “difficult to treat hypertension”. The target BP during the time of this retrospective study was <140/90 mm Hg as per the published guidelines during the time of the study.1 Results: A total of 278 renal transplant recipients were included. The majority (74%) was ≥ 30 years, 58% were men and 80% were living-donor kidney recipients. Preemptive transplantation was 10.1%. PD and HD were 11.5% and 78.4%, respectively. At one year, 70.1% of the patients attained to the target BP goal. Of the total study population; (N: 105, 38%) required ≥ 2 BP medications (i.e., “difficult to treat HTN”). Factors related to a higher need for antihypertensive medications included age (50 vs. 39 years, P<0.001), prior history of hypertension (P=0.006), prior AV fistula vs. dialysis catheter (P=0.044) and diabetes mellitus (P<0.001). Dialysis vintage (including preemptive transplantation), type of dialysis (HD vs. PD), type of transplant (living donor kidney transplant vs deceased donor kidney transplant), and smoking were not different among the two groups. Patients with “difficult to treat HTN” at one year were more likely to have abnormal pre-transplant cardiovascular baseline imaging including abnormal ejection fraction <55% (P=0.044), abnormal wall motion on echocardiography (P=0.004), abnormal perfusion stress test (P<0.001), higher calcium scoring (P=0.002), abnormal cardiac catheterization (P<0.001), and a higher degree of calcifications on CT of pelvic arteries (P=0.006). Patients with “difficult to treat HTN” at one year were likely to have a higher BMI at 12 months (P=0.028) whereas rejection, change of creatinine, weight gain, persistent hyperparathyroidism or anemia at 12 months were not different among the two groups. Multivariate analysis of requiring ≥1 BP medication indicated a relation with age (aOR: 1.025, CI: 1.003-1.048, P=0.026); male vs. female (aOR: 2.413, CI 1.358-4.288, P=0.003); DM (aOR: 2.07, CI: 1.081-3.964, P=0.028); HTN (aOR 2.586, CI: 1.104-6.06, P=0.029). However, the odds ratio for BMI at 12 months was insignificant (aOR: 0.999, CI 0.948-1.053, P=0.98). Conclusion: At one year post transplantation, about two thirds of our renal transplant recipients required no or only one BP medication. Those who required more medications were more likely to be older, males, diabetic, or previously hypertensive. Recipients with abnormal baseline pre-transplant cardiovascular imaging were also more likely to require more medications. Reference:1. Taler SJ, Agarwal R, Bakris GL, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis. 2013;62.

Natural course and determinants of short-term kidney function decline in hereditary transthyretin amyloidosis: a French observational study

Data regarding renal involvement in patients with hereditary transthyretin (ATTRv) amyloidosis are scarce and the natural course of chronic kidney disease (CKD) in this population remains unclear. This observational study, including adult patients diagnosed with ATTRv amyloidosis at the French Reference Centre for Cardiac Amyloidosis, investigated renal function outcome and its determinants. Multivariable logistic regression models identified factors associated with CKD at baseline. Determinants of the change in estimated glomerular filtration rate (eGFR) over 24 months of follow-up were assessed with a multivariable linear mixed-effects model. In total, 232 patients (78 women [34%], mean age: 64 years) with ATTRv amyloidosis were classified on the basis of their TTR variants: ATTRV122I (37%), ATTRV30M (29%), and other variants (34%). Median baseline eGFR was 78 ml/min/1.73 m2. Seventy-two patients (31%) had an eGFR below 60 ml/min/1.73m2 and 27/137 patients (20%) had significant proteinuria (urine protein/creatinine ratio ≥30 mg/mmol). Renal biopsy, performed in four cases, found typical Congo red-positive and TTR-labelled amyloid deposits in all cases. Older age (OR 1.07, p < .001) and a prior history of hypertension (OR 2.09, p = .04) were associated with a higher prevalence of CKD at baseline, whereas higher left ventricular global longitudinal strain (LVGLS) (OR 0.83, p < .001) was associated with a lower prevalence. The estimated change in eGFR was −7.12 [−9.61, −4.63] and −8.21 [−10.81, −5.60] ml/min/1.73 m2 after 12 and 24 months of follow-up, respectively. eGFR decline was independently associated with older age ((67–74], coefficient= −14.35 mL/min/1.73 m2, p < .01, >74, coefficient = −22.93 mL/min/1.73 m2, p < .001, versus <56), ATTRV122I (coefficient = −17.17 mL/min/1.73m2, p < .01, versus ATTRV30M) and LVGLS (coefficient = 1.22, p < .01). These data suggest that CKD is a common finding in patients with ATTRv amyloidosis, and that eGFR decline is rapid during the first year of evaluation. Older age, lower LVGLS and ATTRV122I were associated with a worse renal outcome. Further studies are now needed to evaluate effects of new targeted therapies on long term renal function.

Development and Internal Validation of a Model to Predict Malignancy within a Year After Heart Transplantation in Adults

<h3>Purpose</h3> Malignancy after heart transplantation (HT) is associated with poor outcomes. A model to predict the risk of malignancy within the first year after HT is urgently required. <h3>Methods</h3> We included adults (>18 years of age) who underwent HT included in the Scientific Registry of Transplant Recipients (SRTR) between January 2000 and May 2021. Candidate predictors were identified based on their association with malignancy in literature, included recipient age, gender, race, height, weight, kidney function, heart failure etiology, prior history of hypertension, diabetes, and smoking, induction therapy use, various histocompatibility results (CMV, EBV, DR mismatches), and transplant year. A multivariable regression model for predicting malignancy development within a first year after HT was developed and internally validated via 500 bootstrapped samples to estimate the optimism-corrected measures of model accuracy and performance. <h3>Results</h3> Among the 47,212 HT recipients with a median (25^th, 75^th percentile) age of 56 (46, 62) years, 25.6% were female, 75.8% were White, and 7.2% had prior malignancy. 2.3% developed malignancy within the first year. Recipient age at transplant, history of malignancy, recipient White race, and heart failure etiology were the strongest predictors of malignancy. The optimism-corrected model had modest discrimination (C-statistic: 0.699, 95%CI 0.688-0.714) and good calibration and performance (calibration slope: 0.967; Nagelkerke R² 0.065), particularly at lower predicted risk (Figure). <h3>Conclusion</h3> Despite selecting variables previously linked to malignancy, our model was modestly predictive of the development of malignancy in the first year after heart transplantation. These findings highlight the importance of future work to identify factors that may increase prediction of malignancy and may benefit from incorporation of time-to-event data.

Burden of hypertension in Ghana - Analysis of awareness and screening campaign in the Ashanti Region of Ghana.

ObjectivesHypertension is a major risk factor for cardiovascular mortality globally and in Ghana. May Measurement Month (MMM) is a global awareness and screening campaign initiated by the International Society of Hypertension.MethodsParticipants were recruited by opportunist sampling in the Ashanti region of Ghana. The blood pressures of participants were measured three times and the mean of the last two readings was used for the analysis. Simple and multiple logistic regression was used to determine the predictors of hypertension.ResultsThe MMM 2018 awareness and screening campaign enrolled 5054 participants with a mean age of 39.4 ± 14.7 years. There were 2553 (50.6%) males, 987 (20.1%) of respondents had never checked their blood pressure and 676 (13.9%) had a prior history of hypertension. The prevalence of hypertension was 37.4%. We found that 589(66.8%) of 822 respondents with high blood pressure did not have a history of hypertension. Respondents with a known history of hypertension on medication were 442 (65.9%) and 219(68.0%) of 322 respondents on medication had uncontrolled hypertension. The predictors of high blood pressure in a multiple logistic regression were increasing age (OR = 1.05 CI 1.05–1.06, p < 0.001), history of alcohol intake (OR = 1.33 CI 1.04 −1.70, p = 0.02), overweight (OR = 1.4 CI 1.14–1.76, p = 0.001) and obesity (OR = 1.32, CI 1.01–1.74, p = 0.047).ConclusionThere is a high prevalence of hypertension in the Ashanti region in Ghana. Most participants with hypertension were not aware and the majority of those with hypertension on medications were uncontrolled. This calls for more education and screening of hypertension to decrease cardiovascular mortality.

Sudden or Cardiac Deaths on Ibrutinib-Based Therapy Were Associated with a Prior History of Hypertension or Cardiac Disease and the Use of ACE-Inhibitors at Study Entry: Analysis from the Phase III NCRI FLAIR Trial

Sudden or Cardiac Deaths on Ibrutinib-Based Therapy Were Associated with a Prior History of Hypertension or Cardiac Disease and the Use of ACE-Inhibitors at Study Entry: Analysis from the Phase III NCRI FLAIR Trial

Cardiorenal syndrome and death risk in patients with heart failure or chronic kidney disease: an unmet cardiorenal need?

Abstract Introduction Heart failure (HF) and chronic kidney disease (CKD) have interlinked pathophysiological pathways and patients having both conditions simultaneously are defined as having cardiorenal syndrome (CRS). Purpose To estimate the risk of CRS in patients with initial presentation of HF (without prior CKD) or CKD (without prior HF) compared to mean age overall population in a real-world clinical setting. Also, to estimate the risk of all-cause death, cardiovascular (CV) death and non-fatal major CV events (MACE) in patients with HF, CKD and CRS compared to the mean-age overall population. Methods Clinical database analysis of a single primary and secondary healthcare institution from 2008–2019. We defined 4 incident cohorts: Control - patients at age 75; HF - HF patients without prior CKD; CKD - CKD patients without prior HF; CRS - patients with HF and CKD. Patients were indexed at the date of first event and followed one year. We defined HF as either: i) Ejection Fraction (EF)≤40% and NT-proBNP≥200pg/mL (≥600pg/mL if atrial fibrillation (AF)) OR BNP≥100pg/mL (≥125pg/mL if AF); ii) EF&amp;gt;40% in the presence of structural cardiac abnormalities. We defined CKD as eGFR≤60mL/min using EPI-CKD formula. All definitions were constructed using laboratory-level data complemented with episode-level data. Hazard ratios (HR) and 95% confidence intervals were estimated using Cox regression models adjusted for age, sex, age-sex interaction, prior history of hypertension, myocardial infarction, stroke, peripheral artery disease and type 2 diabetes. Results We identified 3973 patients with HF, 13990 with CKD, 6784 with CRS and 16182 controls. Patients were in general 75–77 years old. The majority were females and were well treated with CV risk reducing drugs (Table 1). All-cause death risk was 4.7 (4.1–5.2) for HF and 4.9 (4.5–5.4) for CKD. CV death risk was 8.6 (6.8–10.8) for HF and 8.7 (7.1–10.6) for CKD. Non-fatal MACE risk was 7.4 (6.3–8.7) for HF, 4.6 (4.0–5.3) for CKD, and 7.1 (6.1–8.3) for CRS. CRS was associated with the highest risks of all-cause and CV death when compared with the control group- 7.1 (6.4–7.9) and 13.7 (11.7–17.0), respectively (Figure 1). More than half of events occurred in the first 90 days of follow-up for all outcomes. Conclusions Cardiorenal disease (HF or CKD) was associated with very high short-term risk (1 year) of developing CRS or death. Consecutively, patients with established CRS had the highest risk of dying. These results demonstrate serious cardiorenal risks in a real-world setting, supporting an urgent need for improved primary and secondary prevention of cardiorenal disease and cardiorenal syndrome. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca Produtos Farmacêuticos, Lda. Table 1. Baseline characteristicsFigure 1. Outcomes for CKD, HF and CRS

HF and CKD present a dire prognosis in young Type 2 Diabetic patients

Abstract Introduction Type-2 diabetes (T2D) is one of the most relevant risk factors for both heart failure (HF) and chronic kidney disease (CKD). Target organ damage causes significant morbi-mortality, especially when these two conditions are combined with diabetes. Understanding the natural history of the combination of these conditions is paramount to implement tailored preventive measures. Purpose To estimate the risk of all-cause death, cardiovascular (CV) death and non-fatal major CV events (MACE) in T2D patients younger than 65 years, either: i) without HF or CKD, ii) with HF (T2D-HF), or iii) with CKD (T2D-CKD) in a real-world clinical setting. Methods Retrospective cohort study performed in a healthcare centre that provides primary and secondary care. It included adults with T2D aged between 40 and 65 years of age stratified into three groups: i) T2D with HF defined as either: Ejection Fraction (EF) ≤40% and NT-proBNP ≥200pg/mL (≥600pg/mL if atrial fibrillation (AF)) or BNP ≥100pg/mL (≥125pg/mL if AF); EF &amp;gt;40% in the presence of structural cardiac abnormalities), ii) T2D with CKD (eGFR ≤60mL/min using EPI-CKD formula) and T2D without HF or CKD. We modelled 1-year risk for CV death, all-cause mortality and non-fatal MACE using multivariate weighted cox regression models clustered by patient. Models were adjusted for age (using penalized splines), sex, age-sex interaction, prior history of hypertension, myocardial infarction, stroke, and peripheral arterial disease. We reported hazard ratios (versus T2D without HF or CKD) with 95% confidence intervals. Results We identified 14986 patients with T2D without HF or CKD, 1101 with T2D with HF and 3114 with T2D with CKD. Patients were in general 55–58 years old, with a slight predominance of the male gender across the groups. Event rate was 14% in T2D with HF, 15% in T2D with CKD and 5% in TD2 without these conditions. One-year all-cause death risk was 2.77 (2.26–3.40) for T2D-HF and 3.09 (2.77–3.45) for T2D-CKD. CV death risk was 2.59 (1.72–3.91) for T2D-HF and 2.75 (2.19–3.46) for T2D-CKD. Non-fatal MACE risk was 2.82 (2.34–3.41) for T2D-HF and 1.90 (1.66–2.17) for T2D-CKD. Regarding MACE, the event rate was 32% in T2D-HF, 13% in T2D-CKD but only 6% in T2D. T2D-HF was associated with the highest risks of myocardial infarction (3.25 [2.60–4.06]) and end-stage kidney disease (9.9 [7.3–13.43]) when compared to T2D-CKD. Conclusions Young patients with T2D combined with HF or CKD have an increased risk of early adverse CV and renal events. HF was linked with highest risk of myocardial infarction and end-stage kidney disease. These findings highlight the importance of an early identification and management of HF and CKD in T2D patients. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca Produtos Farmacêuticos Lda Figure 1. Outcomes for HF and CKD groups

AVOIDING ANCHORING BIAS: DIAGNOSIS OF AL-AMYLOIDOSIS IN WORSENING HEART FAILURE AFTER CORONARY ARTERY BYPASS GRAFTING

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Amyloidosis is a systemic disease caused by deposition of misfolded protein in various tissues and organs. Early recognition of amyloidosis is necessary as cardiac dysfunction is the major determinant of survival(1). The diagnosis is often delayed given the non-specific symptoms at onset. Prognosis in amyloidosis is primarily dependent on the degree of cardiac involvement and, in AL amyloidosis, on circulating light-chain levels(2). CASE PRESENTATION: The patient is a 68-year-old male referred to our institution for assessment of worsening heart failure (HF). Four months prior, he began to experience exertional dyspnea along with jaw pain. Subsequent evaluation included lab work, chest X-ray and electrocardiogram demonstrating troponin elevation, pulmonary edema and complete heart block respectively. An echocardiogram(ECHO) demonstrated a severely reduced ejection fraction(EF). Temporary pacemaker was placed and a subsequent angiogram showed severe multi-vessel coronary artery disease(CAD). He underwent coronary artery bypass graft surgery. Post-operatively EF improved to 45%. Implantable loop recorder was placed due to concerns for post-operative atrial fibrillation. Three months later, he experienced a syncopal event attributed to ventricular tachycardia, and CRT-D was placed. ECHO revealed reduction of his EF (30%) with moderate concentric left ventricular hypertrophy(LVH). A repeat angiogram demonstrated patency of his bypass grafts. After referral to our institution, a repeat ECHO demonstrated findings concerning amyloidosis. Protein electrophoresis revealed monoclonal IgG gammopathy, and fat pad aspirate confirmed the diagnosis of AL amyloidosis. DISCUSSION: Although CAD is the most common cause of HF with reduced EF, other etiologies must be considered when symptoms cannot be explained solely by ischemia. Cardiac amyloidosis was suspected based on a constellation of clinical symptoms as well as suggestive ECHO findings(Biventricular concentric hypertrophy, restrictive filling pattern, Bull's eye appearance on LV strain). The diagnosis should be suspected in patients with HF who have unexplained LVH with no prior history of hypertension(3). Patients also present with syncopal events caused by conduction blocks, bradyarrhythmia, or in the case of our patient, ventricular tachyarrhythmias. Early diagnosis is important given the emerging therapies that can halt cardiac damage, potentially reducing the risk of mortality and allowing amyloid clearance and improved cardiac function. CONCLUSIONS: Anchoring bias is the tendency to stick with initial impressions even as new information becomes available. Clinicians must avoid this and consider alternative diagnoses when patients do not experience the anticipated outcome to a particular treatment. REFERENCE #1: 1. Fontana M. Banypersad SM. Treibel TA, et al. Differential myocyte responses in patients with cardiac transthyretin amyloidosis and light-chain amyloidosis: a cardiac MR imaging study. Radiology. 2015;277:388–97 REFERENCE #2: 2. Kumar S, Dispenzieri A, Lacy MQ, et al. Revised prognostic staging system for light chain amyloidosis incorporating cardiac biomarkers and serum free light chain measurements. J Clin Oncol 2012;30:989-95 REFERENCE #3: 3. Gertz MA. Comenzo R. Falk RH, et al. Definition of organ involvement and treatment response in immunoglobulin light chain amyloidosis (AL): a consensus opinion from the 10th International Symposium on Amyloid and Amyloidosis, Tours, France, 18-22 April 2004. Am J Hematol. 2005;79:319–28 DISCLOSURES: no disclosure on file for Brian Hardaway; No relevant relationships by Michael Liu, source=Web Response No relevant relationships by Amith Reddy Seri, source=Web Response

Use of Machine Learning and Statistical Algorithms to Predict Hospital Length of Stay Following Colorectal Cancer Resection: A South African Pilot Study.

The aim of this pilot study was to develop logistic regression (LR) and support vector machine (SVM) models that differentiate low from high risk for prolonged hospital length of stay (LOS) in a South African cohort of 383 colorectal cancer patients who underwent surgical resection with curative intent. Additionally, the impact of 10-fold cross-validation (CV), Monte Carlo CV, and bootstrap internal validation methods on the performance of the two models was evaluated. The median LOS was 9 days, and prolonged LOS was defined as greater than 9 days post-operation. Preoperative factors associated with prolonged LOS were a prior history of hypertension and an Eastern Cooperative Oncology Group score between 2 and 4. Postoperative factors related to prolonged LOS were the need for a stoma as part of the surgical procedure and the development of post-surgical complications. The risk of prolonged LOS was higher in male patients and in any patient with lower preoperative hemoglobin. The highest area under the receiving operating characteristics (AU-ROC) was achieved using LR of 0.823 (CI = 0.798–0.849) and SVM of 0.821 (CI = 0.776–0.825), with each model using the Monte Carlo CV method for internal validation. However, bootstrapping resulted in models with slightly lower variability. We found no significant difference between the models across the three internal validation methods. The LR and SVM algorithms used in this study required incorporating important features for optimal hospital LOS predictions. The factors identified in this study, especially postoperative complications, can be employed as a simple and quick test clinicians may flag a patient at risk of prolonged LOS.