Severe Hypertensive Retinopathy Research Articles

Baseline characteristics of the first 302 patients included for acute malignant hypertension crisis in the prospective multidisciplinary HAMA cohort.

Malignant hypertension has not disappeared and remains the most severe form of hypertension. More than 100 years after its description, many points remain unanswered. Mechanisms, definitions, and optimal treatment are still controversial. In 2019, we decided to launch a prospective multicentre multidisciplinary cohort in France to try to fill these gaps. This study aimed to describe the baseline characteristics of the first 302 included patients and compared these data to already published cohorts. We included patients with severe hypertension associated with severe hypertensive retinopathy and patients filling the HYP MOD (HYPertension MultiOrgan Damage) definition from a broad range of departments (cardiology, nephrology, neurology intensive care unit, emergency department, internal medicine). We collected clinical, biological, imaging, and target organ damage data at admission, along with social and demographic data. We also recorded diagnostic and therapeutic management, adverse events during hospitalization, and characteristics at discharge. We enrolled 302 patients in 32 months (105/year) among 40 centres and different specialties. They mainly included young men (68%, mean age 48.7 ± 14.5 years). Target organ damage involved the eye in 86.7% of patients, kidney in 58.6%, heart in 50%, brain in 32.8%, and Thrombotic Microangiopathy stigmata in 15.6%. Patients with severe retinopathy shared characteristics similar to those included in the most important cohorts already published. We also reported several additional subgroups of interest: one-third of our patients were less than 40 years old, one-third were of non-European origin, 14.3% were included through the multiorgan damage definition, without fundus severe injuries, 22.8% were treated without the use of IV therapy, 40.9% had normal or low renin level, and almost all patients were not on antihypertensive therapy at the time of the enrolment. These preliminary findings already challenge long-standing dogma, raise numerous questions, and provide a solid basis to address them in ancillary studies of the cohort.

Ocular biomarkers: useful incidental findings by deep learning algorithms in fundus photographs

Background/ObjectivesArtificial intelligence can assist with ocular image analysis for screening and diagnosis, but it is not yet capable of autonomous full-spectrum screening. Hypothetically, false-positive results may have unrealized screening potential arising from signals persisting despite training and/or ambiguous signals such as from biomarker overlap or high comorbidity. The study aimed to explore the potential to detect clinically useful incidental ocular biomarkers by screening fundus photographs of hypertensive adults using diabetic deep learning algorithms.Subjects/MethodsPatients referred for treatment-resistant hypertension were imaged at a hospital unit in Perth, Australia, between 2016 and 2022. The same 45° colour fundus photograph selected for each of the 433 participants imaged was processed by three deep learning algorithms. Two expert retinal specialists graded all false-positive results for diabetic retinopathy in non-diabetic participants.ResultsOf the 29 non-diabetic participants misclassified as positive for diabetic retinopathy, 28 (97%) had clinically useful retinal biomarkers. The models designed to screen for fewer diseases captured more incidental disease. All three algorithms showed a positive correlation between severity of hypertensive retinopathy and misclassified diabetic retinopathy.ConclusionsThe results suggest that diabetic deep learning models may be responsive to hypertensive and other clinically useful retinal biomarkers within an at-risk, hypertensive cohort. Observing that models trained for fewer diseases captured more incidental pathology increases confidence in signalling hypotheses aligned with using self-supervised learning to develop autonomous comprehensive screening. Meanwhile, non-referable and false-positive outputs of other deep learning screening models could be explored for immediate clinical use in other populations.

EARLY RESULTS OF THE PROSPECTIVE MULTIDISCIPLINARY HAMA COHORT: DESCRIPTION OF THE FIRST 302 PATIENTS, COMPARISON WITH ALREADY PUBLISHED COHORT AND NOVEL INSIGHTS

Objective: Malignant hypertension has not disappeared and remains the most severe form of hypertension. More than 100 years after its description, many points remain unanswered. Mechanisms, definition and optimal treatment are still discussed. In 2019 we decided to launch a prospective multicenter multidisciplinary cohort in France try filling these gaps. Thjs study aims to describe the baseline characteristics of the first 302 included patients and compare these data to already published cohorts. Design and method: We included patient with severe hypertension and severe hypertensive retinopathy and patients filling the HYP MOD definition from a broad range of department (cardiology, nephrology, neurology intensive care unit, emergency department, internal medicine). We collected clinical data at admission, biological, imaging and target organ damage along with social and demographic data. We also recorded diagnostic and therapeutic management, adverse events during hospitalization and characteristics at discharge. Results: We recruited 302 patients in 32 month (105 / year) among 40 centres and different specialities. They are mostly young men (68%, mean age 48.7 +/- 14.5 years), with several interesting subgroups. Around one third of our patients were less than 40 years old, one third were from non-European origin, 13.6% were included through the multiorgan damage definition, without fundus severe injuries. Target organ damage involves the eye in 86% of patients, kidney in 54%, heart in 56%, brain in 33% and Thrombotic Microangiopathy in 13%. Our patients with severe retinopathy are very similar with those included in the most important cohorts already published. Interestingly, 22.8% of patients were treated without use of IV therapy, most patients were untreated or showed poor observance of treatments and a significant proportion had normal or low renin level. Conclusions: These preliminary findings already challenge long standing dogma, raise many questions and provide a strong basis to address them in ancillary studies of the cohort.

Association of Gamma-glutamyl transferase with severity of hypertensive retinopathy in the Indian population

: Hypertension is the condition of elevated blood pressure and is a serious medical condition that significantly increases risk of diseases associated with the heart, brain, kidney, eyes, etc. and its most common ocular presentation is Hypertensive retinopathy (HR). Oxidative stress has been extensively studied for its role in the pathophysiology of Hypertensive retinopathy. Through this study, we want to establish an association between the severity of Hypertensive retinopathy and Gamma-glutamyl transferase (GGT).: After obtaining clearance from the ethics committee, an analytical study was carried out comprising 100 individuals having Hypertensive retinopathy. Patients were divided into four groups according to the Keith Wagener classification. The patients underwent thorough clinical examinations. The ocular examination included visual acuity evaluation, IOP measurement by Goldmann tonometry, and fundoscopy. Biochemical investigation of Serum Gamma-glutamyl transferase was done using a CORAL Colorimetric assay kit and SPSS Version 21.0 was used for statistical analysis.: The majority of Grade I HR people belonged to either normal or prehypertensive group, while the majority of Grade IV, II & III were from the Stage I hypertensives group, followed by Grade II and Grade III hypertension. Statistically, a significant association between the increasing severity of retinopathy and the rise in BP was observed. Most patients with Grade I retinopathy (66.7%) had GGT levels < 40 U/l, while all the patients in Grade II, III & IV (100.0% each) had GGT >40 U/L. Statistically, it was also noted that the GGT levels increased with increasing grades in HR.

Risk Stratification on Systemic Target Organ Involvement Associated with Hypertensive Retinopathy.

Hypertensive retinopathy is a common complication among people with hypertension. The current study assessed the risk stratification on systemic target organ involvement of people with hypertensive retinopathy. In a hospital- based cross-sectional study conducted at a tertiary referral eye institute in Nepal, we included consecutive people ≥ 31 years with essential hypertension. Details of histories and systemic target organ involvements were documented. People with un-gradable retinal findings of hypertensive retinopathy and prior retinal surgery were excluded. All participants underwent comprehensive eye examination, including dilated fundus examination. Hypertensive retinopathy was classified by Modified Scheie classification. Multivariate analysis was performed to identify the risks for hypertensive retinopathy and target organ involvement. The study recruited 312 subjects. The mean age was 63.68 ± 12.63 years. The mean duration of hypertension was 7.0 ± 6.5 years. Hypertensive retinopathy was detected in 83.7% (n=261) people and 63.5% (n= 198) had grade 1 hypertensive retinopathy. Target organ involvement was detected in 20.5% (n =64) people. These included cardiac (12.5%; n=39), central nervous (5.1%; n= 16), and renal (4.5%; n=14) systems. In multivariate analysis, concurrent hyperlipidaemia was significantly associated with hypertensive retinopathy and target organ involvement. Target organ involvement increased with the severity of hypertensive retinopathy. Over four-fifths of people with hypertension had hypertensive retinopathy and one-fifth had other systemic target organ involvements. Severity of hypertensive retinopathy and concurrent hyperlipidaemia were associated with target organ involvement. Hypertensive retinopathy can be considered for risk stratification to other target organ involvement in a clinical setting.

S-35-3: HAMA, AN EUROPEAN REGISTRY OF MALIGNANT HYPERTENSION SUPPORTED BY THE EUROPEAN SOCIETY OF HYPERTENSION: PRELIMINARY RESULTS AND CURRENT PERSPECTIVES

Introduction: Malignant hypertension (MH) is one of the most severe acute forms of hypertension. It is very high blood pressure and an acute lesion of target organ damage. Incidence is currently increased in high-income countries and is higher in low-income countries due to difficulty with antihypertensive drug access. Causes of MH are very various, and probably prognosis of MH depends on the etiology. However, MH is not well known. We are conducting a multicentric prospective registry of MH patients started in 2019, primarily in France and is currently undergoing a European expansion with the support of the European Society of Hypertension (ESH) to describe the different forms and prognosis of MH and increase our knowledge of the disease (NCT03755726). Method: From 2019, in the 36 centres in France, Patients with a BP > 180/100 mmHg AND Severe Hypertensive Retinopathy - stade II or III of Kirkendall classification - OR with three criteria among the following: 1) Heart damage (Left ventricular Mass > 140 g/m2 for men of > 120 g/m2 for women); 2) Brain damage (PRES or acute stroke or severe white matter lesions (WML) with a Fazekas score > 2 before 60 years old); 3) Kidney damage (acute kidney injury defined by KDIGO criteria) 4) presence of Thrombotic Microangiopathy (TMA) with the presence of schizocytes and low haptoglobin or high LDH) were included. Results: To date, 278 patients were enrolled. The reason for hospital admission was symptomatic hypertension for 210/272 (77%) and asymptomatic hypertension for 62/272 (23%) BP was 218 ± 28 / 127 ± 23 mmHg. The mean age was 48 ± 15 years old. Males were 186/278 (67%). Non-Caucasians were 114/278 (41%), 101/278 (36%) smoked and 45/278 (16%) had diabetes. Before enrollment, 108/278 (39%) patients had chronic hypertension. Severe retinopathy was present in 251/278 (90%), Heart damage in 172/278 (62%), kidney damage in 176/278 (63%), and creatinine was 261 ± 326 μmol/l at admission. Brain damage was present in 105/278 (38%), 47/105 (45%) patients had severe WML. TMA was present in 40/278 (14%) patients. At discharge, BP was 148 ± 19 / 89 ± 15 mmHg; creatinine was 248 ± 274 μmol/l. The etiology of hypertension was assessed in 181/278 (65%), and a specific cause was found in 75/181 (41%). Conclusion: This multicentric prospective cohort is the opportunity to considerably increase our knowledge of MH, a non-uncommon severe disease. A biobank is currently being started to identify patients clustering to differentiate the etiology, prognosis and pathogenesis of each form of MH.

IS HEADACHE AT ADMISSION ASSOCIATED WITH HIGHER RATE OF RECENT BRAIN MRI INJURY DURING MALIGNANT HYPERTENSION CRISIS?

Objective: Reliable clinical signs associated with recent brain injuries in neurologically asymptomatic patients during malignant hypertension crisis are lacking. We aimed to compare the prevalence of brain MRI injuries between fully asymptomatic patients and those with isolated headache. Design and method: This single-center, cross-sectionnal observational study recruited patients with malignant Hypertension (MHT). MHT was defined by severe hypertension and severe hypertensive retinopathy OR subacute damage of three among the target organs: heart, kidney, brain, vessels (thrombotic microangiopathy). Patients under 18 years old, under chronic dialysis and not willing to participate were excluded. IBrain MRI was performed within 21 days following diagnosis and was reviewed by a stroke neurologist who recorded the following markers: acute ischemic stroke(DWI and FLAIR positive), acute intracerebral hemorrhage (T2* and FLAIR positive), acute brain edema with extensive posterior white matter hyperintensity suggesting a PRES, and small vessel disease including old lacunar infarct, white matter hyperintensities (WMH), presence of dilated perivascular spaces. Primary endpoint was the prevalence of recent brain injury in both group. Results: 92 patients were included. Among them, the average age was 47.8 years, 67 % were men, average admission systolic blood pressure and diastolic blood pressure were respectively 213 +/- 31 mmHg and 119 +/- 19 mmHg, 73 % had severe hypertensive retinopathy, median(IQR) creatininemia was 115 (92–180) mol/l and 11 % had systemic Hemolysis. Patients with no clinical symptoms or isolated headache presented respectively 39.5 % and 40 % of recent brain MRI abnormalities (cerebral Hematoma, ischemic stroke or PRES, p = 0.96). Patients with neurological signs on admission tended to have a higher frequency of recent brain injury than patients with isolated headaches (64,5%, p = 0,06), and a higher prevalence of chronic lacunar infarct (70,5% vs 44%, p = 0,04). We found no difference regarding cerebral microangiopathy in the 3 groups. Conclusions: Prevalence of recent brain injuries among patients with isolated headache and fully asymptomatic patients at admission of malignant hypertensive patients are similar and high. This raises the question of systematically performing brain MRI in patients with malignant hypertensive crisis.

NEUROLOGICALLY ASYMPTOMATIC PATIENTS FREQUENTLY PRESENT CEREBRAL INJURIES DURING MALIGNANT HYPERTENSION: A MRI STUDY

Objective: Acute and diffuse microvascular damage characterizes malignant hypertension (MHT), the deadliest form of hypertension. Although its ophthalmological, renal and cardiological repercussions are well known, brain involvement is considered rare with few descriptions, although it is one of the main causes of death. We aim to describe brain MRI abnormalities in patients admitted for MHT crisis but without objective neurological signs. Design and method: This single-center, cross-sectionnal observational study recruited patients with malignant Hypertension (MHT). MHT was defined by severe hypertension and severe hypertensive retinopathy OR subacute damage of three among the target organs: heart, kidney, brain, vessels (thrombotic microangiopathy). Patients under 18 years old, under chronic dialysis and not willing to participate were excluded. Brain MRI was performed within 21 days following diagnosis and was reviewed by a stroke neurologist who recorded the following markers: acute ischemic stroke(DWI and FLAIR positive), acute intracerebral hemorrhage (T2* and FLAIR positive), acute brain edema with extensive posterior white matter hyperintensity suggesting a PRES, and small vessel disease including old lacunar infarct, white matter hyperintensities (WMH), presence of dilated perivascular spaces. Results: We included 58 patients without neurological signs, 66% were men, and mean age was 45.6+/-11.3 years. Brain MRI were normal in 26% of patients but we found at least one acute abnormality on brain MRI in 29% and an Small Vessel Disease score (SVD score) of two or higher in 52%.In patients with neurological signs, these findings were 9, 53 and 70%, respectively. A PRES was found in 16% of asymptomatic patients and 31% had an ischemic stroke and/or a cerebral hematoma. Conclusions: PRES, recent hematoma, ischemic stroke and severe cerebral microangiopathy are common findings in MHT patients without neurological signs on admission. The impact of these findings on patient management, and their cerebrovascular and cognitive prognostic value, should be established. Brain MRI might need to become systematic in patients suffering from MHT episodes.

Case Series: Paracentral Acute Middle Maculopathy as a Sign of Severe Systemic Vasculopathy

Paracentral acute middle maculopathy represents deep capillary ischemia that can cause acute symptoms of scotoma. This case series describes two cases of symptomatic paracentral acute middle maculopathy that reflect the more severe spectrum of associated etiologies. Case 1: A 65-year-old male with recent history of hypertensive encephalopathy presented with sudden onset central visual disturbance described as amorphic in shape. Dilated fundus exam revealed severe hypertensive retinopathy with paracentral acute middle maculopathy. The patient died one year after the initial discovery of the retinal lesions. Case 2: A 87-year-old male presented with paracentral vision loss in one eye for three days. Clinical examination revealed multiple Hollenhorst plaques and paracentral acute middle maculopathy at presentation, and a subsequent branch retinal artery occlusion two days later. The patient was found to have 76% left carotid artery stenosis with numerous brain infarcts. The detection of paracentral acute middle maculopathy indicates an investigation through ocular and systemic risk factors to determine an attributable etiology. The search for possible etiologies should be tailored to the particular patient, based on age, associated ocular findings, systemic history, and symptomatic versus incidental presentation. The presence of symptomatic paracentral acute middle maculopathy, particularly in at-risk vasculopathic patients, should be addressed urgently as it may be an indicator of an underlying severe systemic disease process. CE Notification: This article is available as a COPE accredited CE course. You may take this course for 1-hour credit. Read the article and take the qualifying test to earn your credit. Click here to Enroll (https://www.crojournal.com/case-series-paracentral-acute-middle-maculopathy-as-a-sign-of-severe-systemic-vasculopathy)

Evidence of retinal arteriolar narrowing in patients with autosomal-dominant polycystic kidney disease

Abstract Introduction The aim of this study was to examine retinal vessels in autosomal dominant polycystic kidney disease (ADPKD) patients with normal kidney function and without diabetes mellitus. Materials and Methods We enrolled 39 adult individuals with ADPKD and 45 gender- and age-matched individuals as controls. A full ophthalmologic examination, including retinal vessel caliber and reactions to flicker stimulation analysis and grading of hypertensive retinopathy according to the Keith-Wagener classification, was performed. Results Multivariable analysis of ADPKD patients and controls, adjusted for age, gender, estimated glomerular filtration rate (e-GFR) and the presence of hypertension, revealed that ADPKD was an independent factor associated with lower arteriovenous ratio (AVR) values (by 0.069 on average, β = −0.50, p < 0.0001). The severity of hypertensive retinopathy according to the Keith-Wagener classification appeared to be more advanced in the ADPKD group than in the controls, despite the lack of vascular abnormalities, such as retinal hemorrhages, exudates, cotton wool spots or papilledema, as well as microaneurysms, which are very characteristic signs of ADPKD in other vascular beds. Conclusions Lower AVR values could be a specific pathophysiological ocular manifestation of systemic vasculopathy in the course of ADPKD.

Evidence of retinal arteriolar narrowing in patients with autosomal-dominant polycystic kidney disease

Abstract Introduction The aim of this study was to examine retinal vessels in autosomal dominant polycystic kidney disease (ADPKD) patients with normal kidney function and without diabetes mellitus. Materials and Methods We enrolled 39 adult individuals with ADPKD and 45 gender- and age-matched individuals as controls. A full ophthalmologic examination, including retinal vessel caliber and reactions to flicker stimulation analysis and grading of hypertensive retinopathy according to the Keith-Wagener classification, was performed. Results Multivariable analysis of ADPKD patients and controls, adjusted for age, gender, estimated glomerular filtration rate (e-GFR) and the presence of hypertension, revealed that ADPKD was an independent factor associated with lower arteriovenous ratio (AVR) values (by 0.069 on average, β = −0.50, p < 0.0001). The severity of hypertensive retinopathy according to the Keith-Wagener classification appeared to be more advanced in the ADPKD group than in the controls, despite the lack of vascular abnormalities, such as retinal hemorrhages, exudates, cotton wool spots or papilledema, as well as microaneurysms, which are very characteristic signs of ADPKD in other vascular beds. Conclusions Lower AVR values could be a specific pathophysiological ocular manifestation of systemic vasculopathy in the course of ADPKD.

Tear And Serum Superoxide Dismutase And Catalase Activities In Hypertensive Retinopathy

The objective was to determine the changes in SOD and catalase activity, markers of oxidative stress/antioxidant balance in serum and tear of patients with hypertensive retinopathy and to identify whether there was a correlation between their levels and HR degree of hypertensive retinopathy (HR). Material and Methods — 90 hypertensive patients were divided in three groups, according to the Keith-Wagener classification: GI-36, GII-35 and GIII-19. SOD was assessed using the Dubinina and Matyushin method and catalase according to Koroliuk, both in modification of Gudumac V. The results were presented by median and interquartile range. The groups were compared using Kruskal-Wallis and Mann-Whitney nonparametric tests, and the Spearman correlation coefficient was calculated (SPSS 23.0). Results — Showed a statistically significant difference of SOD in serum (p=0.035) and tear (p=0.027) between groups. SOD decreased from GI until GIII in serum (-8%, p=0.032) and tear (-16%, p=0.031). In addition, it showed a weak significant negative correlation with the HR degree both in serum (r=-0.246, p=0.019) and tear (r=-0.284, p=0.007), while the correlation attested between serum and tear SOD levels was significant moderate and positive (r=0.336, p=0.001). It was noted a significant catalase elevation in the tear (p=0.033). In serum it was not correlated with HR degree, while in tear showed a significant weak strength, positive correlation (r=0.261, p=0.013). No correlations were found between serum and tear catalase levels. Conclusion — A progressive significant decrease in SOD levels and a tendency to increase of catalase activity was identified as HR advanced both in serum and in tear. The enhancement in the severity of HR was correlated with decreased SOD activity in tear and serum and increased catalase level in tear.

Hypertensive Retinopathy and the Risk of Hemorrhagic Stroke

ObjectiveHemorrhagic stroke (HS) and hypertensive retinopathy are known end organ damage of the brain and eye respectively, with HS having deleterious consequence to the patients. This study is to correlate between hypertensive retinopathy and HS in hypertensive disease. MethodsA control group of hypertensive patients only, and an investigated group of hypertensive HS patients. Fundoscopic examination to determine the grade of retinopathy was performed and then divided into low or high severity hypertensive retinopathy. Clinical and radiological parameter included are demography, vital signs, Glasgow coma scale (GCS) on admission, clot volume, site of clot, Intracerebral hemorrhage (ICH) score and Glasgow outcome scale (GOS). Data were correlated with the severity of hypertensive retinopathy. ResultsFifty patient in the control group and 51 patients in the investigated group were recruited. In the hypertensive HS group, 21 had low severity retinopathy (no or mild retinopathy) accounting for 41.2% and 30 patients had high severity (moderate or severe retinopathy). In the hypertensive patients 49 had low severity and one had high severity (p-value of 0.001). In HS group low severity showed better GCS score of 9–15 on admission (p-value of 0.003), clot volume less than 30 mL (p-value 0.001), and also a better 30 days mortality rate by using the ICH score (p-value 0.006), GOS score of 4 and 5 the low severity retinopathy fair better than the high severity retinopathy (p-value of 0.001), and the relative risk to develop HS in low severity and high severity retinopathy was 0.42 and 29.4, respectively. ConclusionHypertensive retinopathy screening could be used as an indicator in hypertensive patient, to evaluate the risk of developing hypertensive HS in the future.

Retinal nerve fibre layer/ganglion cell‐inner plexiform layer thickness ratio in patients with systemic hypertension

Acute and chronic hypertension may have different pathophysiological mechanisms in the retina. Here, we compared the retinal nerve fibre layer (RNFL)/ganglion cell-inner plexiform layer (GC-IPL) thickness ratios of patients with 'relieved' severe hypertensive retinopathy (relieved HTNR) and chronic hypertension without retinopathy (chronic HTN) to those of normal controls. We performed cross-sectional study. The eyes were divided into the following groups: normal controls (Group A, age ≥50years; Group D, age <50years); chronic HTN (Group B, <10years of HTN; TNHT; Group C, ≥10years of HTN); and relieved HTNR (previously diagnosed with grade IV HTNR and relieved retinopathy for >1year; Group E), and the RNFL/GC-IPL thickness ratio was compared among Groups A-C and between Groups D and E. A total of 379 eyes were included in this study. Groups A-E consisted of 145, 59, 63, 60 and 52 eyes, respectively. The RNFL/GC-IPL thickness ratios were 1.161±0.093, 1.158±0.082 and 1.162±0.089 in groups A-C, respectively, and did not showed a statistically difference (p=0.966). The RNFL/GC-IPL thickness ratio of groups D and E were 1.169±0.080 and 1.221±0.080, respectively, and showed a statistically difference (p=0.001). The RNFL/GC-IPL thickness ratios of the chronic HTN group did not show a difference compared with the normal controls. However, relieved HTNR patients showed a higher ratio than the normal controls. Physicians should be aware that acute hypertensive injury could affect the RNFL/GC-IPL thickness ratio.

First prospective multicentric registry on malignant hypertension: Rational, design and early results from 100 patients of the french HAMA cohort

Malignant hypertension (MHT) still exists, leading young people to a poor prognosis. Yet, we lack clear guidelines, mainly because data are scarce. We initiated the first MHT multicentric network to assess these issues. We built a 28 centers network so far, aiming for 40–50 French centers end 2020, and European participation in 2021. We prospectively recruit patients with severe hypertension (> 180/110) and severe hypertensive retinopathy (common definition) or 3-target organ damage among heart, kidney, brain and thrombotic microangiopathy (MOD HTN definition). We hope to recruit 500 patients in 5 years, with a 5 years follow up. We currently collect clinical and examination data, aiming for building a biobank and a target organ damage corelab to entirely reconsider the disease. During the first 6 months, we recruited as planned 58 patients, 41% were male, 49.1 ± 15 years old. Half of them were not known hypertensive, and one third presented a secondary hypertension. Non-observance was reported in 25% of patients as a trigger. Mean blood pressure was 219 ± 29//119 ± 20 mmHg. Patient care pathway was very different according to initial symptoms, target organ damage and centers: hypertension, neurology, nephrology, cardiology, internal medicine, intensive care unit and emergency department. Target organ damage was respectively 70%, 33%, 25% and 25% for kidney, heart, brain and thrombotic microangiopathy, mostly improving during follow up. Most of patients (70%) benefited from intravenous antihypertensive treatment and saline infusion. Length of stay was on average 8 days. Malignant Hypertension clearly didn’t disappear, but was diluted between the different specialities and forgotten. This most severe presentation has to be considered once again to better manage our patients. The unique HAMA network should make it possible to gather high-quality data to improve our knowledge and rediscover the disease.

Retinal Neurovascular Impairment in Patients with Essential Hypertension: An Optical Coherence Tomography Angiography Study.

PurposeTo investigate retinal neurovascular structural changes in patients with essential hypertension.MethodsThis observational cross-sectional study consisted of 199 right eyes from 169 nondiabetic essential hypertensive patients, divided into groups as follows: group A, 113 patients with hypertensive retinopathy (HTNR); group B, 56 patients without HTNR; and a control group of 30 healthy subjects. Peripapillary retinal nerve fiber layer (RNFL), radial peripapillary segmented (RPC), ganglion cell–inner plexiform layer (GC-IPL), and superficial (SVP) and deep (DVP) vascular plexus density at the macula (6 × 6 mm2) were measured by optical coherence tomography angiography (OCTA).ResultsDVP density was significantly reduced in groups A and B compared to the control group (group A DVP, P = 0.001; group B DVP P = 0.002). GC-IPL, RNFL thickness, and RPC and SVP density in group A were significantly decreased compared to the control group or group B (all P < 0.05). In hypertensive patients, GC-IPL and RNFL thickness were negatively correlated with severity of HTNR (GC-IPL, r = –0.331, P < 0.001; RNFL, r = –0.583, P < 0.001) and level of home blood pressure monitoring (HBPM) (GC-IPL, r = –0.160, P = 0.050; RNFL, r = –0.282, P = 0.001) and were positively correlated with SVP (GC-IPL, r = 0.267, P = 0.002; RNFL, r = 0.361, P < 0.001) and RPC density (GC-IPL, r = 0.298, P < 0.001; RNFL, r = 0.663, P < 0.001). Among subjects with grade 2 or 3 retinopathy, the superior RNFL was significantly thinner in patients with high HBPM level than in those with normal HBPM level (grade 2, P = 0.016; grade 3, P = 0.006).ConclusionsReduction of retinal vessel density and RNFL thickness is observed in patients with HTNR and is inversely associated with level of HBPM.

Hypertensive retinopathy and associated factors among nondiabetic chronic kidney disease patients seen at a tertiary hospital in Tanzania: a cross-sectional study.

Background: Hypertensive retinopathy is a known marker of cardiovascular disease, and among unselected patients with chronic kidney disease (CKD) more severe retinopathy has been associated with lower estimated glomerular filtration rate (eGFR). This association has, however, not been widely studied among nondiabetic hypertensive patients with CKD, especially in sub-Saharan Africa. We aimed to determine the prevalence and severity of hypertensive retinopathy and its relationship with eGFR among nondiabetic CKD patients seen at Muhimbili National Hospital in Dar es Salaam, Tanzania.Methods: A hospital-based cross-sectional study was conducted among nondiabetic CKD adult (≥18 years) patients with hypertension. A structured questionnaire was used to record patients’ demographic characteristics and their cardiovascular risk profile. eGFR was calculated using the Modification of Diet in the Renal Disease (MDRD) equation and only patients with CKD stage 3 or more were enrolled in the study. Grading of retinopathy was done using the Keith–Wagener classification.Results: In total, 224 patients fulfilled the inclusion criteria and were enrolled. Their mean age was 45.8±14.1 years, and 59.4% were men. The proportions of patients with stage 3, 4, and 5 CKD were 21.4%, 19.6%, and 58.9%, respectively. Hypertensive retinopathy was present in 157 (70.1%) patients and the proportions with grade I, grade II, grade III, and grade IV retinopathy were 17.9%, 18.8%, 19.6%, and 13.8%, respectively. The severity of retinopathy increased with decreasing levels of eGFR, and in multivariate logistic regression analysis, factors found to be independently associated with ≥grade II hypertensive retinopathy were more severe CKD, higher hypertension grades, and alcohol use, all p<0.05.Conclusion: The prevalence of hypertensive retinopathy is high among nondiabetic CKD patients seen at a tertiary hospital in Tanzania and is independently associated with CKD severity. Retinopathy grade can be used as a marker of CKD severity among these patients.

Hypertensive Retinopathy: A Prognostic Factor for Morbidity and Mortality after Acute ST Elevation Myocardial Infarction.

To determine the association between hypertensive retinopathy (HR) and post ST elevation myocardial infarction (STEMI) complications among successfully thrombolysed patients. A cohort study. Cardiology Unit, Lady Reading Hospital, Peshawar, from June 2016 to December 2017. Patients with history of hypertension for at least 5 years who presented with STEMI and were successfully thrombolysed, were included. On the basis of fundoscopy, patients were grouped into no, mild, moderate, and severe hypertensive retinopathy. Primary and secondary endpoints included a composite of death, re-MI, stroke, re-hospitalisation secondary to left ventricular failure, cardiogenic shock, arrhythmia, heart block, and ventricular septal rupture at 30 days and 4 months, respectively. Association between hypertensive retinopathy and post STEMI complications was determined by Chi-square test. Regression model was used to calculate relative risk of complications with hypertensive retinopathy. P <0.05 was taken as significant. A total of 118 patients with a mean age of 54.83 ±8.6 years were included in the study. Of these, 49.2% (n=58) were males. Moreover, 38.1% (n=45) of patients were grouped under no HR, 22.8% (n=27) under mild HR, 21.1% (n=25) and 17.7% (n=21) under moderate and severe HR, respectively. Primary endpoints achieved were 0% in no HR group and 19% in severe HR group x² = 18.1, p <0.001). Secondary endpoints were achieved in 2.2% in no HR group and 40.7%, 56% and 100% in mild, moderate and severe HR group, respectively, ( x² = 81.1, p <0.001). HR also increased the relative risk of complications by 3.17 times (p <0.001) and death by 1.75 times (p <0.001). Hypertensive retinopathy is an independent risk factor for post-acute STEMI complications in successfully thrombolysed patients and increased the relative risk for complications by 3.17 times.

Prevalence and clinical spectrum of hypertensive retinopathy among hypertension clinic patients at Queen Elizabeth Central Hospital in Malawi.

Prevalence and spectrum of hypertensive retinopathy in the population reflects the status of hypertension control and the associated risks for cardiovascular events. We investigated the prevalence and clinical spectrum of hypertensive retinopathy among patients attending hypertension clinic at a tertiary hospital in Malawi. This was a cross-sectional study of systematically selected patients attending hypertension clinic at Queen Elizabeth Central Hospital. Patient interviews using a structured questionnaire and review of patients' medical records (health passports) were done to obtain the following information: demographics, duration since the diagnosis of hypertension, history of stroke and blood pressure measurements. The presence and severity of hypertensive retinopathy was determined by dilated fundoscopy through slit lamp biomicroscopy. We recruited 104 patients. Women outnumbered men by 3:1. Women tended to be younger compared to men (mean ages 54 and 61 years respectively). Of the surveyed patients, 80% had sub-optimal blood pressure control and 75% had evidence of hypertensive retinopathy. History of stroke was associated with hypertensive retinopathy. Hypertensive retinopathy is very common in patients attending the hypertension clinic at Queen Elizabeth Central Hospital in Blantyre, Malawi. This may be a reflection of sub-optimal blood pressure control in this patient population. There is a need to identify the actual reasons, rectify them and intensify intervention in control of hypertension in this patient population.

This issue of ACTA

This issue of ACTA