True Hypertension Research Articles

8568 Prevalence of Raised Blood Pressure in Individuals With 46,XY DSD: an I-DSD Registry study

Abstract Disclosure: A.K. Lucas-Herald: None. J. Bryce: None. M. Chen: None. C. Naotunna: None. M. Sepich: None. L. Tack: None. M. Cools: None. S. Poyrazoglu: None. E. Globa: None. M. Stancampiano: None. H.L. Claahsen-van der Grinten: None. T. Guran: None. Z. Yavas Abali: None. L. de Vries: None. S.E. Hannema: None. A. Guven: None. D. Janus: None. H.A. AlShaikh: None. L. Guazzarotti: None. G. Herrmann: None. U. Probst: None. N. Lenherr-Taube: None. D. Konrad: None. M.W. O’Reilly: None. M. Steigert: None. A. Ucar: None. M. Wasniewska: None. R. Coco: None. P. Holterhus: None. V.M. Schwitzgebel: None. S.F. Ahmed: None. Introduction: Males with XY Differences of Sex Development (DSD) may have an increased risk of high blood pressure and accelerated vascular ageing. It is not clear which individuals are most at risk of this. Methods: Data were obtained from centres using the International Disorders of Sex Development (I-DSD) Registry on boys and men with 46,XY DSD. Blood pressure (BP) readings were requested as well as information on risk factors for hypertension (birthweight, obesity, family history, associated malformations) as well as ongoing management of any high BP readings. Results: In total BP readings from 208 individuals with 46,XY DSD were available from 22 centres worldwide. Of these, the median (range) age at the time of the BP reading was 13 years (1, 54). In total 97 (47%) had a non-specific XY DSD; 37 (18%) had a disorder of gonadal development; 34 (16%) had a disorder of androgen synthesis; 23 (11%) had a disorder of androgen action; 14 (7%) had hypogonadotrophic hypogonadism; and 3 (1%) had a disorder of Müllerian development. There were 77 (37%) cases ≥16 years of age, of whom 7 (10%) were classified as hypertensive. The median systolic BP of those adults with an underlying DSD was 120 mmHg (90, 153). Of the 131 (63%) individuals <16 years of age, 25 (19%) had a BP > 95th centile for age and height. The median BP standard deviation score (SDS) of those children with an underlying DSD was 0.3 (-2, 3). Of the 25 children with a raised BP, 6 (24%) had a BP >99.8th centile and 19 (76%) had a BP >98th centile. Boys with disorders of gonadal development had the highest median BP SDS at 0.9, although this was not significantly different to any other condition. There were no differences in BP SDS at the time of the study according to gestation at birth, birthweight, type of underlying of condition or presence of obesity or a co-existing anomaly however BP SDS was significantly associated with age. Of the 32 with hypertension, 3 (9%) were treated with antihypertensives; 2 (6%) had an echocardiogram and none (0%) are reported to have had ambulatory blood pressure monitoring. Conclusions: Up to 20% of young people with XY DSD have a BP in the hypertensive range during childhood at clinic compared to approximately 5% reported global prevalence in children. Our findings suggest that routine BP measurements should be recommended in this group as well as investigation to determine whether this is true hypertension or secondary to clinic anxiety. Management of these individuals requires adherence to international guidelines to prevent future cardiovascular damage. More research into the underlying cause of this phenomenon is required. Presentation: 6/1/2024

8568 Prevalence of Raised Blood Pressure in Individuals With 46,XY DSD: an I-DSD Registry study

Abstract Disclosure: A.K. Lucas-Herald: None. J. Bryce: None. M. Chen: None. C. Naotunna: None. M. Sepich: None. L. Tack: None. M. Cools: None. S. Poyrazoglu: None. E. Globa: None. M. Stancampiano: None. H.L. Claahsen-van der Grinten: None. T. Guran: None. Z. Yavas Abali: None. L. de Vries: None. S.E. Hannema: None. A. Guven: None. D. Janus: None. H.A. AlShaikh: None. L. Guazzarotti: None. G. Herrmann: None. U. Probst: None. N. Lenherr-Taube: None. D. Konrad: None. M.W. O’Reilly: None. M. Steigert: None. A. Ucar: None. M. Wasniewska: None. R. Coco: None. P. Holterhus: None. V.M. Schwitzgebel: None. S.F. Ahmed: None. Introduction: Males with XY Differences of Sex Development (DSD) may have an increased risk of high blood pressure and accelerated vascular ageing. It is not clear which individuals are most at risk of this. Methods: Data were obtained from centres using the International Disorders of Sex Development (I-DSD) Registry on boys and men with 46,XY DSD. Blood pressure (BP) readings were requested as well as information on risk factors for hypertension (birthweight, obesity, family history, associated malformations) as well as ongoing management of any high BP readings. Results: In total BP readings from 208 individuals with 46,XY DSD were available from 22 centres worldwide. Of these, the median (range) age at the time of the BP reading was 13 years (1, 54). In total 97 (47%) had a non-specific XY DSD; 37 (18%) had a disorder of gonadal development; 34 (16%) had a disorder of androgen synthesis; 23 (11%) had a disorder of androgen action; 14 (7%) had hypogonadotrophic hypogonadism; and 3 (1%) had a disorder of Müllerian development. There were 77 (37%) cases ≥16 years of age, of whom 7 (10%) were classified as hypertensive. The median systolic BP of those adults with an underlying DSD was 120 mmHg (90, 153). Of the 131 (63%) individuals <16 years of age, 25 (19%) had a BP > 95th centile for age and height. The median BP standard deviation score (SDS) of those children with an underlying DSD was 0.3 (-2, 3). Of the 25 children with a raised BP, 6 (24%) had a BP >99.8th centile and 19 (76%) had a BP >98th centile. Boys with disorders of gonadal development had the highest median BP SDS at 0.9, although this was not significantly different to any other condition. There were no differences in BP SDS at the time of the study according to gestation at birth, birthweight, type of underlying of condition or presence of obesity or a co-existing anomaly however BP SDS was significantly associated with age. Of the 32 with hypertension, 3 (9%) were treated with antihypertensives; 2 (6%) had an echocardiogram and none (0%) are reported to have had ambulatory blood pressure monitoring. Conclusions: Up to 20% of young people with XY DSD have a BP in the hypertensive range during childhood at clinic compared to approximately 5% reported global prevalence in children. Our findings suggest that routine BP measurements should be recommended in this group as well as investigation to determine whether this is true hypertension or secondary to clinic anxiety. Management of these individuals requires adherence to international guidelines to prevent future cardiovascular damage. More research into the underlying cause of this phenomenon is required. Presentation: 6/1/2024

Ambulatory Blood Pressure Monitoring versus Office Blood Pressure Monitoring to Identify the True Hypertension Status of Living Kidney Donors.

Ambulatory blood pressure monitoring (ABPM) is a reliable modality and is preferred over office blood pressure monitoring (OBPM) for detecting hypertension. However, despite its advantages, the utilization of 24-h ABPM in evaluating living kidney donors has not been universally adopted by transplant centers, partly because of the lack of data about the utility of ABPM. This study aimed to identify patients with masked and white-coat hypertension, thereby ensuring appropriate identification of their true hypertension status and assessments of the risk to donors. This study included 73 potential living kidney donors. BP was measured in the office using a standardized protocol as well as by ABPM. Detailed clinical and biochemical parameters were assessed. Target organ damage was assessed in all the donors by assessing proteinuria, hypertensive retinopathy, and echocardiography. Out of the 73 donors, 64.4% were females and 35.6% were males. The average age of individuals in our donor population was 42.0 ± 11.28 years. In total, 31.5% were detected to be hypertensive by OBPM. With ABPM, only 21.9% of donors were hypertensive. The overall prevalence of white-coat hypertension was 30.4%; that of masked hypertension was 6.0%. In donors diagnosed as hypertensive by OBPM, three individuals were identified as having target organ damage. However, two additional donors who were initially missed as hypertensive using OBPM had target organ damage. OBPM overestimated the prevalence of hypertension compared with ABPM. ABPM is the better modality in terms of diagnosing white coats and masked hypertension. ABPM also more reliably correlates with target organ damage than OBPM.

RELATION BETWEEN WAIST CIRCUMFERENCE AND THE RENAL HEMODYNAMIC IN PATIENTS WITH UNCOMPLICATED HYPERTENSION GRADE 1-2

Objective: Abdominal adiposity, measured by waist circumference (WC), is associated with increased mortality in patients with hypertension. Little is known about the impact of abdominal obesity on the renal perfusion and function in patients with hypertension. We analyzed whether abdominal adiposity changes renal hemodynamics in 36 patients with uncomplicated hypertension grade 1-2 without other cardiovascular (CV) disease. Design and method: We analysed the renal hemodynamic using steady state input clearance with infusion of para-aminohippuric acid and inulin, respectively. Intraglomerular pressure and resistances of the afferent (RA) and efferent (RE) arterioles were calculated according to the Gomez equation. The study population was divided in into two groups based on median of WC of the total study population. Results: The study cohort consisted of 36 male, non-smoking individuals, aged 36 ± 10 years with mean WC of 96.1 ± 10.4 cm and mean BMI of 27 ± 3.8 kg/m2. True hypertension was confirmed using 24-hour ambulatory blood pressure (BP) measurement. Patients in the high WC group (19 patients) showed mean office BP of 145/ 90 mmHg and mean 24-hour ambulatory BP of 139/ 86 mmHg, whereas patients in the low WC group (17 patients) showed mean office BP of 144/ 88 mmHg and mean 24-hour-ambulatory BP of 140/ 86 mmHg (office BP: p = 0.895/ p = 0.662, 24-hour-ambulatory BP: p = 0.645/ p = 0.918). Renal vascular resistance and RA were higher in the high WC compared to the low WC group, whereas glomerular filtration rate and renal plasma flow were lower in the high WC compared to the low WC group (table 1). Conclusions: Higher WC in young, male patients with hypertension grade 1-2 without other cardiovascular disease was associated with increased renal vascular resistance predominantly at the afferent site leading to reduced glomerular filtration rate.

PS-C10-11: COMPARISON OF MEASUREMENT OPTIONS FOR NOCTURNAL HYPERTENSION. STUDY PROTOCOL

Background: Nocturnal hypertension is strongly associated with adverse cardiac events and affects patients prognosis. However, to distinguish between true night hypertension and sleeping disorder might be tricky as patients often misinterpret sleep pattern and the role of standard device inconvenience during the 24 hour ABPM measurement. The effect of sleep disturbance on the validity of the results has not been thoroughly investigated. Aim: The main objective is to examine the validity of currently used conventional methods of ABPM in patients with nocturnal hypertension potentially disturbed by monitoring itself. The secondary objective is to determine whether the new (less obtrusive) methods are more effective in detecting true nocturnal hypertension and whether they are applicable to patients. Methods: The study will enter patient treated for arterial hypertension. They will be recruited consecutively and randomized. The study will have an intrasubject experimental design. Patients will first be measured sleep quality using an actigraph and a proposed questionnaire for this purpose (PSQI + own questionnaire of relation to technologies). We plan to enrol two groups of at 100 probands, with the first group being measured in the following way after baseline actigraphy is detected: 1. Measurement using the Spacelab Healthcare ABPM tonometer. 2. Measurement using a wrist tonometer (Beurer BC54) 3. Measurement using a smart watch tonometer (OMRON HeartGuide). In all of these cases, the actigraphy, or other variables indicating quality and sleep progression (HRV), will be measured simultaneously. For the second group, the order will be reversed, moving from the least obtrusive methods to the more obtrusive ones to eliminate bias sequencing. For the testing of the tonometer obtrusivity during the nigh time BP monitoring BP tonometers were improved by additional Blueetooth receivers, so they can be externally triggered by the command send from the tablet equipped with the specifically designed application. The application can trigger the measurement, consequently collect the measured data and securely send them to the hospital server. Measured sound level is used as one of the correlates of the tonometers obtrusivity along with the actigraphy and subjective perception of the obtrusiveness and sleep disturbance that is also evaluated by the developed questionnaire. Results: Number of true verus pseudonocturnal hypertension will be provided according to whether the root problem is poor sleep quality, which causes changes in blood pressure, or pathological changes in blood pressure itself, which causes a deterioration in sleep quality. Supported by MH CZ DRO (FNOl, 0098892), Mex reg. n.: 8787

Accelerated vascular age in adolescents with primary hypertension.

Primary hypertension may lead to early vascular ageing. We aimed to evaluate differences between expected vascular age based on pulse wave velocity (PWV)/carotid intima-media thickness (cIMT) and actual chronological age (CHA) in adolescents with primary hypertension. Three hundred and fifty-two children (median age of 15.5 years) with office hypertension and 64 normotensive healthy children of the same age underwent anthropometry, office and ambulatory blood pressure (BP), left ventricular mass index, cIMT, PWV, pulse wave analysis and biochemistry measurements. Vascular age was calculated using pooled pediatric and adult normative PWV and cIMT data. The difference between vascular age and CHA was calculated in relation to the 90th percentile for PWV (PWVAgeDiff90) and the 95th percentile for cIMT (cIMTAgeDiff95). One hundred and sixty-six patients had white-coat hypertension (WCH), 32 had ambulatory prehypertension (AmbPreHT), 55 had isolated systolic hypertension with normal central SBP (ISH+cSBPn), 99 had elevated office, ambulatory and cSBP (true hypertension, tHT). The differences between vascular age (both PWV and cIMT based) and CHA were significantly higher in AmbPreHT and tHT compared with normotension, WCH and ISH+cSBPn. Median PWVAgeDidff90 was -3.2, -1.2, -2.1, +0.8 and +0.3 years in normotension, WCH, ISH+cSBPn, AmbPreHT and tHT, respectively. Median cIMTAgeDiff95 was -8.0, -6.3, -6.8, -3.8 and -4.3 years in normotension, WCH, ISH+cSBPn, AmbPreHT and tHT, respectively. Significant predictors of PWVAge90Diff were the DBP and serum cholesterol, whereas cSBP and augmentation index were significant predictors of cIMTAgeDiff95. Children with AmbPreHT and tHT show accelerated vascular age compared with their normotensive peers.

PSUN115 Features of Metabolic and Hemodynamic Parameters in Obese Patients with True and Pseudo-Resistant Hypertension

Abstract Given the negative contribution of obesity-associated metabolic disorders to the formation of cardiovascular complications, adequate blood pressure (BP) control is very important in patients with arterial hypertension (AH) and obesity comorbidity. Objective to conduct a comparative assessment between metabolic and hemodynamic parametersinobese patients with true and pseudo-resistant AH. Methods The study included 302 patients with uncontrolled AH and obesity. Initial treatment efficacy was assessed 3 months after dual therapy was administered. Those patients who did not reach target BP in dual therapy were transferred to triple therapy. Among patients who received triple therapy, 69 people did not reach target BP (they received the fourth drug spironolactone). All patients were additionally examined 6 months after the initiation of antihypertensive therapy. Results A comparative assessment of BP levels was carried out between non-resistant and resistant patients: at the initial stage of enrolling patients, there was no significant difference in BP between non-resistant and subsequently resistant patients; after 3 months of follow-up (after prescribing double fixed combinations), there was a significant difference in the indicators of both office and out-of-office BP in resistance and non-resistance; despite the achievement of target BP levels after 6 months of therapy, in the presence of resistance, both office, home and most ABPM indicators were significantly higher than in non-resistance. An assessment of the possible causes of pseudo-resistance showed that most often, pseudo-resistance was observed in patients with non-compliance with recommendations to increase physical activity (55.26%) and reduce the calorie intake of food consumed (44.77%), as well as with poor compliance to the prescribed therapy (42.11%). At the same time, high salt intake, chronic kidney disease, obstructive sleep apnoea, and the white-coat phenomenon also contributed to the formation of pseudo-resistance. More than half of the patients (63.16%) had a combination of several factors that could contribute to the formation of pseudo-resistance. If at the stage of enrolling patients into the study and 3 months after the start of therapy there was no significant difference in BP levels between true and pseudo-resistant patients, then after 6 months of antihypertensive therapy, patients with true resistance had significantly higher levels of office SBP (p<0.01) and 24 h average SBP according to ABPM data (p<0.05) compared with pseudo-resistant patients. Obese patients with true resistance had also significantly lower BMI and LDL-cholesterol (p<0.05) as well as higher levels of aldosterone and SBP (p<0.05) compared with pseudo-resistance. Conclusions Even when target BP levels in antihypertensive therapy are achieved, obese resistant patients are characterized by higher levels of office and out-of-office BP, compared with non-resistance. Compared with pseudo-resistance, the presence of true resistance in obesity is associated with higher SBP and aldosteron levels, as well as lower BMI and LDL-cholesterol. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Hypertension arising after 20 weeks of gestation: gestational hypertension or masked chronic hypertension?

The objectives of this study were 1-to evaluate the prevalence of masked chronic hypertension in pregnant women classified as gestational hypertension 2-to compare the risks of developing preeclampsia in true gestational hypertension vs those women classified as having gestational hypertension but who had had masked hypertension in the first half of pregnancy. We conducted a cohort study in consecutive high-risk pregnancies who were evaluated before 20 weeks of gestation. Women who developed gestational hypertension (normotension in the office before 20 weeks of gestation and office BP ≥ 140/90 mmHg and/or antihypertensive treatment in the second half of gestation) were divided, according to an ABPM performed before 20 weeks of pregnancy, in two subgroups: subgroup 1-if their ABPM was normal, and subgroup 2-if they had masked chronic hypertension. Risks for preeclampsia (PE) were estimated and compared with normotensive women. Before 20 weeks of gestation, 227 women were evaluated (age 32 ± 6 years, median gestation age 15 weeks); 67 had chronic hypertension (29.5%). Of the remaining 160, 39 developed gestational hypertension (16 in subgroup 1 and 23 insubgroup 2. Compared with normotensive pregnant women, subgroup 1 of women with gestational hypertension did not increase the risk of developing PE (OR = 0.76, 95% CI = 0.16-6.65). Conversely, subgroup 2 of gestational hypertension increased the risk of PE more than 4 times (0R = 4.47 CI = 1.16-12.63). Risk estimation did not change substantially after the adjustment for multiple possible confounders. In conclusion, the59% of women initially diagnosed as gestational hypertensive according to current recommendations had masked chronic hypertension and a very high risk of developing PE.

Lipid spectrum changes and blood pressure levels in obese patients with true and pseudo-resistant hypertension

Lipid spectrum changes and blood pressure levels in obese patients with true and pseudo-resistant hypertension

VASCULAR AGE IN ADOLESCENTS WITH PRIMARY HYPERTENSION

Objective: There is evidence that children with primary hypertension (PH) are more mature than their normotensive peers in terms of bone and the immune system age. The aim of our study was to evaluate vascular age and its relationship with hypertension-mediated organ damage (HMOD) in adolescents with PH. Design and method: We assessed 362 children [90 girls; 15.5 (13.9;16.8) years] referred for work-up of office hypertension and 64 normotensive (NT) subjects [12 girls; 14.5 (13.8;15.6) years] not different in terms of age, body mass (BM) and BMI. We analyzed age- and height-related pulse wave velocity (PWV); the expected vascular age (based on measured PWV) was obtained from pooled pediatric and adult PWV norms and the difference (VascAgeDiff) between the vascular and chronological age was calculated. In all patients we obtained ambulatory blood pressure monitoring (ABPM) and HMOD: left ventricular mass index (LVMi), carotid intima-media thickness (cIMT) and pulse wave analysis (PWA) parameters: stroke volume (SV), cardiac output (CO), aortic BP (AoBP), total peripheral resistance (TPR). Results: Based on office, ABPM and AoBP, patients were classified into white coat hypertension (WCH) - 166 patients, ambulatory prehypertension (AmbPreHT) – 32; spurious hypertension (sHT – isolated systolic hypertension and normal AoBP) – 55; true hypertension (tHT – elevated office, ambulatory and AoBP) – 99. VascAgeDiff progressively increased from NT through sHT, WCH, AmbPreHT to tHT (3.5; 6.2; 7.2; 10.0; 10.7 years; p < 0.01). VascAgeDiff correlated (univariate analysis) significantly with weight, BMI z-score, office systolic (SBP) and diastolic blood pressure (DBP), AoBP, 24-h mean arterial pressure, 24-h DBP, CO, serum uric acid and LDL cholesterol level (p < 0.05). Multivariate regression analysis including above mentioned parameters revealed that significant predictors of VascAgeDiff were: weight, SBP, DBP, AoBP, CO and serum LDL cholesterol (p < 0.05). Conclusions: Out study suggests early vascular aging in adolescents with PH, even at mildly increased BP levels (WCH, prehypertension). Vascular changes were associated with increased weight, DBP, AoBP, CO and LDL cholesterol.

PROGNOSTIC OF PATIENTS WITH REFRACTORY HYPERTENSION IN A COHORT OF RESISTANT HYPERTENSIVES

Objective: To determine prognostic value of true refractory hypertension diagnosis in a large cohort of resistant hypertensives Design and method: Prospective cohort study enrolled 835 patients of a large historical cohort of RHTN. After at least 6 months of follow-up, 147 (17.6%) patients remained refractory to treatment in ABPM despite the use of 5 or more drugs, including a thiazide-like diuretic and spironolactone. All of them were submitted to a standard protocol including laboratory tests, ABPM, echocardiography, and pulse wave velocity (PWV). Primary outcomes were total mortality, cardiovascular mortality, and fatal and non-fatal cardiovascular events. Secondary outcomes were major cardiovascular events separately (coronary artery disease, cerebrovascular disease, chronic kidney disease with substitutive therapy, peripheral arterial disease). Person-time rates for interest outcomes were calculated to find correlations of Kaplan-Meier survival curves using Cox regression multivariate models, after adjustments for several risk factors. Follow-up remained until December 2021 Results: The median follow-up was 162 months [IQR 115–196]. When compared to resistant hypertensives, patients with RfHTN were younger and more obese. Regarding subclinical lesions, refractories presented less aortic stiffness (13 vs 21%, p = 0.02) and stage 3 chronic kidney diseases (26 vs 34%, p = 0.03) with albuminuria and LVMI similar to those of resistant hypertension despite uncontrolled ambulatory blood pressure. There were 232 all causes deaths (21.1 vs 29.2%), of which 122 from CV causes (12.9% vs 15%), and 253 total CV events (44.1% vs 49%). The diagnosis of RfHTN was associated with a significantly lower risk of all-cause mortality when adjusted by sex and age. It also presented a tendency to be a protective factor of cardiovascular death, chronic kidney disease with substitutive therapy and peripheral arterial disease, although without statistical significance. Risk ratio ranged from 0.62 to 0,94 for every analysis/adjustment, except incidence of stroke (IC95%:1.22(0.70–2.17) after every adjustment in RfHTN. Conclusions: Despite uncontrolled ABPM, refractory hypertensive patients presented lower overall and cardiovascular morbimortality at long-term when compared to non-refractory ones, except stroke, which seems to be at least partially influenced by spironolactone use.

Number of measurement days needed for obtaining a reliable estimate of home blood pressure and hypertension status

Purpose Out-of-office blood pressure (BP) measurements are essential for the diagnosis and monitoring of hypertension. Current guidelines vary in their recommendations on the protocol for home blood pressure monitoring (HBPM). We aimed to assess the number of blood pressure (BP) measurement days needed for a reliable estimation of true home BP (the expected BP level over time) and hypertension status, using the European guideline-based 7-day HBPM protocol as a reference. Materials and Methods Data from 567 adults who performed a 7-day HBPM were analysed. Blood pressure was measured twice daily (morning and evening readings) using the Microlife Average Mode (MAM), which takes a weighted average of 3 consecutive BP readings. The variability of average BP for an increasing number of measurements was assessed using a linear mixed model including a random intercept per individual and correlated residuals. The reliability of home hypertension status was assessed by the κ statistic. Results Mean home BP of the population was 143 ± 16/84 ± 10 mm Hg. On average, the first BP measurements gave the highest values which then decreased over time. Systolic BP in the morning was systematically lower than systolic BP in the evening (142 ± 17mm Hg versus 144 ± 17 mm Hg, p <0.05). The average of 7 twice-daily MAM BP measurements was at most 5.2/3.3 mm Hg higher and 9.5/4.8 mm Hg lower than the true home BP for 95% of the individuals. Reducing this protocol to 3 days increased this variability by 1.5/1.0 mm Hg and 4.8/2.3 mm Hg, respectively. For diagnosing home hypertension, there was good agreement with a minimum of 4.5 days of HBPM (ĸ-statistic 0.88; 95% Confidence Interval: 0.82–0.94). Conclusion Twice-daily MAM BP measurements for 3 consecutive days provide a reliable estimate of home BP. At least 4.5 consecutive days of HBPM are required for a reliable diagnosis of home hypertension.

Metabolic and hemodynamic disorders in obese patients with true and pseudo-resistant hypertension

Metabolic and hemodynamic disorders in obese patients with true and pseudo-resistant hypertension

The relationship of frontal QRS-T angle between patients with newly diagnosed true and white coat hypertension.

The frontal QRS-T (f-QRST) angle is a measure of depolarization and repolarization heterogeneity and may be a predictor of poor ventricular health. We aimed to investigate whether the f-QRST angle indicates myocardial damage and predicts newly diagnosed true hypertension (HT) in patients with white coat hypertension. We measured the f-QRST angle of 63 subjects with WHC and 105 patients with newly diagnosed HT. Laboratory tests and ABPM were followed up in all patients. The f-QRST angle was calculated on the surface ECGs. Of the patients in the study, 38.9% were female and 61.1% were male. The mean age was calculated as 59 ± 11 years. A comparison between both groups with the f-QRST angles was seen to be statistically significantly higher in the true HT group. The results of the receiving operating characteristic curve showed that the AUC value of the f-QRST angle was 0.94 (95% confidence interval, 0.91-0.97), the cutoff value was 60.5°, the sensitivity was 89.5%, and the specificity was 81%. In our study, the f-QRST angle was found to be lower in patients with WHC than in true hypertensive patients. We think that ECG, which is a simple test, can be used to distinguish between true HT and WHC.

Isolated systolic hypertension is associated with increased left ventricular mass index and aortic stiffness in adolescents: a cardiac magnetic resonance study.

Despite the high prevalence of isolated systolic hypertension (ISH) among hypertensive adolescents, its clinical significance is not determined. In addition, it is hypothesized that ISH with normal central blood pressure (BP) in young patients is a benign phenomenon and was hence labeled spurious hypertension (sHTN). Using cardiac magnetic resonance we evaluated a group of 73 patients with suspected primary hypertension, aged 13-17 years (median: 16.9, interquartile range 15.8-17.4; 13 girls), in whom, based on 24-h ambulatory BP monitoring either ISH (n = 30) or white-coat hypertension (WCH) (n = 43) was diagnosed. Based on noninvasive central BP measurement 13 participants in the ISH group were classified as having sHTN and 17 were diagnosed with true hypertension. Compared with WCH adolescents, ISH patients presented with higher indexed left ventricular mass index (LVMI) (P < 0.001), maximal left ventricular (LV) wall thickness (P < 0.001), LV concentricity (P = 0.001) and more often had LV hypertrophy (47 vs. 14%, P = 0.002). They had higher average pulse wave velocity (PWV) in the proximal aorta (P = 0.016) and the whole thoracic aorta (P = 0.008). In addition, we observed higher indexed LV stroke volume (P = 0.025) in patients with ISH. The sHTN subgroup had significantly higher LVMI and aortic PWV, and more often had LV hypertrophy compared with the WCH group. The sHTN and true hypertension subgroups did not differ in terms of aortic PWV, LVMI or LV geometry. Compared with adolescents with WCH patients with ISH, including the sHTN subtype, have more pronounced markers of cardiac end-organ damage, higher aortic stiffness and stroke volume.

Comparison of automated office blood pressure measurement with 24-hour ambulatory blood pressure measurement

Purpose Although 24-hour ambulatory blood pressure measurement (24-h ABPM) is the most important method to establish true hypertension, in clinical practice often repeated automated office blood pressure (AOBP) measurements are used because of convenience and lower costs. We aimed to assess the agreement rate between a 30 and 60 min AOBP and 24-h ABPM. Materials and methods Patients with known hypertension (cohort 1) and patients visiting the neurology outpatient clinic after minor stroke or transient ischaemic attack (cohort 2) were selected. We performed AOBP for 30–60 min at 5-min intervals followed by 24-h ABPM and calculated average values of both measurements. Agreement between the two methods was studied with McNemar and Bland–Altman plots with a clinically relevant limit of agreement of ≤10 mm Hg difference in systolic BP. Results Our final cohort consisted of 135 patients from cohort 1 and 72 patients from cohort 2. We found relatively low agreement based on the clinical relevant cut-off value; 64.7% of the measurements were within the limits of agreement for 24-h systolic and 50.2% for 24-h diastolic. This was 61.4% for daytime systolic and 56.6% for daytime diastolic. In 73.5% of the patients, both methods led to the same diagnosis of either being hypertensive or non-hypertensive. This resulted in a significant difference between the methods to determine the diagnosis of hypertension (p < 0.0001). Conclusion We conclude that 30–60 min AOBP measurements cannot replace a 24-h ABPM and propose to perform 24-h ABPM at least on a yearly basis to confirm AOBP measurements.

Prevalence of resistant hypertension in uncontrolled hypertensive patients seen in consultation

Resistant hypertension is defined by hypertension not controlled in consultation and confirmed by measurement outside the doctor's office, despite a therapeutic strategy comprising adapted hygiene and dietetic rules and antihypertensive triple therapy for at least 4 weeks, at optimal dose, including a thiazide diuretic. Screening for resistant hypertension in internal medicine and cardiology consultation. Prospective study including 1862 hypertensive patients, aged 18 and over, treated for at least one year and referred for uncontrolled hypertension, seen between October 2015–December 2019. The verification of the non-achievement of the blood pressure target was performed in all patients, either by ambulatory blood pressure measurement (ABPM) or by AMT (self-measurement of blood pressure), and revealed a blood pressure target not reached each time. Of the 1862 patients screened, mean age 58 ± 13.4 years, including 838 men (45%), and 1024 women (55%), 896 (48%) were receiving non-optimal treatment, 45% of patients had a BMI greater than 30 kg/m 2 (41% men vs. 59% women), 23% were smokers, and 45% were diabetics. In total, 612 (32.8%) were poor observers and 202 (8.5%). A secondary cause of hypertension was identified in 175 (9.4%) patients. Finally, only 112 patients presented with hypertension requiring quadruple therapy or more, either a prevalence of 6.01% (95% CI: 5.6–7.2). It should be noted that three of our patients benefited from renal denervation practiced in our department, the immediate responses were satisfactory. Less than 15% of the patients referred to our consultation present a true hypertension, and almost half present a pseudo-resistance. The majority of patients with apparently resistant hypertension can achieve the blood pressure goal if they are sensitized, observant, and properly treated.

C3. A case of extreme discrepancy between office and ambulatory blood pressure: is it true uncontrolled hypertension?

Abstract Background White coat uncontrolled hypertension (WCUH), defined as drug-treated hypertension but with increased blood pressure in the office and normal ambulatory blood pressure, should be assessed in patients with uncontrolled hypertension to prevent overtreatment. We report a case of an extreme WCUH found by ambulatory blood pressure monitoring (ABPM). Case Summary A 66-year-old woman was a regular patient in Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto with uncontrolled hypertension, CAD post-PCI, and insulin-dependent type 2 diabetes mellitus. The patient was overweight (BMI was 24.56 kg/m2) with dyslipidemia and uncontrolled blood glucose. Despite aggressive treatment with ARB, CCB, beta-blockers, diuretic, and clonidine, the patient had persistent hypertension with mean office systolic blood pressure &amp;gt;160/90 mmHg. Echocardiography showed concentric left ventricular hypertrophy. ABPM result found extreme variability of blood pressure with the average 24-hour blood pressure of 93.6/59 mmHg (mean daytime blood pressure was 90/55 mmHg and mean night-time blood pressure was 98.7/65.2 mmHg), intermittent hypotension, and reverse dipper pattern. The blood pressure once dropped to the lowest point of 69/44 mmHg, and the highest was 211/186 mmHg. Based on this result, we classified the patient’s condition as WCUH and adjusted the antihypertensive regiment. Discussion This case emphasizes the need to evaluate the presence of WCUH by ABPM in patients with uncontrolled hypertension so antihypertensive drugs could be adjusted accordingly and prevent hypotension.

C3. A case of extreme discrepancy between office and ambulatory blood pressure: is it true uncontrolled hypertension?

Abstract Background White coat uncontrolled hypertension (WCUH), defined as drug-treated hypertension but with increased blood pressure in the office and normal ambulatory blood pressure, should be assessed in patients with uncontrolled hypertension to prevent overtreatment. We report a case of an extreme WCUH found by ambulatory blood pressure monitoring (ABPM). Case Summary A 66-year-old woman was a regular patient in Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto with uncontrolled hypertension, CAD post-PCI, and insulin-dependent type 2 diabetes mellitus. The patient was overweight (BMI was 24.56 kg/m2) with dyslipidemia and uncontrolled blood glucose. Despite aggressive treatment with ARB, CCB, beta-blockers, diuretic, and clonidine, the patient had persistent hypertension with mean office systolic blood pressure &amp;gt;160/90 mmHg. Echocardiography showed concentric left ventricular hypertrophy. ABPM result found extreme variability of blood pressure with the average 24-hour blood pressure of 93.6/59 mmHg (mean daytime blood pressure was 90/55 mmHg and mean night-time blood pressure was 98.7/65.2 mmHg), intermittent hypotension, and reverse dipper pattern. The blood pressure once dropped to the lowest point of 69/44 mmHg, and the highest was 211/186 mmHg. Based on this result, we classified the patient’s condition as WCUH and adjusted the antihypertensive regiment. Discussion This case emphasizes the need to evaluate the presence of WCUH by ABPM in patients with uncontrolled hypertension so antihypertensive drugs could be adjusted accordingly and prevent hypotension.

Nonadherence in Hypertension: How to Develop and Implement Chemical Adherence Testing.

Nonadherence to antihypertensive medication is common, especially in those with apparent treatment-resistant hypertension (true treatment-resistant hypertension requires exclusion of nonadherence), and its routine detection is supported by clinical guidelines. Chemical adherence testing is a reliable and valid method to detect adherence, yet methods are unstandardized and are not ubiquitous. This article describes the principles of chemical adherence testing for hypertensive patients and provides a set of recommendations for centers wishing to develop the test. We recommend testing should be done in either of two instances: (1) in those who have resistant hypertension or (2) in those on 2 antihypertensives who have a less than 10 mm Hg drop in systolic blood pressure on addition of the second antihypertensive medication. Furthermore, we recommend that verbal consent is secured before undertaking the test, and the results should be discussed with the patient. Based on medications prescribed in United Kingdom, European Union, and United States, we list top 20 to 24 drugs that cover >95% of hypertension prescriptions which may be included in the testing panel. Information required to identify these medications on mass spectrometry platforms is likewise provided. We discuss issues related to ethics, sample collection, transport, stability, urine versus blood samples, qualitative versus quantitative testing, pharmacokinetics, instrumentation, validation, quality assurance, and gaps in knowledge. We consider how to best present, interpret, and discuss chemical adherence test results with the patient. In summary, this guidance should help clinicians and their laboratories in the development of chemical adherence testing of prescribed antihypertensive drugs.