True Hypertension Research Articles

24-month results and technical approach of catheter-based renal denervation in patients with resistant hypertension

Abstract Aim Increase in efficiency of catheter-based renal denervation (RDN) for the treatment of resistant hypertension. Methods 108 patients with resistant hypertension (inability to achieve target values after lifestyle changes while taking 3 antihypertensive drugs, one of which is a diuretic), were randomized in three groups. In the first two groups (n=36 in each group), RDN were performed using various devices (“Symplicity Flex”, “Symplicity Spyral” and “Vessix Vascular V2”). The third control group included 36 patients who received only standardized antihypertensive therapy (AHT). The fundamental differences in procedure execution in I and II groups were as follows: 1) patients from the I group - RDN were made only of the proximal segment of the renal artery. In group II ablation performed as the proximal segment and the branches of the second and third order, where they can be safe for the patient to deliver the instrument to the electrodes; 2) the number of ablation points in the group II produced more; 3) In the group II ablation was performed in the extension of the renal arteries, while the first group of upper- and lower-pole renal artery no exposure. Inclusion criteria: patients from 18 to 85 years with refractory true systolic-diastolic hypertension I-II degrees (office SBP ≥145 mm Hg. V., DBP ≥90 mm Hg. and non-optimal drug therapy, against which the average 24-hour blood pressure monitoring of SBP ≥145 and/or <170 mm Hg); standardized triple antihypertensive therapy based at least 50% of the maximum tolerated dose for at least 6 weeks of amid lifestyle changes; appropriate renal artery anatomy for endovascular procedures. The primary endpoints: the achievement of the target SBP level (<140 mm Hg) in the first 12 months after RDN according to the results of 24-hour blood pressure monitoring. Results Compared to the baseline blood pressure and 24 months results, the mean SBP and DBP was −5.9 mm Hg, p<0.05 and −3.8 mm Hg, p>0.05. And the maximum decrease in SBP and DBP was noted after 2 years of observation – −9.2 mm Hg, p<0.05 and −4.3 mm Hg, p<0.05, respectively. Also, there was a significant decrease in the daily average and daily average for SBP and DBP for all time of observation. In group III changes were insignificant for the first year of observation: −1.2/0.5 mmHg, p>0.05. After addition of the fourth component AHT 24 month average of SBP and DBP decreased by −4.9/1.9 mmHg, but the p value is not reached the level of less than 0.05. Conclusions Prolonged application of radiofrequency ablation of renal artery and its branches demonstrated similar safety profile and greater efficacy of treatment of patients with resistant hypertension, compared with denervation only the main trunk of the renal artery. Improving the methods and tools for the RDN is a priority for the further development of surgical treatment of arterial hypertension resistant to optimal medical therapy. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian academic excellence project 5-100

Electrocardiographic differences in patients with true and pseudo-resistant hypertension.

Cardiovascular disease is the leading cause of mortality in hypertensives, and patients with true resistant hypertension have an increased risk for premature cardiovascular events. Electrocardiography (ECG) has an essential role in the monitoring of hypertensive heart disease; however, little is known about the importance of ECG parameters in patients with resistant hypertension. We aimed to investigate whether fragmented QRS (fQRS) and frontal plane QRS-T angle, which are novel ECG parameters indicating myocardial damage, predict true resistant hypertension in patients with uncontrolled blood pressure. Four hundred six hypertensive patients with resistant hypertension were prospectively enrolled for the study. Patients were divided into two groups as 'true resistant' or 'pseudo-resistant' hypertensives and compared regarding the ECG parameters. While 73 (18%) patients had true resistant hypertension, 333 (82%) patients had pseudo-resistant hypertension. The frequency of fQRS (47.9% vs. 20.1%, p < 0.001) and average frontal plane QRS-T angle (93.0° ± 19.7° vs. 53.8° ± 10.2°, p < 0.001) were significantly higher in patients with true resistant hypertension compared to those with pseudo-resistant hypertension. Also, fQRS in anterior leads was significantly more frequent in patients with true resistant hypertension (57.1% vs. 23.8%, p < 0.001). Moreover, ROC curve analysis demonstrated that an increased frontal plane QRS-T angle > 90.75° predicted true resistant hypertension with a sensitivity 96% and specificity 61% (AUC:0.874, p < 0.001). Furthermore, multivariate analysis demonstrated that fQRS in anterior leads (OR: 1.251, 95% CI: 1.174-1.778, p = 0.002) and frontal plane QRS-T angle (OR: 1.388, 95% CI: 1.073-1.912, p < 0.001) were independent predictors of true resistant hypertension. In conclusion, fQRS and frontal plane QRS-T angle may be useful to predict true resistant hypertension in patients with uncontrolled blood pressure.

A clinical case of refractory arterial hypertension

Arterial hypertension is considered treatment refractory (resistant), if the treatment, involving a change (improvement) in lifestyle and a rational combined antihypertensive therapy, consisting of three drugs, including a diuretic, in the maximum tolerated doses does not lead to the achievement of the target blood pressure level. Pseudo-refractory and true refractory arterial hypertension are distinguished. According to modern data, true refractory arterial hypertension occurs in no more than 5 % of cases among the entire population of patients with arterial hypertension, however, in certain groups of patients, for instance, with chronic kidney disease, its prevalence can reach 30–50 %. The article presents a clinical case of diagnosis and treatment of refractory arterial hypertension.

HOW MANY BLOOD PRESSURE VALUES WE SHOULD USE TO PREDICT OUT-OF-OFFICE BLOOD PRESSURE ON PROOF-BP ALGORITHM. IS THE MORE BETTER THAN THE LESS ?

Objective: Compare the performance of 3 or 6 sequential blood pressure (BP) measurements to predict awake BP (ABP) values by Predicting Out of Office Blood Pressure in the clinic (PROOF BP). Design and method: This study is a secondary analysis of published research. A nursey collected clinical characteristics, in all participants, taking six sequential observed BP measurements, with a 1-minute interval (Microlife-BP3BTOA). Also, it was recorded ABPM (DynaMAPA). We selected 426 suspected people having hypertension. We estimated out-of-office BP on an algorithm from first to third BP (PROOF BP 1–3) and fourth to sixth (PROOF BP 4–6). We classified the patients in four BP categories, such as true hypertension (HT), true normotension (NT), masked hypertension (MH), and white coat hypertension (WCT). The office standard average considered the first three measurements as office BP (cut off – 140/90) and ABP as a reference standard, and for ABP and tested BP, the cut off was 135/85. We correctly compared the proportion of classified patients, coefficient of correlation (r), receiver operating characteristic curve (AUC), and Bland–Altman plot. The differences of proportions were evaluated using the chi-square test for media analysis of covariance. Results: Among 446 patients, 40.1% were classified as HT, 17.4% (MH), 11.7% (WCH) and 30.8% (NT), age 43.3 ± 13.3, women (44.6%), white people (67.8%), diabetes (2.6%), dyslipidemia (19.2%), obese (39.9%), body mass index 28. 9 ± 5.3, smokers (8.6%). The algorithm recommended AMBP in 41.07%. The proportion of HT was 40.1% MH 17.4%, WCH 11.7%, and NT 30.8%. The main clinical characteristics were age 43.3 ± 13.3, women (44.6%), white people (67.8%), diabetic (2.6%), dyslipidemia (19.2%), obese (39.9%), body mass index 28. 9 ± 5.3, smokers (8.6%). The mains results are in Table 1. Figure 1 shows a Bland and Altman plot of PROOF BP 1–3 and 4–6 against ABP. Conclusions: In conclusion, this secondary analysis data reinforce that the algorithm correctly classifies the vast majority of hypertensive patients and recommends ABPM in less than half of patients. It also adds that six sequential measurements no longer add accuracy to the ambulatory BP prediction tool.

AORTIC STIFFNESS AND LEFT VENTRICULAR MASS ASSESSED BY CARDIOVASCULAR MAGNETIC RESONANCE IN ADOLESCENTS WITH WHITE COAT HYPERTENSION, SPURIOUS HYPERTENSION AND TRUE HYPERTENSION

Objective: Cardiovascular magnetic resonance (CMR) is the gold standard for the noninvasive assessment of left ventricular mass (LVM) and it permits the evaluation of aortic stiffness (AS). Our aim was to assess LVM and AS in adolescents with suspected arterial hypertension (AH), who were divided into the following groups: white coat hypertension (WCHT), spurious hypertension (sHT) and true hypertension (tHT). Design and method: LVM, pulse wave velocity in the proximal (proxPWV) and whole thoracic aorta (thPWV) were assessed by CMR imaging in 72 patients with suspected AH (15 girls, mean age 16.4 ± 1.5years). Based on the results of 24-hour ambulatory blood pressure monitoring AH or WCHT was diagnosed. AH group was further subdivided into sHT, defined as isolated systolic hypertension with normal central blood pressure (cBP), and tHT defined as elevated cBP. Results: WCHT was diagnosed in 42 and AH in 30 patients (12 sHT; 18 tHT). Comparison of WCHT with AH revealed significantly higher LVM index (LVMI, 63.8 ± 11.3 vs 72.6 ± 8.8 g/m2), LVMI z-score (0.4 ± 0.8 vs 1.0 ± 0.7), proxPWV (3.9 ± 0.8 vs 4.5 ± 1.4m/s), proxPWV z-score (0.3 ± 1.1 vs 1.0 ± 1.6) and thPWV (3.7 ± 0.7 vs 4.2 ± 0.8m/s) in AH group (p &lt; 0.05 for all comparisons). LVMI/LVMI z-scores were significantly higher in both sHT (72.8 ± 10.8 g/m2 / 0.96 ± 0.79) and tHT (72.5 ± 7.5 g/m2 / 0.99 ± 0.64) as compared to WCHT (63.6 ± 11.3 g/m2 / 0.34 ± 0.82). Patients with sHT also had significantly higher thPWV (4.4 ± 0.8m/s) compared to WCHT (3.7 ± 0.7m/s) and tHT (4.0 ± 0.8m/s). Conclusions: Both tHT and sHT are associated with greater LVM and AS than WCHT. This supports the argument that sHT is not a benign phenomenon.

FEATURES OF METABOLIC AND HEMODYNAMIC INDICATORS IN OBESE PATIENTS WITH RESISTANT HYPERTENSION

Objective: To establish the features of metabolic and hemodynamic parameters in obese patients with true and pseudo-resistant arterial hypertension (AH). Design and method: The study included 200 patients with AH grade II and obesity I-II classes (age 45–55 years). Patients were initially prescribed dual antihypertensive therapy (ACEI and CCB). Those patients who did not reach target blood pressure (BP) levels after 3 months on dual therapy were additionally assigned a third antihypertensive drug (indapamide). Of the 98 patients who were assigned triple therapy, 48 patients did not reach target BP levels: 27 patients had pseudo-resistant AH (due to low compliance with treatment and insufficient adherence to the physician's instructions to ensure adequate levels of physical activity), and 21 patients had true resistant AH (did not have target BP levels with triple antihypertensive therapy and sufficient physical activity). These patients were additionally prescribed spironolactone. The effectiveness of the treatment in all groups was evaluated 6 months after the start of antihypertensive therapy. Results: Comparative assessment of obese patients in the presence and absence of resistant AH after 6 months of therapy showed that, unlike patients without resistance, individuals with resistant AH differed more pronounced cardiovascular remodeling and metabolic disorders, greater dysbalance of oxidative stress-antioxidant protection, greater proinflammatory activity and higher activity of the RAAS. When performing a comparative evaluation of the indicators in patients with pseudo-resistant and true resistant AH, it was found that patients with true resistance differed from pseudo-resistant patients with significantly lower (p = 0.0229) body mass index (BMI). In addition, in the absence of differences in BP levels, cardiovascular remodeling, lipid and carbohydrate profiles, patients with true resistance had significantly higher levels of aldosterone (p = 0.0449), higher activity of oxidative stress system (malondialdehyde, p = 0.0055 and diene conjugates, p = 0.0299), lower levels of general antioxidant protection (p = 0.0004), higher adiponectin levels (p = 0.0000), and lower leptin level (p = 0.0001), compared to pseudo-resistant patients Conclusions: Obese patients with true resistance differed from pseudo-resistant patients with significantly lower BMI, higher aldosterone level, higher activity of the oxidative stress system, lower activity of the antioxidant protection system, higher adiponectin level, and lower leptin level.

THE VALUE OF EMERGENCY DEPARTMENT BLOOD PRESSURE MEASUREMENT FOR THE SCREENING OF HYPERTENSION. PAIN IS A SIGNIFICANT FACTOR? SEEMS NOT

Objective: The value of emergency department (ED) blood pressure measurement for the screening of hypertension remains unclear. A systematic review was conducted to assess the performance of a screening strategy in adults using blood pressure (BP) measurement at the time of an ED consultation. The link between pain and high blood pressure is also described. Design and method: A systematic literature search on Embase, CINHAL and Medline was carried out. This systematic review was conducted in accordance with the PRISMA-Diagnostic Test Accuracy. Intervention studies with adults including at least one BP measurement for all participants were included. A repeat blood pressure assessment had to have been carried out to assess the validity of the elevated BP value within the next few days after the ED initial visit. Results: After review of 1,030 articles published between 1985 and 2018, 10 articles met the inclusion criteria. Mean age of participants was 51.6 years. A single study reports that BP screening was measured according to all the recommendations within the HTN guidelines referred to in the study. Half of the patients (50.2%) with elevated BP during the ED visit had BP corresponding to uncontrolled elevated blood pressure at follow-up measurement. Data about pain and blood pressure is reported in six of the included studies. None of these found a significant relationship between the concomitant presence of pain and an elevated BP measurement, and the fact of having an elevated or normal BP in a subsequent measurement without the presence of pain. Conclusions: The value of the blood pressure measurement in the ED is far from useless because it allows recognizing a true hypertension in one in two adults presenting with elevated BP. Moreover, it would be a mistake to attribute to pain alone the fact of presenting with an elevated OBPM in ED. Such patients could just as well be hypertensive when an ambulatory measurement is performed later without the presence of pain.

Metabolic effects two years after renal denervation in insulin resistant hypertensive patients. The Re-Shape CV-risk study

Denervation of renal sympathetic nerves (RDN) is an invasive endovascular procedure introduced as an antihypertensive treatment with a potential beneficial effect on insulin resistance (IR). We have previously demonstrated a reduction in blood pressure (BP) six months after RDN, but severe hepatic and peripheral IR, assessed by glucose tracer and two step hyperinsulinemic-euglycemic clamp (HEC), did not improve. The aim of the current study was to evaluate IR and adipokines profiles in relation to BP and arterial stiffness changes two years after RDN. In 20 non-diabetic patients with true treatment-resistant hypertension, ambulatory and office BP were measured after witnessed intake of medications prior to, six and 24 months after RDN. Arterial stiffness index (AASI) was calculated from ambulatory BP. Insulin sensitivity (IS) was assessed using an oral glucose tolerance test (OGTT), the Homeostasis Model Assessment (HOMA-IR), HOMA-Adiponectin Model Assessment (HOMA-AD), the Quantitative Insulin Sensitivity Check Index (QUICKI), the Triglyceride and Glucose Index (TyG) and the Leptin-to-Adiponectin Ratio (LAR). These surrogate indices of IS were compared with tracer/HEC measurements to identify which best correlated in this group of patients. All measured metabolic variables and IS surrogate indices remained essentially unchanged two years after RDN apart from a significant increase in HOMA-AD. OGTT peak at 30min correlated best with reduction in endogenous glucose release (EGR) during low insulin HEC (r=-0.6, p=0.01), whereas HOMA-IR correlated best with whole-body glucose disposal (WGD) (r=-0.6, p=0.01) and glucose infusion rate (r=-0.6, p=0.01) during high insulin HEC. BP response was unrelated to IS prior to RDN. Nocturnal systolic BP and arterial stiffness before RDN correlated positively with a progression in hepatic IR at six-month follow-up. IR, adiponectin and leptin did not improve two years after RDN. There was no correlation between baseline IS and BP response. Our study does not support the notion of a beneficial metabolic effect of RDN in patients with treatment resistant hypertension.

Effects of White-coat Hypertension on Heart Rate Recovery and Blood Pressure Response during Exercise Test

Objectives White-coat hypertension is defined as high blood pressure (BP) on clinical assessment but normal BP elsewhere or on ambulatory measurement. Autonomic dysfunction may be one of the mechanisms causing white-coat hypertension. Slowed heart rate recovery and excessive BP response during exercise test are associated with autonomic dysfunction. The purpose of this study was to determine the association between white-coat hypertension and abnormal autonomic nervous system response. Methods We assessed 295 patients stratified into three groups via 24hr ambulatory BP monitoring, following 2017 ACC/AHA guidelines: normal BP group, white-coat hypertension group, and a hypertension group. We analyzed medical history, blood test, echocardiography, 24hr ambulatory BP monitoring, and exercise test data. Results There was no difference in basement characteristics and echocardiography among the groups. Blunted heart rate recovery of each group showed a significant difference. Control group had 0% blunted heart rate recovery, but 33.3% in white coat group and 27.6% in true hypertension group ( P &amp;lt; 0.001). Also, in the control group, 4.5% showed excessive BP response, but 31.5% in the white coat hypertension group and 29.3% in the true hypertension group ( P &amp;lt; 0.001). Excessive BP response during the exercise test or blunted heart rate recovery, which is an indicator of autonomic nervous system abnormality, was more common in the hypertensive group and white-coat hypertension group than in the normal BP group. Conclusions These results confirmed that white-coat hypertension has an autonomic nervous system risk. Therefore, white-coat hypertension can be a future cardiovascular risk factor.

Clinical and psychological aspects of true arterial hypertension and white coat hypertension

Abstract Purpose To compare the clinical and psychological features, as well as echocardiographic and ambulatory blood pressure monitoring (ABPM) data in patients with true arterial hypertension (AH) and white coat hypertension (WCH). Methods Were studied 154 subjects (58 men and 96 women, average age 52.9±0.7 years) with increased office blood pressure. The control group consisted of 31 healthy individuals (12 men and 19 women, average age 51.5±2.4 years). All individuals underwent ABPM, Doppler echocardiography, and psychological status studies using the MMPI and Spielberger tests. Results ABPM confirmed the presence of AH in 127 (47 men and 80 women, average age 53.3±0.8 years) of 154 examined patients. 27 patients (17.5%) were diagnosed with WCH - 11 men and 16 women, the average age of 50.8±1.4 years. Among healthy individuals, dippers prevailed, while among AH patients the proportion of dippers was significantly lower (p&amp;lt;0.001) compared with the control group, and a larger number of non-dippers, over-dippers and night-peakers was noted (p&amp;lt;0.01). The distribution of patients with WCH by the type of the daily profile of blood pressure (BP) did not significantly differ from that in healthy individuals (p&amp;gt;0.05). Patients with AH compared with healthy patients had higher average values of the left ventricular (LV) posterior wall as well as interventricular septum thickness, left atrium diameter, and LV myocardial mass index. We found no signs of LV hypertrophy in WCH patients and healthy individuals. The correlation analysis confirmed a reliable relationship between most echocardiographic parameters and ABPM in AH patients (p&amp;lt;0.05). The results of the MMPI and Spielberger tests revealed higher levels of reactive and personal anxiety in patients with AH compared with healthy individuals. Patients with WCH were characterized by disharmonious personality profiles and, in comparison with the control group, more pronounced hypochondriac, hysteroid, and psychasthenic features. Compared with AH patients, subjects with WCH were characterized by less pronounced depression, isolation, rigidity of anxious affect, as well as a more pronounced demonstrative behavior. Conclusions In people with AH patients the structural and functional characteristics of the heart there correlate with the ABPM results. In contrast, echocardiographic findings in individuals with WCH do not significantly differ from those in healthy subjects. Individuals with WCH have more pronounced hypochondriacs, anxious-suspicious and hysteroid personality traits, while for patients with AH depression, isolation, and rigidity of anxious affect are more common. Funding Acknowledgement Type of funding source: None

Hemodynamic and metabolic disorders in obese patients with resistant hypertension

Abstract Resistant hypertension (RH) is an important cause of cardiovascular morbidity and mortality. Both true and pseudo-resistant arterial hypertension (AH) represent a big problem not only in blood pressure (BP) control, but also in those possible adverse cardiovascular events, the development of which is associated with failure to achieve target BP levels. The aim of the study was to establish the features of hemodynamic and metabolic parameters in obese patients with true and pseudo-resistant AH. Material and methods The study included 200 patients with uncontrolled AH and obesity. Patients were initially prescribed dual antihypertensive therapy. Those patients who did not reach target BP levels after 3 months on dual therapy were additionally assigned a third antihypertensive drug. Of the 98 patients who were assigned triple therapy, 48 patients did not reach target BP (27 patients had pseudo-resistant and 21 patients had true resistant AH). These patients were additionally prescribed a fourth antihypertensive drug (spironolactone). The effectiveness of the treatment was evaluated 6 months after the start of antihypertensive therapy. Results After 6 months of therapy, patients with RH had higher body mass index (BMI) and higher BP levels compared to patients without this condition. Patients with RH also had more pronounced cardiovascular remodeling, higher levels of triglycerides, insulin, HbA1c, more pronounced insulin resistant (IR), which was confirmed by greater HOMA-IR, greater imbalance of adipokines, proinflamation activity and higher activity of the renin-angiotensin-aldosterone system (RAAS). A comparative assessment of pseudo-resistance and true resistance showed that patients with true resistance differed from pseudo-resistant patients with significantly lower BMI (p=0.02). In addition, in the absence of differences in BP levels, cardiovascular remodeling, lipid and carbohydrate profiles, patients with true resistance had significantly higher levels of aldosterone (p=0.04), higher activity of oxidative stress (malonic dialdehyde, p=0.01 and diene conjugates, p=0.03), a lower level of total antioxidant protection (p=0.00), a higher level of adiponectin (p=0.00), and a lower level of leptin (p=0.00), compared with pseudo-resistant patients. Conclusions Patients with resistant hypertension differed from hypertensive obese patients without resistance with higher BMI and BP, higher levels of triglycerides, insulin, HbA1c, more pronounced IR, cardiovascular remodeling, imbalance of oxidative stress - antioxidant protection system, higher proinflammatory and RAAS activity. Patients with true resistance differed from pseudo-resistant patients with significantly lower BMI, higher aldosterone levels, more pronounced imbalance of the system of oxidative stress - antioxidant protection and less pronounced adipokines imbalance. Funding Acknowledgement Type of funding source: None

La presión arterial ambulatoria, en comparación con la medida clínica, mejora notablemente la estratificación del riesgo cardiovascular de Framingham

Introduction and objectivesAmbulatory blood pressure (BP) better predicts cardiovascular disease (CVD) outcomes than office BP measurements (OBPM). Nonetheless, current CVD risk stratification models continue to rely on exclusively daytime OBPM along with traditional factors, eg, age, sex, smoking, dyslipidemia, and/or diabetes. MethodsData from 19 949 participants of the primary care-based Hygia Project assessed by 48-hour ambulatory BP monitoring (ABPM) and without prior CVD events were used to compare the diagnostic accuracy, discrimination, and performance of the original Framingham risk score (RSOFG) and its adjusted version to the Hygia Project study population (RSAFG) with that of a novel CVD risk stratification model constructed by replacing OBPM with ABPM-derived prognostic parameters (RSABPM). ResultsDuring the follow−up, lasting up to 12.7 years, 1854 participants experienced a primary CVD outcome of CVD death, myocardial infarction, coronary revascularization, heart failure, stroke, transient ischemic attack, angina pectoris, or peripheral artery disease. Asleep systolic BP (SBP) mean and sleep−time relative SBP decline were the only joint significant ABPM−derived predictive factors of CVD risk and were therefore used to substitute for in−clinic SBP in the RSABPM model. The RSABPM model, in comparison with the RSOFG and RSAFG models, showed significantly improved calibration, diagnostic accuracy, discrimination, and performance (always P<.001). The RSAFG−derived event−probabilities of 57.3% of the participants were outside the 95% confidence limits of the event probability determined by the RSABPM model. ConclusionsThese collective findings reveal important limitations of CVD risk stratification when based upon OBPM, as in the Framingham score, and corroborate the clinical value of around−the−clock ABPM to properly diagnose true hypertension and reliably stratify CVD vulnerability.

Cardiovascular disease risk stratification by the Framigham score is markedly improved by ambulatory compared with office blood pressure

Introduction and objectivesAmbulatory blood pressure (BP) better predicts cardiovascular disease (CVD) outcomes than office BP measurements (OBPM). Nonetheless, current CVD risk stratification models continue to rely on exclusively daytime OBPM along with traditional factors, eg, age, sex, smoking, dyslipidemia, and/or diabetes. MethodsData from 19 949 participants of the primary care-based Hygia Project assessed by 48-hour ambulatory BP monitoring (ABPM) and without prior CVD events were used to compare the diagnostic accuracy, discrimination, and performance of the original Framingham risk score (RSOFG) and its adjusted version to the Hygia Project study population (RSAFG) with that of a novel CVD risk stratification model constructed by replacing OBPM with ABPM-derived prognostic parameters (RSABPM). ResultsDuring the follow−up, lasting up to 12.7 years, 1854 participants experienced a primary CVD outcome of CVD death, myocardial infarction, coronary revascularization, heart failure, stroke, transient ischemic attack, angina pectoris, or peripheral artery disease. Asleep systolic BP (SBP) mean and sleep−time relative SBP decline were the only joint significant ABPM−derived predictive factors of CVD risk and were therefore used to substitute for in−clinic SBP in the RSABPM model. The RSABPM model, in comparison with the RSOFG and RSAFG models, showed significantly improved calibration, diagnostic accuracy, discrimination, and performance (always P<.001). The RSAFG−derived event−probabilities of 57.3% of the participants were outside the 95% confidence limits of the event probability determined by the RSABPM model. ConclusionsThese collective findings reveal important limitations of CVD risk stratification when based upon OBPM, as in the Framingham score, and corroborate the clinical value of around−the−clock ABPM to properly diagnose true hypertension and reliably stratify CVD vulnerability.

Ambulatory blood pressure monitoring-based definition of true arterial hypertension.

Daytime office blood pressure measurements (OBPM), still recommended and utilized today for diagnosis and management of hypertension and categorization of cardiovascular disease (CVD) risk, fail to reveal clinically important features of the mostly predictable BP 24 h pattern and leads to a large proportion of individuals being misclassified. Most clinical guidelines now recommend ambulatory BP monitoring (ABPM) be applied to adult patients to confirm the OBPM-based diagnosis of hypertension, based on the high prevalence of masked hypertension and masked normotension plus demonstrated significantly better CVD prognostic value of around-the-clock ABPM than daytime OBPM. Nonetheless, there is yet no consensus of which parameter(s) and ABPM thresholds to utilize to diagnose hypertension. Findings of large prospective ABPM-based CVD outcome trials permit prospective evaluation of treatment and other induced changes in OBPM and ABPM during follow-up on CVD risk by incorporating multiple periodic (at least annual) patient ABPM assessments. They indicate: 1) asleep systolic BP (SBP) mean and sleep-time relative SBP decline (dipping) together are the most significant and only BP-derived prognostic markers of CVD risk; accordingly, around-the-clock ABPM should be the recommended method to diagnose true arterial hypertension and accurately assess CVD risk; and (2) treatment-induced lowering of the asleep SBP mean and rise of the sleep-time relative SBP decline towards the normal dipper BP pattern are both significantly protective against CVD events, thus constituting novel therapeutic targets to substantially better reduce CVD risk compared to the traditional approach that targets control of daytime OBPM or awake BP mean.

Renal sympathetic denervation lowers systemic vascular resistance in true treatment-resistant hypertension

Purpose Renal sympathetic denervation (RDN) is again gaining interest as recent well-designed trials have demonstrated reduced ambulatory blood pressure (BP) after RDN. However, the hemodynamic mechanisms have not been elucidated. We aimed for the first time to investigate the effect of RDN on the “Hallmark of Hypertension” namely increased systemic vascular resistance index (SVRI). Materials and methods We investigated SVRI change in patients with true treatment-resistant hypertension randomised to RDN (n = 9) or drug adjusted control (n = 9). Treatment-resistant hypertension was defined as office systolic BP ≥ 140 mmHg despite ≥ 3 antihypertensive drugs including a diuretic. True treatment-resistant hypertension was confirmed prior to inclusion with ambulatory daytime systolic BP ≥ 135 mmHg immediately after witnessed intake of antihypertensive drugs. Hemodynamic variables were recorded with thoracic impedance cardiography at baseline and at three and six months follow-up after RDN. This non-invasive method also guided further tailoring of drug treatment in the control group aiming to normalise hemodynamic variables and BP. Results From three to six months follow-up after RDN, SVRI decreased with a median of −611 dyn*s*m2/cm5 [IQR −949 to −267] (p < 0.01), while supine mean BP decreased with a median of −11 mmHg [IQR −21 to −3] (p = 0.02). In the same period, SVRI in the control group was reduced with −674 dyn*s*m2/cm5 [IQR −1,309 to −340] (p < 0.01), while supine mean BP decreased with −15 mmHg [IQR −29 to −6] (p = 0.01). Thus, hemodynamic variables and BP in the two groups normalised in parallel. Conclusion Our data suggest that in patients with true treatment-resistant hypertension, renal sympathetic denervation lowers BP by reducing systemic vascular resistance of similar size as in the control group with careful individual selection of antihypertensive drugs and dose titration.

Treatment resistant hypertension among ambulatory hypertensive patients: A cross sectional study.

BackgroundTreatment resistant hypertension(TRH) is detrimental risk of cardiovascular and premature deaths. Globally, the prevalence of resistant hypertension is inclining from time to time and it is yet to be determined in Ethiopia.ObjectiveTo assess the prevalence of apparent TRH and its predictors among ambulatory hypertensive patients on follow up in hypertension clinic of Mekelle Hospital, Northern Ethiopia.MethodA hospital based cross sectional study was conducted from Nov 25, 2018 to July 20, 2019, among 338 adult ambulatory hypertensive patients on follow up in Mekelle Hospital hypertension clinic. Hypertensive patient aged ≥18 years who were on regular follow up and taking antihypertensive medications for at least 6 months were included in the study. A simple random sampling technique was used to recruit the study patients.ResultsA total of 338 adult ambulatory hypertensive patients were analysed. More than half, 182 (53.8%) patients were females and the average age of the patients was 58.9 ±11.5. Three hundred thirty-three (98.5%) patients had no family history of hypertension. Majority, 66.8% of the patients were on monotherapy. The prevalence of apparent TRH was calculated to be 8.6% [Confidence Interval = 0.056–0.116]. Patients with Body Mass Index(BMI) greater than 30[Adjusted Odds Ratio(AOR) = 12.1, 95%CI:2.00–73.19, p = 0.007] and longer duration of hypertension were the predictors of resistant hypertension.ConclusionEven if escalation of antihypertensive medications was not aggressive, apparent TRH was common in the study setting. Obesity (BMI greater than 30) and longer duration of hypertension since diagnosis were the predictors of TRH. Meticulous emphasis should be placed on to detect the prevalence of true hypertension resistance and future studies should discover the impact of aggressive antihypertensive medications scale up on the risks of TRH.

Blood pressure phenotypes in young patients with type 1 diabetes

Aim. To study phenotypes of clinic and 24-hour ambulatory blood pressure (BP), to determine their associations with arterial stiffness parameters, and to assess global cardiovascular risk (CVR) in young patients with type 1 diabetes (T1D).Material and methods. The presented cross-sectional single-center study included 81 T1D patients without a history of hypertension (HTN) and other cardiovascular diseases (CVD) (men — 39%; median age — 27 years; median duration of T1D — 6 years). All participants underwent a routine clinical and laboratory testing, measurement of clinic and 24-hour ambulatory BP (BPLab Vasotens), assessment of central BP and arterial stiffness parameters using applanation tonometry technique. BP phenotypes were analyzed with diagnostic criteria for HTN by ESC/ESH 2018 guidelines. CVR was assessed using the SCORE 10-year risk calculator (ESC 2019). The differences were considered significant at p&lt;0,05.Results. The prevalence of true HTN was 6,2%, masked HTN — 38,3%. Isolated nocturnal HTN was revealed in 30,7% of patients with clinic BP &lt;140/90 mm Hg. The subgroup with masked HTN was dominated by patients with normal clinic BP (58,1%) and in most cases was characterized by isolated diastolic BP increase (64,5%). Masked HTN was associated with a higher carotid-femoral pulse wave velocity (PWV) (median — 7,2 versus 6,3 m/s, p=0,002). The most common profiles of nocturnal BP decrease were non-dipper (63.9%) and night-picker (16.6%). High and very high CVR was recorded in 87,7% of patients. Conclusion. Hypertension occurs in 44,5% of young patients with type 1 diabetes and is characterized by a high prevalence of masked isolated nocturnal HTN and non-dipping. Masked HTN is associated with a higher carotid-femoral PWV. High and very high 10-year CVR was recorded in 87,7% of patients.

Features of hemodynamic and metabolic disorders in obese patients with resistant hypertension

Background. The aim was to establish the features of hemodynamic and metabolic parameters in obese patients with true and pseudo-resistant arterial hypertension (AH). Material and methods. The study included 200 patients with uncontrolled AH and obesity. Patients were initially prescribed dual antihypertensive therapy. Those patients who did not reach target blood pressure (BP) levels after 3 months on dual therapy were additionally prescribed a third antihypertensive drug. Of the 98 patients who were assigned to triple therapy, 48 patients did not reach target BP (27 patients had pseudo-resistant and 21 patients had true resistant AH). These patients were additionally prescribed a fourth antihypertensive drug (spironolactone). The effectiveness of the treatment was evaluated 6 months after the start of antihypertensive therapy. Results. After 6 months of therapy, unlike patients without resistance, individuals with resistant AH had more pronounced cardiovascular remodeling and metabolic disorders, disbalance of oxidative stress-antioxidant protection, proinflammatory activity and higher activity of the renin-angiotensin-aldosterone system. Patients with true resistance differed from pseudo-resistant patients by having significantly lower body mass index (BMI); in the absence of differences in BP levels, cardiovascular remodeling, lipid and carbohydrate profiles, patients with true resistance had significantly higher levels of aldosterone, higher activity of oxidative stress system, lower levels of general antioxidant protection, higher adiponectin levels, and lower leptin level. Conclusions. Obese patients with true resistance differed from pseudo-resistant patients by having significantly lower BMI, higher aldosterone levels, more pronounced imbalance of the system of oxidative stress-antioxidant protection and less pronounced adipokine imbalance.

Ambulatory blood pressure monitoring and management of hypertension at a cardiac clinic in Kumasi Metropolis, Ghana.

Ambulatory blood pressure monitoring (ABPM) is considered a good intervention strategy to avoid misdiagnosis of hypertension and allow for targeted treatment of patients with hypertension. This study sought to assess the contribution of ABPM to blood pressure (BP) control and antihypertensive therapy at a cardiac clinic in Ghana. Medical records of 97 patients, aged 18-85years (mean 55), were reviewed. Among patients with clinic BP (CBP) and ambulatory BP recorded on the same day, we assessed for the different hypertension phenotypes, CBP control 6months following ABPM, and changes to antihypertensive therapy after review of the ABPM records in patients with controlled and uncontrolled ambulatory BP. From the clinic and ambulatory BP records measured at baseline, the proportion of patients with white-coat uncontrolled hypertension (WUCH) was 19.5% (17/87) and those with masked uncontrolled hypertension (MUCH) was 16.1% (n=14). A significant reduction in average systolic CBP in the overall cohort (-6.2mm Hg, P<.01) and in the uncontrolled subgroup (-8.8mm Hg, P<.001) at follow-up was observed. After review of the ABPM records, 51.7% of the patients on treatment had changes made in their antihypertensive therapy. Antihypertensive therapy was deintensified or left unchanged in majority of the patients with WUCH and sustained controlled hypertension. In patients with MUCH and true uncontrolled hypertension (TUCH), therapy was intensified. In conclusion, ABPM improved clinical decision-making for antihypertensive therapy and BP control. ABPM should therefore be used more often in hypertension and cardiac clinics in low/middle-income countries for optimal care.

Hemodynamic Patterns and Target Organ Damage in Adolescents With Ambulatory Prehypertension

Although the importance of office prehypertension/high normal blood pressure (BP) has been well documented, the significance of ambulatory prehypertension (AmbPreHT) has not been determined. We analyzed markers of target organ damage and hemodynamics in adolescents with AmbPreHT in comparison with hypertensive and normotensive subjects. Out of 304 white patients aged 15.0±2.5 years with office hypertension, 30 children had AmbPreHT and were compared with 66 normotensive healthy children and 92 children with true hypertension (elevated office, ambulatory, and central BP), 22 had ambulatory hypertension (AmbHT), and 70 had severe AmbHT (SevAmbHT). Stroke volume and cardiac output were greater in AmbPreHT compared with patients with normotension but did not differ between AmbPreHT, AmbHT, and SevAmbHT. Similarly, AmbPreHT, AmbHT, and SevAmbHT had similar total peripheral resistance, lower than patients with normotension (P<0.05). Central systolic BP was higher in patients with AmbPreHT, AmbHT, and SevAmbHT compared with normotensives (P<0.01). In all 3 groups, the carotid intima-media thickness Z scores were significantly higher than in normotensive (P<0.001). AmbPreHT and AmbHT patients had higher left ventricular mass index and prevalence of left ventricular hypertrophy compared with normotensive but lower compared with SevAmbHT (P<0.001). Pulse wave velocity Z scores were increased in patients with AmbPreHT, AmbHT, and SevAmbHT compared with patients with normotension (P<0.01). Multiple regression analysis showed that body mass index Z score, central systolic BP, and uric acid levels were significant independent predictors of left ventricular mass index. In conclusion, patients with AmbPreHT presented similar cardiovascular adaptations to those observed in patients with hypertensive and may be at risk of developing cardiovascular events.