Well-controlled Hypertension Research Articles

Adherence of low sodium diet and antihypertensive therapy in hypertensive type 2 diabetic patients

High blood pressure is a very common pathology, it is a cardiovascular risk factor, accounting for nearly 4.5% of the global burden of disease according to the World Health Organization. Low sodium diet and good adherence to antihypertensive therapy are key factors in the management of hypertension in all hypertensive patients, especially in diabetics. We carried out a descriptive cross-sectional study that included 45 type 2 diabetics all with high blood pressure. Compliance with antihypertensive therapy was assessed by Girerd's questionnaire. The observation of the low sodium diet was estimated by using a subjective evaluation on an analog scale ranging from 1 (poor compliance) to 5 (very good compliance) and the ExSel Test to quantify the daily salt intake according to sex, body mass index and the diet followed by the patients. Adhesion to the sodium diet was objectively assessed by the 24-hour natriuresis. Poor compliance with the low sodium diet corresponds to a natriuresis of greater than 102 mmol/24hr of sodium (i.e. a salt intake > 6 g/day). The mean age of our patients was 61 ± 8 years with a sex ratio (M/F) of 0.36. According to the analog scale evaluating adherence to the low sodium diet, more than half of them (53%) said they were insufficiently or poorly observant, 8 patients adhered correctly to the diet. 86.7% of patients reported that they had never received nutritional education from their referring physicians. The average natriuresis was 94.7 mmol/24 h. The natriuresis of 24 hours in our patients was greater than 102 mmol/24 h in 42% of cases with a non-controlled hypertension in 73% of these patients. Natriuresis was less than 102 mmol/24 h in 58% of patients, of whom 41% had poorly controlled hypertension. The ExSel Test has been performed for all patients. According to this test the daily salt intake was excessive in almost half of patients (44.5%) with poorly controlled hypertension in only 45% of these patients. According to the Girerd's questionnaire, no patient showed good compliance with medication. 82% were non-observer with poorly controlled hypertension in more than 51% of these patients, and the remaining 8 patients were poorly observant of their antihypertensive treatments; only one patient of these 8 patients had a well-controlled hypertension. High blood pressure is an additional risk factor in the diabetic population. Its correct management is therefore essential. It begins with a good dietary education, adherence to low sodium diet and good compliance with medication.

Recurrent Anion Gap Metabolic Acidosis.

Background:Metabolic acidosis refers to any process that increases the hydrogen ions in the body and reduces the bicarbonate concentration. Metabolic acidosis is subdivided based on presence of anion gap (AG), and AG metabolic acidosis is most often due to ketoacidosis, lactic acidosis, renal failure, or toxic ingestions. AG metabolic acidosis is frequently encountered in the clinical practice. Rarely, the underlying cause of the AG metabolic acidosis is considered a diagnostic dilemma as the established algorithm allows the physicians to identify the etiology.Case presentation:A fifty-three-year-old Black woman with well-controlled human immunodeficiency virus (HIV), hypertension, and asthma presented with recurrent episodes of severe anion gap metabolic acidosis. The patient’s AG metabolic acidosis always corrected with the administration of intravenous normal saline. Laboratory studies were always negative for common causes of acidosis.Conclusion:Nucleoside reverse transcriptase inhibitors-associated lactic acidosis has been reported in the literature. The shift to anaerobic mitochondrial metabolism induced by the HIV medications used in this patient could be explain the recurrent severe metabolic acidosis.

Allopurinol treatment adversely impacts left ventricular mass regression in patients with well-controlled hypertension.

Objectives:Previous studies have demonstrated that high-dose allopurinol is able to regress left ventricular (LV) mass in cohorts with established cardiovascular disease. The aim of this study was to assess whether treatment with high-dose allopurinol would regress LV mass in a cohort with essential hypertension, LV hypertrophy and well-controlled blood pressure but without established cardiovascular disease.Methods:We conducted a mechanistic proof-of-concept randomized, placebo-controlled, double-blind trial of allopurinol (600 mg/day) versus placebo on LV mass regression. Duration of treatment was 12 months. LV mass regression was assessed by Cardiac Magnetic Resonance. Secondary outcomes were changes in endothelial function (flow-mediated dilatation), arterial stiffness (pulse wave velocity) and biomarkers of oxidative stress.Results:Seventy-two patients were randomized into the trial. Mean baseline urate was 362.2 ± 96.7 μmol/l. Despite good blood pressure control, LV mass regression was significantly reduced in the allopurinol cohort compared with placebo (LV mass −0.37 ± 6.08 versus −3.75 ± 3.89 g; P = 0.012). Oxidative stress markers (thiobarbituric acid reactive substances) were significantly higher in the allopurinol group versus placebo (0.26 ± 0.85 versus −0.34 ± 0.83 μmol/l; P = 0.007). Other markers of vascular function were not significantly different between the two groups.Conclusion:Treatment with high-dose allopurinol in normouricemic controlled hypertensive patients and LV hypertrophy is detrimental. It results in reduced LV mass regression and increased oxidative stress over a 12-month period. This may be because of an adverse impact on redox balance. Cohort selection for future cardiovascular trials with allopurinol is crucial.

Drug-induced arterial hypertension

This review is devoted to the problem of drug-induced hypertension (H). It summarizes the literature data on drugs and substances that can increase blood pressure, discusses the mechanisms of their hypertensive action. Many classes of drugs such as steroids, nonsteroidal anti-inflammatory drugs, sympathomimetics, immunosuppressants, oral contraceptives, antidepressants, erythropoietin, etc. can cause episodic or persistent increase in blood pressure, cause uncontrolled hypertension, reduce the effectiveness of antihypertensive drugs. The development of drug-induced hypertension is realized through a number of pathophysiological mechanisms: sodium retention with subsequent increase in the volume of circulating blood, activation of the sympathetic nervous system, direct effect on the smooth muscles of arterioles, there are other, not fully studied mechanisms. Drug-induced H may also be the result of pharmacokinetic or pharmacodynamic drug interactions. To suspect the presence of drug-induced hypertension, in the first place, should be in persons with newly diagnosed hypertension, as well as in patients who previously had a well-controlled hypertension (stable target blood pressure - BP levels) when they have episodes of unexplained increase in BP without a clear relationship with physical or psycho-emotional stress. It is very important to have a properly collected history with a focus on a thorough assessment of the medicines taken by the patient, especially newly prescribed, as well as those purchased at the pharmacy independently, including over-the-counter, this will avoid unnecessary and/or expensive studies and unnecessary prescriptions of additional antihypertensive drugs. The article presents these measures for the prevention and correction of drug-induced H. The appointment of new drugs by a doctor to patients receiving antihypertensive therapy should necessarily take into account their impact on the risk of drug-induced hypertension. Prescribing drugs that cause an increase in BP levels should either be avoided or, if alternative treatment regimens are not possible, strict control of the patient's BP level (including the method of home monitoring of BP) and, if necessary, the correction of antihypertensive therapy. When canceling a drug that causes drug-induced hypertension, BP returns to its original level, which is proof of the iatrogenic cause of hypertension.

Feasibility and Outcomes of an Electronic Health Record Intervention to Improve Hypertension Management in Immigrant-serving Primary Care Practices.

South Asians experience a disproportionate burden of high blood pressure (BP) in the United States, arguably the most preventable risk factor for cardiovascular disease. We report 12-month results of an electronic health record (EHR)-based intervention, as a component of a larger project, "Implementing Million Hearts for Provider and Community Transformation." The EHR intervention included launching hypertension patient registries and implementing culturally tailored alerts and order sets to improve hypertension control among patients treated in 14 New York City practices located in predominantly South Asian immigrant neighborhoods. Using a modified stepped-wedge quasi-experimental study design, practice-level EHR data were extracted, and individual-level data were obtained on a subset of patients insured by a Medicaid insurer via their data warehouse. The primary aggregate outcome was change in proportion of hypertensive patients with controlled BP; individual-level outcomes included average systolic BP (SBP) and diastolic BP (DBP) at last clinic visit. Qualitative interviews were conducted to assess intervention feasibility. Hypertension was defined as having at least 1 hypertension ICD-9/10 code. Well-controlled hypertension was defined as SBP<140 and DBP<90 mm Hg. Postintervention, we observed a significant improvement in hypertension control at the practice level, adjusting for age and sex patient composition (adjusted relative risk, 1.09; 95% confidence interval, 1.04-1.14). Among the subset of Medicaid patients, we observed a significant reduction in average SBP and DBP adjusting for time, age, and sex, by 1.71 and 1.13 mm Hg, respectively (P<0.05). Providers reported feeling supported and satisfied with EHR components. EHR initiatives in practices serving immigrants and minorities may enhance practice capabilities to improve hypertension control.

A large number of cerebral microbleeds in CADASIL patients presenting with recurrent seizures: a case report

BackgroundCerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary arteriopathy associated with the NOTCH3 gene. Clinical manifestations include strokes, transient ischaemic events, psychiatric disturbances, dementia, and migraines. We report a case of a Thai man with a severe CADASIL phenotype who presented with recurrent seizures and acute ischaemic stroke and classic vascular risk factors.Case presentationA 50-year-old man with a history of mood disorder and progressive cognitive decline for 20 years as well as well-controlled diabetes mellitus and hypertension presented with recurrent generalized seizures and acute right-sided weakness. An MRI of the brain showed acute infarction of the left pons, a large number of cerebral microbleeds throughout the brain and white matter abnormalities without classic anterior temporal lobe lesions. Molecular genetic testing identified a homozygous pathologic variant, c.1672C > T (p. Arg558Cys), in the NOTCH3 gene. The diagnosis of CADASIL was confirmed. His clinical symptoms deteriorated, and he died of tracheobronchitis with secretion obstruction.ConclusionThis case raises awareness of an uncommon cause of acute ischaemic stroke in patients with classic vascular risk factors and emphasizes the need for a complete evaluation in cases with unexpected clinical presentation or unexpected diagnostic study results.

Miller Fisher syndrome developing as a parainfectious manifestation of dengue fever: a case report and review of the literature

BackgroundAlthough dengue viral infections have emerged as one of the most important mosquito-borne diseases, neurological manifestations of dengue infections are uncommon. Guillain–Barré syndrome and Miller Fisher syndrome have been reported to occur as immune-mediated complications following dengue infection. We report the case of a patient who developed Miller Fisher syndrome during the acute phase of dengue fever suggesting that Miller Fisher syndrome may arise as a result of direct neurotropism of the dengue virus.Case presentationA 70-year-old Sri Lankan man with well-controlled diabetes mellitus and hypertension presented with fever of 3 days’ duration, drooping of eyelids, dysarthria, and unsteady gait. He developed bilateral asymmetric partial ptosis, complete external ophthalmoplegia, bilateral palatal palsy, unilateral tongue weakness, ataxia, and areflexia from the second day of illness. He did not have limb weakness. He had evidence of acute dengue infection including progressive thrombocytopenia and leukopenia, positive dengue non-structural protein 1 antigen, dengue immunoglobulin M antibodies, and polymerase chain reaction detection of dengue virus genome in serum. Magnetic resonance imaging of his brain and cerebrospinal fluid analysis were normal. Polymerase chain reaction for dengue virus and immunoglobulin M antibodies in cerebrospinal fluid were negative. Nerve conduction studies showed axonal neuropathy. Antibodies (immunoglobulin G, immunoglobulin M, and immunoglobulin A) against GQ1b and GT1a were negative. He was treated with intravenously administered immunoglobulins and a recommended fluid regimen for dengue fever. He made a complete recovery from dengue fever in 7 days and Miller Fisher syndrome in 20 days.ConclusionsThis case report highlights the rare occurrence of Miller Fisher syndrome during the acute phase of dengue fever. Neurological manifestations may occur as a consequence of direct neurotropism of dengue virus.

Prevalence of Apparent Treatment-Resistant Hypertension in the United States According to the 2017 High Blood Pressure Guideline

ObjectiveTo evaluate the prevalence of apparent treatment-resistant hypertension (aTR-hypertension) in US adults with treated hypertension by using the nationally representative National Health and Nutrition Examination Survey (NHANES). Patients and MethodsNonpregnant US adults older than 20 years with a self-reported history of treated hypertension who had blood pressure measured in NHANES cycles 2007 to 2014 were included in this study. Study participants were stratified into 4 groups according to average blood pressure and antihypertensive medication use: well-controlled hypertension, undertreated hypertension, aTR-hypertension by the 2017 guideline, and aTR-hypertension by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline. National Health and Nutrition Examination Survey sample weights were used to estimate the national prevalence. ResultsFrom 2007 to 2014, 5512 participants with treated hypertension representing 46.7 million people nationally were included. Compared with JNC 7 guideline criteria, application of the 2017 high blood pressure guideline criteria increased the prevalence of aTR-hypertension in US adults with treated hypertension from 12.0% to 15.95%, identifying an additional 1.85 million individuals with aTR-hypertension nationally. Individuals newly reclassified as having aTR-hypertension were younger. However, the prevalence of thiazide diuretic use remained less than 70%, and that of mineralocorticoid antagonist use remained less than 10% regardless of the guideline definition. ConclusionOn the basis of the 2017 high blood pressure guideline, the prevalence of aTR-hypertension is 15.95% in US adults with treated hypertension. This represents an absolute increase of 4% (1.85 million additional individuals nationally) compared with the JNC 7 guideline definition, with a consistent increase across all subpopulations with treated hypertension.

MON-LB060 Atypical Presentation of Parathyroid Carcinoma: Case Report

Background: Parathyroid carcinoma is a rare cause of primary hyperparathyroidism (0.74%), with an incidence of 0.36 (2000-2012), age presentation between 44-54 y/o, and symptoms associated with neck mass, bone and renal disease, as a consequence of marked hypercalcemia and elevated Parathyroid Hormone (PTH)1. Clinical Case: 85 y/o male, with 12-month history of weight loss (20Kg) along with unstable gait, laboratory with incidental findings of hypercalcemia (serum Calcium: 15.5mg/dL) and elevated PTH (PTH: 1141pg/mL). SESTAMIBI SPECT showed increased uptake in the inferior left thyroid lobe. Patient is admitted for elective parathyroidectomy with diagnosis of parathyroid adenoma. Patient had well-controlled hypertension and denied bone fractures, kidney stones, neck nodules or tumors. On physical exam, no visible or palpable neck mass was evident. Repeat admission lab results confirm malignant hypercalcemia: calcium: 14.14mg/dL, PTH: 1262pg/mL, creatinine: 2.34mg/dL. Surgery Findings: calcified enlarged left thyroid mass with no clear parathyroid definition. Mass is removed along with lymph nodes. Hypercalcemia and elevated PTH persists postoperatively (Serum calcium: 15.2mg/dL, PTH: 1552pg/mL) and patient is started on zoledronic acid with good response. Final pathology report: neoplastic ovoid and round cells, fibrous bands circumscribing lobes, acinar and trabecular structures with plexiform vasculature, areas of necrosis and calcifications with venous angioinvasion: parathyroid carcinoma. Oncology discharges patient with palliative care upon family request. Being a sporadic parathyroid carcinoma, genetic testing for germline HRPT2 (CDC73) mutations is requested. No mutations were detected. Conclusion: Parathyroid carcinoma is a rare endocrine tumor, with a 5-year survival rate of 64,8% upon complete tumor resection. Our patient represents one of the few case reports on silent parathyroid carcinoma in an elderly patient with residual disease currently on pharmacological management for persistent hypercalcemia, and negative genetic testing. Key words: parathyroid carcinoma, hyperparathyroidism, hypercalcemia, HRPT2 (CDC73) gen

Complications and related risk factors in Uygur patients with type 2 diabetes mellitus

Objective To investigate the prevalence of complication and related risk factors in Uygur patients with type 2 diabetes mellitus (T2DM). Methods Total 1 507 Uygur patients aged above 20 with T2DM were recruited in the First Affiliated Hospital of Xinjiang Medical University from January 2010 to October 2015. Clinical characteristics, biochemical parameters and related complications were analyzed in different age groups of patients. Multivariate logistic regression was performed to determine associated factors for diabetic complications. Results Among 1 507 cases, there were 61.3% male patients (n=924), 37.4% (n=564) with diabetes duration ≥5 years, 12.5% (n=189) with HbA1c>10%, 31.5% (n=475) with hypertension, 28.8% (n=434) with smoking history and 37.4% (n=564) patients without antidiabetic drug treatment. The average body mass index (BMI) of patients was (27.4±5.2) kg/m2 with a obesity rate of 43.0% (648/1 507), and 65.0% (980/1 507) had physical exercise 10% (OR=2.74, 95%CI: 1.40-5.34), obesity (OR=1.54, 95%CI: 1.07-2.21), systolic pressure≥140 mmHg (1 mmHg=0.133 kPa) (OR=1.42, 95%CI: 1.01-1.99), diastolic pressure≥90 mmHg (OR=0.37, 95%CI: 0.21-0.67), smoking (OR=1.53, 95%CI: 1.09-2.15) and physical activity<150 min/week (OR=1.42, 95%CI: 1.07-1.89) were the risk factors of diabetic complications. Conclusion Uygur patients with type 2 diabetes in Xinjiang show a relatively high prevalence of complications.Poor glycemic control,obesity,hypertension,smoking and physical inactivity may contribute to development of complications, while well-controlled blood glucose and hypertension and quitting smoking and increasing physical activity may reduce diabetic complications. Key words: Diabetes mellitus, type2; Diabetes complications; Age factors; Disease duration; Blood glucose

May Measurement Month 2017: an analysis of blood pressure screening results in Colombia-Americas.

Despite the availability of efficient methods to evaluate blood pressure (BP) and of safe and efficient medication to treat and control hypertension, the levels of awareness, treatment and control are very low globally, particularly in low- and middle-income countries. To highlight the importance of improving these rates, the International Society of Hypertension (ISH) endorsed by the World Hypertension League have implemented the May Measurement Month initiative. We present here the results obtained in Colombia. The Fundación Oftalmológica de Santander (FOSCAL) led the implementation of this strategy in Colombia and 11 departments participated. The data collection followed the guidelines of the ISH. The information collected was compiled for the report generation and the submission to the Technical Secretariat of the ISH. Data cleaning was performed locally by FOSCAL. Data were collated and analysed centrally. A total of 22 258 participants (58.8% female) were included in the analysis. Mean age was 40.9 ± 17.7 years. Age and sex-standardized BP excluding participants receiving BP medications was 118/74.3 mmHg, and in those on treatment 125/78 mmHg. High BP was present in 5036 (22.8%) individuals, 1637 of 18 644 (8.8%) who were not receiving anti-hypertensive medications were hypertensive, and 961 of 3359 (28.6%) receiving treatment were not controlled. These results highlight the need to develop innovative promotion strategies at individual and population levels to increase the awareness of the importance of BP, and the consequences of not having well-controlled hypertension. This initiative is an effective and easy to implement strategy that should be maintained in the coming years.

Endovascular Management of Massive Hematemesis due to Aorto-Esophageal Fistula

A 75-year-old man presented with weight loss, left hip pain, and dysphagia of 1-month duration. He has prior history of well-controlled diabetes and hypertension. He was clinically stable at the time of presentation with blood pressure (BP) of 160/100 mm Hg and heart rate (HR) of 82 beats/min. A radiograph of the pelvis demonstrated pathologic fracture of the left iliac bone. Contrast-enhanced computed tomography (CT) of the abdomen revealed multiple necrotic lower mediastinal nodes. During the hospital stay, there was a sudden episode of hypotension (BP of 80/60 mm Hg), tachycardia, tachypnea, and desaturation on room air. The patient was moved to the intensive care unit (ICU) and resuscitated. Hemoglobin decreased from 12 to 7 g/dL. While the patient was being moved to the CT scanner, he had a sudden episode of massive hematemesis. CT angiography of the chest demonstrated diffuse irregular circumferential mural thickening of the thoracic esophagus from D3 to D8 level with extravasation of the contrast material into the esophageal lumen ([Fig. 1A, B]). A nipple was noted in the anterior wall of the thoracic aorta at the level of D5 vertebral body ([Fig. 1C]). Based on these findings, aortoesophageal fistula was diagnosed.

Ambulatory blood pressure monitoring prior to kidney donation

In kidney transplantation (KT) the requirements for organ donation has been extended to older donors or those with a history of cardiovascular (CV) disease that previously have been considered as contraindications. This study aims to determine the interest of ambulatory blood pressure monitoring ABPM prior to kidney donation. A descriptive retrospective study of 6 living kidney donors who underwent casual clinic and ABPM. In our series of 73 living donor, in 67 among them, the CV evaluation of kidney donors (KD) was limited to clinic blood pressure levels. The remaining 6 KD underwent ABPM. Subjects were between the ages of 48 and 56,with a mean of body mass index of 26.5 kg/m 2 [22–29,5 kg/m 2 ]. The clinic systolic blood pressure (SBP) average was 138.5 mmHg [114–150]. For 4 cases the ABPM was used to diagnose high blood pressure (BP). The diagnosis of hypertension was rejected in 2 patient aged < 50 y.o with a clinic BP at 140/90 mmHg and an ABPM daytime BP < 135/85 mmHg and also In 2 patient aged > 50 y.o with normal BP in clinic BP measurement. The ABPM was used to check the BP balance in 2 patients whom were treated by calcium channel blocker associated to an angiotensin II receptor antagonists in one case and confirmed a well-controlled hypertension assessed by ABPM < 130/85 mmHg under treatment but one of them had a non-dipper hypertension. The following Table 1 details the BP measures. All of them had nephrectomy for successful KT in the recipient and simple operative follow-up for the KD. ABPM reveals white coat effect hypertension and confirm well- controlled hypertension. I should be more frequently used before and after kidney donation. The Amsterdam Forum recommend the use of an ABPM and considers that, if KD whose BP exceeds 140/90 mmHg should be generally challenged, some candidates over 50 y.o whose hypertension is easily controlled without visceral repercussions may to be considered as donors.

Effects of Telmisartan and Candesartan on the Metabolism of Lipids and Glucose in Kidney Transplant Patients: A Prospective, Randomized Crossover Study.

BackgroundThe risk of cardiovascular events remains after kidney transplantation (KT). Abnormal glucose metabolism and hyperlipidemia contribute partly to this risk. Among angiotensin II type-1 receptor blockers, telmisartan alone has been shown to ameliorate these effects on glucose and lipid metabolism (GLM). We investigated the effects of telmisartan on GLM in KT patients.MethodsThis trial had a crossover design. Forty-six KT patients with well-controlled hypertension under angiotensin II type-1 receptor blockers were randomized into telmisartan and candesartan groups. After a 12-week treatment, crossover was initiated, and additional 12-week treatment was administered without a washout period. We examined the laboratory parameters of GLM, blood pressure and graft function before and after each treatment period.ResultsForty patients completed the scheduled treatment regimen. Serum levels of triglyceride were significantly lower (114.3 ± 50.8 mg/dL vs 136.5 ± 66.8 mg/dL; P = 0.019), and the estimated glomerular filtration rate was significantly higher (50.4 ± 15.1 mL/min per 1.73 m2 vs 48.5 ± 12.5 mL/min per 1.73 m2; P = 0.038) after telmisartan treatment than after candesartan treatment. There were no significant differences between the 2 treatment groups with regard to the other parameters studied (including serum adiponectin levels and parameters of glucose metabolism).ConclusionsThese data suggest that telmisartan can improve serum triglyceride levels and graft function for KT patients better than candesartan.

Asymptomatic thoracic aortic aneurysm in a resource limited hospital in a 70-year-old man

Aortic aneurysm is a term used to describe more than 50% dilatation of a segment of the aorta (artery) from its original diameter. The etiological factors include hypertension, artherosclerosis, trauma, congenital syphilis, mycotic bacterial dissection, inflammation etc. A case of a 70-year-old man with well-controlled long-standing hypertension whose check chest X-ray showed aortic aneurysm as an incidental finding which latera ruptured was discussed. The case report discusses the importance of follow up imaging in a hypertensive patient even with regular medication as absence of routine medical checkup including X-ray may lead to missing important complication like aortic aneurysm that can rupture if untreated. This is what prompted this case report so as to underscore the importance of at least check chest radiograph in a hypertensive patient.

Outcomes for Patients with Pre-Existing Diabetes or Hypertension Treated with Copanlisib from the CHRONOS-1 Study in Patients with Relapsed or Refractory Indolent B-Cell Lymphoma

Outcomes for Patients with Pre-Existing Diabetes or Hypertension Treated with Copanlisib from the CHRONOS-1 Study in Patients with Relapsed or Refractory Indolent B-Cell Lymphoma

Association of Inadequately Low Left Ventricular Mass with Enhanced Myocardial Contractility in Severe Degenerative Aortic Stenosis.

Background: Left ventricular hypertrophy (LVH), traditionally considered an adaptive mechanism that is aimed at the maintenance of LV systolic function, is absent in 10%–35% of patients with severe aortic stenosis (AS). Our aim was to estimate the clinical and hemodynamic characteristics in patients with severe AS and absent LVH, or inadequately low LV mass (i-lowLVM) relative to an individual hemodynamic load. Methods: We retrospectively analyzed in-hospital records of 100 patients with pure severe degenerative AS, preserved LV systolic function and without relevant coexistent diseases, except for well-controlled hypertension or diabetes. Results: Clinical characteristics were similar in patients with and without LVH, as well as those with and without i-lowLVM, except for slightly lower GFR at i-lowLVM. When compared to their counterparts, subjects without LVH or with i-lowLVM had smaller LV cavities, decreased LV wall thicknesses and higher EF. There were no significant differences in stenosis severity and indices of afterload (valvulo-arterial impedance and circumferential end-systolic LV wall stress), according to the presence or absence of either LVH or i-lowLVM. However, LV fractional shortening at the midwall level was elevated only in patients with i-lowLVM, but not in those without LVH, compared to the remainder (15.8 ± 3.3 vs. 12.9 ± 3.2%, p < 0.001 for those with and without i-lowLVM, respectively; 13.7 ± 3.7 vs. 13.8 ± 3.6% for LVH presence and absence, p = 0.9). Conclusions: Inadequately low LVM relative to the individual hemodynamic load could potentially reflect a different mode of the LV response to severe AS, associated with enhanced load-independent LV systolic performance, i.e., better LV contractility. If confirmed in a large series of patients, our small preliminary study may add to the possible mechanisms of a previously reported counterintuitive tendency of a lower, not higher, risk of adverse outcome in patients with low LV mass despite severe AS. Prospective studies are warranted, in order to determine a potential utility of LVM inadequacy in the risk stratification of patients with AS.

A18380 The status of home blood pressure control 2017–2018 in specialist hypertension centers in Asia - Results from AsiaBP@Home, the first standardized study using the same validated device and following the same protocol in 11 different Asian countries and regions

Objectives: A self-HomeBP-guided strategy is an effective, practical approach for managing hypertension. However, there is no standardized cross-sectional evaluation of home BP measurement across Asia. [email protected] is the first study to evaluate home BP control status simultaneously in 11 countries/regions, utilising the same validated home BP monitoring device and following the same BP measurement schedule. Methods: Patients with hypertension living in Asia, receiving antihypertensive therapy, were provided BP monitoring devices and instructed to measure their BP twice in the morning and twice at bedtime for at least 7 days in a 15-day period. Results: In 1443 patients who were attending 15 specialist hypertension centers in Asia, 68.2 % were well-controlled for morning home systolic BP (SBP) < 135 mmHg, and 55.5% were well-controlled for clinic SBP < 140 mmHg. The finding of well-controlled hypertension for both clinic and morning home SBP was the highest (45.9%) among all the 4 classifications and their thresholds for clinic (140 mmHg) and morning home (135 mmHg) SBP. Even with the new 2017AHA/ACC thresholds, 53.6% were well-controlled for morning home SBP. In the Japanese nationwide general practitioner-based home BP study (J-HOP) with baseline data from 2005 to 2012, 46% were well-controlled for morning home SBP by using the conventional thresholds and 31% were well-controlled with the new thresholds. Conclusion: The finding that home BP status was well controlled in patients attending specialist hypertension centers is the “Hope of Asia”, giving hope that strict morning home BP control outside these centers could perhaps be achieved by transferring the expertise of hypertension management from the hypertension specialists to general practitioners.

Neurovascular coupling during cognitive activity in adults with controlled hypertension.

Hypertension, even when controlled, may accelerate arterial stiffening and impair the ability of the cerebrovasculature to increase blood flow to support neural activity, i.e., neurovascular coupling (NVC). Optimal NVC depends on continuous, nonpulsatile flow, which is partially determined by extra- and intracranial vessel function. We sought to compare extra- and intracranial hemodynamics during cognitive activity (Stroop task) in 30 middle-aged, well-controlled medicated hypertensive and 30 age-, sex-, and body mass index (BMI)-matched nonhypertensive adults (56 ± 6 years, 28.2 ± 2.9 kg/m2 BMI; 32 men). Aortic and carotid (single point) pulse wave velocity (PWV) were assessed via tonometry and ultrasound, respectively. Carotid and middle cerebral artery (MCA) blood velocity pulsatility were measured via ultrasound and Doppler. Prefrontal cortex (PFC) oxygenation was measured via tissue saturation index (TSI) using near-infrared spectroscopy. Accuracy and reaction times were computed to assess cognitive performance. Stroop performance was similar between groups ( P > 0.01). Aortic and carotid PWV increased, carotid flow pulsatility decreased ( P < 0.01), and MCA flow pulsatility and PFC TSI were maintained during Stroop ( P > 0.01). Our findings indicate that middle-age adults with medically controlled hypertension and adults without hypertension demonstrate similar intra- and extracranial cerebrovascular reactivity during cognitive engagement. Despite increases in large artery stiffness, middle-aged adults with controlled hypertension and without hypertension exhibit reductions in extracranial flow pulsatility during cognitive engagement that may be part of a concerted cerebrovascular response to support downstream cerebral oxygenation and overall NVC. NEW & NOTEWORTHY Hypertension is associated with accelerated arterial stiffening, which may alter extra- and intracranial vascular reactivity during cognitive activity and impair neurovascular coupling. Middle-aged adults with medicated hypertension exhibit similar neurovascular coupling and extra-/intracranial vascular reactivity during sustained cognitive activity. Extracranial modulation of central hemodynamics may be an important component of optimal neurovascular coupling.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes “normal” or “good” kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1–2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage “non-ideal” situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial “third element”.