The monthly ESH guide through publications – September 2018

Edited by Costas Tsioufis and Alex Kasiakogias

After an always well welcomed summer and days of vacation for the most of us, we are deep into September and back on track. Apart from the published new ESH/ESC guidelines, there have been lots of interesting new publications. Have a look!

 

Use of long-term cumulative blood pressure in cardiovascular risk prediction models

A cohort study that included 11767 adults from the Lifetime Risk Pooling Project studied whether including long-term (5- and 10-year) cumulative systolic blood pressure (SBP) in risk equations improves the predictive ability compared with single SBP measurements. It was shown that the use of long-term measures of cumulative BP, instead of single measurements, can modestly improve the ability of cardiovascular disease risk prediction models to correctly classify individuals in terms of their risk for cardiovascular disease.

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Achieved diastolic blood pressure and pulse pressure at target systolic blood pressure (120–140 mmHg) and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials

Outcome data from patients age 55 years or older with cardiovascular disease from the ONTARGET and TRANSCEND trials were analysed, in order to examine the association between mean attained diastolic BP (DBP) and cardiovascular (CV) outcomes in patients who achieved an on-treatment SBP in the range of 120 to <140 mmHg. Compared to a DBP of 70 to <80 mmHg, lower and higher DBP was associated with a higher risk in patients achieving a SBP of 120 to <140 mmHg. Associations of DBP and PP to risk were similar notably at controlled SBP.

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Ideal blood pressure in patients with atrial fibrillation

The goal of this study was to investigate the impacts of the 2017 ACC/AHA guideline and to determine the ideal BP threshold for the management of high BP in patients with AF. Data analysed were from 298,374 Korean adults with oral anticoagulant–naive, nonvalvular AF obtained from the National Health Insurance Service. Patients with AF and newly redefined hypertension according to the 2017 ACC/AHA guideline were at higher risk of major cardiovascular events. BP of 120 to 129/<80 mm Hg was the optimal BP treatment target for patients with AF undergoing hypertension treatment

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Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 13 – benefits and adverse events in older and younger patients with hypertension overview, meta-analyses and meta-regression analyses of randomized trials

In this large meta-analysis of 63 BP-lowering randomized controlled trials in 210508 patients, the blood pressure -lowering treatment associated reduction in cardiovascular outcomes as well as adverse events in older versus younger patients was examined. All cardiovascular outcomes were significantly reduced by treatment both in older and younger individuals, without significant age-dependent differences in relative risk reduction but with significantly higher absolute risk reductions in older individuals. There was no evidence that treatment discontinuations for adverse events or hypotension/syncope were more frequent at age greater than 65.

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Fixed low-dose triple combination antihypertensive medication vs usual care for blood pressure control in patients with mild to moderate hypertension in Sri Lanka. A Randomized Clinical Trial

This randomized, open-label trial assessed whether a low-dose triple combination antihypertensive medication (20 mg of telmisartan, 2.5 mg of amlodipine, and 12.5 mg of chlorthalidone) would achieve better blood pressure (BP) control vs usual care among 700 patients with mild to moderate hypertension. Seventy per cent of patients in the triple combination pill therapy group achieved a systolic/diastolic BP of less than 140/90 mm Hg (or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months compared with 55% of patients in the usual care group (P < 0.001). There were no significant between-group differences in the proportion of patient withdrawal from BP-lowering therapy due to adverse events.

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Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study

This analysis done in 18 countries participating in The Prospective Urban Rural Epidemiology study, assessed community-level associations between sodium and potassium intake and BP as well as cardiovascular disease and mortality. Overall, mean systolic BP increased by 2.86 mm Hg per 1 g increase in mean sodium intake. Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. All major cardiovascular outcomes decreased with increasing potassium intake.

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Orthostatic hypotension and symptomatic subclinical orthostatic hypotension increase risk of cognitive impairment: an integrated evidence review and analysis of a large older adult hypertensive cohort

This analysis studied the relationship between baseline orthostatic hypotension, subclinical orthostatic hypotension and cognitive outcomes among hypertensive patients aged ≥80 years from the Hypertension in the Very Elderly Trial (HYVET) cohort. Orthostatic hypotension was associated with an increased risk of cognitive decline [(HR) 1.36 (1.14–1.59)] and incident dementia [HR 1.34 (0.98–1.84)]. Subclinical orthostatic hypotension was also associated with an increased risk of cognitive decline [HR 1.56 (1.12–2.17)] and dementia [HR 1.79 (1.00–3.20)].

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Long-Term cardiovascular risk associated with stage 1 hypertension defined by the 2017 ACC/AHA Hypertension Guideline

In this study on 21,441 participants age ≥35 years and free of cardiovascular disease (CVD) that were followed for up to 20 years in the Chinese Multi-provincial Cohort Study, the authors assessed the relative risk and population-attributable risk of cardiovascular disease associated with stage 1 hypertension as defined by the 2017 American College of Cardiology/American Heart Association hypertension guidelines. Among participants aged 35 to 59 years, the HR comparing stage 1 hypertension to BP <120/<80 mm Hg for CVD incidence was 1.78 (95% confidence interval [CI]: 1.50 to 2.11). Among participants age ≥60 years, however, stage 1 hypertension was not related to an increased risk compared with BP <120/<80 mm Hg.

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Atrial fibrillation detection during 24-hour ambulatory blood pressure monitoring

This study assessed the diagnostic accuracy of a novel 24-hour ambulatory blood pressure (ABP) monitor with implemented algorithm for automated atrial fibrillation (AF) detection during each ABP measurement, on one hundred subjects that had simultaneous 24-hour ABP monitoring and 24-hour Holter monitoring. It was shown that in elderly hypertensives, this 24-hour ABP monitor with AF detector has high sensitivity and moderate specificity for AF screening during routine ABP monitoring. There was a strong association between the proportion of false-positive AF readings and that of supraventricular premature beats.

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Three-dimensional echocardiographic ventricular mass/end-diastolic volume ratio in native hypertensive patients: relation between stroke volume and geometry

This study investigated the ability of three-dimensional (3D) echocardiography in identifying a phenotype of LV concentric geometry according to the Left Ventricular Mass (LVM)/End Diastolic Volume (EDV) ratio, which when measured by MRI has been associated with higher evidence of myocardial fibrosis and dysfunction in hypertensive patients. It was shown that 3D-echo-derived LVM/EDV ratio identifies a higher prevalence of LV concentric geometry than 2D-relative wall thickness. Stroke volume was independently and negatively associated with the LVM/EDV ratio.

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 Pregnancy weight gain before diagnosis and risk of preeclampsia. A population-based cohort study in nulliparous women

The aim of this study was to determine whether pregnancy weight gain before the diagnosis of preeclampsia is associated with increased risks of preeclampsia in 62705 nulliparous women. Odds of preeclampsia increased by ≈60% with every 1 z score increase in pregnancy weight gain among normal weight and overweight women and by 20% among obese women. High pregnancy weight gain before diagnosis was more strongly associated with later-onset preeclampsia than early-onset preeclampsia.

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Refractory hypertension is not attributable to intravascular fluid retention as determined by intracardiac volumes

The study examined whether refractory hypertension (RfHTN- lack of blood pressure control with ≥5 medications, including a long-acting thiazide and a mineralocorticoid receptor antagonist) is characterized by persistent fluid retention, as indexed by greater intracardiac volumes determined by cardiac magnetic resonance. The findings demonstrate greater left ventricular hypertrophy without chamber enlargement in RfHTN, suggesting that antihypertensive treatment failure is not attributable to intravascular volume retention.

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Regression of organ damage following renal denervation in resistant hypertension: a meta-analysis

This study examined the effect of renal denervation on target organ damage by meta-analyzing 17 studies (698 patients). Renal denervation was associated with significant reductions in left ventricular mass index, E wave velocity to E m velocity from tissue Doppler imaging, central augmentation index and carotid−femoral pulse wave velocity.

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Office and ambulatory heart rate as predictors of age-related kidney function decline

A population-based cohort study

The study examined whether heart rate (HR) is a risk factor for GFR decline in the general population, using data from 1627 patients in the Renal Iohexol-Clearance Survey in Tromsø 6. In multivariable-adjusted linear mixed models, 10 bpm higher ambulatory 24-hour and daytime HRs and office HR were associated with steeper GFR decline rates of 0.20 to 0.21 mL/min per year (P≤0.01). It is concluded that HR may be a useful biomarker to identify persons at risk of accelerated GFR decline.

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Renal denervation in resistant hypertension and obstructive sleep apnea. Randomized proof-of-concept phase II trial

The aim of the present study was to investigate in a prospective randomized trial the effect of RDN on BP and clinical course of OSA. Sixty patients with true resistant hypertension coexisting with moderate-to-severe OSA (apnea/hypopnea index, ≥15) were randomly allocated to RDN group and to control group. At 3 months in the RDN group, both office and ambulatory BP were significantly reduced, and a significant decrease in OSA severity (apnea/hypopnea index, 39.4 versus 31.2 events per hour; P=0.015) was observed.

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 Blood pressure response to maximal dynamic exercise testing in an athletic population

The study examined the magnitude and distribution of BP response to exercise in athletic populations by performing cycle ergometry in 2419 healthy competitive adolescent, professional and master athletes for preparticipation screening. ESC guidelines of upper limits of maximal SBP were exceeded in 43% in men (>210 mmHg) and 28% in women (>190 mmHg). SBP response was more pronounced in endurance athletes, whereas DBP was slightly higher in strength athletes.

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Computed Tomography and Adrenal Venous Sampling in the Diagnosis of Unilateral Primary Aldosteronism

This retrospective multicentre study compared clinical and biochemical postsurgical outcomes of patients with unilateral primary aldosteronism diagnosed by CT or adrenal venous sampling and identify predictors of surgical outcomes. A diagnosis by CT was associated with a decreased likelihood of complete biochemical success compared with AVS.

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 Impact of blunted nocturnal blood pressure dipping on cardiac systolic function in community participants not receiving antihypertensive therapy

Whether nocturnal BP dipping pattern and nocturnal BP were associated with indexes of cardiac systolic function was assessed in 491 randomly selected community participants not receiving antihypertensive therapy. After adjustments for potential confounders, left ventricular mass index, endocardial fractional shortening, midwall fractional shortening and ejection fraction were associated with nocturnal BP and BP dipping.

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Clinical characteristics and risk of hypertension needing treatment in young patients with systolic hypertension identified with ambulatory monitoring

The importance of isolated systolic hypertension (ISH) of the young is not well defined. In 1206, 18–45-year-old participants from the Hypertension and Ambulatory Recording VEnetia Study, the predictive role of ISH for incident hypertension was evaluated. Patients were divided in hypertension types based on 24hr BP data and it was shown that in ISH people younger than 45 years, only mean BP is a predictor of future hypertension needing treatment, whereas the ISH status per se does not necessarily imply an increase in risk.

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Electrocardiographic predictors of atrial fibrillation in nonhypertensive and hypertensive individuals

The aim of this study was to compare the predictive value of ECG abnormalities for atrial fibrillation in nonhypertensive versus hypertensive individuals. ECG was recorded and conventional cardiovascular risk factors were measured in a nationwide population-based sample of 5813 Finns who were divided into hypertensives and non-hypertensives and followed for incident atrial fibrillation events. It was shown that several ECG abnormalities associate with incident atrial fibrillation in hypertensive and nonhypertensive individuals but provide only marginal incremental predictive value. Corrected QT interval and T-wave amplitude in lead aVR may relate stronger to incident atrial fibrillation in nonhypertensive than in hypertensive individuals.

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