The monthly ESH guide through publications – June 2018
Edited by Costas Tsioufis and Alex Kasiakogias
We have enjoyed another great ESH meeting in Barcelona, with the presentation of the new European Hypertension Guidelines being undoubtedly its highlight! Let’s have a look at the recent research that came out in the meantime.
Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomised trial
In this international, randomised, single-blind, sham-control, proof-of-concept trial, patients with uncontrolled hypertension (aged 20–80 years) were randomly assigned to undergo radiofrequency energy renal denervation or sham control. The results for the first 80 patients show that the change in blood pressure was significantly greater at 6 months in the renal denervation group than the sham-control group for office systolic blood pressure (difference −6.8 mmHg), 24 h systolic blood pressure (difference −7.4 mm Hg), office diastolic blood pressure (difference −3.5 mmHg), and 24 h diastolic blood pressure (difference −4.1 mmHg). It is concluded that renal denervation in the main renal arteries and branches significantly reduced blood pressure compared with sham control with no major safety events.
Endovascular ultrasound renal denervation to treat hypertension (RADIANCE-HTN SOLO): a multicentre, international, single-blind, randomised, sham-controlled trial
In the multicentre, international, single-blind, randomised, sham-controlled trial RADIANCE-HTN SOLO, 146 patients with combined systolic-diastolic hypertension and ambulatory blood pressure greater than or equal to 135/85 mm Hg free of antihypertensive medications were randomised to undergo renal denervation (n=74) with endovascular ultrasound or a sham procedure (n=72). The reduction in daytime ambulatory systolic blood pressure was greater with renal denervation (-8.5 mm Hg, SD 9.3) than with the sham procedure (-2.2 mm Hg, SD 10.0; baseline-adjusted difference between groups: -6.3 mm Hg, 95% CI -9.4 to -3.1, p=0·0001). It is concluded that compared with a sham procedure, endovascular ultrasound renal denervation reduced ambulatory blood pressure at 2 months in patients with combined systolic-diastolic hypertension in the absence of medication.
A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea
This meta-analysis of seven RCTs aimed to assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA). It was shown that CPAP use was associated with a non-significant 26% relative risk reduction in MACE. CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF). Subgroup analysis revealed that CPAP adherence time ≥4 hours (h)/night reduced the risk of MACE by 57%.
Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts
The multicentre study PREDIMED in Spain in 7447 patients at high cardiovascular risk followed up for 4.8 years (for an interim analysis) studied the association with major cardiovascular events of a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with mixed nuts, or a control diet (advice to reduce dietary fat). In this revised analysis it was shown that the incidence of major cardiovascular events was lower among those assigned to a Mediterranean diet supplemented with extra-virgin olive oil or nuts than among those assigned to the reduced-fat diet.
Blood pressure variability and risk of cardiovascular events and death in patients with hypertension and different baseline risks
In an analysis of the Valsartan Antihypertensive Long-term Use Evaluation trial, standard deviation (SD) of mean systolic blood pressure from visits from 6 months onward in patients with ≥3 visits and no events during the first 6 months was calculated. Patients in the highest quintile of SD had an increased risk of cardiovascular events [HR 2.1, 95% CI 1.7–2.4], and a 5 mmHg increase in SD of systolic blood pressure was associated with a 10% increase in the risk of death (HR 1.10, 95% CI 1.04–1.17). It is concluded that higher visit-to-visit systolic blood pressure variability is associated with increased risk of cardiovascular events in patients with hypertension, irrespective of baseline risk of cardiovascular events. Associations were stronger in younger patients and in those with lower mean systolic blood pressure.
Status of hypertension in China. Results from the China Hypertension Survey, 2012–2015
Although the prevalence of hypertension (HTN) continues to increase in developing countries, including China, recent data are lacking. In a nationwide survey in China, it was shown that 23.2% of the Chinese adult population ≥18 years of age had HTN, and another 41.3% had pre-HTN according to the Chinese guidelines. Among individuals with HTN, 46.9% were aware of their condition, 40.7% were taking prescribed antihypertensive medications, and 15.3% had controlled HTN.
Antihypertensive drug use in resistant and nonresistant hypertension and in controlled and uncontrolled resistant hypertension
This study on 14264 patients treated with three drugs and in 6974 treated with at least four drugs assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of non-treatment-resistant hypertension (TRH) vs. TRH, and with controlled vs. uncontrolled TRH. It was shown that the use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs. Similar results were observed with specific agents inside each class, being ramipril, olmesartan, chlorthalidone, amlodipine, and bisoprolol those exhibiting significant results. An increased use of these drugs might probably reduce the burden of TRH. uncontrolled resistant hypertension.
Simultaneously measured interarm blood pressure difference and stroke. An individual participants data meta-analysis
This meta-analysis examined the validity of interarm blood pressure difference in simultaneous measurement as a marker to identify subjects with ankle-brachial pressure index <0.90 and to predict future cardiovascular events. Binary logistic regression analysis with adjustments identified interarm blood pressure difference >5 mm Hg as being associated with a significant odds ratio for the presence of ankle-brachial pressure index <0.90 (odds ratio, 2.19; 95% confidence interval, 1.60–3.03; P<0.01). Interarm blood pressure difference >15 mm Hg was associated with a significant Cox stratified adjusted hazard ratio for subsequent stroke (hazard ratio, 2.42; 95% CI, 1.27–4.60; P<0.01). These differences may be useful for identifying subjects with an ankle-brachial pressure index of <0.90 in the overall study population, and also a reliable predictor of future stroke in subjects without a past history of cardiovascular disease.
Association of 24-Hour blood pressure with urinary sodium excretion in healthy adults
In this analysis of 2,899 adults free of cardiovascular disease, diabetes or on BP-lowering treatment, the relationships of 24-hour urinary salt excretion with office and ambulatory BP measurements were assessed. A weak linear association was observed between 24-hour ambulatory systolic BP and urinary sodium excretion (β (95% confidence interval [CI]) per 1 g increase in sodium excretion (0.33 % (0.09; 0.57); P = 0.008). No significant relationships were observed for 24-hour ambulatory diastolic BP. In conclusion, in healthy adults urinary sodium excretion was only weakly associated with systolic 24-hour ambulatory BP.
Associations of initial injury severity and posttraumatic stress disorder diagnoses with long-term hypertension risk after combat injury
The associations between injury severity, posttraumatic stress disorder (PTSD), and development of chronic diseases, such as hypertension, among military service members are not understood. Administrative and clinical databases were used to conduct a retrospective cohort study of 3846 US military casualties. Overall prevalence of PTSD was 42.4%, and prevalence of hypertension was 14.3%. Unadjusted risk of hypertension increased significantly with chronicity of PTSD (1–15 diagnoses: hazard ratio, 1.77; 95% CI, 1.46–2.14; >15 diagnoses: hazard ratio, 2.29; 95% CI, 1.85–2.84) compared with patients never diagnosed with PTSD. It is concluded that in a cohort of service members injured in combat, we found that chronicity of PTSD diagnoses and injury severity were independent risk factors for hypertension.
Association of pulse wave velocity with chronic kidney disease progression and mortality findings from the CRIC Study (Chronic Renal Insufficiency Cohort)
In the prospective cohort study Chronic Renal Insufficiency Cohort of 2795 CKD patients, the relationship between PWV and end-stage kidney disease (ESRD), ESRD or halving of estimated glomerular filtration rate, or death from any cause was examined. Patients with the highest tertile of PWV (>10.3 m/s) were at higher risk for ESRD (hazard ratio 1.37 [1.05–1.80]), ESRD or 50% decline in estimated glomerular filtration rate (hazard ratio 1.25 [0.98–1.58]), or death (hazard ratio 1.72 [1.24–2.38]). It is concluded that PWV is a significant predictor of CKD progression and death in people with impaired kidney function.
Case detection in primary aldosteronism: high-diagnostic value of the aldosterone-to-renin ratio when performed under standardized conditions
In this prospective study on 233 patients, the diagnostic value of the aldosterone-to-renin ratio was assessed by using a highly standardized study protocol and by using a saline infusion test as a reference standard. Correlation of the aldosterone-to-renin ratio (cut-off >5) with primary aldosteronism diagnosis showed a sensitivity of 100% (CI 75.9–100), specificity of 86.7% (CI 81.2–90.7), positive-predictive value of 35.6% (CI 22.3–51.3) and negative-predictive value of 100% (CI 97.5–100.0). These findings show that the aldosterone-to-renin ratio is a good screening modality for primary aldosteronism and is without a high risk of missing a primary aldosteronism diagnosis whenever performed under well standardized conditions.
And a couple of statements:
The role of cardiologists in stroke prevention and treatment: position paper of the European Society of Cardiology Council on Stroke
Obesity and cardiovascular risk: a call for action from the European Society of Hypertension Working Group of Obesity, Diabetes and the High-risk Patient and European Association for the Study of Obesity part A and part B