More Versus Less Intensive Blood Pressure-Lowering Strategy: Cumulative Evidence and Trial Sequential Analysis

Several randomized trials compared a more versus less intensive blood pressure-lowering strategy on the risk of major cardiovascular events and death. Cumulative meta-analyses and trial sequential analyses can establish whether and when firm evidence favoring a specific intervention has been reached from accrued literature. Therefore, we conducted a cumulative trial sequential analysis of 18 trials that randomly allocated 53 405 patients to a more or less intensive blood pressure-lowering strategy. We sought to ascertain the extent to which trial evidence added to previously accrued data. Outcome measures were stroke, myocardial infarction, heart failure, cardiovascular death, and all-cause death. Achieved blood pressure was 7.6/4.5 mm Hg lower with the more intensive than the less intensive blood pressure-lowering strategy. For stroke and myocardial infarction, the cumulative Z curve crossed the efficacy monitoring boundary solely after the SPRINT (Systolic Blood Pressure Intervention Trial) study, thereby providing firm evidence of superiority of a more intensive over a less intensive blood pressure-lowering strategy. For cardiovascular death and heart failure, the cumulative Z curve crossed the conventional significance boundary, but not the sequential monitoring boundary, after SPRINT. For all-cause death, the SPRINT trial pushed the cumulative Z curve away from the futility area, without reaching the conventional significance boundary. We conclude that evidence accrued to date strongly supports the superiority of a more intensive versus a less intensive blood pressure-lowering strategy for prevention of stroke and myocardial infarction. Cardiovascular death and heart failure are likely to be reduced by a more intensive blood pressure-lowering strategy, but evidence is not yet conclusive.

[Blood pressure: the lower the better? Maybe yes]

The SPRINT study tested the hypothesis that hypertensive patients randomized to a more intensive treatment, aimed at lowering systolic blood pressure (BP) below 120 mmHg have a lower incidence of major cardiovascular events when compared to patients randomized to a less intensive treatment (systolic BP reduction below 140 mmHg). Overall, 9361 patients were randomized to the more intensive (n=4678) or less intensive (n=4683) antihypertensive treatment. The study was prematurely interrupted because of an excess benefit in the more intensive arm. Indeed, the group randomized to the more intensive arm showed, when compared to the group randomized to the less intensive arm, a 25% reduction in the primary endpoint (1.65 vs 2.19% per year; p<0.001), a 43% reduction in cardiovascular death (0.25 vs 0.43%; p=0.005), a 27% reduction in all-cause death (1.03% vs 1.40%; p=0.003) and a 38% reduction in hospitalizations for heart failure (0.41 vs 0.67%; p<0.002). Unexpectedly, there was no significant reduction in the risk of stroke (not significant 11% reduction). The SPRINT study unequivocally shows that, in hypertensive patients with systolic BP ≥130 mmHg and no history of diabetes, previous stroke and polycystic renal disease, we should try to lower systolic BP to levels below 120 mmHg with the objective to lower the incidence of heart failure in addition to all-cause and cardiovascular death. Future guidelines on the management of patients with hypertension should implement the results of the SPRINT study.

Timing of breakfast does not influence therapeutic efficacy of liquid levothyroxine formulation

Oral levothyroxine (L-T4) is the mainstay of hypothyroidism treatment. Many factors may influence its absorption, including the timing of administration. Objective of the study is to demonstrate the therapeutic equivalence of administering liquid L-T4 with breakfast or 10 min before breakfast. This was a pilot study conducted with a crossover design AB/BA where A stays for L-T4 with breakfast and B for L-T4 10 min before breakfast. A post hoc analysis was conducted to compare L-T4 administered at breakfast or 10 min before breakfast with L-T4 administered 30 min before breakfast. Sixty-one hypothyroid patients were enrolled and assigned to one of the two treatment sequences. All patients were evaluated for TSH levels at the end of each period. Fifty-nine patients completed the study. The mean thyrotropin concentration was 1.52 ± 0.73 µU/ml when L-T4 was administered with breakfast and 1.46 ± 0.81 µU/ml when it was taken 10 min before breakfast, without clinically and statistically significant differences (P = 0.59), regardless of treatment sequence and period. The mean thyrotropin concentration was 1.54 ± 0.9 µU/ml when L-T4 was administered at 0-10 min intervals before breakfast and 1.25 ± 0.7 µU/ml when it was taken 30 min before breakfast (ratio = 1.23, within our definition of equivalence set at 0.8-1.25). There is therapeutic equivalence between liquid L-T4 administration at breakfast or 10 min before breakfast. We can also hypothesize that there are no clinically relevant differences between liquid L-T4 administration 30 min before breakfast or at shorter intervals.

[Italian Registry Dialysis and Transplant 2011-2013]

The Italian Registry of Dialysis and Transplantation (RIDT) has recently resumed the collection of data of patients on RRT in Italy. Data were requested to Regional Registries for the years 2011-2013 and they contributed according to their possibilities. Eighteen Regions or autonomous Provinces provided data with various degrees of completeness and this made possible to bridge the gap between the current and the previous census (referring to 2010).

RESULTS

Incidencedata were associated to a sample with a coverage of 77% of the national population (46/60 million inhabitants). Patients who started dialysis in these three years were, respectively, 168, 166 and 160 patients pmp. If we project this data to the national population is reasonable to think that 9500-10000 patients per year start the dialytic treatment.

PREVALENCE

The prevalence of patients on dialysis in Italy range, in the 10 years of RIDT, between 750 and 825 patients pmp. Based on this we can reasonably estimate that in Italy there are 45-49000 dialysis patients. Incidence and prevalence vary widely in different regions. Mortalityon dialysis in Italy during the period 2011-2013 was on average 16.2 per 100 patient-years (95% CI: 16.1-16.7) with regional variation smaller than that observed in incidence and prevalence.

CONCLUSIONS

In this paper, data analysis are presented in a direct and non comparative manner. However, it provides information on the status of the RRT in Italy and the temporal consistency of the data is a proof of their validity. Registry data were published in the official site of Italian Registry that can be reached through the website of SIN (www.sin-italy.org).

Why switch from warfarin to NOACs?

Several patients with non-valvular atrial fibrillation treated with warfarin or other vitamin-K antagonists (VKA) might benefit from switching to an oral non vitamin-K antagonist anticoagulant (NOAC). In the absence of randomised comparative trials of switching to NOACs versus maintaining VKA treatment, several considerations argue in favour of a switching strategy. First, there is conclusive evidence that haemorrhagic strokes and intracranial bleedings are much fewer in number with NOACs than with warfarin. The risk of intracranial bleeding is 52 % lower with NOACS than with warfarin, with extremes ranging from 33 to 70 %. Such benefit is applicable to different NOACs, and independent of the time-in-therapeutic range under warfarin. Patients at increased risk for intra-cranial bleeding (renal dysfunction, or prior stroke or intra-cranial bleeding) should benefit most from switching to NOACs. Patients with labile International Normalized Ratio are also considered good candidates for switching because of their increased risk of stroke, and the lack of interactions between the effects of NOACs versus warfarin and the time-in-therapeutic range. Furthermore, some NOACs proved to be superior to warfarin in reducing the risk of thromboembolic complications even in intention-to-treat analyses. As further advantage, NOACs show fewer drug-drug and drug-food interactions when compared with warfarin. Last, but not least, NOACs do not need frequent blood drawings except in patients with moderate renal dysfunction, in whom periodic controls of serum creatinine are generally advised. The higher cost remains a barrier to a wider use of NOACs, especially in low-income settings.

Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis

The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.

The 2014 hypertension guidelines: implications for patients and practitioners in Asia

Hypertension is a global public health issue and a major cause of morbidity and mortality. Because of population growth and ageing, the number of people with uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008. Furthermore, the number of adults with hypertension in 2025 has also been predicted to increase by about 60% to a total of 1.56 billion. The prevalence of hypertension in most Asian countries has increased over the last 30 years and more dramatically in the last 10 years. Several factors contributed to such changes in Asia, but acculturation to Western lifestyle, modernisation and urbanisation are considered key contributing factors. There are some unique features in regards to cardiovascular risk in Asia. Specifically, Asian regions have disproportionately higher mortality and morbidity from stroke compared with Western countries. Furthermore, the relationship between blood pressure level and risk of stroke is stronger in Asia than in Western regions. Although evidence-based and qualified guidelines for hypertension diagnosis and management have been released recently from Europe and North America, the unique features of Asian patients with hypertension raise concerns in regards to the real clinical applicability of Western guidelines in Asian populations. Specifically, it is not yet clear to what extent the new blood pressure target proposed by Western guidelines for high risk and elderly hypertensive individuals apply to Asian populations.

Prognostic Value of Ambulatory Blood Pressure in the Obese: The Ambulatory Blood Pressure-International Study

The purpose of this study was to compare the predictive value of ambulatory blood pressure (BP) vs office BP for cardiovascular events during a 5.8-year follow-up period in the obese and nonobese participants of the Ambulatory Blood Pressure-International Study (n=10,817). Both ambulatory BP and office BP considered separately were predictive of cardiovascular events. However, in Cox models including both pressures, only ambulatory BP was associated with outcome. Among obese patients, the hazard ratios for a 10-mm Hg increase in 24-hour and office systolic BPs were 1.37 (95% confidence interval, 1.20-1.53) and 0.91 (95% confidence interval, 0.76-1.07), respectively. Among nonobese patients, the corresponding hazard ratios were 1.39 (95% confidence interval, 1.31-1.47) and 0.94 (95% confidence interval, 0.88-1.00) (P=not significant vs obese). Similar results were obtained for diastolic BP and for daytime and nighttime BPs. Ambulatory BP has similar predictive capacity in obese and nonobese patients, suggesting that ambulatory BP monitoring is a useful diagnostic tool for the assessment of obese individuals.

Efficacy and safety profile of aliskiren: practical implications for clinicians

Renin-angiotensin-system (RAS) is an enzymatic cascade that plays a pivotal role in the development of arterial hypertension, kidney disease and cardiovascular disease. Inhibition of the RAS with angiotensin converting enzyme (ACE) inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) has proved to be a successful strategy for the treatment of hypertension and related cardiovascular disorders. However, by reducing feedback inhibition of renin release, the effects of ACE-Is and ARBs lead to an increase in plasma renin concentration (PRC) and activity (PRA), limiting a complete inhibition of the RAS. Consequently the effects of a different pharmacological strategy that completely blocks the RAS upstream has been assessed in the last years. In this context, aliskiren is the first representative of a new class of non-peptide orally active renin inhibitor that blocks the RAS at its rate-limiting step and induces a net reduction in PRA, angiotensin II and aldosterone levels. Aliskiren effectively reduces blood pressure as a monotherapy as well in combination therapy. In addition, aliskiren has a placebo-like tolerability profile at the licensed doses of 150 mg and 300 mg. Aliskiren also exhibits additive effects on blood pressure reduction when combined with drugs that lead to a reactive increase in the PRA, such as diuretics, ACE-Is or ARBs. In previous studies, aliskiren showed beneficial effects in patients with arterial hypertension and associated clinical conditions. However, later trials indicated that the use of aliskiren should be avoided in patients with renal failure or receiving ACE-Is or ARBs. The main aim of this review is to summarize the available data on its efficacy and safety profile, highlighting clinical implications from recent trials.

Hyperglycemia in acute coronary syndromes: from mechanisms to prognostic implications

Hyperglycemia is a frequent condition in patients with acute coronary syndromes (ACS). Hyperglycemia during ACS is caused by an inflammatory and adrenergic response to ischemic stress, when catecholamines are released and glycogenolysis induced. Although the involved pathophysiological mechanisms have not yet been fully elucidated, it is believed that hyperglycemia is associated with an increase in free fat acids (which induce cardiac arrhythmias), insulin resistance, chemical inactivation of nitric oxide and the production of oxygen reactive species (with consequent microvascular and endothelial dysfunction), a prothrombotic state, and vascular inflammation. It is also related to myocardial metabolic disorders, leading to thrombosis, extension of the damaged area, reduced collateral circulation, and ischemic preconditioning. In the last few years, several observational studies demonstrated that hyperglycemia in ACS is a powerful predictor of survival, increasing the risk of immediate and long-term complications in patients both with and without previously known diabetes mellitus. Glucose management strategies in ACS may improve outcomes in patients with hyperglycemia, perhaps by reducing inflammatory and clotting mediators, by improving endothelial function and fibrinolysis and by reducing infarct size. Recent clinical trials of insulin in ACS have resulted in varying levels of benefit, but the clinical benefit of an aggressive treatment with insulin is yet unproved.

Endoscopic biopsy samples of naïve "colitides" patients: role of basal plasmacytosis

BACKGROUND

Although it is usually not difficult to diagnose inflammatory bowel disease (IBD) on surgical resection specimens, difficulties sometimes arise in differentiating these entities from other forms of colitis on endoscopic biopsy specimens. Basal plasmacytosis is considered as an early feature of IBD colitis, but it is rare in non-IBD colitides.

AIMS

We assessed the value of basal plasmacytosis as an individual variable in untreated patients with colitis.

PATIENTS AND METHODS

Archival slides of patients with untreated colitis (66 IBD and 49 non-IBD) and 20 controls with complete (from the terminal ileum to the rectum) endoscopic biopsy sampling were evaluated blindly for the presence of basal plasmacytosis and a possible association with the presence of eosinophils in the same anatomical location.

RESULTS

Overall, basal plasmacytosis was present in at least one anatomical segment in 58% of cases, and it was always present in patients with IBD, whereas it was sparsely found (9%) in patients with other colitides and in controls. Basal plasmacytosis in three or more segments had more than 80% probability for a patient to be classified as IBD, with the segmental distribution being different between ulcerative colitis and Crohn's disease. Additionally, basal plasmacytosis was always accompanied by eosinophils intermingled with plasma cells in the same anatomical position.

CONCLUSION

As an individual feature, basal plasmacytosis (accompanied by eosinophils) is a strong feature suggesting IBD, particularly when present in three or more colonic segments. This fact may be useful in the evaluation of endoscopic biopsies from patients with "colitis".

Systolic and diastolic blood pressure changes in relation with myocardial infarction and stroke in patients with coronary artery disease

Excessively high and low achieved blood pressure (BP) may be associated with a bad outcome in patients with coronary artery disease, the J curve phenomenon. The effect of BP changes from baseline in relation with the subsequent risk of stroke and myocardial infarction (MI) is unknown. Of the 25 620 patients randomized in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study, we selected 19 102 patients with coronary artery disease at baseline. BP at entry was 141/82 mm Hg, and its average decrease during follow-up was 7/6 mm Hg. BP entered the analysis as time-varying variable modeled with restricted cubic splines. After adjustment for several potential determinants of reverse causality, a change in BP from baseline by -34/-21 mm Hg (10th percentile) was associated with a lesser risk of stroke without any significant increase in the risk of MI. A rise in systolic/diastolic BP from baseline by 20/10 mm Hg (90th percentile) was associated with an increased risk of stroke, whereas the risk of MI increased with systolic BP and not with diastolic BP. In conclusion, in patients with coronary artery disease and initially free from congestive heart failure, a BP reduction from baseline over the examined BP range had little effect on the risk of MI and predicted a lower risk of stroke. An increase in systolic BP from baseline increased the risk of stroke and MI. The relationships of BP with risk were much steeper for stroke than for MI. A treatment-induced BP reduction over the explored range seems to be safe in patients with coronary artery disease.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00153101.

Safety and efficacy of non-vitamin K oral anticoagulants in non-valvular atrial fibrillation: a Bayesian meta-analysis approach

INTRODUCTION

Choosing between different non-vitamin K antagonist oral anticoagulants (NOACs) in non-valvular atrial fibrillation (NVAF) is difficult due to the absence of head to head comparative studies. We performed a Bayesian meta-analysis to explore similarities and differences between different NOACs and to rank treatments overall for safety and efficacy outcomes.

AREAS COVERED

Through a systematic literature search we identified randomized controlled Phase III trials of dabigatran, rivaroxaban, apixaban, and edoxaban versus adjusted-dose warfarin in patients with NVAF.

EXPERT OPINION

Warfarin ranked worst for all-cause mortality and intracranial bleedings and had a nil probability of ranking first for any outcome. The risk of major bleeding versus warfarin was lower with apixaban, dabigatran 110 mg, and both doses of edoxaban. All agents reduced the risk of intracranial bleeding versus warfarin. Edoxaban 30 mg was the best among the treatments being compared for major and gastrointestinal bleeding. Dabigatran 150 mg was the best for stroke and systemic embolism. This study suggests that NOACs are generally preferable to warfarin in patients with NVAF. However, safety and efficacy differences do exist among NOACs, which might drive their use in specific subsets of AF patients, allowing prescribers to tailor treatment to distinct patient profiles.

Ambulatory blood pressure monitoring in the elderly: features and perspectives

Aging leads to a multitude of changes in the cardiovascular system that include a rise in blood pressure. Age-related changes in blood pressure are mainly attributable to an increase in systolic blood pressure, generally associated with a slight decrease diastolic blood pressure. This leads to a widening in pulse pressure. Ambulatory blood pressure monitoring is a useful tool to understand these processes and to refine cardiovascular risk assessment. In the light of emerging data in this area, we reviewed the main features of ambulatory blood pressure in elderly and discussed the evidence showing that ambulatory blood pressure is superior to clinic blood pressure to reflect the true pattern of blood pressure over time. Furthermore, we discussed the role of weight control obtained by fitness programs to prevent an excessive rise in blood pressure with age. A thorough understanding of these concepts is of paramount importance and has therapeutic implications in the growing population of elderly subjects with increased blood pressure.

Edoxaban in the evolving scenario of non vitamin K antagonist oral anticoagulants imputed placebo analysis and multiple treatment comparisons

Background

Edoxaban recently proved non-inferior to warfarin for prevention of thromboembolism in patients with non-valvular atrial fibrillation (AF). We conducted an imputed-placebo analysis with estimates of the proportion of warfarin effect preserved by each non vitamin K antagonist oral anticoagulant (NOAC) and indirect comparisons between edoxaban and different NOACs.

Methods and Findings

We performed a literature search (up to January 2014), clinical trials registers, conference proceedings, and websites of regulatory agencies. We selected non-inferiority randomised controlled phase III trials of dabigatran, rivaroxaban, apixaban and edoxaban compared with adjusted-dose warfarin in non-valvular AF. Compared to imputed placebo, all NOACs reduced the risk of stroke (ORs between 0.24 and 0.42, all p<0.001) and all-cause mortality (ORs between 0.55 and 0.59, all p<0.05). Edoxaban 30 mg and 60 mg preserved 87% and 112%, respectively, of the protective effect of warfarin on stroke, and 133% and 121%, respectively, of the protective effect of warfarin on all-cause mortality. The risk of primary outcome (stroke/systemic embolism), all strokes and ischemic strokes was significantly higher with edoxaban 30 mg than dabigatran 150 mg and apixaban. There were no significant differences between edoxaban 60 mg and other NOACs for all efficacy outcomes except stroke, which was higher with edoxaban 60 mg than dabigatran 150 mg. The risk of major bleedings was lower with edoxaban 30 mg than any other NOAC, odds ratios (ORs) ranging between 0.45 and 0.67 (all p<0.001).

Conclusions

This study suggests that all NOACs preserve a substantial or even larger proportion of the protective warfarin effect on stroke and all-cause mortality. Edoxaban 30 mg is associated with a definitely lower risk of major bleedings than other NOACs. This is counterbalanced by a lower efficacy in the prevention of thromboembolism, although with a final benefit on all-cause mortality.

Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.

Clinical utility of ambulatory blood pressure monitoring in the management of hypertension

Accurate blood pressure (BP) measurement is essential for the diagnosis, monitoring and management of hypertension. However, conventional office-based BP readings have several limitations that include a low reproducibility, the white-coat effect and the existence of masked hypertension. These limitations can be addressed through the use of ambulatory BP monitoring. Because ambulatory monitoring provides measurements at specific time intervals throughout a 24-hour period, this technique represents a better picture of the normal fluctuations in BP levels associated with daily activities and sleep. In addition, end-organ damage associated with hypertension is more closely related to ambulatory BP than office BP measurements and ambulatory BP profile give better prediction of clinical outcome than conventional BP measurements.

Tight Versus Standard Blood Pressure Control in Patients With Hypertension With and Without Cardiovascular Disease

An excessive blood pressure (BP) reduction might be dangerous in high-risk patients with cardiovascular disease. In the Studio Italiano Sugli Effetti CARDIOvascolari del Controllo della Pressione Arteriosa SIStolica (Cardio-Sis), 1111 nondiabetic patients with systolic BP ≥150 mm Hg were randomly assigned to a systolic BP target <140 mm Hg (standard control) or <130 mm Hg (tight control). We stratified patients by absence (n=895) or presence (n=216) of established cardiovascular disease at entry. Antihypertensive treatment was open-label and tailored to each patient’s needs. After 2-year follow-up, the primary end point of the study, electrocardiographic left ventricular hypertrophy, occurred less frequently in the tight than in the standard control group in the patients without (10.8% versus 15.2%) and with (14.1% versus 23.5%) established cardiovascular disease ( P for interaction=0.82). The main secondary end point, a composite of cardiovascular events and all-cause death, occurred less frequently in the tight than in the standard control group both in patients without (1.47 versus 3.68 patient-years; P =0.016) and with (7.87 versus 11.22 patient-years; P =0.049) previous cardiovascular disease. In a multivariable Cox model, allocation to tight BP control reduced the risk of cardiovascular events to a similar extent in patients with or without overt cardiovascular disease at randomization ( P for interaction=0.43). In conclusion, an intensive treatment aimed to lower systolic BP<130 mm Hg reduced left ventricular hypertrophy and improved clinical outcomes to a similar extent in patients with hypertension and without established cardiovascular disease.

Validation of a disease-specific health-related quality of life measure in adult Italian patients with systemic lupus erythematosus: LupusQoL-IT

OBJECTIVE

The objective of this paper is to assess the validity of a linguistically validated version of the Lupus Quality of Life (LupusQoL(©)) in Italian patients affected by systemic lupus erythematosus (SLE).

METHODS

Consecutive SLE patients completed the Italian version of the LupusQoL(©) and the Short Form (SF)-36. Disease activity was evaluated by the SLE disease activity Index-2000 (SLEDAI-2 K), and chronic damage by the Systemic Lupus International Collaborating Clinics/American College Rheumatology (ACR) Damage Index score (SDI). Internal consistency and test-retest reliability, convergent and discriminant validity were examined. Factor analysis with varimax rotation was performed.

RESULTS

A total of 117 Italian SLE patients (M:F 13:104; mean age 40.6 ± 11.6 years, mean disease duration 127.5 ± 94.1 months) were recruited into the study. The Italian version of the LupusQoL(©) demonstrated substantial evidence of convergent validity in these patients when compared with equivalent items of the SF-36. In addition, the LupusQoL(©) discriminated between patients with different degrees of disease activity as measured by the SLEDAI-2 K. SLE patients with higher disease activity (SLEDAI-2K ≥4) showed poor QoL compared with those with lower disease activity (SLEDAI-2K <4), with significant differences in the domains of physical health, planning, burden to others and fatigue (p = 0.001, p = 0.04, p = 0.03, p = 0.04, respectively). The confirmatory factor analysis using the eight domain loadings of the 34 items showed a poor fit (χ(2)/degree of freedom (df) 2.26, χ(2 )= 1128.6 (p < 0.001), root mean square error of approximation (RMSEA) = 0.167; goodness-of-fit index (GFI) = 0.606, comparative fit index (CFI) = 0.649)). Screeplot analysis suggested a five-factor loading structure and confirmatory factor analysis result of which is similar to the eight-factor model. A good internal consistency was observed (Cronbach's α 0.89-0.91). Test-retest reliability was good to excellent between baseline and day 15 (intraclass correlation coefficient (ICC) 0.90-0.98).

CONCLUSION

The Italian version of the LupusQoL(©) is a valid tool for adult patients with SLE.

Prognostic usefulness of left ventricular hypertrophy by electrocardiography in patients with atrial fibrillation (from the Randomized Evaluation of Long-Term Anticoagulant Therapy Study)

It is unknown whether left ventricular hypertrophy (LVH) diagnosis by electrocardiography improves risk stratification in patients with atrial fibrillation (AF). We investigated the prognostic impact of LVH diagnosis by electrocardiography in a large sample of anticoagulated patients with AF included in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) Study. We defined electrographic LVH (ECG-LVH) by strain pattern or Cornell voltage (R wave in aVL plus S wave in V3) >2.0 mV (women) or >2.4 mV (men). LVH prevalence was 22.7%. During a median follow-up of 2.0 years, 303 patients developed a stroke, 778 died (497 from cardiovascular causes), and 140 developed a myocardial infarction. LVH was associated with a greater risk of stroke (1.99% vs 1.32% per year, hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.18 to 1.93, p <0.001), cardiovascular death (4.52% vs 1.80% per year, HR 2.56, 95% CI 2.14 to 3.06, p <0.0001), all-cause death (6.03% vs 3.11% per year, HR 1.95, 95% CI 1.68 to 2.26, p <0.0001), and myocardial infarction (1.11% vs 0.55% per year, HR 2.07, 95% CI 1.47 to 2.92, p <0.0001). In multivariate analysis, the prognostic value of LVH was additive to CHA2DS2-VASc score and other covariates. The category-free net reclassification index and integrated discrimination improvement increased significantly after adding LVH to multivariate models. In conclusion, our study demonstrates for the first time that ECG-LVH, a simple and easily accessible prognostic indicator, improves risk stratification in anticoagulated patients with AF.

Feasibility and effectiveness in clinical practice of a multifactorial intervention for the reduction of cardiovascular risk in patients with type 2 diabetes: the 2-year interim analysis of the MIND.IT study: a cluster randomized trial

OBJECTIVE

To evaluate the feasibility and effectiveness of an intensive, multifactorial cardiovascular risk reduction intervention in a clinic-based setting.

RESEARCH DESIGN AND METHODS

The study was a pragmatic, cluster randomized trial, with the diabetes clinic as the unit of randomization. Clinics were randomly assigned to either continue their usual care (n = 5) or to apply an intensive intervention aimed at the optimal control of cardiovascular disease (CVD) risk factors and hyperglycemia (n = 4). To account for clustering, mixed model regression techniques were used to compare differences in CVD risk factors and HbA1c. Analyses were performed both by intent to treat and as treated per protocol.

RESULTS

Nine clinics completed the study; 1,461 patients with type 2 diabetes and no previous cardiovascular events were enrolled. After 2 years, participants in the interventional group had significantly lower BMI, HbA1c, LDL cholesterol, and triglyceride levels and significantly higher HDL cholesterol level than did the usual care group. The proportion of patients reaching the treatment goals was systematically higher in the interventional clinics (35% vs. 24% for LDL cholesterol, P = 0.1299; 93% vs. 82% for HDL cholesterol, P = 0.0005; 80% vs. 64% for triglycerides, P = 0.0002; 39% vs. 22% for HbA1c, P = 0.0259; 13% vs. 5% for blood pressure, P = 0.1638). The analysis as treated per protocol confirmed these findings, showing larger and always significant differences between the study arms for all targets.

CONCLUSIONS

A multifactorial intensive intervention in type 2 diabetes is feasible and effective in clinical practice and it is associated with significant and durable improvement in HbA1c and CVD risk profile.

Intensive blood pressure control in obese diabetic patients: clinical relevance of stroke prevention in the ACCORD trial

In the ACCORD clinical trial, lowering blood pressure (BP) to normal levels, below currently recommended levels, did not significantly reduce the combined risk of fatal or nonfatal cardiovascular (CV) disease events in adults with Type 2 diabetes. A new post hoc analysis of the same trial also suggests that lowering BP in centrally obese diabetic patients is not a useful means for CV prevention. The authors discuss these findings in the light of accumulated evidence on the relationship between the degree of BP reduction and the risk of CV events in patients with diabetes. In particular, the authors focus on trial and systematic review findings, suggesting that a more intensive reduction of BP in Type 2 diabetes effectively protects from stroke.

Multivariable analysis in cerebrovascular research: practical notes for the clinician

The term 'multivariate analysis' is often used when one is referring to a multivariable analysis. 'Multivariate', however, implies a statistical analysis with multiple outcomes. In contrast, multivariable analysis is a statistical tool for determining the relative contributions of various factors to a single event or outcome. The purpose of this article is to focus on analyses where multiple predictors are considered. Such an analysis is in contrast to a univariable (or 'simple') analysis, where single predictor variables are considered. We review the basics of multivariable analyses, what assumptions underline them and how they should be interpreted and evaluated.

Predictive value of night-time heart rate for cardiovascular events in hypertension. The ABP-International study

BACKGROUND

Data from prospective cohort studies regarding the association between ambulatory heart rate (HR) and cardiovascular events (CVE) are conflicting.

METHODS

To investigate whether ambulatory HR predicts CVE in hypertension, we performed 24-hour ambulatory blood pressure and HR monitoring in 7600 hypertensive patients aged 52 ± 16 years from Italy, U.S.A., Japan, and Australia, included in the 'ABP-International' registry. All were untreated at baseline examination. Standardized hazard ratios for ambulatory HRs were computed, stratifying for cohort, and adjusting for age, gender, blood pressure, smoking, diabetes, serum total cholesterol and serum creatinine.

RESULTS

During a median follow-up of 5.0 years there were 639 fatal and nonfatal CVE. In a multivariable Cox model, night-time HR predicted fatal combined with nonfatal CVE more closely than 24h HR (p=0.007 and =0.03, respectively). Daytime HR and the night:day HR ratio were not associated with CVE (p=0.07 and =0.18, respectively). The hazard ratio of the fatal combined with nonfatal CVE for a 10-beats/min increment of the night-time HR was 1.13 (95% CI, 1.04-1.22). This relationship remained significant when subjects taking beta-blockers during the follow-up (hazard ratio, 1.15; 95% CI, 1.05-1.25) or subjects who had an event within 5 years after enrollment (hazard ratio, 1.23; 95% CI, 1.05-1.45) were excluded from analysis.

CONCLUSIONS

At variance with previous data obtained from general populations, ambulatory HR added to the risk stratification for fatal combined with nonfatal CVE in the hypertensive patients from the ABP-International study. Night-time HR was a better predictor of CVE than daytime HR.

Aggressive blood pressure reduction in patients at high vascular risk: is it dangerous?

Introduction The aim of this review was to summarize the current state of evidence regarding the optimal blood pressure goals in patients with high vascular risk. In particular, this review critically addresses the issue of the “J-curve” paradox – a hypothesis indicating that low treatment-induced blood pressure values are characterized by an increase, rather than a decrease, in the incidence of cardiovascular events. Materials and methods We reviewed evidence from studies published in peer-reviewed journals indexed in Medline, EMBASE and CINAHL that compared different BP goals. Results Post-hoc analyses of randomized trials specifically conducted to test the hypothesis of the “J-shaped curve” yielded conflicting results. However, trials directly comparing different blood pressure goals and meta-analyses showed that in-treatment blood pressure values below the usual goal of less than 140/90 mmHg improve outcomes in patients at increased vascular risk. Discussion The fear that an excessive reduction in blood pressure may be dangerous is inconsistent with the available data and probably conditioned by the adverse impact of other risk factors that may be more frequent in patients with low values of achieved blood pressure. The association between blood pressure reduction and cardiovascular risk seems to be linear and not J-shaped.