Association among blood pressure control in elderly patients with hypertension, left atrial structure and function and new-onset atrial fibrillation: a prospective 2-year study in 234 patients

Impact of nocturnal blood pressure dipping on recurrence of atrial fibrillation after pulmonary vein isolation

Lack of the typical nocturnal blood pressure (BP) fall, i.e non-dipper, has been known as a cardiovascular risk. However, the influence of non-dipper on atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has been unclear. We investigated the clinical impact of non-dipping as evaluated by 24-hour ambulatory BP monitoring on the long-term outcome of AF recurrence post-PVI in 76 AF patients with a history of increased BP. The PVI procedure was successful in all 76 patients (mean age, 66±9years; antihypertensive medication, 89%; non-paroxysmal AF, 24%). Twenty patients had AF recurrence during a median follow-up of 1138 days. There was no difference in BP levels between the AF recurrence and non-recurrence groups (average 24 h systolic BP:126 ± 17 vs.125 ± 14 mmHg; P = 0.84). On the other hand, the patients with non-dipper had a higher AF recurrence than those with dipper (38.9% vs.15.0%; P = 0.018). In Cox hazard analysis adjusted by age, non-paroxysmal AF and average 24-hr systolic BP level, the non-dipper was an independent predictor of AF recurrence (HR 2.78 [95%CI:1.05-7.34], P = 0.039). Non-dipper patients had a larger left atrial (LA) volume index than the dipper patients (45.9 ± 17.3 vs.38.3 ± 10.2 ml/m2, P = 0.037). Among the 58 patients who underwent high-density voltage mapping in LA, 11 patients had a low-voltage area (LVA) defined as an area with a bipolar voltage < 0.5 mV. However, there was no association of LVA with non-dipper or dipper (22.2% vs.16.1%, P = 0.555). Non-dipper is an independent predictor of AF recurrence post-PVI. Management of abnormal diurnal BP variation post-PVI may be important.

Management of atrial fibrillation: two decades of progress - a scientific statement from the European Cardiac Arrhythmia Society

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades.

RESULTS

Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction.

CONCLUSIONS

Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.

Association of clinic and ambulatory blood pressure with new-onset atrial fibrillation: A meta-analysis of observational studies

The aim of this study was to perform a meta‐analysis of studies evaluating the association of clinic and daytime, nighttime, and 24‐h blood pressure with the occurrence of new‐onset atrial fibrillation. We conducted a literature search through PubMed, Web of science, and Cochrane Library for articles evaluating the occurrence of new‐onset atrial fibrillation in relation to the above‐mentioned blood pressure parameters and reporting adjusted hazard ratio and 95% confidence interval. We identified five studies. The pooled population consisted of 7224 patients who experienced 444 cases of atrial fibrillation. The overall adjusted hazard ratio (95% confidence interval) was 1.05 (0.98‐1.13), 1.19 (1.11‐1.27), 1.18 (1.11‐1.26), and 1.23 (1.14‐1.32), per 10‐mmHg increment in clinic, daytime, nighttime, and 24‐h systolic blood pressure, respectively. The degree of heterogeneity of the hazard ratio estimates across the studies (Q and I‐squared statistics) were minimal. The results of this meta‐analysis strongly suggest that ambulatory systolic blood pressure prospectively predicts incident atrial fibrillation better than does clinic systolic blood pressure and that daytime, nighttime, and 24‐h systolic blood pressure are similarly associated with future atrial fibrillation.

Ambulatory blood pressure and risk of new-onset atrial fibrillation in treated hypertensive patients

The aim of this study was to evaluate the influence of clinic and ambulatory blood pressure (BP) on the occurrence of new-onset atrial fibrillation (AF) in treated hypertensive patients. We studied 2135 sequential treated hypertensive patients aged >40 years. During the follow-up (mean 9.7 years, range 0.4-20 years), 116 events (new-onset AF) occurred. In univariate analysis, clinic, daytime, nighttime, and 24-h systolic BP were all significantly associated with increased risk of new-onset AF, that is, hazard ratio (95% confidence interval) per 10 mm Hg increment 1.22 (1.11-1.35), 1.36 (1.21-1.53), 1.42 (1.29-1.57), and 1.42 (1.26-1.60), respectively. After adjustment for various covariates in multivariate analysis, clinic systolic BP was no longer associated with increased risk of new-onset AF, whereas daytime, nighttime, and 24-h systolic BP remained significantly associated with outcome, that is, hazard ratio (95% confidence interval) per 10 mm Hg increment 1.09 (0.97-1.23), 1.23 (1.10-1.39), 1.16 (1.03-1.31), and 1.22 (1.06-1.40), respectively. Daytime, nighttime, and 24-h systolic BP are superior to clinic systolic BP in predicting new-onset AF in treated hypertensive patients. Future studies are needed to evaluate whether a better control of ambulatory BP might be helpful in reducing the occurrence of new-onset AF.

Office, central and ambulatory blood pressure for predicting incident atrial fibrillation in older adults

OBJECTIVES

Recently, more sophisticated blood pressure (BP) measurements, such as central and ambulatory BP (ABP), have proven to be stronger predictors of future cardiovascular disease than conventional office BP. Their predictive value for atrial fibrillation development is not established. We investigated the prognostic impact for incident atrial fibrillation of office, central and ambulatory BP measurements in a predominantly older population-based cohort.

METHODS

Of 1004 participants in the Cardiovascular Abnormalities and Brain Lesions (CABL) study, 769 in sinus rhythm with no history of atrial fibrillation or stroke (mean age 70.5 years) underwent ABP and arterial wave reflection analysis for central BP determination. Fine and Gray's proportional subdistribution hazards models were used to assess the association of BP parameters with incident atrial fibrillation.

RESULTS

During 9.5 years, atrial fibrillation occurred in 83 participants. No office BP variable showed a significant association with incident atrial fibrillation. Central SBP and central pulse pressure were marginally associated with incident atrial fibrillation in multivariate analysis. Among ABP variables, 24-h SBP [adjusted hazard ratio per 10 mmHg, 1.24; 95% confidence interval (CI) 1.07--1.44; P = 0.004], daytime SBP (adjusted hazard ratio per 10 mmHg, 1.21; 95% CI 1.04--1.40; P = 0.011) and night-time SBP (adjusted hazard ratio per 10 mmHg, 1.22; 95% CI 1.07--1.39; P = 0.002) were significantly associated with incident atrial fibillation.

CONCLUSION

In a predominantly older, stroke-free community-based cohort, ABP was a better independent predictor of incident atrial fibrillation than central BP, whereas office BP was inadequate for this purpose.

Relationships among pulmonary capillary wedge pressure, dry weight and natriuretic peptide in patients undergoing hemodialysis: a three-dimensional speckle tracking echocardiography study

BACKGROUND

Although the evaluation of fluid status in hemodialysis (HD) patients is useful, relationship among pulmonary capillary wedge pressure (PCWP), dry body weight (DW) and natriuretic peptide has not been elucidated. In addition, there has been no objective marker for instantaneously monitoring hemodynamic improvement in response to HD. We previously reported that PCWP and time constant of left ventricular pressure decline (Tau) can be noninvasively estimated (ePCWP and eTau) by speckle tracking echocardiography (STE). The aim of this study was to elucidate the relationship among ePCWP, eTau, DW and natriuretic peptide in patients undergoing HD.

METHODS

We measured ePCWP and body weight (BW) by STE in 81 patients and ANP and BNP by blood examination in 31 patients just before and after HD during sinus rhythm.

RESULTS

The ePCWP decreased after HD, and this was associated with reductions in ln ANP, eTau and BW (r = 0.523, 0.271 and 0.814, respectively, p < 0.05). The % change in ePCWP was not correlated with the % change in ln BNP (p = 0.47). The change in ePCWP had a stronger correlation with the % change in BW than the change in any other parameters.

CONCLUSIONS

The ePCWP is more sensitive to estimate the change in BW during HD than any other parameters such as ANP and BNP. These results indicated that a substantial amount of excess fluid can be assessed real-time by STE using ePCWP.

Impact of pre-existing hypertension and control status before atrial fibrillation onset on cardiovascular prognosis in patients with non-valvular atrial fibrillation: A real-world database analysis in Japan

Hypertension is an important risk factor for non-valvular atrial fibrillation (NVAF) and its prognosis. However, there is no study to clarify the impact of pre-existing hypertension and BP control status before the onset of AF on the prognosis after the onset of AF. This retrospective real-world cohort analysis used data from the Japan Medical Data Center Co., Ltd database. The presence of NVAF and hypertension, plus the occurrence of adverse events, was based on ICD-10 codes in the database. The primary composite AF-related cardiovascular event end point included ischemic stroke, hemorrhagic stroke, and acute myocardial infarction. Of the 21 523 patients identified as having new-onset NVAF between January 2005 and June 2016, 7885 had blood pressure (BP) data before the onset of NVAF available and were included in the analysis (4001 with pre-existing hypertension and 3884 without pre-existing hypertension). The rate of primary composite end point events was 10.3 and 4.4 per 1000 patient-years in patients with and without hypertension, respectively (P < .001). In addition, lower systolic BP (<120 mm Hg) before the onset of NVAF was associated with a lower incidence of cardiovascular events after the development of NVAF (P < .001). This highlights the importance of earlier and tighter 24-hour BP control before the onset of NVAF in patients with hypertension, not only for reducing the occurrence of new-onset of NVAF, but also for reducing both hemorrhagic and ischemic cardiovascular events after the onset of NVAF.

Association of left atrial enlargement with ventricular remodeling in hypertensive Chinese elderly

BACKGROUND

It is not well known whether left atrial (LA) enlargement is associated with left ventricular (LV) remodeling in Asian subjects with preserved LV ejection fraction (LVEF ≥50%). Therefore, we studied whether LA enlargement is related to ventricular remodeling in hypertensive Chinese elderly with preserved LVEF.

METHODS

Data of 480 hypertensive Chinese elderly (age from 65 to 94 years) with LVEF ≥50% were consecutively included in the study.

RESULTS

We observed a total of 248 patients (51.7%) with increased LA size. Univariate analysis showed that LA size was positively related to duration of hypertension, prevalence of coronary heart disease and atrial fibrillation, interventricular septal thickness, LV posterior wall thickness, LV end-diastolic and end-systolic diameter, LV mass index, right ventricular (RV) diameter and aortic diameter; meanwhile, LA size was inversely related to LVEF and relative wall thickness of LV. Multivariate regression analysis showed that LA enlargement was positively related to duration of hypertension (P=.012) and RV diameter (P<.001).

CONCLUSIONS

Left atrial enlargement is independently associated with a longer duration of hypertension and RV dilative remodeling in hypertensive elderly with preserved LVEF. LA enlargement is an early sign of RV eccentric remodeling in hypertensive elderly.

Impact of gender and healthy aging on pulmonary capillary wedge pressure estimated by the kinetics-tracking index using two-dimensional speckle tracking echocardiography

Risk stratification in heart failure (HF) among patients and healthy subjects using pulmonary capillary wedge pressure (PCWP) is important for understanding when and why HF develops. The aim of the present study was to evaluate the impact of gender and healthy aging on estimated PCWP using a kinetics-tracking index in patients and in healthy subjects without hypertension. The study population consisted of 198 healthy subjects without cardiovascular or other systemic diseases and who were not taking any medications. Echocardiographic studies were performed using an ACUSON Sequoia 512 ultrasound system. Active left atrial (LA) emptying function (EF) was defined as (pre-atrial contraction LA volume-minimum LA volume)/pre-atrial contraction LA volume × 100%. With an increase in age, the E/A and E/e' ratios (markers of left ventricular (LV) diastolic dysfunction (DD)) showed a similar decrease in males and females. PCWP was maintained at 8.3±1.8 mm Hg in males and 8.2±2.3 mm Hg in females because of compensation by an increase in active LA EF. In contrast, the compensation for LV DD with an increase in active LA EF in females tended to be more gradual (slope=0.11) than in males (slope=0.18, P=0.060 vs. female). The parameters that indicated LV DD deteriorated with advancing age. PCWP might be maintained because of compensation, namely an increase in active LA EF in both males and females. The compensation in female septuagenarians and octogenarians was weaker than in male septuagenarians and octogenarians. This difference in compensation may explain why HF with preserved LV ejection fraction occurs more frequently in females than in males.

A novel management program for hypertension

In this article, we describe a comprehensive management program for hypertension (HTN), based on the experience of leading cardiovascular centers in China. This comprehensive approach, adhering to a number of core principles, includes diagnosis and therapeutic interventions. Therapeutic management includes lifestyle changes, risk factor management and pharmacological intervention and should allow reliable lowering blood pressure (BP). Additional paragraphs discuss the relationship between paroxysmal atrial fibrillation (PAF), and HTN.

Strain/strain rate imaging of impaired left atrial function in patients with metabolic syndrome

Left ventricular (LV) dysfunction has been demonstrated in patients with metabolic syndrome (MetS). However, alterations in left atrial (LA) function in MetS are unknown. We aimed to use strain/strain rate (SR) imaging to investigate the effect of MetS on LA function. A total of 177 MetS patients and 156 normal subjects underwent echocardiography. Strain and SR tissue Doppler imaging values were used to evaluate LA function. Partial correlation and multiple stepwise regression analyses were used to determine the risk factors for impaired LA function. Compared with the controls, the MetS patients showed significantly lower levels of mean strain, mean peak systolic SR and mean peak early diastolic SR (P<0.001 for all), with no difference in the mean peak late diastolic SR. Central obesity, hypertension, dyslipidemia and LV diastolic abnormality were independent risk factors for impaired LA function. LA function was impaired in patients with MetS as a result of metabolic disturbance and LV diastolic abnormality. SR imaging is reliable in assessing LA function in MetS patients.

The case against using hypertension as the only criterion for oral anticoagulation in atrial fibrillation

According to recent guidelines for atrial fibrillation (AF) management, the presence of hypertension warrants anticoagulation, often involving the use of newer oral anticoagulants (NOACs). To discuss this idea, we posited the case against this proposition. We note that the data on hypertension that formulated the most commonly used Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) risk algorithm were not clearly defined and that there are insufficient data that hypertension in the presence of AF produces a meaningful incremental increase in stroke risk over and above the stroke risk increase for hypertension alone. Data exist that persons younger than 65 years of age with only 1 stroke risk factor such as hypertension, have a very small stroke risk. We further note that there are no quantitative data to allow clinicians to decide the level of blood pressure that meaningfully increases stroke risk in AF. Furthermore, there are insufficient data on the blood pressure level at which the risk of cerebral hemorrhage outweighs the risk of cardioembolic events. Clinical trials of NOACs in AF did not usually include hypertension as the only entry criteria. Another issue is the recent changes in the level of blood pressure for the diagnosis of hypertension based on home and ambulatory blood pressure measurement, which were not used to construct either stroke risk algorithms or entry criteria for NOAC clinical trials. These considerations highlight some of the complexities of using hypertension as a sole criterion for decision-making for anticoagulation in AF.