Results of ACCORDIAN in ACCORD with lower blood pressure begetting lower mortality in patients with diabetes

Impact of clinical ultrasound in patients with heart failure treated in home

BACKGROUND AND OBJECTIVE

In Spain, more than 10% of patients discharged with acute heart failure (AHF) are readmitted in the first 30 days. This study is designed to assess whether the treatment of AHF guided by clinical ultrasound (CU) in the setting of hospitalization at home (HAH) reduces the incidence of readmission and mortality compared to the standard care (SC).

PATIENTS AND METHODS

A randomized, open, parallel, single-center and controlled clinical trial (RCT) was designed (NT05042752). Patients >18 years of age admitted for AHF to HAD from January 2021 to April 2021 at the Reina Sofía Hospital in Tudela were consecutively included. The patients were randomized to the UG-ultrasound group (SC and CU performed) and the CG-control group (SC). The diuretic treatment was tailored according to the findings of the SC together with the CU or according to the findings of the SC respectively. The main variables were the relative risk of readmission and mortality from AHF.

RESULTS

A total of 79 patients were randomized, 39 to UG and 40 to CG. Of these, only 35 of the UG and 35 of the CG completed the intervention. The risk of readmission due to AHF was reduced by 60% in UG compared to CG (RR 0.4; 95% CI: 0.1-1) and mortality by 30% (RR 0.7; 95% CI: 0.2-2.2). Despite the relevant magnitude of the effect found, the results did not reach statistical significance due to lack of power.

CONCLUSION

Our results suggest that in HAH, a CE guided strategy for AHF could reduce the risk of readmission and mortality compared to SC alone. However, studies with greater statistical power are needed to confirm these results.

Treatment of Hypertension in Patients with Diabetes Mellitus: a Contemporary Approach

PURPOSE OF REVIEW

Blood pressure guidelines worldwide have changed their recommended blood pressure goals multiple times over the past decade due to an evolving understanding of the treatment of hypertension in patients with diabetes mellitus. While it is evident through randomized trials that treatment of hypertension in diabetes mellitus prevents complications, the optimal blood pressure goal is not clear.

RECENT FINDINGS

Post hoc analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial, its long-term follow along study ACCORDION, and Systolic Blood Pressure Intervention Trial (SPRINT) suggest that patients with diabetes have a reduced risk of adverse cardiovascular events when aiming for more intensive blood pressure targets. High-quality data support guideline recommendations for more aggressive blood pressure targets in patients with diabetes mellitus. Reasoning for a return to more aggressive blood pressure goals in this at-risk population is discussed, and treatment strategies encompassing contemporary therapeutic options are recommended.

Artificial Intelligence and Hypertension: Recent Advances and Future Outlook

Prevention and treatment of hypertension (HTN) are a challenging public health problem. Recent evidence suggests that artificial intelligence (AI) has potential to be a promising tool for reducing the global burden of HTN, and furthering precision medicine related to cardiovascular (CV) diseases including HTN. Since AI can stimulate human thought processes and learning with complex algorithms and advanced computational power, AI can be applied to multimodal and big data, including genetics, epigenetics, proteomics, metabolomics, CV imaging, socioeconomic, behavioral, and environmental factors. AI demonstrates the ability to identify risk factors and phenotypes of HTN, predict the risk of incident HTN, diagnose HTN, estimate blood pressure (BP), develop novel cuffless methods for BP measurement, and comprehensively identify factors associated with treatment adherence and success. Moreover, AI has also been used to analyze data from major randomized controlled trials exploring different BP targets to uncover previously undescribed factors associated with CV outcomes. Therefore, AI-integrated HTN care has the potential to transform clinical practice by incorporating personalized prevention and treatment approaches, such as determining optimal and patient-specific BP goals, identifying the most effective antihypertensive medication regimen for an individual, and developing interventions targeting modifiable risk factors. Although the role of AI in HTN has been increasingly recognized over the past decade, it remains in its infancy, and future studies with big data analysis and N-of-1 study design are needed to further demonstrate the applicability of AI in HTN prevention and treatment.

Clinical correlates of hand-held ultrasound-guided assessments of the inferior vena cava in patients with acute decompensated heart failure

BACKGROUND

Accurately assessing volume status in acutely decompensated heart failure (ADHF) can be challenging. Inferior vena cava (IVC) dynamics by echocardiography allow indirect assessment of volume status in these patients. Recently introduced hand-held ultrasound devices are promising. We aimed to describe the clinical correlates of volume status assessment using a hand-held ultrasound device in ADHF.

METHODS

In this prospective study, we evaluated 106 patients admitted with ADHF. First scan was performed within 24 hours of admission and timed in reference to first dose of intravenous diuretic. Daily resting and inspiratory (sniff) IVC diameters were measured according to standard echocardiography methods during hospitalization including the day of discharge. IVC collapsibility index (IVC-CI = Maximum IVC diameter-Inspiratory IVC diameter/maximum diameter; <0.5 representing hypervolemia) was calculated. Primary study endpoint was 30-day readmission. Research activities were independent of clinical decision-making.

RESULTS

Data for 106 patients was analyzed. Mean age was 66.7 ± 13.8 years, of which 53.8% were females, and a mean ejection fraction was 39 ± 18%. Initial scan of the IVC was obtained at an average time of 5.2 ± 8.04 hours from first diuretic dose. 81.2% of patients at admission had an IVC-CI <0.5. 63.2% patients had an IVC-CI <0.5 at discharge. There were no significant differences in age, length of stay, diuretic dose, or 30-day readmissions between patients with a discharge IVC-CI <0.5 vs ≥ 0.5.

CONCLUSION

Hand-held ultrasound assessment of IVC-CI in ADHF patients, although a feasible concept, is unable to predict 30-day readmissions in our study. Further prospective studies are necessary.