Ambulatory pulse pressure and its contributors in autosomal dominant polycystic kidney disease

BACKGROUND

Pulse pressure (PP) is a pulsatile component of blood pressure (BP), strongly correlated with arterial stiffness (AS) and impacting prognosis. Disproportionally increased PP values in individuals with autosomal dominant polycystic kidney disease (ADPKD) should be expected, given the multifactorial cardiovascular involvement in the natural course of this disease.

OBJECTIVES

To investigate ambulatory PP in a group of ADPKD patients, and to examine the impact of age, sex, kidney function, hypertension, circadian rhythm, and antihypertensive drugs (AH) on studied parameters.

MATERIAL AND METHODS

A total of 130 ADPKD patients (median age 41 years, 35% men) who underwent 24-hour BP measurement with portable oscillometer Spacelabs 90217, were included in the study and their recordings were retrospectively analyzed. Demographic data and the medical history including antihypertensive treatment were collected, ADPKD was diagnosed based on the criteria by Pei et al., and estimated glomerular filtration rate (eGFR) was calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.

RESULTS

Pulse pressure in the whole group was 46 (IQR: 42-53) mm Hg and it was significantly higher in men than in women and during the day compared to nighttime. There was a negative correlation of PP with eGFR and a positive correlation with age. Pulse pressure was not different in ADPKD patients with or without a diagnosis of hypertension.

CONCLUSION

Ambulatory PP is not substantially increased in ADPKD patients across different stages of CKD. It follows a regular pattern of being increased with age, male sex, daytime, and decreasing eGFR, but not with the diagnosis of hypertension.

SO037AMBULATORY BLOOD PRESSURE IN AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE - IMPROVING DIAGNOSIS AND OPTIMIZING THERAPY

Background and Aims

Hypertension (AH) is an early complication of autosomal dominant polycystic kidney disease (ADPKD), which significantly increases the risk of decline of kidney function and impacts cardiovascular risk. The diagnosis of AH is often delayed and the optimal control of blood pressure (BP) is difficult to achieve in this group of patients. Of note, the optimal treatment of AH in ADPKD is yet to be established.

Aim of the study was to diagnose AH (including the prevalence of masked hypertension) and to evaluate the control of BP with the use of ABPM in a cohort of ADPKD patients.

Method

ABPMs were performed in 163 consecutive patients, with ADPKD according to Pei criteria, appointed for the first outpatient visit. Prior to the ABPM, the diagnosis based on office BP or current AH treatment was established as well as age, sex, medication intake, and eGFR (CKD-EPI formula) were recorded. The study had a cross-sectional design.

Results

Out of 163 performed ABPMs, 143 were eligible for further analysis. The study group consisted of 93 females and 50 males, median age was 40 (18-87) years and median eGFR was 79.5(13-90) ml/min/1.73m2. 68% of patients had CKD G1 or 2. Median systolic blood pressure (SBP) was 127 (101-157) mmHg with blood pressure variability (BPV) 12 (7.8-23); median diastolic blood pressure (DBP) was 79 (58-98) mmHg, BPV 10.8 (6.2-17.4). 35% of patients were non-dippers, 2.7% extreme dippers and 4.9% reverse-dippers. In 31 (55%), out of 56 patients without previous diagnosis of AH, masked hypertension was found. Among 87 diagnosed with AH before the measurement, 49% were treated with 1 drug, and 29% with 2, 13% with 3, and 2% with 4. The most prevalent medication was ACE-inhibitor. Among treated, only 5.5% had all ABPM values within the target.

Conclusion

55% of patients previously not diagnosed with AH on the basis of office BP proved to suffer from masked hypertension. The night DBP was the most suboptimally controlled value in ADPKD patients. Whether this is a consequence of nonadherence or suboptimal treatment, needs further investigation. ABPM is an indispensable tool in managing patients inflicted with ADPKD.

Metabolomic Signature of Early Vascular Aging (EVA) in Hypertension

Arterial stiffening is a hallmark of early vascular aging (EVA) syndrome and an independent predictor of cardiovascular morbidity and mortality. In this case-control study we sought to identify plasma metabolites associated with EVA syndrome in the setting of hypertension. An untargeted metabolomic approach was used to identify plasma metabolites in an age-, BMI-, and sex-matched groups of EVA (n = 79) and non-EVA (n = 73) individuals with hypertension. After raw data processing and filtration, 497 putative compounds were characterized, out of which 4 were identified as lysophosphaditylcholines (LPCs) [LPC (18:2), LPC (16:0), LPC (18:0), and LPC (18:1)]. A main finding of this study shows that identified LPCs were independently associated with EVA status. Although LPCs have been shown previously to be positively associated with inflammation and atherosclerosis, we observed that hypertensive individuals characterized by 4 down-regulated LPCs had 3.8 times higher risk of EVA compared to those with higher LPC levels (OR = 3.8, 95% CI 1.7–8.5, P < 0.001). Our results provide new insights into a metabolomic phenotype of vascular aging and warrants further investigation of negative association of LPCs with EVA status. This study suggests that LPCs are potential candidates to be considered for further evaluation and validation as predictors of EVA in patients with hypertension.

Aortic stiffness is not only associated with structural but also functional parameters of retinal microcirculation

OBJECTIVE

The aim of the study was to test the hypothesis that alterations in large arteries are associated with microvascular remodelling and decreased retinal capillary blood flow.

METHODS

The study group comprised of 88 patients with essential hypertension and 32 healthy controls. Retinal microcirculation was evaluated by scanning laser Doppler flowmetry. Macrovascular changes were assessed on the basis of arterial stiffness measurement (carotid-femoral pulse wave velocity), its hemodynamic consequences (central pulse pressure, augmentation pressure, augmentation index) and intima media thickness of common carotid artery.

RESULTS

Pulse wave velocity was inversely correlated to mean retinal capillary blood flow in hypertensive patients (R = -0.32, p < 0.01). This relationship remained significant in multivariate regression analysis after adjustment for age, sex, central systolic blood pressure (BP) and body mass index (β = -31.27, p < 0.001). Lumen diameter (LD) of retinal arterioles was significantly smaller in hypertensive then normotensive subjects (79.4 vs. 83.8, p = 0.03). Central and brachial systolic, diastolic and mean BPs were significantly correlated with LD and outer diameter of retinal arterioles. The relationship between LD and central BPs remained significant in multivariate analysis (β = -0.15, p = 0.03 for cSBP; β = -0.22, p = 0.04 for cDBP; β = -0.21, p = 0.03 for cMBP). Moreover, in a subgroup with cardiac damage central and brachial pulse pressure were positively associated with retinal wall thickness, wall cross sectional area, and wall to lumen ratio.

CONCLUSION

In conclusion, the study provides a strong evidence that microcirculation is coupled with macrocirculation not only in terms of structural but also functional parameters.

Lumen narrowing and increased wall to lumen ratio of retinal microcirculation are valuable biomarkers of hypertension-mediated cardiac damage

Purpose: In the course of hypertension, left ventricular hypertrophy and diastolic dysfunction develop very often and may progress toward heart failure. The aim of the study was to analyze the relationship between abnormalities of retinal microcirculation and cardiac damage defined as left ventricular hypertrophy and/or diastolic dysfunction.Materials and methods: The study comprised 88 patients with essential hypertension. The group was divided into two subgroups: hypertensives without cardiac damage (n = 55) and with cardiac damage (n = 33). Control group comprised 32 normotensive subjects. Scanning laser Doppler flowmetry was used to evaluate retinal microcirculation. Echocardiography was used to assess cardiac damage.Results: Lumen diameter of retinal arterioles was significantly smaller in patients with cardiac damage vs. controls (77 vs. 84 µm, p = 0.02). Additionally, there was an evident trend with respect to lumen diameter (LD) across all three studied subgroups; i.e.: the smallest dimeters were present in cardiac damage patients, moderate size in hypertensives' without cardiac damage, and the largest diameters in healthy controls (pfor trend < 0.01). Lumen diameter was inversely correlated with cardiac intraventricular septum diameter (R = -0.25, p = 0.02), left ventricular mass (R = -0.24, p = 0.02), and left atrial volume (R = -0.22, p = 0.04). Wall to lumen ratio was associated with intraventricular septum diameter (R = 0.21, p = 0.044) and left atrial volume (R = 0.21, p = 0.045). In multivariable regression analysis, lumen diameter was independently associated with intraventricular septum diameter (β = -0.05, p = 0.03), left ventricular mass (β = -1.15, p = 0.04), and left atrial volume (β = -0.42, p = 0.047); wall to lumen ratio was independently associated with intraventricular septum diameter (β = 3.67, p = 0.02) and left atrial volume (β = 30.0, p = 0.04).Conclusions: In conclusion, retinal arterioles lumen diameter and wall to lumen ratio were independent biomarkers of cardiac damage. Retinal examination performed by means of scanning laser Doppler flowmetry might be a valuable tool to improve cardiovascular risk stratification of hypertensive patients.

Abstract P195: Blood Presure is Related to Glucose Fluctuation in Longstanding Type 1 Diabetes

Mechanisms underlying relationship between hypertension and metabolic abnormalities are well established in type 2 diabetes. Much less is known about this link in type 1 diabetes. None of the previous studies has assessed relationship between glucose variability and diurnal blood pressure profile in patients with longstanding type 1 diabetes (DM1).

The Aim: to investigate the possible association of glucose fluctuation with BP levels in longstanding DM1.

Design and Methods: We examined 36 patients with longstanding (>20 years) history of DM1 (without overt cardiovascular disease, including hypertension) and episodes of hyperglycemia >160 mg/dL during 24-hour continuous glucose monitoring (CGM). In all patients simultaneous 24-hour CGM and ambulatory blood pressure monitoring (ABPM) were performed. Intima-media thickness (IMT) of the common carotid artery was also assessed. Patients were divided into two groups: with and without severe hypoglycemia <50 mg/dL (n=18 in each group).

Results: Compared to patients with hypoglycemia, patients without hypoglycemia had a significantly lower day-time SBP variability expressed as standard deviation (12.6 ± 2.5 and 10.9 ± 3.0 mmHg, respectively, p<0.05). In patients without hypoglycemia, mean amplitude of glycemic excursion both up and down was associated with increase in DBP (r=0.49, p<0.05 and r=0.59, p<0.05, respectively), whereas in patients with hypoglycemia it was associated with increase in SBP (r=0.53, p<0.05). In patients without hypoglycemia, time of hyperglycemia was associated with increase in DBP (r=0.57, p<0.05) and in patient with hypoglycemia – with increase in SBP (r=0.67, p<0.05). Furthermore, in patients with short hypoglycemic episodes, time of hypoglycemia was associated with increase in SBP (r=0.57, p<0.05). In patients with hypoglycemia, SBP level had also positive correlation with IMT (r=0.50, p<0.05).

Conclusions: In patients with longstanding DM1, BP is related to glucose fluctuation. While the change in glucose levels towards hypoglycemia is associated with an increase in SBP, hyperglycemia is linked to an increase in DBP. The mechanisms underlying these associations remain to be determined.

Prevalence and distribution of left ventricular diastolic dysfunction in treated patients with long-lasting hypertension

BACKGROUND

Although the presence of sub-clinical left ventricular diastolic dysfunction (LVDD) increases cardiovascular risk, the current ESH/ESC guidelines do not include the presence of this condition in the list of target organ damage or cardiovascular risk charts dedicated to the hypertensive population. Several conditions may predict the LVDD occurrence, however, clustering of these factors with hypertension makes the relationship less clear. Therefore, the aim of this study was to evaluate both the occurrence and the severity of diastolic dysfunction in a large cohort of treated hypertensives.

METHODS

We retrospectively analyzed records of 610 hypertensive participants of the CARE NORTH Study who consented to echocardiography and were free of overt cardiovascular disease. Mean age was 54.0 ± 13.9 years (mean ± SD), BMI 29.7 ± 4.8 kg/m². The exclusion criteria were: established heart failure, LVEF <45%, coronary revascularization, valvular defect, atrial fibrillation, or stroke. The staging of LVDD was based on comprehensive transthoracic echocardiographic measurements.

RESULTS

49.7% percent of the patients had normal diastolic function (38.8% vs. 59.0%, females (F) vs. males (M), respectively; p < .001). Grade 1 LVDD was documented in 24.4% (27.8% and 21.6%; F and M; p = .08) and grade 2 LVDD in 19.3% (24.9% and 14.6%; F and M; p = .001) of the patients. None were diagnosed with grade 3 LVDD. In the logistic regression model, female sex, advancing age, obesity status, established diabetes mellitus, higher 24-hour SBP, and increasing LVMI were identified as the independent variables increasing the odds for the presence of LVDD, whereas blood-lowering therapy attenuated the risk.

CONCLUSIONS

There is an unexpectedly high prevalence of different forms of diastolic dysfunction in treated hypertensive patients who are free of overt cardiovascular disease.

Untargeted Metabolomics Provides Insight into the Mechanisms Underlying Resistant Hypertension

BACKGROUND

Resistant hypertension (RH) affects about 15-20% of treated hypertensive patients worldwide. RH increases the risk of cardiovascular events such as myocardial infarction and stroke by 50%. The pathological mechanisms underlying resistance to treatment are still poorly understood.

OBJECTIVE

The main goal of this pilot study was to determine and compare plasma metabolomic profiles in resistant and non-resistant hypertensive patients.

METHODS

We applied untargeted metabolomic profiling in plasma samples collected from 69 subjects with RH and 81 subjects with controlled hypertension. To confirm patients' compliance to antihypertensive treatment, levels of selected drugs and their metabolites were determined in plasma samples with the LC-ESI-TOF/MS technique.

RESULTS

The results showed no statistically significant differences in the administration of antihypertensive drug in the compared groups. We identified 19 up-regulated and 13 downregulated metabolites in the RH.

CONCLUSION

The metabolites altered in RH are linked to oxidative stress and inflammation, endothelium dysfunction, vasoconstriction and cell proliferation. Our results may generate new hypothesis about RH development and progression.

Prevalence and characteristics of OSAFED syndrome in atrial fibrillation primary care patients

BACKGROUND

Atrial fibrillation (AF) constitutes the most prevalent arrhythmia, affecting up-to 2% of the general population. Apart from well-established risk factors that increase the odds for the development of AF, e.g. age or arterial hypertension, recent analyses indicate that obstructive sleep apnoea (OSA) may independently, negatively modify the arrhythmia occur-rence profile. Concurrently, erectile dysfunction (ED) is a commonly neglected, potent marker of cardiovascular risk, which considerably worsens men's psychological state. Unrecognised or untreated ED results in substantial deterioration of the patient's therapeutic programme adherence. Because AF, OSA, and ED share multiple risk factors and clinical consequences, in 2013 the concept of their frequent concurrence - OSAFED syndrome - was proposed.

AIM

The aim of the study was to evaluate the prevalence of OSAFED patients with AF in primary care practice.

METHODS

Retrospective analysis was carried out of data from primary care physician charts (NZOZ Esculap Gniewkowo, central Poland) including 1372 men aged 40-65 years. The primary goal was to determine the diagnosis of paroxysmal and/or perma-nent AF, which was followed by sleep apnoea screening (polygraphy) and erectile function evaluation (IIED-5 questionnaire).

RESULTS

Twenty-one (1.5%) patients with documented AF were identified. Based on the sleep-polygraphic studies, 14 (67%) of them had confirmation of OSA with mean apnoea-hypopnea index (AHI) equal to 27.5 ± 17.1. Furthermore, 11 (52%) patients met the OSAFED syndrome criteria. Patients with OSAFED syndrome had a mean score in IIEF-5 of 11.6 ± 3.5. The OSAFED-patients who were not diagnosed with all the of the syndrome components prior to the study-enrolment were characterised by substantially lower fat excess compared to their counterparts with already established OSAFED (body mass index: 30.1 ± 4.9 vs. 37.7 ± 3.9 kg/m², respectively, p = 0.03).

CONCLUSIONS

Frequently coexisting OSAFED syndrome components in all AF patients from the primary care setting should encourage a more active search for OSA and ED in patients with any documented form of AF. Most of the studied patients did not have the diagnosis of OSA nor ED done prior to participation in the study.

Serum of obstructive sleep apnea patients impairs human coronary endothelial cell migration

INTRODUCTION

Endothelial cell migration and proliferation play an important role in the growth and development of new blood vessels and endothelium healing. This process occurs in response to injury, inflammation and immune reactions. Dysfunction of the endothelium may play a significant role in development and progression of cardiovascular disease related to sleep-disordered breathing. The aim of our study was to evaluate the chemo-attractant activity of serum from obstructive sleep apnea (OSA) and normal subjects on coronary artery endothelial cell migration.

MATERIAL AND METHODS

We studied 12 severe OSA patients, free of other co-morbidities and on no treatment, along with 12 age-, body mass index, and gender matched healthy controls. Blood was collected at three time points: at 21:00 before sleep, at 6:00 after waking from sleep, and at 11:00 (after 5 h of normal daytime activity). Serum chemo-attractant activity for human coronary endothelial cells was assessed using a colorimetric cell migration assay kit.

RESULTS

In healthy subjects, serum chemo-attractant activity peaked in the morning after waking from sleep (p = 0.02). This early morning increase was blunted in severe OSA subjects, in whom chemo-attractant activity was weaker than in normal controls (p = 0.02), and did not change significantly at the different time-points (p < 0.001 vs. controls).

CONCLUSIONS

Chemo-attractant activity of the serum from OSA patients is lower compared to serum from healthy subjects, especially in the morning. Altered chemo-attractant serum activity may conceivably contribute to the impairment of endothelial function in obstructive sleep apnea patients.

Unilateral Carotid Body Resection in Resistant Hypertension: A Safety and Feasibility Trial

Animal and human data indicate pathological afferent signaling emanating from the carotid body that drives sympathetically mediated elevations in blood pressure in conditions of hypertension. This first-in-man, proof-of-principle study tested the safety and feasibility of unilateral carotid body resection in 15 patients with drug-resistant hypertension. The procedure proved to be safe and feasible. Overall, no change in blood pressure was found. However, 8 patients showed significant reductions in ambulatory blood pressure coinciding with decreases in sympathetic activity. The carotid body may be a novel target for treating an identifiable subpopulation of humans with hypertension.

Impact of obesity on cardiovascular health

This review examines the impact of obesity on cardiovascular health. We will review first, relationship between obesity and hypertension. Second, we will describe obesity-related subclinical abnormalities in cardiovascular function and structure. Third, we will summarize evidence linking obesity to overt cardiovascular disease including coronary artery disease, congestive heart failure, stroke, arrhythmias and sudden cardiac death. Fourth, we will discuss the potential mechanisms underlying increased cardiovascular risk in obese subjects. Last, we will discuss contribution of sleep apnea to the link between obesity and cardiovascular disease. Despite recent progress in understanding epidemiologic and pathophysiological links between obesity and cardiovascular disease, several issues remain to be addressed in the future studies. There is a clear need to identify better markers of obesity-related subclinical cardiovascular damage. Furthermore, we should improve identification of obese subjects at highest cardiovascular risk.

SCORE model underestimates cardiovascular risk in hypertensive patients: results of the Polish Hypertension Registry

OBJECTIVE. The aim of the present study was to compare the effectiveness of Systemic COronary Risk Evaluation (SCORE) charts and European Society of Hypertension/European Society of Cardiology (ESH/ESC) hypertension guidelines for identifying high-risk hypertensive patients. METHODS. The data on hypertensive patients was collected using the Polish Hypertension Registry. We enrolled 636 patients (357 females and 279 males, mean age 54.4 (+/-) 7.9 years) from hypertension centres in Poland. RESULTS. Only 3.5% of the subjects had no additional risk factors. Thirty-six per cent of the patients had three or more risk factors. Metabolic syndrome was found in 40.1% of the patients. According to the SCORE charts, 9.0% of females and 27.2% of males had high to very high cardiovascular risk (p < 0.001). Taking into account risk factors and the metabolic syndrome, 55.7% of females and 56.3% of males (p = NS) had high or very high additional cardiovascular risk according to the 2007 ESH/ESC guidelines. For both females and males, the prevalence of high to very high risk was greater (p < 0.001) from the calculation based on the 2007 ESH/ESC guidelines than from the SCORE charts. Fifty-two per cent of patients classified as low to moderate risk according to the SCORE system, had high or very high risk according to the 2007 ESH/ESC guidelines. CONCLUSIONS. The SCORE charts seem to underestimate the burden of the cardiovascular risk among hypertensive patients. The cardiovascular risk, especially in the hypertensive female population, seems to be much higher when estimated according to the 2007 ESH/ESC guidelines.

Impact of abdominal obesity on the frequency of hypertension and cardiovascular disease in Poland - results from the IDEA study (international day for the evaluation of abdominal obesity)

INTRODUCTION

Cardiovascular disease (CVD) is a major cause of mortality, and has risk factors, which can be treated by lifestyle changes or medications. Abdominal obesity has been identified as the second strongest risk factor for myocardial infarction.

OBJECTIVES

To assess the frequency of abdominal obesity and its relationship with hypertension (HT) and CVD in patients in Poland, and to compare frequencies of adiposity, HT and CVD between Poland and the North-West Europe Region, obtained in the IDEA study.

METHODS

In Poland, general practitioners included 5371 patients, aged 18-80 years, eligible for analysis. Waist circumference (WC) was measured, and the presence of HT and CVD recorded.

RESULTS

Increasing WC was significantly associated with HT and CVD, after adjustment for age (p<0.001). The frequency of abdominal obesity (WC >102/88 cm) was higher in Poland than in North-West Europe (36% vs 33% in men and 54% vs 45% in women, respectively, p<0.0001). Similarly, the frequency of HT in Poland was higher than in North-West Europe (47 vs 36% in men and 45 vs 30% in women, respectively p<0.001). In Poland CVD was 1.7-fold more frequent in men and 2.5-fold more frequent in women, compared with North-West Europe.

CONCLUSION

In Polish adiposity, both WC and body mass index (BMI) were strongly related to HT and CVD. The frequency of abdominal obesity, obesity, HT and CVD in primary care patients is substantially higher in Poland than in North-West Europe.

Daytime, home and office blood pressures in treated hypertensive patients according to accretion of cardiovascular risk

The relative accuracy of office, home and ambulatory blood pressure (BP) measurements has not been established in patients with metabolic syndrome (MS+). We set out to compare BP values obtained using different measurement modalities and their relationship to MS intensity in hypertensive outpatients. Office, ambulatory and home BPs and risk profile were ascertained. MS was defined according to ATPIII criteria. The study included a cohort of 104 men and 132 women with a mean age of 51.8 +/- 14.2 years; 40.3% had metabolic syndrome (MS+). The MS+ patients had higher home SBP (150 vs 142 mmHg, p < 0.01), were treated with more drugs (3.9 vs 3.0, p < 0.001) and had a poorer BP control on home measurements (11.6 vs 24.8%, p = 0.01). However, the clinical BP control rates were overall higher, and did not differ between two groups when daytime ambulatory (34.7 vs 27%) or office (26.7 vs 22.3%) values were employed. The deviation of home measurements was associated in a dose-dependent fashion with intensity of MS. Thus, in MS+ patients, the well standardized measurement protocols and equipment should be used to assess the antihypertensive efficacy. This is especially true for patients with high body mass index.