HFA-PEFF score as a prognostic factor in patients with liver cirrhosis

Introduction

Cardiovascular complications of liver cirrhosis which are frequently referred to as cirrhotic cardiomyopathy (CCM), include high cardiac output, reduced afterload and diastolic dysfunction. However, there are only scarce or even conflicting data about the prognostic significance of CCM. HFA-PEFF score is a diagnostic score for heart failure with preserved ejection fraction (HFpEF), which has prognostic value in HFpEF patients. It has functional, morphological and biomarker domains and the score may vary from 0 to 6. Score of 5 or 6 is diagnostic of HFpEF in symptomatic patients. No study has calculated HFA-PEFF score in cirrhotic patients to date.

Purpose

The purpose of this prospective study was to calculate HFA-PEFF score in cirrhotic patients, correlate it with disease severity and determine its prognostic significance.

Methods

A total number of 92 consecutive cirrhotic outpatients were prospectively examined and 72 fulfilled the inclusion criteria. Patients older than 75 years old or patients with ejection fraction (LVEF) <50%, coronary artery disease, moderate or severe valvular heart disease, atrial fibrillation, ongoing alcohol consumption, hepatocellular carcinoma and poor acoustic window were excluded. In all patients a thorough echocardiographic examination was performed, BNP or NT-pro-BNP levels were measured and subsequently HFA-PEFF score was calculated. MELD score was used to define the severity of cirrhosis. The median follow-up was 20 months and the study end-point was defined as the composite of all-cause death.

Results

Mean age was 58.5±8.3 years, 52 (72.2%) were males, median Meld score was 12.9 (8.5–16.3) and mean LVEF was 61.1±5.4%. HFA-PEFF score was 5 or 6 in 38 (52.8%), 2–4 in 27 (37.5%) and 0 or 1 in 9 (9.7%) patients. According to Spearman's coefficient analysis, HFA-PEFF score was correlated with MELD score (rho=0.566, p<0.001), but not with age, systolic blood pressure (SBP) and heart rate. The survival analysis stratified by the HFA-PEFF score [low, score 0–4 (N=34) vs. high, score 5–6 (N=38)] indicated that the HFA-PEFF score successfully predicted all cause two-year survival (log-rank test p<0.001). According to the Cox-regression proportion hazard models HFA-PEFF score as a continuous variable correlated with six-month, one year and two year survival. When HFA-PEFF was treated as a categorical variable, hazard models were significant for the one and two-year survival. The multivatiate COX regression survival analysis showed that the increased HFA-PEFF score (low: score 0–4, N=34 vs high: score 5–6, N=38) was significantly associated with decreased two-year survival when patient age, gender and MELD score are taken into account [HR=3.659 (1.068–12.536), p=0.039].

Conclusions

HFA-PEFF score is high among patients with liver cirrhosis, especially those with increased disease severity. HFA-PEFF score is associated with survival even when adjusting for the severity of the cirrhosis.

Funding Acknowledgement

Type of funding sources: None.

Distinctive characteristics among MINOCA and Takotsubo patients and their prognostic value in a multicenter prospective cohort

Background/Introduction

In the acute care setting, the working diagnosis of MINOCA exhibits increasing recognition and includes a broad spectrum of conditions, most of them yet not adequately understood. TakoTsubo syndrome (TTS) represents a significant proportion of such cases and despite its predominance on female gender as well as its imaging characteristics on the typical apical form it is not easily distinguishable from other MINOCA causes without the contribution of cardiac magnetic resonance (CMR).

Purpose

The aim of our study is to investigate for distinctive characteristics related to the index event among MINOCA cases from a multi-center prospective cohort with a mean follow up period of 18 months.

Methods

We divided our study population (n=74) into TTS (n=30) and non-TTS (n=44) according to multimodality imaging results. Information regarding the index event (Sep 2019-Feb 2021) were retracted from the medical notes.

Results

CMR results led to a post-discharge diagnosis reconsideration in 12 cases (16.2%). Female gender (n=29; 96.7% vs n=22; 50%, P<0.001), older age (mean age 66±11 vs 59±11, P=0.04) and history of hypertension (n=21; 70% vs n=19; 44.3%, p=0.035) were more frequent in TTS group. There was no statistically significant difference in body mass index, baseline renal function, history of dyslipidemia, diabetes and smoking between the two groups. During the index event, peak troponin levels 576 pg/ml (IQR: 184–9915) vs 767 pg/ml (IQR: 47–47000), P=0.005], were lower in the TTS group, whereas NSTEMI presentation was the commonest among all patients. Angina was the dominant symptom for both groups. However, severe angina expressed as more than 2 episodes within 24 hours was more frequent among the TTS population (n=19; 65.5% vs n=10; 22.7%, P=0.001). TTS probability assessed with the INTERTAK score was higher among the TTS group (68±10 vs 38±21, P<0.001). In hospital major cardiovascular events incidence was higher in the non-TTS group (n=2 vs n=11, P=0.06). Multivariate analysis revealed that the presence of severe angina (OR, 8.118, 95% CI: 1.173–56.157, P=0.038) is highly predictive of TTS in the acute care setting even independently of INTERTAK probability.

Conclusions

These preliminary results indicate that the presence of several anginal attacks may strengthen the predictive value of the INTERTAK score during MINOCA evaluation in the acute setting. Confirmation in a larger population is warranted.

Funding Acknowledgement

Type of funding sources: None.

Parameters indicating development of hypertension in three-year follow-up study of subjects with high normal blood pressure

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity followed by arterial stiffening are linked with development of hypertension (HTN).

Purpose

The aim of this study was to assess the relation of HRE with sympathetic drive as assessed by muscle sympathetic nerve activity (MSNA) and arterial stiffness in subjects with high normal BP who developed hypertension in a 3 year follow up.

Methods

100 subjects with high normal office BP [systolic BP=130-139 mmHg and diastolic BP=85-89 mmHg] underwent a treadmill exercise stress test. Arterial stiffness was evaluated based on carotid to femoral pulse wave velocity (PWV). Sympathetic drive was assessed by MSNA levels. Follow up was every 6 months for 3 years, where BP was measured at both office (OffBP) and ambulatory blood pressure monitoring (ABPM). All participants offered lifestyle advises. Endpoint was development of HTN diagnosed either from OffBP or from ABPM. Then they were divided into Group I: those developed HTN and Group II: those remained normotensive.

Results

Mean age 54±8 years, 42 males, baseline offBP: 132/82 mmHg, ABPM: 122/76 mmHg). Out of them, 50 subjects developed HRE (BP ³210mmHg in men and ³190 mmHg in women) and 40 HTN. Group I developed higher HRE (75% vs. 13%, p=0.026), higher levels of PWV (8.35 vs 7.5 m/sec, p=0.043) and MSNA levels (37 vs. 31 bursts, p=0.04), while did not differ at their metabolic profile. Echocardiographically left ventricular mass index did not differ statistically as E/A ratio of mitral valve inflow (0.92 vs 1.05, p=0.034). Those who developed HTN was related to night systolic BP from ABPM (116 vs 112 mmHg, p<0.04), as also to intermediate stage intervals of 3 min (160 vs 147 mmHg, p=0.068) and 6 min (181 vs 164, p=0.035) of Bruce protocol. A novel metric, the SBP/MET-slope [(peak SBP—resting SBP)/(peak MET-1)] found to add crucial information. Regarding those who developed HTN, SBP/MET-slope was higher in all stages till peak exercise (stage 1: 6.25 vs 4.25, stage 2: 7.6 vs 5.3, peak: 7.22 vs 5.1, p=0.035). It was noticed that they performed a higher exercise capacity (10 vs 11.5 METs) and additionally differ significantly in their maximal heart rate (HR) at peak exercise (154 vs 164, p=0.001).

Conclusion

In subjects with high normal BP, a HRE, the intermediate BP intervals along with the SBP/MET-slope, identifies a state of systemic vascular resistance, arterial stiffening and sympathetic overdrive, as reflected by increased PWV and MSNA levels respectively. Additionally, exercise capacity demonstrates cardiovascular functional tolerance. These findings suggest that exercise testing provides determining clinical information regarding the overall cardiovascular status, proving its superior prognostic value as a hypertension screening tool, that alarms the physician to warn the patient to take action.

Left ventricular mass index unveils differences in sympathetic nervous system activity between patients with MINOCA and Takotsubo syndrome

Background/Introduction

Left ventricular mass index (LVMI) has been long established as an index of target organ damage. It has demonstrated a prognostic role in cardiovascular morbidity and mortality assessed using either echocardiography or cardiac magnetic resonance (CMR) under the prism of coronary artery disease, hypertension, diabetes mellitus, chronic kidney disease. On the other hand, it has shown a strong association with indices of sympathetic nervous system (SNS) activity.

Purpose

The aim of our study is to investigate for potential associations between LVMI and indices of SNS among patients with a working diagnosis of MINOCA.

Methods

Our study population consists of 50 patients [32% male; mean age: 61±12 years old; 50% hypertensives (HTN), 16% with history of diabetes mellitus (DM), 22% smokers] admitted with acute coronary syndrome (ACS) fulfilling the diagnostic criteria of MINOCA. A subsequent CMR demonstrated an ischemic pattern of late gadolinium enhancement (LGE) in 15 cases (27.8%), findings indicative of Takotsubo syndrome (TTS) in 19 patients (35.2%), whereas failed to reveal any abnormalities in 16 cases (29.8%). LVMI was estimated using left ventricular mass per body surface area (LV mass/BSA) as derived from CMR. SNS activity was assessed using muscle sympathetic nerve activity (MSNA) during the first 30 days of patient discharge.

Results

Univariate analysis failed to demonstrate an association between LVMI and indices of SNS in the total population. This was found to be driven by the TTS group. However, for all other MINOCA cases (n=31; including both LGE CMR and clear CMR cases) LVMI demonstrated a significant positive association with MSNA measured as bursts/min (OR, 0.558; CI 95%, 0.200–0.915; p=0.004). A multivariate analysis was conducted in the same group in which LVMI retained its statistical significance independently of age, gender, ejection fraction derived from CMR, history of HTN and DM (OR, 0.518; CI 95%, 0.030 - 0.952; p=0.038). TTS group did not show any association between LVMI and MSNA.

Conclusions

These preliminary results may imply an underlying mechanism of reverse negative feedback on systematic SNS activity after the acute phase of sympathetic overdrive during a TTS event. Further investigation is warranted to confirm our research findings.

Funding Acknowledgement

Type of funding sources: None.

Correlations between sympathetic nervous system activity and smoking, as well as unattended blood pressure in essential hypertension

Background/Introduction

It is a well-known fact that the sympathetic nervous system is involved with the pathophysiology of hypertension. Smoking, which is one of the most significant risk factors for cardiovascular morbidity and mortality, also contributes to the development of hypertension mainly through the stimulation of the sympathetic nervous system. Moreover, measurement of unattended blood pressure (BP) may provide additional information compared to conventionally attended BP.

Purpose

The aim of this study was to demonstrate the impact of smoking on sympathetic nervous system stimulation, and on BP measurement variations with and without medical supervision.

Methods

We studied patients with essential hypertension, who were separated into two groups, depending on their smoking habits (Group I: non-smokers, Group II: smokers). In all participants, sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Both unattended (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements, at 1-minute intervals, after 5 minutes of rest) and attended BP measurements were conducted with the same device, on the same day of MSNA recording, in random order. Then, we compared the two BP measurement values of each patient to assess which of the two was higher.

Results

Ninety-two consecutive patients (58±11 years, 50 males) were evaluated. Smokers (n=19) did not differ as regards 24-h ambulatory BP levels, glucose levels, renal function and left ventricular mass index when compared to non-smokers (n=73). However, higher levels of MSNA were recorded to smokers (73.16±13.42 vs. 61.04±18.10 bursts per 100 heartbeats, p<0.01). Furthermore, higher percentage of smokers recorded to have unattended BP values higher than attended (73.7% vs. 47.9% of them respectively, p=0.045). In particular, in smokers unattended BP was higher than attended by 10.07±6.7 mmHg, while in non-smokers unattended BP was lower than attended by 6.6±7.14 mmHg. No correlation was found between the MSNA and the differences observed in the two values resulting from the two different measurements of BP, maybe due to the small size of the sample.

Conclusions

Cigarette smoking is accompanied with higher sympathetic nervous system activation. Moreover, smokers exhibit higher unattended blood pressure values than normal measurements. The emerging hypothesis is that the stimulation of the sympathetic system causes this difference in measurements. A larger sample of patients is needed to fully determine the clinical significance of the above observation.

Funding Acknowledgement

Type of funding sources: None.

Sympathetic nerve activity changes following acute exposures to electronic and tobacco cigarette smoking in humans

Background/Introduction

Tobacco cigarette (TC) smoking acutely increases blood pressure and sympathetic nerve activity, whereas there are scarce data on the impact of electronic cigarette (EC).

Purpose

The aim of the study was to assess the acute effects of TC, EC and sham smoking on blood pressure, heart rate and sympathetic nervous system in healthy subjects.

Methods

We studied 12 normotensive male habitual smokers (mean age 33 years) free of cardiovascular disease. The study design was randomized and placebo controlled with 3 experimental sessions (sham smoking, tobacco cigarette smoking, and e-cigarette smoking) in random order, each session on a separate day. Subjects smoked 2 tobacco cigarettes containing 1.1 mg nicotine or simulate smoking (sham smoking) with the 2 cigarettes separated by 5 minutes. Additionally, participants smoked e-cigarettes for a period of 5 and 30 minutes. In all occasions, sympathetic drive was assessed by muscle sympathetic nerve activity (MSNA) (baroreflex-dependent) and skin sympathetic nerve activity (SSNA) (baroreflex-independent) based on established methodology (microneurography).

Results

After the first and second TC smoking, there was significant increase in mean arterial pressure (MAP) (by 6 and 8 mmHg, respectively, overall p<0.001) and heart rate (by 8 and 12 beats/minute, respectively, overall p<0.001) compared to baseline. Similarly, EC smoking at 5 and 30 minutes compared to baseline was accompanied by augmentation of MAP (by 6 and 10 mmHg, respectively, overall p<0.001) and heart rate (by 5 and 9 beats/minute, respectively, overall p<0.001). Sham smoking was accompanied by a reduction in MAP after the first and second cigarette compared to baseline (by 2 and 4 mmHg, respectively, p=0.001), whereas there was no significant difference in heart rate (p=NS). The first and second TC smoking was characterized by lower muscle MSNA (by 6 and 6 bursts/minute, respectively, overall p<0.001) compared to baseline, whereas SSNA was increased (by 9 and 10 bursts/minute respectively, overall p<0.001). Additionally, EC smoking at 5 and 30 minutes caused a decrease in MSNA (by 8 and 8 bursts/minute, respectively, overall p<0.00) and an augmentation in SSNA (by 7 and 9 bursts per minute, respectively, overall p<0.001) compared to baseline. Sham smoking had no significant effect on MSNA and SSNA (p=NS for both).

Conclusions

Sympathetic, pressor and heart rate unfavorable responses to EC smoking are similar to those elicited by TC in healthy subjects. Our findings provide novel insights into the negative impact of EC on cardiovascular system and support opinions recommending great caution concerning EC use.

Funding Acknowledgement

Type of funding sources: None.

Superiority of cardiac magnetic resonance derived left-ventricular ejection fraction in the identification of true acute myocardial infarction among MINOCA patients

Background/Introduction

MINOCA constitutes a clinical entity characterized by heterogeneous and poorly understood pathophysiological substrate, whereas current knowledge leaves significant gaps regarding the identification, risk stratification and therapeutical approach of these patients.

Purpose

The aim of our study is to investigate the potential role of clinical, hemodynamic, laboratory and imaging parameters in the early identification of true acute myocardial infarction (AMI) among patients with a working diagnosis of MINOCA.

Methods

Our study population included 62 patients admitted with acute coronary syndrome (ACS) fulfilling the diagnostic criteria of MINOCA. A subsequent cardiac magnetic resonance (CMR) performed at 54 patients demonstrated an ischemic pattern of late gadolinium enhancement (LGE) confirming the diagnosis of true AMI in 15 cases (27.8%). Other findings included Takotsubo syndrome (n=19; 35.2%) and myocarditis (n=4; 7.4%), whereas CMR failed to reveal abnormal findings at 16 cases (29.8%).

Results

Focusing on the combined population of true AMI and clear CMR groups (n=31; 51.6% male; mean age: 58±12 years old; 42% hypertensives (HTN), 16% with history of diabetes mellitus (DM), 28.6% smokers) no significant difference was observed regarding classic cardiovascular risk factors (HTN, DM, smoking, age, dyslipidemia) except for a tendency of overrepresentation of female sex (r=0.354; p=0.051) in the true AMI group. Coronary angiographic (CA) findings did not differ between the two groups: clear vessels: 16/31 (51.6%); lesions causing ≤50% stenosis: 7/31 (22.6%); bridges: 4/31 (12.9%); spontaneous coronary artery dissection (SCAD): 2/31 (6.5%); slow flow phenomenon or spontaneous epicardial spasm: 2/31 (6.5%). No difference was observed in treatment approach with beta-blockers, renin-angiotensin system blockers, statins or the selection of no, single or dual antiplatelet strategy. Univariate regression analysis demonstrated that CMR derived left-ventricular ejection fraction (CMR-LVEF) (OR, 0.846; CI 95%: 0.742–0.965; p=0.012), as well as admission ECG abnormalities (OR, 0.154; CI 95%: 0.026–0.914; p=0.04), admission (OR, 5.689; CI 95%: 1.374–23.553; p=0.016) and peak troponin levels (OR, 15.874; CI 95%: 2.486–101.367; p=0.003) were the only parameters significantly related to a true AMI. Statistical significance was retained in multivariate models adjusted for age, gender, history of HTN and DM. On the contrary echocardiography derived LVEF failed to predict true AMI.

Conclusions

These preliminary results further highlight the need of an early CMR evaluation of MINOCA patients. A timely identification of true AMI is expected to improve patient outcomes by guiding the treatment approach.

Funding Acknowledgement

Type of funding sources: None.

Hydroxychloroquine for colchicine-resistant glucocorticoid-dependent idiopathic recurrent pericarditis: an observational prospective study

Background

Glucocorticoid (GC)-dependent, colchicine-resistant idiopathic recurrent pericarditis (IRP) remains a clinical challenge. We assessed for the first time the efficacy and safety of hydroxychloroquine (HCQ) in IRP.

Methods

This is a single center, post hoc analysis of prospectively collected data of 15 patients with refractory to standard therapy (colchicine plus either GC or anakinra) IRP (≥3 recurrences, disease duration ≥12 months and inability to wean off treatment) treated with HCQ (400 mg/day). These patients were matched 1:1 for age, sex, and treatment type to IRP patients receiving standard-of-care treatment (control group, n=15). Pericarditis recurrence, the time and C-reactive protein (CRP) levels at 1st flare, the % of patients able to achieve a ≥50% reduction of baseline GC dose and the % reduction of GC dose were compared between groups.

Results

Almost all patients (n=29) but one in the HCQ group (14/15) relapsed during follow-up. However, HCQ treatment was associated with an increased median time of flare-free survival (increase by 4 weeks compared to controls) and reduced hazard ratio for flare in survival analysis (HR=0.36, 95% CI 0.16–0.77, p=0.009). HCQ was also associated with a higher proportion of patients obtaining a ≥50% dose reduction of GCs (33.3% vs. 0% in the control group, p=0.037) and reduced GC dose (HCQ: −43.5% vs. control: −4.5%, p<0.001). There were no signficant differences in CRP levels at flare between groups (p=0.615).

Conclusions

In this prospective study, HCQ use was associated with a GC-sparing effect and an increased flare-free survival period in patients with colchicine resistant GC-dependent IRP.

Funding Acknowledgement

Type of funding source: None

Time in blood pressure range for different blood pressure targets and risk of cardiovascular disease: an analysis of a 7-year follow-up registry

Objective

Recent guideline recommendations have revisited the optimal target blood pressure (BP) for hypertensive patients. The Time in BP Range (TBPR) is an alternative metric for evaluation of long-term achieved BP. We investigated the association of TBPR for different levels of BP control with cardiovascular outcome among treated hypertensives.

Design and method

This is a retrospective analysis of 1202 treated hypertensive patients (age 59±11 years) without a history of cardiovascular disease followed for a mean period of 7±3 years. We calculated the TBPR [(No of Visits in BP range/ Total No of Visits) x 100%] for office systolic BP targets of 130–139mmHg, 120–129mmHg and <120mmHg and examined the associated cardiovascular risk. The outcome studied was the composite of stroke and coronary artery disease. Time spent in systolic BP≥140mmHg served as the reference.

Results

In the entire population, mean TBPR for systolic BP 130–139mmHg, 120–129mmH, and <120mmHg were 26%, 19% and 11% respectively. A TBPR of ≥50% for systolic BP 130–139mmHg, 120–129mmHg and <120mmHg was observed in 332 (28%), 226 (19%) and 107 (9%) patients respectively. The composite endpoint occurred in 54 patients (4.5%). Patients with a TBPR for 120–140mmHg of ≥50% presented with a HR: 0.6 (95% CI: 0.34–1.06) for cardiovascular events. The TBPR of ≥50% for systolic BP 130–139mmHg, 120–129mmHg and <120mmHg was associated with HR of 0.48 (95% CI: 0.23–1.01, p=0.05), 0.64 (95% CI: 0.29–1.39, p=0.26) and 0.72 (95% CI: 0.26–2.05) respectively. This pattern was sustained but further attenuated after controlling for standard risk factors. In comparison, a mean BP across visits of 130–139mmHg, 120–129mmHg and <120mmHg was associated with a HR of 0.54 (5% CI: 0.28–1.03), 0.61 (95% CI: 0.29–1.26) and 0.80 (95% CI: 0.24–2.65).

Conclusions

Among treated hypertensives, a time in BP of 130–140mmHg of more than 50% is associated with the greatest reduction in cardiovascular risk. The TBPR is a potentially useful measure of BP control for evaluation of risk reduction in hypertensive patients.

Funding Acknowledgement

Type of funding source: None

Cardiovascular risk and outcome in patients with hypertensive emergencies and urgencies in an emergency department. an italian greek collaboration

Background

At present, few data are available on the prognosis of hypertensive emergencies and urgencies admitted to Emergency Departments (ED). The aim of our study was to evaluate the incidence of total and cardiovascular events during follow-up in hypertensive patients admitted in 2 ED in Italy and Greece with hypertensive emergencies or urgencies.

Methods

Medical records of patients aged >18 yrs, admitted to the ED with blood pressure values ≥180 mmHg (SBP) and/or ≥120 mmHg (DBP) were collected and analysed (24% of patients were classified as “hypertensive emergency” and 76% as “hypertensive urgency”). Data in 1218 patients (556 men and 662 women, mean age 70±13 years) were analysed; the mean duration of follow-up after admission to the ED was 19.5±7 months years.

Results

During the follow-up cardiovascular events occurred in 148 patients (69 cardiac events, 43 cerebrovascular events). In 272 pts (22%) a new episode of acute BP rise was recorded. A total of 87 deaths was recorded during follow-up (in 28 patients for cardiovascular causes). All cause and CV mortality were greater in patients with a previous hypertensive emergency (14.7 vs 4.7%, chi-square p=0.0001 and 5.8 vs 1.2% chisquare p<0.0001 for all-cause and for CV mortality, respectively). The incidence of non fatal cardiovascular events was 10,11 and 2,11 per 100 patient-years in patients with hypertensive emergency and urgency, respectively and similar results were obtained when we considered separately the occurrence of cerebrovascular events.

Conclusions

Admission to the ED for hypertensive emergencies identifies hypertensive patients at increased risk for fatal and non fatal cardiovascular events. Our results underline the need for an accurate follow-up in patients with hypertensive emergencies and urgencies.

Funding Acknowledgement

Type of funding source: None

Exercise duration as apredictor ofcardiovascular disease in arterial hypertension. Data from a 6-year follow-up study

Background

Current hypertension guidelines necessitate an individualized cardiovascular risk assessment through a process that includes several parameters and remains challenging. Exercise capacity has been strongly associated with prognosis in cardiovascular disease and can be easily assessed by the exercise treadmill test (ETT).

Purpose

The aim of the present study was to investigate theprognostic role of exercise capacity for future cardiovascular events in a cohort of essential hypertensive subjects.

Methods

We followed up 1037 hypertensive adults (mean age 56 years, 53% males) with no previous history of cardiovascular disease, for a mean period of 6±3 years. During the baseline visit all subjects underwent a complete echocardiographic study, office blood pressure measurements, ECG, routine blood testing and an ETT with a Bruce protocol.During follow-up, all subjects were reviewed at least annually. Exercise capacity was expressedwithexercise duration the distribution of which was split by the median (9min). Accordingly, the subjects were classified into those with high (51%) and low exercise capacity (49%). The cardiovascular endpoint of interest was the composite of coronary artery disease and stroke.

Results

The incidence of cardiovascular eventsduring the follow-up period was 4.1% (35 cases of coronary artery disease and 10 cases of stroke).Cox regression analysis revealed that high exercise capacity was associated with a lower risk for future cardiovascular events (HR = 0.35 (95% CI 0.172–0.741, p=0.006). In multivariate models adjusting for standard clinical and laboratory cardiovascular risk factors this association was sustained.

Conclusion

Exercise duration shows a significant prognostic value for future CV events among hypertensivepatients. Exercise capacity assessment by means of TTE could enhance the identification of asymptomatic hypertensives at higher risk.

Funding Acknowledgement

Type of funding source: None

P3409Comparison of the European Society of Hypertension stratification and European Society of Cardiology HeartScore for prediction of coronary artery disease and stroke in essential hypertension

Background/Introduction

For estimation of overall cardiovascular risk the European Society of Hypertension (ESH) proposes stratification according to blood pressure (BP), prevalence of risk factors, asymptomatic target organ damage, diabetes, kidney and symptomatic cardiovascular disease, while the European Society of Cardiology (ESC) HeartScore constitutes another potent predictive tool of adverse outcome.

Purpose

The aim of the present study was to compare the predictive role of ESH stratification and ESC HeartScore for the incidence of the composite end-point of coronary artery disease (CAD) and stroke in a cohort of essential hypertensive patients.

Methods

We followed up 2150 essential hypertensives (mean age 55.7 years, 1085 males, office BP=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit. Patients were divided based on the ESH risk categories as well as according to the ESC HeartScore. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure. Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings.

Results

The incidence of CAD, stroke and their composite over the follow-up period were 2.8% (n=60), 1.11% (n=24) and 3.9% (n=84), respectively. By using the ESH stratification, regarding the total population 15.3% (n=329) was of low and moderate risk, 54.4% (n=1170) was of moderate to high and high risk and 30.3% (n=651) was high to very high and very high risk. According to the ESC HeartScore 89.2% (n=1918) was of low to moderate risk, 10% (n=215) of high risk and 0.8% (n=17) of very high risk. Cox-regression analyses revealed that high to very high and very high ESH risk category was related to increased risk for the composite end-point of CAD and stroke (hazard ratio=4.5, p<0.0001), while focusing on the ESC Heart Score the composite end-point was predicted by the high risk category (hazard ratio=3.43, p<0.0001). Using the Akaike's information criterion the ESH risk model had better fit than the ESC HeartScore due to the lowest Akaike's values (1442.66 vs 1498.31, respectively).

Conclusions

In essential hypertensive patients categorization of patients by means of the ESH stratification and the ESC HeartScore are both predictive of future cardiovascular events. Based on our results, the ESH risk stratification constitutes a better prediction model for CAD and stroke than the ESC HeartScore in essential hypertension and its estimation is essential in order to improve overall risk assessment in this setting.

P5464Visit-to-visit glomerular filtration rate variability as a predictor for cardiovascular and renal outcomes in essential hypertension: Data from a Greek 8-year-follow-up study

Background/Introduction

Renal dysfunction is related with adverse prognosis in hypertension, however there are scarce data on the predictive cardiovascular and renal impact of kidney function variability in this setting.

Purpose

The aim of the present study was to assess the predictive role of visit-to-visit renal function changes on the incidence of coronary artery disease (CAD), stroke and end-stage renal disease in a cohort of essential hypertensive patients.

Methods

We followed up 2380 essential hypertensives (mean age 58.9 years, 1240 males, office blood pressure (BP)=144/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and blood sampling was performed in all visits for estimation of glomerular filtration rate (GFR). We calculated standard deviation (SD) of mean GFR from visits from 6 months onward in patients with ≥5 visits during follow-up. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure, while stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings. End-stage renal disease was defined as GFR<15 mL/min/1.73 m2 or the need for long-term dialysis or transplantation.

Results

The incidence of CAD, stroke and end-stage renal disease over the follow-up period were 2.8% (n=68), 1.09% (n=26) and 0.6% (n=14). Hypertensives who developed CAD compared to those without CAD at follow-up (n=2312) had at baseline higher left ventricular mass index (115.7±24.6 vs 103.7±27.3 g/m2, p<0.0001), whereas there was no difference with respect to baseline GFR (78±19.6 vs 79.3±18.6 mL/min/1.73 m2 (p=0.573). In multivariate Cox regression models visit-to-visit glomerular filtration rate predicted end-stage renal disease (hazard ratio=1.758, p=0.01) but not CAD and stroke (p=NS for both). Baseline left ventricular mass index independently predicted CAD (hazard ratio=1.042, p=0.015) and stroke (hazard ratio=1.035, p=0.002).

Conclusions

In essential hypertensive patients GFR variability predicts future development of end-stage renal disease but exhibits no independent prognostic value for CAD and stroke. These results suggest that fluctuations of renal function are related with damage at the kidneys and not at the cardiac and cerebrovascular level.

P6577Isolated systolic hypertension versus combined systolic-diastolic hypertension as predictors of atrial fibrillation: data from a 8-year-follow-up study

Background/Introduction

Isolated systolic hypertension (ISH) and combined systolic-diastolic hypertension (CH) are related with increased cardiovascular risk.

Purpose

The aim of the present study was to compare the predictive role of ISH and CH for the incidence of atrial fibrillation (AF) in a cohort of essential hypertensive patients.

Methods

We followed up 1605 essential hypertensives with office systolic blood pressure (BP)≥140 mmHg [mean age 58.1 years, 842 males, office BP=153/92 mmHg] for a mean period of 8 years. All subjects had at least one annual visit and at baseline underwent echocardiographic study and blood sampling for estimation of metabolic profile. Patients with baseline ISH exhibited office systolic BP ≥140 mmHg and office diastolic BP <90 mmHg, while those with CH had office systolic BP ≥140 mmHg and office diastolic BP ≥90 mmHg. Moreover, new-onset AF was defined as hospitalization for AF or compatible electrocardiographic tracings.

Results

The incidence of new-onset AF over the follow-up period was 3.4% (n=55). Patients with ISH (n=510) compared to those with CH (n=1095) were older (65±10 vs 55±11 years, p<0.0001), had at baseline lower waist circumference (95.5±12 vs 98±12 cm, p<0.0001), office systolic BP (149±10 vs 155±13 mmHg, p<0.0001), office diastolic BP (80±5 vs 98±7 mmHg, p<0.0001), while did not differ regarding left ventricular mass index and lipid levels (p=NS for all). Univariate Cox regression analysis revealed that baseline ISH (hazard ratio=4.612, p=0.013) and CH (hazard ratio=1.794, p=0.036) predicted new-onset AF. However, in multivariate Cox regression model, age (hazard ratio=1.078, p<0.001), left ventricular mass index (hazard ratio 1.012, p=0.014), left atrium diameter (hazard ratio=1.102, p<0.001) and ISH (hazard ratio=1.551, p=0.035) but not CH turned out to be independent predictors of new-onset AF episodes.

Conclusions

In essential hypertensive patients, ISH but not CH exhibits independent prognostic value for AF. These findings support that ISH constitutes a hypertensive phenotype of particularly increased arrhythmia risk needing careful evaluation and treatment.

P5469Isolated systolic hypertension and combined systolic-diastolic hypertension for prediction of new-onset diabetes mellitus: Data from a 8-year-follow-up study

Background/Introduction

Isolated systolic hypertension (ISH) and combined systolic-diastolic hypertension (CH) are related with increased cardiovascular risk, while new-onset diabetes mellitus (NOD) is linked with atherosclerosis progression.

Purpose

The aim of the present study was to compare the predictive role of ISH and CH for the incidence of NOD in a cohort of essential hypertensive patients.

Methods

We followed up 1435 non-diabetic essential hypertensives with office systolic blood pressure (BP)≥140 mmHg [mean age 57 years, 730 males, office BP=153/92 mmHg] for a mean period of 8 years. All subjects had at least one annual visit and at baseline underwent echocardiographic study and blood sampling for estimation of metabolic profile. Patients with baseline ISH exhibited office systolic BP ≥140 mmHg and office diastolic BP <90 mmHg, while those with CH had office systolic BP ≥140 mmHg and office diastolic BP ≥90 mmHg. Moreover, NOD was defined if at one or more of the follow-up visits a previously non-diabetic patient reported being on insulin or an oral hypoglycemic drug or if casual plasma glucose concentration ≥200 mg/dl or fasting glucose concentration ≥126 mg/dl or 2-h post load glucose ≥200 mg/dl during an oral glucose tolerance test.

Results

The incidence of NOD over the follow-up period was 4.2% (n=60). Patients with ISH (n=460) compared to those with CH (n=975) were older (65±11 vs 54±10 years, p<0.0001), had at baseline lower waist circumference (94.5±11 vs 99±13 cm, p<0.0001), office systolic BP (149±12 vs 155±13 mmHg, p<0.0001), office diastolic BP (80±8 vs 98±6 mmHg, p<0.0001), while did not differ regarding left ventricular mass index, glucose and lipid levels (p=NS for all). Univariate Cox regression analysis revealed that baseline ISH (hazard ratio=2.143, p=0.016) and CH (hazard ratio=1.272, p=0.029) predicted NOD. However, in multivariate Cox regression model, age (hazard ratio=1.039, p<0.001), baseline glucose levels (hazard ratio 1.011, p=0.016), waist circumference (hazard ratio=1.067, p<0.001) and ISH (hazard ratio=1.651, p=0.029) but not CH turned out to be independent predictors of NOD.

Conclusions

In essential hypertensive patients, ISH but not CH exhibits independent prognostic value for NOD. These findings support that ISH constitutes a hypertensive phenotype of increased metabolic risk needing careful evaluation and treatment.

P4388Acute detrimental effects of e-cigarette and tobacco cigarette smoking on blood pressure and sympathetic nerve activity in healthy subjects

Background/Introduction

Tobacco cigarette smoking is related with atherosclerosis progression, blood pressure increase and changes in sympathetic nerve activity. However, there are scarce data on the impact of e-cigarettes that have been proposed as less harmful alternatives on the cardiovascular system and sympathetic drive.

Purpose

This study aimed to assess the acute effects of tobacco cigarettes, e-cigarettes and sham smoking on blood pressure and sympathetic nervous system in healthy subjects.

Methods

We studied 10 normotensive male habitual smokers (mean age 33 years, body mass index: 24.1 kg/m2, office blood pressure=117/72 mmHg) free of cardiovascular disease. The study design was randomized and placebo controlled with 3 experimental sessions (sham smoking, tobacco cigarette smoking, and e-cigarette smoking) in random order, each session on a separate day. Subjects smoked 2 tobacco cigarettes containing 1.1 mg nicotine or simulate smoking (sham smoking) with the 2 cigarettes separated by 5 minutes, while 45 minutes after finishing the second cigarette, subjects smoked a third cigarette or sham cigarette. Additionally, participants smoked e-cigarettes for a period of 5 and 30 minutes. In all occasions, sympathetic drive was assessed by muscle sympathetic nerve activity (MSNA) (baroreflex-dependent) and skin sympathetic nerve activity (SSNA) (baroreflex-independent) based on established methodology (microneurography).

Results

After the first, second and third tobacco cigarette smoking there was markedly and significantly increase in mean arterial pressure (by 11.2±1.4%, 12.3±1.3% and 13.1±1.4%, respectively, p<0.05 for all) and heart rate (by 25.1±3.7%, 26.3±2.7% and 25.9±3.7%, respectively, p<0.05 for all). Similarly e-cigarette smoking at 5 and 30 minutes was accompanied by augmentation of mean arterial pressure (by 10.9±1.2% and 12.8±1.4%, respectively, p<0.05 for both) and heart rate (by 22.5±3.3% and 23.9±3.8%, respectively, p<0.05 for both). Regarding the effect on sympathetic nervous system, the first, second and third tobacco cigarette smoking was accompanied by lower MSNA (by 28.1±4.4%, 29.6±5.3% and 30.1±5.2%, respectively, p<0.05 for all), whereas SSNA was increased (by 98.2±19.4%, 100.2±22.7% and 101.5±21.6%, respectively, p<0.05 for all). Additionally, e-cigarette smoking at 5 and 30 minutes caused a decrease in MSNA (by 26.9±3.6%, and 28.3±5.1%, respectively, p<0.05 for both), and an augmentation in SSNA (by 97.9±20.1% and 100.9±20.6%, respectively, p<0.05 for both). Sham smoking was devoid of any effects on blood pressure, MSNA and SSNA.

Conclusions

E-cigarette smoking acutely increases blood pressure and has a detrimental effect on sympathetic nerve activity regulation similar to tobacco smoking in healthy subjects. Our findings underscore the negative impact of e-cigarettes on cardiovascular and autonomic nervous system and could aid further recommendation in their use.

P6221Salt consumption as a predictor of cardiovascular events among hypertensive patients: a 5-year follow-up study

Background/Introduction

Salt intake is linked to hypertension but data on its association with incident cardiovascular events, especially among hypertensives, is limited.

Purpose

To examine the prospective association of different salt consumption levels with cardiovascular morbidity in a hypertensive population.

Methods

We followed 2130 hypertensive patients (age 57±12 years, 11.2% untreated) without a history of cardiovascular disease for a mean period of 5.3±3.3 years. At the baseline examination, salt intake was evaluated by a structured validated questionnaire. Accordingly, the study population was divided into three groups: hypertensives with a low (1079 patients, 51% of the population), a moderate (895 patients, 42%) and a high salt consumption (146 patients, 7%). During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was the composite of non-fatal cardiovascular events.

Results

The composite endpoint (19 strokes and 65 cases of coronary artery disease) occurred in 84 patients (3.9%). At baseline, increasing salt consumption was significantly associated with age, body mass index, office blood pressure and renal function. Unadjusted Cox regression analysis showed that, compared to the reference group, the risk for cardiovascular morbidity was similar in patients with moderate salt consumption (HR: 1.1, 95% CI: 0.71–1.77) but significantly higher in patients with high salt consumption (HR: 2.12, 95% CI: 1.09–4.38). This pattern was clearly sustained after adjusting for multiple risk factors including baseline blood pressure levels.

Conclusions

Among hypertensive patients, heavy salt consumption is associated with an increased cardiovascular risk, while moderate consumption does not affect patient outcome.

P5459Comparison of the predictive role of changes in left ventricular mass and arterial stiffness for coronary artery disease in essential hypertension: Data from a 8-year-follow-up study

Background/Introduction

Although arterial stiffening is related to atherosclerosis progression, its prognostic role in hypertension is not fully elucidated, while augmented left ventricular mass index (LVMI) is linked to adverse outcome.

Purpose

The aim of the present study was to compare the predictive role of changes in arterial stiffness and LVMI for the incidence of coronary artery disease (CAD) in a cohort of essential hypertensive patients.

Methods

We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and at baseline and last visit underwent complete echocardiographic study for estimation of LVMI and measurements of arterial stiffness on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method. The distribution of PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Moreover, LV hypertrophy (LVH) was defined as LVMI ≥125 g/m2 in males and LVMI ≥110 g/m2 in females, while CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure.

Results

The incidence of CAD over the follow-up period was 3.5%. Hypertensives who developed CAD (n=38) compared to those without CAD at follow-up (n=1044) had at baseline higher waist circumference (101.7±10.1 vs 96.2±11.6 cm, p=0.004), LVMI (123.9±22.1 vs 105.8±21.3 g/m2, p=0.026), prevalence of LVH (46% vs 25%, p=0.018) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with CAD and those without CAD with respect to baseline office BP, serum creatinine and lipid levels (p=NS for all). By univariate Cox regression analysis, it was revealed that changes in PWV levels between baseline and last visit predicted CAD (hazard ratio=1.243, p=0.014). However, in multivariate Cox regression model baseline glomerular filtration rate (hazard ratio=1.029, p=0.015) and changes in LVMI (hazard ratio=1.036, p<0.0001) but not alterations of PWV turned out to be independent predictors of CAD.

Conclusions

In essential hypertensive patients changes in LVMI predict future development of CAD, whereas PWV alterations exhibit no independent prognostic value. These findings support that LVMI constitutes a superior prognosticator of events than PWV and its estimation is essential in order to improve overall risk stratification in hypertension.

P802Interrelationships of sympathetic nervous system activity with attended and unattended blood pressure levels in essential hypertensive patients

Background/Introduction

Measurement of unattended blood pressure (BP) may provide additional information over conventionally attended BP. Moreover, hypertension is related to sympathetic drive while there are scarce data on the diverse links of attended and unattended BP with muscle sympathetic nerve activity (MSNA) in hypertensive patients.

Purpose

The aim of this study was to assess the relation of BP levels in the attended and unattended setting with MSNA in patients with essential hypertension.

Methods

We studied 38 patients with essential hypertension (age: 59±11 years, 20 males, office BP: 142/86±19/11 mmHg, 24-hour BP: 137/80±14/12 mmHg). In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Both unattended BP (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements, at 1-minute intervals, after 5 minutes) and attended BP were measured with the same device, on the same day of MSNA recording, in random order. Patients were divided into the combined attended and unattended hypertensive group when BP≥140/90 mmHg in both attended and unattended BP estimations and to the attended hypertensive group when only attended BP≥140/90 mmHg.

Results

Patients with combined attended and unattended hypertension (n=18) compared to those with attended hypertension (n=20) were older (61±11 vs 57±11 years, p=0.03), whereas did not differ regarding 24-h ambulatory BP levels, glucose levels, renal function and left ventricular mass index (p=NS for all). Moreover, patients with combined attended and unattended hypertension compared to those with attended hypertension were characterized by greater levels of MSNA (41.2±11.6 vs 32.2±10.1 bursts per minute, p=0.031). In all participants, sympathetic nerve traffic as assessed by resting MSNA was related to attended systolic BP (r=0.459, p=0.004), attended diastolic BP (r=0.503, p=0.001), unattended systolic BP (r=0.433, p=0.007) and unattended diastolic BP (r=0.423, p=0.008).

Conclusions

The phenotype of combined attended and unattended hypertension compared to attended hypertension is accompanied by higher sympathetic nervous system activation. Moreover, the close association of MSNA with attended and unattended BP levels in essential hypertension, further supports the key role of sympathetic drive in modulating BP.

P805Changes in arterial stiffness independently predict stroke in patients with essential hypertension: Data from a 8-year-follow-up study

Background/Introduction

Although arterial stiffening is related to atherosclerosis progression, the prognostic role of its alterations in cerebrovascular events in hypertension is not fully elucidated.

Purpose

The aim of the present study was to assess the predictive role of changes inarterial stiffness for the incidence of stroke in a cohort of essential hypertensive patients.

Methods

We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit and underwent blood sampling for assessment of metabolic profile, whilearterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method at the initial and last visit. The distribution of baseline PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by computed tomography and magnetic resonance angiography and/or cerebrovascular angiography findings.

Results

The incidence of stroke over the follow-up period was 2.2%. Hypertensives who had stroke (n=24) compared to those without stroke at follow-up (n=1058) were older at baseline (65±9 vs 56±12 years, p=0.032), had higher office BP levels (155±13 vs 145±15mmHg, p=0.014) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with stroke and those without stroke with respect to baseline renal function and lipid levels (p=NS for all). By univariate Cox regression analysis it was revealed that changes in PWV levels between baseline and last visit predicted stroke (hazard ratio=1.352, p=0.004). Moreover, in multivariate Cox regression model, baseline age (hazard ratio=1.087, p=0.03), changes in PWV (hazard ratio=1.115, p=0.024) but not changes in office BP levels turned out to be independent predictors of stroke.

Conclusions

In essential hypertensive patients, changes in PWV predict future development of stroke, independently of established confounders, including BP. These findings support that PWV constitutes a potent prognosticator of cerebrovascular events and its estimation is essential in order to improve risk stratification in hypertension.

P5468Systolic versus diastolic blood pressure as predictors of cardiovascular events among treated hypertensive patients: a 6-year prospective study

Background/Introduction

There has been a long debate regarding the association of systolic versus diastolic blood pressure with cardiovascular outcome and data regarding hypertensive patients under treatment have been conflicting.

Purpose

To investigate the association of different patterns of uncontrolled blood pressure (BP) among treated hypertensive patients.

Methods

We prospectively studied 1507 treated hypertensive patients (age 59±11 years) that are followed in the setting of a single-center, clinic-based registry. During follow-up, patients underwent regular visits for hypertension and risk factor management. Based on the cut-off limits for uncontrolled hypertension of office systolic BP≥140mmHg and diastolic BP≥90mmHg, study participants were divided into four groups: those with controlled hypertension (796 patients, 53% of the population), uncontrolled systolic BP (257 patients, 17%), uncontrolled diastolic BP (135 patients, 9%) and uncontrolled systolic and diastolic BP (319 patients, 21%). The outcome studied was the composite of cardiovascular morbidity set as coronary artery disease and stroke, and the controlled hypertension group served as reference.

Results

The median follow-up period was 6.4±3.0 years and the composite endpoint (13 strokes and 41 cases of coronary artery disease) occurred in 54 patients (3.6%). Unadjusted Cox regression analysis showed that, compared to the reference group of controlled hypertensives, the risk for cardiovascular morbidity was similar in patients with uncontrolled diastolic BP (HR: 0.88, 95% CI: 0.26–2.97) but significantly higher in patients with uncontrolled systolic BP (HR: 2.17, 95% CI: 1.08–4.36), while patients with both uncontrolled systolic and diastolic BP showed the worse prognosis (HR: 2.35, 95% CI: 1.24–4.43). This pattern of risk was overall sustained after adjusting for different sets of confounders.

Conclusions

Among treated hypertensive patients, uncontrolled systolic BP is associated with a greater risk for cardiovascular events compared to uncontrolled diastolic BP while uncontrolled systolodiastolic hypertension presents with the worse prognosis.