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

P5460Prevalence of left atrial enlargement in patients undergoing an echocardiogram for cardiovascular risk stratification at an esh excellence centre in italy

Background

Left atrial (LA) enlargement (LAE) is associated to an increased risk of cardiovascular complications, and in particular of atrial fibrillation. The 2018 ESH/ESC Hypertension guidelines suggested the use of LA volume instead of linear dimensions, and for the first time proposed the indexation to height2 (h2)

The aim of our study was to assess the prevalence of left atrial dilatation in a large sample of patients undergoing an echocardiogram for cardiovascular risk stratification at an ESH excellence centre in Italy.

Design and methods 3872 subjects undergoing a diagnostic work-up for arterial hypertension (known or suspect) were analysed. The mean age was 56±15 years, BMI 26±5 kg/m, 44% normal weight, 39% overweight, 17% obese, 53% males. Left atrial volume was measured by the area-length method using the apical 4-chamber and 2-chamber views.

Results

The prevalence of left ventricular hypertrophy (LVH) was 11% when indexing for BSA and 12% when indexing for height2.7. LAE was observed in 30% of subjects when indexing for h2 and in 9% when indexing for BSA. In obese or overweight subjects the prevalence of LAE was 38% of subjects when indexing for h2 and in 11% when indexing for BSA. The different prevalence of LAE was particularly evident in extremely obese patients.

LAE was very common in patients with LVH: 62% and 26% when indexing for h2 and for BSA, respectively. Interestingly, it was frequent also in patients without LVH, in particular when the indexation for h2 was used (25% as compared to 7% when indexing for BSA).

Conclusions

In a large sample of subjects undergoing a diagnostic work-up for arterial hypertension LAE was frequently observed, particularly when the new indexation proposed by the 2018 ESH/ESC hypertension guidelines was used. Even in the absence of clear-cut LVH, LAE was observed in one quarter of subjects. The indexation to BSA leads to an under-recognition of LAE, in particular in patients with overweight and/or obesity

Next generation physiologically based kinetic (NG-PBK) models in support of regulatory decision making

The fields of toxicology and chemical risk assessment seek to reduce, and eventually replace, the use of animals for the prediction of toxicity in humans. In this context, physiologically based kinetic (PBK) modelling based on in vitro and in silico kinetic data has the potential to a play significant role in reducing animal testing, by providing a methodology capable of incorporating in vitro human data to facilitate the development of in vitro to in vivo extrapolation of hazard information. In the present article, we discuss the challenges in: 1) applying PBK modelling to support regulatory decision making under the toxicology and risk-assessment paradigm shift towards animal replacement; 2) constructing PBK models without in vivo animal kinetic data, while relying solely on in vitro or in silico methods for model parameterization; and 3) assessing the validity and credibility of PBK models built largely using non-animal data. The strengths, uncertainties, and limitations of PBK models developed using in vitro or in silico data are discussed in an effort to establish a higher degree of confidence in the application of such models in a regulatory context. The article summarises the outcome of an expert workshop hosted by the European Commission Joint Research Centre (EC-JRC) - European Union Reference Laboratory for Alternatives to Animal Testing (EURL ECVAM), on "Physiologically-Based Kinetic modelling in risk assessment - reaching a whole new level in regulatory decision-making" held in Ispra, Italy, in November 2016, along with results from an international survey conducted in 2017 and recently reported activities occurring within the PBK modelling field. The discussions presented herein highlight the potential applications of next generation (NG)-PBK modelling, based on new data streams.

Development of a standard documentation protocol for communicating exposure models

An important step in building a computational model is its documentation; a comprehensive and structured documentation can improve the model applicability and transparency in science/research and for regulatory purposes. This is particularly crucial and challenging for environmental and/or human exposure models that aim to establish quantitative relationships between personal exposure levels and their determinants. Exposure models simulate the transport and fate of a contaminant from the source to the receptor and may involve a large set of entities (e.g. all the media the contaminants may pass though). Such complex models are difficult to be described in a comprehensive, unambiguous and accessible way. Bad communication of assumptions, theory, structure and/or parameterization can lead to lack of confidence by the user and it may be source of errors. The goal of this paper is to propose a standard documentation protocol (SDP) for exposure models, i.e. a generic format and a standard structure by which all exposure models could be documented. For this purpose, a CEN (European Committee for Standardisation) workshop was set up with objective to agree on minimum requirements for the amount and type of information to be provided on exposure models documentation along with guidelines for the structure and presentation of the information. The resulting CEN workshop agreement (CWA) was expected to facilitate a more rigorous formulation of exposure models description and the understanding by users. This paper intends to describe the process followed for defining the SDP, the standardisation approach, as well as the main components of the SDP resulting from a wide consultation of interested stakeholders. The main outcome is a CEN CWA which establishes terms and definitions for exposure models and their elements, specifies minimum requirements for the amount and type of information to be documented, and proposes a structure for communicating the documentation to different users.

In vitro-to-in vivo correlation of the skin penetration, liver clearance and hepatotoxicity of caffeine

This work illustrates the use of Physiologically-Based Toxicokinetic (PBTK) modelling for the healthy Caucasian population in in vitro-to-in vivo correlation of kinetic measures of caffeine skin penetration and liver clearance (based on literature experiments), as well as dose metrics of caffeine-induced measured HepaRG toxicity. We applied a simple correlation factor to quantify the in vitro and in vivo differences in the amount of caffeine permeated through the skin and concentration-time profiles of caffeine in the liver. We developed a multi-scale computational approach by linking the PBTK model with a Virtual Cell-Based Assay to relate an external oral and dermal dose with the measured in vitro HepaRG cell viability. The results revealed higher in vivo skin permeation profiles than those determined in vitro using identical exposure conditions. Liver clearance of caffeine derived from in vitro metabolism rates was found to be much slower than the optimised in vivo clearance with respect to caffeine plasma concentrations. Finally, HepaRG cell viability was shown to remain almost unchanged for external caffeine doses of 5-400 mg for both oral and dermal absorption routes. We modelled single exposure to caffeine only.

Maternal cardiovascular function in pregnancies complicated by intrauterine growth restriction

OBJECTIVE

To investigate maternal cardiovascular function in pregnancies complicated by intrauterine growth restriction (IUGR).

METHODS

Maternal echocardiography and ambulatory blood pressure monitoring were performed in pregnancies complicated by IUGR (n = 12) and controls (n = 12), all of whom were normotensive at enrollment.

RESULTS

Compared to controls, maternal blood pressure (P = 0.016) and total vascular resistance (P = 0.008) were higher in IUGR pregnancies. Heart rate was lower (P = 0.003), as was systolic function expressed by midwall fractional shortening (P = 0.04). No significant differences between the two groups were observed for left atrial or left ventricular dimensions, nor for left ventricular geometry. Assessment of diastolic function by means of transmitral Doppler flow measurements revealed a significantly longer isovolumetric relaxation time in pregnancies with IUGR (P = 0.006).

CONCLUSIONS

In normotensive pregnancies complicated by IUGR, as compared to controls, there is decreased diastolic and systolic maternal cardiac function, and a higher blood pressure.