I. Doundoulakis

Comparison Among Recommendations for the Management of Arterial Hypertension Issued by Last US, Canadian, British and European Guidelines

Guidelines for the management of hypertension have been issued by different hypertension societies or organizations. Despite many similarities one can identify major differences in the diagnosis, management and treatment of the hypertensive patients among ESH/ESC, NICE, Canadian and NJC8 guidelines. Differences that can be identified are in the definition of hypertension in the elderly population, the optimal blood pressure targets in different hypertensive populations such as patients with diabetes and chronic kidney disease patients and the choose of the initial and appropriate antihypertensive agent depending on comorbidities of the treated population. Everyday clinical praxis physicians are confused by these differences and these incongruities contribute to doctor and patient inertia to reduce blood pressure levels at an optimal level. Community physicians cannot easily distinguish what recommendations are the best to be used for their patients. The critical view of these differences can also help the guidelines committees to make appropriate changes and finally to agree to a global view of recommendations for the management and treatment of hypertension.

Screening for Malnutrition Among People Accessing Health Services at Greek Public Hospitals: Results From an Observational Multicenter Study.

BACKGROUND Malnutrition is associated with increased hospital stay and subsequently higher healthcare costs. Early detection of malnutrition among people accessing health services at public hospitals is vital to identify and treat malnutrition effectively and in a timewise and cost-effective manner. The aim of this study was to evaluate the nutrition risk of this population. MATERIALS AND METHODS Nutrition screening was performed for 2970 patients (52% male; 55.3 ± 20.1 years old) at 34 hospitals. Nutrition risk was evaluated through 3 nutrition screening tools-Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), and Mini Nutritional Assessment-Screening Form (MNA-SF). RESULTS Malnutrition risk was found: 25.3% with NRS-2002, 22.9% with MUST, and 60.5% with MNA-SF. Nutrition risk among patients accessing health services at public hospitals increases with age (high-risk patients among those ≥80 years old: NRS-2002, 9.8%; MUST, 16.9%; MNA-SF, 43.9%). The highest prevalence of nutrition risk was found at the oncology departments (16.7%, NRS-2002; 23.4%, MUST). According to the NRS-2002 and MUST, surgical patients have a greater risk for malnutrition vs internal medicine patients (adjusted odds ratio [OR] = 1.0, P < .001; adjusted OR = 1.17, P < .001, respectively), whereas according to MNA-SF, surgical patients have 30% lower probability for malnutrition risk against internal medicine patients (adjusted OR = 0.7, P < .001). CONCLUSIONS A high prevalence of malnutrition risk was reported among patients accessing health services at public hospitals. Early detection of malnutrition is vital to allow the allocation of the needed workforce to manage it effectively.

Obesity-Induced Hypertension: New Insights

BACKGROUND New insights on the relationship between weight loss and hypertension and the role of the newly approved anti-obesity drugs on hypertension will be discussed Methods: Weight loss is a major factor to reduce blood pressure when a patient with excess weight is advised from the health care provider to change his lifestyle. A healthy lifestyle with reduction in body weight, reduction in caloric intake, increased fruit and vegetables consumption and reduced salt intake concomitant with an increase in physical exercise can reduce body weight and hypertension in overweight and obese patients, but not all obese are able to reduce their blood pressure and lose weight without treatment and special dietary care. Moreover, most obese people lose weight for a small period and then they regain all the weight that they have lost or even worse, they increase their weight more than before starting a diet. Newly-approved weight loss drugs have variable actions on high blood pressure. Liraglutide and phentermine/topiramate seem to reduce hypertension, while after the bupropion/naltrexone or lorcaserin use trials reported a rise in blood pressure. CONCLUSION Reduction in body weight with treatment is not always associated with reduction in obesity induced hypertension. Weight loss treatments that exhibit sympathomimetic or adrenergic actions should be used with care and for short periods of time.

PERFORMANCE OF THE AAP 2017 GUIDELINE SIMPLE TABLE ON BP SCHOOL-BASED SCREENING IN A EUROPEAN POPULATION

Objective: We assessed the performance on BP population screening of the simplified AAP 2017 clinical practice guideline based on age and 5th percentile of height, and a similar simplified table based on the 4th Report BP reference tables compared to the ESH 2016 guideline diagnostic thresholds. Design and method: We obtained data from a school-based screening study for the prevalence of high BP in the municipality of Kastoria in north Greece. Blood pressure was measured thrice by a mercury sphygmomanometer according to ESH 2016 guidelines and the last two BPs were averaged for the analysis. Results: The study population included 1,846 children aged 6–12 years and 986 adolescents aged 13–18 years. Compared to the ESH 2016 classification, the AAP 2017 table showed AUC 0.936, sensitivity 95.5%, specificity 91.6%, NPV 99.8%, and PPV 36%, while the 4th report table showed AUC 0.963, sensitivity 99.2%, specificity 93.3%, NPV 100%, and PPV 42.2%. The performance of the 4th report table was similar in both age groups, while the performance of the AAP 2017 table was lower in the adolescent group (AUC 0.884, sensitivity 83.2%, specificity 93.5%, NPV 99.3%, and PPV 32.6%, in adolescents versus AUC 0.953, sensitivity 100%, specificity 90.6%, NPV 100%, and PPV 37.2% in 6–12 years-olds, P < 0.05 for difference in AUC between age groups). Comparing the prevalence of elevated BP by the two simple tables we found agreement by both tables in 96.9% of the subjects (86.7% had normotension and 10.2% had high-normal or hypertensive BP levels), and disagreement in 3.1%. All children classified for further screening by AAP 2017 table were normotensive by ESH 2016 classification. However, 20,8% of the adolescents classified for further screening by 4th report, but not by AAP 2017 table, had BP levels at the high-normal category according to ESH 2016 classification. Conclusions: Simple tables for BP screening based on age present good performance to identify children and adolescents with normal BP levels. However, the table by AAP 2017 guideline may provide high rate of false positive results and fail to classify adolescents eligible for further BP measurements and lifestyle modification.

AMBULATORY VERSUS HOME BLOOD PRESSURE: WHICH CAN PREDICT BETTER EARLY VASCULAR AGEING?

Objective: To identify the blood pressure (BP) measuring method, home, 24 h ABPM and clinic, that can better predict early vascular ageing (EVA) and to create a new predictive model for EVA from BP measurements and other risk factors. Design and method: 282 consecutive subjects (39.7% male) aged 56.8 ± 15.8 years were included in the study. BP was measured at office and out of office with 24h-ABPM on a usual working day and seven days home BP monitoring. Pulse wave velocity (PWV) was measured after 15 min of rest in the supine position. EVA represented carotid-femoral PWV values higher than the expected for age average values. Results: In the univariate analysis, EVA correlated with office systolic BP, average 24 h systolic BP, 24 h diastolic BP, average 24 h and home heart rate, and office heart rate (p < 0.05). The area under the curve for the diagnosis of EVA was 0.620 (90% CI 0.55, 0.69), 0.559 (90% CI 0.48, 0.64) and 0.565 (90% CI 0.49, 0.64), for 24 h, home and clinic systolic BP, respectively. The 24 h systolic and diastolic BP, 24 h heart rate and risk factors such as body mass index, gender, age, creatine clearance, diabetes mellitus, were used to develop a new prediction score with Random Forest algorithm for the prediction of EVA providing a total accuracy 0.82 and high rates of sensitivity and specificity. Conclusions: In conclusion, 24 h systolic BP from ABPM is a better predictor for EVA than home and clinic systolic BP. A new risk assessment tool for EVA was created by 24 h ABPM variables, age, sex, body mass index, diabetes mellitus and creatine clearance.

COMPARATIVE EFFICACY OF ANGIOTENSIN CONVERTING ENZYME INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS II IN ESSENTIAL HYPERTENSION: SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Objective: Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are widely used for the treatment of hypertension. However, data on their comparative efficacy is incomplete. The present systematic review and network meta-analysis investigated the comparative efficacy of these two drug categories in blood pressure reduction, mortality and morbidity of adults with essential hypertension. Design and method: Bibliographic search was performed in Medline (PubMed) and Cochrane Central Register of Controlled Trials (CENTRAL) for placebo- and active-controlled, double-blind randomized trials, which had studied for blood pressure reduction, mortality and/or morbidity. Results: Thirty studies with 7370 participants were included for the blood pressure reduction analysis and eight studies with 25158 participants were included for the mortality/morbidity analysis. The two pharmacological categories did not differ in lowering systolic (WMD: 0.59, 95%CI: −0.21 to 1.38) and diastolic blood pressure (WMD: 0.62, 95%CI: −0,06 to 1.30), all-cause mortality (RR: 0.96, 95%CI 0.80 to 1.14), cardiovascular mortality (RR: 0.87, 95%CI 0.67 to 1.14), fatal and non-fatal myocardial infarction (RR: 1.02, 95%CI 0.75 to 1.37) and stroke (RR: 1.13, 95%CI 0.87 to 1.46). ACEIs found to be superior in the development and/or hospitalization for heart failure (RR: 0.71, 95%CI 0.54 to 0.93). Conclusions: ACEIs and ARBs do not differ in blood pressure reduction, mortality and morbidity in patients with essential hypertension. ACEIs were superior in the development and/or hospitalization for heart failure.

Early Vascular Aging Risk Assessment From Ambulatory Blood Pressure Monitoring: The Early Vascular Aging Ambulatory Score

BACKGROUND This study compared the diagnostic accuracy of blood pressure (BP) measurement methods, office BP, ambulatory BP monitoring (ABPM), and home BP, in the identification of early vascular aging (EVA) and developed a score to predict the risk of EVA in hypertensive patients. METHODS Two-hundred eighty-two consecutive subjects (39.7% male) aged 56.8  ±  15.8 years were included. Office and out-of-office BP measurements including ABPM on a usual working day and 7 days home BP monitoring were performed. Carotid-femoral pulse wave velocity (c-f PWV) was measured in all patients. EVA was defined as c-f PWV values higher than the expected for age average values according to European population data. RESULTS In univariate analysis, EVA was significantly correlated with office systolic BP, average 24-hour systolic and diastolic BP, and average 24-hour and office heart rates. The area under the curve for predicting EVA was 0.624 (95% CI 0.551 to 0.697), 0.559 (95% CI 0.484 to 0.635) and 0.565 (95% CI 0.49 to 0.641), for daytime, home, and office systolic BP, respectively. Ambulatory BP variables, age, sex, body mass index, diabetes mellitus (yes/no), and estimated glomerular filtration rate were used to develop a new score for EVA providing a total accuracy of 0.82, 0.84 sensitivity, and 0.78 specificity. CONCLUSIONS In conclusion, the new risk score, Early Vascular Aging Ambulatory score, may accurately identify hypertensive patients with EVA using ABPM values and classic cardiovascular risk factors.

[PP.26.12] 24HOUR SYSTOLIC BLOOD PRESSURE VS CLINIC SYSTOLIC BLOOD PRESSURE: WHICH CAN PREDICT BETTER EARLY VASCULAR AGING?

Objective: The aim of this study was to investigate which way of measuring blood pressure, clinic or 24h-ABPM, can predict better early vascular aging. Design and method: 278 consecutive subjects (47.5% male) aged 47.1 ± 22.9 years were included in the study. Subjects were never treated before for hypertension. All subjects underwent 24h-ABPM on a usual working day. Pulse wave velocity (PWV) was measured after 15 minutes of rest in the supine position. PWV was calculated as the transit time of the arterial pulse along the carotid-femoral distance divided with the distance measured directly and modified according the guidelines. Early vascular aging (EVA) was calculated using the age and the PWV values, according the guidelines. Results: In the univariate analysis, EVA was correlated with clinic SBP and 24 hour average of SBP (p < 0.001 for both). From ROC curves for EVA, AUC of 24-ABPM (0.723, p < 0.001) was larger than that of clinic SBP (0.692, p < 0.001). Multivariate analysis revealed that 24 hour average of SBP (p < 0.01), but not clinic SBP, independently predicted the outcome after adjustment for age, gender, BMI, LDL levels, e-GFR and clinic SBP. Conclusions: The 24 hour average of SBP can be a predictor of early vascular aging. This result shows the importance of 24h-ABPM compared to clinic blood pressure measurement in order to identify high risk patients.

[PP.19.29] DETERMINANTS OF EARLY VASCULAR AGEING: A MULTIVARIATE ANALYSIS

Objective: The aim of the study was to identify determinants of early vascular aging. Design and method: 278 consecutive subjects (47.5% male) aged 47.1 ± 22.9 years were included in the study. Subjects were never treated before for hypertension. All subjects underwent 24h-ABPM on a usual working day. Pulse wave velocity (PWV) was measured after 15 minutes of rest in the supine position. PWV was calculated as the transit time of the arterial pulse along the carotid-femoral distance divided with the distance measured directly and modified according the guidelines. Early vascular aging (EVA) was calculated using the age and the PWV values, according the guidelines. Results: In the univariate analysis, EVA was correlated with age, gender, body mass index (BMI), clinic SBP, clinic DBP, 24 h average of SBP, 24 h average of DBP, LDL levels and e-GFR (p < 0.05 for all), but not with uric acid. However, in the multiple linear regression model, only e-GFR, clinic DBP, 24 h average of SBP and 24 h average of DBP (p < 0.05 for all) remained significant predictors of EVA, even after adjustment for other factors. Conclusions: Kidney function, clinic DBP, 24 h systolic BP and 24 h diastolic BP were found to be statistically significant determinants of early vascular aging. This result shows the importance of establishing 24h-ABPM in the everyday clinical practice, as a determinant of early vascular aging.

Markers of Early Vascular Ageing

BACKGROUND Cardiovascular damage is clinically manifested as coronary artery disease, heart failure, stroke and peripheral artery disease. The prevalence of these adverse conditions is higher with advancing age. Although many patients present cardiovascular damage late in their life, it is common to see patients with early atherosclerosis in cardiovascular intensive care units at ages lower than 50 years in men and 55 for women. METHODS AND RESULTS In this review of the literature we identified risk factors of early vascular damage. The classic risk factors such as age, gender, diabetes mellitus, dyslipidemia, smoking, alcohol, hypertension, obesity, family history and newer biomarkers such as hs-CRP, folic acid, homocysteine, fibrinogen are neither strong nor predictive of the individual patients risk to present early cardiovascular disease. All these risk factors have been used to propose risk scores for possible future events but we still lack a single strong marker indicating new onset of disease that will predict the future independently of the classical factors. The role of vascular imaging techniques to identify patients with subclinical atherosclerotic vascular damage before clinical disease, including the effect of known and unknown risk factors on the vascular tree, seems to be very important for intensifying preventive measures in high risk patients. Early arteriosclerosis measured from pulse wave velocity is associated with reduced arterial elasticity and is associated with future cardiovascular events. CONCLUSIONS Vascular measurements may better represent the continuum of cardiovascular disease from a young healthy to an aged diseased vessel that is going to produce adverse clinical events.