Janani Rangaswami

A Review of Nutritional Factors in Hypertension Management

Hypertension is a major health problem worldwide. Its attendant morbidity and mortality complications have a great impact on patients quality of life and survival. Optimizing blood pressure control has been shown to improve overall health outcomes. In addition to pharmacological therapies, nonpharmacological approach such as dietary modification plays an important role in controlling blood pressure. Many dietary components such as sodium, potassium, calcium, and magnesium have been studied substantially in the past decades. While some of these nutrients have clear evidence for their recommendation, some remain controversial and are still of ongoing study. Dietary modification is often discussed with patients and can provide a great benefit in blood pressure regulation. As such, reviewing the current evidence will be very useful in guiding patients and their physician and/or dietician in decision making. In this review article of nutritional factors in hypertension management, we aim to examine the role of nutritional factors individually and as components of whole dietary patterns.

Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) can risk stratify patients in transcatheter aortic-valve replacement (TAVR).

BACKGROUND Neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) mark systemic inflammation. Patients with high NLR and PLR have worse cardiovascular disease and outcomes. We assessed the role of these ratios in predicting outcomes after transcatheter aortic valve replacement (TAVR). METHODS The association between NLR and PLR with baseline characteristics, 30-day outcomes, and 1-year readmission/survival was determined in patients that underwent TAVR between 2007 and 2014 and had baseline complete blood count with differential. A subgroup analysis determined the association between change in NLR and PLR (discharge-baseline) and 1-year outcomes. RESULTS In 520 patients that underwent TAVR, a higher NLR (p=0.01) and PLR (p=0.02) were associated with a higher STS-PROM score, and with increased occurrence of the 30-day early-safety outcome (by VARC-2), even after adjusting for STS-PROM score, valve generation (Sapien vs. Sapien XT), and access (transfemoral vs. non-transfemoral) (NLR: OR 1.29, 95% CI 1.04-1.61; PLR: OR 1.27, 95% CI 1.01-1.60) but not with 1-year readmission or survival. In our subgroup analysis (N=294), change in PLR was not associated with the 1-year outcomes but a high change in NLR was associated with worse 1-year survival/readmission and 1-year survival, even after adjusting for STS-PROM score, valve generation and access (HR 1.22, 95% CI 1.04-1.44 and HR 1.26, 95% CI 0.99-1.6, respectively). CONCLUSIONS NLR and PLR correlate with surgical risk. An elevated NLR and PLR were associated with the occurrence of 30-day adverse outcomes, similar to the STS-PROM score. A high variation of NLR from baseline to discharge may help stratify patients that underwent TAVR in addition to traditional risk factors.

Dipstick proteinuria is an independent predictor of high on treatment platelet reactivity in patients on clopidogrel, but not aspirin, admitted for major adverse cardiovascular events

Abstract The effectiveness of aspirin and clopidogrel in patients with chronic kidney disease (CKD) suffering from acute cardiovascular events is unclear. High on treatment platelet reactivity (HTPR) has been associated with worse outcomes. Here, we assessed the association of dipstick proteinuria (DP) and renal function on HTPR and clinical outcomes. Retrospective cohort analysis of 261 consecutive, non-dialysis patients admitted for Major Adverse Cardiovascular Events (MACE) that had VerifyNow P2Y12 and VerifyNow Aspirin assays performed. HTPR was defined as P2Y12 reactivity unit (PRU) > 208 for clopidogrel and aspirin reaction units (ARU) > 550 for aspirin. Renal function was classified based on the estimated glomerular filtration rate (eGFR), and dipstick proteinuria was defined as ≥30 mg/dl of albumin detected on a spot analysis. All cause mortality, readmissions, and cardiac catheterizations were reviewed over 520 days. In patients on clopidogrel (n = 106), DP was associated with HTPR, independent of eGFR, diabetes mellitus, smoking or use of proton pump inhibitor (AOR = 4.76, p = 0.03). In patients with acute coronary syndromes, HTPR was associated with more cardiac catheterizations (p = 0.009) and readmissions (p = 0.032), but no differences in in-stent thrombosis or re-stenosis were noted in this cohort. In patients on aspirin (n = 155), no associations were seen between DP and HTPR. However, all cause mortality was significantly higher with HTPR in this group (p = 0.038). In this cohort, DP is an independent predictor of HTPR in patients on clopidogrel, but not aspirin, admitted to the hospital for MACE.

Effects of Staged Versus Adhoc Percutaneous Coronary Interventions on Renal Function—Is There a Benefit to Staging?.

AIM The purpose of this study is to determine whether ad hoc (same session) percutaneous coronary intervention, and staged (multiple session) percutaneous coronary intervention (PCI) have different renal outcomes. METHODS AND RESULTS This is a retrospective cohort study that compares the maximal decline in glomerular filtration rate (GFR) at various times points (3-6days, 1-4weeks, 4-12weeks) after either ad hoc or staged PCI. 115 patients undergoing staged PCI and 115 matched ad hoc PCI controls were included in the study. They were equivalent in baseline GFR, left ventricular ejection fraction and intra-procedural volume status based on LVEDP. The group undergoing staged PCI had greater cumulative fluoroscopy time, SYNTAX score and number of stents placed. Staged PCIs used less contrast per catheterization (155.0±5.6mL) but higher cumulative contrast dose (326.6±14.0mL) compared to ad hoc PCIs (193.4±7.2mL). Following intervention, there was a progressive decline in renal function that did not significantly differ between the ad hoc and staged groups. In the subgroup of patients with initial GFR ≤60cm3/min, staged PCI was associated with 2.6-fold greater decline in renal function 4-12weeks after the procedure compared to ad hoc. A propensity match analysis performed in patients with GFR ≤60cm3/min confirmed worse renal function in the staged group at 4-12weeks. CONCLUSIONS Staged PCI exposes patients to greater cumulative contrast agent loads. The decline in renal function observed in both groups did not differ significantly, however worse renal outcomes were observed in the staged PCI group with baseline GFR ≤60cm3/min.

Nocturnal Non-dipping Blood Pressure Profile in Black Normotensives Is Associated with Cardiac Target Organ Damage

PURPOSE A non-dipping pattern of nocturnal blood pressure in hypertensive patients is an established predictor of cardiovascular risk, especially in Blacks. However, data on non-dipping normotensives and cardiovascular risk in this population is sparse. In this study, we aim to determine if a non-dipping profile in a cohort of Black normotensives is associated with cardiac target organ damage. METHODS We studied ambulatory blood pressure patterns in 43 normotensive Black patients of Caribbean origin and classified their profiles as dippers (DP) and non-dippers (NDP) based on their nocturnal blood pressure profiles. Cardiac target organ damage was estimated from 2-D echocardiogram. RESULTS The mean age of the cohort was 52 years. Both groups were similar with respect to baseline age, sex, weight, height, body mass index and daytime ambulatory BP. There was a statistically significant difference in nocturnal blood pressure between DP and NDP groups (112 ± 7/64 ± 2 mm Hg vs 117 ± 3/69 ± 2 mm Hg, P=.004). The NDP cohort showed evidence of cardiovascular target damage on echocardiography with a significantly increased relative wall thickness (.35 ± .07 cm vs .42 ± .05 cm, P=.001), left ventricular mass index (95 ± 14 vs 105 ± 14 g/m(2), P=.018) and left atrial volume index (26 ± 3.5 vs. 30 ± 3.4, P=.001). Left ventricular geometry in the non-dippers also showed increased concentric remodeling, concentric and eccentric hypertrophy. CONCLUSIONS Our study demonstrates that nocturnal non-dipping of blood pressure in normotensive Blacks of Caribbean origin may be associated with cardiovascular end organ damage thereby providing new surveillance and therapeutic targets.

Blood pressure variability predicts adverse events and cardiovascular outcomes in SPRINT

SPRINT (Systolic Blood Pressure Intervention Trial) highlighted the benefits of intensive targeted antihypertensive therapy but resulted in higher rates of treatment‐related adverse events. Blood pressure (BP) variability has emerged as a significant predictor of outcomes over and above levels of BP. Using the SPRINT data set, we aimed to determine the relationship of BP variability with cardiovascular outcomes and side effects of antihypertensive therapy. The analyses included all participants randomized in SPRINT who reached the target systolic BP (SBP) for their respective groups (intensive < 120 mm Hg; standard < 140 mm Hg). Coefficients of variation (CV) for SBP, diastolic BP (DBP), and PP for each patient characterized variability. Student t test was used to compare treatment arms for each CV metric. Cox proportional hazards regression was used to identify independent predictors of the SPRINT primary outcome and adverse events. P < .15 on univariate analysis was required to enter the model and P < .05 to remain in it. A total of 8884 patients (4561 standard group; 4323 intensive group) met inclusion criteria. DBP CV differed between the groups (9.12 ± 3.20 standard group; 9.47 ± 3.49 intensive group [P < .0001]). DBP CV predicted a greater hazard for the primary outcome (hazard ratio [HR], 1.14) in the overall model as well as separate analyses by treatment arms (standard group HR, 1.15; intensive group HR, 1.19), each P < .0001. DBP CV also independently predicted a greater hazard for acute kidney injury (HR, 1.12) and hypotensive events (HR, 1.12). Visit‐to‐visit DBP variability independently predicted worse cardiovascular outcomes and hypoperfusion‐related adverse events in SPRINT.

Acute kidney injury post-transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a treatment option in high‐risk patients with severe aortic stenosis who are not surgical candidates. In light of emerging evidence, it is being increasingly performed even in intermediate‐risk patients in recent years. Patients who develop acute kidney injury (AKI) following TAVR are known to have worse outcomes. The objective of this concise review was to identify the prevalence and the impact of AKI following TAVR on patient outcomes by including the most recent literature in our search. After a thorough search on MEDLINE, Google Scholar, and PubMed, we included all literature relevant to AKI following TAVR. We found that AKI was caused by a variety of reasons, such as hemodynamic instability during rapid pacing, blood transfusion, periprocedural embolization, and use of contrast medium, to name a few. In patients who developed AKI following TAVR, 30‐day and 1‐year mortality were increased. Further, in these patients, length and cost of hospital stay were increased as well. Preventive measures such as optimal periprocedural hydration, careful contrast use, and techniques to prevent embolization during device implantation have been tried with limited success. Given that TAVR is expected to be increasingly performed, this review aimed to summarize the rapidly expanding currently available literature in an effort to reduce procedural complications and thereby improve patient outcomes.

Resuscitation for the specialty of nephrology: is cardionephrology the answer?

The specialty of nephrology faces major fellowship recruitment challenges, with ongoing declining interest among internal medicine residents. The field of Cardionephrology can help instill new interest and enthusiasm in choosing nephrology as a career amongst trainee physicians.

Cost-effectiveness of Intensive Blood Pressure Management—Is There an Additional Price to Pay?

Cost-effectiveness of Intensive Blood Pressure Management—Is There an Additional Price to Pay? To the Editor We read with interest the recent article by Richman et al published in JAMA Cardiology.1 Their analysis looked at outcomes and costs for a Markov cohort model using treatment effects and adverse event rates as reported in the Systolic Blood Pressure Interventional Trial.2 The authors concluded that standard blood pressure (BP) management yielded 9.6 quality-adjusted life-years and accrued

Thirty-Day Readmissions After Hospitalization for Clostridium difficile Enteritis Measures and Predictors: A Nationwide Analysis

155 261 in lifetime costs, while intensive BP management yielded 10.5 quality-adjusted life-years and accrued