Julia Pareja

Underdiagnosis and prognosis of chronic obstructive pulmonary disease after percutaneous coronary intervention: a prospective study

Background Retrospective studies based on clinical data and without spirometric confirmation suggest a poorer prognosis of patients with ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) following percutaneous coronary intervention (PCI). The impact of undiagnosed COPD in these patients is unknown. We aimed to evaluate the prognostic impact of COPD – previously or newly diagnosed – in patients with IHD treated with PCI. Methods Patients with IHD confirmed by PCI were consecutively included. After PCI they underwent forced spirometry and evaluation for cardiovascular risk factors. All-cause mortality, new cardiovascular events, and their combined endpoint were analyzed. Results A total of 133 patients (78%) male, with a mean (SD) age of 63 (10.12) years were included. Of these, 33 (24.8%) met the spirometric criteria for COPD, of whom 81.8% were undiagnosed. IHD patients with COPD were older, had more coronary vessels affected, and a greater history of previous myocardial infarction. Median follow-up was 934 days (interquartile range [25%–75%]: 546–1,160). COPD patients had greater mortality (P=0.008; hazard ratio [HR]: 8.85; 95% confidence interval [CI]: 1.76–44.47) and number of cardiovascular events (P=0.024; HR: 1.87; 95% CI: 1.04–3.33), even those without a previous diagnosis of COPD (P=0.01; HR: 1.78; 95% CI: 1.12–2.83). These differences remained after adjustment for sex, age, number of coronary vessels affected, and previous myocardial infarction (P=0.025; HR: 1.83; 95% CI: 1.08–3.1). Conclusion Prevalence and underdiagnosis of COPD in patients with IHD who undergo PCI are both high. These patients have an independent greater mortality and a higher number of cardiovascular events during follow-up.

Renal Denervation vs. Spironolactone in Resistant Hypertension: Effects on Circadian Patterns and Blood Pressure Variability

BACKGROUND Sympathetic renal denervation (SRD) has been proposed as a therapeutic alternative for patients with resistant hypertension not controlled on pharmacological therapy. Two studies have suggested an effect of SRD in reducing short-term blood pressure variability (BPV). However, this has not been addressed in a randomized comparative trial. We aimed to compare the effects of spironolactone and SRD on circadian BP and BPV. METHODS This is a post-hoc analysis of a randomized trial in 24 true resistant hypertensive patients (15 men, 9 women; mean age 64 years) comparing 50mg of spironolactone (n = 13) vs. SRD (n = 11) on 24-hour BP. We report here the comparative effects on daytime (8 AM–10 PM) and nighttime (0 AM–6 AM) BP, night-to-day ratios and BP and heart rate variabilities (SD and coefficient of variation of 24-hour, day and night, as well as weighted SD and average real variability (ARV)). RESULTS Spironolactone was more effective than SRD in reducing daytime systolic (P = 0.006), daytime diastolic (P = 0.006), and nighttime systolic (P = 0.050) BP. No differences were observed in the night-to-day ratios. In contrast, SRD-reduced diastolic BPV (24 hours, daytime, nighttime, weighted, and ARV; all P < 0.05) with respect to spironolactone, without significant differences in systolic BPV. CONCLUSION Spironolactone is more effective than SRD in reducing ambulatory BP. However, BPV is significantly more reduced with SRD. This effect could be important in terms of potential prevention beyond BP reduction and deserves further investigation.

[OP.4A.10] RENAL DENERVATION VERSUS SPIRONOLACTONE IN RESISTANT HYPERTENSION. EFFECTS ON CIRCADIAN PATTERNS AND BLOOD PRESSURE VARIABILITY.

Objective: We have previously reported that spironolactone (S) was superior to renal denervation (RD) in reducing 24-hour blood pressure in resistant hypertensive subjects. The present analysis examines the effect of both treatments on daytime and nighttime values, as well as in blood pressure variability (BPV). Design and method: Randomised, clinical trial in resistant hypertensives (office SBP > 150 and 24-h SBP > 140 mmHg). After eligibility, 24 patients were assigned to S (13) at a dose of 50 mg/day or RD (11). A 24-h ABPM was performed at baseline and after 6 months. Circadian effects were analysed by computing daytime (08:00–22:00) and nighttime (00:00–06:00) BP and heart rate (HR), as well as night-to-day ratios. Measures of BPV included standard deviations (SD) and coefficient of variation (CV) for 24-h, day and night BP and HR, as well as weighted SD and average real variability (ARV). Differences between baseline and final ABPM were calculated. The effect of treatment was examined by generalized linear models adjusted by baseline values (for circadian values) and for the correspondent difference in BP or HR (for BPV). Results: Spironolactone was superior to RD in reducing daytime SBP (25.6 vs 3.4 mmHg; p = 0.006) and DBP (10.3 vs 1.8 mmHg; p = 0.006), and nighttime SBP (23.4 vs 7.1 mmHg; p = 0.050). No differences were observed between treatments in night-to-day ratios of BP or HR. DBP variability was reduced with RD in comparison to S. This was observed for both SD and CV for 24-h, day and night values, as well as for weighted SD (p = .013) and ARV (p = 0.023). No differences were observed between treatments in changes in SBP or HR indexes of variability. Conclusions: Spironolactone is superior to RD in reducing day and night BP, without differences in the circadian pattern. RD reduces diastolic BPV in comparison to S. The importance of this effect should be further examined in terms of possible prognostic implications.

Central blood pressure variability is increased in hypertensive patients with target organ damage

We aimed to evaluate the association of aortic and brachial short‐term blood pressure variability (BPV) with the presence of target organ damage (TOD) in hypertensive patients. One‐hundred seventy‐eight patients, aged 57 ± 12 years, 33% women were studied. TOD was defined by the presence of left ventricular hypertrophy on echocardiogram, microalbuminuria, reduced glomerular filtration rate, or increased aortic pulse wave velocity. Aortic and brachial BPV was assessed by 24‐hour ambulatory BP monitoring (Mobil‐O‐Graph). TOD was present in 92 patients (51.7%). Compared to those without evidence of TOD, they had increased night‐to‐day ratios of systolic and diastolic BP (both aortic and brachial) and heart rate. They also had significant increased systolic BPV, as measured by both aortic and brachial daytime and 24‐hours standard deviations and coefficients of variation, as well as for average real variability. Circadian patterns and short‐term variability measures were very similar for aortic and brachial BP. We conclude that BPV is increased in hypertensive‐related TOD. Aortic BPV does not add relevant information in comparison to brachial BPV.

Organ damage changes in patients with resistant hypertension randomized to renal denervation or spironolactone: The DENERVHTA (Denervación en Hipertensión Arterial) study

Renal denervation and spironolactone have both been proposed for the treatment of resistant hypertension, but their effects on preclinical target organ damage have not been compared. Twenty‐four patients with 24‐hour systolic blood pressure ≥140 mm Hg despite receiving three or more full‐dose antihypertensive drugs, one a diuretic, were randomized to receive spironolactone or renal denervation. Changes in 24‐hour blood pressure, urine albumin excretion, arterial stiffness, carotid intima‐media thickness, and left ventricular mass index were evaluated at 6 months. Mean baseline‐adjusted difference between the two groups (spironolactone vs renal denervation) at 6 months in 24‐hour systolic blood pressure was −17.9 mm Hg (95% confidence interval [CI], −30.9 to −4.9; P = .01). Mean baseline‐adjusted change in urine albumin excretion was −87.2 (95% CI, −164.5 to −9.9) and −23.8 (95% CI, −104.5 to 56.9), respectively (P = .028). Mean baseline‐adjusted variation of 24‐hour pulse pressure was −13.5 (95% CI, −18.8 to −8.2) and −2.1 (95% CI, −7.9 to 3.7), respectively (P = .006). The correlation of change in 24‐hour systolic blood pressure with change in log‐transformed urine albumin excretion was r = .713 (P < .001). At 6 months there was a reduction in albuminuria in patients with resistant hypertension treated with spironolactone as compared with renal denervation.

Cuff-Based Oscillometric Central and Brachial Blood Pressures Obtained Through ABPM are Similarly Associated with Renal Organ Damage in Arterial Hypertension

Background/Aims: Central blood pressure (BP) has been suggested to be a better estimator of hypertension-associated risks. We aimed to evaluate the association of 24-hour central BP, in comparison with 24-hour peripheral BP, with the presence of renal organ damage in hypertensive patients. Methods: Brachial and central (calculated by an oscillometric system through brachial pulse wave analysis) office BP and ambulatory BP monitoring (ABPM) data and aortic pulse wave velocity (PWV) were measured in 208 hypertensive patients. Renal organ damage was evaluated by means of the albumin to creatinine ratio and the estimated glomerular filtration rate. Results: Fifty-four patients (25.9%) were affected by renal organ damage, displaying either microalbuminuria (urinary albumin excretion ≥30 mg/g creatinine) or an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Compared to those without renal abnormalities, hypertensive patients with kidney damage had higher values of office brachial systolic BP (SBP) and pulse pressure (PP), and 24-h, daytime, and nighttime central and brachial SBP and PP. They also had a blunted nocturnal decrease in both central and brachial BP, and higher values of aortic PWV. After adjustment for age, gender, and antihypertensive treatment, only ABPM-derived BP estimates (both central and brachial) showed significant associations with the presence of renal damage. Odds ratios for central BP estimates were not significantly higher than those obtained for brachial BP. Conclusion: Compared with peripheral ABPM, cuff-based oscillometric central ABPM does not show a closer association with presence of renal organ damage in hypertensive patients. More studies, however, need to be done to better identify the role of central BP in clinical practice.