Konstantinos Kintis

Noninvasive assessment of haemodynamics in resistant hypertension: the role of the renal resistive index

Objective: The association of resistant hypertension (RHTN) with renal haemodynamics is unclear. Our aim was to evaluate differences in haemodynamic characteristics of patients with RHTN compared with patients with controlled hypertension (HTN) at the level of the heart, kidney and aorta. Methods: We studied 50 patients with RHTN confirmed by ambulatory blood pressure monitoring and 50 controlled hypertensive patients matched for age and sex. All participants underwent renal Doppler ultrasound to determine the renal resistive index (RRI), a complete echocardiographic study including measurements of diastolic function and evaluation of augmentation index. Results: Hypertensive patients with RHTN compared with those without RHTN had a significantly decreased E/A ratio (by 0.12, P = 0.043), an increased E/e′ ratio (by 3.1, P < 0.001), increased albumin-to-creatinine ratio levels (by 49 mg/g, P = 0.023) and a significantly higher RRI (by 0.078, P < 0.001) but similar augmentation index values (P = 0.79). Logistic regression revealed that presence of RHTN was the strongest predictor of an RRI more than 0.7 after controlling for other haemodynamic variables including blood pressure levels. Receiver-operator characteristic analysis revealed an area under the curve for prediction of RHTN by the RRI alone of 80.3% (95% confidence interval: 0.72–0.89, P < 0.001). An RRI cut-point of 0.648 has a sensitivity of 78% and a specificity of 72% for prediction of RHTN. Conclusion: In a well treated hypertensive population, patients with RHTN show more pronounced renal and cardiac haemodynamic dysfunction compared with patients with controlled HTN. A greater RRI seems to be associated with RHTN and may help identify such patients.

Needle versus cannula over needle for radial artery cannulation during transradial coronary angiography and interventions

PURPOSE To evaluate the efficacy of radial artery cannulation with needle versus cannula over needle during transradial coronary angiography and intervention. METHODS Five hundred patients scheduled to undergo transradial catheterization were randomized between the two methods. Primary endpoint of the study was the combined endpoint of switching to another access site due to inability of successful sheath insertion or switching to another method of cannulation (from needle to cannula over needle and vice versa). RESULTS The primary end point was met in 12 patients (4.8%) from the needle group and 14 patients (5.6%) from the cannula over needle group (p=0.695). There were no differences in switching of cannulation method [10 (4.0%)% versus 11 (4.4%), p=0.831], switching of access site [6 (2.8%) versus 9 (3.6%), p=0.441), time for artery cannulation [1.20 (0.80-2.20) min versus 1.26 (1.01-2.39) min, p=0.152], total procedure time [15.05 (9.47-29.03) min versus 19.14 (10.13-32.02) min, p=0.112] number of attempts [2 (1-4) versus 2 (1-5), p=0.244] and number of skin punctures [1 (1-2) versus 1 (1-2), p=0.399] before successful radial artery cannulation. There were no differences recorded in the safety endpoints of EASY grade III or more radial hematomas [2 (0.8%) versus 1 (0.4%), p=1.000] or the incidence of radial artery occlusion after the procedure [9 (3.6% versus 16 (6.8%), p=0.358]. CONCLUSION Radial artery cannulation with needle and cannula over needle seems to be equal in terms of efficacy and safety.

RotaWire-induced coronary perforation and tamponade during rotational atherectomy

A 64-year-old male with a history of hypertension and dyslipidaemia presented to our Department complaining of worsening effort angina. Coronary angiography demonstrated multiple lesions of 80–90% stenosis until the mid-segment of the left anterior descending (LAD) artery. The left circumflex artery was severely calcified. Two lesions of 90–95% stenosis were detected in the first obtuse marginal (OM) branch (Fig. 1A). The lesion site of the LAD was subsequently stented with three drug-eluting stents. Due to severe calcification we decided to use rotational atherectomy (Rotablator, Boston Scientific) to debunk the OM calcified lesions. The dedicated rotational atherectomy wire is a specific wire of 0.014-inch diameter, called RotaWire. The RotaWire placement plays an important role in the efficiency of debulking. We used an extra support guide RotaWire with a 2.8-cm spring coil tip to cross through the lesions; the distal end was parked in a mid-sized OM branch (Fig. 1B). Rotablation was performed with a 1.25-mm burr at 160,000 rotations per minute, and when finished, we performed contrast injections and noticed a perforation at the distal segment of the OM, where the end of the RotaWire was (Fig. 1C). At this time the patient was haemodynamically stable, reported mild symptoms, and no pericardial infusion was revealed, so we decided to continue with the intervention; the lesion site of OM was stented with three drug-eluting stents. After the patient was moved to the Intensive Cardiac Care Unit (ICCU) for monitoring, he felt dizziness and chest pain. Echocardiogram confirmed the presence of a large pericardial effusion. He became haemodynamically unstable due to cardiac tamponade. Emergency pericardiocentesis was performed. The patient was moved back to the catheter laboratory, where an angiogram revealed severe blood drain from the distal segment of the OM into the pericardium. Initially we tried to stop the drain by inflating a balloon without success. Since microcoil and fat embolism were not available, we sealed the drain by using a covered stent. Test injections revealed no further extravasation (Fig. 1D). The patient was stable and symptom free while returning to the ICCU and discharged four days later. Guidewire-induced coronary perforation is a rare but potentially life-threatening complication. It is characterised by increased risk of tamponade with delayed presentation. These perforations are more likely to occur if hydrophilic and stiff guidewires are used. In our case, perforation seems to have occurred during rotational atherectomy, and we assume that the burr’s rotational movement transferred to the distal edge of the RotaWire causing the artery’s rupture. Our case suggests that it should be kept in mind that RotaWire-induced coronary perforation may have a more insidious subacute presentation during rotational atherectomy. Prevention, early diagnosis, and immediate therapy are the keys to successful outcomes.

Strategies to increase the use of forearm approach during coronary angiography and interventions

The aim of this article is to focus on the utilization of forearm approach for cardiac catheterization in challenging groups of patients. Radial and ulnar approaches have gained significant popularity among the majority of interventional cardiologists. Multiple studies have demonstrated the feasibility, safety and efficacy of forearm route for cardiac catheterization and have highlighted the significant reduction in bleeding complications by avoiding the puncture of the groin. In this review we present the strategies need to be followed in order to apply the forearm approach in challenging group of patients.

Heart Rate and Blood Pressure: “Connecting the Dots” in Epidemiology and Pathophysiology

There is robust evidence from epidemiological and clinical studies showing that elevated heart rate (HR) constitutes a powerful predictor of morbidity and mortality in patients with hypertension, underlining the significance of HR measurement in them. Autonomous nervous system dysfunction and atherosclerosis are important features in the pathogenesis of the untoward events. However, the relationship between HR and blood pressure (BP) is complex and differs depending on the type of BP measurement which is considered. This differentiation implicates complex physiological mechanisms and is of clinical importance regarding the divergent effect of the different types of antihypertensive agents on these parameters. The aim of this review is to summarize the current evidence on the relationship between HR and BP based on epidemiological, clinical, and experimental studies.

DOES RENAL HAEMODYNAMICS RELATE WITH CARDIAC AND AORTIC HAEMODYNAMICS IN THE EARLY STAGES OF ESSENTIAL HYPERTENSION

Introduction: The relationship of renal haemodynamics with cardiac and aortic hameodynamics is still unclear. Hypothesis: We evaluated the relationship of increased renal resistive index (RRI) with Augmentation index (AIx) and cardiac haemodynamics by means of mitral annular early diastolic velocity (E/Ea) in untreated patients with essential hypertension. Methods: 76 newly diagnosed untreated non diabetic patients with stage I-II essential hypertension [35 males, aged 50 years, office blood pressure (BP) = 143/ 91 mm Hg], underwent ABPM, complete echocardiographic study for determination of E/Ea and blood sampling for assessment of metabolic profile. Moreover, data on renal resistive index (RRI), obtained by Doppler ultrasound sampling of the intrarenal arteries, as well as augmentation index (AIx), were retrospectively analyzed. Results: Based on the mean value of RRI (0.60), hypertensives were classified into those with high and low RRI. Hypertensives with high RRI values compared to those with low values were older (55.6±9.8 vs 44.4±11.6 years, p Conclusions: Increased vascular resistance of intrarenal arteries is associated with impaired aortic and cardiac haemodynamics, as reflected by increased AIx and E/Ea (lateral) values. RRI may be considered a useful surrogate of haemodynamics in essential hypertension.

[PP.20.12] SYSTOLIC AND DIASTOLIC DYSFUNCTION AMONG TREATED HYPERTENSIVE PATIENTS: ASSOCIATIONS WITH RESPECT TO HYPERTENSION CONTROL AND TREATMENT RESISTANCE

Objective: Uncontrolled as well as apparent resistant hypertension (aRHT) are clinical conditions that deserve a thorough evaluation of heart function to assess the relevant risk profile. We investigated echocardiographic characteristics of patients without symptoms of heart failure with respect to their blood pressure (BP) control status. Design and method: We studied 1094 asymptomatic, treated hypertensives (mean age 58 ± 11 years, 48% males) without a history of cardiovascular disease. Clinical data were collected and patients underwent routine blood testing and additional workup for exclusion of secondary causes of RHT. Uncontrolled HT was defined as office BP > or = 140 and/or 90 mmHg and aRHT as uncontrolled HT under at least 3 drugs including a diuretic. A 2D and Doppler echocardiographic study was performed in all patients and left ventricular mass was calculated and indexed for body surface area (LVMI). Tissue Doppler imaging was performed for calculation of myocardial velocities. Patients were divided into 3 groups depending on BP control and presence of aRHT; 243 (22%) patients with controlled HT, 557 (51%) patients with uncontrolled HT and 294 (27%) patients with RHT. Results: Mean BP was 124 ± 9 mmHg in the controlled HT group while patients with uncontrolled and aRHT had similar BP values (149 ± 13 vs 153 ± 19 mmHg, p = NS). There was no significant difference in the ejection fraction among groups. LVMI was higher in patients with aRHT compared to those with uncontrolled and controlled HT (94 ± 22 vs 87 ± 20 and 85 ± 20 g/m2, p < 0.001 for all). Concentric hypertrophy/remodelling was more often in patients with aRHT compared to the other groups (25% compared to 12% and 8%, p < 0.001). Patients with aRHT compared to patients with uncontrolled HT had lower values of E/A (0.93 ± 0.24 vs 0.98 ± 0.26 m/sec, p = 0.025), lower values of E’ (7.2 ± 2.4 vs 7.8 ± 2.4, p = 0.05) and higher values of E/E’ (11.6 ± 4.2 vs 10.3 ± 3.3 cm/sec, p < 0.01). A value of E/E’ above 13 was more prevalent in patients with aRHT (26%) compared to those with uncontrolled (21%) and controlled HT (20%). Conclusions: Among asymptomatic treated hypertensives, patients with aRHT exhibit measures of a worse diastolic function compared to patients with uncontrolled hypertension despite similar values of BP.

INCIDENCE OF CORONARY ARTERY DISEASE AND STROKE IN RELATION TO THE PHYSICAL COURSE OF RESISTANT HYPERTENSION: A TIME UPDATED ANALYSIS OF A 4 YEAR COHORT STUDY

Methods: In a prospective observational study, 1911 treated hypertensive patients (aged 59±11 years, 49% males) were followed for a mean period of 3.9±1.7 years. Four groups were created depending on presence or absence of RH at baseline and follow-up: never having RH, resolved RH, incident RH and persistent RH. Endpoint of interest was the composite of coronary artery disease and stroke. For the subjects with differential RH status at baseline and follow up a uniform distribution was assumed for the estimation of the time point of status change. A time updated Cox regression analysis was then applied to estimate hazards of the predefined outcome.

8A.07: NON-INVASIVE ASSESSMENT OF HAEMODYNAMICS IN RESISTANT HYPERTENSION: THE ROLE OF RENAL HAEMODYNAMICS.

Objective: Hypertension is a multisystem disease in which the kidney plays a key role in long term regulation of blood pressure and the development of hypertension. The aim of this study was to evaluate the role of intrarenal resistance indices in the renal interlobular arteries measured by Doppler ultrasound in resistant hypertensive patients. Design and method: We studied 50 patients with resistant hypertension (RH) [age: 61 ± 11 years, 31 males, office blood pressure (BP): 163/89 ± 24/15 mmHg, under 4.2 ± 0.5 drugs] and 50 hypertensive patients controlled on three or less drugs [age: 59 ± 9 years, 26 males, BP: 131/79 ± 9/8 mmHg, under 2.2 ± 0.3 drugs] that underwent transthoracic echocardiographic study for determination of mitral annular early diastolic velocity (E/e’) and blood sampling for assessment of metabolic profile. Moreover, data on renal resistive index (RRI), obtained by Doppler ultrasound sampling of the intrarenal arteries, were retrospectively analyzed. Results: Hypertensives with RH compared to those without RH exhibited higher RRI by 0.078 (p < 0.001) and E/e’ values by 3.1 (p < 0.001). In the entire study population, RRI was negatively related to office diastolic BP (r = −0.239, p < 0.05), while it was positively associated with office systolic BP (r = 0.310, p < 0.05), office PP (r = 0.583, p < 0.01), age (r = 0.322, r < 0.001), and LVMI (height) (r = 0.283, p < 0.001). Systolic BP (beta 0.864, p < 0.001) and diastolic BP (beta −0.907, p < 0.001) were the only independent predictors of RRI in linear regression analysis, while according to multivariate logistic regression analysis, the major factors influencing whether a person reported having RH were RRI, E/e’, duration of hypertension, and age. Conclusions: Increased renal and cardiac haemodynamics, as reflected by increased vascular resistance of intrarenal arteries and E/e’, are associated closely with the presence of RH. These findings imply that RRI and E/e’ values should be taken into account for the prediction of insufficient control of BP in hypertensive patients.

PREDICTORS AND CARDIOVASCULAR PROGNOSIS OF INCIDENT AND PERSISTENT RESISTANT HYPERTENSION: A 4-YEAR FOLLOW-UP STUDY

Little is known regarding the clinical course and prognosis of resistant hypertension (RHT). We evaluated predictors of persistent RHT and the associated cardiovascular risk. We studied 1,911 treated hypertensive patients (aged 59±11 years, 49% males) for a mean period of 3.9 years. At baseline,