Loide Barbosa

Different patterns of peripheral versus central blood pressure in hypertensive patients treated with β-blockers either with or without vasodilator properties or with angiotensin receptor blockers.

BackgroundIt is unclear whether the assumed inferiority of atenolol to reduce central (aortic) blood pressure (BP) extends to other β-blockers with vasodilating properties and, within that scope, how these drugs differ from the angiotensin receptor blockers (ARBs). MethodsIn a retrospective study, we compared three groups of hypertensive patients (aged 35–65 years) chronically treated with either ARBs (n=83, group 1), carvedilol/nebivolol (n=75, 25+25 mg/day/5 mg/day, group 2) or atenolol (n=84, 50–100 mg/day, group 3), matched for age (mean 52 years), sex (61% female), brachial BP and concomitant use of diuretics (75–81%)and dihydropyridine calcium antagonists (27–33%). We measured aortic stiffness by pulse wave velocity (Complior), and central BP, central-peripheral pulse pressure amplification, wave reflection [augmentation index (AIx) corrected for heart rate] and augmentation pressure (Sphygmocor). ResultsFor similar age, sex distribution, brachial BP levels (145/85±11/10 mmHg) and pulse wave velocity (10±2 m/s), the atenolol group showed significantly (P<0.03 analysis of variance) higher central systolic BP (139±9 mmHg) versus group 2 (135±10 mmHg) and group 1 (132±11 mmHg), higher AIx (34±12%) versus group 2 (27±7%) and group 1 (23.0±9%), lower pulse pressure amplification (1.16±0.09) versus group 2 (1.22±0.10) and group 1 (1.31±0.11) and lower heart rate beats/min (61±9) versus group 2 (69±11) and group 1 (82±11). The differences on these values, between group 2 and group 1, were also significant (P<0.04). After adjustment for the heart rate, AIx became similar in groups 2 and 1, but still lower (P<0.04) than the atenolol group. ConclusionThese findings suggest that, for similar brachial BP and aortic stiffness, treatment with either vasodilating β-blockers or angiotensin receptor blockers associates with lower central systolic BP and wave reflections than treatment with atenolol. These findings may suggest that the vasodilating β-blockers may exert more favourable central haemodynamic effects, compared with atenolol, which are more alike, although not completely equal, to those of the ARBs.

Improvement of aortic reflection wave responses 6 months after stopping smoking: a prospective study.

BackgroundCigarette smoking is one important preventable cause of cardiovascular illness that has been associated with increased stiffness of large arteries and wave reflection, which are independent predictors of cardiovascular disease. MethodsWe investigated the effect of a 6-month quitting smoking programme on aortic stiffness, central pressure and wave reflections in chronic heavy smokers. Seventy-one (83% normotensives) long-term heavy smokers [>20 cigarettes/day and exhaled carboxy haemoglobin (COHb) (≥4% and CO ppm ≥21)] completed a 6-month psychological-based stop-smoking program. Patients were divided into two groups. Thirty-one patients aged 45±2 years, 71% male, fully quit smoking for 6 months (COHb <2% and CO ppm <10 at 1, 3 and 6 months) – group I, whereas 40 patients aged 45±1 years, 73% male, did not change their smoking habits – group II. We measured between baseline and changes after 6 months in aortic stiffness assessed as pulse wave velocity (Complior), central–peripheral pulse pressure (PP) amplification ratio (PPAr), wave reflection (augmentation index corrected for heart rate), augmentation pressure and transit time (Sphygmocor). Ambulatory 24 h blood pressure (ABP) data were obtained at baseline and after 6 months in 36 patients (n = 19) of group I and 17 of group II. ResultsIn group I, but not in group II, there were significant reductions of peripheral systolic BP (baseline: 131±4 to after 6 months: 127±4 mmHg, P<0.04) and of systolic BP (baseline: 121±4 to after 6 months: 114±4 mmHg, P<0.03). In group I from baseline to after 6 months, PPAr increased by 13.1±4.1% and transit time (ms) by 8.7±2.9%; augmentation index was reduced by 9.2±1.6%, augmentation pressure by 5.7±1.9 mmHg (all P<0.03 vs. baseline and vs. group II); and pulse wave velocity by 2.3±2.8% (P = 0.062). In group I, only daytime ABP was reduced from baseline to after 6 months (129/82±2/2 to 123/78±2/2 mmHg, P<0.03), whereas no change in 24h-ABP was found in group II. ConclusionSix months of smoking cessation is associated with clear improvement of reflected waves, central pressure and aortic stiffness, and with a reduction of daytime BP. This may contribute to the improvement of cardiovascular prognosis attributed to smoking cessation.

Association of 24-h urinary salt excretion with central haemodynamics and assessment of food categories contributing to salt consumption in Portuguese patients with hypertension

ObjectiveHigh salt intake has been associated with the development of arterial hypertension, but it still remains controversial as to how salt consumption relates with central haemodynamics and central pressures. For interventional purposes, it is crucial to identify the main food categories that contribute toward high salt consumption. MethodsIn 638 Caucasian hypertensive patients (age 50±15 years, 329 women) enrolled for 7 years, we evaluate the independent relationship between urinary sodium (UNa+, mean 207±78 mEq/24 h) or potassium (UK+, mean 79±26 mEq/24 h) excretion measured in validated 24-h samples and office blood pressure (BP), 24 h BP, central pulse pressure, and parameters of central pulse wave analysis. A subgroup (n=154) of this population (UNa+, mean 205±75 mEq/24 h) was also subjected to structured validated food frequency questionnaires on dietary habits. ResultsMultiple regression analysis showed that UNa+ was associated independently with increases in 24-h systolic BP, central pulse pressure, and augmented aortic augmentation index (AIx) and associated inversely with pulse pressure amplification. In the subgroup, patients of the upper tercile of distribution of UNa+ (288±21 mEq/24 h) ate significantly higher amounts (g/day) of vegetables, sauces, bread, cheese, fries and sausages/cold meat, yielding an estimation that bread could account for 20–27% of all daily salt intake. ConclusionReduction of salt intake on the basis of the main food sources that we have identified could also influence cardiovascular risk throughout effects on 24-h and central pressures.

Association between ambulatory blood pressure values and central aortic pressure in a large population of normotensive and hypertensive patients

Objective Our aim was to examine the association of ambulatory blood pressure monitoring (ABPM) and central blood pressure (CBP) data in a large set of normotensive and hypertensive patients and its relation with pulse wave velocity (PWV). Patients and methods This cross-sectional study was carried out in a single centre and included 2864 individuals who carried out an ABPM, measurement of CBP from the aortic waveform (SphygmoCor) and carotid-femoral PWV (Complior). Results In our study, 26.6% of the normotensive individuals and 32.5% of controlled hypertensive patients had abnormal values of at least one or of both ABPM and CBP values, compared with 96.6% of uncontrolled hypertensive patients. In the overall population, normal ABPM and CBP occurred in 25.3% (group 1), abnormal ABPM and CBP occurred in 44.4% (group 4), abnormal ABPM and normal CBP occurred in 10.5% (group 3) and normal ABPM and abnormal CBP occurred in 19.8% (group 2). PWV was significantly superior in group 4 versus group 3; group 4 versus group 1 and group 3 versus group 2 and group 2 versus group 1 (Mann–Whitney U-test; P<0.001). Conclusion At least 26–32% of patients classified as normotensive or controlled hypertensive patients have abnormal ABPM or CBP associated with target organ damages. When abnormal values of ABPM and CBP coexist, target organ damage (aortic stiffness) is greater than that occurring when only one abnormal ABPM or CBP is present in the absence of the other. Isolated central hypertension entails greater organ damage than both normal ABPM and CBP. These patients may be at higher risk of further target organ damage because of unawareness of their central hypertension.

UNATTENDED VERSUS OFFICE, AMBULATORY AND CENTRAL BLOOD PRESSURE MEASUREMENTS IN HYPERTENSIVE AND DIABETIC PATIENTS

Objective: To compare unattended blood pressure (BP) data with casual, 24-ambulatory and central measurements in hypertensive patients with and without diabetes Design and method: In the same hypertension clinic we evaluate 130 consecutive hypertensive patients (HTs, 56% female, 59+16 yrs, BMI 28+5 Kg/m2) and 96 hypertensive diabetics (DMs, 62% female, 64+9 yrs, BMI 29 ± 5 Kg/m2) who were referred to perform a 24-h ambulatory BP and who within the interval of 48 hours were underwent casual BP (average of 3 recordings) to an unattended 3 BP measurements separated by 2 minutes with a pre-programmed Omron M10-IT and to the evaluation of central BP from the aortic wave form (SpygmoCor). Figure. No caption available. Results: Table shows that in both HTs and DMs unattended BP was significantly lower than casual BP although less pronounced in DMs. Average of anti-hypertensive drugs were 2.7+0.6 in HTs and 3.2+0.7 in DMs. In both groups the difference persisted along the terciles of distribution of unattended systolic BP values. Unattended SBP values were similar to ambulatory BP values (to 24 h SBP in HTs and daytime BP in DMs). Conclusions: In HTs with and without DM the unattended BP measurement significantly underestimates by SBP 12–17; DBP 3–6 mm Hg the BP measured in office, being more close to ambulatory BP values. That difference should be taken into account since targets based on these measurements are not equivalent.

IMPORTANCE OF THE DIRECTLY OBSERVED TREATMENT INTAKE ON THE APPROACH OF PATIENTS WITH RESISTANT HYPERTENSION

Objective: The diagnosis of resistant hypertension (HRes) and the efficacy of renal denervation ensure proper compliance with the therapy. We intend to assess the usefulness of directly observed treatment intake (OTI) in the control of adherence to anti-hypertensive medication in patients with HTAres. Figure. No caption available. Design and method: We studied 46 patients with Hres (BP>/ou 150 90 mm Hg under with at least 3 different classes of drugs in optimal doses) in outpatient hypertension clinic. Four were previously submitted to renal denervation. 24-h ambulatory BP (ABP) was evaluated before the procedure. In OTI patients took all medications in the morning for 5 days under the supervision of a technician and performing on the fifth day a second ABP. Results: Out of the 46 patients 76% were female, ageing 63 ± 11 years and BMI 30 ± 5 Kg/m2. The average of antihypertensive agents was 4.5 ± 1.2 /day. After OTI casual, daytime and nighttime BP decreased significantly (Table). After OTI, 16 patients (34.8%) reported adverse drug reactions not reported before, and 54.3% normalized ABP (24 h < 130/80 mm Hg). Also 4 patients who persisted with HRes after renal denervation were shown to be BP controlled after OTI. Conclusions: In an organized clinic, OTI can be performed, thereby becoming a valuable tool to identify the non-compliance to therapy as a cause of HRes and to identify false non-responders to techniques such as renal denervation due to loss of drug adherence.

[LB.01.06] LONG-TERM RISK OF CARDIOVASCULAR EVENTS IN WHITE-COAT HYPERTENSION DEFINED BY DAYTIME AND NIGHTTIME BLOOD PRESSURE LIMITS

Objective: The prognostic impact of white-coat hypertension (WCHT) is a subject of debate and controversy. Nighttime blood pressure (BP) is strongly related with cardiovascular (CV) prognosis but thiat has not been currently considered in the definition of WCHT. Figure. No caption available. Design and method: We investigated the occurrence of fatal and non-fatal CV events in 1230 subjects with sustained hypertension (SHTA), 617 with WCHT and 812 with normotension (NT) during a mean of follow-up 93 months (95% CI 90–96), all matched for age (by clusters) - mean age 50 yrs (95% CI 49–51). Percentage of female in the 3 groups were (55–59%). WCHT was defined as hypertension in office and daytime BP <135/85 mm Hg and nighttime BP <120/70 mm Hg. Results: During the follow-up 257 CV events were detected (46% strokes, 32% coronary and 22% others). The event rate per 100 patient-years in the subjects with NT, WCHT and SHTA was 0.66, 0.60 and 2.09 respectively. Event-free survival was significantly (p < 0.0001) different among the three groups (see Figure 1). Cox regression analysis with adjustment for covariables were able to show that risk of CV events was significantly (p < 0.001) higher with a Relative Risk of 4.12 (CI 95% 2.99–6.69) in subjects with SHTA than in those with WCHT whereas there was no difference between subjects with WCHT and with NT. Within the group of WCHT 29% received therapy during the follow-up for at least six months but the RR of CV events betweenWCHT either treated or non-treated did not differ: RR = 0.76 (CI95% 0.37–1.51, p = 0.42). Conclusions: In subjects with WCHT with normal daytime and nighttime BP the risk of CV events was significantly lower than that in SHTA and not significantly different from normotensive subjects. Also anti-hypertensive treatment seems not to modify the low risk of CV events in WCHT.

Avaliação das propriedades dinâmicas da pressão arterial em mulheres com antecedentes de pré‐eclâmpsia

BACKGROUND We investigated viscoelastic properties of the arterial wall in women with previous preeclampsia (PE) compared to those with normal pregnancy (NP). METHODS In a cross-sectional study 45 women with previous PE and 55 with NP were included, matched for age (PE 38±6 vs. NP 38±5 years, NS) and body mass index: (PE 25±4 vs. NP 26±4 kg/m(2), NS) studied, respectively, 76±34 and 86±48 months after delivery. We assessed arterial distensibility - pulse wave velocity (PWV, Complior) and reflected waves (augmentation pressure [AP], mmHg) and augmentation index (AIx) - in the central pressure wave and blood pressure (BP) on 24-h ambulatory BP monitoring (ABPM). RESULTS PE showed higher (p<0.01) peripheral systolic blood pressure (SBP): PE 131±18 vs. NP 121±19, and central SBP: PE 122±18 vs. NP 110±19 mmHg, with less amplification of central-peripheral pressure: PE 10±4 vs. NP 12±5, p=0.041, and higher (p<0.05) AP: PE 10±3 vs. NP 8±2, and AIx: PE 26±5 vs. NP 20±5 mmHg, but PE and NP did not differ in pulse wave velocity. On ABPM, PE (n=39) vs. NP (n=33) had higher nighttime SBP: PE 121±10 vs. NP 108±10 mmHg and lower percentage nocturnal SBP fall: PE 11±6 vs. NP 18±11%, both p<0.02. During follow-up, the need for antihypertensive medication was seven times higher in PE than in NP. CONCLUSION Women with previous PE have a greater risk of hypertension, higher nighttime BP values, blunted nocturnal BP fall and changes in central pressure suggestive of increased reflected waves and peripheral vascular resistance. These factors may contribute to their higher cardiovascular risk after pregnancy.

OP0008-HPR Challenges with the applicability of the eular recommendations for rheumatology nursing management in portugal

Background Several studies have highlighted the added value of nurses in the management of patients with chronic inflammatory arthritis[1,2], which led the EULAR Nursing Task Force to formulate a set of recommendations for the role of nurses in this particular context[3]. Rheumatology as a nursing specialty does not exist in Portugal, and this may constitute an important barrier for the implementation of these recommendations. Objectives We aimed to evaluate the level of agreement of Portuguese nurses working in rheumatology departments with the EULAR recommendations and the degree of their applicability in routine clinical practice. Methods During January 2012, a questionnaire was sent to all Portuguese Rheumatology centers inviting practicing nurses to answer anonymously to a closed-type set of questions that addressed the level of agreement with each of the recommendations (1 – total disagreement to 5 – total agreement), the recommendations’ application in practice (not applied (0), partly (1) or full applied (2)) and the level of confidence in the applicability of each of the recommendations (0-not at all confident; to 5 totally confident). Chi2 and Mann-Whitney tests were used to plot the results. Results A total of 42 nurses (83% female; 4.8±4.4 years of practice) from 10 rheumatology centers were included. Twenty-eight (67%) worked at the outpatient clinic, 7 at the inpatient clinic and 7 at both places. Only twelve (29%) worked exclusively at rheumatology departments. Although all nurses stated to be interested in getting more training in rheumatology and 67% would like to have the formal specialty in rheumatology, only eleven (45%) had received some type of training. On average, the level of agreement with all the EULAR recommendations was 4.9±0.2 (with averages for the individual recommendations ranging from 4.6±0.7 to 5±0). In the majority of cases (76.2%) these recommendations were partly applied in practice and the level of confidence in their full applicability was 3.7±0.9 (with averages for the individual recommendations ranging from 3.1±1.5 to 4.3±0.9). Comparing nurses with and without specific training in rheumatology, a significantly higher proportion of those who received training totally agreed with providing care based on protocols and guidelines (94% vs 63%, p=0.02) – Recommendation 7. Similar results were found among nurses working at day-care units when compared to the others (87% vs 50%, p=0.03). A significantly higher proportion of nurses from day-care units showed total agreement with Recommendation 9, which states that nurses should be encouraged to undertake extended roles after specialised training, according to national regulations (97% vs 67%, p=0.02). The level of confidence in the applicability of recommendation 7 was also significantly higher in those two subgroups. Conclusions There is a high level of agreement with the EULAR recommendations for rheumatology nursing management in Portugal, despite the fact that most of the nurses are working in partial dedication to rheumatology and without specific training. The highest level of agreement was verified among nurses with specific training and working at day-care units, underlining the importance of specific training for future commitment. References Hill et al. Br J Rheumatol 1994; 33:283-8. Ryan et al, J Adv Nurs 2006;53:277-86. Eijk-Hustings et al. Ann Rheum Dis 2012; 71:13-19. Disclosure of Interest None Declared