Pierre-Yves Courand

Cumulative Effects of Several Target Organ Damages in Risk Assessment in Hypertension.

BACKGROUND The prognostic value of screening multiple target organ damages (TODs) in hypertensive subjects has not been extensively studied. We estimated the prognostic value of considering 3 TODs in estimating the 10-year survival in hypertensive subjects. METHODS At baseline 1,848 out of a cohort of 1,963 hypertensive patients had a previous cardiovascular disease (CVD) or assessments of 3 TODs: Modification in Diet in Renal Disease (MDRD) <60ml/min or albuminuria >300mg/day, Sokolow index >3.5 mV, and advanced hypertensive retinopathy (grades 3 and 4 of Keith-Wagener-Barker classification). The cohort was divided into 5 groups: 0 TOD (N = 978), 1 TOD (N = 308), 2 TODs (N = 94), 3 TODs (N = 30), and previous CVD (N = 438). RESULTS After 10 years of follow-up, we observed 418 deaths of which 254 from cardiovascular cause. The adjusted hazard ratios for the major cardiovascular risk factors showed a progressive risk associated with the number of TODs. For all-cause death, the hazard ratios [95% confidence intervals] vs. 0 TOD of the other 4 groups were 1.91 [1.39-2.63], 1.99 [1.28-3.10], 4.33 [2.42-7.72], and 3.09 [2.35-4.05], respectively. For cardiovascular death, the hazard ratios [95% confidence intervals] were of the same order of magnitude: 2.14 [1.38-3.32], 2.12 [1.15-3.89], 4.22 [1.83-9.72], and 4.24 [2.95-6.11], respectively. CONCLUSIONS Our results indicate that hypertensive patients with several TODs had a worst outcome. Thus, it seems important to screen for multiple TODs in hypertension; especially check for severe hypertensive retinopathy in patients with left ventricular hypertrophy (LVH) and renal damage.

Mesure de la pression artérielle centrale : intérêt clinique

Central pressure is that observed at the level of the heart. Central pressure is characterized by a lower systolic and a similar diastolic pressure than brachial blood pressure. The additional prognostic value of central pressure over brachial pressure is not definitely ascertained. Treatments can exert differential effects on peripheral and central pressures.

Plasma NT-proBNP mirrors the deleterious cardiovascular and renal continuum in hypertension

Background The aims of this study were (a) to test the ability of N-terminal pro-brain natriuretic peptide (NT-proBNP) to detect subclinical target organ damage (TOD) denoted by left ventricular hypertrophy (LVH), aortic stiffness or renal damage and (b) to test its reproducibility in two different conditions in an ancillary study. Methods The study included 837 patients (50.9% men) with hypertension aged 50 ± 24 years with a median 24-h ambulatory blood pressure (BP) of 148/90 mmHg. LVH was assessed by transthoracic echocardiography and echocardiography, aortic stiffness was assessed by carotid–femoral pulse wave (PWV) measurements and renal dysfunction by measurements of the estimated glomerular filtration rate (eGFR) and microalbuminuria. Results After the exclusion of patients with a history of heart failure, NT-proBNP was independently correlated with sex, systolic BP, primary hypertension, PWV, LVH and eGFR, but not with microalbuminuria. The median (interquartile range) NT-proBNP increased gradually according to the number of target organs damaged: 42 (24–70), 77 (39–151), 141 (81–250) and 334 (177–556) pg/mL, for damage to 0, 1, 2 and 3 target organs, respectively (p < 0.001). . For the same number of target organs damaged, NT-proBNP was higher in women and for secondary hypertension. A threshold at 90 pg/mL for men and 142 pg/mL in women had a specificity of 95% to detect at least one TOD (areas under ROC curve 0.790 and 0.783, respectively). The reproducibility of NT-proBNP was fairly good in this setting (r = 0.952, p < 0.001, N = 325) Conclusion This study demonstrates that NT-proBNP mirrors the harmful effect of high BP on TOD. NT-proBNP could be used as an integrative tool for risk stratification in hypertension.

CO-07: Prognostic value of protein intake assessed by 24-hour urinary excretion in hypertension

BACKGROUND Protein intake may have some favorable influence on blood pressure and cardiovascular events but the results are controversial. The objective of the present study was to test the prognostic value of protein intake assessed by 24-hour urinary excretion in a cohort of hypertensive subjects with preserved renal function. METHODS 1.128 hypertensive patients with a 24-hour urinary analysis were initially included in the present study. They were classified according to tertiles of protein intake adjusted for ideal body weight (IBW, the IBW was derived by using a BMI value of 22kg/m(2) as a reference): 1: <0.70, 2: 0.70-0.93 and 3: >0,93g/kg. RESULTS Baseline characteristics were: age 45.1±13.2 years, blood pressure 185±32 / 107±20mmHg and eGFR 82±32ml/min. After a 10-year follow-up, there were 289 deaths of whom 177 from cardiovascular cause. As shown by Kaplan-Meier curves, the survival rates decrease for patients in the lowest tertile either for all-cause mortality (p=0.008) for cardiovascular mortality (p=0.161) and for non-cardiovascular mortality (p=0.036). After adjustment for major cardiovascular risk factors, patients in the second and third tertiles had a decrased risk of all-cause (HR 0.73; 95% CI [0.57-0.95]), cardiovascular (HR 0.78; 95% CI [0.56-1.08]), and non-cardiovascular death (HR 0.63; 95% CI [0.43-0.94]) in comparison to those belonging to the first one. Exclusion of patients with eGFR <45ml/ min or secondary hypertension or who died in the first year of follow-up demonstrated similar results. High protein intake had a more marked positive influence in a subset of our population: younger, low salt intake, absence of aortic atherosclerosis or previous cardiovascular events (p for interaction <0.10 for all) (see figure above). CONCLUSIONS We demonstrated that a protein intake above 0,7g/kg of IBW had a protective effect on the prognostic value of all-cause, cardiovascular and non-cardiovascular mortality in hypertensive patients. This may be due to the fact that some amino-acids (arginine and tryptophan) may influence bioavailability of NO. These mechanisms have probably a major role to preserve endothelial function. This is consistent with the results we observed: the effect of protein intake is particularly observed when the endothelium is preserved in young hypertensive patients without overt cardiovascular disease.