Sébastien Savard

Cardiovascular Complications Associated With Primary Aldosteronism A Controlled Cross-Sectional Study

A higher risk of cardiovascular events has been reported in patients with primary aldosteronism (PA) than in otherwise similar patients with essential hypertension (EH). However, the evidence is limited by small sample size and potential confounding factors. We, therefore, compared the prevalence of cardiovascular events in 459 patients with PA diagnosed in our hypertension unit from 2001 to 2006 and 1290 controls with EH. PA cases and EH controls were individually matched for sex, age (±2 years), and office systolic blood pressure (±10 mm Hg). Patients with PA and EH differed significantly in duration of hypertension, serum potassium, plasma aldosterone and plasma renin concentrations, aldosterone-to-renin ratio, and urinary aldosterone concentration (P<0.001 for all comparisons). The prevalence of electrocardiographic and echocardiographic left ventricular hypertrophy was about twice higher in patients with PA even after adjustment for hypertension duration. PA patients also had a significantly higher prevalence of coronary artery disease (adjusted odds ratio, 1.9), nonfatal myocardial infarction (adjusted odds ratio, 2.6), heart failure (adjusted odds ratio, 2.9), and atrial fibrillation (adjusted odds ratio, 5.0). The risks associated with PA were similar across levels of serum potassium and plasma aldosterone. To conclude, patients with PA are more likely to have had a cardiovascular complication at diagnosis than otherwise similar patients with EH. Target organ damage and complications disproportionate to blood pressure should be considered as an additional argument for suspecting PA in a given individual and possibly for broadening the scope of screening at the population level.

Eligibility for renal denervation in patients with resistant hypertension: when enthusiasm meets reality in real-life patients.

To the Editor: Percutaneous renal sympathetic denervation (RDN) by radiofrequency ablation is a novel therapeutic intervention that has been shown to decrease blood pressure (BP) significantly ([1][1]) and persistently ([2][2]) in patients with resistant hypertension (RH). However, the evidence

Association Between 2 Angiographic Subtypes of Renal Artery Fibromuscular Dysplasia and Clinical Characteristics

Background— Initially based on histology, the diagnosis of renal artery fibromuscular dysplasia (FMD) is now based mostly on angiographic appearance because arterial tissue samples are rarely available. This retrospective cross-sectional study aimed to assess the clinical relevance of a binary angiographic classification of FMD lesions (unifocal or multifocal) based on computed tomographic or magnetic resonance angiography. Methods and Results— Adult patients diagnosed with FMD in a single tertiary care center for hypertension management were identified by screening of electronic files. FMD lesions were reviewed and classified according to computed tomography or magnetic resonance angiography as multifocal if there were at least 2 stenoses in the same arterial segment; otherwise, they were classified as unifocal. Of 337 patients with established renal artery FMD, 276 (82%) were classified as multifocal. Patients with unifocal and multifocal lesions differed significantly in median age at diagnosis of FMD (30 and 49 years) and hypertension (26 and 40 years), sex distribution (female:male ratio, 2:1 and 5:1), initial blood pressure (157/97 and 146/88 mm Hg), current smoking (50% and 26%), prevalence of unilateral renal artery lesions (79% and 38%), presence of kidney asymmetry (33% and 10%), renal revascularization procedures (90% and 35%), and hypertension cure rates in patients who underwent revascularization (54% and 26%). Conclusions— A binary angiographic classification into unifocal or multifocal renal artery FMD is straightforward and discriminates 2 groups of patients with different clinical phenotypes.

Association of Smoking With Phenotype at Diagnosis and Vascular Interventions in Patients With Renal Artery Fibromuscular Dysplasia

The pathogenesis of fibromuscular dysplasia (FMD) remains unclear, but tobacco use is thought to be involved. This retrospective cross-sectional study aimed to evaluate smoking first as a risk factor for renal artery FMD diagnosis and second as a modifier of the clinical and radiological phenotype of this disease. We retrieved 337 adult patients diagnosed with FMD in a referral center for hypertension management, who were first individually matched to controls with essential hypertension for sex, age, systolic blood pressure, number of antihypertensive drugs, and year of visit. Smoking status and other relevant data were collected at first visit. The proportion of current smokers was higher for patients with FMD than for the controls (30% and 18%, respectively, P<0.001; odds ratio, 2.5 [95% confidence interval, 1.6–3.9]). Second, characteristics of FMD were compared between current smokers and other patients. Among patients with multifocal FMD, current smokers experienced an earlier diagnosis of hypertension (36 versus 42 years, respectively; P<0.001) and FMD (43 versus 51 years; P<0.001) than other patients, and a greater likelihood of renal artery interventions (57% versus 31%; P<0.001) and of kidney asymmetry (21% versus 4%; P=0.001). In conclusion, current smoking is associated with a higher likelihood of renal artery FMD diagnosis. Rather than a higher incidence of FMD, this may reflect a more aggressive course in smokers, who have earlier hypertension leading to increased and earlier recognition of the disease. Smoking cessation should be strongly encouraged in patients with FMD.

Clinical management of renal artery fibromuscular dysplasia: temporal trends and outcomes

Objectives: Renal artery fibromuscular dysplasia (FMD) is a heterogeneous condition with a broad and evolving phenotypic and angiographic spectrum. We documented therapeutic management in patients with renal artery FMD, by analyzing the medical records of hypertensive patients diagnosed with FMD at a single referral center from 1986 to 2012. Methods: Characteristics at presentation, treatments and outcomes were compared between patients diagnosed with FMD before and after the year 2000. Characteristics at presentation and outcomes were compared between patients managed conservatively, by angioplasty or surgery. Results: Patients seen since 2000 (n = 278) were older, had lower blood pressure (BP) levels and were more often managed conservatively than those diagnosed before 2000 (n = 134). Revascularized patients had more often focal FMD and were more often men, diagnosed with hypertension and FMD at a younger age, had higher BP levels and a higher prevalence of renal asymmetry or infarction than patients treated conservatively. At the most recent visit, BP was below 140/90 mmHg in two-thirds of the patients, in all treatment groups. Multifocal FMD was managed conservatively in 60% of the cases (older patients, less severe hypertension) with similar BP outcome compared to revascularization, even after adjustment for potential confounding factors. Conclusions: The trends towards the diagnosis of FMD in older patients with less severe hypertension underscore the need for a careful selection of patients who might benefit from revascularization. This is especially true for multifocal FMD, which might be adequately managed by medication in a substantial number of cases.

Automated interpretation of home blood pressure assessment (Hy-Result software) versus physician's assessment: a validation study.

ObjectiveHy-Result is the first software for self-interpretation of home blood pressure measurement results, taking into account both the recommended thresholds for normal values and patient characteristics. We compare the software-generated classification with the physician’s evaluation. Design methodThe primary assessment criterion was whether algorithm classification of the blood pressure (BP) status concurred with the physician’s advice (blinded to the software’s results) following a consultation (n=195 patients). Secondary assessment was the reliability of text messages. ResultsIn the 58 untreated patients, the agreement between classification of the BP status generated by the software and the physician’s classification was 87.9%. In the 137 treated patients, the agreement was 91.9%. The &kgr;-test applied for all the patients was 0.81 (95% confidence interval: 0.73–0.89). After correction of errors identified in the algorithm during the study, agreement increased to 95.4% [&kgr;=0.9 (95% confidence interval: 0.84–0.97)]. For 100% of the patients with comorbidities (n=46), specific text messages were generated, indicating that a physician might recommend a target BP lower than 135/85 mmHg. Specific text messages were also generated for 100% of the patients for whom global cardiovascular risks markedly exceeded norms. ConclusionClassification by Hy-Result is at least as accurate as that of a specialist in current practice (http://www.hy-result.com).

LB03.06: AUTOMATED INTERPRETATION OF HOME BLOOD PRESSURE ASSESSMENT (HY-RESULT® SOFTWARE) VERSUS PHYSICIAN'S ASSESSMENT. A VALIDATION STUDY.

Objective: Hy-Result® software is designed to help patients to comply with the home blood pressure measurement (HBPM) protocol and self-interpret their results. We compare in a daily routine care setting, the classification generated by Hy-Result® with the physicians clinical evaluation. Design and method: The algorithm combines BP readings with patients characteristics. According to the ESH guidelines, BP readings and automatically generated text messages are made available to the patient in a report. The primary assessment criterion was whether classification of the BP status generated by the software concurred with the physicians classification (blinded to the softwares results) following a consultation (n = 195 patients) (gold standard). Results: In the 58 untreated patients, the agreement between classification of the BP status generated by the software and the physicians classification was 87.9%. In the 137 treated patients, the agreement was 91.9%. The kappa test applied for all the patients was 0.81 [95%CI: 0.73–0.89]. After correction of errors identified in the algorithm during the study, agreement increased to 95.4% (kappa 0.9[95% CI: 0.84–0.97]). For 100% of the patients with comorbidities (n = 46), specific text messages were generated indicating that a physician might recommend a target BP lower than 135/85 mmHg. Specific text messages were also generated for 100% of the patients for whom global cardiovascular risks greatly exceeded norms relating to BMI, tobacco and/or alcohol consumption. Remaining discrepancies were more attributable to human error (physician), than software. The limitation is that the algorithm remains dependent on patients capacity to complete their profile. Conclusions: Classification by Hy-Result® is at least as accurate as that of a specialist in current practice. Hy-Result® is the first validated free use software for self-interpretation of HBPM results, taking into account both the recommended thresholds for normal values and patient characteristics (www.hy-result.com). Hy-Result® will soon be available as a Smartphone application (Health Mate), accessible in an entirely automated format in conjunction with a validated wireless BP monitor (Withings BP-800).

[LB.03.02] HOME BLOOD PRESSURE MEASUREMENT WITH HY-RESULT SYSTEM: PATIENTS VERSUS WEB USERS OPINION STUDY

Objective: Hy-Result is a free web-based rule management software designed to help patients to comply with the home blood pressure measurement (HBPM) protocol and to self-interpret their results. The validation study was published in 2016. Here, we compare the opinion on the system of two groups of users: Patients seen in ESH Excellence Centres and Web Users. Design and method: We administered a web-based questionnaire with 24 independent closed questions to patients using the Hy-Result system. The same questionnaire was openly available through the system. A total of 194 anonymous subjects completed the questionnaire: 87 patients from 2 ESH centers (Paris and Brussels) and 107 Web Users. Results: Eighty percent of respondents were between 35 and 75-years old in both groups but ESH Centre patients tended to be younger (p = 0.04). Eighty six percent of the ESH Centre group received antihypertensive drugs, 48% of the subjects in the Web Users group (p < 0.001). Figure. No caption available. In the subgroup of 39 persons (36% of the total) who transmitted the Hy-Result report to their general practitioner, 92% reported that their doctor had considered the report useful (7% of their doctors did not look at the report and 1% advised against the use of the software). Almost all respondents (99% in the ESH Centers group and 97% of the Web Users) trust the software. The high rate of confidence in the web users group was unexpected because we did not know if a medical doctor recommended the Hy-Result system or not. In the future, it will be necessary to study to what extent health professionals are ready to integrate this tool into their practice. Conclusions: The Hy-Result system is well accepted by the majority of responders to this survey, both ESH Patients and Web Users.

[OP.LB01.05] AUTOMATED INTERPRETATION OF HOME BLOOD PRESSURE MEASUREMENTS WITH WIRELESS BLOOD PRESSURE MONITOR AND HY-RESULT SOFTWARE: A USER PERCEPTION STUDY

Objective: Hy-Result is a software designed to help patients to: i) comply with the home blood pressure (BP) measurement protocol (the software does not provide results before having 42 BP readings (3 in the morning and 3 in the evening, during 5 to 7 days, and it sends reminders to the users to increase and complete their measurement); ii) self-interpret their results. The validation study was published in 2015 (www.hy-result.com). We evaluate here the user‘s perception. Design and method: In March 2016, a questionnaire was sent to 3000 patients using Hy-Result embedded in a mobile app (Health Mate) connected with a wireless BP monitor (Withings BP 800). Population: 228 users (7.6%; mean age 48 ± 13 years) responded to an online self-questionnaire. Results:Ergonomy and understanding: 95% of responders find easy or very easy to understand text messages; 79% declare easy or very easy to send results through pdf report; 80 % agree that the recommendations given by Hy-Result are adapted to their situation; 85 % agree that Hy-Result helps them understand their blood pressure readings.Compliance to self measurement protocol: 88% of responders declare the reminder functionality of measurements useful; 68% accept to get a calendar reminder to check again their BP in several months as suggested by the system.Communication with the health care provider. 67% of responders agree that the software may help when talking with their physician about their BP values. Only 1% state that the software may cause difficulties in this situation 32% neither; 23% actually shared their report with their physician. In this subgroup, 73% declare that their physician thinks Hy-Result is a useful tool (for 26% the physician did not look the report). In one case, the physician advised the patient to stop using Hy-Result.Further use: 75% of the responders declare that they will continue to use Hy-Result (15% do not know, and 10% will stop); 61% will recommend Hy-Result to their family.Limitation: Responder bias Conclusions: The Hy-Result software embedded in the Withings wireless BP monitor is well accepted by the majority of responders to this survey.