Soon Kil Kim

Not nondipping but nocturnal blood pressure predicts left ventricular hypertrophy in the essential hypertensive patients: the Korean Ambulatory Blood Pressure multicenter observational study.

Objective: The aim of this study was to investigate whether nocturnal blood pressure (BP), established on the basis of a single 24-h BP monitoring, is a stronger predictor of left ventricular hypertrophy (LVH) compared with nondipping status in the essential hypertensive patients. Methods: A total of 682 hypertensive patients (mean age 56.1 ± 14.5 years, 50.7% women) who underwent echocardiography were enrolled. ‘Nondipping status’ was defined as a nocturnal SBP fall less than 10% of daytime mean SBP. LVH was defined as a left ventricular mass index exceeding 54.0 g/m2.7 in men and 53.0 g/m2.7 in women. Each patient was categorized in three groups according to the total cardiovascular risk using 2007 European Society of Hypertension/ European Society of Cardiology guidelines as average or low, moderate, and high or very high added risk. Results: Among 682 participants, 184 (26.9%) showed LVH on echocardiography. The proportion of individuals with high or very high added cardiovascular risk profile was 356 (52.1%). In multiple logistic regression analysis, age 56 years at least [odds ratio (OR) 1.047, 95% confidence interval (CI) 1.031–1.063, P < 0.0001], female participants (OR 1.751, 95% CI 1.172–2.616, P = 0.0062), BMI higher than 24.6 kg/m2 (OR 1.178, 95% CI 1.110–1.250, P < 0.0001), smoking (OR 1.793, 95% CI 1.028–3.127, P = 0.0397), and nocturnal SBP at least 127 mmHg (OR 1.032, 95% CI 1.009–1.055, P = 0.0059) were significant independent predictors for LVH whereas nondipping was not (OR 0.857, 95% CI 0.481–1.528, P = 0.6013). Conclusion: These findings suggest that nocturnal BP rather than nondipping may be a better predictor of LVH, especially in secondary or tertiary referral hospital setting targeting relatively high cardiovascular risk patients.

Discordance between ambulatory versus clinic blood pressure according to global cardiovascular risk group.

Background/Aims: The detection of white coat hypertension (WCH), treated normalized hypertension, and masked hypertension (MH) is important to improve the effectiveness of hypertension management. However, whether global cardiovascular risk (GCR) profile has any effect on the discordance between ambulatory blood pressure (ABP) and clinic blood pressure (CBP) is unknown. Methods: Data from 1,916 subjects, taken from the Korean Multicenter Registry for ABP monitoring, were grouped according to diagnostic and therapeutic thresholds for CBP and ABP (140/90 and 135/85 mmHg, respectively). GCR was assessed using European Society of Hypertension 2007 guidelines. Results: The mean subject age was 54.1 ± 14.9 years, and 48.9% of patients were female. The discordancy rate between ABP and CBP in the untreated and treated patients was 32.5% and 26.5%, respectively (p = 0.02). The prevalence of WCH or treated normalized hypertension and MH was 14.4% and 16.0%, respectively. Discordance between ABP and CBP was lower in the very high added-risk group compared to the moderate added-risk group (odds ratio [OR], 0.649; 95% confidence interval [CI], 0.487 to 0.863; p = 0.003). The prevalence of WCH or treated normalized hypertension was also lower in the very high added-risk group (OR, 0.451; 95% CI, 0.311 to 0.655). Conclusions: Discordance between ABP and CBP was observed more frequently in untreated subjects than in treated subjects, and less frequently in the very high added-risk group, which was due mainly to the lower prevalence of WCH or treated normalized hypertension.

Efficacy of fimasartan/hydrochlorothiazide combination in hypertensive patients inadequately controlled by fimasartan monotherapy

Background The study reported here compared the blood pressure (BP)-lowering efficacy of fimasartan alone with that of fimasartan/hydrochlorothiazide (HCTZ) combination in patients whose BP goal was not achieved after 4 weeks of treatment with once-daily fimasartan 60 mg. Methods Patients with sitting diastolic blood pressure (siDBP) ≥90 mmHg with 4 weeks of once-daily fimasartan 60 mg were randomly assigned to receive either once-daily fimasartan 60 mg/HCTZ 12.5 mg or fimasartan 60 mg for 4 weeks. After 4 weeks, the dose was increased from fimasartan 60 mg/HCTZ 12.5 mg to fimasartan 120 mg/HCTZ 12.5 mg or from fimasartan 60 mg to fimasartan 120 mg if siDBP was ≥90 mmHg. Results Of the 263 randomized patients, 256 patients who had available efficacy data were analyzed. The fimasartan/HCTZ treatment group showed a greater reduction of siDBP compared to the fimasartan treatment group at Week 4 (6.88±8.10 mmHg vs 3.38±7.33, P=0.0008), and the effect persisted at Week 8 (8.67±9.39 mmHg vs 5.02±8.27 mmHg, P=0.0023). Reduction of sitting systolic BP in the fimasartan/HCTZ treatment group was also greater than that in the fimasartan treatment group (at Week 4, 10.50±13.76 mmHg vs 5.75±12.18 mmHg, P=0.0069 and, at Week 8, 13.45±15.15 mmHg vs 6.84±13.57 mmHg, P=0.0007). The proportion of patients who achieved a reduction of siDBP ≥10 mmHg from baseline and/or a mean siDBP <90 mmHg after 4 weeks of treatment was higher in the fimasartan/HCTZ treatment group than in the fimasartan treatment group (53.6% vs 39.8%, P=0.0359). The overall incidence of adverse drug reaction was 11.79% with no significant difference between the treatment groups. Conclusion The combination treatment of fimasartan and HCTZ achieved better BP control than fimasartan monotherapy, and had comparable safety and tolerance to fimasartan monotherapy.

A case of arteriovenous type cardiac hemangioma.

Cardiac hemangiomas are rare primary tumors of the heart and constitute only 2.8% of primary cardiac tumors. They are classified into capillary, cavernous, epitheloid and arteriovenous type and the last one is the most uncommon type. We experienced a case of cardiac hemangioma which was diagnosed as arteriovenous type for the first time in Korea in the literature. The patient was a 54-year-old woman who presented with palpitation and anterior chest pain. The diagnosis was based upon coronary angiography which showed two tumor blushings located in the interatrial and interventricular septum with venous drainage to the coronary sinus and right atrium. Associated atrial fibrillation with rapid ventricular response was controlled with digitalis.

Evaluation of the Efficacy and Safety of the Lercanidipine/Valsartan Combination in Korean Patients With Essential Hypertension Not Adequately Controlled With Lercanidipine Monotherapy: A Randomized, Multicenter, Parallel Design, Phase III Clinical Trial

PURPOSE The objective of this study was to evaluate the efficacy and safety of the lercanidipine/valsartan combination compared with lercanidipine monotherapy in patients with hypertension. METHODS Part 1 of this study was the randomized, multicenter, double-blind, parallel group, Phase III, 8-week clinical trial to compare superiority of lercanidipine 10 mg/valsartan 80 mg (L10/V80) and lercanidipine 10 mg/valsartan 160 mg (L10/V160) combinations with lercanidipine 10 mg (L10) monotherapy. At screening, hypertensive patients, whose diastolic blood pressure (DBP) was >90 mm Hg after 4 weeks with L10, were randomized to 3 groups of L10, L10/V80, and L10/V160. The primary end point was the change in the mean sitting DBP from baseline (week 0) after 8 weeks of therapy. Patients who were randomly assigned to L10/V160 and whose mean DBP was still ≥ 90 mm Hg in part 1 were enrolled to the up-titration extension study with lercanidipine 20 mg/valsartan 160 mg (L20/V160) (part 2). FINDINGS Of 772 patients screened, 497 were randomized to 3 groups (166 in the L10 group, 168 in the L10/V80 group, and 163 in the L10/V160 group). Mean (SD) age was 55 (9.9) years, and male patients comprised 69%. The mean (SD) baseline systolic blood pressure (SBP)/DBP were 148.4 (15.1)/94.3 (9.5) mm Hg. No significant differences were found between groups in baseline characteristics except the percentages of previous history of antihypertensive medication. The primary end points, the changes of mean (SD) DBP at week 8 from the baseline were -2.0 (8.8) mm Hg in the L10 group, -6.7 (8.5) mm Hg in L10/V80 group, and -8.1 (8.4) mm Hg in L10/V160 group. The adjusted mean difference between the combination groups and the L10 monotherapy group was -4.6 mm Hg (95% CI, -6.5 to -2.6; P < 0.001) in the L10/V80 group and -5.9 mm Hg (95% CI, -7.9 to -4.0, P < 0.001) in the L10/V160 group, which had significantly greater efficacy in BP lowering. A total of 74 patients were enrolled in the part 2 extension study. Changes of mean (SD) DBP and SBP from week 8 to week 12 and week 16 were -5.6 (7.9)/-8.0 (12.0) mm Hg and -5.5 (7.0)/-8.5 (11.3) mm Hg, respectively. For evaluation of the safety profile, the frequencies of adverse events between groups were also not significantly different. The most frequently reported adverse events were headache (6 cases, 20.7%) in the L10 group, dizziness (8 cases, 16.3%) in L10/V80 group, and nasopharyngitis (3 cases, 9.4%) in L10/V160 group, and the incidences of adverse events were not different between groups. IMPLICATIONS Treatment of L10/V80 or L10/V160 combination therapy resulted in significantly greater BP lowering compared with L10 monotherapy. Moreover, the L20/V160 high dose combination had additional BP lowering effect compared with nonresponders with the L10/V160 combination. ClinicalTrials.gov: NCT01928628.

PS 11-06 Relationship between moderate drinking with systolic blood pressure and impact on cardiovascular outcome in Korean National Health Insurance Service – National Sample Cohort (NHIS-NSC)

Objective: The impact of moderate drinking on systolic blood pressure (SBP) and cardiovascular (CV) outcome is known to be as, so-called, J shaped relationship showing more beneficial than little drinking or than heavy drinking. In Korean study, there is some controversial data and the drinking may be confounded by socioeconomic status. The author analyzed the impact of moderate drinking on SBP and CV outcome. Design and Method: In Korean National Health Insurance Service – National Sample Cohort (NHIS-NSC) established in 2002 and followed until 2010, 41104 subjects with the complete data for age, sex, BMI, fasting glucose, total cholesterol, family history of hypertension, cardiac disease and stroke history, physical activity, smoking, and drinking. Moderate drinking was defined as daily alcohol intake between 8∼20 gram per day. Primary composite end points were composite of acute myocardial infarction, stroke and cardiovascular death. Results: Age was 46.6 ± 11.3 and female was 33.8% (n = 41104). Least square means ± standard error of SBPs were 124.4 ± 0.12, 125.3 ± 18.8, 126.7 ± 0.12, and 126.6 ± 0.26 mmHg for Q1 (<3 gram/day), Q2 (3∼8 gram/day), Q3 (8∼20 gram/day), and Q4 (>20 gram/day), respectively. There was no J shaped relationship in SBP and drinking. For cardiovascular outcomes, only Q3 showed statistically significant protective effect compared to no drinking (HR: 0.81, p = 0.0071 for 950 events) as well as age, smoking, house income (p = 0.037), sex, SBP, family history, and fasting glucose. Conclusions: In NHIS-NSC data, drinking had positive linear relationship with SBP without J curve. And for cardiovascular outcomes, only moderate drinking showed beneficial effect suggesting J shaped relationship.

PS 17-66 INDEPENDENT ASSOCIATION BETWEEN DIASTOLIC BLOOD PRESSURE VARIABILITY AND LEFT VENTRICULAR MASS INDEX IN RELATIVELY YOUNGER HYPERTENSIVE MEN AND WOMEN

Objective: The impact of blood pressure (BP) variability on left ventricular hypertrophy (LVH) remains uncertain and furthermore, its gender differences have not been elucidated. We investigated whether BP variability, assessed by 24-hour ambulatory blood pressure monitoring (24-h ABPM) is independently associated with LV mass index (LVMI) in essential hypertensive men and women. Design and method: A total of 526 hypertensive patients (mean age 54.5 ± 13.6 years, 292 men and 234 women) who underwent echocardiography were enrolled. LVM was measured by M-mode echocardiography using Devereuxs formula and calculated as LVM (g)/height (m) 2.7 (LVMI). Results: Compared to men, women were older and had lower hemoglobin (Hb) levels, higher LVMI, 24-h systolic BP (SBP) and diastolic BP (DBP) variability values (all p < 0.05). In multivariate analysis, body mass index (BMI) (&bgr; = 0.248, p = 0.001), 24-h heart rate (HR) (&bgr; =  −0.266, p = 0.001), night-time SBP (&bgr; = 0.162, p = 0.027), 24-h DBP variability (&bgr; = 0.179, p = 0.021) were associated with LVMI in men. On the other hand, in women, age (&bgr; = 0.168, p = 0.002), BMI (&bgr; = 0.499, p < 0.0001), Hb (&bgr; =  −0.222, p < 0.0001) and night-time DBP variability (&bgr; = 0.161, p = 0.003) were found to be independent determinants of LVMI. Conclusions: Among essential hypertensive patients, DBP variability was associated with LVMI independent of 24-h ABP levels in both men and women. However, in men, night-time SBP and 24-h HR were also independently related to LVMI, and the effect of age and Hb level on LVMI were greater in women than in men.

MPS 10-06 Seasonal variations of 24-hour ambulatory blood pressure and blood pressure variability in the young and elderly essential hypertensive patients

Objective: Seasonal blood pressure (BP) changes has been described in clinic BP. Few studies have examined the seasonal variation in BP and BP variability, assessed by 24-hour ambulatory blood pressure monitoring (ABPM) and it remains uncertain whether the seasonal trend differs between young and elderly hypertensive patients. Design and Method: A total of 1028 untreated essential hypertensive patients (mean age 52 ± 14 years) who underwent 24-hour ABPM between January 2009 and April 2013 were enrolled. Patients were divided into young (age ⩽ 70 years, n = 927) and elderly (age > 70 years, n = 101) groups. Results: Compared to elderly group, young age group had higher clinic, 24-hour, daytime and night-time diastolic BP (DBP), higher clinic, 24-hour and daytime heart rate (HR), higher 24-hour and daytime HR variability (HRV), lower night-time systolic BP (SBP) and daytime SBP variability. In young age group, significant seasonal variation of clinic DBP and daytime SBP variability with a peak in autumn, and nighttime DBP and HR with a peak in spring and the increased prevalence of non-dippers in summer were observed. On the other hand, elderly group demonstrated seasonal variation of clinic, 24-hour, daytime and nighttime HR with a peak in autumn, daytime DBP with a peak in winter and night-time SBP variability with a peak in summer. Conclusions: There was an apparent seasonal variation of DBP, HR and SBP variability in both young and elderly hypertensive patients. However, elderly patients showed more pronounced seasonal change in HR compared to younger patients. Figure. No caption available.

PS 14-30 PREVALENCE OF RESISTANT HYPERTENSION AND ASSOCIATED FACTORS FOR BLOOD PRESSURE CONTROL STATUS USING KOREAN AMBULATORY BLOOD PRESSURE MONITORING REGISTRY DATA

Objective: Resistant hypertension (RH) may be one of the cause of the plateau in improving the control rate in hypertension (HT) management. The misdiagnosis of RH by clinic blood pressure (BP) is important clinical problem. Aim of the study were to investigate the prevalence of RH by ambulatory blood pressure monitoring (ABPM) and the factor associated with control status of ambulatory BPs. Design and Method: For 1230 subjects taking one or more antihypertensive medication (AHM) enrolled in the Korean Ambulatory Blood Pressure Monitoring (Kor-ABP) registry, the prevalence of RH was calculated which was defined as uncontrolled BP by three AHM classes including diuretic or BP in need of four or more AHM classes. The prevalence determined by clinic versus ambulatory BP was compared. Results: The age was 59.3 ± 12.5 years, and 44.3% were female (n = 1230). Among them 72 subjects were taking three AHM drugs including diuretics and 105 subjects were taking four or more AHM classes. With uncontrolled daytime ambulatory BP in 41 among 72 subjects, prevalence of RH was 11.9% (146/1230). By using nighttime BP criteria, there was significant difference in the prevalence of RH for clinic versus nighttime BP (146/177 vs. 159/177, p = 0.0124). For control status of daytime BP, masked uncontrolled BP was 16.9% and controlled BP with white-coat effect was 14.1%. For nighttime BP control status, odd ratios for smoking (0.624), drinking (1.512), coronary artery disease (0.604), calcium antagonist (1.705), and loop diuretics (0.454) were all significant. Conclusions: The prevalence of RH was 11.9% by daytime BP and it was significantly higher when using nighttime BP criteria. Control status of daytime BP was misclassified in 31.0%. Smoking, drinking, coronary artery disease, calcium antagonist, and loop diuretics were associated with nighttime BP control status.

OS 07-05 DETERMINANTS OF MORNING BLOOD PRESSURE SURGE IN NORMOTENSIVE SUBJECTS AND UNTREATED HYPERTENSIVE PATIENTS: THE KOREAN AMBULATORY BLOOD PRESSURE MULTICENTER OBSERVATIONAL STUDY.

Objective: Morning blood pressure (BP) surge has been regarded as a predictor of adverse cardiovascular events. However, its determinants remain controversial and no previous studies have evaluated whether or not there is a difference in the determinants of morning BP surge between normotensive and hypertensive subjects. Design and Method: We included 476 normotensive subjects (mean age 52.8 ± 15.4 years, 49.2% males) and 1028 untreated hypertensive patients (age 51.7 ± 13.9 years, 56.1% males) from the Korean Ambulatory Blood Pressure Registry. Sleep-trough morning BP surge was defined as the difference between mean systolic BP (SBP) during the 2 hours after awakening and the average of three readings centered on the lowest sleep SBP level. Results: Hypertensive patients had higher sleep-trough morning BP surge compared to normotensive subjects (27.6 ± 17.8 mmHg vs 25.7 ± 13.7 mmHg, p = 0.023). In multivariate linear regression analysis, 24-hour heart rate (24-h HR) variability (&bgr; = 0.397, p < 0.0001) was associated with MS in normotensive subjects. Meanwhile, in hypertensive patients, age (&bgr; = −0.113, p = 0.046), diabetes mellitus (&bgr; = −0.109, p = 0.043), daytime SBP (&bgr; = 0.301, p < 0.0001), night-time SBP (&bgr; = −0.375, p < 0.0001), 24-h SBP variability (&bgr; = 0.290, p < 0.0001) and night-time diastolic BP (DBP) variability (&bgr; = 0.185, p = 0.001) were found to be independent determinants of morning BP surge. Conclusions: Morning BP surge was more pronounced in hypertensive patients than in normotensive subjects, and its determinants were also different between them. These findings suggest that different pathogenic mechanism of morning BP surge may exist in normotensive subjects and hypertensive patients, respectively.