Umberto Boffa

Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes

A significant proportion of individuals taking antihypertensive therapies fail to achieve blood pressures <140/90 mmHg. In order to develop strategies for improved treatment of blood pressure, we examined the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors in a cohort of adults at increased cardiovascular risk.

N-terminal B-type natriuretic peptide and the association with left ventricular diastolic function in a population at high risk of incident heart failure: results of the SCReening Evaluation of the Evolution of New-Heart Failure Study (SCREEN-HF)

Impaired diastolic function is associated with increased morbidity and mortality, but antecedents and predictors of progression to heart failure (HF) are not well understood. We examined associations between NT‐proBNP, HF risk factors, and diastolic function in a population at high risk for incident HF.

NT-proB natriuretic peptide, risk factors and asymptomatic left ventricular dysfunction: results of the SCReening Evaluation of the Evolution of New Heart Failure study (SCREEN-HF).

BACKGROUND We assessed left ventricular dysfunction in a population at high risk for heart failure (HF), and explored associations between ventricular function, HF risk factors and NT-proB natriuretic peptide (NT-proBNP). METHODS AND RESULTS 3550 subjects at high risk for incident HF (≥60 years plus ≥1 HF risk factor), but without pre-existing HF or left ventricular dysfunction, were recruited. Anthropomorphic data, medical history and blood for NT-proBNP were collected. Participants at highest risk (n = 664) (NT-proBNP highest quintile; >30.0 pmol/L) and a sample (n = 51) from the lowest NT-proBNP quintile underwent echocardiography. Participants in the highest NT-proBNP quintile, compared to the lowest, were older (74 years vs. 67 years; p < 0.001) and more likely to have coronary artery disease, stroke or renal impairment. In the top NT-proBNP quintile (n = 664), left ventricular systolic impairment was observed in 6.6% (95% CI: 4 to 8%) of participants and was associated with male gender, coronary artery disease, hypertension and NT-proBNP. At least moderate diastolic dysfunction was observed in 24% (95% CI 20 to 27%) of participants and was associated with diabetes and NT-proBNP. In this high risk population, NT-proBNP was associated with left ventricular systolic impairment (p < 0.001) and moderate to severe diastolic dysfunction (p < 0.001) after adjustment for age, gender, coronary artery disease, diabetes, hypertension and obesity. CONCLUSION A high burden of ventricular dysfunction was observed in this high risk group. Combining NT-proBNP and HF risk factors may identify those with ventricular dysfunction. This would allow resources to be focused on those at greatest risk of progression to overt HF.

Amino-terminal-pro-B-type natriuretic peptide levels and low diastolic blood pressure: Potential relevance to the diastolic J-curve

Background: There is debate whether the J-curve relationship between cardiac event risk and DBP is because of inherent cardiac risk or is a consequence of blood pressure (BP) lowering therapy. Methods: We examined the association between the cardiovascular risk marker amino-terminal-pro-B-type natriuretic peptide (NT-proBNP) and DBP in 1781 women and 2211 men aged at least 60 years with one or more cardiovascular risk factors; exclusion criteria were known heart failure or cardiac abnormality on a cardiac imaging study. Results: The lowest median serum NT-proBNP levels were for DBP 85–89 mmHg for both women and men. DBP less than 70 mmHg in women and less than 80 mmHg in men was associated with higher NT-proBNP levels than the levels at DBP 85–89 mmHg, and this relationship was present for those with SBP equal to or less than 140 and SBP greater than 140 mmHg. In conditional logistic regression models, the association of elevated NT-proBNP levels with low DBP in women was no longer statistically significant after adjustment for age, ischaemic heart disease (IHD), pulse rate, atrial fibrillation, haemoglobin and glomerular filtration rate, whereas the association in men was no longer statistically significant after adjustment for age and IHD. By contrast, the association between elevated NT-proBNP levels and low DBP remained statistically significant after adjustment for the number of antihypertensive drug classes alone or together with all antihypertensive drugs, including &bgr;-blocker therapy. Conclusion: There was a J-curve relationship between the cardiovascular risk marker NT-proBNP and DBP that was explained by the clinical variables and not by the BP-lowering therapy.

Risk factor management in a contemporary Australian population at increased cardiovascular disease risk

Effective management of cardiovascular and chronic kidney disease risk factors offers longer, healthier lives and savings in healthcare.

A packaged secondary prevention program outside primary care

[1] Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery–a prospective outcome study. Br J Anaesth 2006;96(6):686–93. [2] Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005;293 (17):2126–30. [3] Grines CL, Bonow RO, Casey Jr DE, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol 2007;49(6):734–9. [4] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.

Risk factors for incident heart failure with preserved or reduced ejection fraction, and valvular heart failure, in a community-based cohort

Background The lack of effective therapies for heart failure with preserved ejection fraction (HFpEF) reflects an incomplete understanding of its pathogenesis. Design We analysed baseline risk factors for incident HFpEF, heart failure with reduced ejection fraction (HFrEF) and valvular heart failure (VHF) in a community-based cohort. Methods We recruited 2101 men and 1746 women ≥60 years of age with hypertension, diabetes, ischaemic heart disease (IHD), abnormal heart rhythm, cerebrovascular disease or renal impairment. Exclusion criteria were known heart failure, left ventricular ejection fraction <50% or valve abnormality >mild in severity. Median follow-up was 5.6 (IQR 4.6–6.3) years. Results Median time to heart failure diagnosis in 162 participants was 4.5 (IQR 2.7–5.4) years, 73 with HFpEF, 53 with HFrEF and 36 with VHF. Baseline age and amino-terminal pro-B-type natriuretic peptide levels were associated with HFpEF, HFrEF and VHF. Pulse pressure, IHD, waist circumference, obstructive sleep apnoea and pacemaker were associated with HFpEF and HFrEF; atrial fibrillation (AF) and warfarin therapy were associated with HFpEF and VHF and peripheral vascular disease and low platelet count were associated with HFrEF and VHF. Additional risk factors for HFpEF were body mass index (BMI), hypertension, diabetes, renal dysfunction, low haemoglobin, white cell count and β-blocker, statin, loop diuretic, non-steroidal anti-inflammatory and clopidogrel therapies, for HFrEF were male gender and cigarette smoking and for VHF were low diastolic blood pressure and alcohol intake. BMI, diabetes, low haemoglobin, white cell count and warfarin therapy were more strongly associated with HFpEF than HFrEF, whereas male gender and low platelet count were more strongly associated with HFrEF than HFpEF. Conclusions Our data suggest a major role for BMI, hypertension, diabetes, renal dysfunction, and inflammation in HFpEF pathogenesis; strategies directed to prevention of these risk factors may prevent a sizeable proportion of HFpEF in the community. Trial registration number NCT00400257, NCT00604006 and NCT01581827.

Author reply: To PMID 22909211.

Campbell et al. present a well-designed study that reflects the population we treat. The wide range of variables (encompassing other cardiac conditions, comorbidities, tobacco usage and use of various medications) is thoroughly analysed. However, the study seems oblivious to the major hurdle to adequate blood pressure control in patients with hypertension not adequately treated pharmacologically. The elephant in the room is compliance (and lack thereof). In our experience of the treatment of a range of such patients, poor compliance is the most prevalent reason for inadequate blood pressure control. This is equally true of public and private patients. It occurs just as frequently in cardiology clinics as it can in internal medicine or geriatrics. It is pervasive regardless of all other factors, including how many classes of medications prescribed, the geographical location and the socioeconomic status of patients. Compliance with antihypertensive medications is a common problem in our community and has significant costs. Needless to say, inadequate blood pressure control is strongly linked to concurrent or future cardiovascular and/or cerebrovascular disease. In fact, compliance affects every specialty in the treatment of any chronic condition one can think of. It has been estimated that up to 75% of patients are not taking medications as prescribed. The underlying reasons are many and varied; what a medical practitioner does next is not straightforward. It seems the only thing harder than measuring compliance is improving it. While we are not disputing the findings of this study, we remain mindful that any study in this domain will be significantly distorted by compliance issues. Accounting for this factor adequately is difficult. However, omitting it altogether is ignoring the proverbial elephant.

Presence of an anaesthetist during cataract surgery

1.17 dioptres with 3.80 D being the highest amount of astigmatism corrected. The mean postoperative spherical equivalent was 0.03 D 0.43; uncorrected distance visual acuity 6/7.5 was present in 82% (86/105) of eyes; corrected distance visual acuity was 6/7.5 in 96% (101/105) of eyes; spectacle independence was achieved in 100% (105/105 eyes). In our study population of uncomplicated patients receiving toric IOLs, the mean reduction in astigmatism was 1.17 D. Comparing the reduction in astigmatism between our study and others was limited by the use of different endpoints (Table 1). However, from the data reported by Roensch et al., we calculated that they achieved a 1.78 D mean reduction in astigmatism, which is similar to our results. Using uncorrected visual acuity and spectacle independence, our outcomes were comparable to or better than prior studies by resident and experienced surgeons implanting toric IOLs (Table 1). Hence, this suggests that, in uncomplicated patients, refractive outcomes with toric IOLs for resident and experienced surgeons may be similar. Limitations of this study include its retrospective design and the use of different technicians and techniques (e.g. automated versus manual keratometry) for preoperative biometry. In addition, we were unable to control for the degree of attending intervention during the cataract surgeries, which may impact our results. In summary, this study helps establish benchmarks for patients undergoing cataract surgery with toric IOLs in teaching hospitals. Further research is needed to assess the impact of toric IOLs on the quality of life in this patient cohort.

471 MOST INDIVIDUALS WITH TREATED BLOOD PRESSURES ABOVE TARGET RECEIVE ONLY ONE OR TWO ANTIHYPERTENSIVE DRUG CLASSES: CROSS-SECTIONAL STUDY OF AUSTRALIANS AT INCREASED CARDIOVASCULAR RISK

Objective: To measure, in a cohort of adults at increased cardiovascular risk and receiving antihypertensive therapies, the proportion with blood pressures above target (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) and to examine the association of blood pressure control with antihypertensive therapies, clinical and lifestyle factors. Design, Setting and Participants: A cross-sectional study of 3994 adults from Melbourne and Shepparton, Australia, enrolled in the SCReening Evaluation of the Evolution of New Heart Failure (SCREEN-HF) study; 3660 (92%) had private medical insurance. Inclusion criteria were age ≥60 years with one or more of self-reported ischaemic or other heart disease, atrial fibrillation, cerebrovascular disease, renal impairment, or treatment for hypertension or diabetes for ≥2 years. Exclusion criteria were known heart failure or cardiac abnormality on echocardiography or other imaging. The main outcome measures were the proportion of participants receiving antihypertensive therapy with blood pressures ≥140/90 mmHg and the association of blood pressure control with antihypertensive therapies, clinical and lifestyle factors. Results: Of 3623 participants (1975 men and 1648 women) receiving antihypertensive therapy, 1867 (52%) had blood pressures ≥140/90 mmHg. Of these 1867 participants with blood pressures ≥140/90 mmHg, 1483 (79%) were receiving only one or two antihypertensive drug classes. Blood pressures ≥140/90 mmHg were associated with increased age, male sex, waist circumference, and log amino-terminal-pro-B-type natriuretic peptide levels. Conclusions: Prescribing additional antihypertensive drug classes and lifestyle modification may improve blood pressure control in this population of individuals at increased cardiovascular risk.