17-19 September 2023

Osaka University Nakanoshima Center, Osaka, Japan Meeting Chairpersons: Kei Asayama, Kei Kamide, and Jan A. Staessen

Session 1: Home blood pressure: Chairpersons - Takayoshi Ohkubo and Ji-Guang Wang HOME BLOOD PRESSURE TELEMONITORING IN A SOUTH AFRICAN CONTEXT

Gontse G. Mokwatsi1,2

1) Hypertension in Africa Research Team, North-West University, South Africa. 2) MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University; South Africa.

Hypertension is currently the leading contributor to the development of cardiovascular disease and related deaths globally. In South Africa, awareness, treatment, and control levels of hypertension remain low. Challenges that hinder optimal control of hypertension in South Africa mainly lie within the public health system, which is faced with constraints regarding the availability and cost of essential medicines as well as the healthcare workforce. To achieve optimal levels of hypertension control, several guidelines recommend the use of home blood pressure telemonitoring (HTM). HTM is a promising telemedicine strategy to improve the delivery of optimal care for patients and serve to enhance the connection between patients and healthcare providers. To date, there is evidence from various controlled trials reporting that prolonged and regular use of HTM can significantly control blood pressure of hypertensive patients compared to usual care. Despite the positive reports showing the great potential of HTM in other countries, the feasibility of HTM in South Africa is scant. To date, only one HTM study has been reported in South Africa, with results showing a significant reduction in systolic blood pressure of patients as well as improved adherence to medication. To address the current gap in investigating the feasibility of the use of HTM in South Africa, the Hypertension in Africa Research Team from the North-West University is working with various international institutions on a randomized clinical trial known as UPRIGHT-HTM to collect HTM data in South African population.

BLOOD PRESSURE TREATMENT ADHERENCE RATE OF CARE INVOLVING ONLINE VISITS WAS SIGNIFICANTLY BETTER THAN THAT OF USUAL CARE RELYING ONLY ON OFFICE VISITS

Midori Yatabe, Kazuya Ishida, Junichi Yatabe

General Incorporated Association Telemedease

Background: Essential hypertension is undermanaged in many populations, despite its ease of diagnosis and established pharmacological treatments. One factor behind insufficient BP management is low treatment adherence. It is reported that half of the patients drop out by one year after the start of hypertension treatment. Online consultation can reduce the burden of outpatient treatment. We reported that 40% of the patients who used hypertension online consultation were seeking hypertension treatment for the first time, and 40% were returning to therapy after discontinuing treatment, suggesting that there may be groups of people who find it difficult to visit medical institutions and receive face-to-face consultations (the International Society of Hypertension [ISH] 2022, Kyoto). However, how the treatment adherence of online management compares to usual care, which relies only on office visits, is unclear.

Objective: We aim to assess whether online consultations are associated with an improved adherence rate of hypertension treatment.

Methods: An observational retrospective cohort study was conducted. We compared the online and outpatient treatment groups in treatment adherence for 1 year from the first visit. The patient selection criteria were hypertensive patients, the online treatment group was first seen by the end of March 2023, and the online treatment was used, and the exclusion criteria were patients who had coexisting diseases for which on-site outpatient treatment was desirable in the pre-treatment consultation. The outpatient treatment group consisted of those who had their first visit by the end of March 2023. Treatment adherence was calculated using proportion of days covered (PDC) as the percentage of those who continued treatment from the first visit online or at an outpatient clinic.

Results: We analyzed 42 cases in the online consultation group and 95 cases in the outpatient treatment group. As a result, the median PDC was 89.4% in the online consultation group and 72.9% in the outpatient consultation group. When the difference in population ratio between the two groups was tested using the z-test, the former showed significantly higher treatment compliance (P<0.001). In the online consultation group, the median home blood pressure value at the start of treatment was 148.1/98.0 mmHg, but a significant improvement was observed at 134.2/90.0 mmHg after 1 year (P<0.001).

Conclusions: Adherence to hypertension treatment has improved with online consultation. It was also suggested that online consultation may be better for blood pressure treatment adherence than face-to-face consultations for hypertension treatment.

HOME BLOOD PRESSURE VALUES BY FRAILTY CLASSIFICATION, SEASONAL VARIATION AMONG COMMUNITY-DWELLING OLDER ADULTS—NOSE STUDY

Yuka Ohata1, Kayo Godai1, Mai Kabayama1, Arisa Wada1, Michiko Kido1, Kei Asayama2, Takayoshi Ohkubo2, Hiromi Rakugi1,3, Yasuharu Tabara4, Kei Kamide1

1) Osaka University Graduate School of Medicine, Division of Health Science 2) Teikyo University Graduate School of Medicine, Department of Hygiene and Public Health 3) Osaka Rosai Hospital 4) Shizuoka Graduate University of Public Health

Objective: Few studies have investigated long-term home blood pressure values and seasonal variation in blood pressure measured by frailty classification. This study aimed to clarify home blood pressure (HBP) values, blood pressure (BP) variability, and seasonal variation by frailty category in community-dwelling older adults.

Methods: Among those >63 years old who participated in the NOSE Study, those who measured HBP and submitted HBP recording notes between August 2020 and August 2022 were included in this study. Those with missing frailty classifications and HBP data measured <5 times per month were excluded from this analysis. The average of the first and second HBP measurements was used as the daily systolic BP and diastolic BP values, and the mean monthly systolic and diastolic BP values were calculated based on daily mean values. Furthermore, the overall mean systolic and diastolic BP values, standard deviation (SD), and coefficient of variation (CV) were calculated from the monthly mean values. Winter and summer BP were calculated as the index of seasonal variation. For winter BP, the mean value of BP from December to February during the measurement period was used, and for summer BP, the mean value of BP from July to September was used. Hypertension was defined as a mean HBP of systolic BP ≥135 or diastolic BP ≥85 during the entire measurement period or those taking anti-hypertensive medications. Using the J-CHS criteria, the classification was determined as robust, pre-frailty, or frailty. BP values, SD, and CV were compared by one-way analysis of variance for each hypertension status and frailty classification.

Results: 418 participants were analyzed, with a mean age of 72.8 years, and the number of females was 253 (60.5%). In terms of frailty classification, 127 (30.4%) were robust, 265 (63.4%) were pre-frailty, and 26 (6.2%) were frailty. In the overall participants, systolic BP values were significantly higher in the frailty group (P<0.05) than in the robust group. Additionally, systolic BP values in winter were significantly higher in the frailty group (P<0.05). There were 251 with hypertension (72 robust, 161 pre-frailty, 18 frailty). Of them, SD of systolic BP and CV of diastolic BP were greater in the frailty group than in the robust group (P<0.05).

Conclusions: Systolic BP values were higher and showed a seasonal variation in the frailty group compared to the robust group. This study also revealed a greater index of BP variability in the frailty group with hypertension.

THE NUMBER OF HOME BP READINGS TO QUANTIFY BP VARIABILITY: THE OHASAMA STUDY

Kei Asayama1,2,3, Takayoshi Ohkubo1, the Ohasama study group

1) Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan 2) KU Leuven Department of Cardiovascular Sciences, Leuven, Belgium 3) Research Institute Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium

Blood pressure variability based on home measurement (HBPV) has a prognostic significance, though limitedly, on cardiovascular outcome as well as cognitive dysfunction. However, HBPV were calculated based on the various measurement times, which affects the reliability of HBPV. In the Ohasama study, 2093 residents (women 63.6%; mean age, 59.2 years; 1489 untreated) measured home blood pressure for 14 days or more both in the morning and in the evening. We assessed the average HBPV, i.e., standard deviation (SD), coefficient of variation (CV), average real variability (ARV), variability independent of the mean (VIM), and max-min difference (MMD) while the number of morning home measurement days was increased from 3 to 14. Compared with the average values in the 14 days’ measurement, averages in the 3 days of SD, CV, and VIM were around 90%, while ARV excessed (105.7%) and MMD was almost half level (49.2%). The days when the average values became <5% different to the 14-day average were day 4 in ARV, 5 in SD and VIM, 6 in CV, and 12 in MMD. The average MMD values had not reached the ceiling, as they increased 2.81%, 2.29%, and 2.21% between 11-12, 12-13, and 13-14 days, respectively. The results were consistent when evening home measurements were assessed. In the Japanese general population, 5 days of home blood pressure measurements would be sufficient to quantify HBPV except for MMD; whereas, we would need more than 14 days of home blood pressure measurements to capture MMD appropriately.

Session 2: Ambulatory blood pressure and central hemodynamics: Chairpersons - Augustine N. Odili and Gladys E. Maestre CARDIOVASCULAR ENDPOINTS AND MORTALITY IN RELATION TO THE FORWARD AND BACKWARD AORTIC PULSE WAVE

Angela J. Woodiwiss1, De-Wei An2,3,4, Lucas S. Aparicio5, Yu-Ling Yu3,4, Fang-Fei Wei6, Teemu J. Niiranen7,8, Chen Liu6, Katarzyna Stolarz-Skrzypek3,9, Wiktoria Wojciechowska9, Antti M. Jula7,8, Marek Rajzer9, Dries S. Martens10, Peter Verhamme11, Yan Li2, Kalina Kawecka-Jaszcz9, Tim S. Nawrot4,10, Gavin R. Norton1, Jan A. Staessen3,12, The International Database of Central Arterial Properties for Risk Stratification (IDCARS) Investigators

1) Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 2) Department of Cardiovascular Medicine, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China 3) Non-Profit Research Association Alliance for the Promotion of Preventive Medicine, Belgium 4) Research Unit Environment and Health, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium 5) Servicio de Clínica Médica, Sección Hipertensión Arterial, Hospital Italiano de Buenos Aires, Argentina 6) Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China 7) Department of Chronic Disease Prevention, Finnish Institute for Health and Welfare, Turku, Finland 8) Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland 9) First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland 10) Center for Environmental Sciences, Hasselt University, Diepenbeek, Belgium 11) Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium 12) Biomedical Science Group, Faculty of Medicine, University of Leuven, Leuven, Belgium

Background: With advancing age, the pulsatile blood pressure (BP) components, systolic BP and pulse pressure (PP) override the steady components, diastolic BP and mean arterial pressure, in determining cardiovascular mortality and morbidity. Wave separation analysis enables individualized evaluation of the aortic pulse wave into its component forward (Pfor) and backward (reflected, Pref) pressure waves. However, the contributions of these component waves to cardiovascular risk remain controversial. Previous studies focused on the peak pressure height of Pfor and Pref with overall positive but differing results. In the present analysis, we assessed the associations of Pfor and Pref, as well as the time to the peak of the forward (Tfor) and backward (Tref) wave pressures with prospective cardiovascular endpoints in the International Database of Central Arterial Properties for Risk Stratification (IDCARS) population.

Methods: Participants in three IDCARS cohorts (Argentina, Belgium, and Finland) aged ≥20 years with valid pulse wave analysis and follow-up data were included in the analysis. Pulse wave analysis was done using the SphygmoCor device, and pulse waves were separated using the triangular flow method to derive Pfor, Pref, Tfor and Tref. The primary endpoints consisted of cardiovascular mortality and non-fatal cardiovascular and cerebrovascular events. Multivariable adjusted Cox regression was carried out.

Results: A total of 2206 participants (mean age, 57.0 years; 55.0% women) were included in the current analysis. Over a median follow-up of 4.4 years, 146 (6.6%) participants experienced primary endpoints. One standard deviation increment in Pfor, Tfor, and the ratio of Tfor to Tref (Tfor/Tref) was associated with a 27% (95% CI: 1.07–1.49), 25% (1.07–1.45), and 32% (1.12–1.56) higher risk, respectively (all P≤0.005). Adding Tfor and Tfor/Tref to the full model consisting of established cardiovascular risk factors resulted in significant improvement in model prediction (Uno’s C statistic: 0.829 vs 0.812, difference: 0.020±0.007 and 0.020±0.008 for Tfor and Tfor/Tref, respectively; all P<0.01).

Conclusions: Pulse wave components of aortic pressure were predictive of composite cardiovascular events, with Tfor/Tref showing significant improvement in risk prediction. Pending further confirmation, the ratio of the time to peak forward and backward wave pressure may be a useful tool to evaluate increased afterload and signify increased cardiovascular risk.

DERIVATION OF AN OUTCOME-DRIVEN THRESHOLD FOR AORTIC PULSE WAVE VELOCITY: AN INDIVIDUAL-PARTICIPANT META-ANALYSIS

De-Wei An1,2, Tine W. Hansen2,3, Jan A. Staessen2,4, Yan Li1, and the International Database of Central Arterial Properties for Risk Stratification (IDCARS) Investigators

1) Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China 2) Non-Profit Research Association Alliance for the Promotion of Preventive Medicine, Belgium 3) The Steno Diabetes Center Copenhagen, Denmark 4) Biomedical Science Group, Faculty of Medicine, University of Leuven, Belgium

Background: Aortic pulse wave velocity (PWV) predicts cardiovascular events (CVE) and total mortality (TM), but previous studies proposing actionable PWV thresholds have limited generalizability. This individual- participant meta-analysis is aimed at defining, testing calibration, and validating an outcome-driven threshold for PWV, using two population studies, respectively, for derivation (the International Database of Central Arterial properties for Risk Stratification; IDCARS) and replication (MONItoring of trends and determinants in CArdiovascular disease; MONICA).

Methods: A risk-carrying PWV threshold for CVE and TM was defined by multivariable Cox regression, using stepwise increasing PWV thresholds and determining the threshold yielding a 5-year risk equivalent to the systolic blood pressure of 140 mmHg. The predictive performance of the PWV threshold was assessed by computing the integrated discrimination improvement (IDI) and the net reclassification improvement (NRI).

Results: In well-calibrated models in IDCARS, the risk-carrying PWV thresholds converged at 9 m/s (10 m/s considering the anatomical pulse wave travel distance). With full adjustments applied, the threshold predicted CVE (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15–2.45) and TM (HR, 1.61; 95% CI, 1.01–2.55) in IDCARS and in MONICA (HR, 1.40; 95% CI, 1.09–1.79; and HR, 1.55; 95% CI, 1.23–1.95). In IDCARS and MONICA, the predictive accuracy of the threshold for both endpoints was ~0.75. IDI was significant for TM in IDCARS and for both TM and CVE in MONICA, whereas NRI was not for any outcome.

Conclusions: PWV integrates multiple risk factors into a single variable and might replace a large panel of traditional risk factors. Exceeding the outcome-driven PWV threshold should motivate clinicians to stringent management of risk factors, in particular hypertension, which over a person’s lifetime causes stiffening of the elastic arteries as a waypoint to CVE and death.

THE ROLE OF BLOOD PRESSURE COMPONENTS IN RISK STRATIFICATION IN HFPEF: A RE-ANALYSIS OF THE TOPCAT TRIAL

Fang-Fei Wei1, Jan A. Staessen2,3, Yugang Dong1, Chen Liu1

1) Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China 2) Research Institute Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium 3) Biomedical Science Group, University of Leuven, Leuven, Belgium

Objective: We aimed to investigate the role of blood pressure (BP) components in risk stratification in heart failure with preserved ejection fraction (HFpEF).

Methods: We computed hazard ratios for adverse health outcomes associated with 1-SDincrease in BP components in patients with HFpEF enrolled in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial. BP components were mean arterial pressure (MAP), pulse pressure, cumulative BP and BP variability (i.e., SD, variability independent of the mean, and average real variability).

Results: In multivariable-adjusted analyses of both placebo and spironolactone groups, lower MAP and higher pulse pressure predicted the primary composite end point (P≤0.028) and hospitalized HF (P≤0.002), whereas MAP was also significantly associated with total mortality (P≤0.007). In multivariable-adjusted analyses that additionally accounted for baseline BP, cumulative systolic BP predicted the primary composite endpoint (hazard ratio, 1.15; 95% CI, 1.01-1.31) and hospitalization for HF (1.18; 1.02- 1.37), respectively. In the placebo group, the primary composite endpoint and hospitalized HF were significantly associated with systolic and diastolic BPV (hazard ratios, ≥1.28; P<0.001) and total mortality with systolic BPV (hazard ratios ≥1.20; P≤0.010). In the spironolactone group, the primary endpoint and hospitalized HF were associated with both systolic and diastolic BPV (hazard ratios ≥1.17; P≤0.006).

Conclusions: The clinical application of BP components may refine risk estimates in patients with HFpEF. These observations may help further investigation for the development of HFpEF preventive strategies targeting BP control and refining risk stratification.

OPPORTUNITIES TO STUDY 24-H AMBULATORY BLOOD PRESSURE MONITORING IN RELATION TO BRAIN MACROCIRCULATION AND NEUROLOGICAL OUTCOMES

Jesus D. Melgarejo1,2, Luis Mena3, Egle R. Silva4, Daniel Bos5, Joseph Lee6,Joseph Terwilliger6, Zhenyu Zhang7, Gladys Maestre1,2

1) Institute of Neuroscience, University of Texas Rio Grande Valley, Harlingen, Texas, USA 2) Laboratory of Neuroscience, Maracaibo, Zulia, Venezuela 3) Polytechnic University of Sinaloa, Mazatlán, Sinaloa, Mexico 4) Laboratory of Ambulatory Recordings, Cardiovascular Institute, University of Zulia, Maracaibo, Venezuela 5) Department of Radiology and Nuclear Medicine, Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands 6) Columbia University Irving Medical Center, New York, USA 7) Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, KU Leuven, Leuven Belgium

Background: In addition to conventional blood pressure (BP) measurements, 24-hour ambulatory BP monitoring provides stronger predictive information for investigating disease development and progression. However, evidence studying the link between markers of poor cerebrovascular aging and 24-h BP measures is limited. Therefore, we have addressed this gap by 1) investigating the association of 24-h ambulatory BP measurements with brain artery macrocirculation and neurological outcomes and 2) determining what factors explain the relationship between BP and neurological outcomes.

Methods: Data from population-based studies were analyzed and included between 429 and 1320 individuals aged ≥40 years with 24-h BP monitoring, and between 292 and 1458 participants aged ≥40 with magnetic resonance angiography (MRA) or CT brain scans. Mean BP level was estimated for 24-h, daytime, and nighttime systolic BP. Brain macrocirculation was studied as (i) brain artery stenosis measured on MRA and (ii) intracranial carotid artery calcification (ICAC) quantified from CT scans. Neurological outcomes included cerebral small vessel disease and dementia of Alzheimer’s type. Statistics methods included logistic, linear, and Cox-proportional regression models.

Results: The mean age of the participants analyzed ranged from 58 ± 11 and 68.0 ± 5.7 years (≤75% were women). Each unit increase in 24-h systolic BP increased by 1.03 (95% confidence interval [CI], 1.01–1.05) the odd ratios of brain artery stenosis; for day and nighttime BP, these estimates were 1.21 (95% CI, 1.01–1.04) and 1.26 (95% CI, 1.01–1.04). Nighttime systolic BP was the strongest BP index associated with cerebral small vessel disease (P≤0.023) and predicted the development of dementia (hazard ratio, 1.44; 95% CI, 1.04–2.00). We also observed that among BP components, 24-h pulse pressure was positively associated with brain stenosis (odds ratios ranged from 1.28 per +5 mmHg increase in 24-h pulse pressure to 2.00) and ICAC of stiffness type (β-correlation, 0.020 per unit increase in pulse pressure). ICAC of stiff type (indirect effects for white matter hyperintensities and lacunes ranged from -45.8% to 26.9%) and apolipoprotein E4 (for dementia of Alzheimer’s type) mediated the relationship between high BP and neurological outcomes.

Conclusions: Elevated 24-h BP levels, especially during the night, are associated with markers of poor cerebrovascular aging. The stiffness of the brain macrocirculation and genotypes partially explain the relationship between high BP and neurological outcomes. The interplay between poor cerebrovascular aging and 24-h BP indexes might provide opportunities to study physiopathological mechanisms involved in the development and progression of neurological complications of presumed vascular origin.

EFFECTIVENESS OF SALT SUBSTITUTE ON CARDIOVASCULAR OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Yi-Ching Tsai1, Yen-Po Tsao2, Chi-Jung Huang3, Yen-Hsuan Tai1, Yang-Chin Su1, Chern-En Chiang4,5, Shih-Hsien Sung4,6, Chen-Huan Chen1,4,7, Jong-Shiuan Yeh8,9, Hao-Min Cheng1,3,4,7

1) Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan 2) Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan 3) Center for Evidence-Based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan 4) School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan 5) General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan 6) Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan 7) Institute of Public Health and Community Medicine Research Center, National Yang-Ming Chiao Tung University School of Medicine, Taipei, Taiwan 8) Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wanfang Hospital, Taipei, Taiwan 9) Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan

Background: Hypertension-related death is the leading cause of mortality worldwide, making blood pressure (BP) control a significant issue. Salt substitute is a non-pharmaceutical strategy to improve hypertension. The goal of this study was to evaluate the effect of salt substitutes on BP and cardiovascular disease.

Methods: We searched the Cochrane Library and PubMed databases through March 2022, and assessed the risk of bias for included studies by the Cochrane risk-of-bias tool. A meta-analysis with random effects was performed to analyze the effects of salt substitutes on systolic and diastolic BP, 24-hour urinary sodium and potassium, and cardiovascular and all-cause mortality.

Results: 23 randomized controlled trials with 32073 subjects were included in our systematic review. In the random-effects model, participants consuming salt substitute showed a significant reduction in systolic BP (mean difference (MD) -4.80 mmHg, 95% confidence interval [CI] -6.12 to -3.48, P<0.0001) and diastolic BP (MD -1.48 mmHg, 95% CI -2.06 to -0.90, P<0.001) compared with participants consuming normal salt. In the urine electrolyte analysis, the salt substitute group had a significant reduction in 24-hour urine sodium (MD -22.96 mmol/24-hour, P=0.0001) and significant elevation in 24-hour urine potassium (MD 14.41 mmol/24-hour, P<0.0001). Of the five studies with mortality outcome data, salt substitutes significantly reduced all-cause mortality (hazard ratio 0.88, P=0.0003).

Conclusions: Our analyses showed that salt substitute has a strong effect on lowering BP and reducing all-cause mortality. By modifying the daily diet with salt substitutes, we can improve BP control by using this non- pharmaceutical management.

Session 3: Live-stream presentations: Chairpersons - Angela J. Woodiwiss and Michael Bursztyn FORWARD AND BACKWARD PULSE WAVE TRANSIT TIME IN THE PREDICTION OF ALL-CAUSE MORTALITY AND CARDIOVASCULAR EVENTS

Yi-Bang Cheng1, De-Wei An1,2,3, Lucas S. Aparicio4, Yan Li1, Jan A. Staessen2,5, and the International Database of Central Arterial Properties for Risk Stratification (IDCARS) Investigators

1) Department of Cardiovascular Medicine, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China 2) Non-Profit Research Association Alliance for the Promotion of Preventive Medicine, Belgium 3) Research Unit Environment and Health, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium 4) Servicio de Clínica Médica, Sección Hipertensión Arterial, Hospital Italiano de Buenos Aires, Argentina 5) Biomedical Sciences Group, Faculty of Medicine, University of Leuven, Leuven, Belgium

Background: Time-domain parameters of arterial pulse waveform are closely related to cardiac function and systemic arterial stiffness; however, predictive values of these indices remain unknown.

Methods: In the International Database of Central Arterial Properties for Risk Stratification (n=5529; 54.2% women; mean age 54.2 years), radial and estimated aortic pulse waveforms were analyzed by the SphygmoCor software. Time intervals between heart ejection and the first (TP1) and the second systolic peak (TP2) of pulse waveforms were defined as the forward and backward wave transit time, respectively.

Results: Over 4.1 years (median), 201 all-cause mortalities and 248 composite cardiovascular events occurred. Regardless of the analyzed arterial site (aortic or radial artery), the incidences of all-cause mortality decreased significantly (P≤0.007) from the lowest quartile to the highest quartile of the standardized TP1 and TP2. The multivariate-adjusted standardized hazard ratios (95% confidence intervals) associated with aortic and radial TP2 were 0.81 (0.71–0.93) and 0.82 (0.71–0.94) for all-cause mortality, respectively. Hazard ratios associated with aortic TP2 were 0.86 (0.76–0.98) and 0.82 (0.67–1.00) for cardiovascular and cerebrovascular events, respectively. While for TP1, only the association of cardiac events with aortic TP1 was significant with a multivariate-adjusted hazard ratio of 0.80 (0.67-0.96).

Conclusions: In adult populations, backward pulse wave transit time predicted outcomes independent of conventional risk factors.

RELATIONSHIP BETWEEN ABPM PARAMETERS AND MORTALITY IN THE SPANISH ABPM REGISTRY

Alejandro de la Sierra

Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Barcelona, Spain

In 2004 an initiative promoted by the Spanish Society of Hypertension with the funding support of a local pharmaceutical company initiated the Spanish Ambulatory Blood Pressure Monitoring (ABPM) Registry. Its main objective was to promote the use of ABPM among physicians, especially those working in Primary Care. At that time, the use of this method of measurement was restricted to referral units. However, we strongly believed that with relatively simple instructions, healthcare providers (physicians and nurses) would incorporate this technology into their usual clinical practice.

About 1000 ABPM monitors were distributed mostly in Primary Care Centres. Several meetings were organized to instruct participants in the use of ABPM, and a call center was created to solve doubts and troubles appearing with the use of ABPM. Data on each ABPM measurement was directly transferred to a central server, along with essential demographic and clinical information, and a report was delivered in real-time containing main results of the procedure, along with other useful information regarding risk stratification.

The Registry had a big success, with hundreds of records being uploaded every week. Almost 200,000 records from more than 150,000 patients were collected during the time the Registry was active. Several reports have been obtained from this cross-sectional data regarding the prevalence of different BP phenotypes, circadian patterns, and BP variability, as well as special populations of interest, such as resistant hypertension, diabetes, or patients with chronic kidney disease.

The existence of a national database of deaths in the Spanish population, including the main cause of death, allowed to obtain data on the follow-up of a selected population of patients included in the Registry, a selection based on the completeness of clinical data and quality of the ABPM Registry. After merging data on mortality with clinical and ABPM data from the Registry, 59,124 patients had information regarding such follow-up, which was established until December 2019, with a median follow-up of almost 10 years. A total of 7174 patients died (12.1%), including 2361 (4.0%) from cardiovascular causes.

Main results regarding the association of different BP estimates with all- cause and cardiovascular mortality revealed a superiority of ABPM estimates (24-h, daytime, and nighttime mean values) over office BP (the mean of 2 readings performed in standard conditions). Office BP lost the association with mortality when adjusted for 24-hour BP. In contrast, the adjustment for office BP did not modify the relationship between ABPM estimates and mortality. Nighttime systolic BP was the most informative estimate associated with mortality, being 6 times more informative than office BP. Regarding BP phenotypes and in comparison to patients with normal office and 24-hour BP, masked and sustained hypertension increased the risk of mortality, whereas white-coat hypertension did not.

Other analyses currently in progress are focused on circadian pattern alterations, subtypes of masked hypertension, as well as in special populations such as patients with resistant hypertension, diabetes, and chronic kidney disease.

EPIDEMIOLOGY OF HYPERTENSION IN AFRICA

Albertino Damasceno

Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique

In the last two decades, the use of the WHO STEPS methodology has brought us large and useful information about the epidemiology of hypertension in sub-Saharan Africa. We have assisted, contrary to what is happening in the developed world, that hypertension in Africa is increasing, and today the continent has one of the highest prevalences of this risk factor. This increase, associated with the rapid growth and ageing of the population, resulted in practice in an enormous increase in the total number of hypertensive patients.

On the other hand, although already politically defined as a health priority, high blood pressure does not receive the attention that it deserves. In consequence, the levels of awareness, treatment and control are extremely low. This is manifested by an increase in the incidence of strokes, with a large percentage of hemorrhagic ones, heart failure and ischemic heart disease. Probably more important is that these consequences occur during the early years of life with an enormous weight for society and families.

Innovative ways must be thought of to surpass this problem.

Session 4: UPRIGHT-HTM and related emerging topics: Chairpersons - José R. Banegas and Jan A. Staessen REPRODUCIBILITY OF THE ECHOCARDIOGRAPHIC TRAITS IN POLISH UPRIGHT-HTM PARTICIPANTS

Błażej Kaleta, Katarzyna Stolarz-Skrzypek, Marek Rajzer

First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland

Background: Heart failure is a progressive condition that begins with risk factors for left ventricular (LV) dysfunction (e.g., hypertension), proceeds to asymptomatic changes in cardiac structure (e.g., LV hypertrophy) and function (e.g., impaired relaxation) and then evolves into clinically overt HF, disability, and death. The diagnosis of asymptomatic LV dysfunction is usually achieved through imaging techniques including echocardiography. However, the echocardiographic diagnosis is influenced by intra- and inter- operator variability.

Aim: We sought to test the inter- and intra-observer reproducibility of echocardiographic measurements within one of the centers involved in the Urinary proteomics combined with home blood pressure telemonitoring for health care reform trial (UPRIGHT-HTM).

Methods: Three observers have been involved within one center in the acquisition (VIVID S60) and offline assessment of the echocardiographic recordings in hypertensive outpatients.

Study population: Each observer provided recordings with high-quality echocardiographic windows, stratified by age group (55-64 and 65-75 years old), 6 patients in each stratum, with an equal number of men and women between both strata.

Offline analyses included measurements of systolic and diastolic wall thickness (intraventricular septum and LV posterior wall) and LV dimension.

We measured transmitral early and late diastolic velocities (E and A) by pulsed wave Doppler, and mitral annular velocities (E’ and A’) by tissue Doppler.

To quantify intra-observer variability, each observer read the recordings twice. To assess inter-observer variability, each observed read 6 recordings of two other observers. The total number of read-outs was therefore 108 in the UPRIGHT-HTM patients.

Statistical analysis: We will assess the agreement between paired measurements by Bland and Altman’s method. Reproducibility is twice the SD of the pairwise differences between repeat measurements, expressed as a percentage of the average of all first and repeat measurements. To enable comparison with the literature, we will also compute the intra- class correlation coefficient (ICC) between repeat measurements and the interclass correlation between observers. We will evaluate sex, age, mean arterial pressure, smoking, serum total cholesterol, and plasma glucose as possible covariates of the echocardiographic traits in adults.

The reproducibility study, once its protocol is proved feasible in one center, will be repeated across other UPRIGHT-HTM centres.

INTRA- AND INTER-OBSERVER REPRODUCIBILITY OF THE ECHOCARDIOGRAPHIC DATA OF THE NIGERIAN UPRIGHT-HTM TRIAL PARTICIPANTS

Godsent C. Isiguzo1, Samuel E. Antia1, Collins N. Ugwu1, Chidiebere V. Ugwueze2, Babangida S. Chori3, De-Wei An4, Jan A. Staessen4, Augustin N. Odili3,5

1) Cardiology Division, Internal Medicine Department Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State, Nigeria 2) Endocrinology Division, Internal Medicine Department Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State, Nigeria 3) Circulatory Health Research Laboratory, College of Health Sciences, University of Abuja, Abuja, Nigeria 4) Non-Profit Research Association Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium 5) Margaret Lawrence University Galilee, Delta State, Nigeria

Background: Echocardiography is the most non-invasive, readily available low-cost cardiology imaging modality; however, issues of validity and repeatability limit its use in epidemiological studies. In the UPRIGHT- HTM trial, the need to ensure methodological rigor in echocardiography data has informed this study to evaluate the reproducibility and repeatability of the acquired images.

Methods: Ten patients were randomly selected from the 131 participants already recruited, and in 10-year bands (10 × 2×2=40), two independent accessors conducted repeat 2D echocardiography, Tissue Doppler, and speckle tracking studies, blinded to each other’s findings. The acquired images were analyzed offline. Four modalities of coefficient of variation (COV), Inter-class correlation coefficient (ICC), Bland-Altman limits of agreement of 95% (BA) and prevalence- and bias-adjusted kappa (PABAK) were used in evaluating the inter- and intra-observer reproducibility and repeatability.

Results: Mean age of the study participants was 59 ± 4 years, males 7(70%) with a mean BMI of 28.9 ± 6 kg/m2. The mean LVM was 197.32 (Observer A) and 184.34 (Observer B), with ICCs of 0.97 and 0.93, respectively. EF had ICCs > 0.9, the mean FS were 35.60% and 31.36%, respectively, and the COVs were 24.99 and 32.48, respectively.

The inter-observer agreement was excellently reliable, with ICC (>0.75) for LVM and EF by Simpson while EF by wall thickness and E/E’ were from 0.70 to 0.90. The BA agreement levels of LVM and EE were 12.97 (-63.50 to 89.44) and -0.45 (-5.20 to 4.30), respectively. Prevalence adjusted bias adjusted kappa coefficient (PABAK) was used to analyze the level of agreement between the two measurements with the almost perfect agreement in LVM, EF (Simp), and E/E (PABAK score of 0.86)

Conclusions: Minimizing inter-observer variability is essential in validating repeated measures such as echocardiography and ensuring quality control. This will allow trained operators to obtain comparable images with reliable estimates for their application in clinical decision-making. In these initial Nigeria UPRIGHT-HTM cohorts, the 2D echocardiography and tissue Doppler measurement showed good reproducibility and repeatability among the assessors. However, more rigor is needed in image acquisition and measurement, with a repeated check as this is encouraged in all recruiting centers.

FACTORS DETERMINING THE OUTCOMES OF PCI WITH ROTABLATION—A PROSPECTIVE STUDY WITH THE USE OF CARDIAC MULTIMODALITY IMAGING AND BIOMARKERS.

Paweł Lis, Katarzyna Stolarz-Skrzypek, Marek Rajzer

First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland

Background: Coronary interventions in heavily calcified lesions present a major challenge due to technical difficulties and possible impaired long- term outcomes. Rotational atherectomy (RA) is a commonly used lesion- preparation technique to facilitate percutaneous coronary interventions in this group of patients.

Aim: The planned study is going to investigate the usefulness and potential prognostic value of echocardiographic global longitudinal strain (GLS) and myocardial work (MW) parameters as well as their association with cardiac magnetic resonance (CMR) in stable coronary syndrome patients with heavily calcified lesions, undergoing RA.

Methods: The study population will include consecutive patients undergoing percutaneous coronary intervention with RA in University Hospital in Krakow, with the goal number of over 60 patients recruited. Among study procedures, the standard clinical parameters at the baseline (including age, sex, and comorbidities among others) will be assessed. In addition, a procedural parameter will be evaluated – intravascular ultrasonography (IVUS) calcium score (according to Zhang et al.). The systolic function of the left ventricle assessed at the baseline (before RA procedure) and during short-term (1 month after discharge) and long-term (12 months after discharge) follow-up will be analyzed with echocardiography and cardiac magnetic resonance imaging. Echocardiographic parameters will include ejection fraction, global longitudinal strain (GLS) and an emerging parameter - MW derived from pressure-strain loops. The occurrence of major adverse cardiovascular events (cardiovascular death and unplanned coronary revascularization) will be assessed during follow-up.

Multivariate regression analysis will be applied to assess the associations between clinical, echocardiographic and CMR parameters. Outcome data will be analyzed using Kaplan-Meier survival functions and linear and Cox regression.

EPIDEMIOLOGY OF BLOOD PRESSURE AND OT