hidden

Hypertension and Stroke: Current State of Evidence

Stroke is the fifth leading cause of death in the country and the top reason for adult disability (1). Each year about 795,000 people experience a stroke in the United States with nearly 25% of these strokes being recurrent events in people with a prior history of a stroke (2).  Hypertension is the considered to be the most important modifiable risk factor for stroke. Therefore, treatment of hypertension is one of the most effective strategies for primary and secondary prevention of stroke (3). In a large meta-analysis from 2002, which included 1 million patients, a direct association was seen between blood pressure measurements and risk of vascular mortality including stroke and ischemic heart disease (4). There is a continuous relationship with risk throughout the normal range of blood pressure, down at least as far as 115/75 mm Hg according to this meta-analysis of 61 prospective clinical studies. However, there has been a lack of consensus among experts about the most appropriate blood pressure targets for cardiovascular disease and stroke prevention.

In the Secondary Prevention of Small Subcortical Strokes (SPS-3) trial, investigators compared systolic blood pressure targets of 130-149 mm Hg and less than 130 mm Hg (5). About 3000 patients with a recent history of an MRI confirmed lacunar stroke were randomized to one of the two treatment groups and followed for a mean of 3.7 years. Primary outcome of recurrent stroke was seen at a lower rate in the lower target group with an annualized stroke rate of 2.25% as compared to 2.77% in the higher target group. Despite a signal toward benefit of a lower BP target, these results did not reach statistical significance. The rates of intracerebral hemorrhage were noted to be significantly lower with a lower BP target.

In a clinical trial enrolling patients with diabetes and a high cardiovascular risk, blood pressure target of less than 120 mm Hg was not superior to a target of less than 140 mm Hg for reducing risk of cardiovascular events with the exception of stroke (6). In this study, the intensive blood pressure target lead to a significant risk reduction for stroke but not for myocardial infarction or all-cause mortality.

To further ascertain an ideal blood pressure target, investigators in the SPRINT trial enrolled over 9000 persons with SBP of more than 129 mm Hg without a history of diabetes (7). The participants were randomized to intensive treatment (target <120 mm Hg) or standard treatment groups (target <140 mm Hg). Primary outcome was a composite of myocardial infarction, heart failure, stroke or vascular death. After a median follow up of 3.3 years, the trial was stopped early due to a significantly lower rate of primary composite outcome in the intensive blood pressure group as compared to the standard treatment. Interestingly, even though there was a signal of benefit for stroke risk reduction, this was not statistically significant. The investigators of the study make note of this finding and hypothesize that this could be due to the fact that this trial excluded patients with a prior history of stroke and TIA. This has also raised questions about the limited applicability of these results to patients with a history of stroke.

The investigators also looked at cognitive outcomes for the two groups of patients in this trial (8). The composite outcome of mild cognitive impairment and dementia was seen in a significantly lower number of patients in the intensive BP treatment group as compared to the standard treatment group. Due to the early termination of SPRINT, the study was underpowered to show a significant difference in the risk of dementia.

The current guidelines (9) from the American Heart Association/ American College of Cardiology recommend initiating treatment at SBP>130 mm Hg for patients with a high cardiovascular risk. Using the current definition of hypertension, it is estimated that 46% of adults in the US have hypertension and about 36% should be prescribed antihypertensive medications (10). Applying these new guidelines, only about half of all US adults on medications for hypertension are currently below the target BP numbers.

With hypertension playing such an important role in the development of the two most common neurological illnesses (Stroke and cognitive disorders), authors of a recent paper in JAMA Neurology (11) urge neurologists to play a greater role in treatment of hypertension as a preventive strategy for their patients. Traditionally stroke neurologists and neurointensivists have been involved in treatment of the cardiovascular risk factors including hypertension but most of that is done after the patient has had a major event such as an ischemic stroke or intracerebral hemorrhage. The authors argue that neurologists should participate in treatment of hypertension for their patients as a primary preventive strategy as it would lead to an overall improved brain health of our ageing population.

To learn more about the latest advancements in the field of hypertension research, I encourage the readers to attend Hypertension 2019 Scientific Sessions being held in New Orleans September 5-8, 2019.

 

References:

  1. Vital Signs: Recent trends in stroke death rates – United States, 2000-2015. MMWR 2017;66.
  2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135:e229-e445.
  3. Katsanos AH, Filippatou A, Manios E, et al. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension. 2017;69(1):171-179.
  4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies Lancet. 2002;360(9349):1903-1913.
  5. Benavente OR, Coffey CS, Conwit R, et al; SPS3 Study Group. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013;382(9891):507-515.
  6. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-1585
  7. Wright JT  Jr, Williamson  JD, Whelton  PK,  et al; SPRINT Research Group.  A randomized trial of intensive versus standard blood-pressure control  [published correction appears in N Engl J Med. 2017;377(25):2506].  N Engl J Med. 2015;373(22):2103-2116.
  8. Williamson JD, Pajewski NM, Auchus AP, et al; SPRINT MIND Investigators for the SPRINT Research Group. Effect of intensive vs standard blood pressure control on probable dementia: a randomized clinical trial.JAMA. 2019;321(6):553- 561
  9. Whelton PK, Carey RM, Aronow WS, et al.
  10. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
  11. Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2018;137(2): 109-118.
  12. Betjemann J, Hemphill JC, Sarkar U. Time for Neurologists to Drop the Reflex Hammer on Hypertension. JAMA Neurol.Published online August 19, 2019. doi:10.1001/jamaneurol.2019.2588
hidden

Managing High Blood Pressure by Managing Stress

manage stressWe are faced with a number of changes in our lives. The old saying, “life happens” generally means take the changes as they come and keep it moving. The human body is not equipped to distinguish between distress and eustress. Amazing life changes happens such as getting acknowledged for an accomplishment, passing the preliminary exams for a PhD program, getting the job of your dreams, or even getting the funding you have worked so hard to apply for consideration. Contrarily, changes that can be viewed as less than optimal such as being passed over for a promotion, losing the sole source of your family’s income, death of dreams, and rejection are all sources of stress. Good or bad, these events affect hypertensive rates potentially leading to a more serious chronic illness such as heart attacks, strokes, or even metabolic disease.

Often people, especially scientist and clinicians think their stress is just a way of life and there is nothing that can be done about that constant state. Scientist are always on the hunt for research funding and publishing; while clinicians holds the consequences of a person’s life in each of their decisions. These are significant burdens for a person to hold. It is imperative to manage stress as a means of preventing and treating high blood pressure. It is definitely easier said than done, but attempting these steps to control stress could lead to a better life:

  • Sleep quality and quantity can make a huge difference in managing mental alertness and energy but sleep allows the body time to relax and heal. Quality sleep can aid in the reduction of blood pressure leading to vascular repair.
  • Reiki principles that include meditation enhances muscle and mental relaxation. This include activities such as guided imagery, deep breathing, and massage therapy to act as stress-relievers.
  • Strengthen your social network. Connect with others by taking a class, joining an organization, or participating in a support group.
  • Try to resolve negative situations quickly so they do not fester. It is best to let go of adverse events and interactions; whether it is something that is in or out of your control
  • Don’t be afraid to ask for help from a counselor. Although there is a negative stigma surrounding seeing a therapist they are the best resource for dealing with stressful situations because your spouse, friends, and neighbors generally have as much going on as you and their opinions can be clouded by their own experiences.

I recently started working with a mentor to help with stress and how to interact with individuals to manage stress. As the young adults say, “I like to keep it 100” but often being brutally honest is not received well by the masses. I also made the determination that whether working or interacting on a personal level, I will not extend myself beyond my comfort zone nor will I compromise my values or ethics to fit into anyone’s idea of what I should be doing. Staying true to oneself is among the first steps to happiness and managing blood pressure. I have found that when I over extend myself, my stress level increases and my performance decrease in some areas (namely self care). My life, your life, is not worth negativity. Being that stress is inevitable, I choose the eustress. It is my opinion that this type of stress leads to self happiness and the contribution of the happiness of others.

Thank you for reading this blog. If you would like to share some of your methods for dealing with stress or how you keep your life stress limited, let me know comment or tweet @AnberithaT so we can share ideas.

 

hidden

Let’s Talk About Race and Stroke Recurrence

There has been a growing body of evidence pointing to potential differences in outcomes of stroke based on race/ethnicity. Recent investigations by Hao et al1, presented at the ISC 19, examined ethnic variation in stroke recurrence, from the angle of intracranial atherosclerotic stenosis [ICAS]. ICAS is estimated to be the underlying pathology in about 15% of ischemic stroke patients2, and is associated with high risk of stroke recurrence even with utmost medical treatment1. The investigators of this study included patients with ICAS in major vessels with >50% stenosis identified on Magnetic resonance angiography or computed tomography angiography. The authors observed higher rate of 3-months as well as long-term recurrence among non-White compared to White patients, although this did not reach statistical significance, possibly due to insufficient power.

Going from ischemic stroke [IS] to intracerebral hemorrhage [ICH], King et al3 assessed recurrence of ICH based on race/ethnicity. They used comprehensive claims data that included hospital discharges in California between 2005-2011. The authors included patients who survived to discharge. Similar to what has been observed in IS, King et al found higher rates of ICH recurrence among Black and Asian compared to White patients.

There are some suggestions on potential explanations on those differences based on the burden of specific clinical conditions by race/ethnicity, such as hypertension4 and chronic kidney disease as reported by Hao et al1. However, this is an area that needs further investigations in representative samples of patients.

 

REFERENCES:

[1] Hao, Qing, et al. “Abstract TP157: Ethnic Difference in Stroke Recurrence for Patients With Intracranial Atherosclerotic Stenosis.” Stroke 50.Suppl_1 (2019): ATP157-ATP157.

[2] Bose, Arani, et al. “A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study.” Stroke 38.5 (2007): 1531-1537.

[3] King, Zachary A., et al. “Abstract WMP97: Racial/Ethnic Disparities in the Risk of Intracerebral Hemorrhage Recurrence.” Stroke 50.Suppl_1 (2019): AWMP97-AWMP97.

[4] Rodriguez-Torres, Axana, et al. “Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals.” Neurology 91.1 (2018): e37-e44.

 

 

hidden

Under Pressure: What Does Retina Say About Hypertension?

An eye oftentimes feels like the most underappreciated systems in the field of vascular biology. An eye is a highly vascular organ then it gets credit for and here’s why – ranging from high blood pressure or diabetes to early signs of stroke, an eye exam can, in fact, tell a physician a lot about one’s health. In a series of blog posts, I decided to highlight these key connections between the eye and the human body. This article will focus on the current knowledge linking eye and hypertension.

 

Hypertension or high blood pressure is predominantly caused due to increased resistance to the walls of the blood vessels. What this leads to is increased chances of developing diseases of the cerebral, cardiovascular or even peripheral arteries. Risk factors can range from dietary habits to genetics and ethnicity, and less than half of those with hypertension are unaware of their condition. Interestingly, the eye offers a very useful set-up to get a closer look at blood vessels – without even having to inject or cut open anything. This non-invasiveness of the eye has been widely used by clinicians and researchers to diagnose diseases of the blood vessels – hypertension being one of them. This article highlights some interesting findings that researchers derived simply by examining the retinal blood vessels.

A fundoscopic photograph of the back of the eye (like seen in the image below), allows to capture the retinal blood vessels. These blood vessels share many physiological and anatomical similarities with vessels in other systems, like the brain and the heart. Naturally, any changes in the structure or integrity of these vessels have been documented and researchers have found many links and associations with the pathology of hypertension5. I previously discussed how the retinal vessels gave a sneak peek into the brain and heart, where dimensions like the diameter or tortuosity were able to indicate early signs of stroke or cardiovascular diseases.

Source: Cheung et al., Hypertension. 2012;60:1094–1103

 

As early as the 1960s, scientists learned that narrowing of retinal arteries were important signs of hypertension. The population-based Rotterdam study published in 2005 looked at individuals in over 55 years of age and were “pre-hypertensive.” Their findings suggested that the narrowing of both retinal arterioles and venules were associated with increased risk of hypertension and preceded development of high blood pressure2. Similarly, the Blue Mountains Eye study in Sydney found that these abnormalities in the retinal vessels predicted a 5-year incidence of severe hypertension in a patient population of older cohort3.

Source: M. Kamran Ikram et al., Hypertension. 2005;47:189–194 

This image of an eye fundus shows a semi-automated system used to measure the diameters of arterioles and venules in the retina.

 

Making use of this unique retinal fundoscopic tool, another group explored measurement of blood flow to the retina, in response to light-flicker in patients with high blood pressure3. They found that hypertensive patients had impaired blood flow in the retina, possibly caused due to prolonged constricted vessels. This approach is among the first to test blood flow to the retinal, instead of measuring the vessel itself – adding another asset to retinal fundus images.

Retinal images have also been used in genetic linkage studies. Large population data sets are analyzed for tracing genes and variations of the genes associated with diseases among different individuals. It is clear that changes in the diameter of retinal vessels can precede hypertension, but are there genetic predeterminants to an individual’s retinal diameters? In 2006, the Beaver Dam Study found that apart from genetic linkages found between retinal diameters and hypertension and other associated diseases, there are genetic factors that predetermine the retinal diameters – independent of hypertension4.

This simply means that there are other factors present in our systems that are genetically related to the structure and size of one’s retinal vessels. Interestingly, another research group looked retinal vessels of 6-year-old students with hypertensive parents6. They found that only the girls (not boys) had narrowing retinal vessels and were predisposed to developing hypertension later in life. This also suggests a genetic link between retinal vessels and blood pressure.

Researchers around the world have used retinal parameters as indicators of hypertension. Evidently, retinal imaging provides for a powerful tool in identifying markers of cardiovascular complications. However, this still remains a tool widely used only among researchers, and validation of retinal imaging for clinical use still remains to be seen. With emerging advanced technology, clinicians should consider a non-invasive method like this one as a diagnostic tool.

 

References:

  1. M. Kamran Ikram et al., Retinal Vessel Diameters and Risk of Hypertension. Hypertension. 2005;47:189–194
  2. Smith et al., Retinal Arteriolar Narrowing Is Associated With 5-Year Incident Severe Hypertension. Hypertension. 2004;44:442–447
  3. Ritt et al., Impaired Increase of Retinal Capillary Blood Flow to Flicker Light Exposure in Arterial Hypertension. Hypertension. 2012;60:871–876.
  4. Xing et al., Genome-Wide Linkage Study of Retinal Vessel Diameters in the Beaver Dam Eye Study. Hypertension. 2006;47:797–802
  5. Cheung et al., Retinal Microvasculature as a Model to Study the Manifestations of Hypertension. Hypertension. 2012;60:1094–1103.
  6. Gopinath et al., Parental History of Hypertension Is Associated With Narrower Retinal Arteriolar Caliber in Young Girls. Hypertension. 2011;58:425–430.
hidden

What’s Happening Here At The International Stroke Conference in Hawaii?

Getting to Hawaii was quite the event! I underestimated the flight and how I would feel with such time zone changes. However, the International Stroke Conference 2019 (#ISC19) was worth all the efforts. The meeting objectives were sufficiently described in the program book and my previous blog. As promised, there were sessions to equip scientists and clinicians with tools in diagnosis, treatment, prevention, management, and rehabilitation of cerebrovascular disease as well as nursing. The sessions that I was able to partake in were the following:

  1. Clinical Rehabilitation and Recovery Oral – I spent the first part of the morning here learning about the biomarkers to improve stroke rehabilitation covered in the clinical trial data and predictors of post stroke depression using qualitative data in patient after ischemic stroke. Although these presentations were informative, I had my eye set on other topics as well, so I had to leave the session a tad early.
  2. Medical therapy for Symptomatic Carotid Stenosis: Time for Modern Data – Seemant Chaturvedi, MD shared his research on ‘Genetic Guidance for Antiplatelet Therapy’ followed by Brian Hoh, MD discussing the answers he found to the question ‘Do HTN Targets Matter?’ Studies presented here show there is a link between hypertension and changes in white matter in the brain that affect cognitive functions. Dr. Bath expounded on his recent article in Stroke (2018) sharing mechanisms of how this damage could potentially occur.
  3. Looking into the Brain Through the Eye: Re-examining the Retina as a Surrogate Marker for Cognitive Disorders – There is growing evidence that the dental and optical examinations can be a window into health. I previously blogged about the bacteria found in the mouth is also identified in atherosclerotic plaques. In this session, clinicians/scientist looked at the retina as a window to the brain and subsequently health. These sessions suggested the retina can assist in the post-mortem prediction of Alzheimer’s disease and stroke based on the linear relationship between number of plaques in the retina and the brain. Current research tools are extremely invasive thus predictions are not feasible in living patients. The tools described here included Optical Coherence Tomography (OCT, not to be confused with over-the-counter) as a diagnostic tool, adding to repertoire of skills to increase the ability to interpret cognitive impairment.

I am looking forward to the information presented on tomorrow. I will give more insights into what I think is the highlights of the meet in my next blog. Keep following me on Twitter @AnberithaT and be sure to ask any question that may be answered during the ISC19 or after.

 

hidden

Joint Hypertension 2018 Scientific Sessions – You Should Have Been There

hypertension 2018

Just as promised, the Joint Hypertension 2018 Scientific Sessions (Hypertension18) was indeed among the most impactful meetings one could have attended. Council on Hypertension Scientific Sessions Planning Committee Vice Chair Dr. Karen Griffin, FAHA was accurate in her statement that it would be “the premier scientific meeting.” There were experts from all parts of the world covering more cardiovascular topics that I think my fingers could not keep up with in note taking, and each session was more informative than the next with up-to-date information on hypertension.

During the President’s Welcome Address, Dr. Ivor Benjamin, FAHA foreshadowed what was to be expected during the meeting. He gave general overviews of the hypertension guidelines, what the changes mean to clinicians and researchers, as well as the role AHA will play in helping drive those changes forward. His welcome was a great introduction to the ‘Recent Advances in Hypertension’ Session chaired by Drs. Joey Granger from the University of Mississippi Medical Center and John Bisognano from University of Rochester Medical Center. This session covered the new guidelines, implementation, and basic research advances of clinical hypertension moving forward by Drs Basile, Egan, Oparil, and Ellison. The whirlwind of information was just the icebreaker! During the refreshment break and exhibits, I met a number of “Rockstars” including clinicians and researchers from University of Alabama Birmingham, Drs. David and Jennifer Pollock and AHA Early Career blogger Tanja Dudenbostel. Additionally, this was the only time I spent visiting with vendors. Among them, Hulu explained the importance of calibrating automatic blood pressure machines. Historically blood pressure was taken with a manual sphygmomanometer and a technician listening for ausculatory sounds via a stethoscope, but now it is all automated. Generally one machine is used for all patients. This technology forces us to question the accuracy of the readings of the machines. Are they calibrated? Should the BP be taken radially or at the wrist? Should the machine be changed throughout the day? There was Aegis representatives sharing information about products to assist medical professionals determine patient compliance to therapy and toxicology testing equipment. During these conversations, it was surprising to discover some of the rationales behind why people would opt to not take medicine as prescribed.

With my research being focused on oxidative stress-induced vascular injury and since I have become increasingly more interested in health and wellness, I took particular interest in the session focused on “Lifestyle Modifications and Impact on BP” chaired by the Associate Editor of Hypertension, David Harrison, MD, FACC, FAHA, “Recent Advances Obesity and Cardiovascular Disease” chaired by the consulting Editor of Hypertension Suzann Oparil, MD, FAHA, and “Obesity, Diabetes, and Metabolic Syndrome” chaired by Drs. Kamal Rahmouni and Carmen De Miguel. During these sessions, it was not surprising that regular exercise reduced vascular stiffness, but what was noteworthy was that weight training contributes to atherosclerosis. Additionally, the sympathetic nervous system seems to be important in glomerular filtration. Dr. Elizabeth Lambert delivered an intriguing talk about how diet and exercise can significantly decrease metabolic syndrome in middle aged obese individuals, which is consistent with a recent study (Hypertension18 Meeting Report P388) that suggests lifestyle changes can reduce hypertension in both men and women. Further, the study suggests that following the DASH diet, exercising, and weight management over a course of 16 weeks were contributing factors in reducing BP in test subjects. We all know anti-hypertensives work in reducing BP. Lifestyle changes should be the first line of defense in evading hypertension and getting it under control at the onset, according to the American Heart Association/American College of Cardiology  Hypertension Guidelines. We have all heard that we have to get out there and get moving. Choosing the right exercise is just as important as exercising, according to Dr. Tanaka.

I recently wrote a blog discussing metabolic syndrome and therein indicated there is not a direct correlation between obesity and diet. During this conference, Dr. John Hall lectured on the recent advances in CVD and obesity. He suggested that epigenetic transmission of obesity in humans (and others) is associated with increased adiposity and insulin resistance, depletion of nuclear protein, influence chromatin conformation, and altered germ cell methylation and gamete micro RNA.

The new concurrent session Clinical Practice Clinical Science and Primary Care tracks did not go unnoticed. Although I did not get to attend many of these sessions, I did pass them to see that they were well attended. I did attend some of the lunch meetings and they were very insightful. Please refer to my Twitter to see my detailed notes. As mentioned in my pre-conference blog, with all the sessions that were available one should not have had an issue meeting the goals outlined in the program by coordinators (infra vide). Several sessions that met the interest of all researchers/clinicians, early career, and everyone in between. Not a person that attended Hypertension18 could say they could not find a learning opportunity at the Joint Hypertension 2018 Scientific Sessions! Even if one was merely a passerby, there was a session relevant to them. For example, I was on my way to get coffee when I encountered Drs. Yagna Jarajapu from North Dakota State University and Daniel Batlle from University of Chicago discussing research concerning STZ diabetic Foxn1 mice that were ischemic for several days. Subsequently, Eric Metterhausen shared his mission of services (MOS, for you military people) with me as we conversed about field medicine with the United States Public Health Services (USPHS). I did know our US Armed Forces had research officers and divisions of research, but the amount of detail that Major Metterhausen described was a beast that I had not known. Conversations such as these lead to increased mentoring relationship, as well as potential collaborations in research and grant proposals. We all go to conferences to learn, to purchase new research equipment, and to present our data, but we also should not forget to network and build relationships.

Conference Learning Objectives:

  • Discuss changes to the AHA/ACC guidelines for the management of hypertension and their clinical implications.
  • Describe opportunities to improve blood pressure measurement in the clinical setting to provide more accurate results.
  • Identify immune and inflammatory mechanisms that contribute to the development of hypertension and hypertension-related end-organ damage and discuss the research and clinical implications.
  • Educate participants about medical approaches for the management of comorbid obesity in patients with hypertension.

 

  • Describe participants on the impact of value-based reimbursement on hypertension management and identify opportunities to improve its management.

 

See you all in Chicago at Scientific Sessions 2018!!!

  • Leave a comment and follow me on Twitter @AnberithaT and @AHAMeetings if you have questions or are interested in something else specifically.

 

Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.

hidden

What to expect at Joint Hypertension 2018 Scientific Sessions – Treating Hypertension in 2018

Two AHA Councils, the Council on HAHA|ASH Hypertension Scientific Sessions 2018ypertension and the Council on Kidney in Cardiovascular Disease, have joined forces with the American Society of Hypertension to make Joint Hyptertension 2018 Scientific Sessions (#Hypertension18) among the most impactful. Dr. Karen Griffin, FAHA Vice Chair for the Council on Hypertension Scientific Sessions Planning Committee calls it the “premier scientific meeting on hypertension in the world”. Understandably so; it boast experts from areas of cardiorenal disease, cardiovascular disease, stroke, and genetics to make for a vast cross-disciplianry session with the up-to-date information on hypertension. This year’s meeting received 439 abstracts in 37 categories, over 125 expert peer reviewers, and more than 20 countries represented.

There will be several interactive sessions that will target the established researcher/clinician, early career, and everything in between. With the addition of the new concurrent session D-Track, Clinical Practice Clinical Science and Primary Care tracks, a dimension will be added for elucidate the research science/clinical practice as it relates to patient care. In light of all the sessions that are available one should not have a problem reaching the milestones set by the program coordinators (infra vide).

To point out a few conference highlights, there will be 24 oral sessions, 3 poster sessions, and travel award talks:

The Excellence Award for Hypertension Research (Saturday, September 8, 2018)

  • R. Clinton Webb, PhD, FAHA presents “A Study of the Innate Immune Response in Hypertension”
  • Paul K. Whelton, MB, MD, MSc, FAHA presents “Clinical Trials and Practice Guidelines: Evidence-Based Progress in Lowering Blood Pressure”

Conference Awards

  • 10 Council on Hypertension New Investigator Travel Awards
  • 10 Council on Kidney in Cardiovascular Disease New Investigator Awards
  • 4 New Investigator Travel Awards
  • 6 Hypertension Early Career Oral Award Finalists
  • 12 AFHRE Travel Award for Patient-Oriented or Clinical Research in Hypertension
  • 1 Clinical Science Investigator Award for Excellence in Translational or Clinical Hypertension Research
  • 3 New Investigator Awards for Japanese Fellows

25 Poster Presenters can potentially win the competition this year! Which has gone up significantly from the previous years.

I am excited to go to Chicago for #Hypertension18 this year. If there is anything you need to enhance your experience during your time at the conference contact the program officials (directions in the program book).

I look forward to meeting you all! If you see me around tweeting, introduce yourself. I love meeting new people and learning new things. After all, that is why we are all going, right? 🙂

#Hypertension18 Conference Learning Objectives:

  1. Discuss changes to the AHA/ACC guidelines for the management of hypertension and their clinical implications.
  2. Describe opportunities to improve blood pressure measurement in the clinical setting to provide more accurate results.
  3. Identify immune and inflammatory mechanisms that contribute to the development of hypertension and hypertension-related end-organ damage and discuss the research and clinical implications.
  4. Educate participants about medical approaches for the management of co-morbid obesity in patients with hypertension.
  5. Describe new and emerging strategies for treating resistant hypertension.
  6. Describe participants on the impact of value-based reimbursement on hypertension management and identify opportunities to improve its management.

 

Leave a comment or tweet @AnberithaT and @AHAMeetings if you have questions or are interested in something else specifically.

Follow me and @American_Heart @AHA_Research @AHAScience and @HyperAHA on twitter for more #HeartSmart information.

For meeting Tweets follow @AHAMeetings @HyperAHA @AHAScience #JAHAMeetingReports @JAHA_AHA for the latest on#Hypertension18!

hidden

Clinical Significance of Sigmoid Shaped Interventricular Septum

A sigmoid-shaped interventricular septum (SIS) is generally considered a normal part of the aging process and is of little clinical significance. However, certain patients with SIS may experience clinical symptoms, such as dyspnea upon effort and different types of cardiac arrhythmias. SIS is frequently observed on transthoracic echocardiography (TTE) and in cardiac magnetic resonance (MR) imaging modality in daily clinical practice. However, nothing usually occurs in subjects with SIS, and the clinical significance of the presence of SIS is unclear.

The precise mechanisms leading to isolated SIS have yet to be determined, but plausible reasons exist as to why the basal septum might be uniquely susceptible to hypertrophy. For example, Laplace’s law states that the larger a vessel’s radius, the larger the wall tension required to withstand internal fluid pressures. Because the longitudinal fibers of the basal septum have some of the largest radii in the human heart, they would be expected to experience the greatest inward component of wall stress. This is compounded by the fact that the basal septum is the last part of the ventricle to be electrically activated, so contractions from other myocardial segments further increase its wall stress (Fig. 1). Moreover, the additional load created by pressure from the right ventricle exerts additional stress on the septum. Therefore, it is conceivable that the basal septum hypertrophies earlier than other LV regions in response to increased afterload as it already operates under higher loading conditions.

Clinical Significance of Sigmoid Shaped Interventricular Septum

Prospective studies suggest that up to 20% of cardiovascular cohorts may have isolated SIS. Some researchers have reported that the cause of SIS may be aging or arteriosclerosis. This may involve a change in the spatial relationship between ascending aorta (AA) and left ventricle (LV) due to elongation or tortuosity of arteriosclerotic AA. An alternative hypothesis suggests that SIS may be a form of cardiomyopathy. However, there is no evidence to support such a hypothesis due to the limited capabilities of traditional TTE. Use of other diagnostic approaches like CMR may be needed where characteristics of LV myocardium and the spatial relationship between AA and LV and degree of arteriosclerosis of AA can be evaluated simultaneously.

It is known that LV hypertrophy with different remodeling patterns is one of the major cardiac manifestations of hypertensive heart disease, and echocardiographic LV hypertrophy could be detected in 20-40% of patients with arterial hypertension. However, there are often no specific echocardiographic features for hypertensive patients at the early stage of disease. Previous echocardiographic studies have described asymmetric septal hypertrophy with a localized septal thickening at the basal-mid portion in patients with hypertrophic cardiomyopathy or aortic valve stenosis.

Basal-septal hypertrophy may also occur in a subset of older normal subjects, with normal wall thickness (WT) elsewhere, and is considered to be an age-related anatomic variant. This morphologic echocardiographic sign is termed as septal bulge (SB), sigmoid septum, or discrete upper septal thickening or knuckle. A large community-based population study reported that SB was documented frequently in elderly individuals with higher systolic blood pressure (BP). It was shown that the overall prevalence of SB was 1.5% and was markedly higher (18%) in the eighth decades of life.

Although pathologic and echocardiographic observations have indicated that SB is a structural response in hypertensive patients, the nature and significance of the SB in subclinical arterial hypertension was never investigated. In addition, despite the fact that BP can be easily measured, AH sometimes cannot be diagnosed due to the underreported BP reading in the casual or self-measured BP measurement. BP measurement with appropriate tools is essential to diagnosing AH early as well as to guiding AH management. It has been shown that, besides resting BP measurement in the office, arterial hypertension could be clinically diagnosed by 24-hour ambulatory BP monitoring (ABPM) as well as exercise stress test in some resting normotensive individuals.

Focal hypertrophy of the basal inter-ventricular septum can be seen in up to 20% of cardiac patients without HCM, being more prevalent in the elderly and hypertensives. While it’s anatomical location plausibly renders it more susceptible to hypertrophy, evidence suggests that the basal septum enlarges mainly due to pressure overload from hypertension. This discrete upper septal hypertrophy is associated with exertional LVOT obstruction and SOB, and appears symptomatically amenable to β -blockade. While diastolic dysfunction likely also contributes to symptoms in this condition, the data to date are equivocal. Focused analyses conducted using a consensus definition of SB, in patients undergoing simultaneous assessment of myocardial systolic and diastolic performance during physiological exercise, are needed to further understand the clinical relevance of this entity.

 

Fawaz Alenezi Headshot

Dr. Fawaz Abdulaziz M Alenezi is a Clinical Imaging Fellow at the Duke University Health Systems. He conducts medical research on the derivation and validation of novel echocardiographic approaches to myocardial deformation and a new echocardiographic technique which assists patients with heart ventricular function.

hidden

How the Immune System Favors Females in Pulmonary Artery Hypertension? Another Regulatory T Cell Story.

While it is commonly thought that cardiovascular disease is a man’s disease, CVD is the number one killer of women with the same number of deaths per year as cancer, diabetes and respiratory disease combined (according to 2015 statistical data from AHA). In addition, women exhibit different and more silent symptoms of heart attacks. There is a lot of interest in the difference between how males and females respond to CVD. A lot of emphasis is put on hormonal differences, but the immune system also seems to play an important role in this disparity. Females have a more robust immune system and therefore respond faster to infections providing more protection than in males. However, a more responsive immune system also means a more reactive immune system that can result in increased incidence of autoimmune diseases, such as rheumatoid arthritis and lupus.

Part of the difference in the immune system response in females can be attributed to the fact that multiple immune-related genes are expressed on the X chromosome. Since females have two alleles of the X chromosomes and males have only one, it is evident that females express more genes that regulate immune system functions. One of these genes is Foxp3, the key transcription factor for regulatory T cells, an adaptive immune cell which I have discussed before in a previous post. Regulatory T cells play an important protective role in CVD, especially in atherosclerosis and hypertension.

Pulmonary artery hypertension (PAH) is a fatal cardio-pulmonary disorder where the pulmonary arterioles narrow leading to a right ventricular fibrosis, heart failure and death. Regulatory T cells play an important role in this disease as animal models that lack regulatory T cells are more susceptible to PAH. Adding regulatory T cells back prevents the development of PAH showing the protective power of these cells. A recent study published in the journal Circulation Research, shows that in the absence of regulatory T cells, females rats are more prone to PAH than male animals due to a lower levels of PGI2, a pulmonary vasodilator, and the lack of the enzyme COX-2 that regulated PGI2. The researchers conducting the study show that by transferring regulatory T cells into these rats, these immune cells were sufficient to restore the levels of COX-2 and PGI2, as well as other immune inhibitory molecules PDL1 and IL-10. The authors suggest that regulatory T cells have both a direct and indirect effects on the arteries. The direct effects are exerted on the endothelial cells directly via COX-2 and PGI2, and the indirect effect is through the release of inhibitory molecules such as IL-10 and TGF, both of which would result in immune suppression and preventing inflammation. The results from this report suggested that females are more reliant on regulatory T cells for protection against PAH.

These new findings highlight the subtlety of immune regulation between females and males and further proves that in addition to hormonal differences, immune regulation disparities between genders that can alter the outcome of cardiovascular diseases. By understanding more about gender differences in CVD and the immune system, and figuring out ways to manipulate these subtle differences, scientists hope to achieve a more personalized and effective therapies to women versus men to combat CVD.

 

Dalia Gaddis Headshot

Dalia Gaddis is a postdoctoral fellow at the La Jolla Institute for Allergy and Immunology. She has a Ph.D. in microbiology and immunology. She is currently working on understanding the interactions between the immune system and atherosclerosis development

 

hidden

Post-Call Hypertension – Physician Health in High Stress Specialties

Should we be getting hazard pay for taking in-house call?  As awareness of physician wellness topics (most buzzworthy: #burnout) is growing, it’s important to realize that we, as physicians, are human and have all the requisite needs for health, wellness, rest, and routine as our patients do. 

A few weeks ago, I had a routine doctor’s appointment for myself, which I had scheduled on a post-call morning (when else do we have time to take care of ourselves?).  As she took my blood pressure and repeated it twice, the MA seemed flustered.  I’ve been quite healthy my whole life and had never had an issue with hypertension.  Of course, the new AHA hypertension guidelines do put me closer to the at-risk group, but I’ve still been well below the cutoffs and I’m (relatively) young.  My systolic during this visit was above 140.  Admittedly, I had just had a Venti coffee and a Monster energy drink in the waning hours of the call night, but this was very unusual for me. 

Of course, I had it rechecked when I wasn’t full of caffeine and low on sleep and the values were back in the normal range.  However, when I mentioned this encounter to some of my more experienced colleagues, they were not surprised.  Apparently, there is a silent epidemic of hypertension and diabetes plaguing otherwise healthy cardiac intensivists that begins in the early-mid-career range.  Colleagues and colleagues of colleagues have all been touched by this phenomenon, but I can’t find much of anything about how to address this in the literature. 

There are several recent studies linking shift work with hypertension.  And it makes sense that the chronic stress of frequently being in a hospital for 12-24 hours continuously with a phone/pager that could go off with a disaster or emergency at any second may begin to take its toll on your arteries in mid-life.  But there are not really any great solutions at this point.  We need to be around to take care of our patients.  In the era of increasing in-house attending physician coverage in cardiac ICU’s, this is only likely to get worse. 

The common sense bullet points seem to be the focus of many of the anti-burnout physician wellness programs: good nutrition, adequate/regular exercise, sleep/rest, resilience, and self-care behaviors.  However, I think another important aspect is prevention.  Any of us beginning our careers in these high-stress shift-work specialties should be proactive in reducing our cardiovascular risk as much as possible and as early as possible.  And we should be active participants in seeing our own physicians so they can screen for these issues; better patients are better doctors.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.