Hypertension Control: J-Curve Revisited

Over the last three decades there is an increasing number of investigators and meta-analyses focusing on the dangers of lowering blood pressure below certain levels. Several studies such as Invest, Ontarget, Value and TNT showed a significant decrease in cardiovascular morbidity and mortality by lowering blood pressure levels. However, blood pressure decrease below a certain level had exactly the opposite effect. The increase of cardiovascular morbidity and mortality was attributed to the excessive reductions in blood pressure which may explain why in major clinical trials blood pressure below certain levels increases cardiovascular adverse events mainly in patients with coronary heart disease. In these patients a fall in diastolic blood pressure might lower perfusion pressure distal to a stenosis below a critical level at which autoregulation is effective.  This phenomenon led the European Society of Hypertension to propose a "J-shaped curve" relationship between blood pressure and cardiac morbidity and mortality, whereby lowering blood pressure below a critical point is no longer beneficial and possibly even deleterious. The challenge is to better define the limits of intervention and to define groups of people who are particularly vulnerable to over-aggressive lowering of blood pressure

Electrocardiographic Changes in a Patient With Pulmonary Embolism and Septic Shock

Various electrocardiography (ECG) abnormalities have been reported in patients who present with pulmonary embolism (PE). Severe sepsis is also associated with ECG changes that may mimic ST elevation myocardial infarction. We report a case of an elderly patient with PE and septic shock associated with striking ECG changes

The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment

[Case Report] Stress induced (Takotsubo) cardiomyopathy triggered by the COVID-19 pandemic.

Stress induced (Takotsubo) cardiomyopathy (TC) represents an acute heart failure syndrome triggered by physical or emotional stressors. COVID-19 pandemic has caused an unprecedented health crisis resulting in fear, distress and anxiety, with emerging cardiovascular implications. COVID-19 related stress can act as potential trigger for TC. We present a case of an elderly female who developed TC due to stress surrounding COVID-19

The effect of B-blocker therapy on NT pro BNP plasma levels in patients with heart failure

Background: NT pro BNP is a sensitive marker of LV function in patients with heart failure. Β-blocker therapy has been established as a powerful strategy to reverse remodeling and improve systolic function in HF. Aim: The aim of the study was to analyse the influence of carvedilol on NT pro BNP plasma levels in HF patients as well as the use of NT pro BNP for the prediction of low functional class patients and also their possible superiority at peak exercise over resting levels. Methods: We prospectively followed up 100 patients (81 men and 19 women) with impaired left ventricular function. Mean age was 59±13 years. All patients were in clinically stable condition for at least 6 weeks before study and show no signs of acute cardiac decompensation. Results: NT pro BNP plasma levels correlate both with LVEF and aerobic capacity can predict low functional class patients, in accordance with other studies, this investigation has confirmed the increase of NT pro BNP plasma levels with the increased of the severity of HF. We found that NT pro BNP plasma levels significantly increased at peak exercise of NT pro BNP compared with baseline levels with cardiopulmonary exercise indices or echo indices of left ventricular function. The results of the current study indicate that carvedilol seems to affect NT pro BNP plasma levels a) indirectly through an improvement in LV function and a decrease of NT pro BNP levels and b) directly by a drug induced down-regulation of natriuretic peptide-clearance receptor (NPRC) with an increase of NT pro BNP plasma levels.Εισαγωγή: Το NT pro BNP, είναι ένας ισχυρός δείκτης λειτουργικότητας της αριστερής κοιλίας σε ασθενείς με καρδιακή ανεπάρκεια. Η θεραπεία με β-αναστολέα έχει καθιερωθεί ως ισχυρή στρατηγική για ν’ αναστρέψει την αναδιαμόρφωση της αριστερής κοιλίας και να βελτιώνει τη συστολική λειτουργία σε αυτούς τους ασθενείς. Σκοπός: Ο σκοπός της μελέτης αυτής ήταν ν’ αξιολογηθεί η επίδραση της χορήγησης του β-αναστολέα (καρβεδιλόλης) στα επίπεδα του εγκεφαλικού νατριουρητικού προπεπτιδίου (NT pro BNP) και ο συσχετισμός των επιπέδων του NT pro BNP με τους δείκτες λειτουργικότητας της αριστερής κοιλίας, με την καρδιοαναπνευστική λειτουργική ικανότητα αλλά και τον πιθανό βαθμό κλινικής βελτίωσης. Μέθοδοι: Μελετήθηκαν προοπτικά 100 ασθενείς (81 άνδρες και 19 γυναίκες) με έκπτωση της λειτουργικότητας της αριστερής κοιλίας με μέσο κλάσμα εξώθησης (VE) 33±6%. H λήψη αίματος για τον προσδιορισμό του NT pro BNP έγινε εν ηρεμία και στο μέγιστο της άσκησης. Η καρδιοαναπνευστική λειτουργική ικανότητα εκτιμήθηκε σε κυλιόμενο τάπητα βάση του πρωτοκόλλου Dargie. Οι δείκτες λειτουργικότητας της αριστερής κοιλίας μετρήθηκαν βάση υπερηχογραφήματος καρδιάς. Οι ασθενείς επαναξιολογήθηκαν μετά από δώδεκα μήνες. Αποτελέσματα-Συμπεράσματα: Το NT pro BNP μπορεί ν’ ανιχνεύσει ασθενείς με χαμηλή καρδιοαναπνευστική λειτουργική ικανότητα, σχετιζόμενη με την μέγιστη κατανάλωση οξυγόνου και με τους δείκτες λειτουργικότητας της αριστερής κοιλίας, αυξάνονται ανάλογα με την βαρύτητα της καρδιακής ανεπάρκειας. Δεν ευρήκαμε ισχυρότερη συσχέτιση των νατριουρητικών πεπτιδίων στο μέγιστο της άσκησης σε σχέση με την ηρεμία. Ο β-αποκλειστής και ειδικότερα η καρβεδιλόλη επηρεάζουν τα επίπεδα του NT pro BNP α) έμμεσα, βελτιώνοντας την λειτουργικότητα της αριστερής κοιλίας με άνοδο πτώση των επιπέδων του NT pro BNP, β) άμεσα, απεσβεστιοποιώντας τους υποδοχείς υπεύθυνους για την κάθαρση των νατριουρητικών πεπτιδίων NPRC αυξάνοντας έτσι τα επίπεδα του NT pro BNP στο πλάσμα

Effectiveness and Adherence to Treatment with Perindopril/Indapamide/Amlodipine Single-Pill Combination in a Greek Population with Hypertension

Background: Despite the overwhelming evidence and the established benefits of antihypertensive treatment, adherence to treatment remains low. Objective: To assess the adherence to treatment with a perindopril/indapamide/amlodipine single-pill combination (SPC), its effectiveness on blood pressure (BP) reduction, as well as the safety and tolerability of this SPC over a 4-month treatment period. Methods: This multicenter, non-interventional study prospectively included 2285 hypertensive patients on perindopril/indapamide/amlodipine SPC. The data were recorded at baseline, 1 month, and 4 months. Results: Of the 2285 hypertensive patients included in the study, 50.5% were at “high/very high risk”. Mean systolic (SBP)/diastolic (DBP) decreased from 162.3 ± 13.3/93.1 ± 9.3 mmHg at baseline to 129.7 ± 8.3/78.6 ± 7.1 mmHg at 4 months (p < 0.001). Patients with higher baseline BP levels showed greater BP reduction. Patients with hypertension stages 1, 2, and 3 showed mean SBP/DBP reductions of 21.5/10.4 mmHg, 34.2/14.7 mmHg, and 51.2/22.5 mmHg, respectively, at study end (p < 0.001). Only 26 patients (1.1%) prematurely discontinued treatment (0.58% due to an adverse reaction or event). Conclusions: Perindopril/indapamide/amlodipine SPC decreased BP levels rapidly and significantly. The degree of BP reduction was associated with the severity of hypertension and/or with total cardiovascular risk at baseline. Simplifying the drug regimen by using this SPC improved adherence and showed excellent tolerability. © 2019, Springer Nature Switzerland AG

Blood pressure reduction and control with fixed-dose combination perindopril/amlodipine: A Pan-Hellenic prospective observational study

Introduction: Hypertension guidelines recommend fixed-dose combinations for enhanced blood pressure (BP) reduction and compliance. The objective of this study was to assess the effectiveness and safety of fixed-dose perindopril/amlodipine combination in reducing and controlling BP in Greek hypertensive patients, as well as the effect of baseline BP and added cardiovascular risk on BP reduction. Methods: This 6-month prospective observational study included male or female patients a3/418 years with essential hypertension prescribed fixed-dose combination perindopril/amlodipine. BP was measured at baseline and 3 and 6 months. Baseline cardiovascular risk and treatment compliance were also assessed. Results: In 2231 per protocol patients, mean systolic BP decreased from 157.0±15.4 mm Hg to 129.0±7.9 mm Hg after 6 months, and diastolic BP from 91.5±10.1 to 78.8±6.7 mm Hg (both p < 0.001). BP control was achieved in 84.8% at 6 months. Patients with higher baseline added cardiovascular risk or BP had greater BP reduction (p < 0.001). Compliance was good (97.1% took treatment "every daya" or "quite oftena") and few (n = 27; 1.2%) discontinued treatment prematurely due to adverse events. Conclusions: Fixed-dose perindopril/amlodipine safely and effectively reduced high BP in real-life practice, achieving BP control in most patients. About half of Greek hypertensive patients have high/very high added cardiovascular risk. © 2015 The Author(s)