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Objective The efficacy of renal sympathetic denervation (RDN) has been affirmed by a number of recent clinical studies, despite controversies in this field over the last five years. Therefore, it is of paramount importance that hypertension experts debate the merits of RDN by revealing and expressing their personal beliefs and perspectives regarding this procedure. Methods A cross-sectional survey was conducted among Greek leaders of the Hypertension Excellence Centers with the use of a closed-type questionnaire specifically designed to elicit information and evaluate the respondent's views and perspectives about RDN efficacy, safety and ideal target patient population. Results A total of 36 participants completed the survey. Based on the results, RDN was considered efficient (91.7%) and safe (94.5%), while the overwhelming majority of the participants felt confident in the long-term efficacy (88.9%) of the intervention and that it lacks reliable predictors of blood pressure response (94.5%). Patients with resistant (91.7%), ultra-resistant (94.4%), and uncontrolled hypertension (80.6%) were suggested as ideal candidates for RDN. Establishing a close co-operation between interventionalists and hypertension experts was considered essential to ensure the efficacy (97.2%) as well as the safety (97.3%) of the procedure. Conclusion The vast majority of Greek hypertension experts surveyed were convinced of the efficacy and safety of RDN based on the preponderance of available scientific and clinical data. Identification of the ideal patient group remains controversial. Respondents generally agreed on the necessity of building close collaborative relationships between interventionalists and hypertension experts in order to improve RDN clinical outcome.

Aims Despite the existence of many studies, there are still limited data about the characteristics of myocarditis in Greece. This led to the creation of the Greek Myocarditis Registry aiming to document the different symptoms and treatment of myocarditis, assess possible prognostic factors, and find similarities and differences to what is already published in literature. This paper is a preliminary descriptive analysis of this Registry. Methods and results We analysed data for the hospitalization period of all patients included in the Registry from December 2015 until November 2017. Statistics are reported as frequency (%) or median and inter‐quartile range (IQR) as appropriate. In total, 146 patients were included; 83.3% of the patients reported an infection during the last 3 months. The most common symptom, regardless of the underlying infection, was chest pain (82.2%) followed by dyspnoea (18.5%), while the most common finding in clinical examination was tachycardia (26.7%). Presentation was more frequent in the winter months. ECG findings were not specific, with the repolarization abnormalities being the most frequent (60.3%). Atrial fibrillation was observed in two patients, both of whom presented with a reduced ventricular systolic function. Left ventricular ejection fraction changed significantly during the hospitalization [55% (IQR: 50–60%) on admission vs. 60% (IQR: 55–60%) on discharge, P = 0.0026]. Cardiac magnetic resonance was performed in 88 patients (61%), revealing mainly subepicardial and midcardial involvement of the lateral wall. Late gadolinium enhancement was present in all patients, while oedema was found in 39 of them. Only 11 patients underwent endomyocardial biopsy. Discharge medication consisted mainly of beta‐blockers (71.9%) and angiotensin‐converting enzyme inhibitors (41.8%), while 39.7% of the patients were prescribed both. Conclusions This preliminary analysis describes the typical presentation of myocarditis patients in Greece. It is a first step in developing a better prognostic model for the course of the disease, which will be completed after the incorporation of the patients' follow‐up data.

Σκοπός: Να διερευνηθεί η αποτελεσματικότητα της εφαρμογής αρχών χρονοθεραπείας στην αντιυπερτασική αγωγή σε υπερτασικούς ασθενείς με Αποφρακτική Υπνική Άπνοια και χωρίς ημερήσια υπνηλία σε συνδυασμό με τη χρήση Συνεχούς Θετικής Πίεσης Αεραγωγών (CPAP). Υλικό και Μέθοδοι: Σε μία προοπτική, ανοικτή, διασταυρούμενη μελέτη χρονοθεραπείας σταθερής δόσης διάρκειας 16 εβδομάδων, παρακολουθήθηκαν 41 ασθενείς (ηλικίας 52±8 ετών, 78% άνδρες) με ιδιοπαθή υπέρταση και τουλάχιστον μέτριας βαρύτητας ΑΥΑ (δεικτής άπνοιας-υπόπνοιας-ΔΑΥ:37±20/ώρα), χωρίς ημερήσια υπνηλία (κλίμακα ημερήσιας υπνηλίας Epworth≤10 βαθμοί). Σε δύο διαδοχικές περιόδους 8 εβδομάδων έκαστη, χορηγήθηκε θεραπεία με βαλσαρτάνη (υπέρταση σταδίου Ι) ή συνδυασμένη θεραπεία με βαλσαρτάνη και αμλοδιπίνη (υπέρταση σταδίου ΙΙ) σε μία πρωινή και μία βραδυνή ημερήσια δόση αντίστοιχα. Στην αρχική επίσκεψη και στο πέρας κάθε περιόδου πραγματοποιήθηκε μέτρηση ΑΠ ιατρείου και 24ωρης ΑΠ. Βάσει της αποδοχής της θεραπείας με CPAP οι ασθενείς διαχωρίσθηκαν σε δύο ομάδες: υπό-CPAP (n=20) και άνευ-CPAP (n=21).Αποτελέσματα: Δεκαέξι ασθενείς είχαν υπέρταση σταδίου Ι και 25 ασθενείς υπέρταση σταδίου ΙΙ. Η ΑΠ ιατρείου μειώθηκε σημαντικά μετά από τις περιόδους πρωινής και βραδυνής δόσης σε σχέση με τα αρχικά επίπεδα (κατά 19.4±11/15.0±8.6mmHg και 23.1±11/16.7±8.4mmHg, ANOVA p

Aims Currently there are scarce epidemiological data regarding prevalence, clinical phenotype, and therapy of hypertensive urgencies (HU) and emergencies (HE). The aim of this article was to record the prevalence, clinical characteristics, and management of patients with HU and HE assessed in an emergency department (ED) of a tertiary hospital. Methods and results The population consisted of patients presenting with HE and HU in the ED (acute increase in systolic blood pressure (BP) ≥ 180 mmHg and/or diastolic BP ≥120 mmHg with and without acute target organ damage, respectively). Of the 38 589 patients assessed in the ED during a 12-month period, 353 (0.91%) had HU and HE. There were 256 (72.5%) cases presented as HU and 97 (27.5%) as HE. Primary causes for both HU and HE were stress/anxiety (44.9%), increased salt intake (33.9%), and non-adherence to medication (16.2%). Patients with HU reported mainly dizziness/headache (46.8%) and chest pain (27.4%), whereas those with HE presented dyspnoea (67%), chest pain (30.2%), dizziness/headache (10.3%), and neurological disorders (8.2%). In HE, the underlying associated conditions were pulmonary oedema (58%), acute coronary syndrome (22.6%), and neurological disorders/stroke (7.2%). All HE cases were hospitalized and received intensive healthcare, including dialysis. Conclusion This 1-year single-centre registry demonstrates a reasonable prevalence of HU and HE contributing to the high volume of visits to the ED. Stress, increased salt intake and non-adherence were main triggers of HE and HU. Dizziness and headache were the prevalent symptoms of HU patients while heart failure was the most common underlying disease in patients with HE.

Background: Targeting the renin-angiotensin-aldosterone axis is one of the most important therapeutic pathways for blood pressure control, renal and cardiovascular protection. Objective: In this review, the new nonsteroidal mineralcorticoid receptor antagonists will be presented with a special focus on finerenone and its randomized controlled trials along with an introduction to the clinically promising aldosterone synthase inhibitors. Method: We conducted an in-detail review of the literature in order to draft a narrative review on the field. Results: Development of new anti-aldosterone agents focusing on the diverse components of aldosterone production and action is now taking place. Nonsteroidal mineralοcorticoid receptor antagonists are safe and effective therapeutic solutions with finerenone being the most well-studied agent with promising clinical data extending its efficacy in diabetes mellitus, chronic kidney disease and heart failure. Aldosterone synthase inhibitors impact the hormonal balance but there are still limitations regarding the duration of action and adverse effect of the glycolcorticoid axis. Conclusion: Novel third-generation, nonsteroidal mineralocorticoid receptor antagonists seem to offer great advantages, which may lead to a wider use of mineralocorticoid receptor antagonists. Future randomized controlled trials are needed to evaluate significant perspectives.

Background: Arterial stiffness is linked to the progression of atherosclerosis, while activation of vitamin D receptor exerts favorable cardiovascular effects in patients with renal insufficiency. In this study, we investigated the effects of oral treatment with paricalcitol, a potent vitamin D receptor activator, on arterial stiffness and osteopontin, a marker of atherosclerosis, in hypertensive patients with chronic kidney disease (CKD) and secondary hyperparathyroidism. Methods: We followed up 29 treated hypertensive patients (mean age: 74.1 years, 19 men, office blood pressure = 132/85 mmHg) with CKD stages 3–5 (mean glomerular filtration rate [GFR] = 19.4 ml/min/1.73 m2) who were on therapy with oral paricalcitol for 1 year. The control group consisted of 10 age-, sex-, and GFR-matched hypertensive patients with secondary hyperparathyroidism. Results: After 1 year of treatment with paricalcitol compared to baseline, there was no statistical difference in levels of GFR, office blood pressure, and osteopontin (p = NS for all), while carotid-femoral PWV was reduced from 11.8 ± 2.6 m/s to 11.2 ± 2.4 m/s (p

Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action.

Background/Introduction Measurement of unattended blood pressure (BP) may provide additional information over conventionally attended BP. Moreover, hypertension is related to sympathetic drive while there are scarce data on the diverse links of attended and unattended BP with muscle sympathetic nerve activity (MSNA) in hypertensive patients. Purpose The aim of this study was to appraise the relation of BP levels in the attended and unattended setting with MSNA in patients with essential hypertension. Methods We studied 117 patients with essential hypertension (age: 58±11 years, 60 males, office BP: 142/85±17/10 mmHg, 24-hour BP: 133/80±11/9 mmHg). In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Both unattended BP (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements, at 1-minute intervals, after 5 minutes) and attended BP were measured with the same device, on the same day of MSNA recording, in random order. Patients were divided into the combined attended and unattended hypertensive group when BP≥140/90 mmHg in both attended and unattended BP estimations and to the attended hypertensive group when only attended BP≥140/90 mmHg. Results Patients with combined attended and unattended hypertension (n=70) compared to those with attended hypertension (n=47) did not differ regarding 24-h ambulatory BP levels, glucose levels, renal function and left ventricular mass index (p=NS for all). Moreover, patients with combined attended and unattended hypertension compared to those with attended hypertension were characterized by greater levels of MSNA (43.7±9.9 vs 37.7±9.7 bursts per minute, p=0.032). In all participants, sympathetic nerve traffic as assessed by resting MSNA was related to attended systolic BP (r=0.270, p=0.003), attended diastolic BP (r=0.344, p=0.001), unattended systolic BP (r=0.263, p=0.004) and unattended diastolic BP (r=0.274, p=0.003). Conclusions The phenotype of combined attended and unattended hypertension compared to attended hypertension is accompanied by higher sympathetic nervous system activation. Moreover, the close association of MSNA with attended and unattended BP levels in essential hypertension, further supports the key role of sympathetic drive in modulating BP. Funding Acknowledgement Type of funding source: None

Background Current hypertension guidelines necessitate an individualized cardiovascular risk assessment through a process that includes several parameters and remains challenging. Exercise capacity has been strongly associated with prognosis in cardiovascular disease and can be easily assessed by the exercise treadmill test (ETT). Purpose The aim of the present study was to investigate theprognostic role of exercise capacity for future cardiovascular events in a cohort of essential hypertensive subjects. Methods We followed up 1037 hypertensive adults (mean age 56 years, 53% males) with no previous history of cardiovascular disease, for a mean period of 6±3 years. During the baseline visit all subjects underwent a complete echocardiographic study, office blood pressure measurements, ECG, routine blood testing and an ETT with a Bruce protocol.During follow-up, all subjects were reviewed at least annually. Exercise capacity was expressedwithexercise duration the distribution of which was split by the median (9min). Accordingly, the subjects were classified into those with high (51%) and low exercise capacity (49%). The cardiovascular endpoint of interest was the composite of coronary artery disease and stroke. Results The incidence of cardiovascular eventsduring the follow-up period was 4.1% (35 cases of coronary artery disease and 10 cases of stroke).Cox regression analysis revealed that high exercise capacity was associated with a lower risk for future cardiovascular events (HR = 0.35 (95% CI 0.172–0.741, p=0.006). In multivariate models adjusting for standard clinical and laboratory cardiovascular risk factors this association was sustained. Conclusion Exercise duration shows a significant prognostic value for future CV events among hypertensivepatients. Exercise capacity assessment by means of TTE could enhance the identification of asymptomatic hypertensives at higher risk. Funding Acknowledgement Type of funding source: None

Background/Introduction Exaggerated blood pressure response (EBPR) during the exercise treadmill test (ETT) is often observed in individuals without known cardiovascular disease. Although it is generally considered as an abnormal response and a risk factor for hypertension development, its clinical significance remains controversial. On the other hand, regression of left ventricular hypertrophy (LVH) is independently associated with improved cardiovascular outcome. Purpose In this study we aimed to investigate the role of EBPR during exercise in LVH regression in hypertensive subjects over time. Methods 1413 hypertensive subjects, (mean age 57±11 years), 51% males, with baseline office blood pressure (BP) 144/89mmHg were followed for a mean period of 6.4±3.0 years. At baseline and last follow-up visit all patients underwent office BP, laboratory tests and echocardiographical determination of left ventricular mass index (LVMI). At baseline, all subjects underwent treadmill exercise testing (Bruce protocol) in order to identify the presence of EBPR based on the systolic BP elevation at peak exercise (> or =210 mmHg for men and > or =190 mmHg for women). Main outcome variable was LVH Regression/prevention (LVH Regr/prev), defined as: LVH at baseline visit with normal LVMI values at last visit or absence of LVH at baseline and last visit. BP control was considered optimal when the mean of office BP measurements during follow-up was Results 46% of study population presented LVH Regr/prev during follow-up period. Cox-regression analysis, after adjustment for clinical and biochemical variables, revealed that low levels of baseline LVMI (HR=0.98, 95% CI 0.97–0.99, p Conclusions Beyond optimal BP control, EBPR is a significant predictor of left ventricular mass changes overtime. Hence, ETT can provide clinical relevant information, including EBPR, which may help in the improvement of risk stratification of hypertensive subjects. Funding Acknowledgement Type of funding source: None

Background At present, few data are available on the prognosis of hypertensive emergencies and urgencies admitted to Emergency Departments (ED). The aim of our study was to evaluate the incidence of total and cardiovascular events during follow-up in hypertensive patients admitted in 2 ED in Italy and Greece with hypertensive emergencies or urgencies. Methods Medical records of patients aged >18 yrs, admitted to the ED with blood pressure values ≥180 mmHg (SBP) and/or ≥120 mmHg (DBP) were collected and analysed (24% of patients were classified as “hypertensive emergency” and 76% as “hypertensive urgency”). Data in 1218 patients (556 men and 662 women, mean age 70±13 years) were analysed; the mean duration of follow-up after admission to the ED was 19.5±7 months years. Results During the follow-up cardiovascular events occurred in 148 patients (69 cardiac events, 43 cerebrovascular events). In 272 pts (22%) a new episode of acute BP rise was recorded. A total of 87 deaths was recorded during follow-up (in 28 patients for cardiovascular causes). All cause and CV mortality were greater in patients with a previous hypertensive emergency (14.7 vs 4.7%, chi-square p=0.0001 and 5.8 vs 1.2% chisquare p Conclusions Admission to the ED for hypertensive emergencies identifies hypertensive patients at increased risk for fatal and non fatal cardiovascular events. Our results underline the need for an accurate follow-up in patients with hypertensive emergencies and urgencies. Funding Acknowledgement Type of funding source: None

Background Data on prevalence and associated prognosis of repolarization abnormalities among hypertensive patients are limited. Purpose We investigated the presence and extent of ST-segment and T-wave changes in a hypertensive population and their predictive ability for cardiovascular disease. Methods We studied 1851 white Caucasian hypertensive patients (age 58±12 years, 51%females) without a history of cardiovascular disease for a mean period of 5.3±3.4 years. At the baseline examination, all patients underwent standard 12-lead electrocardiography. T-wave inversion (TWI) was defined as T-wave deflection ≥−0.1 mV in ≥2 contiguous leads,unless associated with bundle branch block. Anterior, lateral or inferior TWI was defined as TWIin leads V2-V4 or V5,V6, I, AVL or II, aVF respectively. Thedepth in millimeters of TWI in each lead was recorded and the maximum depth per location was calculated. ST depression was defined as ≥1mm in depth in two or more contiguous leads.During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was theincidence of cardiovascular morbidity set as the composite of non-fatal coronary artery disease and stroke. Results In the entire population, prevalence of TWI was 3.8%, of which 39% presented withanterior TWI, 73% withlateral TWI and 11% with inferior TWI. ST depression was observed in 3.6% of patients (anterior in 0.8%, inferior in 0.9% and lateral in 2.6%). Incidence of the composite endpoint during follow-up was 4%. Cox regression analysis revealed that presence of TWI was associated with a significantly greater risk for cardiovascular events (HR: 2.6, 95% CI: 1.1–5.9, p=0.025). The association was stronger for lateral TWI (HR: 3.3, 95%: CI: 1.34–8.30, p=0.01) compared to other locations. In multivariate models controlling for standard confounders these associations were overall sustained. Depth of TWI and presence of ST depression were not associated with cardiovascular risk. Conclusions Among hypertensive patients without cardiovascular disease, TWI is infrequent but significantly associated with future cardiovascular events.Lateral TWI carries the worse prognosis Funding Acknowledgement Type of funding source: None

Background: High blood pressure (BP) is a leading risk factor for coronary artery disease and other major cardiovascular events. Objective: Blood pressure variability (BPV), ambulatory arterial stiffness index (AASI) and ankle- brachial index (ABI) have been proposed as indices that can improve risk stratification for an adverse cardiac outcome. However, their utility in the setting of acute coronary syndromes (ACS) is unclear. Methods: The ACS-BP study is a single-centre observational cohort study designed to investigate the prognostic role of haemodynamic load and arterial stiffness indices for cardio-renal outcomes in patients with acute myocardial infarction (AMI). All consecutive patients admitted with a diagnosis of acute AMI with or without ST segment elevation were screened for inclusion in the study. The management of AMI will follow current guidelines. Results and Discussion: Data from baseline clinical and laboratory parameters during their hospitalization were collected. The haemodynamic load of each patient was determined by clinical BP values as well as 24-h ambulatory BP monitoring. The AASI was calculated from the raw 24-h BP data and ABI was measured after the third day of hospitalization using a certified device. Patients were followed-up for 12 months in order to collect data for hard cardiovascular and renal endpoints. Conclusion: The study results should clarify the role of these non-invasive tools in secondary risk stratification of such patients.

Summary Background Catheter-based renal denervation has significantly reduced blood pressure in previous studies. Following a positive pilot trial, the SPYRAL HTN-OFF MED (SPYRAL Pivotal) trial was designed to assess the efficacy of renal denervation in the absence of antihypertensive medications. Methods In this international, prospective, single-blinded, sham-controlled trial, done at 44 study sites in Australia, Austria, Canada, Germany, Greece, Ireland, Japan, the UK, and the USA, hypertensive patients with office systolic blood pressure of 150 mm Hg to less than 180 mm Hg were randomly assigned 1:1 to either a renal denervation or sham procedure. The primary efficacy endpoint was baseline-adjusted change in 24-h systolic blood pressure and the secondary efficacy endpoint was baseline-adjusted change in office systolic blood pressure from baseline to 3 months after the procedure. We used a Bayesian design with an informative prior, so the primary analysis combines evidence from the pilot and Pivotal trials. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov , NCT02439749 . Findings From June 25, 2015, to Oct 15, 2019, 331 patients were randomly assigned to either renal denervation (n=166) or a sham procedure (n=165). The primary and secondary efficacy endpoints were met, with posterior probability of superiority more than 0·999 for both. The treatment difference between the two groups for 24-h systolic blood pressure was −3·9 mm Hg (Bayesian 95% credible interval −6·2 to −1·6) and for office systolic blood pressure the difference was −6·5 mm Hg (−9·6 to −3·5). No major device-related or procedural-related safety events occurred up to 3 months. Interpretation SPYRAL Pivotal showed the superiority of catheter-based renal denervation compared with a sham procedure to safely lower blood pressure in the absence of antihypertensive medications. Funding Medtronic.

A young elite cyclist was investigated for episodes of fast heart rate shortly after exercise. A wide-complex tachycardia with right-bundle branch morphology was recorded and complete work-up documented a structurally normal heart. Electrophysiologic testing confirmed a diagnosis of idiopathic fascicular left ventricular tachycardia and successful catheter ablation was performed.

Spectral Doppler ultrasonography provides the evaluation of renal resistive index (RRI), a noninvasive and reproducible measure to investigate arterial compliance and/or resistance. RRI seems to possess an important role in the evaluation of diverse cases of secondary hypertension. In essential hypertension, RRI is associated with subclinical markers of target organ damage and reflects renal disease progression beyond albuminuria and creatinine clearance. Also, RRI can estimate cardiovascular and renal risk. The evaluation of RRI may also help the therapeutic decisions. Given its simple assessment, RRI emerges as a simple method and a “multifunctional” tool that could help on the cardiovascular risk evaluation of the hypertensive patient.

Extensive clinical research has provided robust evidence that exercise is a cost‐effective measure to substantially alleviate the burden of a large number of diseases, many of which belong to the cardiovascular (CV) spectrum. In terms of cardiac benefit, the positive effects of exercise are attributed to improvements in standard risk factors for atherosclerosis, as well as to its positive impact on several pathophysiological mechanisms for CV diseases. For secondary prevention, exercise, optimally in the context of a cardiac rehabilitation program, has been shown to improve functional capacity and survival. Clinicians should encourage physical activity and provide exercise recommendations for all patients, taking into consideration any underlying pathology. In the present review, the benefits of exercise for the prevention and treatment of major CV risk factors and heart conditions are analyzed.

Background/objectives Short-term blood pressure variability (BPV) is affected by multiple factors including the sympathetic nervous system drive. Regarding the latter, the novel interventional technology of renal denervation (RDN), by modulating the sympathetic system activation, could have a beneficial impact on BPV. The aim of the current study is to review and meta-analyze the available evidence on the effect of RDN on short-term BPV. Methods We searched Medline/PubMed database until October 2016 for studies with eligible content. We performed random-effect meta-analyses for 12 outcomes of interest: the standard deviation (SD) of SBP (24 h, daytime and night-time) and DBP (24 h, daytime and night-time), the weighted SD of SBP and DBP across 24 h, the coefficient of variation of SBP and DBP across 24 h and the average real variability of SBP and DBP across 24 h. Results RDN reduced the SD of SBP across 24 h [mean change: -1.212 (95% confidence intervals (CIs): -2.354/-0.071), P = 0.037] and decreased the SD of systolic daytime BP [mean difference: -1.617 (95% CIs: -3.21/-0.026), P = 0.046] and diastolic daytime BP (marginally) [mean difference: -2.605 (95% CIs: -5.21/-0.003), P = 0.05]. The effect of RDN in reducing SD of SBP across 24 h or DBP across daytime was not influenced by absolute or relative reduction in SBP and DBP indices. (P > 0.1 for all). Conclusion Catheter-based RDN in resistant hypertensive patients can favorably affect short-term BPV, independent of the level of BP reduction. Further investigation of the effect of RDN on BPV is needed with large randomized trials.

OBJECTIVE The association of resistant hypertension (RHTN) with renal haemodynamics is unclear. Our aim was to evaluate differences in haemodynamic characteristics of patients with RHTN compared with patients with controlled hypertension (HTN) at the level of the heart, kidney and aorta. METHODS We studied 50 patients with RHTN confirmed by ambulatory blood pressure monitoring and 50 controlled hypertensive patients matched for age and sex. All participants underwent renal Doppler ultrasound to determine the renal resistive index (RRI), a complete echocardiographic study including measurements of diastolic function and evaluation of augmentation index. RESULTS Hypertensive patients with RHTN compared with those without RHTN had a significantly decreased E/A ratio (by 0.12, P = 0.043), an increased E/e' ratio (by 3.1, P

The efficacy of catheter-based renal sympathetic denervation (RDN) in terms of blood pressure (BP) reduction has been questioned, while “real-world” data from registries are needed. In this study, we report the complete set of 12-month data on office and ambulatory BP changes as well as the predictors for BP response to RDN from a national registry. In 4 Greek hospital centers, 79 patients with severe drug-resistant hypertension (age 59 ± 10 years, 53 males, body mass index 33 ± 5 kg/m2; office BP and 24-h ambulatory BP were 176 ± 15/95 ± 13 and 155 ± 14/90 ± 12 mmHg, respectively, 4.4 ± 0.9 antihypertensive drugs) underwent RDN and were followed-up for 12 months in the Greek Renal Denervation Registry. Bilateral RDN was performed using percutaneous femoral approach and standardized techniques. Reduction in office systolic/diastolic BP at 6 and 12 months from baseline was −30/−12 and −29/−12 mmHg, while the reduction in 24-h ambulatory BP was −16/−9 and −15/−9 mmHg, respectively (p

Background/Introduction Although arterial stiffening is related to atherosclerosis progression, its prognostic role in hypertension is not fully elucidated, while augmented left ventricular mass index (LVMI) is linked to adverse outcome. Purpose The aim of the present study was to compare the predictive role of changes in arterial stiffness and LVMI for the incidence of coronary artery disease (CAD) in a cohort of essential hypertensive patients. Methods We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and at baseline and last visit underwent complete echocardiographic study for estimation of LVMI and measurements of arterial stiffness on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method. The distribution of PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Moreover, LV hypertrophy (LVH) was defined as LVMI ≥125 g/m2 in males and LVMI ≥110 g/m2 in females, while CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure. Results The incidence of CAD over the follow-up period was 3.5%. Hypertensives who developed CAD (n=38) compared to those without CAD at follow-up (n=1044) had at baseline higher waist circumference (101.7±10.1 vs 96.2±11.6 cm, p=0.004), LVMI (123.9±22.1 vs 105.8±21.3 g/m2, p=0.026), prevalence of LVH (46% vs 25%, p=0.018) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with CAD and those without CAD with respect to baseline office BP, serum creatinine and lipid levels (p=NS for all). By univariate Cox regression analysis, it was revealed that changes in PWV levels between baseline and last visit predicted CAD (hazard ratio=1.243, p=0.014). However, in multivariate Cox regression model baseline glomerular filtration rate (hazard ratio=1.029, p=0.015) and changes in LVMI (hazard ratio=1.036, p Conclusions In essential hypertensive patients changes in LVMI predict future development of CAD, whereas PWV alterations exhibit no independent prognostic value. These findings support that LVMI constitutes a superior prognosticator of events than PWV and its estimation is essential in order to improve overall risk stratification in hypertension.

Background/Introduction Measurement of unattended blood pressure (BP) may provide additional information over conventionally attended BP. Moreover, hypertension is related to sympathetic drive while there are scarce data on the diverse links of attended and unattended BP with muscle sympathetic nerve activity (MSNA) in hypertensive patients. Purpose The aim of this study was to assess the relation of BP levels in the attended and unattended setting with MSNA in patients with essential hypertension. Methods We studied 38 patients with essential hypertension (age: 59±11 years, 20 males, office BP: 142/86±19/11 mmHg, 24-hour BP: 137/80±14/12 mmHg). In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Both unattended BP (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements, at 1-minute intervals, after 5 minutes) and attended BP were measured with the same device, on the same day of MSNA recording, in random order. Patients were divided into the combined attended and unattended hypertensive group when BP≥140/90 mmHg in both attended and unattended BP estimations and to the attended hypertensive group when only attended BP≥140/90 mmHg. Results Patients with combined attended and unattended hypertension (n=18) compared to those with attended hypertension (n=20) were older (61±11 vs 57±11 years, p=0.03), whereas did not differ regarding 24-h ambulatory BP levels, glucose levels, renal function and left ventricular mass index (p=NS for all). Moreover, patients with combined attended and unattended hypertension compared to those with attended hypertension were characterized by greater levels of MSNA (41.2±11.6 vs 32.2±10.1 bursts per minute, p=0.031). In all participants, sympathetic nerve traffic as assessed by resting MSNA was related to attended systolic BP (r=0.459, p=0.004), attended diastolic BP (r=0.503, p=0.001), unattended systolic BP (r=0.433, p=0.007) and unattended diastolic BP (r=0.423, p=0.008). Conclusions The phenotype of combined attended and unattended hypertension compared to attended hypertension is accompanied by higher sympathetic nervous system activation. Moreover, the close association of MSNA with attended and unattended BP levels in essential hypertension, further supports the key role of sympathetic drive in modulating BP.

Background/Introduction There has been a long debate regarding the association of systolic versus diastolic blood pressure with cardiovascular outcome and data regarding hypertensive patients under treatment have been conflicting. Purpose To investigate the association of different patterns of uncontrolled blood pressure (BP) among treated hypertensive patients. Methods We prospectively studied 1507 treated hypertensive patients (age 59±11 years) that are followed in the setting of a single-center, clinic-based registry. During follow-up, patients underwent regular visits for hypertension and risk factor management. Based on the cut-off limits for uncontrolled hypertension of office systolic BP≥140mmHg and diastolic BP≥90mmHg, study participants were divided into four groups: those with controlled hypertension (796 patients, 53% of the population), uncontrolled systolic BP (257 patients, 17%), uncontrolled diastolic BP (135 patients, 9%) and uncontrolled systolic and diastolic BP (319 patients, 21%). The outcome studied was the composite of cardiovascular morbidity set as coronary artery disease and stroke, and the controlled hypertension group served as reference. Results The median follow-up period was 6.4±3.0 years and the composite endpoint (13 strokes and 41 cases of coronary artery disease) occurred in 54 patients (3.6%). Unadjusted Cox regression analysis showed that, compared to the reference group of controlled hypertensives, the risk for cardiovascular morbidity was similar in patients with uncontrolled diastolic BP (HR: 0.88, 95% CI: 0.26–2.97) but significantly higher in patients with uncontrolled systolic BP (HR: 2.17, 95% CI: 1.08–4.36), while patients with both uncontrolled systolic and diastolic BP showed the worse prognosis (HR: 2.35, 95% CI: 1.24–4.43). This pattern of risk was overall sustained after adjusting for different sets of confounders. Conclusions Among treated hypertensive patients, uncontrolled systolic BP is associated with a greater risk for cardiovascular events compared to uncontrolled diastolic BP while uncontrolled systolodiastolic hypertension presents with the worse prognosis.

Background/Introduction Renal dysfunction is related with adverse prognosis in hypertension, however there are scarce data on the predictive cardiovascular and renal impact of kidney function variability in this setting. Purpose The aim of the present study was to assess the predictive role of visit-to-visit renal function changes on the incidence of coronary artery disease (CAD), stroke and end-stage renal disease in a cohort of essential hypertensive patients. Methods We followed up 2380 essential hypertensives (mean age 58.9 years, 1240 males, office blood pressure (BP)=144/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and blood sampling was performed in all visits for estimation of glomerular filtration rate (GFR). We calculated standard deviation (SD) of mean GFR from visits from 6 months onward in patients with ≥5 visits during follow-up. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure, while stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings. End-stage renal disease was defined as GFR Results The incidence of CAD, stroke and end-stage renal disease over the follow-up period were 2.8% (n=68), 1.09% (n=26) and 0.6% (n=14). Hypertensives who developed CAD compared to those without CAD at follow-up (n=2312) had at baseline higher left ventricular mass index (115.7±24.6 vs 103.7±27.3 g/m2, p Conclusions In essential hypertensive patients GFR variability predicts future development of end-stage renal disease but exhibits no independent prognostic value for CAD and stroke. These results suggest that fluctuations of renal function are related with damage at the kidneys and not at the cardiac and cerebrovascular level.

Background/Introduction Salt intake is linked to hypertension but data on its association with incident cardiovascular events, especially among hypertensives, is limited. Purpose To examine the prospective association of different salt consumption levels with cardiovascular morbidity in a hypertensive population. Methods We followed 2130 hypertensive patients (age 57±12 years, 11.2% untreated) without a history of cardiovascular disease for a mean period of 5.3±3.3 years. At the baseline examination, salt intake was evaluated by a structured validated questionnaire. Accordingly, the study population was divided into three groups: hypertensives with a low (1079 patients, 51% of the population), a moderate (895 patients, 42%) and a high salt consumption (146 patients, 7%). During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was the composite of non-fatal cardiovascular events. Results The composite endpoint (19 strokes and 65 cases of coronary artery disease) occurred in 84 patients (3.9%). At baseline, increasing salt consumption was significantly associated with age, body mass index, office blood pressure and renal function. Unadjusted Cox regression analysis showed that, compared to the reference group, the risk for cardiovascular morbidity was similar in patients with moderate salt consumption (HR: 1.1, 95% CI: 0.71–1.77) but significantly higher in patients with high salt consumption (HR: 2.12, 95% CI: 1.09–4.38). This pattern was clearly sustained after adjusting for multiple risk factors including baseline blood pressure levels. Conclusions Among hypertensive patients, heavy salt consumption is associated with an increased cardiovascular risk, while moderate consumption does not affect patient outcome.

Arterial hypertension is a well‐established cardiovascular risk factor, and blood pressure (BP) control has largely improved the prognosis of hypertensive patients. A number of studies have assessed the role of BP levels in the prognosis of patients with acute coronary syndromes. Pathophysiologic links of hypertension to acute myocardial infarction (MI) include endothelial dysfunction, autonomic nervous system dysregulation, impaired vasoreactivity, and a genetic substrate. A history of hypertension is highly prevalent among patients presenting with MI, and some, but not all, studies have associated it with a worse prognosis. Some data support that low levels of admission and in‐hospital BP may indicate an increased risk for subsequent events. Risk scores used in patients with MI have, therefore, included BP levels and a history of hypertension in their variables. Of note, good long‐term BP control, ideally initiated prior to discharge, should be pursued in order to improve secondary prevention.

A sympathetic overdrive is central to the development and clinical course of heart failure. As the kidneys are significant modulators of sympathetic activity, renal nerve ablation (RNA) stands as an intriguing therapeutic option to control the progression and prognosis of the disease. A number of studies have provided evidence of an effect of RNA on blood pressure as well as on heart size and function. Experimental studies in heart failure models have shown that RNA interferes with water and salt retention, the renin-angiotensin axis, and the sympathetic overflow to the heart. A series of small studies of RNA in humans with heart failure have provided promising data with respect to functional status, neurohormonal activation, and clinical and prognostic biomarkers. As pending trials will provide data on the true efficacy of transcatheter RNA, the solid pathophysiologic basis supports the need for larger trials in heart failure patients.

Left ventricular (LV) hypertrophy and diastolic dysfunction predict long-term cardiovascular events. We evaluated whether multielectrode renal denervation (RDN) can provide beneficial cardiac adaptations in patients with resistant hypertension and LV hypertrophy long term at 24 months. Seventeen patients with true drug-resistant hypertension (age: 57±9 years, 11 men, body mass index: 33.79±5.49 kg m-2, office blood pressure (BP): 183±20/97±18 mm Hg and ambulatory BP: 152±16/86±15 mm Hg receiving 4.5 anti-hypertensive drugs per day) and LV hypertrophy underwent multielectrode RDN (EnligHTNTM, St Jude Medical). At baseline, LV mass index averaged 141.1±16.8 g m-2 (58.4±7.8 g m-2.7) and mitral lateral E/E' 14.7±6.2. At 6, 12 and 24 months after RDN, the LV mass/body surface area (LV mass per height2.7) reduced significantly by 9.1% (8.8%), 11.3% (10.5%) and 15.5% (14.1%), respectively; and the mitral lateral E/E' reduced significantly by 14.0%, 15.3% and 29.7%, respectively. At 24 months after RDN, majority (70.6%) of the patients showed regression of LV hypertrophy of at least one level; the proportion of patients with concentric LV hypertrophy had dropped by 47.1% from baseline; and the proportion of patients with office systolic BP level of ⩾160 mm Hg had dropped by 76.5% from baseline. No statistically significant association was observed between the changes in office BP and the changes in LV mass index or diastolic function. In patients with drug-resistant hypertension and LV hypertrophy, multielectrode RDN can contribute to significant and sustained improvements of diastolic dysfunction and attenuation of LV mass indices long term at 24 months.

The metabolic syndrome (MS) is widespread among hypertensive patients. However, the net impact of MS on major atherosclerotic events beyond the cardiovascular risk imposed by its individual components remains controversial in this group. We sought to assess both the independent and incremental prognostic role of MS for unfavorable cardiovascular events in a cohort of essential hypertensives.We followed up 2176 essential hypertensives free of cardiovascular disease for a median period of 40 months. All subjects had at least one annual visit. MS was defined according to the updated NCEP III criteria. Endpoint of interest was the incidence of stroke, coronary artery disease (CAD) and their composite.MS was present at baseline in 819 hypertensives (37.6%). MS group presented increased prevalence of resistant hypertension in comparison to MS free group (18.4% versus 10.6%, p0.001). The incidence of the composite end-point was 3.1% (69 events) across the follow-up period. Patients with MS were more likely to experience major adverse cardiovascular events (MACE) in comparison to reference category (3.7% versus 1.9%, log rank p = 0.024). While MS was an independent predictor for MACE, none of the individual components of the syndrome was associated independently with the endpoint. MS provided incremental discriminative value (Harrell's c, p0.05 for all) over individual risk factors for the incidence of MACE.MS predicts adverse cardiovascular events in hypertensives incrementally of its individual components. Early identification of MS in this population may enable more accurate prediction of future cardiovascular risk and could implement more efficient strategies in terms of primary prevention.

Long term safety and efficacy data of multi-electrode ablation system for renal denervation (RDN) in patients with drug resistant hypertension (dRHT) are limited.We studied 46 patients (age: 60 ± 10 years, 4.7 ± 1.0 antihypertensive drugs) with drug resistant hypertension (dRHT). Reduction in office BP at 24 months from baseline was -29/-13 mmHg, while the reduction in 24-hour ambulatory BP and in home BP at 24 months were -13/-7 mmHg and -11/-6 mmHg respectively (p0.05 for all). A correlation analysis revealed that baseline office and ambulatory BP were related to the extent of office and ambulatory BP drop. Apart from higher body mass index (33.3 ± 4.7 vs 29.5 ± 6.2 kg/m(2), p0.05), there were no differences in patients that were RDN responders defined as ≥10 mmHg decrease (74%, n=34) compared to non-responders. Stepwise logistic regression analysis revealed no prognosticators of RDN response (p=NS for all). At 24 months there were no new serious device or procedure related adverse events.The EnligHTN I study shows that the multi-electrode ablation system provides a safe method of RDN in dRHT accompanied by a clinically relevant and sustained BP reduction.

Isolated systolic hypertension (ISH) and combined systolic-diastolic hypertension (CH) are related with increased cardiovascular risk. The aim of the present study was to compare the predictive role of ISH and CH for the incidence of atrial fibrillation (AF) in a cohort of essential hypertensive