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Platelet function testing (PFT) could be a useful clinical tool to guide individualized antithrombotic treatment in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). We aimed to investigate platelet reactivity (PR) in the context of a contemporary registry. “Real-world” data were retrieved from a nationwide, multicenter, observational study of AF patients on oral anticoagulants (OAC) undergoing PCI. Patients treated with a P2Y12 inhibitor, namely clopidogrel or ticagrelor, as part of double or triple antithrombotic therapy, were submitted to PFT before discharge and were followed up for 12 months. Out of 101 patients included in the study, 66 were submitted to PFT while on clopidogrel and 35 while on ticagrelor; PR was 162.9 ± 68 PRU and 46.02 ± 46 PRU, respectively (P

Εισαγωγή/σκοπός: Ο νεφρός παίζει καθοριστικό ρόλο στην ρύθμιση της αρτηριακής πίεσης (ΑΠ) και η αιμοδυναμική του νεφρού μπορεί να εκτιμηθεί με έναν μη επεμβατικό και αναπαραγώγιμο δείκτη, το νεφρικό δείκτη αντίστασης (RRI). Σκοπός της μελέτης ήταν να αξιολογήσει τη σχέση της αιμοδυναμικής του νεφρού (RRI) με την αιμοδυναμική της καρδιάς (Ε/e’) και της αορτής (αυξητικός δείκτης, AIx) σε ασθενείς με ιδιοπαθή υπέρταση άνευ αγωγής. Επιπλέον, στόχος μας ήταν να αξιολογήσουμε τις διαφορές στα αιμοδυναμικά χαρακτηριστικά των ασθενών με ανθεκτική υπέρταση (RHTN) σε σύγκριση με τους υπερτασικούς με ρυθμισμένη ΑΠ στο επίπεδο της καρδιάς, του νεφρού και της αορτής.Υλικό και Μέθοδοι: 310 νεοδιαγνωσθέντες υπερτασικοί ασθενείς άνευ αγωγής [164 άνδρες, μέση ηλικία 51 έτη, ΑΠ ιατρείου = 142/88 mmHg] υπεβλήθησαν σε 24ωρη καταγραφή ΑΠ και λήψη δείγματος αίματος για προσδιορισμό του μεταβολικού προφίλ. Επιπλέον, Μελετήσαμε 50 ασθενείς που πληρούσαν τα κριτήρια της RHTN και 50 υπερτασικούς ασθενείς με ρυθμισμένη ΑΠ που ελάμβαναν 3 ή λιγότερα αντιυπερτασικά φάρμακα. Όλοι οι συμμετέχοντες υποβλήθηκαν σε Doppler υπερηχογράφημα νεφρών για τον προσδιορισμό του RRI, εκτίμηση του AIx, καθώς και πλήρη υπερηχοκαρδιογραφική μελέτη συμπεριλαμβανομένου του λόγου του πρώιμου κύματος Ε της ταχύτητας στη μιτροειδή προς το κύμα e’ της ταχύτητας του μιτροειδικού δακτυλίου (Ε/e’).Αποτελέσματα: Με βάση τη διάμεση τιμή του RRI (0.600), οι υπερτασικοί ταξινομήθηκαν σε εκείνους με υψηλές και χαμηλές τιμές RRI. Οι υπερτασικοί με υψηλές τιμές RRI σε σύγκριση με εκείνους με χαμηλές τιμές ήταν πιο ηλικιωμένοι (56.4 vs 45 έτη, p < 0.001), είχαν χαμηλότερη 24ωρη διαστολική ΑΠ (77 vs 85 mmHg, p < 0.001), υψηλότερες τιμές AIx (27 vs 18%, p < 0.01), και υψηλότερες τιμές E/e’ (9.7 vs 8, p < 0.001). Η πολλαπλή ανάλυση παλινδρόμησης έδειξε ότι η ηλικία, η πίεση παλμού, ο λόγος E/e’ και η ταχύτητα του σφυγμικού κύματος συσχετίζονταν ανεξάρτητα με τον RRI (R2 = 0.434, p < 0.001). Οι υπερτασικοί με RHTN σε σύγκριση με εκείνους χωρίς RHTN εμφάνιζαν υψηλότερες τιμές RRI (κατά 0.078, p < 0,001) και τιμές E/e’ (κατά 3.1, p < 0.001) αλλά παρόμοιες τιμές του AIx (p = 0.79). Σε ένα μοντέλο λογιστικής παλινδρόμησης, η παρουσία της RHTN ήταν ο ισχυρότερος προγνωστικός δείκτης της εμφάνισης του RRI με τιμή μεγαλύτερη από 0.7 μετά από έλεγχο για άλλες αιμοδυναμικές μεταβλητές συμπεριλαμβανομένων των επιπέδων της ΑΠ. Η ανάλυση ROC αποκάλυψε μία AUC για την πρόβλεψη της RHTN από τον RRI της τάξεως του 80.3% (95% confidence interval 0.72–0.89, p < 0.001). Το σημείο διαχωρισμού 0.648 του RRI εμφάνιζε ευαισθησία 78% και ειδικότητα 72% για την πρόβλεψη της RHTN.Συμπεράσματα: Η αυξημένη αγγειακή αντίσταση στις ενδονεφρικές αρτηρίες σχετίζεται με επηρεασμένη αιμοδυναμική της καρδιάς και της αορτής, όπως αντικατοπτρίζεται από τις αυξημένες τιμές του AIx και του E/e’. Ο RRI θα μπορούσε να θεωρηθεί ένα χρήσιμο υποκατάστατο της αιμοδυναμικής στην ιδιοπαθή υπέρταση. Σε μια ομάδα υπερτασικών ασθενών, η αιμοδυναμική του νεφρού και της καρδιάς σχετίζονται στενά με την παρουσία της RHTN. Τα ευρήματα αυτά υποδηλώνουν ότι οι τιμές του RRI και του λόγου E/e’ θα πρέπει να λαμβάνονται υπόψη για την πρόβλεψη του ανεπαρκούς ελέγχου της ΑΠ στους υπερτασικούς ασθενείς.

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

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

Percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) are the most challenging type of procedure in interventional cardiology and are traditionally associated with increased complexity and reduced procedural success rates. New techniques, such as retrograde approach and dissection reentry technique, offer alternatives in case of traditional antegrade wiring failure. In this paper, we present a successful implantation of a stent parallel to other existing stent in an in-stent CTO (IS-CTO) using dissection reentry technique. The technical details involved and the clues to successful outcome in an individual with in-stent CTO are discussed.

The aim of this article is to focus on the utilization of forearm approach for cardiac catheterization in challenging groups of patients. Radial and ulnar approaches have gained significant popularity among the majority of interventional cardiologists. Multiple studies have demonstrated the feasibility, safety and efficacy of forearm route for cardiac catheterization and have highlighted the significant reduction in bleeding complications by avoiding the puncture of the groin. In this review we present the strategies need to be followed in order to apply the forearm approach in challenging group of patients.

End-stage renal disease (ESRD) is considered a relative contraindication for forearm (radial or ulnar) cardiac catheterization. However, in everyday practice, many ESRD patients are catheterized from the forearm. The aim of this study was to compare femoral and forearm approach for cardiac catheterization in ESRD patients.All cardiac catheterization procedures performed in ESRD patients in three Greek hospitals in a 2-year period (2014-2015) were retrospectively evaluated. The primary endpoint of the study was major access-site complication, defined as any Blood Academic Research Consortium class ≥3 bleeding or limb ischemia requiring intervention or prolonging hospitalization.During the study period, a total of 124 procedures were performed in 109 ESRD patients: 44 procedures (35.5%) were performed transfemorally and 80 procedures (64.5%) were performed from the forearm approach (77 transradial [96.3%] and 3 transulnar [3.7%]). Forearm access was always performed from the contralateral arm of a functional hemodialysis access site. Sixty-one procedures (49.6%) were diagnostic coronary artery angiographies (CAAs) and 63 procedures (50.4%) were percutaneous coronary interventions with or without CAA. Two deaths and 1 procedure-related myocardial infarction were recorded during hospitalization. Five patients suffered major access-site complications, all from the femoral group (5/44 vs 0/80; P.01). Three transradial patients had asymptomatic radial artery occlusion after a diagnostic procedure. Five patients (4.0%) had problems with their hemodialysis access site during long-term follow-up, and required a new access site.Forearm approach for cardiac catheterization is feasible and safe in ESRD patients. All measures to preserve radial patency should be taken in this high-risk patient group, where a possible forearm artery occlusion might have serious consequences.

There is robust evidence from epidemiological and clinical studies showing that elevated heart rate (HR) constitutes a powerful predictor of morbidity and mortality in patients with hypertension, underlining the significance of HR measurement in them. Autonomous nervous system dysfunction and atherosclerosis are important features in the pathogenesis of the untoward events. However, the relationship between HR and blood pressure (BP) is complex and differs depending on the type of BP measurement which is considered. This differentiation implicates complex physiological mechanisms and is of clinical importance regarding the divergent effect of the different types of antihypertensive agents on these parameters. The aim of this review is to summarize the current evidence on the relationship between HR and BP based on epidemiological, clinical, and experimental studies.

Purpose To evaluate the efficacy of radial artery cannulation with needle versus cannula over needle during transradial coronary angiography and intervention. Methods Five hundred patients scheduled to undergo transradial catheterization were randomized between the two methods. Primary endpoint of the study was the combined endpoint of switching to another access site due to inability of successful sheath insertion or switching to another method of cannulation (from needle to cannula over needle and vice versa). Results The primary end point was met in 12 patients (4.8%) from the needle group and 14 patients (5.6%) from the cannula over needle group (p = 0.695). There were no differences in switching of cannulation method [10 (4.0%)% versus 11 (4.4%), p = 0.831], switching of access site [6 (2.8%) versus 9 (3.6%), p = 0.441), time for artery cannulation [1.20 (0.80–2.20) min versus 1.26 (1.01–2.39) min, p=0.152], total procedure time [15.05 (9.47–29.03) min versus 19.14 (10.13–32.02) min, p=0.112] number of attempts [2 (1–4) versus 2 (1–5), p=0.244] and number of skin punctures [1 (1–2) versus 1 (1–2), p=0.399] before successful radial artery cannulation. There were no differences recorded in the safety endpoints of EASY grade III or more radial hematomas [2 (0.8%) versus 1 (0.4%), p = 1.000] or the incidence of radial artery occlusion after the procedure [9 (3.6% versus 16 (6.8%), p = 0.358]. Conclusion Radial artery cannulation with needle and cannula over needle seems to be equal in terms of efficacy and safety.

The extent of the increased risk of pregnancy hypertensive disorders following assisted reproductive technology (ART) was investigated. PubMed and the Cochrane Collaboration Library were used as data sources to identify and select longitudinal cohorts comparing pregnancies following ART with spontaneously conceived pregnancies, between 1978 and June 2016. Risk ratios and 95% confidence intervals (CIs) of three outcomes, ie, gestational hypertension (GH), preeclampsia (PE), and their sum (PHD), were calculated. Stratification of results by gestation order (singletons and nonsingletons) was pursued, but a separate “all orders” mixed stratification was considered. Sixty-six longitudinal studies (7 038 029 pregnancies; 203 375 following any ART) were eligible. All outcomes independent of gestation order (“all orders”) were increased following any invasive ART: GH (+79% [95% CI, 24%–157%]) and PE (+75% [95% CI, 50%–103%]) to a greater extent, with smaller increases in PHD (+54% [95% CI, 39%–70%]). The risk of PHD following ART steadily increased independent of gestation order.

Introduction: Resistant hypertension is related to sympathetic overdrive and arterial stiffening, while there are scarce data whether metabolic syndrome further potentiates sympathetic activity and vascular abnormalities in this setting. Hypothesis: The aim of this study was to assess the effect of the metabolic syndrome on muscle sympathetic nerve activity (MSNA) and arterial stiffness in resistant hypertensive patients. Method: We studied 24 patients with resistant hypertension [age: 58±10 years, 15 males, office blood pressure (BP): 178/94±15/12 mmHg, 24-hour BP: 149/84±15/11 mmHg, under 4.2±0.5 drugs] that underwent transthoracic echocardiographic study and blood sampling for assessment of the metabolic profile. Metabolic syndrome was defined according to the Adult Treatment Panel III criteria and arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV). In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Results: Resistant hypertensive patients with metabolic syndrome (n=11) compared to those without (n=13) exhibited higher waist circumference (108.1±5.4 vs 94.6±9.2 cm, p=0.001), fasting glucose (131.8±2.9 vs 94.6±2.1 mg/dl, p Conclusions: In resistant hypertensive patients, metabolic syndrome is associated with high MSNA and PWV levels. These findings support that metabolic syndrome further deteriorates sympathetic activity and arterial stiffening characterizing resistant hypertension.

Introduction: The relationship of renal haemodynamics with cardiac and aortic hameodynamics is still unclear. Hypothesis: We evaluated the relationship of increased renal resistive index (RRI) with Augmentation index (AIx) and cardiac haemodynamics by means of mitral annular early diastolic velocity (E/Ea) in untreated patients with essential hypertension. Methods: 76 newly diagnosed untreated non diabetic patients with stage I-II essential hypertension [35 males, aged 50 years, office blood pressure (BP) = 143/ 91 mm Hg], underwent ABPM, complete echocardiographic study for determination of E/Ea and blood sampling for assessment of metabolic profile. Moreover, data on renal resistive index (RRI), obtained by Doppler ultrasound sampling of the intrarenal arteries, as well as augmentation index (AIx), were retrospectively analyzed. Results: Based on the mean value of RRI (0.60), hypertensives were classified into those with high and low RRI. Hypertensives with high RRI values compared to those with low values were older (55.6±9.8 vs 44.4±11.6 years, p < 0.001), had lower 24-hour diastolic BP (77.5±7.7 vs 84.3±6.7 mmHg, p < 0.001), lower 24-hour HR (71.2±10.3 vs 76.2±9.2 bpm, p < 0.05), higher levels of AIx (27.2±8.2 vs 17.8±14.8 %, p < 0.01), and higher values of E/Ea (lateral) (7.7±1.8 vs 6.2±2.3, p < 0.05). In the total population, RRI was negatively related to 24-hour diastolic BP (r = -0.523, p < 0.001) and 24-hour HR (r = -0.281, p < 0.05), while it was positively associated with CRP (r = 0.335, p < 0.05), TChol (r = 0.296, p < 0.01), age (r = 0.443, r < 0.001), AIx (r = 0.413, p = 0.001) and E/Ea(lateral) (r = 0.465, p < 0.05). Multiple regression analysis revealed that 24-hour diastolic BP and E/Ea (lateral) were independent associated with RRI (R2 = 0.434, p < 0.05). Conclusions: Increased vascular resistance of intrarenal arteries is associated with impaired aortic and cardiac haemodynamics, as reflected by increased AIx and E/Ea (lateral) values. RRI may be considered a useful surrogate of haemodynamics in essential hypertension.

Percutaneous catheter-based transluminal renal nerve ablation (RNA) by delivery of radiofrequency energy constitutes a novel therapeutic strategy for the treatment of resistant hypertension. The sympathetic nervous activation to the kidney and the sensory afferent signals to the central nervous system represent the targets of RNA. In this review we summarize current recommendations for appropriate patient selection for RNA and multimodal strategies in order to optimize pharmacological treatment for resistant hypertension. The safety and efficacy of the RNA based on published trials are also presented. Furthermore, a detailed description of the periprocedural management, the methodology of the RNA procedure and appropriate follow-up are provided. In conclusion, in order to improve the overall clinical outcome and achieve optimal management of resistant hypertensive patients before and after the RNA, experienced and certified centers are of major importance.

Emerging evidence suggests that the soluble receptor for advanced glycation end-products (sRAGE) is implicated in the development of vascular disease. We investigated the interrelationships of sRAGE with albumin to creatinine ratio (ACR) and arterial stiffness in essential hypertension.In 309 untreated non-diabetic hypertensives, ACR values were determined as the mean of three non-consecutive morning spot urine samples and aortic stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (c-f PWV). In all subjects, venous blood sampling was performed for the estimation of sRAGE levels. Patients with low (n = 155) compared to those with high sRAGE values (n = 154) had greater 24-h systolic BP (140 ± 8 vs. 134 ± 7 mmHg, p0.0001), exhibited higher ACR (36.3 ± 51.6 vs. 17.2 ± 1.2 mg g(-1), p0.0001) and c-f PWV (8.3 ± 1.5 vs. 7.8 ± 1.1 m s(-1), p = 0.003), independently of confounding factors. Multiple regression analyses revealed that age, male sex, 24-h systolic BP and sRAGE were the 'independent correlates' of ACR (R(2) = 0.493, p0.0001), while age, 24-h systolic BP and sRAGE were the 'independent correlates' of c-f PWV (R(2) = 0.428, p0.0001).In hypertensives, decreased sRAGE levels are accompanied by pronounced albuminuria and arterial stiffening. The association of sRAGE with ACR and c-f PWV suggests involvement of sRAGE in the progression of hypertensive vascular damage.

Objective:Hypertension is a multisystem disease in which the kidney plays a key role in long term regulation of blood pressure and the development of hypertension. The aim of this study was to evaluate the role of intrarenal resistance indices in the renal interlobular arteries measured by Doppler u

Little is known regarding the clinical course and prognosis of resistant hypertension (RHT). We evaluated predictors of persistent RHT and the associated cardiovascular risk. We studied 1,911 treated hypertensive patients (aged 59±11 years, 49% males) for a mean period of 3.9 years. At baseline

Purpose: Patients with Obstructive Sleep Apnea (OSA) are often hypertensive, and Continuous Positive Airway Pressure (CPAP) may improve at least the circadian profile of blood pressure (BP). As asymptomatic patients with OSA often refuse to follow CPAP treatment, we investigated the efficacy of antihypertensive drug chronotherapy on BP management in this setting. Methods: In a cross-over trial, we studied 40 patients (aged 52±9 years, 77% males) with newly diagnosed hypertension and never treated, at least moderate OSA (apnea-hypopnea index-AHI: 37±20/hour), without daytime sleepiness (Epworth Score ≤10 points). Patients were first applied treatment with valsartan (± amlodipine) in a single morning dose for 8-weeks. In a second period of 8-weeks, patients were assigned to receive the same regimen in a single evening dose before bedtime. Office and ambulatory BP were measured at baseline and after each treatment phase. Based on concurrent start of CPAP application, patients were divided into two groups: on-CPAP (n=19) and off-CPAP (n=21). Results: Office BP was significantly reduced at the end of both the morning and evening dose phases compared to baseline (by 19.5±11.0/15.0±8.6 mmHg and 23.1±11/16.5±8.4 mmHg, repeated measures ANOVA p

The long-term efficiency of CPAP on BP management of hypertensive patients with OSA on top of optimal antihypertensive medication has not been investigated. We prospectively studied 91 non-sleepy patients (aged 54±9 years, 69 males) with essential hypertension and newly diagnosed moderate-to