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Importance Modern data regarding incidence and modes of death of patients with aortic stenosis (AS) are restricted to tertiary centers or studies of aortic valve replacement (AVR). Objective To provide new insights into the natural history of outpatients with native AS based on a large regionwide population study with inclusion by all cardiologists regardless of their mode of practice. Design, Setting, and Participants Between May 2016 and December 2017, consecutive outpatients with mild (peak aortic velocity, 2.5-2.9 m/s), moderate (peak aortic velocity, 3-3.9 m/s), and severe (peak aortic velocity, ≥4 m/s) native AS graded by echocardiography were included by 117 cardiologists from the Nord-Pas-de-Calais region in France. Analysis took place between August and November 2020. Main Outcomes and Measures Natural history, need for AVR, and survival of patients with AS were followed up. Indications for AVR were based on current guideline recommendations. Results Among 2703 patients (mean [SD] age, 76.0 [10.8] years; 1260 [46.6%] women), 233 (8.6%) were recruited in a university public hospital, 757 (28%) in nonuniversity public hospitals, and 1713 (63.4%) by cardiologists working in private practice. A total of 1154 patients (42.7%) had mild, 1122 (41.5%) had moderate, and 427 (15.8%) had severe AS. During a median (interquartile range) of 2.1 (1.4-2.7) years, 634 patients underwent AVR and 448 died prior to AVR. Most deaths were cardiovascular (200 [44.7%]), mainly associated with congestive heart failure (101 [22.6%]) or sudden death (60 [13.4%]). Deaths were noncardiovascular in 186 patients (41.5%) and from unknown causes in 62 patients (13.8%). Compared with patients with mild AS, there was increased cardiovascular mortality in those with moderate (hazard ratio, 1.47 [95% CI, 1.07-2.02]) and severe (hazard ratio, 3.66 [95% CI, 2.52-5.31]) AS. The differences remained significant when adjusted for baseline characteristics or in time-dependent analyses considering AS progression. In asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality (hazard ratio, 0.99 [95% CI, 0.44-2.21]). Conclusions and Relevance While patients in this study with moderate AS had a slightly higher risk of cardiovascular death than patients with mild AS, this risk was much lower than that observed in patients with severe AS. Moreover, in asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality.

Pascal Delsart1, Philippe Marboeuf1, Cedric Delhaye2, Gilles Lemesle2, Claire Mounier-Vehier11Service de Médecine Vasculaire et Hypertension Artérielle, 2Service d’hémodynamique et de Cardiologie B, University Hospital of Lille, FranceBackground: The influence of hypertension on cardiovascular risk is well known. Ambulatory blood pressure measurement (ABPM) is able to identify patients with masked hypertension (MH) underdetected by clinical BP measurement. The benefit of screening for MH in a highrisk population was investigated.Aims: To detect MH in a population with no prior history of hypertension and medically treated for peripheral or coronary arterial disease.Methods: Thirty-eight consecutive patients with peripheral or coronary artery disease documented with arteriography, without a history of hypertension, and with an admission BP < 140/90 mmHg underwent ABPM after discharge. Ambulatory BP ≥ 125/80 mmHg were defined as MH.Results: MH was found in 11 patients (28.9%). The MH group had a mean systolic and diastolic hospitalization BP significantly higher (127 versus 115 mmHg, respectively, P = 0.002 and 76 versus 66 mmHg, P = 0.01), and tended to have a higher admission systolic BP and pulse pressure (127 versus 121 mmHg, respectively, P = 0.07; and 54 versus 46 mmHg, P = 0.06). The first BP measurement on the 24-hour ABPM was significantly higher in the MH group 140 versus 121 mmHg, P = 0.001, for systolic BP and 84 versus 74 mmHg, P = 0.03, for diastolic BP.Conclusions: MH was found in patients with documented and medically treated vascular disease. BP in the prehypertensive range is associated with MH. Systematic screening for MH in this high-risk population requires further investigation.Keywords: blood pressure, monitoring, masked hypertension, vascular disease

Resume Introduction En l’absence de traitement specifique, des patients ayant une maladie vasculorenale developpent une atrophie renale. Cette population presente frequemment une hypertension refractaire au traitement medical. Les patients potentiellement repondeurs a une revascularisation ou a l’extreme a une nephrectomie necessitent d’etre identifies pour optimiser la prise en charge therapeutique. Methodes Nous avons realise une etude retrospective observationnelle sur les patients hypertendus avec atrophie renale unilaterale (hauteur renale Resultats La periode de suivi etait en moyenne de 1,3 ± 0,2 ans. Huit patients etaient traites medicalement (groupe 1). Les sujets dont la fonction du rein atrophique representait plus de 10 % de la fonction renale totale et une stenose de l’artere renale (> 70 %) etaient revascularises par voie endovasculaire (groupe 2, n = 19). Ceux ayant un petit rein non fonctionnel ( 1,5 par rapport au rein controlateral) ont fait l’objet d’une nephrectomie (groupe 3, n = 8). Les reductions de la pression arterielle systolique (PAS) et de la pression arterielle diastolique (PAD) ont ete respectivement de 27 et 14 mmHg sur l’ensemble de la population etudiee (p Conclusion Les resultats de ce travail soulignent l’importance d’une prise en charge pluridisciplinaire des patients porteurs de petits reins ischemiques. Une preselection des patients en situation clinique desequilibree (HTA resistante, insuffisance renale evolutive, œdeme aigu du poumon flash ) par une evaluation renale isotopique et endocrinienne permet d’etayer la decision therapeutique. L’existence d’un ratio de renine (>1,5) permet en effet d’identifier les patients les plus « repondeurs » a la nephrectomie. Il faut prendre en compte l’amputation de la fonction renale suite a la nephrectomie dans la discussion therapeutique. Le seuil fonctionnel initialement defini a 10 % pourrait etre rabaisse a 5 %, pour limiter l’amputation de la fonction renale postoperatoire.

Obstructive sleep apnea (OSA) is the most common factor involved in uncontrolled blood pressure (BP). Management of OSA is part of cardiologist work. We have few data on BP control in a population of OSA followed by cardiologists. We evaluated the prevalence of effective BP control using ambulatory measurement in a population of patients followed in cardiology. Data from 69 OSA patients treated for more than 6 months by continuous positive airway pressure (CPAP) were collected prospectively from March 2012 until December 2012. These patients were divided into 2 groups according to the results of 24-h ambulatory BP monitoring (ABPM). Controlled BP was defined as a 24 h BP

Background and design: The effects of aspirin on blood pressure (BP) are controversial and a chronopharmacological effect of aspirin on 24-hour BP was reported recently in otherwise untreated hypertensive patients. The study was designed to test the timing effect of aspirin dosing on 24-hour BP in treated hypertensive patients routinely taking aspirin for cardiovascular prevention.Method and results: Seventy-five patients were randomized into two groups. One group was to receive aspirin in the evening then in the morning for 1 month and the other group in the morning then in the evening, following a cross-over design. The principal assessment criterion was 24-hour systolic BP (SBP) measured by 24-hour ambulatory BP monitoring (ABPM). Patients were aged 65 ± 9 years and had been hypertensive for 12 ± 10 years. They were all taking a mean of 2.8 antihypertensive drugs and did not modify their treatment throughout the study. Of the included subjects, 70% were men and 33% were diabetics. Mean 24-hour SBP values were clinically equivalent and were not statistically different, depending on whether the aspirin was taking in the morning or evening (128.3 ± 1.4 vs. 128.3 ± 1.4 mmHg, respectively). Neither was there any significant difference in diurnal and nocturnal SBP or in 24-hour, diurnal, and nocturnal diastolic BP (DBP).Conclusion: It does not appear useful to advise patients with long-standing hypertension to modify timing of aspirin intake in order to reduce BP values.

Inferior vena cava agenesis (IVCA) is a rare condition, found in almost 5% of patients under 30 years old with unprovoked deep venous thrombosis (DVT). We describe 10 consecutive patients with IVCA-associated DVT and conducted an extensive literature review to investigate the typical spectrum of IVCA-associated DVT. Among our patients (eight men and two women; mean age, 25 ± 4.5 years), DVT followed intense and unusual (major) physical activity for eight of them. DVT was bilateral in six patients and unilateral in four. Ultrasonography was unable to detect IVCA, which was visualized by computed-tomography scans for seven patients, and magnetic resonance imaging and angiography for 10. Hereditary thrombophilia screening, to detect factor V Leiden or prothrombin gene heterozygosity (G20210A mutation), was positive for only two patients. Wearing elastic stockings and taking an indefinite or long-term vitamin K antagonist were prescribed for all 10 patients and nine complied with the latter. To date, 62 patients with IVCA-associated DVT have been reported in the English literature. Analysis of them and our patients yielded a typical spectrum of IVCA-associated DVT characteristics: IVCA occurs in young adults, particularly males, and is revealed by proximal DVT following major physical exertion. All were treated with a prolonged vitamin K antagonist and advised to wear elastic stockings. No precise duration of anticoagulation has been established.

Aims The metabolic syndrome (MS) is associated with an increased cardiovascular risk. Patients with the MS have endothelial dysfunction, decreased circulating adiponectin, and a high expression of angiogenic inhibitors such as plasminogen activator inhibitor-1 (PAI-1). We hypothesized that such patients, in the event of a coronary occlusion, might exhibit a less developed collateral circulation. Methods and results Three hundred and eighty-seven consecutive patients with at least one coronary occlusion of a major coronary vessel at diagnostic angiography were prospectively enrolled. Collateral development was graded with validated angiographic methods. The MS was defined according to the ATP-III definition. Fasting glucose, adiponectin, insulin concentrations, and PAI-1 were measured at the time of angiography. MS was associated with less developed collateral vessels ( P = 0.005). In multivariable analysis adjusting for potential confounding factors including the duration of coronary occlusion ( P = 0.0001), fasting glycaemia ( P = 0.0007), low adiponectin concentration ( P = 0.01), insulin-resistance (HOMA-IR; P = 0.01), high circulating PAI-1 concentration ( P = 0.01), and hypertension ( P = 0.008) were independently associated with poor coronary collateral vessel development. Conclusion This study shows that in patients with coronary occlusion, collateral circulation is impaired in patients with the MS. This association is partly related to fasting glycaemia and to key parameters linked to insulin resistance.

In the absence of specific treatment, patients with renal vascular disease develop renal atrophy. This population frequently has hypertension refractory to medical treatment. The patients who may respond to revascularization or at the worst to a nephrectomy must be identified to optimize their therapeutic management.We conducted an observational retrospective study of hypertensive patients with unilateral renal atrophy (renal height9 cm) followed at the Lille University Hospital Center from 1998 to 2006. Hypertension, renal clearance (by scintigraphy with MAG3), and hypersecretion of renin (segmental/selective venous renin samples) were studied. We subsequently classified the patients into 3 groups. Medical treatment was optimized for all.The mean follow-up period was 1.3+/-0.2 years. Eight patients were treated medically (group 1). Endovascular revascularization was used to treat the subjects for which atrophic kidney function accounted for more than 10% of their total renal function and with stenosis of the renal artery (70%) (group 2, n=19). Those with a small nonfunctional kidney (10% of total renal function) and hypersecretion of renin (ratio1.5 in relation to the contralateral kidney) underwent a nephrectomy (group 3, n=8). The reduction in systolic blood pressure (SBP) was 27 mm Hg and diastolic blood pressure (DBP) 14 mm Hg for the overall study population (p0.001), without any significant aggravation of renal function. In group 1, the reduction in blood pressure was lower, with medical treatment alone; SBP fell by 13 mm Hg and DBP by 4mm Hg (p=ns) ; this group had the lowest initial blood pressure. In group 2, revascularization made it possible to improve SBP by 26 mm Hg and DBP by 14 mm Hg (p0.01) without significant impairment of renal function. Group 3 showed the most spectacular improvement in blood pressure, with SBP dropping by 40 mm Hg and DBP by 19 mm Hg (p=0.016). But it was also in this group that we observed an aggravation in the rate of glomerular filtration with a nonsignificant reduction of 12.8 mL/min, nonetheless superior to that expected according to the preoperative scintigraphy.The results of this work underline the importance of multidisciplinary management of patients with small ischemic kidneys. Preselection of patients in unstable clinical situations (refractory hypertension, progressive kidney failure, flash pulmonary edema) by isotopic and endocrinal renal evaluation provides a basis for deciding on treatment. The existence of a renin ratio1.5 can identify the patients most likely to respond to nephrectomy. The reduction of renal function following nephrectomy must be considered in the discussion about treatment. The functional threshold initially defined at 10% may be lowered to 5%, to limit this postoperative reduction.

Background Aortic dissection is a well rare disease with pour mid and long term prognosis. The treatment of initial phase of acute aortic syndrom (AAS) affecting the descending aorta is essentially based on lowering blood pressure and on relieving pain. The emergence of endovascular therapy offers new perspectives in the management of this old disease. Few data exist on the long term prognosis of patients who discharge alive after a medical treatment of a type B AAS. The aim of our study was to determine factors of the acute phase associated with adverse long term survival. Methods and Results We study the long term outcome of 77 patients, hospitalized in our center from 1996 to 2008, who discharge alive after type B AAS. All patients received a medical treatment and an endovascular therapy if needed. The mean follow-up period was 50.8 month, with a survival rate of 78%. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality from any cause. Factors that influence the mortality (p Conclusion Patients who discharge alive after medically treated type B acute aortic disease keep a worse mid and long term prognosis. Our study identifies new risk factors of mortality after discharge, and a population at very high risk. The treatment of the acute phase needs further study to better understand and optimize care of this patients.

Objective In this study we investigated the interest to detect masked hypertension (MH) in a population of patients with no prior history of hypertension, at very high cardiovascular risk and who received hypotensive medications prescribed for their vascular disease, as angiotensin- converting enzyme inhibitor (ACE). Design and Method In this prospective study, 38 patients were send to our unit for the realisation of a coronarography or an arteriography. Subjects have no prior history of hypertension, with a blood pressure (BP) at admission under 140/90 mmHg, and documented vascular disease. They underwent a 24-h ambulatory BP monitoring(ABMP) after discharge. Subjects who showed normotension at admission and an ambulatory BP under 125/80 mmHg on the 24-h ABMP were considered as normotensive (NT). Subjects who showed normotension at admission and an ambulatory BP upper or equal to 125/80mmHg were defined as MH. Results MH was found in 11 patients, represented 28.9% of our population. The prevalence of MH was significantly higher in subjects whose mean systolic BP and mean diastolic BP (127.2 mmHg vs 115.8 mmHg, p=0.002 and 76.1 mmHg vs 66.6 mmHg, p=0.01) during the hospitalisation than the confirmed NT did. At admission the systolic BP and the pulse pressure tend to be higher in the MH group than in the NT group (127.5 mmHg vs 121 mmHg, p= 0.07 and 54.5 mmHg vs 46.7 mmHg,p=0.06). The first measurement of blood pressure of the 24-h ABPM, who was considered as a pressure of consultation, was significantly higher in the MH group than in the NT group (140 mmHg vs 121 mmHg, p = 0.001 for the systolic BP and 84 mmHg vs 74 mmHg, p=0.03, for the diastolic BP). Conclusions MH is frequent in our population with a documented vascular disease under medication, with no prior history of hypertension. The screening of MH hypertension in this population seems to be necessary. The pre hypertensive rank seems to be a good predictor of MH.