Cardiovascular risk stratification and antihypertensive therapy according to guidelines in the outpatient setting.

UNLABELLED: BASIC CONCEPTS AND METHODOLOGY: Acceptance of the ESH/ESC 2007 hypertension guidelines and their reappraisal 2009 are not known by Austrian practitioners. Therefore, within the frame of a noninterventional trial we investigated 3,488 ambulatory hypertensive patients. Primary goal was the evaluation of the assignment to cardiovascular risk categories according to the ESH/ESC charts by office-based physicians compared to an independent risk adjudication using the same data and method. Further goals were assessment of compliance with the recommendation to start combination treatment in grade 2 and 3 hypertension and efficacy and tolerability of treatment with candesartan. RESULTS: The comparison revealed incorrect physicians' risk assessment for approximately 60% of the patients with a strong tendency for underestimation. Despite guidelines recommending an initial combination therapy for hypertension ≥160/90 mmHg, 15.4% of these patients still received candesartan as a monotherapy. Target blood pressure ≤140/90 mmHg could be well achieved (in 81.6%) with candesartan as monotherapy or combined with hydrochlorothiazide (HCTZ) for hypertension grade 1-3. CONCLUSIONS: Guidelines for assessment of individual risk and derived therapy algorithms should be better communicated in the outpatient setting. Candesartan alone or combined with HCTZ is an effective and well tolerated therapeutic option to control blood pressure in the majority of patients.

[Treatment of hypertension in diabetic patients]. / Therapie der Hypertonie bei Diabetikern.

Hypertension, diabetes and visceral adiposity are very common co-morbidities with an exceedingly high risk of cardiovascular and renal complications. Therefore, emphatic treatment is necessary. Blood pressure goal is recommended below 130/80 mmHg with office measurements, and less than 7 out of 30 values below 135/85 mmHg with home measurements. Strict blood pressure control reduces macro- and microvascular morbidity. Usually combination of different drugs is necessary to achieve a satisfactory blood pressure control. First line should be an inhibitor of the RAS, commonly combined with a calcium channel blocker and/or a diuretic. Fixed-dose combinations are recommended. If indicated or necessary, newer generation betablockers may be given as an adjunct. Life style measures and active reduction of further risk factors are essential.

[Achievement of blood lipid target levels with Ezetimibe/Simvastatin in patients with atherosclerosis and/or diabetes mellitus--an Austrian observational study]. / Zielwerterreichung unter lipidsenkender Therapie mit Ezetimib/Simvastatin bei Patienten mit Atherosklerose und/oder Diabetes mellitus--eine österreichische Anwendungsbeobachtung.

BACKGROUND: In patients at risk for cardiovascular complications, established LDL cholesterol (LDL-C) target levels are frequently not achieved using standard statin therapy regimens. The additional lipid-lowering efficacy of the fixed combination ezetimibe/simvastatin was evaluated in a countrywide non-interventional observational study in Austria. METHODS: About 3,156 subjects with clinically manifest atherosclerosis and/or diabetes at high cardiovascular risk and with LDL-C-levels >113 mg/dl under statin therapy met the inclusion criteria and 2,903 of these patients were treated by primary care physicians, in hospitals and in rehabilitation centers with 10 mg ezetimibe and 10-40 mg simvastatin daily in a fixed-combination tablet (Inegy). RESULTS: During the follow-up period of 4-12 weeks, LDL-C levels were reduced by a median of 27-31% of baseline values (mean 153.1 +/- 33.5 mg/dl) mainly regardless of previous statin therapy (rosuvastatin, atorvastatin, simvastatin, pravastatin, fluvastatin, and lovastatin) and dosing (pooled median values). LDL-C reduction correlated proportional with baseline LDL-C values and increased with increasing simvastatin dosage. Overall, 45.3% (10/10 mg), 43.9% (10/20 mg) and 62.7% (10/40 mg ezetimibe/simvastatin) achieved LDL-C target levels of <100 mg/dl. CONCLUSIONS: The fixed combination therapy with ezetimibe/simvastatin showed a clinically significant additional lipid-lowering potential as compared with established statin monotherapies and enabled more patients at cardiovascular risk to reach the LDL-C target level of <100 mg/dl.

[Austrian Consensus on High Blood Pressure 2019]. / Österreichischer Blutdruckkonsens 2019.

Elevated blood pressure remains a major cause of cardiovascular disease, disability, and premature death in Austria, with suboptimal rates of detection, treatment and control also in recent years. Management of hypertension is a common challenge for physicians with different spezializations. In an attempt to standardize diagnostic and therapeutic strategies and, ultimately, to increase the rate of patients with controlled blood pressure and to decrease the burden of cardiovascular disease, 13 Austrian medical societies reviewed the evidence regarding prevention, detection, workup, treatment and consequences of high blood pressure in general and in various clinical scenarios. The result is presented as the first national consensus on blood pressure. The authors and societies involved are convinced that a joint national effort is needed to decrease hypertension-related morbidity and mortality in our country.

"Oldest old" patients in intensive care: prognosis and therapeutic activity.

OBJECTIVE: In view of ethical considerations and the limited resources in intensive care medicine, the present investigation aims to give a descriptive overview of the prognosis and therapeutic activity for the oldest age group of elderly patients admitted to an intensive care unit (ICU) in comparison with younger ICU patients. PATIENTS AND METHODS: 3069 patients admitted to the ICU during a seven-year period were categorized into four age groups: under 65 years (48%), 65 to 74 years (26%), 75 to 85 years (22%) and 85 years or older (5%). Type and reason for ICU admission, length of ICU stay, severity of illness as measured by the simplified acute physiology score (SAPS)-II, level of provided care as measured by the simplified therapeutic intervention scoring system (TISS)-28, and vital status at the date of ICU discharge were recorded. RESULTS: The ICU mortality rate of patients aged 85 years or older was significantly higher than in patients under 65 (OR of mortality: 1.8, p < 0.001). Non-survivors had higher SAPS II levels (even when excluding age points) in all age groups, but higher daily average TISS points only in patients under 85. The daily average TISS score was negatively correlated to age (r = -0.03; p < 0.001) and was significantly lower in the oldest group when compared with all the younger groups (p < 0.001). The oldest patients had a significantly shorter length of stay (median: 2; interquartile range [IQR] 1-3, p < 0.001) than the younger patient groups. CONCLUSIONS: Within the very elderly population, age is an important and independent predictor of mortality, but acute severity of illness is even more strongly associated with mortality. Consequently, age alone may be an inappropriate criterion for allocation of ICU resources.

Hypertension and coronary artery disease: epidemiology, physiology, effects of treatment, and recommendations : A joint scientific statement from the Austrian Society of Cardiology and the Austrian Society of Hypertension.

High blood pressure is a major modifiable risk factor for all clinical manifestations of coronary artery disease (CAD). In people without known cardiovascular disease, the lowest systolic (down to 90-114 mmHg) and the lowest diastolic (down to 60-74 mmHg) pressures are associated with the lowest risk for developing CAD. Although diastolic blood pressure is the strongest predictor of CAD in younger and middle-aged people, this relationship becomes inverted and pulse pressure shows the strongest direct relationship with CAD in people above 60 years of age.Pathophysiological mechanisms of blood pressure as a risk factor for CAD are complex and include the influence of blood pressure as a physical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion. Treatment of arterial hypertension has been proven to prevent coronary events in patients without clinical CAD. In patients with established CAD, the effect of blood pressure lowering per se is beneficial, probably more than specific drugs or drug classes. The important exceptions are beta blockers (BBs), which are superior to all other drug classes for use after a recent myocardial infarction. Blood pressure targets in patients with established CAD have created controversy in the light of the so-called J-curve phenomenon, which describes an increase in coronary events at lower diastolic blood pressures. One explanation for this observation is that perfusion of the left ventricle occurs predominantly during diastole, and that coronary autoregulation may be exhausted with low diastolic blood pressure in the setting of left ventricular hypertrophy and atherosclerotic narrowing of the epicardial coronaries. The worst situation is a high systolic blood pressure in the presence of a low diastolic blood pressure, both a hallmark of increased aortic stiffness. However, the lowering of systolic blood pressure is clearly beneficial in this setting, even at the price of further lowering diastolic pressure. Primary blood pressure goal in patients with established CAD is below 140/90 mmHg. Recent studies suggest that a lower systolic blood pressure may be appropriate, whereas caution is advised with diastolic blood pressure below 60 mmHg.

Endurance running acutely raises plasma osteoprotegerin and lowers plasma receptor activator of nuclear factor kappa B ligand.

Abstract The balance of the 2 cytokines, osteoprotegerin (OPG) and the receptor activator of nuclear factor kappa B ligand (soluble (s)RANKL), is known to have considerable influence on bone formation and degradation. Plasma concentrations of OPG and (s)RANKL were determined in a total of 31 long-distance runners before and immediately after running distances of either 15 or 42.195 km, respectively. In both groups of endurance runners, a significant decrease of sRANKL was observed during the run, the extent of which correlated to the running distance. Furthermore, OPG increased only in runners covering the marathon distance of 42.195 km. We hypothesize that the known positive effect of long-distance running on the skeletal mass may be mediated by the OPG/sRANKL system.

Increases in plasma levels of atrial and brain natriuretic peptides after running a marathon: are their effects partly counterbalanced by adrenocortical steroids?

OBJECTIVE: Long-distance running results in considerable stress. Little evidence exists about the role of the atrial and brain natriuretic peptides, ANP and BNP, deriving from the myocardium. The aim of our study was to investigate the influence of running 42.195 km on changes in circulating natriuretic propeptides and adrenocortical steroids. DESIGN AND METHODS: We studied 17 male and 2 female runners (age: 28-62 Years) participating in a marathon. Blood samples were obtained before and immediately after the competition. proANP(1-98) and proANP(1-30) as well as Nt-proBNP(8-29) were determined by enzyme immunoassays. RESULTS: Runners finished the competition between 2 h 58 min and 4 h 25 min. We observed a more pronounced increase in proANP(1-98) (+58%) and proANP(1-30) (+99%, both P<0.001) compared with Nt-proBNP(8-29) (+6%; P=0.005). Increases in proANP(1-30) positively correlated with runners' age (r=0.53; P=0.02). We also observed a marked increase in cortisol (+73%) and especially in aldosterone (+431%, both P<0.001). CONCLUSIONS: Cardiac strain during long-distance running may explain the pronounced increase in proANP. Other explanations for the observed rise in plasma levels might be a change in the permeability of myocardial cells and an impaired clearance. A rise in adrenocortical steroids may compensate for the negative influence of ANP on natriuresis and blood pressure. Positive effects of ANP during a marathon could be the regulation of body temperature by influencing sweat glands as well as the stimulation of lipolysis compensating for the enormous energy demand.

[Blood pressure goals on the test bench]. / Blutdruck Zielwerte auf dem Prüfstand.

There is little evidence from controlled prospective studies to support the low blood pressure goals stipulated for the treatment of hypertension by present guidelines, especially in high-risk patients with diabetes, renal insufficiency or coronary heart disease. Aim of this review is to scrutinize the potential benefit and risk of low blood pressure on the basis of recent studies and secondary analyses of older studies. RESULTS: In patients with coronary heart disease or equivalent or with diabetes lowering systolic blood pressure to 130 to 135 mmHg reduced primary or secondary cardiovascular endpoints in the majority of studies. Between 120 and 129 mmHg some positive effects could be shown in patients with coronary heart disease but not in patients with diabetes or metabolic syndrome. In patients with diabetic or nondiabetic nephropathy including those with proteinurea no convincing data exist which show a better outcome with systolic blood pressure below 130 versus below 140 mmHg. However, several studies suggest that the risk of stroke may decrease by lowering systolic pressure to 120 mmHg or even lower. Below 120 mmHg an increased risk of cardiac and noncardiac events or death was shown in quite a number of studies. In patients between 70 and 80 years, current evidence suggests lowering systolic blood pressure to 135 to 145 mmHg and in those above 80 years to 145 to 155 mmHg. No evidence was found to justify different diastolic pressure goals for different groups of patients; optimal values fall between 70 and 85 mmHg. Limitations of recent studies are short follow-up, few event rates and small differences in achieved pressure between groups leaving uncertainty about long-term effects. PRACTICAL CONSEQUENCES: Apart from prevention of stroke there is sparse evidence that lowering systolic blood pressure below 130 mmHg may be beneficial. Current evidence suggests that lowering systolic and diastolic pressure into a range of 130 to 140/70 to 85 may be adequate for all patients with the exception of children, adolescents and patients over 80 years. Further lowering of systolic pressure seems to offer little additional benefit and lowering diastolic pressure below 70 mmHg might increase risk.

[Hypertension and overweight]. / Hochdruck und Adipositas.

Obesity shows a strong association with hypertension, primarily due to secretion of an abundance of para- and endocrine peptides by the visceral adipose tissue that play a key role in the pathogenesis of high blood pressure and are responsible for the accelerated atherothrombosis encountered in overweight individuals. Increased activity of the RAAS and the sympathetic nerve system are the main pathophysiologic factors; hypertension in obese subjects is characterized by increased peripheral arterial resistance, high cardiac output, hypervolemia and salt sensitivity. Medical therapy sees blockade of the RAAS in front. Priority in treatment should be given to improvements in life style, primarily in increasing physical activity and decreasing caloric intake, and to medical treatment of associated risk factors according to the modern concept of global risk management.

Stroke in diabetic and non-diabetic patients: course and prognostic value of admission serum glucose.

BACKGROUND, AIMS: Whether diabetes mellitus affects the prognosis of stroke patients, and whether admission hyperglycemia influences prognosis similarly in diabetic as in non-diabetic patients is assessed controversially. The aims of the study were: 1) to compare the course of diabetic and non-diabetic acute stroke patients, and 2) to assess the influence of admission serum glucose levels on case fatality. METHODS: In 57 Austrian medical departments the hospital course of consecutive stroke patients was documented prospectively between June 1999 and October 2000. RESULTS: Two hundred and ninety-six (30%) of 992 patients had a history of diabetes mellitus. Intracerebral hemorrhage was more frequent in non-diabetic patients than diabetic (13% versus 5%, P=0.0001). Coronary heart disease was more frequent in diabetic than in non-diabetic patients (35% versus 24%, P=0.0003). The case fatality was 18% among non-diabetic and 16% among diabetic patients (P=0.3559). Among patients who were discharged alive, the Barthel Index increased from 50 to 90 in non-diabetic and from 45 to 75 in diabetic patients (P=0.0403). In non-diabetic patients, admission serum glucose>9.2 mmol/L was associated with a more than 4-fold increase in case fatality, compared with patients with serum glucose<5.7 mmol/L (P<0.0001). CONCLUSIONS: Diabetic stroke patients need special care since they tend to have a poorer recovery than non-diabetic patients. Admission hyperglycemia in non-diabetic acute stroke patients predicts a poor prognosis.

Intracranial pressure monitoring and case mix-adjusted mortality in intracranial hemorrhage.

OBJECTIVE: Intracranial pressure (ICP) monitoring is frequently used in intensive care treatment of patients with intracranial hemorrhage. Data demonstrating an improved outcome from this intervention are lacking. We analyzed standardized mortality ratios in patients with and without ICP monitoring to determine its efficacy. DESIGN: A nonrandomized study of case records of consecutively admitted intensive care unit (ICU) patients with intracranial hemorrhage. SETTING: General and medical ICU of a 900-bed tertiary-care hospital. PATIENTS: A total of 225 patients with intracranial hemorrhage (mainly nontraumatic) admitted consecutively between April 1997 and March 2000. MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, diagnosis, age, sex, use of ICP monitoring, and in-hospital mortality rates were collected from the hospital's ICU database. Expected mortality was provided by means of SAPS II. Standardized mortality ratios were calculated and compared in 119 patients with ICP monitoring and 106 patients without ICP monitoring. MAIN RESULTS: The case mix-adjusted hospital mortality in the group with ICP monitoring was in the expected range (standardized mortality ratio, 1.09 [95% confidence interval (CI), 0.87-1.31]). Patients without ICP monitoring had a significantly higher standardized mortality ratio than expected (1.26 [95% CI, 1.06-1.46]). CONCLUSIONS: A beneficial effect of ICP monitoring in patients with intracranial hemorrhage may be reflected in an improved standardized mortality ratio.

Problems, interventions and complications in long-term oral anticoagulation therapy.

BACKGROUND: If problems, interventions and complications occurring during oral anticoagulation (OAC) are related with age, indication for OAC, hypertension, diabetes, previous stroke, and number of additional drugs. MATERIAL AND METHODS: Clinical characteristics, additional drugs, problems, interventions and complications of outpatients whose OAC was controlled between two years were registered. Potential gastrointestinal and urologic bleeding sources were eliminated prior to initiation of OAC. Five-hundred-seventy-nine patients (mean age 65 years, 44% female) were observed for 590 patient-years. RESULTS: Medical problems occurred in 352/100 patient-years (% p-y), organisational problems in 276% p-y, interventions in 636% p-y and complications in 13.8% p-y. Patients >65 years had less organisational problems (254 vs. 302% p-y, p = 0.0092) and interventions (574 vs. 713% p-y, p = 0.0003) than patients < or =65 years. The 35 patients with heart valve prosthesis had more life-threatening and fatal complications (12% p-y) than the 360 patients with atrial fibrillation (1.0% p-y), 128 patients with venous thromboembolism or 56 patients with other indications (0.0% p-y, p = 0.0024). Problems, interventions and complications were not related with hypertension (n = 297), diabetes (n = 97) or previous stroke (n = 90). Patients with >3 additional drugs/day had a higher complication rate than patients with < or =3 drugs/day (21 vs. 8.7% p-y, p = 0.0238). Patients with complications had more headache (27 vs. 20% p-y, p = 0.0036), chest pain (45 vs. 27% p-y, p = 0.0150), abdominal pain (25 vs. 15% p-y, p = 0.0350) and pain in the limbs (55 vs. 42% p-y, p = 0.0044) than patients without complications. CONCLUSIONS: By careful monitoring, eliminating potential bleeding sources, treating pain adequately and minimizing additional drugs the complications of OAC can be kept low.

Stroke patients with atrial fibrillation have a worse prognosis than patients without: data from the Austrian Stroke registry.

AIMS: Stroke patients with atrial fibrillation (AF) have a poorer neurological outcome than stroke patients without AF. Whether stroke patients with AF also have a higher rate of medical complications is unknown. The aim of the study was to compare the in-hospital course of acute stroke patients with and without AF. METHODS AND RESULTS: The Austrian Stroke registry was a prospective multi-centre study involving 57 medical departments documenting the hospital course of consecutive stroke patients from June 1999 to October 2000. AF was diagnosed in 304 (31%) of 992 patients. Patients with AF were older (79 versus 75 years, p < 0.0004) than no-AF patients. There were more cases of pneumonia (23% versus 9%, p < 0.0004), pulmonary oedema (12% versus 6%, p < 0.0004) and symptomatic intracerebral haemorrhage (8% versus 2%, p < 0.0004) in AF compared to no-AF. In-hospital mortality was higher in AF (25% versus 14%, p < 0.0004), and neurological outcome was poorer (65 versus 90 Barthel index, p < 0.0004). On multivariable logistic regression analysis, however, AF was no predictor for mortality, but a Barthel index of zero (odds ratio 5.30, 95% CI 3.10-9.08, p < 0.0001), a National Institutes of Health Stroke Scale > 21 or comatose (odds ratio 3.13, 95% CI 2.26-4.32, p < 0.0001), age > 75 years (odds ratio 3.15, 95% CI 1.85-5.37, p < 0.0001), heart rate > 100 min(-1) (odds ratio 2.15, 95% CI 1.26-3.66, p = 0.0049), obstructive pulmonary disease (odds ratio 2.58, 95% CI 1.03-6.48, p = 0.0442) and creatinine > 125 micromol/l (odds ratio 1.84, 95% CI 1.00-3.37, p = 0.0479). CONCLUSION: Stroke in AF is associated with a poor prognosis, an increased rate of medical and neurological complications and a higher in-hospital mortality than in no-AF.