Percutaneous cutting balloon angioplasty for the treatment of renovascular hypertension in children and adolescents.

OBJECTIVE: Percutaneous transluminal renal angioplasty (PTRA), the recommended treatment in children with renovascular hypertension (RVH), often has unsatisfactory outcomes. Cutting balloons may improve the results of angioplasty in different vascular beds with complex and resistant lesions. We retrospectively analysed the effects of percutaneous cutting balloon angioplasty (PCBA) on blood pressure, cardiac mass and renal artery acceleration time in children/adolescents referred to our centre for RVH. PATIENTS AND METHODS: Thirteen patients (aged 9-19 years) with renal artery stenosis (RAS) and severe hypertension were identified. RASs were focal fibromuscular (FMD) or FMD-like dysplasia (in six cases bilateral, in five associated with mid aortic syndrome). Ten patients had uncontrolled hypertension, in nine cases associated with left ventricular hypertrophy (LVH). Acceleration time was abnormal in all stenotic arteries. Eighteen PCBA were performed, in three arteries associated with stent implantation. RESULTS: PCBA was technically successful in all individuals without major complications. In one patient, an intra-stent restenosis occurred, successfully redilated with conventional angioplasty without recurrence at 4 years distance. One year after PCBA, mean SBP and DBPs were markedly reduced from 146 ±â€Š25 to 121 ±â€Š10 mmHg and from 87 ±â€Š11 to 65 ±â€Š12 mmHg, respectively ( P  < 0.001 for both). At that time, hypertension was cured in seven children and controlled in five individuals. This favourable outcome was confirmed with ambulatory blood pressure measurement in four patients. At the latest follow-up, left ventricular mass and acceleration time were normal in all patients. CONCLUSION: PCBA proved to be a well tolerated and effective procedure that can be considered as an alternative to PTRA to treat hypertensive children/adolescents with recurrent or resistant RAS.

May Measurement Month 2018: an analysis of blood pressure screening results from Italy.

Cardiovascular (CV) diseases are burdened by high mortality and morbidity, being responsible for half of the deaths in Europe. Although hypertension is recognized as the most important CV risk factor, hypertension awareness and blood pressure (BP) control are still unsatisfactory. In 2017, 30.6% of a >10 000 individual sample who took part in the May Measurement Month (MMM) campaign in Italy was found to have high BP. To raise awareness on the hypertension issue and to report BP data on a nation-wide scale in Italy. In the frame of the MMM campaign, an opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2018. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. Screenings were conducted in multiple sites by health care personnel. Among the 5554 people screened (females: 48.3%, mean age 58 ± 17 years) mean BP was 127/77 mmHg, and after imputations, 1462 (26.3%) participants were found to have high BP levels. Body mass index >25 was associated with higher systolic BP and diastolic BP (DBP), while diabetes was associated with high DBP only. Our data provide a nation-wide snapshot of BP control in a sample of individuals participating in a national health care campaign, and confirm the power of this kind of healthcare-related activities in reaching a significant number of people to raise awareness on health topics. The apparent positive trend in BP control compared to available data from other similar campaigns carried out during the past years needs to be confirmed with more methodologically robust studies.

Genetics, prevalence, screening and confirmation of primary aldosteronism: a position statement and consensus of the Working Group on Endocrine Hypertension of The European Society of Hypertension.

: Autonomous aldosterone overproduction represents the underlying condition of 5-10% of patients with arterial hypertension and carries a significant burden of mortality and morbidity. The diagnostic algorithm for primary aldosteronism is sequentially based on hormonal tests (screening and confirmation tests), followed by lateralization studies (adrenal CT scanning and adrenal venous sampling) to distinguish between unilateral and bilateral disease. Despite the recommendations of the Endocrine Society guideline, primary aldosteronism is largely underdiagnosed and undertreated with high between-centre heterogeneity. Experts from the European Society of Hypertension have critically reviewed the available literature and prepared a consensus document constituting two articles to summarize current knowledge on the epidemiology, diagnosis, treatment, and complications of primary aldosteronism.

The 2020 Italian Society of Arterial Hypertension (SIIA) practical guidelines for the management of primary aldosteronism.

BACKGROUND AND AIM: Considering the amount of novel knowledge generated in the last five years, a team of experienced hypertensionlogists was assembled to furnish updated clinical practice guidelines for the management of primary aldosteronism. METHODS: To identify the most relevant studies, the authors utilized a systematic literature review in international databases by applying the PICO strategy, and then they were required to make use of only those meeting predefined quality criteria. For studies of diagnostic tests, only those that fulfilled the Standards for Reporting of Diagnostic Accuracy recommendations were considered. RESULTS: Each section was jointly prepared by at least two co-authors, who provided Class of Recommendation and Level of Evidence following the American Heart Association methodology. The guidelines were sponsored by the Italian Society of Arterial Hypertension and underwent two rounds of revision, eventually reexamined by an External Committee. They were presented and thoroughly discussed in two face-to-face meetings with all co-authors and then presented on occasion of the 36th Italian Society of Arterial Hypertension meeting in order to gather further feedbacks by all members. The text amended according to these feedbacks was subjected to a further peer review. CONCLUSIONS: After this process, substantial updated information was generated, which could simplify the diagnosis of primary aldosteronism and assist practicing physicians in optimizing treatment and follow-up of patients with one of the most common curable causes of arterial hypertension.

First International Consensus on the diagnosis and management of fibromuscular dysplasia.

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

First international consensus on the diagnosis and management of fibromuscular dysplasia.

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

Aldosterone-to-renin ratio depends on age and sex in children attending a clinic for cardiovascular risk assessment.

OBJECTIVE: To determine plasma aldosterone concentration (PAC) and plasma renin concentration (PRC) and aldosterone-to-renin ratio (ARR) values in a population attending a Clinic for Cardiovascular Risk Assessment in Children. METHODS: We assessed ARR and associated factors in a cohort of 287 children (137 female, 4-18 years). Weight and blood pressure (BP) were recorded. PAC (ng/dl) and PRC (mU/l) were measured using direct immunochemiluminescent assays. Data were examined by sex and according to four age classes. RESULTS: Median PAC was similar from the youngest to the oldest age class ranging from 7.5 to 9.9 ng/dl in males and from 11.0 to 12.6 ng/dl in females. Median PRC was also similar across age classes in males ranging from 58.2 to 55.5 mU/l, whereas it progressively decreased from 61.5 to 36.6 mU/l in females (P < 0.01). Median PRC was higher in prepubertal than in pubertal females only (53.6 vs. 40.2 mU/l, P < 0.03). As a result ARR was unchanged with increasing age in males (from 0.18 to 0.19), whereas in females it increased from 0.19 to 0.36 (P < 0.03). After adjusting for body weight, BP and other possible confounders, age was inversely related with PRC and directly with PAC and ARR (P < 0.001 for all), in females only. No relationship was found in both sexes between ARR values, BP, weight and family history of hypertension. CONCLUSION: In our children population, ARR is lower than in adults and diverges with increasing age between sexes, due to the age and puberty driven fall in PRC observed only in females. BP and weight are not associated with ARR distribution.

Resistant hypertension: Renal denervation or intensified medical treatment?

Resistant hypertension (RH) can be diagnosed if blood pressure (BP) is not controlled with the combination of three antihypertensive drugs, including a diuretic, all at effective doses. Patients affected by this condition exhibit a marked increase in the risk of cardiovascular and renal morbid and fatal events. They also exhibit an increased activity of the sympathetic nervous system which is likely to importantly contribute at the renal and other vascular levels to the hypertensive state. Almost 10years ago renal denervation (RDN) by radiofrequency thermal energy delivery to the walls of the renal arteries was proposed for the treatment of RH. Several uncontrolled studies initially reported that this procedure substantially reduced the elevated BP values but this conclusion has not been supported by a recent randomized control trial, which has almost marginalized this therapeutic approach. A revival, however, is under way because of recent positive findings and technical improvement that hold promise to make renal denervation more complete. The antihypertensive efficacy and overall validity of RDN will have to be tested against drug treatment of RH. Several studies indicate that an excess of aldosterone production contributes to RH and recent evidence documents indisputably that anti-aldosterone agents such as spironolactone can effectively control BP in many RH patients, although with some side effects that require close patients' monitoring. At present, it is advisable to treat RH with the addition of an anti-aldosterone agent. If BP control is not achieved or serious side effects become manifest RDN may then be considered.

Nocturnal Blood Pressure Dipping is Abolished in Old-Elderly Hospitalized Patients.

INTRODUCTION: During sleep there is reduction of blood pressure (BP) caused by a decrease of the sympathetic nervous tone. This nocturnal "dipping" phenomenon, assessable with ambulatory blood pressure monitoring (ABPM), is blunted with increasing age. AIM: To assess the effect of hospitalization on night-time BP fall in old-elderly patients. METHODS: We analysed 78 ABPM of old-elderly hospitalized patients (mean age 91 ± 0.5 years) and those of 18 outpatients as control group. The nocturnal BP fall was assessed calculating: the dipping value (DV) i.e. the difference between mean diurnal systolic BP (mDSBP) and mean nocturnal systolic BP (mNSBP) and the "dipping pattern" i.e. mNSBP/mDSBPx100. RESULTS: Hospitalized patients showed a lower rate of normal dipping patterns (9 vs. 39%), an higher rate of reverse dippers (59 vs. 28%; p < 0.05) and a lower DV (-0.9 ± 1 vs. 9 ± 4 mmHg; p < 0.05) than patients of control group. At multivariate regression analysis including age, gender and hospitalization, DV was significantly correlated only with the hospitalization (ß -0.3, t -2.9; p < 0.05). CONCLUSIONS: In old-elderly hospitalized patients nocturnal BP fall is abolished. This enhancement of the age related reduction of nocturnal BP dipping may be due to the stress associated with hospital environment.

ABPM Induced Alarm Reaction: A Possible Cause of Overestimation of Daytime Blood Pressure Values Reduced By Treatment with Beta-Blockers.

INTRODUCTION: Alarm reaction to clinical blood pressure (BP) measurement, defined white-coat effect (WCE), can cause overestimation of true BP values. AIM: To assess whether ambulatory blood pressure monitoring (ABPM) can similarly affect BP values during the initial hours of recording. METHODS: In 420 ABPMs selected for a first systolic BP (SBP) reading at least 10 mmHg higher than the mean daytime SBP, we calculated mean diurnal and 24 h SBP with and without the exclusion of the two first hours of recording defined as the WCE window (WCEw). We also calculated the magnitude and duration of WCE. These analyses were also performed separately in patients off anti-hypertensive treatment (n = 156), and on treatment with and without the inclusion of beta-blockers (respectively n = 113 and 151). RESULTS: Exclusion of WCEw period reduced mean diurnal and 24 h SBP respectively from 135 ± 0.5 to 133 ± 0.5 (p < 0.01) and from 131 ± 0.5 to 130 ± 0.5 (p < 0.02). As a result the percentage of patients diagnosed as having diurnal or 24 h hypertension was reduced respectively from 48 to 40 % and from 52 to 47 %. The magnitude of WCEw was similar in both genders but the duration was longer in females (66 ± 2 vs. 56 ± 2 min, p < 0.01). Treatment with beta-blockers was associated with a shorter duration of WCE in both genders but this effect was statistically significant only in males. CONCLUSIONS: In some patients ABPM is not free from WCE. WCE may affect the overall estimation of BP profile and is longer but less blunted by beta-blockers in females than in males.

Clinical validation for the aldosterone-to-renin ratio and aldosterone suppression testing using simultaneous fully automated chemiluminescence immunoassays.

BACKGROUND: As larger numbers of hypertensive patients are screened for primary aldosteronism with the aldosterone-to-renin ratio (ARR), automated analyzers present a practical solution for many laboratories. We report the method-specific ARR cutoff determined with direct, automated chemiluminescence immunoassays allowing the simultaneous measurement of plasma aldosterone concentrations (PACs) and plasma renin concentrations (PRCs). METHODS: Method comparisons to commonly employed assays and tandem mass spectrometry were undertaken. Patients were previously diagnosed based on the local ARR cutoff of 1.2 (ng/dl)/(µIU/ml) in samples collected in upright seated position. Lack of aldosterone suppression in response to salt load to less than 5 ng/dl confirmed primary aldosteronism. For the new assays, the optimal ARR cutoff was established in 152 patients with essential hypertension, 93 with primary aldosteronism and 147 normotensive patients. Aldosterone suppression was assessed in 73 essential hypertensive and 46 primary aldosteronism patients. RESULTS: PAC and PRC were significantly correlated to values determined with currently available methods (P < 0.001). In patients with primary aldosteronism, patients with essential hypertension and controls, mean (95% confidence interval) PAC was 28.4 (25.4-31.8), 6.4 (5.9-6.9) and 6.2 (5.6-6.9) ng/dl, respectively. In the same groups, PRC was 6.6 (5.6-7.7), 12.9 (11.2-14.8) and 26.5 (22.2-31.5) µIU/ml. An ARR cutoff of 1.12 provided 98.9% sensitivity and 78.9% specificity. Employing the new assay aldosterone suppression confirmed the diagnosis of primary aldosteronism and essential hypertension using the cutoff of 5 ng/dl. CONCLUSION: Our data demonstrate that the new assays present a convenient alternative for the measurement of PAC and PRC on a single automated analyzer. Availability of these simultaneous assays should facilitate screening and diagnosis of primary aldosteronism.

Are the antagonists of the renin-angiotensin system also anticancer agents?

The antagonists of the renin-angiotensin system (RAS) have gained increasing popularity in the last two decades due to their indisputable efficacy in a number of cardiovascular disorders, coupled with an unsurpassed tolerability. However some years ago a partial and non-predefined meta-analysis raised the possibility that angiotensin receptor antagonists in particular may increase the incidence of cancer. This observation, although not confirmed by subsequent, larger analyses, caused a remarkable and understandable concern even outside the medical community. Herein we will summarize the available evidence pro and con the hypothesis of a carcinogenetic activity of RAS antagonists coming to the conclusion that these drugs may actually exert an anticancer action.

European consensus on the diagnosis and management of fibromuscular dysplasia.

The main objectives of this expert consensus are to raise awareness about fibromuscular dysplasia, which is more frequent and more often systemic than previously thought and can sometimes have devastating consequences; to provide up-to-date recommendations for the diagnosis, evaluation, and management of the disease; and to identify research priorities. The emphasis has been put on recommendations for daily practice. The main topics covered include definition, classification, diagnosis, and management of fibromuscular dysplasia in adult patients with symptomatic involvement of the renal arteries, supra-aortic trunks, and digestive and peripheral arteries.

Measurement of plasma renin concentration instead of plasma renin activity decreases the positive aldosterone-to-renin ratio tests in treated patients with essential hypertension.

BACKGROUND: The plasma aldosterone-to-renin ratio (ARR) for the diagnosis of primary aldosteronism is normally calculated with plasma renin activity (PRA) as denominator. However, new direct renin assays that measure plasma renin concentration (PRC) are progressively replacing PRA because these are faster, simpler, and more reproducible. OBJECTIVE: To assess whether the calculation of ARR with a direct assay (ARRD, ng/dl/mU/l) instead of PRA (ARRP, ng/dl/ng/ml/h) affects the rate of positive tests in patients on liberal antihypertensive treatment. DESIGN AND PARTICIPANTS: PRA, PRC, and plasma aldosterone concentration (PAC) were measured in 88 patients with essential hypertension, both in the supine position and after 60 min of active standing while on treatment with a variety of antihypertensive medications. The same measurements were carried out, for comparison, in 10 patients with proven aldosterone-producing adenoma. SETTING: Single center, outpatient hypertension clinic in a tertiary care hospital. RESULTS: In patients with essential hypertension, median ARRP was 12 (range 0-71) in the supine position and 13 (range 0-80) after standing. The corresponding values of ARRD were 0.4 (range 0.01-3) and 0.5 (range 0.02-7.8). Between ARRP and ARRD, there was a linear, highly significant relationship both in supine and standing position (r=0.88 and r=0.92, respectively). Using as threshold of normalcy for ARRP a value less than 30, as it is recommended by guidelines, there were 13 (15%) and 18 (20%) false positives, respectively in supine and standing position, whereas with the threshold of 3.7 for ARRD, there were no false positives in recumbent position and four (5%) after standing. Accordingly, the specificity of ARRP was 0.85 and 0.78 and that of ARRD 1 and 0.95. In 10 patients with primary aldosteronism, median supine ARRP was 298 (range 48-1222) and ARRD 34 (range 2.8-244). Among these patients, no false negatives were found with ARRP and just one with ARRD. CONCLUSION: The rate of positive tests calculating ARR with PRC is lower than with PRA, the lower rate being found in patients studied in the recumbent position and apparently it is not affected by ongoing antihypertensive treatment.

Excess dietary sodium and inadequate potassium intake by hypertensive patients in Italy: results of the MINISAL-SIIA study program.

INTRODUCTION: The aim of the study was to assess the age-specific, sex-specific, and region-specific average sodium and potassium intake and its association with anthropometric characteristics in a sample of the Italian adult hypertensive population. METHODS: A total of 1232 hypertensive patients were recruited consecutively by 47 centers recognized by the Italian Society of Hypertension. The enrolled participants were on stable antihypertensive treatment. Anthropometric indices, blood pressure, 24-h urinary sodium, and potassium excretion were measured and used as proxy for the average daily sodium and potassium intake. RESULTS: The average sodium intake was 172  mmol (or 10.1  g of salt/day) among men and 138 (or 8.1) among women, with no difference among geographical areas. Over 90% of men and 81% of women had a consumption higher than the recommended standard dietary intake of 5  g/day. The average potassium intake was 63 and 56  mmol, respectively in men and women, again without geographical differences, nearly 92% of men and 95% of women having an intake lower than the recommended intake (100  mmol/day or 3.9  g/day). There was a significant trend to a gradual decrease in sodium intake with age in both sexes (P <0.001). There was also a direct association between BMI and sodium intake in both sexes, this association being independent of age (P < 0.001). CONCLUSION: In this national sample of the Italian hypertensive population, dietary sodium intake was largely higher and potassium intake much lower than the recommended intakes, and this was true for all geographical areas. Overweight and obese hypertensive patients had particularly high sodium intakes.

National survey on excellence centers and reference centers for hypertension diagnosis and treatment: geographical distribution, medical facilities and diagnostic opportunities.

INTRODUCTION: Blood pressure (BP) control is poorly achieved in Western Countries, including Italy. Several interventions have been proposed at national and local level to improve BP control rate. AIM: This survey of the Italian Society of Hypertension (SIIA) is aimed at analysing the number and the distribution of reference centers and excellence centers for the diagnosis and treatment of arterial hypertension (hypertension centers) in Italy. METHODS: In October 2011, a specifically designed survey questionnaire was developed by SIIA National Committee, both to evaluate geographical distribution of the reference hypertensive population and to assess general requirements (days of activity, number of active physicians, medical facilities, diagnostic opportunities, use of electronic support), deemed necessary to identify an outpatient clinic as hypertension center in Italy. This questionnaire was locally distributed by regional coordinators of the Society and all collected data were centrally analysed by two independent study coordinators. RESULTS: From October 2011 to September 2012, 89 centers with clinical expertise in the diagnosis and treatment of hypertension provided data on their own activity. Among these, 45 (50.5 %) centers are located in the North, 20 (22.5 %) in the Center and 24 (27.0 %) in the South of Italy. Approximately 50 % of the hypertensive outpatients who are referred from general practitioners to hypertension centers are living in the province and about one third in the region. More than half of the centers is active for 3-5 days per week, and approximately 40 % of the centers have 3-5 active physicians. Beyond outpatient visits for hypertension, these centers are able to organize day hospital (25 %), day service (29 %), or hospital admission (29 %) for advanced diagnostic evaluation or therapeutic interventions. All centers collect data from clinic and 24-hour ambulatory BP measurements, and almost all (95 %) centers are able to perform a standard 12-lead electrocardiogram. In addition, the majority of the centers are able to perform advanced diagnostic examinations, including echocardiography (74 %) or carotid Doppler ultrasound (71 %) analysis. Finally, 78 % of the centers use an electronic case report form, specifically designed for the clinical management of hypertensive patients. CONCLUSIONS: Although with some limitations related to the study methodology applied for data collection, the survey illustrates a quite unbalanced distribution of the hypertension centers, the majority of which are located in the North of Italy, with a medium-high standard of quality of care. This analysis may provide useful elements for a rational and effective use of existing resources, in order to improve BP control in our Country.