Management of High Blood Pressure in Peripheral Arterial Disease

Arterial hypertension (HTA) is a promoter of peripheral arterial disease (PAD) in association with other atherosclerotic risk factors. Systolic HTA is the most frequently noted form in such disease, secondary to marked increase in large artery stiffness.

The existence of PAD confers on the hypertensive patient a very high cardiovascular (CV) risk, requiring an intensive global therapeutical approach. Treating HtA is one of such beneficial actions. The optimal blood pressure (BP) to be reached is at least < 140/90 mmHg but lower BP should be targeted if possible (< 130/80 mmHg). First of all, a modification of the lifestyle and diet should be proposed. But to reach such a low target, different antihypertensive agents must be very often used in association. The inhibitors of the renin-angiotensin system constitute one of the main axis of such drug treatment, after having avoided the pitfall of renal artery stenosis.     

Commentary on the 2014 BP Guidelines from the Panel Appointed to the Eighth Joint National Committee (JNC 8)

The recently published article “2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8)” (James et al., JAMA 311: 507–520, 2014) has generated considerable controversy. In this commentary, we evaluate the document and compare the recommendations contained within it with those of the JNC 7 and other national and international guidelines. The evidence quality rating approach followed by the article “2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8)” (James et al., JAMA 311: 507–520, 2014) disqualified nearly 98% of previous studies from review; as a result, some of the key recommendations were on the basis of expert opinion alone. We are especially concerned that the recommendation to raise the systolic/diastolic BP levels at which treatment is initiated to ≥150/≥90 mmHg in adults≥60 years old may affect cardiovascular and renal health in these patients. Additionally, we recommend that hypertension guidelines should be updated every 3–4 years with a fresh approach to the definition of target BP levels, the use of modern technology in the diagnosis of hypertension, and the treatment of hypertension in special populations not addressed in earlier guidelines.     

Effects of Intensive Blood Pressure Treatment on Acute Kidney Injury Events in the Systolic Blood Pressure Intervention Trial (SPRINT)

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Effect of Intensive Blood Pressure Lowering on Kidney Tubule Injury: Findings From the ACCORD Trial Study Participants

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Recruitment experiences in a stress incontinence clinical trial

Major delays and subsequent alterations in randomized controlled clinical trials have been attributed to poor or failed recruitment. This paper presents the recruitment methods used successfully to obtain a homogenous sample of females with stress urinary incontinence. This sample was recruited to investigate the effectiveness of a behavioral treatment. Recruitment methods and their cost effectiveness are presented for the trial's three year duration. Yields are presented as ratios of recruited/randomized subjects. Analysis showed professional referrals to have the lowest cost/yield, while newspaper advertisement produced the highest recruited/subject retention. As a result of this trial's experiences recommendations were made for differing recruitment strategies according to source/yield with additional special plans for recruiting elderly, lower income, inner city, or minority subjects.     

Effects of Intensive Blood Pressure Lowering on Kidney Tubule Injury in CKD: A Longitudinal Subgroup Analysis in SPRINT

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Liver resection for hepatocellular carcinoma in patients with portal hypertension: the role of laparoscopy

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is a major issue since patients are at risk of serious intraoperative and postoperative complications. The current EASL/AASLD guidelines recommend LR only in case of patients with stage A HCC with well-preserved liver function and consider the presence of portal hypertension (PHT) as a contraindication to surgery. Nevertheless, the literature on this topic is conflicting. Recently several studies reported that favorable outcomes can be achieved with a careful patients’ selection in high volume centers. Laparoscopic LR, when performed by well-trained surgeons and with appropriate indications, proved to be a valid option for the surgical treatment of HCC on cirrhosis offering similar oncologic outcomes but a reduction in surgical related morbidities. Laparoscopic LR thanks to a reduction in the incidence of post-operative liver failure and ascites development in comparison to standard open LR could, in selected cases challenge alternative treatments in the treatment of HCC patients with preserved liver function and clinical signs of mild PHT.     

Elevated BP after AKI

The connection between AKI and BP elevation is unclear. We conducted a retrospective cohort study to evaluate whether AKI in the hospital is independently associated with BP elevation during the first 2 years after discharge among previously normotensive adults. We studied adult members of Kaiser Permanente Northern California, a large integrated health care delivery system, who were hospitalized between 2008 and 2011, had available preadmission serum creatinine and BP measures, and were not known to be hypertensive or have BP>140/90 mmHg. Among 43,611 eligible patients, 2451 experienced AKI defined using observed changes in serum creatinine concentration measured during hospitalization. Survivors of AKI were more likely than those without AKI to have elevated BP—defined as documented BP>140/90 mmHg measured during an ambulatory, nonemergency department visit—during follow-up (46.1% versus 41.2% at 730 days; P<0.001). This difference was evident within the first 180 days (30.6% versus 23.1%; P<0.001). In multivariable models, AKI was independently associated with a 22% (95% confidence interval, 12% to 33%) increase in the odds of developing elevated BP during follow-up, with higher adjusted odds with more severe AKI. Results were similar in sensitivity analyses when elevated BP was defined as having at least two BP readings of >140/90 mmHg or those with evidence of CKD were excluded. We conclude that AKI is an independent risk factor for subsequent development of elevated BP. Preventing AKI during a hospitalization may have clinical and public health benefits beyond the immediate hospitalization.     

Inequality in access to CABG and PCI

Abstract

Non-inferiority trials are questionable when death and serious complications are included among outcomes. The term itself “non-inferiority” is misleading, since such a study would not demonstrate that a new treatment is non-inferior to a control treatment, but simply that the inferiority would not reach a pre-specified level, deemed as acceptable by the designers of the trial. Group cross-over, assay-sensitivity and the need of a placebo arm are major issues for the reliability of non-inferiority trials.

The SYNTAX trial for severe coronary artery disease was designed on a non-inferiority margin of 6.6%. In this paper we show that the SYNTAX designers were ready to accept up to 30% higher rate of death and major adverse events to claim the non-inferiority of percutaneous coronary intervention versus coronary artery bypass grafting. Eventually the SYNTAX study failed because percutaneous patients sustained an even higher rate of adverse events. We propose major caution in performing non-inferiority randomized trials.     

Clinical significance of removal of tumor thrombi in the main portal vein in patients with hepatocellular carcinoma

Twenty-two patients with portal vein tumor thrombi secondary to hepatocellular carcinoma were studied to evaluate the effectiveness of diagnostic and treatment procedures. B-mode ultrasonography is a simple and accurate means for the detection of tumor thrombus in the portal vein. All of the 22 patients were correctly diagnosed by this method, which should be used as the initial screening procedure in such patients. Fourteen of the 22 patients underwent surgical procedures, including embolectomy from the portal trunk; removal of the tumor thrombi combined with hepatectomy or through the rechanneled umbilical vein; and operative transcatheter arterial chemotherapy. The other 8 patients were treated by transcatheter arterial embolization or were not treated. The surgical treatment effectively prevented acute variceal bleeding in the patients who underwent the procedures successfully. The mean value of the portal venous pressure was reduced from 46 cmH₂O to 32 cmH₂O after the surgery. As a result of the effective portal decompression, the patients in the surgical group had a better prognosis and longer mean survival than the others. Our study suggests that portal vein tumor thrombus is not an absolute contraindication for surgery, and that accurate detection and prompt treatment are the keys to the achievement of better clinical results.     

Reduction of left ventricular hypertrophy in children undergoing hemodialysis

Left ventricular hypertrophy (LVH) is related to a 1,000-fold increased risk of cardiovascular morbidity and mortality in young adults with end-stage renal disease (ESRD) treated with hemodialysis (HD) or peritoneal dialysis. We report a series of 17 children (5 girls, 12 boys), with a median (range) age of 11 (2–18) years, all treated by HD, who presented with an increased left ventricular mass (LVM) index of 54.8±4.5 g/m^2.7 at onset of HD and reached 36.2±2.6 g/m^2.7 (mean±SEM, P<0.0001) at last follow up. Over the observation period, systolic (P<0.0001) and diastolic (P<0.0001) blood pressure (indexed for height, gender, and age) decreased and hemoglobin (+2.8 g/dL; P<0.0001) increased compared to initial values. Only BP as well as plasma protein level at onset of HD session correlated with LVM in multiple correlation analysis. In conclusion, increased LVM is a common feature in pediatric patients with ESRD. Normalization of BP and reduction of the extracellular volume (represented by plasma protein at onset of HD session) are key points in reducing LVH during HD in children.     

Intramedullary nailing versus proximal plating in the management of closed extra-articular proximal tibial fracture: a randomized controlled trial

BackgroundExtra-articular proximal tibial fractures account for 5–11 % of all tibial shaft fractures. In recent years, closed reduction and minimally invasive plating and multidirectional locked intramedullary nailing have both become widely used treatment modalities for proximal and distal tibial metaphyseal fractures. This study was performed to compare plating and nailing options in proximal tibia extra-articular fractures.ResultsPostoperative hospital stay (p = 0.035), time to full weight-bearing, and union time (p = 0.004) were significantly less in the IMN group than in the PTP group, but there was no clear advantage of either technique in terms of operative time (p = 0.082), infection rate (p = 0.738), range of motion of the knee (p = 0.462), or degrees of malunion and nonunion.ConclusionBoth implants have shown promising results in extra-articular proximal tibial fractures, and provide rigid fixation that prevents secondary fracture collapse.

Level of evidence

Level 2, randomized controlled trial.