Abstract
The 7th Meeting on Hypertension and Atherosclerosis was organized in collaboration with the Society of Hypertension and Atherosclerosis and endorsed by the European Society of Hypertension. From basic sciences to clinical aspects, the congress covered the wide spectrum of cardiovascular health, providing a venue for the conversation of scientists from all around the world. At the end of the 5 days, participants had the opportunity discuss the main topics and updates on hypertension and atherosclerosis.
Hypertension is one of the most important areas in public health owing to its high prevalence, related risk factors, morbidity and mortality. Its importance stimulates research and cooperation between clinicians and investigators from multiple disciplines. On this basis, the 7th Meeting on Hypertension and Atherosclerosis was organized in collaboration with the Society of Hypertension and Atherosclerosis and endorsed by the European Society of Hypertension. The scientific program included lectures on hot topics, oral presentations, posters, video sessions, educational activities and satellite symposia.
The 5-day-long meeting started with a lecture from Serap Erdine (Istanbul University, Istanbul, Turkey) on blood pressure (BP) control. She stated that with the current evidence available, BP reduction, regardless of the antihypertensive drug, results in improvement in cardiovascular protection. Combining antihypertensive drugs is usually required in order to control BP. Questions still waiting to be answered were discussed in detail. Discussion focused on initiating antihypertensive therapy in low-risk hypertensive patients and BP goals in diabetic patients and in the elderly.
Michael H Olsen (Glostrup University Hospital, Glostrup, Denmark) presented his group’s recent trial on the prognostic importance of reduction of the urine albumin/creatinine ratio (UACR) during antihypertensive treatment. They found that N-terminal pro-brain natriuretic peptide was related to hemodynamic cardiovascular risk factors, reflecting myocardial hypertrophy and heart failure; high-sensitivity C-reactive protein was related to metabolic cardiovascular risk factors reflecting early atherosclerosis; and UACR was related to hemodynamic as well as metabolic risk factors reflecting early (endothelial dysfunction) as well as later (microvascular damage) atherosclerosis. Reduction in UACR during antihypertensive treatment was associated with improved prognosis independently of changes in blood pressure and left ventricular hypertrophy.
The presentation on the ‘role of early subclinical markers in the management of hypertension’ by Denis L Clement (University of Ghent, Ghent, Belgium) began with an explanation of the term ‘subclinical’; it was defined as organ damage, even when it had not yet come to a clinical level. Markers of subclinical organ damage such as microalbuminuria, left ventricular hypertrophy in electrocardiography, peripheral artery disease measured by ankle brachial artery pressure index and early atherosclerosis determined by fundoscopy could bring in a large amount of new information on long-term prognosis. Analysis of these changes could lead to much earlier treatment, hopefully more effectively preventing the hypertensive changes in the cardiovascular system that cause long-term events.
Michel Burnier (Centre Hospitalier Universitarie Vaudois, Lausanne, Switzerland) extended our knowledge about night-time blood pressure in renal disease. He explained that in recent years, several studies have examined the determinants of night-time BP in humans, and more recent concepts suggest that the nondipping pattern is associated with a reduced capacity to excrete sodium during daytime and hence to maintain an adequate sodium balance during the day. This might explain why, as renal function decreases in chronic kidney disease, night-time BP tends to increases and the normal dipping pattern disappears. More recent studies have now demonstrated that the absence of a physiological dip of BP at night is associated with a worse prognosis of renal disease; furthermore, these patients have more progression of their disease.
Fetal environmental roots of high BP is one of the most interesting areas of hypertension study, and was discussed by Empar Lurbe (University of Valencia, Valencia, Spain). She explained that during childhood there was a mismatch between the conditions that the fetus was programmed for in utero and the environment that the child met. Consequently, BP was influenced by both size at birth, as well as by weight gain in childhood. The adverse effects of excessive weight gain on BP, and the association of weight gain with a higher incidence of hypertension later in life, represented major issues in healthcare. Indeed, because of the increasing tendency of obesity to appear during childhood and to track, to some extent, into adult life, children with low birthweight who became obese could be at particularly high risk for an undesired increase in BP.
The role of calcium antagonists in antihypertensive treatment and renal function was discussed in depth by José L Rodicio (12 de Octubre Hospital, Madrid, Spain). Benefits of calcium antagonists in stroke prevention, their superiority to β-blockers and diuretics as supported by some other trials and their better efficacy in combination therapies with ACE inhibitors than ACE inhibitor plus diuretic combinations as supported by the Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension (ACCOMPLISH) trial were discussed.
Josep Redon’s (University of Valencia, Valencia, Spain) presentation on ‘Stroke and Hypertension in Europe’ gave information about the prevalence of hypertension and stroke in European countries, and their associations between different social, cultural and economic properties. The data presented in his speech clearly demonstrated the necessity to adopt actions to increase the diagnosis, treatment and control of hypertension in countries where the burden of hypertension sequelae were still growing. Policies to increase the rate of BP control offer the best approach, while primary prevention strategies must also be implemented.
Serap Erdine presented the results of the the Survey of Health, Ageing and Retirement in Europe (SHARE) study, which investigated perceptions about guideline-recommended BP targets and provided a Turkish perspective on the burden of ‘challenging patients’ in hypertension management. Turkish physicians were more familiar with the European Society of Hypertension (ESH)–European Society of Cardiology (ESC) guidelines than with other treatment guidelines, finding the former the most helpful in relation to their day-to-day clinical practice. Most Turkish physicians agreed with the ESH–ESC BP targets, but 50% found it difficult to get their patients to these targets in practice. Turkish physicians were found to be underestimating the number of their patients who were challenging patients; that is, the proportion of their patients who were not achieving BP of less than 140/90 mmHg. Challenging patients had a higher risk of cardiovascular events and often required more frequent return examinations than those with controlled BP and, therefore, by underestimating the number of challenging patients, physicians were also underestimating the burden associated with these patients.
The methods and design of the Challenges in the Design and Conduct of Cluster Randomized Trial to Compare Treatment Strategies for Coronary Risk Reduction (CRUCIAL) trial were presented by Serap Erdine. The trial is a prospective, multinational, open-label, 12-month cluster randomized study comparing a new treatment strategy based on the systematic and simultaneous reduction in BP and cholesterol using single-pill amlodipine-besylate/atorvastatin-calcium with usual care.
Left ventricular hypertrophy and cardiac remodeling in hypertension was discussed by Zehra Buğra (Istanbul University, Istanbul, Turkey), including topics ranging from pathophysiology and echocardiographic appearance to recent related clinical trials. Clinical and echocardiographic studies have shown that the majority of patients with untreated hypertension have normal left ventricular geometry, and the remaining samples were distributed among the categories of concentric remodeling, eccentric hypertrophy and concentric hypertrophy in variable percentages for each study. The effects of left ventricular hypertrophy and geometric remodeling on prognosis were taken into account in a number of studies. In The Framingham Heart Study, subjects with concentric hypertrophy had the worst prognosis, followed by those with eccentric hypertrophy, concentric remodeling and normal geometry. The The Multi-Ethnic Study of Atherosclerosis (MESA) evaluated the relationship of left ventricular mass and geometry measured with cardiac MRI to incident cardiovascular events. Patients with increased left ventricular mass had the strongest association with incident heart failure events, stroke and coronary heart disease, and concentric remodeling was found to be predictive of stroke and coronary heart disease. In patients with hypertension and high-risk acute myocardial infarction, baseline left ventricular mass and geometry had prognostic implications. In the Valsartan in Acute Myocardial Infarction Trial (VALIANT) Echocardiography Study, concentric hypertrophy carried the greatest risk of adverse cardiovascular events including death. In the Framingham Heart Study, a substudy of the Losartan Intervention for Endpoint Reduction (LIFE) trial and several other studies had shown that regression of left ventricular hypertrophy was associated with a reduced risk of cardiovascular morbidity and mortality.
Kalina Kawecka-Jaszcz (Jagiellonian University Medical College, Krakow, Poland) shared updated data and her own experiences about the effect of the menopause on cardiovascular risk. Women showed a steeper increase in systolic blood pressure after menopause, but whether this was due to the effect of age or menopause was debated because cross-sectional and longitudinal studies that have explored this issue have obtained diverging results. During the transition from premenopause to postmenopause, many women experienced weight gain and central fat deposition. Recently published data indicate that age-related weight gain may also importantly influence cardiovascular risk profile in perimenopausal women. The results of their own studies showed that menopause did not influence blood pressure but affected global cardiovascular risk via metabolic changes and influence on subclinical organ damage. The decrease in left ventricular diastolic function observed in postmenopausal women as well as subclinical atherosclerosis might link the complex relationship between menopause, hypertension, aging and cardiovascular morbidity in the female population.
One of the popular issues in the pathophysiology of hypertension is its interactions with the sympathetic nervous system, as discussed by Krzysztof Narkiewicz (Medical University of Gdańsk, Gdańsk, Poland). Increment in adrenergic activity in hypertensive patients was supported by several lines of evidence. Mechanisms are usually divided into two:
• Disturbed regulation in the peripheral nervous system such as arterial baroreceptors, cardiopulmonary mechanoreceptors and chemoreceptors;
• Increase in sympathetic activity in the CNS.
The sympathetic nervous system was found to act like a bridge between mental stress and hypertension. Adrenergic activation was of crucial importance, not only in hypertension, but also in metabolic syndrome, obstructive sleep apnea, congestive heart failure and chronic kidney disease. The renin–angiotensin–aldosterone system (RAAS) and the sympathetic nervous system was thought to be the common pathway in these diseases. Pharmacological blockade of the RAAS and sympathetic systems was therapeutic in different ways.
Guiseppe Mancia (University of Milano-Bicocca, Milan, Italy) gave a detailed lecture on the updated hypertension guidelines, and focused on comparing changes in 2009 from the 2007 edition of the guidelines.
Peter Nilsson (Lund University Hospital, Malmö, Sweden) defined early vascular ageing (EVA) as a more rapid deposition of lipids in the vessel wall and the formation of atherosclerosis in some subjects with a high risk for cardiovascular disease (CVD) events, and often a positive family history for CVD. EVA could be measured by simple pulse pressure determination based on office blood pressure, ankle–brachial pressure measurement, ultrasound evaluation of early atherosclerosis and measurement of pulse wave velocity by special devices, which were all included in the reappraisal of European guidelines on hypertension as subclinical organ damage measurement techniques. The concept of EVA syndrome was useful owing to the ability to increase awareness of the pathophysiological consequences of a heavy cardiovascular risk factor burden for CVD. Being aware of risk factors’ cluster and a broad evaluation of them would provide long-term benefits.
Sleep apnea syndrome’s (SAS) relationship with cardiovascular mortality and morbidity was evaluated by Ali Serdar Fak (Marmara University, Istanbul, Turkey). He noted that the severity of hypertension seems to be related to the existence and the severity of SAS in recent international guidelines. SAS was accepted to be a cause of hypertension and also a cause of resistant hypertension. Patients with SAS have been shown to have several hemodynamic disturbances such as an increased risk of isolated diastolic hypertension, decreased relative risk interval, increased blood pressure variability and the loss of nocturnal decrease in blood pressure. In addition to hemodynamic disturbances, patients with SAS had an increased risk of left ventricular hypertrophy even after the adjustment for hypertension. Treatment includes sleep postural changes, other lifestyle modifications and continuous positive airway pressure treatment, which has been more widely used in recent years.
Conclusion
The purpose of the Hypertension and Atherosclerosis Congress was to draw attention to the importance of hypertension as a public health problem, an area of investigation and a multidisciplinary science, by hosting scientists from all around the world. The meeting successfuly covered information about cardiovascular health, updated our knowledge of hypertension and acted as a perfect venue to host discussions between scientists from around the world.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.