Periodontitis, Blood Pressure, and the Risk and Control of Arterial Hypertension: Epidemiological, Clinical, and Pathophysiological Aspects—Review of the Literature and Clinical Trials

Purpose of Review Arterial hypertension is an important risk factor for cardiovascular disease. In the world, about 45% of people suffer from arterial hypertension, while good blood pressure control is achieved by only approximately 50% of all hypertensive patients treated. The reason for the high prevalence of arterial hypertension and its poor control is low knowledge of hypertensinogenic factors. One such factor is periodontitis, which is a disease of social importance. Recent Findings It has been shown that the occurrence of periodontitis leads to an increase in blood pressure, increasing the risk of arterial hypertension. Periodontitis can also lead to ineffectiveness of antihypertensive treatment. Some interventional studies have shown that treatment of periodontitis reduced blood pressure in patients with arterial hypertension. The pathogenesis of arterial hypertension in periodontitis is complex and concerns mainly the impairment of the vasodilatation properties of the endothelium. Summary Hygiene and periodontitis treatment should be a method of preventing arterial hypertension and a method of increasing the effectiveness of antihypertensive treatment.

Adrenal Venous Sampling–Guided Adrenalectomy Rates in Primary Aldosteronism: Results of an International Cohort (AVSTAT)

Context Adrenal venous sampling (AVS) is the current criterion standard lateralization technique in primary aldosteronism (PA). Japanese registry data found that 30% of patients with unilateral PA did not undergo adrenalectomy, but the reasons for this and whether the same pattern is seen internationally are unknown. Objective To assess the rate of AVS-guided adrenalectomy across an international cohort and identify factors that resulted in adrenalectomy not being performed in otherwise eligible patients. Design, Setting, and Participants Retrospective, multinational, multicenter questionnaire-based survey of management of PA patients from 16 centers between 2006 and 2018. Main Outcome Measures Rates of AVS implementation, AVS success rate, diagnosis of unilateral PA, adrenalectomy rate, and reasons why adrenalectomy was not undertaken in patients with unilateral PA. Results Rates of AVS implementation, successful AVS, and unilateral disease were 66.3%, 89.3% and 36.9% respectively in 4818 patients with PA. Unilateral PA and adrenalectomy rate in unilateral PA were lower in Japanese than in European centers (24.0% vs 47.6% and 78.2% vs 91.4% respectively). The clinical reasoning for not performing adrenalectomy in unilateral PA were more likely to be physician-derived in Japan and patient-derived in Europe. Physician-derived factors included non-AVS factors, such as good blood pressure control, normokalemia, and the absence of adrenal lesions on imaging, which were present before AVS. Conclusion Considering the various unfavorable aspects of AVS, stricter implementation and consideration of surgical candidacy prior to AVS will increase its diagnostic efficiency and utility.

Abstract P232: Dilated Cardiomyopathy With Electrocardiographic Changes And Coronary-Pulmonary Fistula: An Uncommon Presentation Of Primary Aldosteronism In The Covid-19 Era

Primary aldosteronism is the most frequent forms of curable hypertension and elevated aldosterone levels have been associated with endothelial proliferation and pathological remodeling of the heart and arteries; however, coronary arterial abnormalities have never been reported in patients with primary aldosteronism. We report the case of a 53-year-old Caucasian obese man (BMI 37 Kg/m 2 ) with recent history of hypertension, fatigue and subjective dyspnea who was admitted to our hospital after performing an outpatient echocardiography that showed hypertensive and ischemic heart disease in dilated phase (LVEDVI 95 mL/m 2 ; LVEF 43%). His laboratory results showed hypokalemia (3 mmol/L) and an elevated aldosterone-renin ratio [(294 ng/L)/(1μU/mL)]. After case confirmation with saline infusion test, the abdominal CT scan showed a subcentimeter adenoma in the right adrenal gland. Surprisingly we noticed that, after oral potassium correction, the electrocardiogram revealed a symmetrical T-wave inversion and subsequently a coronary angiography detected a coronary artery fistula between the left anterior descending artery and the pulmonary artery in the absence of significant stenosis. In the Italy's CoViD-19 pandemic full spread, we preferred to postpone the diagnosis of the lateralization of aldosterone hypersecretion by adrenal vein sampling and we started a mineralocorticoid receptor antagonist with a clinical follow-up of cardiovascular symptoms for the optimal treatment of coronary artery fistula. After about two months of follow-up, the patient remains asymptomatic with good blood pressure control, normal potassium levels and significant echocardiographic improvement (LVEDVI 67 mL/m 2 ; LVEF 51%). Our case highlights a possible association between hypertensive patients with coronary artery fistulas and primary aldosteronism. We recommend cardiologists and clinicians to maintain a high level of suspicion of primary aldosteronism in these patients.

OR34-04 Efficiency of Adrenal Venous Sampling in the Treatment Choice of Primary Aldosteronism (AVSTAT Study)

BACKGROUND: Adrenal venous sampling (AVS) is strongly recommended for a subtype diagnosis of primary aldosteronism (PA) if adrenalectomy (ADX) is desired by the patient. Given various issues related to AVS such as technical demand, invasive nature, expensive cost and radiation exposure, AVS is expected to lead efficiently to the subtype diagnosis and ADX. Aim: Primary objective was to assess the performance of AVS to determine treatment of PA by investigating the ratio of unilateral disease and rate of ADX following AVS in patients with unilateral disease. Methods: Sixteen major referral centers in ENS@T (n=10) and Japan (n=6) participated in the study. Study period was from 2006 to 2018. Data on total number of PA patients, AVS (total number and number of successful procedures), number of patients with unilateral diseases, and number of patients that underwent ADX were collected by a questionnaire-based survey. In addition, reasons for not proceeding to ADX in patients with a unilateral diagnosis were investigated. The diagnosis of PA was based on the positive case detection and at least one positive result in confirmatory testing. Results: Total number of confirmed PA patients and conducted AVS showed a dramatic increase during the past decade (PA: 1061 pts/ 2006–2011 to 3718 pts/ 2012–2018; AVS: 720/ 2006–2011 to 2448/ 2012–2018). Success rate of AVS was improved from 79.0% (2006–2011) to 92.5% (2012–2018). Both rate of unilateral PA and ADX of successful procedures decreased from 42.7% (2006–2011) to 37.3% (2012–2018) and from 40.8% (2006–2011) to 34.9% (2012–2018), respectively. Of the patients with successful AVS, bilateral disease was diagnosed in 63.5% (1812/2854 pts). Of the unilateral PA patients, 11.9% (125/ 1054 pts) were not subjected to ADX. The rate of the patients not subjected to ADX was significantly higher in Japan than in ENS@T centers both in patients with successful AVS (75.8% vs. 53.4%) and with unilateral disease (19.9% vs. 8.6%). Clinical decision against ADX in unilateral disease was made by the physicians in 33.3%, the patients in 33.3%, and both in 33.3%. Medical factors for Dr.’s decision against ADX in unilateral disease included good blood pressure control, normokalemia, comorbidities (e.g. DM, CKD), non-lateralized CT findings (e.g. no tumor, contralateral tumor), and discordant results among different criteria of AVS. Conclusions: High prevalence of bilateral disease and change of treatment policy after implementation affected the efficiency of AVS as an essential diagnostic procedure prior to ADX. Development of non-invasive procedures to exclude bilateral PA and more strict indication of AVS are warranted.

Atrial fibrillation and hypertension

Hypertension is one of the most important independent risk factors for atrial fibrillation (AF). Conversely, AF is associated with an increased risk of stroke in hypertensive patients. While the pathophysiology linking the two conditions is not completely understood, it is likely attributed to interplay between mechanical stress, activation of the renin–angiotensin–aldosterone system, oxidative stress, and inflammatory response in hypertension to cause atrial electroanatomical remodelling, and thus AF. Management of hypertensive patients with AF encompasses lenient rate control, thromboprophylaxis, and good blood pressure control.

Typical Hemodialysis in India: A Case Report

We report here a typical case of a patient on hemodialysis (HD) for end-stage renal disease (ESRD) in India that highlights some of the management issues encountered in a country with an enormous burden of ESRD and major challenges of underdialysis and management of comorbidities. The patient, a 42-year-old multiparous woman with chronic kidney disease (CKD) stage V, type 2 diabetes mellitus, and hypertension is a homemaker from a middle-class family, living in a large city, with no family history of CKD. From May 2013 to December 2016, she has been receiving twice-weekly maintenance HD for 4 h (intermittent HD); access was via an internal jugular line initially and then via a left brachiocephalic arteriovenous fistula (AVF) from late June 2013. Medical problems in this patient included poor medication and dietary compliance, underdialysis, anemia, volume overload, congestive cardiac failure with recurrent pulmonary edema, and hypertensive crisis. In December 2016, she complained of pain in the fistula arm during dialysis, and in January 2017, she developed edema of the arm. Specific endovascular intervention with balloon angioplasty resulted in a resolution of the stenosis of the venous side of the AVF and the edema. Counselling for dietary compliance and drug adherence resulted in good blood pressure control. Unlike in most other dialysis units, we have been able to increase her HD to thrice weekly and institute several ancillary services, including skilled dietary counselling, cardiac care, and regular bioimpedance analysis with favorable outcomes. Thus, a multidisciplinary team approach offering such ancillary services would allow for better management and improved outcomes in patients with ESRD in resource-poor settings.