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Congress report: European Society of Cardiology (ESC) Congress, 2012

Congress report: European Society of Cardiology (ESC) Congress, 2012
  • Cardiometabolic
  • Hypertension

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Resource type

Article

Tags

PURE study
Prospective Urban Rural Epidemiology (PURE) study
Physical activity
Diet
Renal denervation
Stroke

Professor Brian Tomlinson reports from the European Society of Cardiology (ESC) Congress, 2012. As usual, the ESC Congress 2012 (25−29 August, Munich, Germany) was a lively and well-attended meeting with over 27,000 participants and themes arranged into ‘villages’.

The PURE study

The Prospective Urban Rural Epidemiology (PURE) study enrolled 153,996 individuals from 628 urban and rural communities in 17 countries across the world, and examined lifestyle and diet in relation to gross domestic product (GDP) and wealth index. Consumption of fruits and vegetables increased with increasing income but this was offset by increased energy from total fat, saturated fats and protein, whereas carbohydrate intake was reduced in wealthier nations. Likewise, recreational physical activity increased with increasing GDP and wealth, but this was offset by a reduction in the amount of obligatory physical activity, such as activity required for physical work, so that overall there was a reduction in physical activity among countries with higher incomes. It seemed unlikely that these changes in physical activity could be overcome by recreational exercise and health policy changes are required to create an appropriate environment to thwart the epidemic of increasing obesity and associated problems, including hypertension.

Further analysis of the PURE study found the prevalence of hypertension varied by income, from around 30% in lowest-income countries to around 50% in upper-middle-income economies. There were higher rates of hypertension in urban areas than in rural areas in low income countries but this was reversed in upper-income countries, where hypertension was more prevalent in rural areas. In subjects with hypertension, only 46% were aware of their condition, 40% were treated but only 13% were controlled. Awareness, treatment and control of hypertension was higher in urban than in rural communities and higher in women compared to men. In rural communities in lower-income countries hypertension control was virtually absent. Better screening methods for hypertension and increased use of combination medications were recommended.

Renal denervation studies

A major advance in the treatment of patients with drug-resistant hypertension has been the renal sympathetic denervation procedure. The 18-month follow-up results of the Symplicity HTN-2 (Renal Denervation With Uncontrolled Hypertension) trial were presented, in which patients in the control group were allowed to cross over to receive the renal denervation treatment after six months. In 43 patients initially randomized to renal denervation, the average reduction in blood pressure after 18 months was 32.3/12.5 mmHg, sustained over 18 months. No device-related serious adverse effects were seen and no damage to the renal vessels was reported.  These results look very encouraging, and concerns about the potential placebo effect in a device trial will be addressed in the pivotal Symplicity HTN-3 trial using a ‘sham’ procedure in the control group.

Other presentations on the results from renal denervation studies reported improvements in anxiety, depression and quality of life from Germany, and encouraging but variable blood pressure reductions in a small group of patients from Paris.

New data with potential implications for hypertension treatment

Results were presented from the ALiskiren Trial In Type 2 diabetes Using carDio-renal Endpoints (ALTITUDE), which has been stopped early. The study involved 8561 diabetic patients with renal disease randomized to aliskiren 300mg once daily or placebo on top of ACE-inhibitor or angiotensin-receptor-blocker (ARB) therapy, but there was an increase in adverse events, the primary composite endpoint showed a non-significant trend toward a worse outcome in the aliskiren group, and there was a non-significant increase in ischemic stroke despite the small additional average reduction in blood pressure of 1.3/0.6 mmHg with aliskiren. There was also an increase in hyperkalemia with aliskiren. The authors concluded that adding aliskirin on top of ACE-inhibitor or ARB treatment in diabetic nephropathy or in hypertension was not recommended, but that potential effects of the combination in heart failure remain to be reported.

Data from the Prospective compArison of ARNI with ARB on Management Of heart failUre with preserved ejectioN fracTion (PARAMOUNT) phase 2 study showed that the angiotensin-receptor/neprilysin inhibitor (ARNI) LCZ696 produced greater reductions in N-terminal-pro-BNP levels and systolic blood pressure and resulted in improvements in left atrial size and volume, and in NYHA functional class when compared to valsartan, while being well tolerated. Further studies in hypertension patients are ongoing.

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