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VOLUME 9 NUMBER 3 • SEPTEMBER 2012
CONFERENCE REPORT
SA JOURNAL OF DIABETES & VASCULAR DISEASE
22
nd European meeting on hypertension and cardiovascular
protection, London 26–29 April 2012
F
ollowing the release of the updated NICE
(
British Hypertension Society) guidelines
last year and the South African guidelines
recently, this meeting presented an
opportunity to hear opinion leaders analyse,
debate and discuss the best way to detect and
manage hypertension in the 21st century.
Regarding treatment, the issue of
diuretics was highlighted. The NICE
guidelines advocate the use of thiazide-like
diuretics (indapamide) and chlorthalidone.
The South African guidelines also advocate
these agents; however the choice of diuretic
still includes low-dose hydrochlorothiazide.
Prof Franz Messerli, an eminent American
opinion leader, was asked what is used in
his country and the answer was thiazides,
often in fixed combination.
The lesson is to use the thiazides with
caution, be aware of the metabolic side
effects and understand that the agents now
advocated have been shown to have better
outcomes data. ProfGBakris stressed theneed
to ensure that patients are not hypokalaemic,
as this contributes to vasoconstriction of
vessels and resistant hypertension. It is
important to correct potassium levels before
adding in more therapy.
A focus of the meeting was renal nerve
denervation (RDN) in resistant hypertension.
Prof M Esler gave the Bjorn Folkow award
lecture titled ‘The clinical physiology of the
sympathetic nervous system: no longer
a promissory note in hypertension’. He
highlighted the pathophysiology of the
sympathetic nervous system and why
surgical splanchnicectomy, done from 1934
to 1960, did not work.
Renal denervation using radiofrequency
laser is a minimally invasive percutaneous
procedure characterised by short recovery
times and the absence of systemic side
effects. It appears that this technique will be
consideredanadjunctive therapy in the future.
TheEuropeanSocietyofHypertensionposition
paper, ‘Renal denervation – an interventional
therapy of resistant hypertension’, intends
to facilitate a better understanding of the
effectiveness, safety, limitations and issues
still to be addressed with RDN.
The meeting covered issues of
cardiovascular protection. The cardio–ankle
vascular stiffness index (CAVI) is a non-
invasive technique used in Japan to assess
arterial stiffness. It is expressed as a ratio
between the internal pressure in blood
vessels (blood pressure) and changes in
vascular diameter, and measures pulse-wave
velocity between the heart and femoral
artery. The clinical implications are whether it
will be a useful tool to assess arterial disease
independent of blood pressure levels. There
is also an association between CAVI and
atherosclerosis. All the work has previously
been done in Asians and Japanese, and
data were presented on the reliability of this
index in a cohort of 4 000 Swiss subjects. Of
note is that the index increases with age and
women have a lower score than men.
A workshop dedicated to Bill Kannel,
father of the Framinghamstudy, was delivered
by co-workers. Prof S Franklin, nephrologist,
discussed the five seminal articles published
regarding blood pressure, ageing and
cardiovascular disease, and highlighted
findings that changed our understanding
of the disease. Prof D Levy, involved with
cardiovascular gene therapy, highlighted
the genotype and phenotype genome-wide
association data from this study.
Although it was predicted in June
2000
that within 10 years one would be
able to find out what particular genetic
conditions patients have, the individual
single-nucleotide polymorphisms identified
do not really contribute to the magnitude
of hypertension. Those identified for systolic
hypertension only contribute to a 1-mmHg
increase, and diastolic to 0.5 mmHg. There
are associations with stroke risk and left
ventricular mass but no association with
renal markers of hypertension.
Regarding the Framingham scoring
system for cardiovascular risk assessment,
it was fascinating to hear how the scoring
system was developed. Prof RB D’Agostino,
mathematician and statistician, discussed
the validation of this score in the non-
Framingham population; the transportability
and external validation, which allows one to
use it for other populations such as non-
Caucasians. It has also been validated for
non-US populations such as the Chinese.
Hypertension in the elderly
The VALISH trial enrolled patients with
isolated systolic hypertension (age range
70–84
years). These patients were divided
into two groups. In one group, target systolic
blood pressure was < 140 mmHg whereas in
the second group the target systolic blood
pressure was between 140 and 149 mmHg.
They found no difference in outcome with
strict versus less strict blood pressure control
(
< 140 vs 140–149 mmHg).
There was some discussion about the
J-shaped curve regarding diastolic blood
pressure in elderly patients. The data suggest
that if diastolic blood pressure is lowered to
< 80 mgHg in patients who have coronary
heart disease at baseline, there is an increase
in cardiovascular mortality.
Prior to blood pressure measurement,
patients must have rested for at least five
minutes and the readings are repeated. In
the elderly, particular emphasis should be
placed on standing blood pressure.
The HYVET trial recruited patients over
the age of 80 years with a systolic blood
pressure of > 160 mmHg. Patients were
eligible for the trial if the systolic blood
pressure was > 160 mmHg but not if the
standing systolic blood pressure was < 140
mmHg. In this study, target blood pressure
was < 150/80 mmHg. Active treatment with
indapamide-based therapy was associated
with a significant reduction in total mortality
(25%),
cardiovascular mortality (35%), stroke
mortality (60%) and heart failure (50%).
The JATOS trial, published in
Hypertension
Research
in 2008, confirmed that a systolic
bloodpressureof <140mmHgwas associated
with more deaths in those over the age of 75
years. It was finally concluded that the target
blood pressure in the very elderly is 150/80
mmHg. Currently, there are no data on the
optimal blood pressure goal in patients with
mild hypertension (140–160/< 90 mmHg)
as trials have only recruited patients with a
systolic blood pressure > 160 mmHg.
Blood pressure variability
This refers to visit–visit variability, within-visit
variability, as well as variability over a longer
period of time such as a week or a month.
The greater the variability in blood pressure,
the higher the risk. No specific number
was given for the cut-off measure which
predicted higher versus lower variability.
A good technique to assess variability
