Great debate: Hypertension during exercise should be treated
- Hypertension during exercise is common and may contribute to the overall burden of pressure-related and residual CV risk.
- Exercise BP:
- Cannot be used to diagnose hypertension.
- Does not reflect vascular pathology or pre-hypertension.
- Is not associated with reduced exercise capacity.
- One should not be concerned about an increase in blood pressure during exercise; rather, blood pressure should be under control before commencing the exercises.
How to treat a patient with heart failure and LVEF> 40%
- Heart failure with preserved ejection fraction (HFpEF) is often under-diagnosed in clinical practice and poses a threat.
- Empagliflozin is the first drug to reduce CV death or first hospitlization for heart failure (HHF) in HFpEF patients.
- Effect of Empagliflozin on CV death and first HHF is consistent across multiple patient subgroups with HFpEF.
- In HFpEF patients Empagliflozin protects the kidney by slowing the decline of renal function.
TAVI: Gaps in evidence and expanding indications
- Biomarker screening/inclusion criteria is an important tool to identify patients with less severe aortic stenosis (AS) with evidence of left venticular damage.
- The expanding indications for transcatheter aortic valve implantation (TAVI) are asymptomatic severe AS and “at risk” moderate AS.
- The future is upstream AS treatment which consists of improved biomarkers, access to care, pre-emptive aortic valve repair.
Minimalist TAVR and rapid discharge protocols: The future standards of care
- Minimalist transcatheter aortic valve replacement is a safe, predictable, and well-planned procedure with tailored resources.
- It lacks GA, Swan Ganz, Arterial Line, and Foley.
- If the team agrees on same-day discharge for post-TAVR patients, it occurs before 7 PM, and out-patient visits on post-TAVR days 1 and 2.
Valve-in-valve TAVI for bioprosthetic valve failure
- As per 2020 ACC/AHA guidelines, SAVR is indicated for patients aged < 65 years, SAVR or TAVI for age 65-80 years and TAVI for age > 80 years.
- For patients with longer life-expectancy, consider life-time management before first re-valving.
- Choose a bioprosthetic valve with good durability and possibility for safe valve-in-valve when it fails.
Hypertension guidelines: the experts’ perspective
- For adults with hypertension requiring pharmacological treatment, WHO 2021 recommends combination therapy, preferably with SPC as an initial treatment.
- Latest evidence guideline recommends SPCs as a first line treatment.
- SPCs promote adherence, simplify the treatment strategy, improve medication persistence, and improve blood pressure management.
Which SPC for this patient with diabetes and chronic kidney disease?
- Renin angiotensin blockers are more effective at reducing albuminuria than other antihypertensive agents.
- Renin angiotensin blockers are recommended as part of treatment strategy in HTN patients in the presence of microalbuminuria or proteinuria.
- Blood pressure target for CKD patients recommended by international guidelines is <140/90 mmHg.
In search of atrial fibrillation in stroke patients: How to find it and handle it
- The diagnosis of AF on post-stroke monitoring requires documentation by an ECG of sufficient quality to allow confirmation by a health professional with expertise in ECG rhythm interpretation.
- In adult patients with ischemic stroke or TIA of undetermined origin, it is recommended that the longer duration of cardiac rhythm monitoring of more than 48 h and if feasible with implantable loop recorder to increase the detection of subclinical AF.
- In adult patients with ischemic stroke or TIA of undetermined origin, it is suggested to use of additional outpatient monitoring compared with in-hospital cardiac rhythm monitoring to increase the detection of AF.
Are ACE inhibitors still the cornerstone of cardiovascular protection?
- Perindopril improves life/death cycle of the endothelium and works well when combined with either Ca2+ antagonists, diuretics and/or statins.
- Prescribing ARBs for hypertension deprives patients from the benefit of ACEi on the coronary artery.
- In RCTs, ACEi exert a better coronary artery protection than ARBs.
- Perindopril reduces death and improves life of endothelium leads to prevention of ACS.
- In post AMI patients, perindopril decreases endothelial apoptosis.
Can we individualize treatment of hypertensive patients with single-pill combination therapies?
- Recent guidelines suggests to start with two drugs and ideally as a SPC.
- Single pill combination is more effective and provides rapid BP control than monotherapy and two free drugs.
- Single pill combination enhances adherence, improves CV protection and is more cost-effective.
- In PROGRESS trial, Perindopril and/or Indapamide showed 28% risk reduction of recurrent stroke.
Optimal medical treatment of chronic coronary syndromes (CCS)- from the old model to a new combination approach
- More tailored pharmacological treatment before considering percutaneous coronary intervention is required.
- The stepwise approach for CCS should be abandoned for a rationale combination of hemodynamic and metabolic agents alogn with reconsideration of preventive strategies.
- Triemtazidine can be used for symptom control in CCS as an early combination therapy with BB and CCB.
What should be the optimal quadri-therapy in clinical practice?
- A substantial proportion of patients (possibly 10-20%) need 4 drugs for BP control, i.e., to reach target.
- Beta-blockers are effective on BP reduction and have favourable effects on variety of clinical conditions that may co-exist with hypertension.
- A novel quadruple SPC with Perindopril/Indapamide/Amlodipine/Bisoprolol will offer a novel attractive asset of BP control.