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Chen-Huan Chen

National Yang-Ming University / Taiwan

Session Meet the Expert Session IV: Clinical Application of Central Blood Pressure [E]
Lecture Title Application of central blood pressure in the young
Lecture
Introduction
Increased arterial stiffness and wave reflections are major determinant of central blood pressure. From puberty to mid-life, systolic blood pressure (SBP) increases steeply during childhood, reaches a plateau phase between 20 and 40 years, and then increases subsequently, whereas diastolic blood pressure (DBP) displays a cubic trajectory with a plateau-like behavior followed by a decline as age increases. Therefore, at the population level, pulse pressure (PP) values may be high around the age of 20 years and low in the age range between 20 and 40 years. The transient physiological elevation of SBP and PP detected in some young adults may reach the criteria of isolated systolic hypertension (ISH) and create an innocent condition called pseudo or spurious systolic hypertension of youth whose central blood pressure is normal. ISH is the most common form of hypertension in adolescents and young adults. However, an increase in arterial stiffness has been found in about 20% of the young individuals with ISH. Moreover, obesity, metabolic disturbances, and white-coat hypertension have often been documented to be associated with ISH in the young. Measurements of arterial stiffness and central blood pressure may be useful in identifying the high risk phenotype of ISH in the young.
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Chien-Chang Lee

National Taiwan University Hospital / Taiwan

Session Infection and Hypertension [E]
Lecture Title ARB and short-term mortality in sepsis
Lecture
Introduction
Antagonists of the renin-angiotensin-aldosterone system (RAAS), including ACEIs (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin II receptor blockers), may prevent organ failure. We, therefore, investigated whether specific RAAS inhibitors are associated with reduced mortality in patients with sepsis. We conducted a population-based retrospective cohort study. To directly compare ACEI users, ARB users, and nonusers, a 3-way propensity score matching approach was performed. Results were pooled with previous evidence via a random-effects meta-analysis. Using propensity score–matched analyses, prior ACEI use was associated with decreased 30-day and 90-day mortality compared with nonuse. Prior ARB use was associated with an improved 90-day survival. These results persisted in sensitivity analyses focusing on patients without cancer and patients with hypertension. The short-term mortality after sepsis was substantially lower among those who were already established on RAAS inhibitor treatment when sepsis occurred. Our talk will also discuss the potential mechanisms and its clinical implication to COVID-19.
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Giuseppe Faraco

Weill Cornell Medical College, Cornell University / USA

Session Special Lecture
Lecture Title Dietary salt promotes cognitive impairment through tau phosphorylation
Lecture
Introduction
Dietary habits and vascular risk factors promote both Alzheimer’s disease and cognitive impairment caused by vascular factors. Furthermore, accumulation of hyperphosphorylated tau, a microtubule associated protein and a hallmark of Alzheimer’s pathology, is also linked to vascular cognitive impairment. In mice, a salt-rich diet leads to cognitive dysfunction associated with a nitric oxide (NO) deficit in cerebral endothelial cells and cerebral hypoperfusion. Here, we show that dietary salt induces accumulation of hyperphosphorylated tau followed by cognitive dysfunction, effects prevented by restoring NO production in cerebral endothelial cells. The NO deficiency reduces neuronal calpain nitrosylation resulting in enzyme activation, which, in turn, leads to tau phosphorylation by activating cyclin dependent kinase-5. Salt-induced cognitive impairment is not observed in tau-null mice or in mice treated with anti-tau antibodies, despite persistent cerebral hypoperfusion and neurovascular dysfunction. These findings unveil a causal link between dietary salt, endothelial dysfunction and tau pathology, independent of hemodynamic insufficiency. Avoiding excessive salt intake and maintaining vascular health may help stave off vascular and neurodegenerative pathologies underlying late-life dementia.
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Franz Schaefer

Heidelberg University Hospital / Germany

Session Ambulatory BP Monitoring in Pediatric Hypertension (Pediatric Hypertension Society) [E]
Lecture Title "Normal ambulatory BP reference values and staging of ambulatory BP levels in children
Lecture
Introduction
Updated guidelines have emphasized the value of ABPM as the gold standard of blood pressure assessment in children. ABPM is necessary to diagnose white coat hypertension, masked hypertension, and nocturnal hypertension. ABPM has been demonstrated to be more predictive of end-organ damage in pediatric hypertension compared to office blood pressure. ABPM is useful both for the diagnosis and management of pediatric hypertension. Routine use of ABPM could potentially prevent early cardiovascular morbidity and mortality in a wide variety of populations.
Session Evaluation and Measurement in Pediatric Hypertension(소아고혈압연구회) [E]
Lecture Title Application of ambulatory BP monitoring in children
Lecture
Introduction
Regular home blood pressure (HBP) measurement appears as an attractive alternative to ABPM for the evaluation of suspected or treated hypertension. HBP monitoring has good reproducibility, diagnostic performance and acceptability by users at low cost. HBP monitoring with morning and evening measurements for 7 days has shown to be useful both in the initial evaluation of children with suspected hypertension and for monitoring of children with treated hypertension. In case of major disagreement between office and HBP measurements, ABPM should remain the basis for treatment decision making.
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He-feng Huang

International Peace Maternity and Child Health Hospital of China Welfare Institute / China

Session Controversies in Hypertension [E]
Lecture Title Risk of prehypertension in pregnancy
Lecture
Introduction
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James Sharman

Menzies Institute for Medical Research, University of Tasmania / Australia

Session Updates on central blood pressure [E]
Lecture Title The value of accurate measurement of central blood pressure
Lecture
Introduction
Accurate measurement of blood pressure is among the most important of all medical tests. Central blood pressure devices have been developed with the goal of providing measurements that are more clinically valuable (accurate representation of central aortic blood pressure) than conventional upper arm cuff blood pressure devices. The current evidence and future needs with respect to accurate measurement of central blood pressure will be examined in this lecture.
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Kazuomi Kario

Jichi Medical University School of Medicine / Japan

Session Timing of Anti-hypertensive Drug Administration
Lecture Title Approaches for disrupted circadian rhythm of blood pressure in hypertensive patients
Lecture
Introduction
As well as increased average of 24-hr blood pressure (BP), disrupted circadian rhythm of BP and exaggerated BP variability (such as morning surge) are associated with cardiovascular events and organ damage in hypertensive patients. In our recent prospective study, Japan Morning Surge Prospective (JAMP) study on 6,000 or more patients, demonstrated that riser pattern (higher nighttime BP than daytime BP) on ambulatory BP monitoring is associated with increased risk of heart failure 2.5 times compared with normal dippers (Kario, et al. Circulation 2020, in press). The new mineral corticoid receptor blocker, esaxerenone lowers nighttime BP more extendedly than daytime BP, resulting in the shift from non-dippers to dippers (Kario, et al. Am J Hypertens 2020, in press). Stepwise approach to 24-hr BP control, consisted of morning BP control and subsequent nocturnal BP control, would be practically effective to suppress the cardiovascular disease in hypertensive patients.
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Keita Saku

National Cerebral and Cardiovascular Center / Japan

Session Emerging Treatment for Hypertension [E]
Lecture Title Development of Smart Baroreflex Activation therapy Targeting Blood Pressure Variability
Lecture
Introduction
In an advanced aging society, the numbers of patients with hypertension (HT) and chronic heart failure as a consequence of HT continue to increase. It is well known that HT increases the risk of cardiovascular (CV) events. Recent studies also demonstrate that the presence of blood pressure variability (BPV) in HT increases CV events. Thus, optimal management of BPV in HT patient may reduce CV events. However, there is no established therapy for treating BPV. Baroreflex is the major regulator of BPV because it antagonizes the change in BP by its negative feedback mechanism through sympathetic regulation. The presence of baroreflex failure significantly increases BPV. Baroreflex activation therapy (BAT), which electrically stimulates the baroreceptors, have been developed for the treatment of resistant HT. Since the device stimulates baroreceptors with a constant amplitude and fixed frequency, it can reduce BP by sympatho-inhibition but cannot attenuate BPV. We have developed the BAT by adding a sensor of pressure information and a BP feedback algorithm, so called the smart BAT (S-BAT). Recently, we reported the impact of S-BAT algorithm on BPV in a hypertensive rat model of baroreflex failure. We are now proceeding the strategies to develop S-BAT as a clinical approval device.
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Takayoshi Ohkubo

Teikyo University School of Medicine / Japan

Session Blood Pressure Monitoring: Therapeutic approach in Nocturnal Blood Pressure (혈압모니터연구회) [E]
Lecture Title Nocturnal blood pressure measured by home devices: evidence and perspective for clinical application
Lecture
Introduction
Nocturnal blood pressure is an established predictor of future cardiovascular events. Historically, nocturnal blood pressure has been measured in a certain particular night with ambulatory blood pressure monitoring devices. However, reproducibility of nocturnal blood pressure values measured in such a way are generally poor since those values are affected by physical and emotional conditions of the night. Recently, new technology has make it possible to measure nocturnal blood pressure with home blood pressure measuring devices. Associated findings have been accumulated. Furthermore, more convenient wrist-cuff devices to measure nocturnal blood pressure at home have been validated. In this lecture, I would like to talk on evidence and perspective for clinical application of nocturnal blood pressure measured by home devices.
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Paolo Mulatero

University of Torino / Italy

Session Updates in aldosterone and hypertension
Lecture Title Real world primary aldosteronism and screening strategy
Lecture
Introduction
Diagnosis of primary aldosteronism (PA), the most frequent cause of secondary hypertension, in the early stages of disease, is important because affected patients display an increased cardiovascular risk compared with patients with essential hypertension. In particular, PA patients display a significant increase in cardiovascular and cerebrovascular events and organ damage, compared with patients with essential hypertension. These effects are reverted by adrenalectomy in patients with unilateral PA and by mineralocorticoid receptor antagonists in patients with bilateral disease, if given at sufficiently high doses. Unfortunately, patients with hypertension are rarely screened for PA that remain largely underdiagnosed. Most patients with hypertension should be screened, in particular patients with hypokalemia (either spontaneous or diuretic induced), with grade 2-3 or resistant hypertension, young age, adrenal incidentalomas, lone atrial fibrillation and with suspected familial forms. A positive screening test should be followed by confirmatory/exclusion test and, if positive, by subtype differentiation with CT scanning and adrenal vein sampling.
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Rhian Touyz

University of Glasgow / UK

Session Emerging Treatment for Hypertension [E]
Lecture Title Targeting the brain renin angiotensin system – new therapeutic approaches
Lecture
Introduction
There is clear evidence that the brain has an active renin angiotensin system. Whether all components of the system are produced in the brain or whether some derive from the circulation is still under discussion. The brain RAS plays an important role in blood pressure regulation, volume homeostasis and memory amongst other physiological functions. Hyperactivity of the brain RAS has been implicated in the pathophysiology of hypertension and its interruption by agents that block components of the RAS have significant blood pressure lowering effects and cardiovascular protection. Of the many angiotensin-derived peptides, Ang III, produced from Ang II by aminopeptidase A (APA) seems to be especially important in the brain, since it exerts a tonic stimulatory effect on blood pressure. Targeting Ang III by inhibiting APA is a novel and effective approach to reduce blood pressure as demonstrated in experimental models. With the development of a selective AOA inhibitor, RB150 a prodrug of EC33, there is growing interest in its use in human hypertension. RB150 crosses the blood brain barrier and generates EC33 that blocks brain APA activity. This is associated with decreased Ang III production and consequent reduction in blood pressure. Successful phase 1a/1b trials have led to phase 11 trials, where RB150 is being tested in patients with resistant hypertension. This drug, called firibastat represents a new class of antihypertensive drugs targeting the brain RAS.
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Miguel Camafort Babkowski

University of Barcelona / Spain

Session Plenary Lecture
Lecture Title Blood pressure and HFPEF, Pending Issues and Future Perspectives
Lecture
Introduction
Hypertension is one of the main etiologies, and a major comorbidity, related to HFPEF. Antihypertensive treatment has proven to improve Hypertension mediated organ damage (for example Left Ventricular Hypertrophy) that usually precede HFPEF, but when it comes to HFPEF itself antihypertensive treatment has not proven to reduce mortality nor hospitalization due to Heart Failure. On the other hand data about BP goals are contradictory as some studies have shown better outcomes for those with higher BP levels when compared with low BP levels. Beside that frailty is a common situation in the Hypertensive HFPEF patient and this has not been taken into account in many studies. Finally ABPM gives us more reliable BP measurements, and data about some hemodynamic biomarkers that are related to outcomes. Unfortunately, data on ABPM in HFPEF are very Scarce, therefore the Ambulatory Blood Pressure in HFPEF Outcomes Global Registry will gives us more data on this subject.
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Yuda Turana

Atma Jaya Catholic University of Indonesia / Indonesia

Session Meet the Expert Session III: Blood Pressure Variability [E]
Lecture Title How low should we go to prevent dementia?
Lecture
Introduction
Hypertension is a risk factor for several adverse health outcomes, including a decline in cognitive function. Recent data show that the prevalence of hypertension and age-related dementia are rising in Asian countries. Twenty-four-hour blood pressure ( BP ) profiles and BP variability have been associated with silent cerebral infarction or white matter lesions, which are predisposing conditions for dementia. Hypertension that occurs in midlife also affects the incidence of cognitive impairments in later life. Managing and controlling blood pressure could preserve cognitive functions.
Blood pressure treatment in older adults for cognitive outcomes remains controversial due to concerns over the consequences of very low or aggressive treatment targets. The recent evidences , the optimum systolic blood pressure should be in the 120–130 mmHg, especially in non-diabetic hypertensive patients with significant risk factors. In the oldest-old group of patients, hypertension may have a protective effect. Personalized care for patients with hypertension is encouraged, especially in patients with frailty and very old patients.
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Thilo Burkard

University Hospital Basel / Switzerland

Session Smartphone applications for blood pressure measurement [E]
Lecture Title Remained task of photoplethysmographic-based BP measurement
Lecture
Introduction
Blood pressure measurement (BPM) is an integral part of nearly every medical examination. The usual non-invasive BPM technique is still based on the principles described 130 years ago by Scipione Riva-Rocci. During the last years, there has been a rise of new BPM techniques using pulse-transit-time (PTT) or photoplethysmographic signals (PPG) and complex algorithms to estimate a person’s blood pressure. Especially the combination of a smartphone and smartphone camera using PPG may have the potential to revolutionize BPM in the future. But this future has not started yet! Accuracy is an absolute prerequisite in BPM. To date, there is no app using PPG that has passed a clinical validation study. In April 2020, Samsung announced, that a BPM app using PPG signals acquired by the sensor of a wristworn watch was approved by the Ministry of Food and Drug Safety, Korea. Unfortunately, no corresponding study describing the applied validation protocol, the accuracy and the tested patient population has been published. Considering the additional need of calibration before the use of this and some other apps, there are plenty open questions, regarding the validation process, the applicability of validation protocols and especially the clinical implementation of such a new BPM technique.
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