Oral free session: New approaches for better outcomes
| Friday, November 29, 2024 |
| 11:50 AM - 12:50 PM |
| Blackwattle Bay Room 1 & 2, Level R |
Speaker
Assoc Prof Jun Yang
Scientist and Clinician
Hudson Institute Of Medical Research
Development and application of international consensus on primary aldosteronism medical treatment outcomes (PAMO)
11:50 AM - 12:05 PMAbstract:
Background and Aims
Primary aldosteronism can be treated medically to achieve blood pressure control and cardiovascular risk reduction. However, there is no standardised approach to assess treatment outcomes. We aimed to establish criteria for assessing the outcomes of targeted medical treatment of primary aldosteronism, evaluate outcomes in an international cohort and identify factors associated with a complete treatment response.
Methods
An international panel of 31 PA experts used the Delphi method to reach consensus. Clinical data at baseline and 6-12 months post-treatment were collected from patients with primary aldosteronism who started targeted medical treatment between 2016 and 2021 at 28 participating centres across four continents.
Results
Consensus was reached for defining complete, partial, or absent biochemical or clinical response. Of 1258 patients (52 ± 11.5 years, 48% female), 1047 had paired clinical and biochemical outcome data at 6-12 months post-treatment and 106 (10.1%) had both complete biochemical and clinical responses. Of the 1057 patients with biochemical outcome data, 52.8% had a complete biochemical response, while 20% had an absent response. The daily dose of spironolactone, the most commonly used medical therapy, was significantly higher in the complete biochemical responders than absent responders (40mg vs 25mg, p=0.011). Of the 1248 patients with clinical outcome data, 18.3% had a complete clinical response and 16% had an absent response. Patients with a complete clinical response were more likely than those with partial or absent clinical response to be women (OR 2.099 [1.485-2.968], p<0.001), requiring lower dose of antihypertensive drugs at baseline (0.687 [0.603-0.782], p<0.001) and were less likely to have microalbuminuria or left ventricular hypertrophy (OR 0.584 [0.391-0.873], p=0.009).
Conclusions
The PAMO criteria represent an internationally developed outcome standard which can guide clinical practice and research. By applying the criteria to an international patient cohort, we show that the rates of complete clinical and biochemical response in patients with medically treated primary aldosteronism are sub-optimal. Efforts to optimise treatment intensity and minimize factors associated with an absent treatment response will be needed to improve patient outcomes.
Primary aldosteronism can be treated medically to achieve blood pressure control and cardiovascular risk reduction. However, there is no standardised approach to assess treatment outcomes. We aimed to establish criteria for assessing the outcomes of targeted medical treatment of primary aldosteronism, evaluate outcomes in an international cohort and identify factors associated with a complete treatment response.
Methods
An international panel of 31 PA experts used the Delphi method to reach consensus. Clinical data at baseline and 6-12 months post-treatment were collected from patients with primary aldosteronism who started targeted medical treatment between 2016 and 2021 at 28 participating centres across four continents.
Results
Consensus was reached for defining complete, partial, or absent biochemical or clinical response. Of 1258 patients (52 ± 11.5 years, 48% female), 1047 had paired clinical and biochemical outcome data at 6-12 months post-treatment and 106 (10.1%) had both complete biochemical and clinical responses. Of the 1057 patients with biochemical outcome data, 52.8% had a complete biochemical response, while 20% had an absent response. The daily dose of spironolactone, the most commonly used medical therapy, was significantly higher in the complete biochemical responders than absent responders (40mg vs 25mg, p=0.011). Of the 1248 patients with clinical outcome data, 18.3% had a complete clinical response and 16% had an absent response. Patients with a complete clinical response were more likely than those with partial or absent clinical response to be women (OR 2.099 [1.485-2.968], p<0.001), requiring lower dose of antihypertensive drugs at baseline (0.687 [0.603-0.782], p<0.001) and were less likely to have microalbuminuria or left ventricular hypertrophy (OR 0.584 [0.391-0.873], p=0.009).
Conclusions
The PAMO criteria represent an internationally developed outcome standard which can guide clinical practice and research. By applying the criteria to an international patient cohort, we show that the rates of complete clinical and biochemical response in patients with medically treated primary aldosteronism are sub-optimal. Efforts to optimise treatment intensity and minimize factors associated with an absent treatment response will be needed to improve patient outcomes.
Biography
A/Professor Jun Yang is the Head of the Endocrine Hypertension Group at Hudson Institute of Medical Research, Consultant Endocrinologist at Monash Health and Senior Researcher in the Department of Medicine at Monash University, Victoria, Australia. Jun graduated from Monash University with a MBBS (Hon) in 2001, obtained the FRACP in 2010 and completed her PhD on tissue-selective coregulators of the mineralocorticoid receptor in 2013. She has continued basic and clinical research in the field of aldosterone-mediated hypertension, with >110 publications in peer-reviewed journals. She established Melbourne’s only Endocrine Hypertension Service in 2016 and co-leads the NHMRC Centre of Research Excellence in Primary Aldosteronism. Jun is passionate about creating change through “bench-to-bedside” translational research and implementing research outcomes in clinical practice. Together with her PhD students and national/international collaborators, her research program seeks to improve the detection and understanding of primary aldosteronism so as to achieve improved patient outcomes.
Dr Alexandra Matthews
Princess Alexandra Hospital, Brisbane
The utility of 24-hour urinary aldosterone concentration analysed by LC-MS/MS for the diagnosis of primary aldosteronism
12:05 PM - 12:20 PMAbstract:
Background & Aim: Diagnosis of primary aldosteronism (PA) in current practice involves initial screening by plasma aldosterone-renin ratio (ARR) followed by confirmatory testing such as seated saline suppression test (SSST). Measurement of 24-hour urinary aldosterone concentration (24hr-UAC) collected after adequate sodium intake has been suggested as a potential test for diagnosis of PA, but its diagnostic performance/utility has not been well established. The aim of this study was to determine the diagnostic performance of 24hr-UAC analysed using liquid chromatography-tandem mass spectrometry (LC-MS/MS) for diagnosis of PA.
Methods: This is a retrospective data analysis of 24hr-UAC measured by LC-MS/MS and 24-hour urinary sodium concentration (24hr-UNa) (total n=182) collected prospectively from 177 patients who had SSST performed due to elevated ARR and/or to assess for biochemical cure post adrenalectomy for unilateral PA (n=14 out of 177) at the Princess Alexandra Hospital between August 2018 and July 2023. All tests were performed without interfering medications. Receiver operating characteristic curve (ROC) analyses were performed to assess the performance of 24hr-UAC at various 24hr-UNa for diagnosis of PA using the SSST as the gold standard reference test.
Results: One-hundred and twenty-seven (127) out of 182 were diagnosed as PA by positive SSST and 55 of 182 had negative SSST. Mean±SD 24hr-UAC were 50.6±3.2 nmol/24h in cases with positive SSST and 20.8±1.9 nmol/24h in those with negative SSST. ROC analysis revealed that 24hr-UAC ≥23.5 nmol/24h had 92.1% sensitivity and 82.6% specificity to identify PA in cases with 24hr-UNa ≥190 mmol/24hr (n=52; area under the curve=0.946). A higher cut-off 24hr-UAC ≥27.5 nmol/24h provided a higher specificity (92.3%) with 78.9% sensitivity.
Conclusion: 24hr-UAC analysed by LC-MS/MS in the setting of 24hr-UNa ≥190 mmol/24h can identify PA cases with high sensitivity and specificity.
Methods: This is a retrospective data analysis of 24hr-UAC measured by LC-MS/MS and 24-hour urinary sodium concentration (24hr-UNa) (total n=182) collected prospectively from 177 patients who had SSST performed due to elevated ARR and/or to assess for biochemical cure post adrenalectomy for unilateral PA (n=14 out of 177) at the Princess Alexandra Hospital between August 2018 and July 2023. All tests were performed without interfering medications. Receiver operating characteristic curve (ROC) analyses were performed to assess the performance of 24hr-UAC at various 24hr-UNa for diagnosis of PA using the SSST as the gold standard reference test.
Results: One-hundred and twenty-seven (127) out of 182 were diagnosed as PA by positive SSST and 55 of 182 had negative SSST. Mean±SD 24hr-UAC were 50.6±3.2 nmol/24h in cases with positive SSST and 20.8±1.9 nmol/24h in those with negative SSST. ROC analysis revealed that 24hr-UAC ≥23.5 nmol/24h had 92.1% sensitivity and 82.6% specificity to identify PA in cases with 24hr-UNa ≥190 mmol/24hr (n=52; area under the curve=0.946). A higher cut-off 24hr-UAC ≥27.5 nmol/24h provided a higher specificity (92.3%) with 78.9% sensitivity.
Conclusion: 24hr-UAC analysed by LC-MS/MS in the setting of 24hr-UNa ≥190 mmol/24h can identify PA cases with high sensitivity and specificity.
Biography
Dr Alexandra Matthews completed her endocrinology training in 2023 and is completing a fellowship year in the Hypertension Unit at the Princess Alexandra Hospital in Brisbane.
Dr Isabella Tan
Research Fellow
The George Institute for Global Health
Listen to Your Heart and Mind: combined screening of raised blood pressure, atrial fibrillation, cognitive impairment and hearing loss
12:20 PM - 12:35 PMAbstract:
Background and Aim. Raised blood pressure (BP) increases the risk of heart disease, stroke, hearing loss and dementia—all leading burdens of disease in older Australians. It also increases the risk of atrial fibrillation (AF), which substantially increases the risk of stroke. However, latest National Health Survey data showed over half of Australian adults aged ≥65 years who had measured raised BP did not report having hypertension. AF is similarly often undetected. Better detection of raised BP, AF, hearing loss and cognitive decline in older adults may reduce burden of disease. This study aimed to implement a combined screening strategy for these conditions, and to assess the feasibility and acceptability of the screening.
Methods. Adults aged ≥65 years without a prior diagnosis of cognitive impairment or dementia were invited to participate through advertisements posted in university and community group newsletters and noticeboards. At the study visit, participants had BP measured three times on one arm using an oscillometric BP monitor with AF detection (Microlife WatchBP Office 2G), then underwent cognitive (General Practitioner Assessment of Cognition, GPCOG) and hearing assessments. A subset of participants was interviewed post study to evaluate feasibility and acceptability.
Results. Of the 35 participants (age 73±6 years, 51% females), majority (n=22, 63%) had hypertension (self-reported but not treated: n=1; self-reported and on antihypertensive medication: n=19; unaware: n=2). Four participants with hypertension had uncontrolled BP. Possible AF was detected in two participants (one previously diagnosed) and seven had possible cognitive decline (GPCOG score <9). Hearing loss was detected in 13 (37%) participants. Interviews (n=16, 50% females) revealed that combined screening was acceptable and feasible as participants felt it was “convenient”, “saves time”, “a brilliant idea”, and that “… conditions are related and therefore appropriate to be together”. All interviewees felt the appointment was of acceptable duration (approximately 60-75 minutes).
Conclusions. Combined screening of raised BP, AF, cognitive decline and hearing loss in older adults is feasible and acceptable. As part of the National Hypertension Taskforce’s strategy to improve BP control through better detection of raised BP, programs can consider combined health screening in older adults as a potential strategy.
Methods. Adults aged ≥65 years without a prior diagnosis of cognitive impairment or dementia were invited to participate through advertisements posted in university and community group newsletters and noticeboards. At the study visit, participants had BP measured three times on one arm using an oscillometric BP monitor with AF detection (Microlife WatchBP Office 2G), then underwent cognitive (General Practitioner Assessment of Cognition, GPCOG) and hearing assessments. A subset of participants was interviewed post study to evaluate feasibility and acceptability.
Results. Of the 35 participants (age 73±6 years, 51% females), majority (n=22, 63%) had hypertension (self-reported but not treated: n=1; self-reported and on antihypertensive medication: n=19; unaware: n=2). Four participants with hypertension had uncontrolled BP. Possible AF was detected in two participants (one previously diagnosed) and seven had possible cognitive decline (GPCOG score <9). Hearing loss was detected in 13 (37%) participants. Interviews (n=16, 50% females) revealed that combined screening was acceptable and feasible as participants felt it was “convenient”, “saves time”, “a brilliant idea”, and that “… conditions are related and therefore appropriate to be together”. All interviewees felt the appointment was of acceptable duration (approximately 60-75 minutes).
Conclusions. Combined screening of raised BP, AF, cognitive decline and hearing loss in older adults is feasible and acceptable. As part of the National Hypertension Taskforce’s strategy to improve BP control through better detection of raised BP, programs can consider combined health screening in older adults as a potential strategy.
Biography
Dr Isabella Tan is a Research Fellow from The George Institute. She has been involved in several clinical trials focusing on blood pressure monitoring and hypertension management. Her current research interest is in innovative approaches to improve screening and detection of raised blood pressure.
Dr Audrey Adji
Scientist
St Vincent's Hospital/UNSW/VCCRI
Pulsatile Vascular Afterload Measurement Improves Prediction of Right-Ventricular Dysfunction in Pulmonary Hypertension
12:35 PM - 12:50 PMAbstract:
Background and Aim
Pulmonary vascular afterload is currently estimated by mean pulmonary pressure (mPAP) or pulmonary vascular resistance (PVR). Pulmonary artery compliance (PAC) represents the pulsatile component of afterload presented to the right ventricle (RV) by the pulmonary vasculature. Our study aims to determine if PAC can improve prediction of RV dysfunction in patients with pulmonary hypertension (PH).
Method
We recruited 86 patients referred for right heart catheterisation (RHC) for suspected PH. RHC-derived measurements included systolic (sPAP), diastolic (dPAP), mPAP, and wedge pulmonary pressure (mPCWP). Pre-capillary PH (Pre-PH) was defined as a mPAP>20mmHg and PVR>240dynes.s.cm-5; Isolated post-capillary PH (Ipc-PH) as a mPAP>20mmHg, PVR<240dynes.s.cm-5 and mPCWP>15mmHg; Combined pre- and post-capillary PH (Cpc-PH) as a mPAP>20mmHg, PVR>240dynes.s.cm-5 and mPCWP>15mmHg, and the remaining patients were grouped to mPAP 20-25 mmHg. RV ejection fraction (EF, %) was calculated from cardiac magnetic resonance imaging. PAC (mL/mmHg) was calculated as ratio between stroke volume and pulmonary pulse pressure (sPAP-dPAP).
Results
No significant between-group differences in sex, height, weight or BSA were observed, although there was more female (77%) across the study cohort. There was 31% Pre-PH, 20% Cpc-PH and 20% Ipc-PH. sPAP (all p<0.001) was highest in Pre-PH (68+23mmHg) and Cpc-PH (72+25mmHg), lower in Ipc-PH (49+16mmHg), and lowest in mPAP20-25 (31+5mmHg), and similarly with mPAP (Pre-PH 42+14mmHg; Cpc-PH 47+16mmHg; (Ipc-PH 33+8mmHg, mPAP20-25 21+4mmHg, all p<0.001), Meanwhile mPCWP (all n<0.001) was higher in Cpc-PH (23+6) and Ipc-PH (23+5), lower in Pre-CPC (13+3) and mean20-25 (12+2mmHg). PVR remained diagnostic in confirmed PH subjects (all p<0.001; Pre-PH 485+233, Cpc-PH 443+245, Ipc-PH 181+60, mPAP20-25 132+52dynes.s.cm-5).
PAC differed significantly between groups (p=0.017); the lowest (1.9 ± 0.9mL/mmHg) in Pre-PH, followed by Cpc-PH (2.0+1.4mL/mmHg), Ipc-PH (3.1+1.6mL/mmHg), and mPAP20-25 (4.9+1.7mL/mmHg). There was a significant correlation between PVR (r -0.539; p<0.001), PAC (r 0.555; p<0.001), and RVEF<50%. In patients with mPAP20-25 or Ipc-PH, PAC appears to be the optimal model to determine a RVEF<50% ((ß=-0.583 CI0.046-1.12 p=0.033).
Conclusion
PAC characterisation may assist in determining impaired RV function than PVR alone. Consideration of pulmonary vascular afterload may lead to new insights into predicting RV dysfunction, especially in whom PH is due to left sided disease.
Pulmonary vascular afterload is currently estimated by mean pulmonary pressure (mPAP) or pulmonary vascular resistance (PVR). Pulmonary artery compliance (PAC) represents the pulsatile component of afterload presented to the right ventricle (RV) by the pulmonary vasculature. Our study aims to determine if PAC can improve prediction of RV dysfunction in patients with pulmonary hypertension (PH).
Method
We recruited 86 patients referred for right heart catheterisation (RHC) for suspected PH. RHC-derived measurements included systolic (sPAP), diastolic (dPAP), mPAP, and wedge pulmonary pressure (mPCWP). Pre-capillary PH (Pre-PH) was defined as a mPAP>20mmHg and PVR>240dynes.s.cm-5; Isolated post-capillary PH (Ipc-PH) as a mPAP>20mmHg, PVR<240dynes.s.cm-5 and mPCWP>15mmHg; Combined pre- and post-capillary PH (Cpc-PH) as a mPAP>20mmHg, PVR>240dynes.s.cm-5 and mPCWP>15mmHg, and the remaining patients were grouped to mPAP 20-25 mmHg. RV ejection fraction (EF, %) was calculated from cardiac magnetic resonance imaging. PAC (mL/mmHg) was calculated as ratio between stroke volume and pulmonary pulse pressure (sPAP-dPAP).
Results
No significant between-group differences in sex, height, weight or BSA were observed, although there was more female (77%) across the study cohort. There was 31% Pre-PH, 20% Cpc-PH and 20% Ipc-PH. sPAP (all p<0.001) was highest in Pre-PH (68+23mmHg) and Cpc-PH (72+25mmHg), lower in Ipc-PH (49+16mmHg), and lowest in mPAP20-25 (31+5mmHg), and similarly with mPAP (Pre-PH 42+14mmHg; Cpc-PH 47+16mmHg; (Ipc-PH 33+8mmHg, mPAP20-25 21+4mmHg, all p<0.001), Meanwhile mPCWP (all n<0.001) was higher in Cpc-PH (23+6) and Ipc-PH (23+5), lower in Pre-CPC (13+3) and mean20-25 (12+2mmHg). PVR remained diagnostic in confirmed PH subjects (all p<0.001; Pre-PH 485+233, Cpc-PH 443+245, Ipc-PH 181+60, mPAP20-25 132+52dynes.s.cm-5).
PAC differed significantly between groups (p=0.017); the lowest (1.9 ± 0.9mL/mmHg) in Pre-PH, followed by Cpc-PH (2.0+1.4mL/mmHg), Ipc-PH (3.1+1.6mL/mmHg), and mPAP20-25 (4.9+1.7mL/mmHg). There was a significant correlation between PVR (r -0.539; p<0.001), PAC (r 0.555; p<0.001), and RVEF<50%. In patients with mPAP20-25 or Ipc-PH, PAC appears to be the optimal model to determine a RVEF<50% ((ß=-0.583 CI0.046-1.12 p=0.033).
Conclusion
PAC characterisation may assist in determining impaired RV function than PVR alone. Consideration of pulmonary vascular afterload may lead to new insights into predicting RV dysfunction, especially in whom PH is due to left sided disease.
Biography
Dr Audrey Adji is a senior research scientist at Victor Chang Cardiac Research Institute and St Vincent’s Hospital, Sydney, Australia. Her research focus is on changes in human pulsatile cardiovascular function with heart and lung diseases, and mechanical assist devices implanted in heart failure patients. Her current project includes quantification of pulsatile load in patients with heart valve disease and pulmonary hypertension, as well as those with circulatory shock. Dr Adji is also investigating the hemodynamics features of individuals with the heart assist device or “reduced pulsatility” mechanical circulatory system. Dr Adji also has involved in studies in investigating vascular stiffness contribution in individuals who has metabolic disorder such as obesity and diabetes.
To date, Dr Adji has published papers in various scientific journals, and presented her work in numerous international and local scientific meetings. She has won scientific awards and prizes, including the inaugural 2018 International Society of Hypertension Mid-Career Award for Women Researchers. Dr Adji is a Fellow of the International Society of Hypertension, and the chair of Pulse of Asia Early-Mid Career Research Network Committee. Dr Adji is the current chair for Women in Hypertension Committee of Hypertension Australia, and a member of Hypertension Taskforce Working Group.
