CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 4, May 2012
232
AFRICA
Conference Report
Expert report on the 22nd European meeting on hypertension
and cardiovascular protection, London, 26–29 April 2012
Following 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. Prof G Bakris stressed
the need 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.
Renaldenervationusingradiofrequency
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 considered an adjunctive therapy
in the future. The European Society of
Hypertension position 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 Framingham study, 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.
Acute and chronic cardiovascular
responses to endurance and
ultra-endurance exercise
During this session the Morganroth
hypothesis was revisited. The question
was asked whether the heart adapts
differently to endurance and resistance
exercise.
In the 1970s, using only non-two-
dimensional guided echocardiography,
it was concluded that left ventricular
mass index is increased in athletes who
undertake either isotonic or isometric
exercise. The mechanism underlying the
increased left ventricular mass related
to chamber dilatation in the endurance
athlete versus an increase in left
ventricular wall thickness in the athlete
undertaking isometric exercise.
Use of more modern technology
such as cardiac magnetic resonance
imaging (MRI) confirmed that cyclists,
swimmers and runners, at peak training,
did demonstrate left ventricular chamber
dilatation (42–62 mm) and that the
septal wall thickness ranged from 6–14
mm. In addition, right ventricular mass
was increased, mainly as a result of an
increase in end-diastolic volume. There
was balanced eccentric hypertrophy of
both the right and left ventricle. However,
in athletes undertaking strength training,
there was no evidence of concentric left
ventricular hypertrophy. In fact less than
2% had a left ventricular wall thickness
in excess of 13 mm.
In another session, Rob Shave from
