Winter-meeting in Oslo

The Norwegian Hypertension Society held its bi-annual scientific meeting in Oslo last week. It was a long time in planning. We set the place and date about two years ago. Sent the first announcement in the spring of 2012 and the call for abstracts in September. Then, at the very deadline, the abstracts and registrations start to trickle in. As with all meetings, we pushed the submission-deadline back a week just to allow people without basic planning skills with pressed schedules to join the meeting and present their data. Then, in as little time as possible, all the abstracts have to be formatted into a program, and session-chairs has to be found and matched so that they have an interest but aren't speaking themselves.

Anyway, we got some 17 free communications, varying from experimental physiology to international research politics, but with a heavy focus on epidemiology and clinical research. There were a couple of talks on the recently very hot topic of renal sympathetic denervation for treatment-resistant hypertension (more on that in another post), some interesting sub-group analyses from the LIFE and SCAST studies, and follow-ups on the now 40-year-old Oslo-Ischemia-Study. More of the program at the society home-page.

In addition, we had two invited lectures on statistics in clinical research. The first on how to develop and validate prognostic models by Ingar Holme, and the second on over-adjustment bias in multiple regression models held by Knut Liestøl. It was a useful repetition of the uses and pitfalls of these two very similar kinds of models that require very different study-designs and give very different information in the end. A common problem is that one tries to get etiological information from prognostic research, i.e. treating a risk-factor as a cause for the chosen end-point even though the observational design makes that impossible. The converse is equally common, i.e. trying to infer prognostic information from etiological studies, such as clinical trials, where the highly selected population makes general conclusions very suspect.

All told, it was a very successful meeting, well worth the time both for planning it, and attending.

Hypertension course - Day 2

After a too short night's sleep we started day two at 8:45 in the morning. The morning sessions covered treatment and current guidelines. Even though I was a bit tired, I managed to remember to take some pictures (for the blog), and write an extra presentation to replace a lecturer that could not attend.

There is massive data that shows that reducing the pressure under 140/90 mmHg is the first priority. Use what ever means necessary, just get the pressure down. Then there is data to show that renin-angiotensin-system-blockers may have some additional benefit. In type 1 diabetes this is indisputable. Type 1 diabetic patients should have an ACE-inhibitor or an ARB as soon as they show microalbuminuria, no matter what their pressure is. Unless you have a specific need for a beta-blocker you should start with a RAS-inihibitor and a calcium blocker.

The afternoon focused on target organ damage and associated diseases, such as diabetes, stroke and old age. To protect the heart and kidneys, ACE-inhibitors or ARBs are the best choices. To protect against renal failure and stroke it is quite clear that lower pressure is better down to 120/70, at least. For the heart, the nadir may be around 130/80, considering that the coronary arteries are perfused in diastole, this is not surprising. After stroke, certainly ischemic and maybe hemorrhagic, the pressure should not be treated the first couple of days, with the possible exception of systolic pressures above 220mmHg.

In the elderly, pulse pressure is a much stronger predictor of mortality than systolic pressure or diastolic pressure, so that 160/110 mmHg is actually better than 160/60 mmHg. Much better.

Hypertension is therapy resistant when treated with three antihypertensives at the maximal doses, including a thiazide-diuretic. It may then be time for renal nerve ablation, or to ask the patient if they eat a lot of salt. Another under-appreciated reason for uncontrolled blood pressure is doctor's-, or even investigator's-inertia. That is, the patient has an uncontrolled blood pressure, does not have the maximal dose, have not experienced any adverse events, and still the dosage isn't increased by the doctor.

All in all, it was a very successful course. 130 attendees, and some 20 lecturers. The next one will be in two years, in 2014.

On a side-note, free wifi on the airplane home is brilliant. All airlines should provide it, on all flights.

Actually, everywhere should provide free wifi.