2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

Ambulatory Blood Pressure Monitoring in HIV-Infected Patients: Usefulness for Cardiovascular Risk Assessment

Background:

There is a lack of consensus regarding the risk of hypertension in HIV-infected patients compared to the general population. Ambulatory blood pressure monitoring (ABPM) is the most accurate method for the hypertension diagnosis. Nevertheless, it is rarely used in HIV clinical care.

Materials and Methods:

All HIV-infected patients who underwent 24 hours ABPM were included. The agreement between office blood pressure (BP) readings and ABPM was analyzed. The rate of patients with masked hypertension (MH), isolated clinical hypertension, and nocturnal hypertension was obtained. Furthermore, it was analyzed if the differences between both methods may affect the cardiovascular risk (CVR) assessment.

Results:

A total of 116 patients were included. The κ coefficient between office BP and ABPM was 0.248. Over a quarter of the cohort was diagnosed with MH—25.8% (CI 95% 17.7%-34.0%), and 12% (CI 95%: 6.1%-16.1%) was diagnosed with ICH. Moreover, 19% of patients had hypertension exclusively during the night. The patients classified as low risk according to the CVR scores had a different diagnosis with ABPM than with office BP (P < .001).

Conclusions:

The agreement between office BP and ABPM was low in HIV-infected patients. Ambulatory BP monitoring is useful in HIV-infected patients as a hypertension diagnosis method, especially among patients classified as low risk.

Estimating the gains of early detection of hypertension over the marginal patient

This study estimated the potential impact of early diagnosis programs on health outcomes in England. Specifically, if advising individuals to visit their family doctor due to a suspected case of mild hypertension would result in (i) an increase in the diagnosis and treatment of high blood pressure; (ii) an improved lifestyle reflected in objective measures such as the body-mass-index and blood pressure levels; (iii) a reduced probability of the onset of other cardiovascular diseases, such as diabetes. To address potential selection bias in screening, a feature of the English Longitudinal Study of Ageing is exploited, motivating a regression discontinuity design. If respondents' blood pressure measurements are above a standard clinical threshold, they are advised to visit their family doctor to confirm hypertension. Two years after the protocol, there is evidence of an increase in diagnosis (5.7 pp, p-val = 0.06) and medication use (6 pp, p-val = 0.007) for treating the condition. However, four years after the protocol, the difference in diagnosis and medication disappeared (4 pp, p-val = 0.384; 3.4 pp, p-val = 0.261). Moreover, there are no differences on observed blood pressure levels (systolic 0.026 mmHg, p-val = 0.815; diastolic -0.336 mmHg, p-val = 0.765), or Body-Mass-Index ((0.771, p-val = 0.154)). There are also no differences on diagnosis of diabetes (1.7 pp, p-val = 0.343) or heart related conditions (3.6 pp, p-value = 0.161). In conclusion, the nudge produces an earlier diagnosis of around two years, but there are no perceivable gains in health outcomes after four years.

Pre-Stroke Statin Therapy Improves In-Hospital Prognosis Following Acute Ischemic Stroke Associated with Well-Controlled Nonvalvular Atrial Fibrillation

Many studies have confirmed the positive effect of statins in the secondary prevention of ischemic stroke. Although several studies have concluded that statins may also be beneficial in patients with atrial fibrillation-related stroke, the results of those studies are inconclusive. Therefore, the aim of this study was to analyze the effect of pre-stroke statin therapy on atrial fibrillation-related stroke among patients with a well-controlled atrial fibrillation. This retrospective multicenter analysis comprised 2309 patients with acute stroke, with a total of 533 patients meeting the inclusion criteria. The results showed a significantly lower neurological deficit on the National Institutes of Health Stroke Scale at hospital admission and discharge in the group of atrial fibrillation-related stroke patients who took statins before hospitalization compared with those who did not (p < 0.001). In addition, in-hospital mortality was significantly higher in the atrial fibrillation-related stroke patients not taking statins before hospitalization than in those who did (p < 0.001). Based on the results of our previous research and this current study, we postulate that the addition of a statin to the oral anticoagulants may be helpful in the primary prevention of atrial fibrillation-related stroke.

Dietary and lifestyle inflammatory scores and risk of incident diabetes: a prospective cohort among participants of Tehran lipid and glucose study

Background

Inflammation is a precursor of chronic disease, which is affected by lifestyle and dietary habits. Recently empirical dietary inflammatory patterns (EDIP), dietary inflammation scores (DIS), and lifestyle inflammation scores (LIS) were developed to indicate lifestyle and dietary contributions in systemic inflammation. The current study aimed to investigate the associations between these indices and the incidence of diabetes among Tehranian adults.

Methods

A total of 4624 individuals, aged 20–75 years, who were free of diabetes at baseline (2008–2011), were followed for 5.71 years (2014–2017) to ascertain incident diabetes. Dietary intakes were collected at baseline using the food frequency questionnaire. The hazard ratio (HR) of diabetes was calculated by Cox proportional hazards regression across quartiles of EDIP, DIS, and LIS, adjusted for potential confounders.

Results

The mean ± SD for the age and BMI of the study population (45.1% male) were 40.8 ± 12.7 years and 27.1 ± 4.1 Kg.m2, respectively. At the end of the follow-up, 329 (7.1%) diabetes cases were identified. In the multivariable-adjusted model, individuals in the highest compared to the lowest quartile of EDIP (HR = 0.83; 95%CI:0.59–1.15, p for trend = 0.286), and LIS (HR = 2.41; 95%CI:1.61–3.60, P for trend < 0.001) had increased risk of diabetes. However, no significant associations were found between the score of DIS and diabetes incidents (HR = 0.83; 95%CI:0.59–1.15, p for trend = 0.286).

Conclusion

Greater adherence to EDIP and LIS scores was associated with a higher risk of diabetes, while no significant association was found between the DIS score and diabetes incident.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11327-1.

Advanced glycation end-products, measured as skin autofluorescence, associate with vascular stiffness in diabetic, pre-diabetic and normoglycemic individuals: a cross-sectional study

Background

Advanced glycation end-products are proteins that become glycated after contact with sugars and are implicated in endothelial dysfunction and arterial stiffening. We aimed to investigate the relationships between advanced glycation end-products, measured as skin autofluorescence, and vascular stiffness in various glycemic strata.

Methods

We performed a cross-sectional analysis within the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort, comprising n = 3535 participants (median age 67 years, 60% women). Advanced glycation end-products were measured as skin autofluorescence with AGE-Reader™, vascular stiffness was measured as pulse wave velocity, augmentation index and ankle-brachial index with Vascular Explorer™. A subset of 1348 participants underwent an oral glucose tolerance test. Participants were sub-phenotyped into normoglycemic, prediabetes and diabetes groups. Associations between skin autofluorescence and various indices of vascular stiffness were assessed by multivariable regression analyses and were adjusted for age, sex, measures of adiposity and lifestyle, blood pressure, prevalent conditions, medication use and blood biomarkers.

Results

Skin autofluorescence associated with pulse wave velocity, augmentation index and ankle-brachial index, adjusted beta coefficients (95% CI) per unit skin autofluorescence increase: 0.38 (0.21; 0.55) for carotid-femoral pulse wave velocity, 0.25 (0.14; 0.37) for aortic pulse wave velocity, 1.00 (0.29; 1.70) for aortic augmentation index, 4.12 (2.24; 6.00) for brachial augmentation index and − 0.04 (− 0.05; − 0.02) for ankle-brachial index. The associations were strongest in men, younger individuals and were consistent across all glycemic strata: for carotid-femoral pulse wave velocity 0.36 (0.12; 0.60) in normoglycemic, 0.33 (− 0.01; 0.67) in prediabetes and 0.45 (0.09; 0.80) in diabetes groups; with similar estimates for aortic pulse wave velocity. Augmentation index was associated with skin autofluorescence only in normoglycemic and diabetes groups. Ankle-brachial index inversely associated with skin autofluorescence across all sex, age and glycemic strata.

Conclusions

Our findings indicate that advanced glycation end-products measured as skin autofluorescence might be involved in vascular stiffening independent of age and other cardiometabolic risk factors not only in individuals with diabetes but also in normoglycemic and prediabetic conditions. Skin autofluorescence might prove as a rapid and non-invasive method for assessment of macrovascular disease progression across all glycemic strata.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01296-5.

Cost Effectiveness of ACEIs/ARBs versus Amlodipine Monotherapies: A Single-Center Retrospective Chart Review

The aim of this retrospective chart review study was to examine the cost effectiveness of angiotensin-converting enzyme inhibitors (ACEIs); angiotensin receptor blockers (ARBs); and dihydropyridine calcium channel blockers (CCBs) such as amlodipine, monotherapies in the management of essential hypertension among adult patients (≥18 years) without cancer, cardiovascular disease, and chronic kidney disease in the primary care clinics of a university-affiliated tertiary care hospital. Patients were followed up for at least 12 months from the initiation of therapy. Propensity score bin bootstrapping with 10,000 replications was conducted to generate the 95% confidence intervals (CI) for both treatment outcome (e.g., reduction of the systolic (SBP) and diastolic blood pressures (DBP) in mmHG) and the cost (e.g., costs of drugs, clinic visits, and labs in Saudi riyals (SAR)). Among the 153 included patients who met the inclusion criteria, 111 patients were on ACEIs/ARBs, while 44 patients were on amlodipine. On the basis of the bootstrap distribution, we found that the use of ACEIs/ARBs was associated with an incremental reduction of SBP of up to 4.46 mmHg but with an incremental cost of up to SAR 116.39 (USD 31.04), which results in an incremental cost effectiveness ratio (ICER) of SAR 26.09 (USD 6.95) per 1 mmHg reduction with 55.26% level of confidence. With regard to DBP, ACEIs/ARBs were associated with an incremental reduction of DBP of up to 5.35 mmHg and an incremental cost of up to SAR 144.96 (USD 38.66), which results in an ICER of SAR 27.09 (USD 7.23) per 1 mmHg reduction with 68.10% level of confidence. However, ACEIs/ARBs were less effective and costlier than amlodipine in reducing SBP and DBP with 44.74% and 31.89% levels of confidence, respectively. The findings of this study indicate that the use of ACEI or ARB as a monotherapy seems to be more effective than amlodipine monotherapy in the management of essential hypertension in primary care settings with minimal incremental cost.

Development and Validation of an HPLC Method Using an Experimental Design for Analysis of Amlodipine Besylate and Enalapril Maleate in a Fixed-dose Combination

Objectives

The aim of this study was to develop and optimize a simple, cost-effective, and robust high-performance liquid chromatography (HPLC) method by taking an experimental design approach to the assay and dissolution analysis of amlodipine besylate and enalapril maleate from a fixed-dose combination tablet.

Materials and Methods

The chromatographic analysis was performed on a C18 column (4.6x250 mm id., particle size of 5 μm). The injection volume was 5 μL, and the detection wavelength was 215 nm. A Box-Behnken design was used to test the robustness of the method. The flow rate (1, 1.2, and 1.4 mL/min), column temperature (25°C, 30°C, and 35°C), methanol ratio of the mobile phase (5, 10, and 15%), and pH of the mobile phase (2.8, 3, and 3.2) were selected as independent variables. The method was validated according to International Conference on Harmonization guidelines. Dissolution of the tablets was performed by using USP apparatus 2 and analyzed using the optimized HPLC method. Multivariate linear regression analysis and ANOVA were used in the statistical evaluation.

Results

Linear models were fitted for all variables. The flow rate was the most significant factor affecting the APIs' concentrations. The optimized method included the following parameters: Column temperature of 25°C, 10% methanol as the mobile phase, pH of 2.95, and flow rate of 1.205 mL/min. Retention times were 3.8 min and 7.9 min for enalapril and amlodipine, respectively. The method was found to be linear in the range of 0.8-24 μg/mL (R² >0.999) and 1.6-48 μg/mL (R² >0.999) for amlodipine and enalapril, respectively. Both APIs were dissolved more than 85% within 10 min.

Conclusion

The experimental design was proved as a useful tool for the determination and separation of enalapril maleate and amlodipine besylate in dosage forms. The optimized method can be used for in vitro performance and quality control tests of fixed-dose tablet combinations containing enalapril maleate and amlodipine besylate.

Impact of Diabetes on Cardiac Function in Patients with High Blood Pressure

Background: Although the combination of high blood pressure (HBP) and type 2 diabetes (T2DM) increases the risk of left ventricular (LV) dysfunction, the impact of T2DM on LV geometry and subclinical dysfunction in hypertensive patients and normal ejection fraction (EF) has been infrequently evaluated. Methods: Hypertensive patients with or without T2DM underwent cardiac echocardiography coupled with LV global longitudinal strain (GLS) assessment. Results: Among 200 patients with HBP (mean age 61.7 ± 9.7 years) and EF > 55%, 93 had associated T2DM. Patients with T2DM had a higher body mass index (29.9 ± 5.1 kg/m² vs. 29.3 ± 4.7 kg/m², p = 0.025), higher BP levels (158 ± 23/95 ± 13 vs. 142 ± 33/87 ± 12 mmHg, p = 0.003), a higher LV mass index (115.8 ± 32.4 vs. 112.0 ± 24.7 g/m², p = 0.004), and higher relative wall thickness (0.51 ± 0.16 vs. 0.46 ± 0.12, p = 0.0001). They had more frequently concentric remodeling (20.4% vs. 16.8%, p < 0.001), concentric hypertrophy (53.7% vs. 48.6%, p < 0.001), elevated filling pressures (25.8 vs. 12.1%, p = 0.0001), indexed left atrial volumes greater than 28 mL/m² (17.2 vs. 11.2%, p = 0.001), and a reduced GLS less than −18% (74.2 vs. 47.7%, p < 0.0001). After adjustment for BP and BMI, T2DM remains an independent determinant factor for GLS decline (OR = 2.26, 95% CI 1.11–4.61, p = 0.023). Conclusions: Left ventricular geometry and subclinical LV function as assessed with GLS are more impaired in hypertensive patients with than without T2DM. Preventive approaches to control BMI and risk of T2DM in hypertensive patients should be emphasized.

Preadmission Antihypertensive Drug Use and Sepsis Outcome: Impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs)

BACKGROUND

Several studies have reported improved sepsis outcomes when certain preadmission antihypertensive drugs, namely, calcium channel blockers (CCBs), are used. This study aims to determine whether preadmission antihypertensive drug use, especially angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), is associated with decreased total hospital mortality in sepsis.

METHODS

This study was conducted using the unique database of a sepsis cohort from the National Health Insurance Research Database in Taiwan. Frequency matching for age and sex between preadmission antihypertensive drug users (study cohort) and nonusers (comparison cohort) was conducted. The primary outcome was total hospital mortality. Logistic regression analyses were performed to calculate the odds ratios (ORs) of important variables. Further joint effect analyses were carried out to examine the impacts of different combinations of antihypertensive drugs.

RESULTS

A total of 33,213 sepsis antihypertensive drug use patients were retrieved as the study cohort, and an equal number of matched sepsis patients who did not use antihypertensive drugs were identified as the comparison cohort. The study cohort had a higher incidence rate of being diagnosed with septic shock compared with the comparison cohort (4.36%-2.31%, P < 0.001) and a higher rate of total hospital mortality (38.42%-24.57%, P < 0.001). In the septic shock condition, preadmission antihypertensive drug use was associated with a decreased adjusted OR (OR = 0.66, 95% confidence interval [CI], 0.55-0.80) for total hospital mortality, which was not observed for the nonseptic shock condition. Compared with antihypertensive drug nonusers, both ACEI and ARB users had decreased adjusted ORs for total hospital mortality in sepsis (adjusted OR = 0.93, 95% CI, 0.88-0.98 and adjusted OR = 0.85, 95% CI, 0.81-0.90); however, CCB, beta-blocker, and diuretic users did not. In the septic shock condition, ACEI, ARB, CCB, and beta-blocker users all had decreased ORs for total hospital mortality. Joint effect analysis showed ACEI use, except in combination with diuretics, to be associated with a decreased adjusted OR for total hospital mortality in sepsis. Similar results were observed for ARB users.

CONCLUSIONS

Preadmission ACEI or ARB use is associated with a decreased risk of total hospital mortality, regardless of a nonshock or septic shock condition.

Contribution of sleep characteristics to the association between obstructive sleep apnea and dyslipidemia

OBJECTIVES/BACKGROUND

Little information is available about the association of obstructive sleep apnea (OSA) with atherogenic dyslipidemia and the contribution of sleep characteristics to lipid alterations. We compare dyslipidemia prevalence among non-apneic subjects and mild-severe OSA patients to identify the sleep characteristics that are independently associated with dyslipidemia and serum lipid levels in OSA patients.

PATIENTS/METHODS

We recruited 809 consecutive patients who had been referred for polysomnography study by OSA suspicion. Anthropometric characteristics, body composition and comorbidities were recorded. Spirometry and 24-h ambulatory blood pressure monitoring were performed the same day of the sleep study. The day after attended polysomnography, fasting blood samples were drawn to measure the lipid profile.

RESULTS

Dyslipidemia prevalence increased with the presence of OSA, from non-OSA subjects to mild, moderate and severe OSA patients (31%, 33%, 42% and 51%, respectively; p < 0.001). After adjusting for sex, age, body mass index and smoking habit, only severe OSA had an independent association with dyslipidemia when compared to non-OSA subjects (adjusted odds ratio 1.71, 95%CI 1.09 to 2.69, p = 0.019). In OSA patients, multivariate logistic regression identified active smoking, apnea-hypopnea index (AHI) and mean nocturnal saturation as variables independently associated with dyslipidemia. However, in these patients, arousal index, slow wave sleep duration and REM latency were also independently associated with cholesterol and low-density lipoprotein levels.

CONCLUSIONS

The association between dyslipidemia and OSA is limited to severe patients, with high AHI and nocturnal hypoxemia. However, sleep fragmentation and increased sympathetic activity could also contribute to OSA-related lipid dysregulation.

Update of the position paper on arterial hypertension and erectile dysfunction

: Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.

Dietary Pattern and Long-Term Effects of Particulate Matter on Blood Pressure: A Large Cross-Sectional Study in Chinese Adults

[Figure: see text].

Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases

Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.

Risk of hypertension into adulthood in persons born prematurely: a national cohort study

AIMS

Preterm birth has been associated with elevated blood pressure early in life; however, hypertension risks from childhood into adulthood remain unclear. We conducted a large population-based study to examine gestational age at birth in relation to hypertension risks from childhood into adulthood.

METHODS AND RESULTS

A national cohort study was conducted of all 4 193 069 singleton live births in Sweden during 1973-2014, who were followed up for hypertension identified from nationwide inpatient and outpatient (specialty and primary care) diagnoses from any health care encounters through 2015 (maximum age 43 years; median 22.5). Cox regression was used to examine gestational age at birth in relation to hypertension risk while adjusting for other perinatal and maternal factors, and co-sibling analyses assessed the potential influence of unmeasured shared familial (genetic and/or environmental) factors. In 86.8 million person-years of follow-up, 62 424 (1.5%) persons were identified with hypertension (median age 29.8 years at diagnosis). Adjusted hazard ratios for new-onset hypertension at ages 18-29 years associated with preterm (<37 weeks) and extremely preterm (22-27 weeks) birth were 1.28 [95% confidence interval (CI), 1.21-1.36] and 2.45 (1.82-3.31), respectively, and at ages 30-43 years were 1.25 (1.18-1.31) and 1.68 (1.12-2.53), respectively, compared with full-term birth (39-41 weeks). These associations affected males and females similarly and appeared substantially related to shared genetic or environmental factors in families.

CONCLUSIONS

In this large national cohort, preterm birth was associated with increased risk of hypertension into early adulthood. Persons born prematurely may need early preventive evaluation and long-term monitoring for the development of hypertension.

Development of a novel CT-derived measure of cardiovascular health: the CT aortic stiffness index (CTASI)

AIMS

Aortic stiffness, measured as aortic pulse wave velocity (PWV), is a powerful predictor of cardiovascular health but is difficult to accurately obtain non-invasively. This study sought to develop a novel CT aortic stiffness index (CTASI) which incorporates both anatomical (calcification) and physiological (distensibility) aspects of aortic health.

METHODS

Invasive PWV and CT scans were obtained for 80 patients undergoing TAVI (cohort 1). CT data alone were obtained from an additional 238 patients (cohort 2). Aortic calcification was quantified using a modified Agatston's methodology. Distensibility-PWV was calculated from minimum and maximum ascending aorta areas. Linear regression of these values was used to construct CTASI from cohort 1. CTASI was then calculated for cohort 2 who were prospectively followed-up.

RESULTS

CTASI correlated with invasive PWV (rho = 0.47, p < 0.01) with a higher correlation coefficient than distensibility-PWV (rho = 0.35, p < 0.01) and aortic calcification (rho = 0.36, p < 0.01). Compared to invasive PWV, CTASI had a good accuracy as a diagnostic test (AOC 0.72 [95% CI 0.61-0.84]), superior to aortic calcification and distensibility-PWV alone (χ² = 0.82, p = 0.02). There were 61 deaths during a median follow-up of 771 days (95% CI 751.4-790.5). CTASI was able to predict 1-year mortality (OR 2.58, 95% CI 1.18-5.61, p = 0.02) and Kaplan-Meier survival (log-rank p = 0.03).

CONCLUSION

CTASI is a stronger measure of aortic stiffness than aortic calcification or distensibility alone. Given the prolific use of CT scanning for assessing coronary and vascular disease, the additional calculation of CTASI during these scans could provide an important direct measurement of vascular health and guide pharmacological therapy.

The effect of chronic intermittent hypoxia on atherosclerosis in rat offspring

BACKGROUND

To determine whether rat offspring born under conditions of chronic intermittent hypoxia (CIH) would develop systemic inflammation and be susceptible to CIH-mediated injury on artery.

METHODS

CIH rat model was established. The expression levels of p38MAPK, NF-κB p65, CRP, TNFα, and IL-8 were measured. The arterial pathology of offspring whose mothers were exposed to CIH during pregnancy was evaluated.

RESULTS

The levels of p-P38MAPK and NF-κB p65 were significantly up-regulated following induction of intra-uterine CIH Induction of intra- and extra-uterine CIH had an interaction regarding the expression profiles of these markers (P < 0.01, P < 0.01, P < 0.01, P < 0.01, P = 0.020, respectively). Pathologic analysis of the arteries confirmed that intra-uterine CIH increased the tunica intima thickness (P < 0.01), but had no effect on the tunica media (P = 0.974). Furthermore, induction of intra- and extra-uterine CIH had a synergistic interaction on tunica intima thickness (P = 0.004).

CONCLUSIONS

Intra-uterine CIH caused tunica intima thickening and development of pre-atherosclerotic lesions in offspring via NF-κB p65 and p-p38 MAPK. Furthermore, the expression of NF-κB p65 and p-p38 MAPK and the extent of pre-atherosclerotic lesions were either exacerbated or alleviated in offspring when re-exposed to CIH later.

Monotherapy vs combination treatments of different complexity: a meta-analysis of blood pressure lowering randomized outcome trials

BACKGROUND

Use of drug combinations is recommended by hypertension guidelines for most patients because of the greater blood pressure (BP)-lowering effect compared with monotherapy. However, no evidence is available on outcome benefits of treatment strategies based on drug combinations vs. simpler treatment regimens, using data from randomized clinical trials (RCTs). We evaluated drug combination therapies of different complexity.

METHODS

Electronic databases were searched for BP-lowering RCTs that compared combination treatment or monotherapy vs. placebo, no-treatment or less-complex treatment. Combination treatment was considered as follows: background treatment continued during follow-up on top of the trial drug(s) of interest and drug(s) were added to the initial drug(s) of interest in the majority of the patients. Monotherapy was considered whenever pre-randomization treatment was withdrawn or absent and a single drug was administered at randomization. Complexity of treatment indicates the higher averaged number of daily medications used in the eligible RCTs.

RESULTS

We selected 93 trials (290 304 patients; follow-up, 3.9 years). The on-treatment mean number of drugs was 2.10 and 0.99 in the more and less actively treated patients, respectively. Compared with placebo, no-treatment or less-complex treatment, combination treatments of any complexity (mean number of drugs, 1.40 vs. 0.41, 2.32 vs. 0.48, 2.56 vs. 1.62 and 3.14 vs. 2.19) were associated with reduction of all or most fatal and nonfatal outcomes. There was also an increased rate of side effects leading to treatment discontinuation, although in absolute numbers the benefit usually prevailed.

CONCLUSION

These data provide randomized-based trial evidence that antihypertensive combination treatment up to three or more drugs is protective. The net benefit, however, may be attenuated when side effects are considered.

Echocardiographic evaluation of the elasticity of the ascending aorta in patients with essential hypertension

BACKGROUND

Hypertension is the most common chronic disease and the most important risk factor for cardiovascular and cerebrovascular diseases. Atheroma and arteriosclerosis plays a key role in the occurrence and development of hypertension. The purpose of this study was to evaluate the elasticity of ascending aorta wall in patients with essential hypertension (EH) using M-mode echocardiography.

MATERIALS AND METHODS

We prospectively enrolled 54 EH patients and 51 healthy subjects (HS). They all underwent transthoracic echocardiography to measure ascending aorta inner diameters and brachial blood pressure measurement to calculate aortic elastic variables: compliance, distensibility, strain, stiffness index, and Peterson's elastic modulus. All participants also underwent bilateral carotid ultrasonographic examination.

RESULTS

There were no significant differences in age, sex, body mass index, blood lipids, blood glucose, and ascending aorta inner diameters between the two groups. We found neither intimal thickening nor plaque formation in the left or right carotid arteries in both groups. The aortic elastic properties were significantly impaired in EH patients compared with HS.

CONCLUSIONS

Echocardiography can be used for the noninvasive evaluation of ascending aorta wall elasticity as an early screening technique. Subclinical arteriosclerosis appeared to occur in the ascending aorta of patients with essential hypertension even though carotid ultrasonography was normal.

Liver Fibrosis and Steatosis in Alström Syndrome: A Genetic Model for Metabolic Syndrome

Alström syndrome (ALMS) is an ultra-rare monogenic disease characterized by insulin resistance, multi-organ fibrosis, obesity, type 2 diabetes mellitus (T2DM), and hypertriglyceridemia with high and early incidence of non-alcoholic fatty liver disease (NAFLD). We evaluated liver fibrosis quantifying liver stiffness (LS) by shear wave elastography (SWE) and steatosis using ultrasound sonographic (US) liver/kidney ratios (L/K) in 18 patients with ALMS and 25 controls, and analyzed the contribution of metabolic and genetic alterations in NAFLD progression. We also genetically characterized patients. LS and L/K values were significantly higher in patients compared with in controls (p < 0.001 versus p = 0.013). In patients, LS correlated with the Fibrosis-4 Index and age, while L/K was associated with triglyceride levels. LS showed an increasing trend in patients with metabolic comorbidities and displayed a significant correlation with waist circumference, the homeostasis model assessment, and glycated hemoglobin A1c. SWE and US represent promising tools to accurately evaluate early liver fibrosis and steatosis in adults and children with ALMS during follow-up. We described a new pathogenic variant of exon 8 in ALMS1. Patients with ALMS displayed enhanced steatosis, an early increased age-dependent LS that is associated with obesity and T2DM but also linked to genetic alterations, suggesting that ALMS1 could be involved in liver fibrogenesis.

Relative Handgrip Strength as Marker of Cardiometabolic Risk in Women with Systemic Lupus Erythematosus

This study aimed to examine the association of relative handgrip strength (rHGS) with cardiometabolic disease risk factors in women with systemic lupus erythematosus (SLE). Methods: Seventy-seven women with SLE (mean age 43.2, SD 13.8) and clinical stability during the previous six months were included. Handgrip strength was assessed with a digital dynamometer and rHGS was defined as absolute handgrip strength (aHGS) divided by body mass index (BMI). We measured blood pressure, markers of lipid and glucose metabolism, inflammation (high sensitivity C-reactive protein [hs-CRP]), arterial stiffness (pulse wave velocity [PWV]), and renal function. A clustered cardiometabolic risk index (z-score) was computed. Results: Pearson′s bivariate correlations revealed that higher rHGS was associated with lower systolic blood pressure (SBP), triglycerides, hs-CRP, PWV, and lower clustered cardiometabolic risk (r_range = from −0.43 to −0.23; all p < 0.05). Multivariable linear regression analyses adjusted for age, disease activity (SLEDAI), and accrual damage (SDI) confirmed these results (all p < 0.05) except for triglycerides. Conclusions: The findings suggest that higher rHGS is significantly associated with lower cardiometabolic risk in women with SLE.

Effectiveness of a workplace intervention reducing psychosocial stressors at work on blood pressure and hypertension

Objectives

To assess the effectiveness of a workplace intervention reducing psychosocial stressors at work in lowering blood pressure and hypertension prevalence.

Methods

The study design was a quasi-experimental pre–post study with an intervention group and a control group. Post-intervention measurements were collected 6 and 36 months after the midpoint of the intervention. Participants were all white-collar workers employed in three public organisations. At baseline, the intervention and the control groups were composed of 1088 and 1068 workers, respectively. The intervention was designed to reduce psychosocial stressors at work by implementing organisational changes. Adjusted changes in ambulatory blood pressure and hypertension prevalence were examined.

Results

Blood pressure and hypertension significantly decreased in the intervention group while no change was observed in the control group. The differential decrease in systolic blood pressure between the intervention and the control group was 2.0 mm Hg (95% CI: −3.0 to –1.0). The prevalence of hypertension decreased in the intervention group, when compared with the control group (prevalence ratio: 0.85 (95% CI: 0.74 to 0.98)).

Conclusions

Findings suggest that psychosocial stressors at work are relevant targets for the primary prevention of hypertension. At the population level, systolic blood pressure reductions such as those observed in the present study could prevent a significant number of premature deaths and disabling strokes.

Rescue Operations Lead to Increased Cardiovascular Stress in HEMS Crew Members: A Prospective Pilot Study of a German HEMS Cohort

Helicopter emergency medical service (HEMS) is an essential part of prehospital emergency medicine. The working conditions lead to high physical stress, especially in rescue operations. The study aimed to determine the cardiovascular stress profile during rescue situations in HEMS crew members. Twenty-one HEMS crew members (male n = 20) participated in the prospective study. Heart rate, blood pressure and long-term ECG measurements were recorded during the whole operation day. The changes of measurements during rescue operation (52 operations in total) were compared to these of standby time. Rescue operations lead to increased load on the cardiovascular system, as expressed by significantly higher blood pressure, heart rate values and rate of cardiac events compared to standby time. Of special note, the difference in systolic blood pressure mean was 7.4 ± 9.0 mmHg (CI [5.1; 9.7], p < 0.001). Maximal heart rate was on average 33.7 bpm higher during rescue operation than in the standby time (CI [26.2; 40.8], p < 0.001). Cardiac events occurred significantly more frequently during the period of rescue operation than in standby time hours (p = 0.02). The results reported a significant load on the cardiovascular system during rescue operations in HEMS crew members. Therefore, it is necessary to carry out a risk stratification of the HEMS crew members to prevent cardiovascular risk and events.

Diabetes modifies the association of prehypertension with cardiovascular disease and all-cause mortality

Prehypertension is a risk factor for cardiovascular disease (CVD) and all‐cause mortality. However, it is unclear whether prehypertension combined with diabetes associate with a higher risk for cardiovascular disease and all‐cause mortality. The purpose of this study was to explore the relationship between prehypertension and the risk of CVD and all‐cause mortality was different among individuals with or without diabetes. In the prospective community‐based Kailuan study, 67 344 participants without hypertension or a history of CVD at baseline (2006) were included. Prehypertension was defined as systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg. The outcomes were CVD and all‐cause mortality were followed up through December 31, 2017. We performed Cox proportional hazards models to evaluate the relationships between prehypertension and CVD and all‐cause mortality by diabetes status. During a median follow‐up of 11.03 years, 2981 CVD events and 4655 all‐cause mortality occurred. After adjusting age, sex, and other factors, the associations of prehypertension with risk of CVD and all‐cause mortality were significant in participants without diabetes (hazard ratio and 95% confidence interval: 1.54 [1.38–1.71] and 1.27 [1.17–1.38]), but not in participants with diabetes (1.20 [0.93–1.56] and 0.88 [0.73–1.07]). The interactions between prehypertension and diabetes for the risk of CVD and all‐cause mortality were all significant (all p < .05). Prehypertension was only associated with an increased risk for CVD and all‐cause mortality in non‐diabetes participants. Diabetes modifies the relation of prehypertension with the risk of CVD and all‐cause mortality.

Firibastat: A Novel Brain Aminopeptidase Inhibitor - A New Era of Antihypertensive therapy

Global incidence and prevalence of hypertension continues to increase and remains a significant challenge. The ever-increasing number of cases are due to comorbid conditions such as obesity and diabetes, as well as lifestyle indiscretions such as excessive salt intake. Hypertension, congestive heart failure, and kidney disease are all conditions resulting from abnormal Renin-Angiotensin-Aldosterone activation and adverse remodeling. Firibastat, a novel Brain Aminopeptidase inhibitor, may be able to help achieve blood pressure control in those with resistant hypertension. In this review article, we will discuss the biochemical pathway of firibastat and various trials assessing drug efficacy in animals and humans. This drug has the potential to curb the risk of uncontrolled hypertension and help improve long term cardiovascular morbidity and mortality.

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Antithrombotic Therapy Recommendations in the European Society of Cardiology Guidelines: How Robust Are the Randomized Controlled Trials Underpinning Them?

Introduction  Criticisms have been raised against the sole use of p -value in interpreting results from randomized controlled trials (RCTs). Additional tools have been suggested, like the fragility index (FI), a measure of a trial's robustness/fragility, and derivative measures. The FI is the minimum number of patients who would have to be converted from nonevents to events, in the group with the least events, for a result to lose statistical significance. Objective  This study aimed to evaluate RCT supporting European Society of Cardiology (ESC) guidelines regarding antithrombotics, using the FI and FI-related measures. Methods  FI, fragility quotient (FQ), and FI minus LTF lost to follow-up (FI - LTF) were calculated for the RCT underpinning recommendations regarding antithrombotic therapy from the updated ESC guidelines. LTF was compared with FI. Results were calculated for the total group of studies, as per guideline and as per recommendation type. Results  Overall, 61 studies were included. The median FI was 24.5 (interquartile range [IQR]: 9.0-60.0) and median FQ was 0.0035 (IQR: 0.0019-0.0056). Median FI - LTF was 2.0 (IQR: 0.0-38.0). Twenty (32.8%) of the studies had one primary or main safety outcome with LTF exceeding FI. Peripheral arterial disease guideline and chronic coronary syndrome guideline had the lowest (2.5; IQR: 1.8-3.3) and the highest (48.5; IQR: 23.8-73.0) FI, respectively. Conclusion  The median FI suggests robustness of clinical trials evaluating antithrombotic drugs cited in the guidelines, but about one-third of them had LTF larger than FI. This emphasizes the need for assessing trials' robustness when constructing guidelines.

Primary aldosteronism is highly prevalent in patients with hypertension and moderate to severe obstructive sleep apnea

STUDY OBJECTIVES

It has been suggested that there might be a pathophysiological link and overlap between primary aldosteronism (PA) and obstructive sleep apnea (OSA). Therefore, in a prospective study, we evaluated the frequency of PA in hypertensive patients suspected of having OSA.

METHODS

We included 207 consecutive hypertensive patients (mean age 53.2 ± 12.1 years, 133 M, 74 F) referred for polysomnography on the basis of one or more of the following clinical features: typical OSA symptoms, resistant or difficult-to-treat hypertension, diabetes, or cardiovascular disease. PA was diagnosed based on thew saline infusion test.

RESULTS

Moderate-to-severe OSA was diagnosed in 94 patients (45.4% of the whole group). PA was diagnosed in 20 patients with OSA (21.3%) compared with 9 patients in the group without OSA (8.0%; P = .006). PA was also frequent in patients in whom symptoms of OSA were a sole indication for PA screening (15.4%) and in patients with and without resistant hypertension (24.5% and 17.8%, respectively). Most patients with PA and OSA were diagnosed with bilateral adrenal hyperplasia (18 patients, 90%). There were no major differences in clinical characteristics between patients with OSA with PA and those without PA. In multivariate models, moderate-to-severe OSA predicted the presence of PA (odds ratio 2.89, P = .018).

CONCLUSIONS

Patients with clinically important moderate-to-severe OSA are characterized by a relatively high frequency of PA. Our results support the recommendations to screen patients with moderate-to-severe OSA for PA, regardless of the presence of other indications for PA screening.

Associations Between Relative Morning Blood Pressure, Cerebral Blood Flow, and Memory in Older Adults Treated and Controlled for Hypertension

[Figure: see text].

Arterial Stiffness and Hemodynamics in Young Women: The Effects of Oral Contraceptive Intake and Physical Habits

Oral contraceptive (OC) intake seems to be associated with increased central hemodynamics and arterial stiffness. Conversely, physical activity (PA) is known to induce benefits on vascular structure and function, suggesting that the negative effects of the OC pill could be counterbalanced by regular PA. The aim of this cross-sectional study was to determine (1) whether OC intake in young women is associated with higher values of hemodynamic parameters and arterial stiffness and (2) whether these negative effects could be counterbalanced by regular physical activity. Forty-nine young healthy women (21.9 years ± 2.1) were recruited and divided into 4 groups, depending on their hormonal status (OC users: OC+ or non-OC users: OC−) and their physical habits (active/inactive). Assessments of central hemodynamics (central blood pressure, Aix75) and pulse wave velocity (PWV) were performed using applanation tonometry. cBP was higher in OC+ vs. OC−, while PWV was similar between these two groups. No interaction between physical activity and hormonal status was observed for any of these variables. Nevertheless, PWV was lower in young active women compared with age-matched inactive women, suggesting that the positive effect of regular physical exercise on the cardiovascular system is already visible in the first years of women’s adulthood, whatever the hormonal status.

Medication adherence in hypertension

: Suboptimal adherence to antihypertensive medication is a major contributor to poor blood pressure control. Several methods, direct or indirect, are available for measuring adherence, including the recently developed biochemical screening, although there is no gold-standard method routinely used in clinical practice to accurately assess the different facets of adherence. Adherence to treatment is a complex phenomenon and several of the barriers to adherence will need to be addressed at the healthcare system level; however, when looking at adherence from a more practical side and from the practitioner's perspective, the patient-practitioner relationship is a key element both in detecting adherence and in attempting to choose interventions tailored to the patient's profile. The use of single-pill combinations enabling simplification of treatment regimen, the implementation of a collaborative team-based approach and the development of electronic health tools also hold promise for improving adherence, and thus impacting cardiovascular outcomes and healthcare costs.

Ischemic Stroke Risk Factors in Patients with Atrial Fibrillation Treated with New Oral Anticoagulants

The most commonly used therapeutic option for the prevention of ischemic stroke in patients with atrial fibrillation is new- or old-generation oral anticoagulants. New oral anticoagulants are at least as effective as old-generation oral anticoagulants in the prevention of ischemic stroke, with a reduced risk of life-threatening hemorrhage. Moreover, the constant monitoring of these drugs in the patient’s blood is not required during routine use. However, ischemic stroke can still occur in these patients. Therefore, the aim of this study was to investigate the pattern of risk factors for ischemic stroke in patients with atrial fibrillation treated with new oral anticoagulants. Our multicenter retrospective study involved 2032 patients with acute ischemic stroke. The experimental group consisted of 256 patients with acute ischemic stroke and nonvalvular atrial fibrillation, who were treated with new oral anticoagulants. The control group consisted of 1776 ischemic stroke patients without coexisting atrial fibrillation. The results of our study show that patients with atrial fibrillation treated with new oral anticoagulants are more likely to display thrombotic, proatherogenic, and proinflammatory factors in addition to the embolic factors associated with atrial fibrillation. Therefore, solely taking new oral anticoagulants is insufficient in protecting this group of patients from ischemic stroke.

Prognostic Significance of Systemic Arterial Stiffness Evaluated by Cardio-Ankle Vascular Index in Patients with Idiopathic Pulmonary Hypertension

BACKGROUND

In a previous study, the cardio-ankle vascular index (CAVI) was increased significantly in idiopathic pulmonary arterial hypertension (IPAH) patients compared to the healthy group and did not much differ from one in systemic hypertensives. In this study the relations between survival and CAVI was evaluated in patients with IPAH.

PATIENTS AND METHODS

We included 89 patients with new-diagnosed IPAH without concomitant diseases. Standard examinations, including right heart catheterization (RHC) and systemic arterial stiffness evaluation, were performed. All patients were divided according to CAVI value: the group with CAVI ≥ 8 (n = 18) and the group with CAVI < 8 (n = 71). The mean follow-up was 33.8 ± 23.7 months. Kaplan-Meier and Cox regression analysis were performed for the evaluation of our cohort survival and the predictors of death.

RESULTS

The group with CAVI≥8 was older and more severe compared to the group with CAVI< 8. Patients with CAVI≥8 had significantly reduced end-diastolic (73.79±18.94 vs 87.35±16.69 mL, P<0.009) and end-systolic (25.71±9.56 vs 33.55±10.33 mL, P<0.01) volumes of the left ventricle, the higher right ventricle thickness (0.77±0.12 vs 0.62±0.20 mm, P < 0.006), and the lower TAPSE (13.38±2.15 vs 15.98±4.4 mm, P<0.018). RHC data did not differ significantly between groups, except the higher level of the right atrial pressure in patients with CAVI≥ 8-11.38±7.1 vs 8.76±4.7 mmHg, P<0.08. The estimated overall survival rate was 61.2%. The CAVI≥8 increased the risk of mortality 2.34 times (CI 1.04-5.28, P = 0.041). The estimated Kaplan-Meier survival in the patients with CAVI ≥ 8 was only 46.7 ± 7.18% compared to patients with CAVI < 8 - 65.6 ± 4.2%, P = 0.035. At multifactorial regression analysis, the CAVI reduced but saved its relevance as death predictor - OR = 1.13, CI 1.001-1.871.

SUMMARY

We suggested the CAVI could be a new independent predictor of death in the IPAH population and could be used to better risk stratify this patient population if CAVI is validated as a marker in a larger multicenter trial.

The "Hitchhiker's Guide to the Galaxy" of Endothelial Dysfunction Markers in Human Fertility

Endothelial dysfunction is an early event in the pathogenesis of atherosclerosis and represents the first step in the pathogenesis of cardiovascular diseases. The evaluation of endothelial health is fundamental in clinical practice and several direct and indirect markers have been suggested so far to identify any alterations in endothelial homeostasis. Alongside the known endothelial role on vascular health, several pieces of evidence have demonstrated that proper endothelial functioning plays a key role in human fertility and reproduction. Therefore, this state-of-the-art review updates the endothelial health markers discriminating between those available for clinical practice or for research purposes and their application in human fertility. Moreover, new molecules potentially helpful to clarify the link between endothelial and reproductive health are evaluated herein.

The Relationship of Modifiable Risk Factors with Indicators of Arterial Stiffness and Vascular Age in Patients with Arterial Hypertension

Aim. To study the relationship of modifiable risk factors (RF) with indicators of arterial stiffness and vascular age based on the contour analysis of the pulse wave velocity in hypertensive patients.

Material and methods. The material of the study was the data from a survey of patients undergoing clinical observation at the polyclinic of MMC SOGAZ. A total of 107 patients were examined, in which 70 were men and 37 were women. The average age was 52.3±18.29. Photoplethysmography was used as a special research method, performed using the AngioScan-01 diagnostic complex. The main indicators used to evaluate the stiffness of large vessels were: stiffness index (SI), reflection index (RI), augmentation index (Alp75), age index (AGI), pulse wave types (PV) and vascular age (VA).

Results. The mean values of arterial stiffness indices in patients with essential arterial hypertension (AH) and healthy individuals (control) had significant differences. The mean SI, Alp75, and VA values in the group of patients with AH were 7.8±1.03, 7.0±14.44 and 50.8±15.93 versus 7.2±1.73, 0.5±18.02 and 43.8±16.94, respectively (p< 0.05). In both groups, a strong inverse correlation of passport age with C-type PV was revealed (r=0.74, p< 0.01), which reflected the dynamics of a gradual age-dependent decrease in vascular compliance. The average VA value in the control group was 63.1±16.99 years with an average passport age of 59.5±8.79 years, which significantly differed from VA in hypertensive patients (p< 0,05). Overweight, hypercholesterolemia, elevated low-density lipoprotein levels, lack of adequate antihypertensive control, and left ventricular diastolic dysfunction were significantly associated with early vascular (arterial) aging.

Conclusion. Patients with hypertension, in addition to high blood pressure, significantly differ from normotensive control in terms of arterial stiffness. The lack of control over modifiable RF of patients with hypertension is associated with early vascular aging.

Prevalence of chronic kidney disease and associated factors in the Spanish population attended in primary care: Results of the IBERICAN study

OBJECTIVES

To determine the prevalence of chronic kidney disease (CKD) and the factors associated with impaired renal function in the population attended in primary care (PC).

PATIENTS AND METHOD

Cross-sectional and multicentre study carried out in the baseline patients of the IBERICAN study (Identificación de la poBlación Española de RIesgo CArdiovascular y reNal). CKD was considered with an estimated glomerular filtration (eGF) <60ml/min/1.73 m2 or elevated albuminuria (≥ 30mg/g). According to the eGF, the CKD was classified in six stages (1, 2, 3a, 3b, 4 and 5) and according to albuminuria in three stages (A1 or normal / slightly increased, A2 or moderately increased and A3 or severely increased). The clinical characteristics and the relationship of CKD with the main cardiovascular risk factors (CVRF) and other variables of interest were analysed using unconditional logistic regression.

RESULTS

7,895 patients were included (mean age 57.9±14.8 years; 54.5% women). 14.4% (95% CI: 13.6-15.1) had CKD; 16.1% (95% CI: 14.9-17.3) in men and 12.9% (95% CI: 11.9-14.0) in women. A continuous increase of the prevalence was observed with age (24.8% in≥65 years) and with CVFR aggregation. The variables that were most associated with the probability of suffering CKD were left ventricular hypertrophy (OR: 1.95; p <.001), diabetes (OR: 1.58; P<.001) and hypertension (OR: 1.56; P<.001).

CONCLUSIONS

Fourteen out of every 100 patients included in the IBERICAN study have CKD. The prevalence of CKD affects a quarter of patients ≥ 65 years and increases exponentially with the aggregation of FRCV.

Relation between fragmented QRS complex and cardio-ankle vascular index in asymptomatic subjects

OBJECTIVES

Stiffness of large arteries has been related to cardiovascular mortality. Cardio-ankle vascular index (CAVI) is a novel marker of arterial stiffness. Herein, we aimed to study the relationship between fragmented QRS (fQRS) in electrocardiogram and CAVI.

METHODS

Asymptomatic patients with fQRS and without fQRS were enrolled in the study consecutively. The fQRS complexes were analyzed in the 12-lead electrocardiogram. Arterial stiffness was assessed by using cardio ankle vascular index (CAVI). It was measured by a VaSera VS-1000 CAVI instrument.

RESULTS

CAVI values of the patients with fQRS was significantly higher compared to those without fQRS (8.625 (7.9-9.2) versus 6.65 (6.7-8.4) p < .001). In a univariate analysis, it was revealed that there was a significant correlation between increased CAVI and fQRS, age, and epicardial fat thickness. Multiple binary logistic regression analysis revealed that age [95% confidence interval (CI): 1,068-1.214, p < .001] and fQRS [95% (CI): 1.766-23.117, p: 0.005] were the independent determinants of increased CAVI values.

CONCLUSIONS

ECG is a widely and readily available, inexpensive, reproducible technique that can be examined by almost every physician. fQRS values in electrocardiogram may provide a significant predictive value for arterial stiffness in asymptomatic subjects.

Circulating miRNAs Are Associated with the Systemic Extent of Atherosclerosis: Novel Observations for miR-27b and miR-146

The mechanisms that regulate the systemic extent of atherosclerosis are not fully understood. We investigated whether the expression of circulating miRNAs is associated with the extent of stable atherosclerosis to a single territory or multiple territories (polyvascular) and with the severity of atherosclerosis in each territory. Ninety-four participants were prospectively recruited and divided into five age- and sex-matched groups: presenting no atherosclerosis, isolated coronary atherosclerosis, coronary and lower extremity atherosclerosis, coronary and carotid atherosclerosis, and atherosclerosis of the coronary, lower extremity, and carotid territories. The expression of six circulating miRNAs with distinct biological roles was assessed. The expression of miR-27b and miR-146 differed across groups (p < 0.05), showing a decrease in the presence of atherosclerosis, particularly in the three territories. miR-27b and miR-146 expression decreased in association with a higher severity of coronary, lower extremity, and carotid atherosclerosis. Polyvascular atherosclerosis involving the three territories was independently associated with a decreased miR-27b and miR-146 expression. Both miRNAs presented an area under the curve of ≥0.75 for predicting polyvascular atherosclerosis involving the three territories. To conclude, miR-27b and miR-146 were associated with the presence of severe polyvascular atherosclerosis and with the atherosclerosis severity in each territory. Both are potential biomarkers of severe systemic atherosclerosis.

Identification of biomarkers for essential hypertension based on metabolomics

AIM

Essential hypertension (EH) is one of the most important public health problems worldwide. However, the pathogenesis of EH is unclear and early diagnostic methods are lacking. Metabolomics demonstrates great potential for biomarker discovery and the mechanistic exploration of metabolic diseases.

DATA SYNTHESIS

This review included human and animal metabolomics studies related to EH in the PubMed and Web of Science databases between February 1996 and May 2020. The study designs, EH standards, and reported metabolic biomarkers were systematically examined and compared. The pathway analysis was conducted through the online software MetaboAnalyst 4.0. Twenty-two human studies and fifteen animal studies were included in this systematic review. There were many frequently reported biomarkers with consistent trends (e.g., pyruvate, lactic acid, valine, and tryptophan) in human and animal studies, and thus had potential as biomarkers of EH. In addition, several shared metabolic pathways, including alanine, aspartate, and glutamate metabolism, aminoacyl-tRNA biosynthesis, and arginine biosynthesis, were identified in human and animal metabolomics studies. These biomarkers and pathways, closely related to insulin resistance, the inflammatory state, and impaired nitric oxide production, were demonstrated to contribute to EH development.

CONCLUSIONS

This study summarized valuable metabolic biomarkers and pathways that could offer opportunities for the early diagnosis or prediction of EH and the discovery of the metabolic mechanisms of EH.

[The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study]

INTRODUCTION

Although methylphenidate (MPH) used for treatment of Attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety.

MATERIAL AND METHODS

Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of Blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties.

RESULTS

73 patients completed the study, with an average age of 9+/- 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7±9mmHg (P).004) and 2±11,5mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovolumic relaxation time (IVRT) (P=.046) and deceleration time (P=.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found.

CONCLUSION

Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.

Hypertension trials update

Hypertension is one of the most prevalent cardiovascular diseases and its treatment requires multimodal therapeutic approaches. This review aims to provide a summary and update on relevant evidence in hypertension research published in 2019/2020. These include trials dealing with the prognostic effect of systolic and diastolic blood pressure values, the association between hypertension and valve disease, reproducibility of masked and white-coat hypertension, and the prognostic importance of ambulatory and night-time blood pressure measurements. Treatment of hypertension focusing on elderly patients but also the potential cancer risk of thiazide diuretics, the valsartan recall, chronotherapy, and device-based hypertension therapy are discussed.

The Proinflammatory Soluble CD40 Ligand Is Associated with the Systemic Extent of Stable Atherosclerosis

Background and objectives: Polyvascular atherosclerosis is frequent and associated with a high cardiovascular risk, although the mechanisms regulating the atherosclerosis extent to single or multiple arterial territories are still poorly understood. Inflammation regulates atherogenesis and soluble CD40 ligand (sCD40L) is an inflammatory mediator associated with the presence of single-territorial atherosclerosis. We assessed whether the sCD40L expression is associated with the atherosclerosis extent to single or multiple arterial territories and with the atherosclerosis severity in different territories. Materials and Methods: We prospectively enrolled 94 participants with no atherosclerosis (controls, n = 26); isolated coronary atherosclerosis (group 1, n = 20); coronary and lower extremity (LE) atherosclerosis (group 2, n = 18); coronary and carotid atherosclerosis (group 3, n = 12); and coronary, LE, and carotid atherosclerosis (group 4, n = 18). Serum sCD40L levels were quantified. Results: The sCD40L levels (ng/mL, mean (standard deviation)) were 4.0 (1.5), 5.6 (2.6), 7.2 (4.2), 5.9 (3.7), and 5.1 (2.4) in controls and groups 1 to 4, respectively (ANOVA p = 0.012). In nonrevascularized patients, the sCD40L levels were significantly higher in group 2 than in group 1 and were correlated with the number of LE diseased segments. Prior LE bypass surgery was associated with lower sCD40L levels. Coexistence of coronary and LE atherosclerosis was independently associated with the sCD40L levels. Conclusions: The sCD40L levels were increased in stable atherosclerosis, particularly in polyvascular coronary and LE atherosclerosis. The number of LE diseased segments and prior LE revascularization were associated with sCD40L expression. To our knowledge, these are novel data, which provide insights into the mechanisms underlying multi-territorial atherosclerosis expression. sCD40L may be a promising noninvasive tool for refining the stratification of the systemic atherosclerotic burden.

Left ventricular hypertrophy in chronic kidney disease: A diagnostic criteria comparison

BACKGROUND AND AIMS

CKD patients have a high prevalence of LVH and this leads to an increase of cardiovascular risk. The aim of this study was to assess the prevalence of left ventricular hypertrophy (LVH) and left ventricular geometry in a group of 293 hypertensive patients with stage 2-5 chronic kidney disease (CKD), compared with 289 essential hypertensive patients with normal renal function.

METHODS AND RESULTS

All patients underwent echocardiographic examination. Patients on stage 1 CKD, dialysis treatment, or with cardiovascular diseases were excluded. LVH was observed in 62.8% of patients with CKD and in 51.9% of essential hypertensive patients (P < 0.0001). We found increasingly higher left ventricular diameters, thicknesses, and mass from stage 2-5 CKD. Distribution of concentric and eccentric LVH was not very different between the two groups. However, after introducing mixed hypertrophy, the difference between the two groups group was disclosed (P = 0.027). Multiple regression analysis confirmed that the association between renal function and left ventricular mass (β -0.287; P < 0.0001) was independent by potential confounders. Diastolic function was significantly worse in patients with CKD, especially in more advanced stages.

CONCLUSION

Our study confirms that LVH is highly prevalent in patients with CKD, especially by using the most recent cut off; in this population, LVH is often characterized by the simultaneous increase of wall thicknesses and diameters with negative effects on diastolic function.

Blood Pressure and Tooth Loss: A Large Cross-Sectional Study with Age Mediation Analysis

We aimed to investigate the association between blood pressure (BP) and tooth loss and the mediation effect of age. A cross-sectional study from a reference dental hospital was conducted from September 2017 to July 2020. Single measures of BP were taken via an automated sphygmomanometer device. Tooth loss was assessed through oral examination and confirmed radiographically. Severe tooth loss was defined as 10 or more teeth lost. Additional study covariates were collected via sociodemographic and medical questionnaires. A total of 10,576 patients were included. Hypertension was more prevalent in severe tooth loss patients than nonsevere tooth lost (56.1% vs. 39.3%, p < 0.001). The frequency of likely undiagnosed hypertension was 43.4%. The adjusted logistic model for sex, smoking habits and body mass index confirmed the association between continuous measures of high BP and continuous measures of tooth loss (odds ratio (OR) = 1.05, 95% CI: 1.03–1.06, p < 0.001). Age mediated 80.0% and 87.5% of the association between periodontitis with both systolic BP (p < 0.001) and diastolic BP (p < 0.001), respectively. Therefore, hypertension and tooth loss are associated, with a consistent mediation effect of age. Frequency of undiagnosed hypertension was elevated. Age, gender, active smoking, and BMI were independently associated with raised BP.

Association between depressive symptoms and pulse wave velocity is mediated by increased adiposity in older adults with type 2 diabetes

BACKGROUND

Studies investigating the association between depression and aortic stiffness in older patients with type 2 diabetes are lacking. We postulated an association between depressive symptoms and aortic stiffness, and this relationship may be mediated by increased adiposity.

METHODS

We analyzed participants with type 2 diabetes aged 55 years or older (n = 958). We measured aortic stiffness using carotid-femoral pulse wave velocity (cut-off ≥ 12 m/s) using the tonometry method. We defined depressive symptoms as a score of greater than 5 on the Geriatric Depression Scale-15 (GDS-15). Adiposity indices we assessed were body mass index, waist circumference, waistto-height ratio, visceral fat area and fat mass.

RESULTS

Among the participants, 27.2% had aortic stiffness, of whom 6.5% had depressive symptoms. Score on the GDS-15 was correlated with pulse wave velocity, and both variables were correlated with the adiposity markers we analyzed (all p < 0.05). Depressive symptoms were associated with pulse wave velocity (B = 1.79, 95% confidence interval [CI] 0.83-2.75) or aortic stiffness (risk ratio 1.60, 95% CI 1.10-2.33) in the unadjusted model. The association persisted after controlling for demographics, duration of diabetes, glycated hemoglobin, comorbidities and medications. Further adjustment for visceral fat area and fat mass in separate models reduced the association between depressive symptoms and pulse wave velocity or aortic stiffness. Mediation models revealed that the mediation proportions of fat mass and visceral fat area on the association between depressive symptoms and pulse wave velocity were 11.8% and 9.7%, respectively. A preliminary analysis of longitudinal data (n = 184) showed similar findings.

LIMITATIONS

Causality cannot be inferred from the associations we observed.

CONCLUSION

Depressive symptoms are associated with elevated pulse wave velocity in older people with type 2 diabetes, and this relationship may be partially mediated by increased adiposity.

A high triglyceride-glucose index is associated with left ventricular dysfunction and atherosclerosis

Background: The triglyceride-glucose (TyG) index has been reported to be a simple and reliable surrogate marker of insulin resistance. The aim of this study was to investigate associations between the TyG index and echocardiographic parameters including left ventricular mass (LVM), left atrial diameter (LAD) and left ventricular ejection fraction (LVEF), and markers of peripheral artery disease, ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV). Methods: A total of 823 (483 males and 340 females) patients were enrolled from 2007 to 2011 at a regional hospital in southern Taiwan. Multivariable stepwise linear regression analysis was performed to identify the factors related to echocardiographic parameters and peripheral artery disease. Results: The patients were stratified into four groups according to TyG index quartile. Multivariable stepwise linear regression analysis showed that a higher TyG index was associated with elevated observed/predicted LVM (p = 0.081), increased LAD (p = 0.004), decreased LVEF (p = 0.003) and lower ABI (p = 0.030), but not observed/predicted LVM and baPWV. Conclusions: A high TyG index was significantly associated with high LAD, low LVEF and low ABI. However, the TyG index was not significantly associated with inappropriate LVM or baPWV. The results suggest that the TyG index, as a simple indicator of insulin resistance, may reflect cardiac remodeling and dysfunction and atherosclerosis.

Atrial fibrillation risk factors in patients with ischemic stroke

INTRODUCTION

Atrial fibrillation (AF) is the most common heart arrhythmia. The condition is known to increase the risk of ischemic stroke (IS). Classical risk factors for the development of AF include advanced age, hypertension, diabetes mellitus, coronary heart disease and lipid metabolism disorders. Importantly, these are also recognized risk factors for ischemic stroke. Therefore, the purpose of this study was to investigate AF risk factors in patients with IS.

MATERIAL AND METHODS

This is single-centre retrospective study which included 696 patients with acute ischemic stroke and nonvalvular atrial fibrillation and 1678 patients with acute ischemic stroke without atrial fibrillation.

RESULTS

In this study we found - based on a univariable and multivariable logistic regression model - that compared to the patients with IS without AF, the group of patients which suffered from IS with nonvalvular atrial fibrillation (NVAF) had a higher proportion of patients who smoked cigarettes (OR = 15.742, p < 0.01; OR = 41.1, p < 0.01), had hypertension (OR = 5.161, p < 0.01; OR = 5.666, p < 0.01), history of previous stroke (OR = 3.951, p < 0.01; OR = 4.792, p < 0.01), dyslipidemia (OR = 2.312, p < 0.01; OR = 1.592, p < 0.01), coronary heart disease (OR = 2.306, p < 0.01; OR = 1.988, p < 0.01), a greater proportion of female patients (OR = 1.717, p < 0.01; OR = 2.095, p < 0.01), higher incidence of diabetes mellitus (OR = 1.341, p < 0.01; OR = 1.261, p = 0.106) and more patients in old age (OR = 1.084, p < 0.01; OR = 1.101, p < 0.01).

CONCLUSIONS

Our study demonstrates a need for thorough and systematic monitoring of post-ischemic stroke patients in whom AF has not been detected and who display other important risk factors. Regardless of the stroke, these factors may be responsible for development of AF.

Arterial stiffness in type 2 diabetes: determinants and indication of a discriminative value

OBJECTIVES

To identify the clinical discriminative value and determinants of arterial stiffness in individuals with type 2 diabetes mellitus (T2DM).

METHODS

This prospective cohort study included 51 individuals (53.57±9.35 years) diagnosed with T2DM (stage glucose≥126 mg/dL; diagnostic time: 87.4±69.8 months). All participants underwent an initial evaluation of personal habits, medications, and history; arterial stiffness assessment by carotid-femoral pulse wave velocity (cfPWV) using SphygmoCor; and blood laboratory analysis. A statistical analysis was performed using SPSS software, and values of p≤0.05 were considered significant.

RESULTS

A cut-off cfPWV value of 7.9 m/s was identified for T2DM [Sensitivity (SE): 90% and Specificity (SP): 80%]. A subgroup analysis revealed higher glycated hemoglobin (Hb1Ac) (p=0.006), obesity (p=0.036), and dyslipidemia (p=0.013) than those with cfPWV ≥7.9 m/s. Multivariate analysis identified higher stage glucose (p=0.04), Hb1Ac (p=0.04), hypertension (p=0.001), and dyslipidemia (p=0.01) as determinant factors of cfPWV; positive and significant correlation between cfPWV and glucose (r=0.62; p=0.0003) and Hb1Ac (r=0.55; p=0.0031).

CONCLUSIONS

In T2DM, an indicator of the discriminative value of arterial stiffness was cfPWV of 7.9 m/s. Clinical findings and comorbidities, such as hypertension, glucose, poor glycemic control, and dyslipidemia, were associated with and were determinants of arterial stiffness in T2DM. Reinforcement of monitoring risk factors, such as hypertension, dyslipidemia, and glycemic control, seems to be essential to the process of arterial stiffening. Confirmation of this discriminative value in larger populations is recommended.

Ambulatory Blood Pressure Profiles and Correlation with Cardiovascular Risk Factors in a Sample of 390 University Employees in Tanzania

Background

Hypertension is a major risk factor for cardiovascular morbidity and mortality. Increasingly, evidence suggests that 24-hour ambulatory blood pressure (BP) monitoring (ABPM) is more accurate than clinic BP in predicting cardiovascular risk. However, this association has not been widely studied in subSaharan Africa, especially in Tanzania.

Aim

To explore the relationship between 24-hour ABPM profiles and cardiovascular risk factors in comparison with clinic BP among Muhimbili University of Health and Allied Sciences (MUHAS) employees.

Methods

A descriptive cross-sectional study was conducted from October 2018 to February 2019. Socio-demographic and cardiovascular risk information was gathered. We used an automated ABPM device to record 24-hour ambulatory BP. Correlation between BP profiles and cardiovascular risk factors was done using Pearson’s correlation coefficient, and independent factors for hypertension were determined using logistic regression analysis. P-value of <0.05 was considered statistically significant.

Results

In total, 390 employees participated. Their mean age was 40.5 ± 8.9 years, and 53.6% were men. The mean office systolic and diastolic BP were 126±12 mmHg and 78±13 mmHg, respectively, while the corresponding values for mean 24-hour ABPM were 122±14 and 75±10 mmHg. The prevalence of hypertension was 23.1%. The prevalence of white coat hypertension was 16.2%, while masked hypertension and nocturnal non-dipping were present in 11.5 and 66.7%, respectively. Overall, the mean 24-hour systolic BP showed the strongest correlations with cardiovascular risk factors while mean office systolic BP showed least. Independent associated factors of hypertension were male gender, age ≥40 years, family history of hypertension, central obesity, raised cholesterol and uric acid levels, all p<0.01.

Conclusion

Compared to office BP, ABPM measurements had stronger correlations with cardiovascular risk factors in this population, and therefore likely to reflect true BP. ABPM has revealed high proportion of masked, white coat and nocturnal non-dipping, supporting use of ABPM to detect these clinically important BP profiles.