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)

Berberine for the treatment of hypertension: A systematic review

BACKGROUND

Hypertension is the highest risk factor for disease globally. When prescription of drug therapy is recommended, patients might decline treatment due to hypertension asymptomatic nature, sometimes turning to alternative therapies. One popular therapy is berberine, a plant alkaloid that has been used in eastern medicine for millennia to treat several ailments, including cardiovascular diseases and their risk factors.

AIMS

Through a transparent and pragmatic approach towards searching, synthesising, assessing, and reporting the available clinical evidence, the present review aimed to investigate berberine effect on blood pressure and cardiovascular disease risk. It also intended to provide guidance for clinician when advising their patients, and to highlight gaps in the research along offering suggestions to fill them.

METHODS

The review was conducted following the protocol PRISMA-P, and reported according to the related PRISMA statement. The PICO framework was used to define the scope of the review, and to arrive at a database search strategy. The strategy was run on the databases Medline, CINAHL, AMED, Embase, and Cochrane Library through the platforms EBSCOhost and Ovid. Citations were exported to Mendeley citation manger for screening. Relevant studies were selected based on specified inclusion and exclusion criteria. Data from included studies was extracted in the form of a detailed table of characteristics of studies, and summarised in an evidence table. Quality of studies was assessed using the SIGN methodology checklist for controlled trials. The results from the quality assessment were summarised through an adaptation of the Robvis tool software package output. Effect estimates and their precision were calculated with RevMan 5 computer program from the extracted study outcomes.

RESULTS

Five randomised controlled trials and two non-randomised controlled trials were included with 614 participants. All provided data on blood pressure, but none measured cardiovascular events or long-term adverse events. The group of studies was highly heterogeneous in terms of experimental intervention, comparator intervention, length to follow-up, participants' diagnosis, and setting. The heterogeneity prevented a meaningful meta-analysis. Berberine plus amlodipine was not significantly better than amlodipine alone at reducing systolic and diastolic blood pressure. Compared to metformin, berberine provided a statistically significant moderate reduction effect on systolic blood pressure (-11.87 [-16.64, -7.10] mmHg). A proprietary nutraceutical containing berberine as one of its ingredients was in one study significantly effective at reducing blood pressure compared to placebo (-11.80 [-18.73, -4.87] mmHg systolic, and -11.10 [-15.17, -7.43] mmHg diastolic), and also effective in another study compared to dietary advice (-3.40 [-5.48, -1.32] mmHg for systolic 24 h ambulatory blood pressure), although effects could not be reliably attributed to berberine alone. The herbal extract Chunghyul-dan, which contains berberine, showed a significant beneficial moderate effect compared to no treatment on systolic 24 h ambulatory blood pressure (-7.34 [-13.14, -1.54] mmHg) in one study, but in another study employing higher dose and longer treatment duration, no effects were detected. Again, the effects could not be attributed to berberine alone. The quality of the body of evidence was low, especially due to lack of trial design details and presence of outcome reporting bias.

CONCLUSIONS

The evidence around berberine effect on blood pressure is limited, of low quality, and ultimately inconclusive. Clinicians should be aware that the evidence from randomised trials is not sufficient to establish berberine effectiveness and safety in the treatment of hypertension, and they should balance these findings with the long history of berberine use in the Eastern world. Researchers should aim at improving quality of studies, by raising the standard of designing and reporting them, e.g., by following the CONSORT guidelines, and strive to measure meaningful clinical endpoints, such as cardiovascular events, mortality, and adverse outcomes.

Blood pressure targets in adults with hypertension

BACKGROUND

This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target.

OBJECTIVES

The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above).

DATA COLLECTION AND ANALYSIS

Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach.  MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB  167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%,  number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target".

AUTHORS' CONCLUSIONS

For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.

Catestatin peptide of chromogranin A as a potential new target for several risk factors management in the course of metabolic syndrome

Obesity, lipodystrophy, diabetes, and hypertension collectively constitute the main features of Metabolic Syndrome (MetS), together with insulin resistance (IR), which is considered as a defining element. MetS generally leads to the development of cardiovascular disease (CVD), which is a determinant cause of mortality and morbidity in humans and animals. Therefore, it is essential to implement and put in place adequate management strategies for the treatment of this disease. Catestatin is a bioactive peptide with 21 amino acids, which is derived through cleaving of the prohormone chromogranin A (CHGA/CgA) that is co-released with catecholamines from secretory vesicles and, which is responsible for hepatic/plasma lipids and insulin levels regulation, improves insulin sensitivity, reduces hypertension and attenuates obesity in murine models. In humans, there were few published studies, which showed that low levels of catestatin are significant risk factors for hypertension in adult patients. These accumulating evidence documents clearly that catestatin peptide (CST) is linked to inflammatory and metabolic syndrome diseases and can be a novel regulator of insulin and lipid levels, blood pressure, and cardiac function. The goal of this review is to provide an overview of the CST effects in metabolic syndrome given its role in metabolic regulation and thus, provide new insights into the use of CST as a diagnostic marker and therapeutic target.

Renal Function, Albumin-Creatinine Ratio and Pulse Wave Velocity Predict Silent Coronary Artery Disease and Renal Outcome in Type 2 Diabetic and Prediabetic Subjects

INTRODUCTION

Silent coronary heart disease is frequently undetected in type 2 diabetes mellitus (DM2) and pre-diabetes determined by glucose intolerance (GI). Pulse wave velocity (PWV) and albumin-creatinine ratio (ACR) have been considered markers of cardiovascular mortality, coronary heart disease and chronic renal failure.

AIM

To evaluate the incidence of coronary artery disease (CAD) and the relationship between urinary albumin-creatinine ratio, glomerular filtration rate (GFR) and PWV in type 2 DM with silent CAD.

METHODS

We analyzed 92 individuals (44 male), 49 (60±7y) type 2 DM non-insulin dependents and 43 prediabetics (43±4y), with Grade I-II hypertension and no symptoms of CAD. All type 2 DM patients were under antidiabetic treatment with A1C hemoglobin between 5.5 and 6.5%. Every patient underwent a myocardial perfusion SPECT scan. In those subjects with ischemic patterns, coronary angiography was performed. In addition, PWV, glomerular filtration rate, and ACR were evaluated.

STATISTICS

mean±SEM, and ANOVA among groups.

RESULTS

48.59% of DM2 and 25.58% of GI patients had silent coronary artery had silent coronary artery disease and higher ACR, PWV and reduced GFR. Higher ACR and PWV and reduced GFR. DM2 and GI showed a negative relationship between GFR and ACR. Moreover, this relation was also observed in different levels of GFR (>60 ml/min and <60ml.min (p<0.05) in patients with CAD, suggesting a cardio-renal interaction in DM2.

CONCLUSION

Higher PWV, lower GFR and ACR predict the incidence of CAD in DM2. Dysglycemic individuals also represent a group of higher risk for coronary artery disease with similar predictors as in DM2. Diabetic and prediabetics still develop renal microalbuminuria. Thus, PWV seems to represent a reliable marker of renal impairment and coronary artery disease.

Women discontinue antihypertensive drug therapy more than men. Evidence from an Italian population-based study

OBJECTIVE

Several factors affect adherence to antihypertensive drug treatment, but whether these factors include a sex difference is unclear. Aim of the study was to compare persistence with antihypertensive drug therapy between men and women in a large cohort of patients.

METHODS

The 60 526 residents of the Italian Lombardy Region aged 40-80 years newly treated with antihypertensive drugs during 2010 were identified and followed for 1 year after the first prescription. Discontinuation of treatment was defined as lack of prescription renewal for at least 90 days. Log-binomial regression models were fitted to estimate the risk ratio of treatment discontinuation in relation to sex. Other than for the whole population, analyses were stratified according to age, comorbidity status and the initial antihypertensive treatment strategy.

RESULTS

Thirty-seven percent of the patients discontinued the drug treatment during follow-up. Compared with women, men had a 10% lower risk of discontinuation of drug treatment (95% confidence interval: 8-12). Persistence on antihypertensive treatment was better in men than in women, this being the case in both younger (40-64 years) and older patients (65-80 years), in patients starting treatment with any major antihypertensive drug and in patients who had a low comorbidity status. There was no evidence that men and women had a different risk of treatment discontinuation when their comorbidity status was worse, or initial antihypertensive treatment was based on drug combinations.

CONCLUSION

Our data show that in a real-life setting, men are more persistent to antihypertensive drug therapy than women.

The Association Between Obesity and Visit-to-Visit Variability in Systolic Blood Pressure: A Prospective Study

With the prevalence of obesity and all accompanying health risks, both prevention and health education, as well as identifying predictors for the development of obesity-related diseases are primary. The pathophysiological relationship between obesity and visit-to-visit variability in systolic blood pressure (SBPV) has not been completely resolved. To investigate the association between obesity and SBPV in hypertensive patients. The prospective study comprised three visits was performed at the hypertension outpatient clinic during the follow up period of 22-months between March 2014 and January 2016. This study included 300 randomly selected hypertensive patients (average 67.76±9.84 years), who were divided in groups of obese/non-obese examinees. SBPV was defined as the standard deviation (SD) from three values of SBP. The values of SBP and SBP-SD were significantly higher in the group of obese hypertensive patients than in the group of non-obese patients (127.06±8.30 vs. 120.37±7.75; 11.29±5.67 vs. 7.37±3.94 mmHg; p<0.01). The highest SBPV was recorded in the 4th quartile in obese patients (43.13±7.50 mmHg). SBPV was strongly correlated with BMI and Waist cirumferences (WC) (ρo=0.425, ρo=0.356, p<0.01). During 22-months follow up there was a significant decrease of SBPV for 8.2 mmHg, BP for 31/5 mmHg, BMI for 3.8 kg/m2, WC for 10 cm and body weight for 8.24 kg. During 22-months follow-up, reduction of body weight was associated with reduction of blood pressure variability in hypertensive patients. Persistently decrease both body weight and long term visit-to-visit variability may explain lower cardiovascular risk in obese-related disease.

Renal handling of zinc in chronic kidney disease patients and the role of circulating zinc levels in renal function decline

BACKGROUND

Zinc deficiency is commonly encountered in chronic kidney disease (CKD). The aims of this study were to assess whether zinc deficiency was related to increased renal excretion of zinc and to the progression of CKD.

METHODS

Plasma and 24-h urinary zinc levels, urinary electrolytes and uromodulin were measured in 108 CKD patients and 81 individuals without CKD. Serum creatinine values were collected for 3 years to calculate the yearly change in estimated glomerular filtration rate (eGFR). Multivariable regression analysis was performed to assess the association between baseline zinc levels and yearly change in eGFR.

RESULTS

CKD patients had lower circulating zinc levels and higher 24-h urinary zinc excretion than non-CKD participants (612.4 ± 425.9 versus 479.2 ± 293.0 µg/day; P = 0.02). Fractional excretion (FE) of zinc was higher and it significantly increased at more advanced CKD stages. Zinc FE was correlated negatively with 24-h urinary uromodulin excretion (r=-0.29; P < 0.01). Lower baseline plasma zinc levels were associated with a faster yearly decline of renal function in age, gender, diabetes and hypertension adjusted models, but this relationship was no longer significant when baseline eGFR or proteinuria were included.

CONCLUSIONS

Zinc levels are lower in CKD, and not compensated by reduced renal zinc excretion. The inverse association between urinary zinc excretion and uromodulin possibly points to an impaired tubular activity, which could partly account for zinc imbalance in CKD. These data suggest that zinc status is associated with renal function decline, but further studies elucidating the underlying mechanisms and the potential role of zinc supplements in CKD are needed.

Increased masked hypertension prevalence in patients with polycystic ovary syndrome (PCOS)

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a common disorder with important clinical consequences. Many studies have proven that hypertension is one of the most important comorbid disorders in PCOS. Masked hypertension is defined as a presence of normal office blood pressure together with abnormal results in 24-h ambulatory blood pressure monitoring (ABPM). The prevalence of this condition in patients with PCOS is not well defined. The aim of this study was to evaluate the prevalence of masked hypertension in PCOS compared to control subjects.

METHODS

Sixty patients with PCOS and 60 control subjects were enrolled in the study. All patients with PCOS and controls without a history of hypertension underwent physical examination including office blood pressure measurement, ABPM, and measurement of laboratory and anthropometric parameters.

RESULTS

Mean age was 30.5 ± 6.6 in control group and 26.4 ± 7.1 year in patients with PCOS (p = .001). Twenty-four patients (40%) had masked hypertension in PCOS group whereas 11 patients (18.3%) in the control group (p = .009). Twenty-four-hour diastolic blood pressure (p = .03), daytime systolic (p < .001), and daytime diastolic blood pressure (p = .01) and nighttime systolic blood pressure (p = .01) were significantly higher in patients with PCOS compared with control group.

CONCLUSIONS

This study demonstrates increased masked hypertension prevalence in patients with PCOS. We suggest that all patients with PCOS should undergo ambulatory blood pressure monitoring for detecting masked hypertension.

Cardiovascular risk factors during cancer treatment. Prevalence and prognostic relevance: insights from the CARDIOTOX registry

Aims

The actual usefulness of cardiovascular (CV) risk factor assessment in the prognostic evaluation of cancer patients treated with cardiotoxic treatment remains largely unknown. Prospective multicentre study in patients scheduled to receive anticancer therapy related with moderate/high cardiotoxic risk.

Methods and results

A total of 1324 patients underwent follow-up in a dedicated cardio-oncology clinic from April 2012 to October 2017. Special care was given to the identification and control of CV risk factors. Clinical data, blood samples, and echocardiographic parameters were prospectively collected according to protocol, at baseline before cancer therapy and then at 3 weeks, 3 months, 6 months, 1 year, 1.5 years, and 2 years after initiation of cancer therapy. At baseline, 893 patients (67.4%) presented at least one risk factor, with a significant number of patients newly diagnosed during follow-up. Individual risk factors were not related with worse prognosis during a 2-year follow-up. However, a higher Systemic Coronary Risk Estimation (SCORE) was significantly associated with higher rates of severe cardiotoxicity (CTox) and all-cause mortality [hazard ratio (HR) 1.79 (95% confidence interval, CI 1.16–2.76) for SCORE 5–9 and HR 4.90 (95% CI 2.44–9.82) for SCORE ≥10 when compared with patients with lower SCORE (0–4)].

Conclusions

This large cohort of patients treated with a potentially cardiotoxic regimen showed a significant prevalence of CV risk factors at baseline and significant incidence during follow-up. Baseline CV risk assessment using SCORE predicted severe CTox and all-cause mortality. Therefore, its use should be considered in the evaluation of cancer patients.

Short-Term but not Long-Term Blood Pressure Variability Is a Predictor of Adverse Cardiovascular Outcomes in Young Untreated Hypertensives

BACKGROUND

Whether blood pressure variability (BPV) measured with ambulatory monitoring (short-term BPV) or computed from office visits (long-term BPV) are related to each other and carry similar prognostic information is not well known. We investigated the independent determinants of short-term and long-term BPVs and their predictive capacity for the development of major adverse cardiovascular and renal events (MACEs) in a cohort of young hypertensive participants.

METHODS

Long-term BPV was calculated as visit-to-visit SD and average real variability from office blood pressure (BP) measured during 7 visits, within 1 year. Short-term BPV was calculated as weighted 24-hour SD and coefficient of variation. Hazard ratios (HRs) for risk of MACE were computed from multivariable Cox regressions.

RESULTS

1,167 participants were examined; mean age was 33.1 ± 8.5 years. Variables independently associated with 24-hour systolic SD were 24-hour systolic BP, low physical activity, smoking, baseline office pulse pressure, systolic BP dipping, and diastolic white coat effect, while those associated with long-term BPV were mean systolic BP, age, female gender, and baseline office heart rate. During a median follow-up of 17.4 years 75 MACEs occurred. In Cox analysis only short-term BPV resulted a significant predictor of MACE (HR, 1.31 (1.07-1.59); P = 0.0086), while no index of long-term BPV was independently associated with outcome.

CONCLUSIONS

In young hypertensive subjects only short-term BPV resulted a significant predictor of MACE on top of traditional ambulatory BP monitoring parameters. Whether reduction of short-term BPV with therapy may reduce the cardiovascular risk independently from the effects on 24-hour BP is a matter for future research.

The uraemic hypertensive patient: a therapeutic challenge—right you are (if you think so)

High blood pressure (BP) is a leading cause of chronic kidney disease (CKD) and at the same time represents its most frequent complication. High BP is an independent risk factor for advanced CKD; on the other hand, at least 40% of patients with normal glomerular filtration rate (GFR) and virtually all patients with GFR <30 mL/min are hypertensive. CKD and microalbuminuria are powerful risk factors for cardiovascular morbidity and mortality. Consequently, in uraemic hypertension, it is of utmost importance to carefully manage both high BP and microalbuminuria, in order to slow down the progression of kidney damage and to reduce the incidence of cardiovascular events. The first purpose of the medical treatment in hypertensive patients is to normalize BP, regardless of the drug used. Nevertheless, some drugs have an ‘additional’ nephroprotective effect at the same BP target achieved. In this regard, first-line drugs are definitely renin–angiotensin–aldosterone inhibitors, mainly for their proved efficacy in reducing hypertension-related kidney damage and proteinuria. Anyway, a combined approach (two or more drugs) is usually needed to achieve the optimal BP target and reduce the worsening of CKD.

Prevalence and Mortality of Sarcopenia in a Community-dwelling Older Japanese Population: The Hisayama Study

BACKGROUND

The prevalence of sarcopenia defined using the Asian Working Group for Sarcopenia (AWGS) criteria in Asian communities has not been fully addressed. Moreover, few studies have addressed the influence of sarcopenia on mortality.

METHODS

A total of 1,371 and 1,597 residents aged 65 years or older participated in health surveys in 2012 and 2017. Sarcopenia was determined using the AWGS definition. Factors associated with the presence of sarcopenia were assessed using a logistic regression model in participants in the 2012 survey. Subjects in the 2012 survey were followed-up prospectively for a median of 4.3 years. Mortality risk for subjects with sarcopenia was examined using the Cox proportional hazards model.

RESULTS

The crude prevalence of sarcopenia was 7.4% and 6.6% in participants at the 2012 and 2017 surveys, respectively; there was no significant difference between surveys (P = 0.44). The prevalence of sarcopenia increased significantly with age in both sexes (both P for trend <0.001). Subjects with sarcopenia were more likely to exercise less regularly, to intake less total energy, and to exhibit a disability in activity of daily living than those without. The multivariable-adjusted hazard ratio for all-cause mortality was 2.20 (95% confidence interval, 1.25-3.85) in subjects with sarcopenia, compared to those without.

CONCLUSIONS

Approximately 7% of older subjects had sarcopenia in a community-dwelling older Japanese population. Moreover, subjects with sarcopenia had an increased mortality risk. Our findings suggest that a public health strategy for sarcopenia is needed to extend healthy life expectancy.

Prevalence and Associated Factors of Compliance Behaviors among Middle-Aged and Older Hypertensive Patients in China: Results from the China Health and Retirement Longitudinal Study

Partial or total non-adherence has been recognized as major issues in the long-term management of hypertension. This study aims to investigate the prevalence and associated factors of compliance behaviors among Chinese middle-aged and older hypertensive patients. A sample of 6308 hypertensive patients aged ≥45 years was obtained from the 2015 China Health and Retirement Longitudinal Study (CHARLS) data. Two compliance behaviors were involved including medication and blood pressure monitoring. Stratified binary logistic regression analysis was employed to examine the associated factors. 77.2% of the participants reported medication compliance, and 40.7% complied with blood pressure monitoring. Better medication compliance associated with older age, overweight or obesity, one or ≥3 complications, no drinking, living in urban areas, and health education. Better blood pressure monitoring compliance associated with older age, overweight or obesity, ≥3 complications, normal activities of daily living (ADL), no smoking, sleep duration of 6-8 h, better cognitive function, living in urban areas, education level of middle school or above, and health education. Chinese middle-aged and older hypertensive patients experienced unoptimistic compliance behaviors, especially for blood pressure monitoring. Special attention and targeted interventions are urgent for the high-risk population of poor compliance behaviors, such as rural individuals, low educational population, and younger hypertensive patients.

Antihypertensive therapy and short-term blood pressure variability

BACKGROUND AND AIM

Blood pressure variability (BPV) is recognized as a prognostic contributor in hypertension. We aimed to assess differences in short-term BPV in treated hypertensive patients depending on the number, classes, combinations and individual compounds of the antihypertensive treatment.

METHODS

We selected 38 188 treated patients from the Spanish Ambulatory BP Monitoring (ABPM) Registry. SBP and DBP standard deviations (SD) from 24-h, daytime and night-time, weighted SD (WSD), and average real variability (ARV) were calculated through ABPM. They were compared (after adjustment for clinical confounders and BP) depending on the number of antihypertensive drugs, antihypertensive drug classes and compounds (in 13 765 patients on monotherapy), or combinations (in 12 716 patients treated with two drugs and 7888 treated with three drugs).

RESULTS

Systolic and diastolic BPV significantly increased in patients treated with multiple drugs with respect to monotherapy. Among drug classes, calcium channel blockers, especially amlodipine, and diuretics were associated with lower systolic BPV, including daytime and night-time SD, WSD and ARV, compared with beta blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Likewise, in patients treated with two-drug and three-drug combinations, those which included a calcium channel blocker showed lower BPV in comparison to those without such drug class.

CONCLUSION

Treatment with calcium channel blockers, especially amlodipine, and with diuretics is associated with slight, but significant lower values of short-term BPV in comparison to other major drug classes, both in monotherapy and in combination. These results could be helpful when considering BPV reduction as an additional treatment target.

Sex-Related Differences in Cardiac Remodeling and Reverse Remodeling After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis in a Japanese Population

Left ventricular (LV) remodeling with aortic stenosis (AS) appears to differ according to sex, but reverse remodeling after transcatheter aortic valve implantation (TAVI) has not been elucidated in a Japanese population. This study aims to determine whether any sex-related differences in LV or reverse remodeling after TAVI exist in the context of severe AS.Of 208 patients who received TAVI for severe AS in our institution, 100 (men, 42; mean age, 83.0 ± 4.9 years) underwent transthoracic echocardiography before and 3 months after TAVI. Despite similar valvular gradients, women with severe AS had lower indexed LV mass (LVMi) than did men (152.3 ± 35.4 versus 173.2 ± 44.6 g/m², P = 0.005), with smaller indexed LV end-diastolic (LVEDVi) (50.2 ± 13.3 versus 61.4 ± 20.7 mL/m², P = 0.001) and end-systolic (LVESVi; 17.9 ± 8.7 versus 24.3 ± 13.8 mL/m², P = 0.006) volumes. After TAVI, women (-6.0% ± 14.4%) had higher reduction in the rate of change of relative wall thickness (RWT) than did men (4.4% ± 19.0%, P = 0.003). Men (-8.9% ± 3.9%) had higher reduction in the rate of change of LVEDVi than did women (1.5% ± 3.3%, P = 0.045). Incidence of LV reverse remodeling defined as a reduction in LVESV of >15% was significantly higher in men (50%) than in women (26%, P = 0.013).In addition to sex differences in the pattern of LV remodeling with AS, reverse LV remodeling after TAVI also differed between sexes.

Heart-brain interactions during social and cognitive stress in hypertensive disease: A multidimensional approach

Hypertensive disease (HTD), a prominent risk factor for cardiovascular and cerebrovascular diseases, is characterized by elevated stress-proneness. Since stress levels are underpinned by both cardiac and neural factors, multidimensional insights are required to robustly understand their disruption in HTD. Yet, despite their crucial relevance, heart rate variability (HRV) and multimodal neurocognitive markers of stress in HTD remain controversial and unexplored respectively. To bridge this gap, we studied cardiodynamic as well as electrophysiological and neuroanatomical measures of stress in HTD patients and healthy controls. Both groups performed the Trier Social Stress Test (TSST), a validated stress-inducing task comprising a baseline and a mental stress period. During both stages, we assessed a sensitive HRV parameter (the low frequency/high frequency [LF/HF ratio]) and an online neurophysiological measure (the heartbeat-evoked potential [HEP]). Also, we obtained neuroanatomical data via voxel-based morphometry (VBM) for correlation with online markers. Relative to controls, HTD patients exhibited increased LF/HF ratio and greater HEP modulations during baseline, reduced changes between baseline and stress periods, and lack of significant stress-related HRV modulations associated with the grey matter volume of putative frontrostriatal regions. Briefly, HTD patients presented signs of stress-related autonomic imbalance, reflected in a potential basal stress overload and a lack of responsiveness to acute psychosocial stress, accompanied by neurophysiological and neuroanatomical alterations. These multimodal insights underscore the relevance of neurocognitive data for developing innovations in the characterization, prognosis and treatment of HTD and other conditions with autonomic imbalance. More generally, these findings may offer new insights into heart-brain interactions.

Syndecan-4 as a Marker of Endothelial Dysfunction in Patients with Resistant Hypertension

(1) Background: Arterial hypertension (HTN) is one of the most relevant cardiovascular risk factors. Nowadays multiple pharmaceutical treatment options exist with novel interventional methods (e.g., baroreflex activation therapy (BAT)) as a last resort to treat patients with resistant HTN. Although pathophysiology behind resistant HTN is still not fully understood. There is evidence that selected biomarkers may be involved in the pathophysiology of HTN. (2) Methods: We investigated serum SDC4-levels in patients suffering from resistant HTN before and 6 months after BAT implantation. We collected 19 blood samples from patients with resistant HTN and blood pressure above target and measured serum SDC4-levels. (3) Results: Our results showed high serum SDC4-levels in patients with resistant HTN as compared to a healthy population. Patients with both, resistant HTN and diabetes mellitus type II, demonstrated higher serum SDC4-levels. β-blockers had lowering effects on serum SDC4-levels, whereas calcium channel blockers were associated with higher levels of serum SDC4. BAT implantation did not lead to a significant difference in serum SDC4-levels after 6 months of therapy. (4) Conclusion: Based on our results we propose SDC4 is elevated in patients suffering from resistant HTN. Thus, SDC4 might be a potential marker for endothelial dysfunction in patients with resistant hypertension.

Anti-Inflammatory and Tissue Adhesion Properties of an α-Linolenic Acid-Modified Gelatin-Based In Situ Hydrogel

Poly unsaturated fatty acids (PUFAs)-natural chemicals derived from fish and nuts-have anti-inflammatory and antioxidative properties that are attributed to the inhibition of inflammatory pathways and the radical scavenging activity of their double bonds. In this study, Alaska pollock-derived gelatin (ApGltn), which has a low sol-gel transition temperature, was modified with α-linolenic acid (ALA) to obtain ALA-ApGltn, which was subsequently cross-linked to give a hydrogel (ALA-gel). Although the elastic modulus of ALA-gel and nonmodified ApGltn gel (Org-gel) was almost the same, ALA-gel exhibited a higher tan δ as well as a lower swelling ratio and enzymatic degradation rate than Org-gel. Moreover, ALA-gel showed enhanced tissue adhesive strength compared with a commercial fibrin adhesive. The concentration of a tumor necrosis factor (TNF)-α secreted from macrophage-like cells and the intracellular mitochondrial activity indicated that ALA-ApGltn exerted anti-inflammatory effects and maintained cell viability compared with the higher toxicity nonconjugated ALA. In addition, ALA-gel demonstrated suppressed formation of lamellipodia and secretion of TNF-α. ALA-gel therefore has potential as an adhesive biomaterial for wound sealing and treating burn injuries.

Serum concentrations of free fatty acids are associated with 3-month mortality in acute heart failure patients

Background

Plasma free fatty acids (FFA) are higher in heart failure (HF) patients compared to healthy controls. Considering that the extent of FFA elevation in HF might mirror the severity of HF, we hypothesized that the serum levels of FFA may be a useful prognostic indicator for 3-month mortality in acute heart failure (AHF).

Methods

We analyzed the serum samples of AHF patients obtained at admission to the emergency department. Serum levels of FFA were analyzed using an enzymatic reagent on an automatic analyzer.

Results

Out of 152 included AHF patients that were originally included, serum samples of 132 patients were available for the quantification of FFA. Of these, 35 (26.5%) died within 3 months of onset of AHF. These patients had significantly higher serum levels of FFA compared to AHF patients who were alive 3 months after onset of AHF. Univariable logistic regression analyses showed a significant positive association of FFA levels with 3-month mortality (odds ratio [OR] 2.76 [95% confidence interval 1.32–6.27], p = 0.010). Importantly, this association remained significant after adjusting for age and sex, as well as for further clinical and laboratory parameters that showed a significant association with 3-month mortality in the univariate analyses.

Conclusions

We conclude that the admission serum levels of FFA are associated with 3-month mortality in AHF patients. Therefore, measurements of circulating FFA levels may help identifying high-risk AHF patients.

Clinical Characteristics of Hospitalized Patients with Drug-Induced Acute Kidney Injury and Associated Risk Factors: A Case-Control Study

Background

Drug-induced acute kidney injury (D-AKI) is increasingly common and can extend the hospital length of stay and increase mortality. This study is aimed at analyzing the clinical characteristics of hospitalized patients with D-AKI and the associated risk factors in a multidrug environment.

Methods

A retrospective study among hospitalized patients was conducted in July 2019 based on the Adverse Drug Events Active Surveillance and Assessment System-2 developed by the authors. Four controls were matched with each case according to the matching criteria. The risk factors for D-AKI were identified by binary multivariate logistic regression.

Results

A total of 23,073 patients were hospitalized in July 2019, 21,131 of whom satisfied the inclusion criteria. The independent risk factors for D-AKI consisted of alcohol abuse (odds ratio (OR), 2.05; 95% confidence interval (CI), 1.04-4.07), nonsteroidal anti-inflammatory drug (NSAID) use (OR, 2.39; 95% CI, 1.25-4.58), diuretic use (OR, 2.64; 95% CI, 1.42-4.92), prior anemia (OR, 4.10; 95% CI, 1.94-8.67), and prior chronic kidney disease (OR, 2.33; 95% CI, 1.07-5.08).

Conclusions

The occurrence of D-AKI in hospitalized patients had significant associations with alcohol abuse, combination therapy with NSAIDs or diuretics, and prior anemia or chronic kidney disease. Clinicians should meticulously follow patients with the above characteristics.

Changes in blood pressure thresholds for initiating antihypertensive medication in patients with diabetes: a repeated cross-sectional study focusing on the impact of age and frailty

OBJECTIVE

To assess trends in systolic blood pressure (SBP) thresholds at initiation of antihypertensive treatment in patients with type 2 diabetes and the impact of age and frailty on these trends.

STUDY DESIGN AND SETTING

A repeated cross-sectional cohort study (2007-2014) using the Groningen Initiative to Analyse Type 2 diabetes Treatment database was conducted. The influence of calendar year, age or frailty and the interaction between year and age or frailty on SBP thresholds were assessed using multilevel regression analyses adjusted for potential confounders.

RESULTS

We included 4819 patients. The mean SBP at treatment initiation was 157 mm Hg in 2007, rising to 158 mm Hg in 2009 and decreasing to 151 mm Hg in 2014. This quadratic trend was significant (p<0.001). Older patients initiated treatment at higher SBP, but similar decreasing trends after 2009 were observed in all age groups. There were no significant differences in SBP thresholds between patients with different frailty groups. The association between year and SBP threshold was not influenced by age or frailty.

CONCLUSION

After an initial rise, the observed SBP thresholds decreased over time and were not influenced by age or frailty. This is in contrast with changed guideline recommendations towards more personalised treatment during the study period and illustrates that changing prescribing practice may take considerable time. Patient-specific algorithms and tools focusing on when and when not to initiate treatment could be helpful to support personalised diabetes care.

Association of Cardiovascular Mortality and Deep Learning-Funduscopic Atherosclerosis Score derived from Retinal Fundus Images

PURPOSE

The prediction of atherosclerosis using retinal fundus images and deep learning has not been shown possible. The purpose of this study was to develop a deep learning model which predicted atherosclerosis by using retinal fundus images and to verify its clinical implications by conducting a retrospective cohort analysis.

DESIGN

Retrospective cohort study.

METHODS

The database at the Health Promotion Center of Seoul National University Hospital (HPC-SNUH) was used. The deep learning model was trained using 15,408 images to predict carotid artery atherosclerosis, which was named the deep-learning funduscopic atherosclerosis score (DL-FAS). A retrospective cohort was constructed of participants 30-80 years old who had completed elective health examinations at HPC-SNUH. Using DL-FAS as the main exposure, participants were followed for the primary outcome of death due to CVD until Dec. 31, 2017.

RESULTS

For predicting carotid artery atherosclerosis among subjects, the model achieved an area under receiver operating curve (AUROC) and area under the precision-recall curve (AUPRC), accuracy, sensitivity, specificity, positive and negative predictive values of 0.713, 0.569, 0.583, 0.891, 0.404, 0.465, and 0.865 respectively. The cohort consisted of 32,227 participants, 78 cardiovascular disease (CVD) deaths, and 7.6-year median follow-up visits. Those with DL-FAS greater than 0.66 had an increased risk of CVD deaths compared to those with DL-FAS <0.33 (hazard ratio: 8.33; 95% confidence interval [CI], 3.16-24.7). Risk association was significant among intermediate and high Framingham risk score (FRS) subgroups. The DL-FAS improved the concordance by 0.0266 (95% CI, 0.0043-0.0489) over the FRS-only model. The relative integrated discrimination index was 20.45% and net reclassification index was 29.5%.

CONCLUSIONS

A deep learning model was developed which could predict atherosclerosis from retinal fundus images. The resulting DL-FAS was an independent predictor of CVD deaths when adjusted for FRS and added predictive value over FRS.

Combining angiotensin receptor blockers with chlorthalidone or hydrochlorothiazide - which is the better alternative? A meta-analysis

BACKGROUND

Hypertension is a disease with significant clinical and socio-economic consequences. The reduction in cardiovascular mortality and morbidity in patients treated for hypertension is directly related to the magnitude of blood pressure reduction. Diuretics have proven useful for the prevention of cardiovascular complications in addition to a long history of safety and efficacy. The main aim for this meta-analysis is to compare the efficacy of the combination of angiotensin receptor blocker (ARB) and chlorthalidone (CTLD) to the combination of ARB and hydrochlorothiazide (HCTZ) in patients with hypertension.

METHODS

A comprehensive literature search was conducted through electronic databases PubMed, MEDLINE, Scopus, PsyInfo, Cochrane, eLIBRARY.ru, http://ClinicalTrials.gov and http://www.clinicaltrialsregister.eu in July 2020 to identify studies that investigate the effect of the combination of angiotensin receptor blocker with chlorthalidone or hydrochlorothiazide on the systolic and diastolic blood pressure in patients with hypertension. Changes in systolic and diastolic blood pressure (BP) expressed as a weighted mean difference (WMD) were our primary outcomes. The random-effects method was chosen as the primary analysis and results were presented with a 95% confidence interval (CI). Sensitivity analysis was performed and bias was assessed.

RESULTS

Our search returned 2745 titles. Of them, 51 full-text articles remained to be subjected to assessment. Comparisons of ARB/HCTZ versus ARB showed changes in BP of -6.89 (-8.09, -5.69) mmHg for systolic BP and - 3.67 (-4.15, -3.19) mmHg for diastolic BP. For the ARB/CTLD versus ARB/HCTZ comparison changes were - 6.30 (-7.30, -5.29) mmHg for systolic BP and - 3.57 (-4.17, 2.98) mmHg for diastolic BP.

CONCLUSION

Our analysis suggests a small but significant favor for CTLD in blood pressure control when compared to HCTZ. We believe it should be considered as a valuable alternative for HCTZ and an option for fixed dose combinations with an ARB although further research is required.

Development of a risk score to predict abnormal glycemic status among Thai dental patients

Purpose

To construct a risk score using both clinical and intra-oral variables and to determine a risk score to screen individuals according to their risk of hyperglycemia.

Design/methodology/approach

A cross-sectional study was carried out among 690 Thai dental patients who visited the Special Clinic, Faculty of Dentistry, Mahidol University and a mobile dental unit of His Majesty the King of Thailandss Dental Service Unit. Participants aged ≥25 years without a previous history of type 2 diabetes mellitus were included in the study. Participants diagnosed with severe anemia and polycythemia were excluded. Questionnaires were used to collect demographic data. Point-of-care HbA1c, body mass index (BMI), blood pressure and periodontal status were analyzed.

Findings

A total of 690 participants were included in the study. A risk scoring system including five variables was developed. It exhibited fair discrimination (area under the curve = 0.72, 95%CI 0.68–0.71). The risk score value of 9 was used as the cut-off point for increased risk of abnormal HbA1c. Subjects that had a total risk score of 9 or more had a high probability of having abnormal HbA1c and were identified for referral to physicians for further investigation and diagnosis.

Originality/value

A risk score to predict hyperglycemia using a dental parameter was developed for convenient evaluation in dental clinics.

Triglycerides are related to left ventricular mass in hypertensive patients independently of other cardiometabolic risk factors: the effect of gender

Given the inconsistent results on the prognostic significance of triglycerides (TGs), the purpose of the present study was to investigate the association of plasma TGs with left ventricular mass (LVM) in hypertensive patients. We studied 760 never treated, non diabetic, hypertensive patients. Τransthoracic echocardiography was performed and LVMI was calculated according to the Devereux formula, adjusted to body surface area. Triglycerides were associated with LVMI after adjustment for age, gender, systolic blood pressure (SBP), smoking and fasting glucose (b = 0.08, p = 0.009). This relationship remained significant even after adjustment for BMI, LDL-C and ApoB/ApoA1 ratio (b = 0.07, p = 0.04). Gender-stratified analysis indicated that TGs were related to LVMI in men (p = 0.001) but not in women (p = NS). In addition, TGs were related with LV hypertrophy (LVH) in men, increasing the odds by 7% to present LVMI over 115 g/m² (OR = 1.07 per 10 mg/dl increase in TGs, p = 0.01). In conclusion, TGs are associated with LVMI in hypertensive patients, independently of other risk factors, including LDL-C. Given the prognostic significance of LVH, it might be suggested that TGs may serve as a useful marker for indentifying hypertensive patients at high risk. The gender discrepancy may suggest a possible gender-specific modulatory effect of TGs on LV structure.

Repeatability and reproducibility of pulse wave velocity in relation to hemodynamics and sodium excretion in stable patients with hypertension

OBJECTIVE

Pulse wave velocity (PWV) is a useful marker for determining subclinical vascular damage and patient risk stratification. Repeatability and reproducibility of PWV in relation to influencing factors have not yet been determined. This study examined the repeatability and reproducibility of PWV, and whether hemodynamics and sodium excretion impact on PWV in hypertensive patients remaining on stable medication.

METHODS

Office blood pressure (BP), heart rate (HR), carotid--femoral PWV and central BP (SphygmoCor device), impedance cardiography (HOTMAN device) and 24-h urinary sodium excretion (UNa) were measured at baseline and after 4 weeks in 74 hypertensive patients (age 56.8 ± 11.5 years, mean ± SD). Two PWV measurements were performed at each visit.

RESULTS

Intraclass correlation coefficient (ICC) and 95% confidence interval (95% CI) between the two PWV measurements were 0.981 (0.970--0.988) at baseline, 0.975 (0.960--0.984) after 4 weeks and 0.851 (0.773--0.903) between both visits. There were no significant changes in BP, HR, thoracic fluid content, stroke volume and UNa between visits. Despite excellent ICC, reproducibility of PWV was related to BP (P < 0.001) and HR (P = 0.07) changes between visits. Nineteen out of 74 patients had a difference in PWV greater than ±1 m/s between both visits.

CONCLUSION

In the medium-term observation, changes in BP and HR seem to affect PWV values. Our findings suggest that the assessment of PWV should be performed under stabilized BP and HR values, particularly in patients with newly diagnosed hypertension and/or low--moderate cardiovascular risk in whom the detection of asymptomatic hypertension-mediated organ damage impact on patient risk stratification.

Clinical efficacy of various anti-hypertensive regimens in hypertensive women of Punjab; a longitudinal cohort study

BACKGROUND

Gender wise differences exist in anti-hypertensive treatment outcomes, yet still un-explored in Pakistan. Thus, we aimed to estimate the clinical efficacy of four different anti-hypertensive regimens in hypertensive women of Punjab, Pakistan.

METHODS

A longitudinal cohort study of 12 months duration was conducted by enrolling 300 hypertensive women on four anti-hypertensive regimens. Chi-square for significance, logistic regression for association and multilevel regression for changes in outcomes were used.

RESULTS

Majority of subjects were < 60 years of age, weighing > 65 Kg, having family history, married and hailing from urban areas, with diabetes as the most common comorbidity. Hypertension, adjusted for covariates, was significantly associated with salt intake (OR:2.27, p <  0.01) and physical activity (OR;2.16, p <  0.01). High-risk subjects, compared to low-risk, were consuming more fat (OR;1.54), meat (OR; 2), salt (OR; 2.48) and even vegetables/fruits (OR;3.43). Compared to baseline, the maximum reduction in BP was observed with combination therapy, N-GITS+LTN + HCT (SBP; - 50.17, p <  0.01, DBP; - 16.55, p <  0.01), followed by N-GITS alone (SBP; - 28.89, p <  0.01, DBP; - 12.21, p <  0.01). Compared to baseline, adjusted for treatment effects, significant reductions in SBP (low-risk; - 17.92, p <  0.01 high-risk; - 19.48, p <  0.01) and DBP (low-risk; - 17.92, p <  0.01, high-risk; - 19.48, p <  0.01) were observed in low and high risk patients. Among all four cohorts, orthostatic hypotension and edema were common in N-GITS+LTN + HCT only, but variable effects were observed on biochemical values; urea, BSR and creatinine.

CONCLUSION

In conclusion, compared to a single agent, combination therapy conferred improved BP controls followed by N-GITS alone in low and high risk women with manageable side effects.

Effect of direct renin inhibition on vascular function after long-term treatment with aliskiren in hypertensive and diabetic patients

OBJECTIVE

We tested the hypothesis that chronic treatment with the direct renin inhibitor aliskiren improves vascular function in resistance and conduit arteries of type two diabetic and hypertensive patients.

METHOD

Sixteen patients with mild essential hypertension and with a previous diagnosis of noninsulin-dependent diabetes mellitus were included in the study. Patients were then randomized to aliskiren (150 mg once daily, n = 9), or ramipril (5 mg once daily, n = 7). Each patient underwent a biopsy of the subcutaneous tissue and small arteries were dissected and mounted on a pressurized micromyograph to evaluate endothelium dependent vasorelaxation in response to acetylcholine ± N omega-nitro-L-arginine methyl ester hydrochloride in vessels precontracted with norepinephrine. Endothelial function has been quantified also in large conduit arteries by flow-mediated dilation.

RESULTS

A similar office blood pressure-lowering effect was observed with the two drugs, although changes in DBP were not statistically significant in the ramipril group. Aliskiren significantly improved endothelium-dependent relaxation in subcutaneous resistance arteries, as well as increased flow-mediated dilation in conduit arteries, whereas the effects induced by ramipril did not reach statistical significance. Only aliskiren significantly increased the expression of p1177-endothelial nitric oxide synthase in the endothelium. Both aliskiren and ramipril had a negligible effect on markers of oxidative stress.

CONCLUSION

Aliskiren restored endothelial function and induced a more prompt peripheral vasodilation in hypertensive and diabetic patients possibly through the increased production of nitric oxide via the enhanced expression and function of the active phosphorylated form of endothelial nitric oxide synthase.

Sex differences in the adherence of antihypertensive drugs: a systematic review with meta-analyses

OBJECTIVES

Poor worldwide rate of blood pressure control is largely due to poor adherence to antihypertensive (AHT) drug treatment. The question of whether sex affects adherence has long been debated but conflicting findings have been reported on this issue. Our objective was to evaluate sex differences in the adherence to AHT therapy.

RESEARCH DESIGN AND METHODS

Studies were identified through a systematic search of PubMed, CINAHL, PsycINFO, Web of Science and Google Scholar (through January 2020) and manual handsearching of relevant articles. Observational studies reporting adherence to AHT drugs measured by self-report or pharmacy refill prescription-based methods among men and women were included. Summarised estimates of OR_s with 95% CIs were calculated using random-effects model and meta-regression models.

RESULTS

From 12 849 potentially relevant publications, 82 studies (15 517 457 men and 18 537 599 women) were included. No significant between-sex differences in adherence to AHT were observed, whether all study-specific estimates were summarised (OR_s 1.04, 95% CI 1.00 to 1.09, p=0.07), nor estimates were pooled according to the method for measuring adherence. Among patients aged 65 years or older, lower self-reported adherence was observed in women (OR_s 0.84, 95% CI 0.72 to 0.97, p=0.02), while the main result remained unchanged according to other subgroup analyses.

CONCLUSIONS

Definitive evidence of sex differences in adherence to AHT therapy cannot be drawn. Our little knowledge about factors affecting adherence, in particular of sex effect among elderly, urgently requires high-quality studies investigating these issues.

Associations between honey consumption and prehypertension in adults aged 40 years and older

Background: Honey has been shown to have multiple positive effects on human health. However, data on the associations of honey consumption with prehypertension are scarce. The aim of this study was to investigate whether honey consumption is associated with prehypertension in a Chinese population. Method: A cross-sectional study was conducted in 4,561 individuals aged ≥40 years. A validated 100-item semi-quantitative food frequency questionnaire was used to assess honey consumption. Blood pressure was measured at least twice by trained nurses. Multiple logistic regression models were used to explore the associations between honey consumption and prehypertension. Results: After adjustment for potential confounders, the odds ratios and 95% confidence intervals of prehypertension across increasing frequency of honey consumption were 1.00 (reference) for almost never, 1.17 (0.96, 1.41) for ≤6 times/week, and 1.25 (0.86, 1.84) for ≥7 times/week in men (P _{for trend} = 0.09); 1.00 (reference) for almost never, 0.76 (0.62, 0.92) for ≤6 times/week, and 0.84 (0.63, 1.12) for ≥7 times/week in women (P _{for trend} = 0.055), respectively. Conclusion: Our results showed that light-to-moderate intake of honey was associated with lower prevalence of prehypertension in women, but not men. Future studies are required to confirm these associations.

Accuracy of Pulse Wave Velocity Predicting Cardiovascular and All-Cause Mortality. A Systematic Review and Meta-Analysis

Increased arterial stiffness has been associated with an increased risk of developing cardiovascular diseases and all-cause mortality. Pulse wave velocity (PWV) is an innovative and affordable measurement of arterial stiffness which may be an accessible tool to estimate mortality risk; however, no meta-analysis has estimated its predictive performance for cardiovascular and all-cause mortality. Moreover, reference values for PWV have only been established by consensus for healthy populations. The aim of this review was to estimate PWV and especially carotid femoral PWV performance predicting cardiovascular and all-cause mortality as well as comparing the resulting cfPWV thresholds with already established values in order to increase its validity. Original studies measuring PWV thresholds and its association with cardiovascular and all-cause mortality were systematically searched. The DerSimonian and Laird method was used to compute pooled estimates of diagnostic odds ratio (dOR), and overall test performances were summarized in hierarchical summary receiver operating characteristic curves (HSROC). Six studies were included in the meta-analysis. The pooled dOR values for the predictive performance of cfPWV were 11.23 (95 % CI, 7.29-1.29) for cardiovascular mortality and 6.52 (95% CI, 4.03-10.55) for all-cause mortality. The area under the HSROC curve for cfPWV was 0.75 (95% CI, 0.69-0.81) for cardiovascular mortality and 0.78 (95% CI, 0.74-0.83) for all-cause mortality, where the closest cut-off point to the summary point was 10.7 and 11.5, respectively. This systematic review and meta-analysis demonstrates that cfPWV is a useful and accurate cardiovascular mortality predictor and that its previously estimated reference values for estimating risk may be used in high-risk populations.

A predictive value of the dynamic changes of the P-wave terminal force in lead V1 in the long-term prognosis of patients with non-ST-segment elevation acute coronary syndrome

BACKGROUND

The purpose of this study was to investigate the prognostic value of dynamic changes of P-wave terminal force in lead V1 (PtfV1 ) at electrocardiogram (ECG) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) during the long-term major adverse cardiovascular events (MACEs) of patients.

METHODS

According to the PtfV1 value, the patients were divided into four groups: PtfV1 (-)/PtfV1 (-), PtfV1 (-)/PtfV1 (+), PtfV1 (+)/PtfV1 (-), and PtfV1 (+)/PtfV1 (+).

RESULTS

The highest incidence of MACEs was the PtfV1 (-)/(+) group with 24 patients (24.7%). The lowest incidence was the PtfV1 (-)/(-) group with 28 patients (4.9%). Compared with the PtfV1 (-)/(-) group, the risk for the occurrence of MACEs in the PtfV1 (-)/(+)group was significantly increased (24.7% vs 4.9%, P = .000). Similarly, the risk in the PtfV1 (+)/(+) group was also increased (10.1% vs 4.9%, P = .000).

CONCLUSION

The persistence of PtfV1 (+) and conversion of PtfV1 /(-) to PtfV1 /(+) at discharge significantly increased the incidence of MACEs.

Drug-related Problems in Hypertensive Patients: A Cross-sectional Study from Indonesia

OBJECTIVE

The treatment of hypertension requires special attention because of comorbidities and polypharmacy. In a previous study, polypharmacy has been associated with a high risk of drug-related problems (DRPs). This study aimed to analyze DRPs in Indonesian hypertensive patients focusing on drug therapy effectiveness and adverse drug reactions.

METHODS

A cross-sectional study was conducted using medical records' data, prescriptions, and nursing records to observe DRPs that occurred in outpatients with hypertension from February to April 2019. A total of 114 outpatients aged ≥23 years with a primary diagnosis of primary hypertension were included in this study. DRPs were reviewed based on literature, recent guidelines, and drug interaction software. Classification DRPs were done using Indonesian-translated Pharmaceutical Care Network Europe V6.02. The data obtained were analyzed using univariate descriptive analysis.

FINDINGS

Of all participants, 65 (57%) outpatients were found to have DRPs related to treatment effectiveness (54 cases) and adverse drug reactions (36 cases). The primary cause of the problems was an inappropriate drug (94.14%) and dose selection (2.86%). Potential drug interactions were found high (62.14%) in the combination of an antihypertensive agent with other drugs among patients. Overprescribing drugs without clear indications, untreated indications, and subtherapeutic dosage were also reported in this study.

CONCLUSION

A significant percentage of outpatients being treated for hypertension experienced DRPs. The role of clinical pharmacists and physicians in monitoring drug therapy needs to be prioritized to prevent and resolve DRPs in outpatients with hypertension.

Value of ambulatory blood pressure measurement in diagnosing hypotension in hypertensive diabetic patients with medication-controlled BP

Background

Hypotension is a common clinical finding in diabetic patients on anti-hypertensive medications. In the absence of clearly defined and documented hypotensive episodes, clinicians are faced with the challenge of modifying antihypertensive medication in potentially symptomatic diabetic patients.

Objective

To determine the value of ambulatory blood pressure monitor (ABPM) in diagnosing hypotensive episodes in hypertensive diabetic patients with medication-controlled blood pressure.

Patients and methods

The records of all hypertensive diabetic patients with medication-controlled were obtained between 2017 and 2018. Patients' demographic data, comorbid conditions, hypotensive symptoms and echocardiography results were obtained and compared to office-based blood pressure and ABPM.

Results

Of 926 patients screened in the department of medicine outpatient clinics, 231 patients had diabetes and hypertension and were taking antihypertension medications, so only 86 patients were recruited. Using 24 h ABPM, hypotensive events were documented in 65 (75.6%) patients without correlated hypotensive symptoms in the patient sheet. Patients who had hypotensive episodes recorded by ABPM tended to have these between 5 and 10 a.m. and were significantly older - 60.71 versus 58.76 (P = .022) - and more likely to have lower ejection fractions by echocardiography 46.31 versus 62.85 (EF) (P < .001).

Conclusion

In treated hypertensive diabetic patients with antihypertensive medication, ABPM may be beneficial in capturing bouts of asymptomatic (silent) hypotension readings that occur in the out-of-hospital setting. Diabetic patients with controlled hypertension based on office reading showed a significant number of asymptomatic hypotensive readings detected with ambulatory BP monitoring that can have a role in following up such patients.

Quality of Life and Symptom Burden among Chronic Kidney Disease of Uncertain Etiology (CKDu) Patients in Girandurukotte, Sri Lanka

Symptom burden and health-related quality of life (HRQOL) are important predictors of how a disease affects patients' lives, especially for endemic health problems such as chronic kidney disease of uncertain etiology (CKDu). Our study describes symptom burden, HRQOL, and associated demographic and clinical variables in CKDu patients in the Girandurukotte area, Sri Lanka. A cross-sectional study included 120 CKDu patients attending the renal clinic in the endemic area. The instruments applied were the Kidney Disease Quality of Life-Short Form (KDQOL-SFTM) version 1.3 and CKD Symptom Index-Sri Lanka. Socio-demographic, disease-related, and anthropometric variables were also investigated. The mean age of patients was 61.87 (SD 11.31), while 69.2% were male. The mean glomerular filtration rate was 28.17 (SD 14.03) mL/min/1.73 min2, and 70.8% were anemic. Bone/joint pain was the most experienced symptom while the median number of symptoms reported by patients was 5 (IQR 3-7). The mean symptom burden, physical component summary, mental component summary, and kidney-disease-specific component scores were 12.71 (SD 10.45), 68.63 (SD 19.58), 78.53 (SD 18.78), and 81.57 (SD 5.86), respectively. Age was found to be a significant predictor of HRQOL, while hemoglobin level and being a farmer were significant predictors of symptom burden. Our data indicate that CKDu patients in all stages experience at least one symptom affecting all aspects of HRQOL.

Do patients or their physicians more accurately assess long-term risk associated with hypertension? A population-based study

Objective: To compare the assessments of 10-year probability by patients and their physicians of cardiovascular complications of hypertension with actual outcomes.Design: Patients with uncomplicated hypertension treated with at least one antihypertensive drug at inclusion were followed for 10 years through mandatory national health registers.Setting: 55 primary health care centres, 11 hospital outpatient clinics in SwedenPatients: 848 patient, 212 physicians.Main outcome measures: Patients and physicians estimated the probability of hypertension-related complications with treatment (death, heart failure, acute myocardial infarction/AMI, and stroke) for each patient in 848 pairs. Estimates were compared with the clinical outcomes 10 years later using data from the Mortality Register and the National Patient Register.Results: Patients were significantly better (p < 0.001) than their physicians in estimating the average probability of heart failure compared with actual outcome data (14% vs. 24%, outcome 15%), AMI (16% vs. 26%, outcome 8%), and stroke (15% vs. 25%, outcome 11%). Patients were significantly worse (p < 0.001) at estimating the average probability of death (10% vs. 18%, actual outcome 20%). Neither the patients nor the physicians were able to distinguish reliably between low-risk and high-risk patients after adjustment for age and sex.Conclusions: Patients were better than their physicians in estimating the average probability of morbidity due to hypertension. Both the patients and their attending physicians had difficulty in estimating the individual patient's risk of complications. The results support the use of evidence-based tools in consultations for assessing the risk of cardiovascular complications associated with hypertension.Key points • Shared decision making relies on a common understanding of risks and benefits. Tools for risk assessment of hypertension have been introduced in the last two decades. • Without tools for risk assessment, both patients and physicians had difficulties in estimating the individual patient's risk of cardiovascular morbidity. • Patients were better than physicians in estimating actual average cardiovascular morbidity due to hypertension during a follow-up of 10 years. • The results support the use of evidence-based tools in consultations for assessing the risk of cardiovascular complications associated with hypertension.

Blood microRNA 202-3p associates with the risk of essential hypertension by targeting soluble ST2

MicroRNA (miR)-202-3p has attracted a great deal of attention in the fields of oncology, gynecology, and metabolic disorders. However, its role in cardiovascular diseases remains to be clarified. We previously found that disruption of miR-202-3p mediated regulation of expression of soluble (s)ST2, a decoy receptor for interleukin (IL)-33, promotes essential hypertension (EH). In the present study, we first measured miR-202-3p expression levels in the blood of 182 EH cases and 159 healthy controls using TaqMan assays. miR-202-3p levels were shown to be significantly higher in EH cases than controls (fold change = 3.58, P<0.001). Logistic regression analysis revealed that higher miR-202-3p expression was associated with an increased occurrence of EH (adjusted odds ratio (OR): 1.57; 95% confidence interval (CI), 1.36-1.82; P<0.001). Addition of miR-202-3p to traditional risk factors showed an additive prediction value for EH. Further functional experiments indicated that miR-202-3p could be induced by angiotensin II (Ang II) and inhibited by Ang II-triggered soluble ST2 (sST2) expression in a negative feedback manner. Moreover, blood miR-202-3p levels were negatively correlated with sST2 expression in vivo. Our study shows that blood miR-202-3p levels were significantly associated with the occurrence of EH. These findings indicate that miR-202-3p exerts a protective role against EH by antagonizing the induction of sST2 by Ang II.

Understanding the most commonly billed diagnoses in primary care: Hypertension

Hypertension is a preventable cause of poor health outcomes. This first article in a series about the most commonly billed diagnoses in primary care settings explores the pathophysiology, diagnostic evaluation, and management of hypertension. Relevant billing issues are addressed.

Poor Awareness of Hypertension in France: The CONSTANCES Population-Based Study

OBJECTIVES

We aimed to assess the hypertension (HTN) awareness and associated factors in France.

METHODS

We conducted a cross-sectional analysis using data from the CONSTANCES population-based cohort involving 87,808 volunteer participants included between 2012 and 2018. HTN was defined as average blood pressure (BP) over 140/90 or use of BP medication, awareness as self-reported HTN. Multivariable logistic regression models were used to identify the associated factors.

RESULTS

Overall, 27,160 hypertensive participants (men = 16,569) above 18 years old were analyzed. Hypertension awareness rate was 37.5%. In the multivariable regression model, awareness was predicted by female gender, age, prior cardiovascular disease (CVD), presence of diabetes mellitus (DM), presence of chronic kidney disease (CKD), level of education, and obesity or overweight. Older participants (P < 0.001), females (P < 0.001), participants with comorbidities (P < 0.001), were more likely to be aware when compared with younger participants, males and participants without comorbidities, respectively. The unawareness among participants without cardiometabolic factors (CMF, i.e., CVD, DM, CKD) was higher than participants with CMF (67% vs. 41%, respectively, P < 0.001). Moreover, some differences appeared in both genders in the association between awareness of HTN and health and lifestyle factors.

CONCLUSION

Our findings show that HTN awareness is low. Particular attention should be given to young men without comorbidities as these characteristics were predictors of poor awareness. Immediate action is required to improve HTN awareness in France.

Blood pressure and risk of cancer in the European Prospective Investigation into Cancer and Nutrition

Several studies have reported associations of hypertension with cancer, but not all results were conclusive. We examined the association of systolic (SBP) and diastolic (DBP) blood pressure with the development of incident cancer at all anatomical sites in the European Prospective Investigation into Cancer and Nutrition (EPIC). Hazard ratios (HRs) (95% confidence intervals) were estimated using multivariable Cox proportional hazards models, stratified by EPIC-participating center and age at recruitment, and adjusted for sex, education, smoking, body mass index, physical activity, diabetes and dietary (in women also reproductive) factors. The study included 307,318 men and women, with an average follow-up of 13.7 (standard deviation 4.4) years and 39,298 incident cancers. We confirmed the expected positive association with renal cell carcinoma: HR = 1.12 (1.08-1.17) per 10 mm Hg higher SBP and HR = 1.23 (1.14-1.32) for DBP. We additionally found positive associations for esophageal squamous cell carcinoma (SCC): HR = 1.16 (1.07-1.26) (SBP), HR = 1.31 (1.13-1.51) (DBP), weaker for head and neck cancers: HR = 1.08 (1.04-1.12) (SBP), HR = 1.09 (1.01-1.17) (DBP) and, similarly, for skin SCC, colon cancer, postmenopausal breast cancer and uterine adenocarcinoma (AC), but not for esophageal AC, lung SCC, lung AC or uterine endometroid cancer. We observed weak inverse associations of SBP with cervical SCC: HR = 0.91 (0.82-1.00) and lymphomas: HR = 0.97 (0.93-1.00). There were no consistent associations with cancers in other locations. Our results are largely compatible with published studies and support weak associations of blood pressure with cancers in specific locations and morphologies.

C677T MTHFR Gene Polymorphism is Contributing Factor in Development of Renal Impairment in Young Hypertensive Patients

Homocysteine concentration affected by the activities of the enzymes methylene tetra-hyrdofolate reductase (MTHFR). Polymorphisms in MTHFR gene associated with an impairment of MTHFR activity. Hyperhomocysteinemia is a result of single nucleotide polymorphisms (SNPs) in MTHFR 677 C>T that can cause homocysteine levels in the blood to increase. The purpose of this study is to investigate the relationships between MTHFR C677T (rs1801133) gene polymorphism, changes in homocysteine concentrations and progress of renal impairment in young adult hypertensive patients. Two hundred young hypertensive patients (age 21-24 years) were involved in this study; they were classified into patients with and without renal impairment in addition to 200 age and sex matched healthy controls. All participants were submitted to laboratory investigations as assay of MTHFR gene polymorphism C677T (rs1801133) by PCR/RFLP, determination of lipid profile, homocysteine and folic acid concentrations in addition to urinary albumin creatinine ratio (UACR). The levels of both homocysteine and UACR in the TT genotype patients were higher than those in the CC genotype group. Individuals who carry the T allele were more risky to hypertension and progress to early renal impairment in young age compared with those carrying the C allele [OR 2.02 (1.33-3.08), P < 0.001]. Genetic variants of C677T MTHFR gene and hyperhomocysteinemia may be responsible for rapid progress of renal impairment in Egyptian young age hypertensive patients. TT genotype or T allele may be considered as a predisposing factor for both elevated Hcy levels and the development of renal impairment. This study believed that lowering of homocysteine level can reduce renal impairment of hypertensive patients.

Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review

Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines.

Increased risk of atherosclerosis associated with pesticide exposure in rural areas in Korea

Atherosclerosis is a progressive inflammation in systemic vessels, and pesticide exposure has been emerging as its risk factor. This cross-sectional study investigated the association between pesticide exposure and the risk of atherosclerosis in a rural population in Korea using carotid intima-media thickness (CIMT). This study used dataset from the baseline survey of the Korea Farmers Cohort Study between November 2005 and January 2008, and the final analysis included 477 participants. Well-structured questionnaires were used to estimate pesticide exposure. CIMT ≥ 0.9 mm was established for carotid atherosclerosis. Multiple logistic regression analyses were undertaken to evaluate the association between pesticide exposure and atherosclerosis, adjusting demographic and health-related confounders. Even after adjustments, the increased risk of atherosclerosis was significantly associated with pesticide exposure, such as a lifetime history of farming (odds ratio [OR] 3.25 95% confidence interval [CI] 1.51–6.98), a history of using pesticide (OR 3.42 95% CI 1.63–7.16), using pesticide 10 times or more annually (OR 2.55 95% CI 1.21–5.39), and higher cumulative exposure index level (OR 3.63 95% CI 1.65–7.97). Further prospective studies are required to elucidate effects of pesticide exposure on the risk of atherosclerosis.

Prediction of stroke with electrocardiographic left ventricular hypertrophy in hypertensive patients: A meta-analysis

BACKGROUND

Electrocardiographic left ventricular hypertrophy (LVH) has been used to predict adverse prognosis in hypertensive patients. This meta-analysis aimed to investigate the association between LVH using the different electrocardiographic criteria in patients with hypertension.

METHODS

A comprehensive literature search was performed PubMed and Embase databases up to September 1, 2019. Observational studies evaluating the association between electrocardiographic LVH (Cornell voltage, Cornell product or Sokolow-Lyon voltage) at baseline and risk of stroke among hypertensive patients were selected. The risk ratio (RR) with 95% confidence interval (CI) was pooled for patients with electrocardiographic LVH versus without LVH.

RESULTS

Seven studies enrolling 58,098 hypertensive patients were included. When compared those with or without LVH patients showed that the pooled RR of stroke was 1.63 (95% CI 1.38-1.93) for Cornell voltage criteria, 1.41 (95% CI 1.07-1.86) for Cornell product criteria, and 1.42 (95% CI 1.20-1.69) for Sokolow-Lyon voltage criteria, respectively. However, the predictive significance of Cornell product criteria was not reliable in the sensitivity analysis.

CONCLUSIONS

Baseline electrocardiographic LVH detecting by Sokolow-Lyon or Cornell voltage criteria can predict the development of stroke in hypertensive patients. Use of electrocardiographic LVH can improve stroke risk stratification in hypertensive patients.