2020 International Society of Hypertension global hypertension practice guidelines

Hemoglobin A1c in type 2 diabetes mellitus patients with preserved ejection fraction is an independent predictor of left ventricular myocardial deformation and tissue abnormalities

BACKGROUND

Early detection of subclinical myocardial dysfunction in patients with type 2 diabetes mellitus (T2DM) is essential for preventing heart failure. This study aims to search for predictors of left ventricular (LV) myocardial deformation and tissue abnormalities in T2DM patients with preserved ejection fraction by using CMR T1 mapping and feature tracking.

METHODS

70 patients and 44 sex- and age-matched controls (Cs) were recruited and underwent CMR examination to obtain LV myocardial extracellular volume fraction (ECV) and global longitudinal strain (GLS). The patients were subdivided into three groups, including 19 normotensive T2DM patients (G1), 19 hypertensive T2DM patients (G2) and 32 hypertensive patients (HT). The baseline biochemical indices were collected before CMR examination.

RESULTS

LV ECV in T2DM patients was significantly higher than that in Cs (30.75 ± 3.65% vs. 26.33 ± 2.81%; p < 0.05). LV GLS in T2DM patients reduced compared with that in Cs (-16.51 ± 2.53% vs. -19.66 ± 3.21%, p < 0.001). In the subgroup analysis, ECV in G2 increased compared with that in G1 (31.92 ± 3.05% vs. 29.59 ± 3.90%, p = 0.032) and that in HT, too (31.92 ± 3.05% vs. 29.22 ± 6.58%, p = 0.042). GLS in G2 significantly reduced compared with that in G1 (-15.75 ± 2.29% vs. -17.27 ± 2.57%, p < 0.05) and in HT, too (-15.75 ± 2.29% vs. -17.54 ± 3.097%, p < 0.05). In T2DM group, including both G1 and G2, hemoglobin A1c (HbA1c) can independently forecast the increase in ECV (β = 0.274, p = 0.001) and decrease in GLS (β = 0.383, p = 0.018).

CONCLUSIONS

T2DM patients with preserved ejection fraction show increased ECV but deteriorated GLS, which may be exacerbated by hypertension of these patients. Hemoglobin A1c is an index that can independently predict T2DM patients' LV myocardial deformation and tissue abnormalities.

Effectiveness and safety evaluation of sacubitril/valsartan in blood pressure control and clinical outcomes for elderly patients with heart failure and hypertension: A prospective cohort study

AIM

This study was conducted to investigate the safety and effectiveness of sacubitril/valsartan (sac/val) for elderly patients with hypertension and heart failure in the real-world setting.

METHODS

Patients with established hypertension complicated with structural or functional impairment of ventricular fillings [New York Heart Association (NYHA) functional class II-IV)] were enrolled. The effectiveness of sac/val in terms of BP reduction and improvement in frailty and echocardiographic evaluation of cardiac function were examined from baseline to 6-month administration.

RESULTS

Overall, 241 patients were treated with sac/val and 227 with renin angiotensin aldosterone system inhibitor (RAASi) for hypertension control. There were significant difference in the degree of systolic blood pressure reduction between two groups. Echocardiography showed that sac/val significantly improved left ventricular ejection fraction [4.0% (95% CI: 2.0-7.5) vs -1.0 (95% CI: -4.0-2.0), P = 0.001] during the follow-up visits. Significant improvements in NYHA function class and FRAIL scores post sac/val were observed after 3 and 6 month treatment. The rate of primary cardiovascular composite outcome was higher in patients in the RAASi group (26.9%; 95% CI: 19.6-34.0) than in the sac/val group (22.0%; 95% CI: 16.7-27.3).

CONCLUSIONS

Sac/val may be useful not only for reducing BP, but also for improving the structural and functional parameters of echocardiography, eventually resulting in a significant improvement of the overall symptomatic status, a significant reduction in NYHA class, and functional improvement.

Lactate dehydrogenase is associated with flow-mediated dilation in hypertensive patients

The level of lactate dehydrogenase (LDH) has been proved to be positively associated with albuminuria, which represents glomerular endothelial damage in hypertension (HTN). In this study, the relationship between LDH and endothelial function evaluated by flow-mediated dilation (FMD) was investigated in hypertensives. 1507 subjects (aged 61.2 ± 12.5 years) were enrolled. All hypertensives (n = 1216) were subdivided into 3 groups: LDH1 (lowest tertile of LDH, n = 399), LDH2 (mediate tertile of LDH, n = 409) and LDH3 (highest tertile of LDH, n = 408). Meanwhile, 291 normotensives served as controls. FMD of right anterior tibial artery was assessed by high-resolution color Doppler ultrasound. The level of LDH in hypertensives was significantly higher than normotensives (p < 0.001). Whereas, FMD was obviously more blunted in hypertensives (p < 0.001). There was an increasing trend of FMD < 8% from control, LDH1, LDH2 to LDH3 group (χ² = 36.751, p < 0.001). Stepwise multiple liner regression analysis demonstrated an independent correlation between LDH and FMD in hypertensives (β =  - 0.145, p < 0.05). After stratified analysis, the relevance persisted in the male, young and middle-aged, hypertensives with grade 2 HTN, duration of HTN < 3 years, metabolic syndrome and those without statin therapy. In conclusion, the level of LDH was inversely correlated with FMD among hypertensives. Those hypertensives with increased LDH need to be scanned for target organ damage, such as microalbuminuria and endothelial dysfunction, and more frequent following up are also recommended.

Triglyceride Glucose Index Increases Significantly Risk of Hypertension Development in Chinese Individuals Aged ≥45 Years Old: Analysis from the China Health and Retirement Longitudinal Study

Objective

Our purpose was to explore the relationship between triglyceride glucose (TyG) index and the risk of new-onset hypertension in Chinese individuals aged ≥45 years.

Methods

From 2011 to 2018, data from the China Health and Retirement Longitudinal Survey (CHARLS) were analyzed. The relationship between TyG index and hypertension was assessed utilizing Cox regression and restricted cubic spline (RCS) plot, and the importance of the TyG index in hypertension development was demonstrated by a random forest machine learning model. Finally, subgroup analysis was conducted to test for potential interactions on hypertension development between the TyG index and subgroups.

Results

19.7% of the 4755 individuals who were involved in this survey developed hypertension over an average follow-up period of 5.22 years. Compared with the first quartile of albumin, the multivariate HR (95% CI) for the risk of new-onset hypertension across the TyG index quartiles was 1.09 (0.89, 1.33), 1.09 (0.89, 1.33), and 1.29 (1.06, 1.58), respectively (P for trend <0.001). The RCS plot revealed a linear relationship (P for nonlinear = 0.322), and the random forest machine learning model illustrated that the TyG index was a significant hazard factor on hypertension development. There was no interaction between subgroups and the relationships of the TyG index with the prevalence of hypertension (all P-value >0.05).

Conclusion

TyG index was an independent hazard indicator for new-onset hypertension, and routine measurement and control of TyG index level might be great for preventing hypertension development.

The Changing Face of Turner Syndrome

Turner syndrome (TS) is a condition in females missing the second sex chromosome (45,X) or parts thereof. It is considered a rare genetic condition and is associated with a wide range of clinical stigmata, such as short stature, ovarian dysgenesis, delayed puberty and infertility, congenital malformations, endocrine disorders, including a range of autoimmune conditions and type 2 diabetes, and neurocognitive deficits. Morbidity and mortality are clearly increased compared with the general population and the average age at diagnosis is quite delayed. During recent years it has become clear that a multidisciplinary approach is necessary toward the patient with TS. A number of clinical advances has been implemented, and these are reviewed. Our understanding of the genomic architecture of TS is advancing rapidly, and these latest developments are reviewed and discussed. Several candidate genes, genomic pathways and mechanisms, including an altered transcriptome and epigenome, are also presented.

Carotid-body modulation through meditation in stage-I hypertensive subjects: Study protocol of a randomized and controlled study

Adjunctive therapy for hypertension is in high demand for clinical research. Therefore, several meta-analyses have provided sufficient evidence for meditation as an adjunct therapy, without being anchored on reliable physiological grounds. Meditation modulates the autonomic nervous system. Herein, we propose a hierarchical-dependent effect for the carotid body (CB) in attenuating blood pressure (BP) and ventilatory variability (VV) fine-tuning due to known nerve connections between the CB, prefrontal brain, hypothalamus, and solitary tract nucleus. The aim of this exploratory study was to investigate the role of CB in the possible decrease in BP and changes in VV that could occur in response to meditation. This was a prospective, single-center, parallel-group, randomized, controlled clinical trial with concealed allocation. Eligible adult subjects of both sexes with stage 1 hypertension will be randomized into 1 of 2 groups: transcendental meditation or a control group. Subjects will be invited to 3 visits after randomization and 2 additional visits after completing 8 weeks of meditation or waiting-list control. Thus, subjects will undergo BP measurements in normoxia and hyperoxia, VV measurements using the Poincaré method at rest and during exercise, and CB activity measurement in the laboratory. The primary outcome of this study was the detection of changes in BP and CB activity after 8 weeks. Our secondary outcome was the detection of changes in the VV at rest and during exercise. We predict that interactions between hyperoxic deactivation of CB and meditation; Will reduce BP beyond stand-alone intervention or alternatively; Meditation will significantly attenuate the effects of hyperoxia as a stand-alone intervention. In addition, VV can be changed, partially mediated by a reduction in CB activity. Trial registration number: ReBEC registry (RBR-55n74zm). Stage: pre-results.

The Utilization, Expenditure, and Price of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in the US Medicaid Programs: Trends Over a 31 Year Period

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are used for several indications including hypertension. Our aim is to evaluate the utilization, expenditure, and drug price of ACEIs and ARBs in the US Medicaid population.

METHODS

A retrospective descriptive trend analysis was conducted using Medicaid State Drug Utilization outpatient pharmacy summary files managed by the Centers for Medicare and Medicaid Services from 1991 to 2021. Study drugs included ACEIs (e.g., captopril) and ARBs (e.g., losartan). Annual reimbursement and utilization were calculated for both classes. The average reimbursement per prescription was calculated as a proxy for drug prices. Market share competition between ACEIs and ARBs was analyzed over time.

RESULTS

ACEI and ARB utilization rose by 25% from 1991 to 2021. Brand ACEIs utilization peaked in 2002 with 28 million prescriptions while brand ARBs utilization continued to increase until 2005 with over 23 million prescriptions. However, generic products took the lead and exceeded brand ACEI and ARB utilization in 2006 and 2012 respectively. Medicaid spent over $ 33.7 billion on ACEIs and ARBs over 31-year. Brand ACEIs and ARBs average prices increased sharply to $8,104 and $6,908 respectively in 2021. The total prescription market share for ACEIs was 68% compared to 32% of ARBs over the entire study.

CONCLUSION

ACEIs and ARBs utilization increased over the last 31 years. Brand utilization switched over to generic resulting in less reimbursement. The average prices of brand ACEIs and ARBs continue to increase even after generics were introduced to the market.

[Comprehensive Therapeutic Approach to Hypertension. Recommendations for Central America and the Caribbean]

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area.

Inflammation markers and the risk of hypertension in people living with HIV

Background

The incidence of hypertension is high in people living with HIV (PLWH). High-sensitivity C-reactive protein (hsCRP), systemic inflammation response index (SIRI), and neutrophil-to-monocyte ratio (NMR) are considered economic and convenient parameters that reflect the levels of inflammation in patients. Our aim was to explore whether indirect inflammation markers are associated with hypertension in PLWH.

Methods

This was a case-control study. The case group (hypertension) comprised PLWH with hypertension, and the control group (non-hypertension) comprised sex- and age-(± 3 years)-matched PLWH without hypertension. Demographic parameters, hsCRP, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune- inflammation index (SII), SIRI, lymphocyte-to-monocyte ratio (LMR), platelet-to-neutrophil ratio (PNR), platelet-to-monocyte ratio (PMR), NMR, time to HIV diagnosis, antiretroviral therapy (ART) duration, recent CD4⁺ and CD8⁺ cell counts, recent CD4⁺/CD8⁺ ratio, recent HIV viral load (HIV-RNA),and recent ART regimen were obtained from the patients' electronic medical records. A t-test or Wilcoxon rank-sum test was performed to compare differences between the two groups, and conditional logistic regression was used to analyze the risk factors of hypertension. Correlations between inflammation markers and CD4⁺ cell counts, CD8⁺ cell counts, and CD4⁺/CD8⁺ ratio were analyzed using Spearman's correlation.

Results

In the hypertension group, body mass index (BMI), hsCRP, NLR, SII, SIRI, NMR, time to HIV diagnosis, ART duration, CD4⁺ and CD8⁺ cell counts, and CD4⁺/CD8⁺ ratio, the ratio of HIV-RNA < 100 copies/mL were all higher than those in the non-hypertension group, while the PNR was lower than that in the non-hypertension group. ART duration, CD4⁺ cell counts, HIV-RNA < 100 copies/mL, hsCRP, SIRI, and NMR were positively associated with hypertensive risk in PLWH. CD8⁺ cell counts and CD4⁺/CD8⁺ ratio was negatively associated with hypertensive risk in PLWH. SIRI was negatively correlated with CD4⁺ cell counts and CD8⁺ cell counts, but positively correlated with CD4⁺/CD8⁺ ratio.

Conclusions

We identified positive associations between inflammation markers hsCRP, SIRI, NMR and hypertensive risk in PLWH. Alleviating inflammation may help control or delay the occurrence of hypertension in PLWH.

Association between trunk-to-peripheral fat ratio and renal function in elderly Japanese men: baseline data from the Fujiwara-kyo Osteoporosis Risk in Men (FORMEN) study

BACKGROUND

Central obesity as measured by waist-to-hip circumference ratio (WHR) has been reported to be associated with renal hemodynamics and function. However, the adipose component of WHR, which is a composite measure of fat mass and fat-free mass, is small, particularly in nonobese subjects. Trunk-to-peripheral fat ratio as measured using dual-energy absorptiometry (DXA) is a more precise method for evaluating central fat distribution than WHR. The present study investigated the cross-sectional association between DXA-measured trunk-to-peripheral fat ratio and estimated glomerular filtration rate (eGFR) in community-dwelling elderly Japanese men.

METHODS

Participants were 575 men aged ≥65 years at the time of the baseline survey of the second Fujiwara-kyo Osteoporosis Risk in Men (FORMEN) cohort study. Trunk-to-appendicular fat ratio (TAR) was calculated as trunk fat divided by appendicular fat (sum of arm and leg fat), and trunk-to-leg fat ratio (TLR) as trunk fat divided by leg fat.

RESULTS

eGFR values significantly decreased from the lowest to the highest quintile of TAR/TLR. After adjusting for potential confounding factors including whole-body fat, the highest quintile of both TAR and TLR showed statistically significant odds ratios for the risk of eGFR <60 ml/min/1.73 m², relative to the lowest quintile. In addition, a significant decreasing trend was observed for eGFR values from the lowest to the highest quintile of TAR/TLR after adjusting for confounding factors including whole-body fat.

CONCLUSION

Elderly men with a large trunk-to-peripheral fat ratio tended to have a lower eGFR. This association occurred independently of that between whole-body fat and eGFR.

Effect of renin-angiotensin-aldosterone system inhibitors on survival outcomes in cancer patients treated with immune checkpoint inhibitors: a systematic review and meta-analysis

Background

Effect of renin-angiotensin-aldosterone system inhibitors (RAASIs) in combination with immune checkpoint inhibitors (ICIs) on prognoses in cancer patients remains controversial. This study systematically evaluated the effect of RAASIs on survival outcomes in cancer patients receiving ICIs treatment and provided an evidence-based reference for the rational use of RAASIs and ICIs combination therapy in clinical practice.

Methods

Studies evaluating the prognosis of RAASIs-used versus RAASIs-free in cancer patients receiving ICIs treatment from inception to 1 November 2022 were retrieved by searching PubMed, Cochrane Library, Web of Science, Embase, and major conference proceedings. Studies in English reporting hazard ratios (HRs) with 95% confidence intervals (CIs) for overall survival (OS) and/or progression-free survival (PFS) were included. Statistical analyses were conducted using the software Stata 17.0.

Results

A total of 12 studies containing 11739 patients were included, comprising ~4861 patients in the RAASIs-used and ICIs-treated group and ~6878 patients in RAASIs-free and ICIs-treated group. The pooled HR was 0.85 (95%CI, 0.75-0.96; P = 0.009) for OS and 0.91 (95%CI, 0.76-1.09; P = 0.296) for PFS, indicating a positive effect of RAASIs concomitant with ICIs on cancer patients. This effect was observed especially in patients with urothelial carcinoma (HR, 0.53; 95%CI, 0.31-0.89; P = 0.018) and renal cell carcinoma (HR, 0.56; 95%CI, 0.37-0.84; P = 0.005) on OS.

Conclusion

Concomitant use of RAASIs and ICIs enhanced the efficacy of ICIs and this combination regimen was associated with significantly improved OS and a trend towards better PFS. RAASIs can be considered as adjuvant drugs when hypertensive patients receive ICIs treatment. Our results provide an evidence-based reference for the rational use of the RAASIs and ICIs combination therapy to improve the efficacy of ICIs in clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022372636; https://inplasy.com/, identifier INPLASY2022110136.

Beta-Blockers in the Prevention and Treatment of Ischemic Heart Disease: Evidence and Clinical Practice

Coronary artery disease (CAD) is the most prevalent cardiovascular disease characterized by atherosclerotic plaque buildup that can lead to partial or full obstruction of blood flow in the coronary arteries. Treatment for CAD involves a combination of lifestyle changes, pharmacologic therapy, and modern revascularization procedures. Beta-adrenoceptor antagonists (or beta-blockers) have been widely used for decades as a key therapy for CAD. In this review, prior studies are examined to better understand beta-adrenoceptor antagonist use in patients with acute coronary syndrome, stable coronary heart disease, and in the perioperative setting. The evidence for the benefit of beta-blocker therapy is well established for patients with acute myocardial infarction, but it diminishes as the time from the index cardiac event elapses. The evidence for benefit in the perioperative setting is not strong.

The Interaction Between Age and Risk Factors for Diabetes and Prediabetes: A Community-Based Cross-Sectional Study

OBJECTIVE

This study aimed to investigate the interaction between age groups and risk factors for diabetes and prediabetes in Shanghai communities and to identify the effect of age on other risk factors for diabetes and prediabetes.

METHODS

This study recruited 3540 participants with undiagnosed diabetes or prediabetes in 14 communities in Shanghai from February to August 2019. All participants underwent a comprehensive examination, including filling out a detailed questionnaire, physical examination, 75 g oral glucose tolerance test, and blood sample collection. In addition, logistic regression was used to analyze the interaction between age and risk factors for prediabetes and diabetes.

RESULTS

The statistical analysis included 2776 people. In this study, the prevalence of diabetes and prediabetes were 15.1% and 52.3%, respectively. The prevalence of diabetes and prediabetes is higher in the elderly than in the middle-aged group. Among the risk factors for diabetes, overweight was associated with higher age (P-interaction 0.028). In addition, among the risk factors for prediabetes, a high level of education was associated with higher age (P-interaction 0.039) and elevated serum cholesterol level was associated with lower age (P-interaction 0.019).

CONCLUSION

This study confirmed an interaction between age and other influencing factors, which may be important in explaining differences in risk factors for diabetes and prediabetes in the middle-aged and elderly populations. Community health facilities can provide health guidance to people of different age groups to prevent and control prediabetes and diabetes.

Clinical observation of sacubitril valsartan sodium in the treatment of resistant hypertension: A randomized clinical trial

Objective

To investigate the effectiveness and safety of sacubitril valsartan sodium in the treatment of resistant hypertension (RH).

Methods

This study is a single-center, prospective, randomized controlled study. According to the inclusion and exclusion criteria, patients with RH who met the criteria were screened, and all patients adjusted their drug treatment (valsartan 80 mg, amlodipine 5 mg, and hydrochlorothiazide 12.5 mg). After 4 weeks of drug elution, the random envelope method was used for random grouping. The treatment group took sacubitril valsartan sodium 200 mg, amlodipine 5 mg, hydrochlorothiazide 12.5 mg, and the control group took valsartan 80 mg, amlodipine 5 mg, and hydrochlorothiazide 12.5 mg for 8 weeks. The 24 h ambulatory blood pressure (BP) and the echocardiography index using the office sphygmomanometer were observed in the patients.

Results

A total of 100 patients with RH were included in the two groups, with 50 cases in each group. There were no significant differences in sex, age, or comorbid diseases between the two groups. During the 8-week follow-up, the office BP of the research group were significantly decreased (24.78/17.86 mmHg) compared with those of the control group. In the research group the 24 h average BP, daytime average BP, and nighttime average BP were 144.84/79.82, 147.10/82.06, and 138.67/76.31 mmHg at baseline, and reduced to 128.96/73.32, 131.50/74.94, and 122.11/69.27 mmHg at week 8, which were significantly decreased (P < 0.05 or P < 0.01), and the left ventricular ejection fraction was significantly increased (P < 0.05), compared with the control group.

Conclusion

Sacubitril valsartan sodium can effectively reduce BP and improve cardiac function in RH.

Nomogram based on clinical features at a single outpatient visit to predict masked hypertension and masked uncontrolled hypertension: A study of diagnostic accuracy

Patients with masked hypertension (MH) and masked uncontrolled hypertension (MUCH) are easily overlooked, and both cause target organ damage. We propose a prediction model for MH and MUCH patients based on clinical features at a single outpatient visit. Data collection was planned before the index test and reference standard were after. Thus, we retrospectively collect analyzed 804 subjects who underwent ambulatory blood pressure monitoring (ABPM) at Renmin Hospital of Wuhan University. These patients were divided into normotension/controlled hypertension group (n = 121), MH/MUCH (n = 347), and sustained hypertension (SH)/sustained uncontrolled hypertension group (SUCH) (n = 302) for baseline characteristic analysis. Models were constructed by logistic regression, a nomogram was visualized, and internal validation by bootstrapping. All groups were performed according to the definition proposed by the Chinese Hypertension Association. Compared with normotension/controlled hypertension, patients with MH/MUCH had higher office blood pressure (BP) and were more likely to have poor liver and kidney function, metabolic disorder and myocardial damage. By analysis, [office systolic blood pressure (OSBP)] (P = .004) and [office diastolic blood pressure (ODBP)] (P = .007) were independent predictors of MH and MUCH. By logistic regression backward stepping method, office BP, body mass index (BMI), total cholesterol (Tch), high-density lipoprotein cholesterol (HDL-C), and left ventricular mass index are contained in this model [area under curve (AUC) = 0.755] and its mean absolute error is 0.015. Therefore, the prediction model established by the clinical characteristics or relevant data obtained from a single outpatient clinic can accurately predict MH and MUCH.

Design, synthesis and biological evaluation of dehydroabietic acid derivative as potent vasodilatory agents

Using dehydroabietic acid as the lead compound for structural modification, 25 dehydroabietic acid derivatives were synthesized. Among them, compound D1 not only showed the strongest relaxation effect on the aortic vascular ring in vitro (Emax = 99.5 ± 2.1%, EC50 = 3.03 ± 0.96 µM), but also significantly reduced systolic and diastolic blood pressure in rats at a dose of 2.0 mg/kg in vivo. Next, the vascular protective effect of the best active D1 and its molecular mechanism were further investigated by HUVECs. The results showed that D1 induced endothelium-dependent diastole in the rat thoracic aorta in a concentration-dependent manner. Endothelium removal or aortic ring pretreatment with NG-nitro-l-arginine methylester (l-NAME), 1H-[1,2,4]-oxadiazolo-[4,3-a]-quinoxalin-1-one (ODQ), and tetraethylammonium (TEA) significantly inhibited D1-induced relaxation. In addition, wortmannin, KT5823, triciribine, diltiazem, BaCl2, 4-aminopyridine, indomethacin, propranolol, and atropine attenuated D1-induced vasorelaxation. D1 increased the phosphorylation of eNOS in HUVECs Furthermore, D1 attenuated the expression of TNF-α-induced cell adhesion molecules such as ICAM-1 and VCAM-1. However, this effect was attenuated by the eNOS inhibitors l-NAME and asymmetric dimethylarginine (ADMA). The findings suggest that D1-induced vasorelaxation through the PI3K/Akt/eNOS/NO/cGMP/PKG pathway by activating the KCa, Kir and KV channels or muscarinic and β-adrenergic receptors, and inhibiting the l-type Ca2+ channels, which is closely related to the hypotensive action of the agent. Furthermore, D1 exhibits an inhibitory effect on vascular inflammation, which is associated with the observed vascular protective effects.

Efficacy and safety of Songling Xuemaikang capsule for essential hypertension: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Hypertension is one of the most significant public health challenges worldwide. An increasing number of patients prefer to incorporate traditional Chinese medicine into their hypertensive care. The Songling Xuemaikang capsule (SXC), a Chinese herbal formula, is widely used in China for essential hypertension.

PURPOSE

To assess the efficacy and safety of SXC for essential hypertension.

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We conducted a systematic literature search of seven databases to identify randomized controlled trials of SXC for hypertension. The outcome measures included blood pressure parameters and patient-reported outcomes. Potential heterogeneity between the studies was resolved by subgroup and sensitivity analyses. The quality of the results was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

RESULTS

A total of 34 trials with 4306 patients were included. The results showed that SXC plus antihypertensive drugs produced a greater effect on reducing systolic blood pressure (SBP) (MD: -7.54 mmHg; 95% CI: -8.92, -6.17; p < 0.00001), diastolic blood pressure (DBP) (MD: -6.42 mmHg; 95% CI: -7.54, -5.29; p < 0.00001), 24-hour SBP (MD: -6.88 mmHg; 95% CI: -8.36, -5.39; p < 0.00001), and 24-hour DBP (MD: -4.31 mmHg; 95% CI: -6.55, -2.07; p = 0.0002) and improving hypertensive symptoms (SMD: -1.09; 95% CI: -1.34, -0.84; p < 0.00001) than antihypertensive drugs alone. SXC monotherapy was less effective than antihypertensive drugs for 24-hour SBP reduction (MD: 2.07 mmHg; 95% CI: 0.19, 3.96; p = 0.03). No significant difference was observed in the incidence of adverse events between the SXC and control groups.

CONCLUSION

SXC is beneficial for essential hypertension; it can lower BP, improve hypertensive symptoms and is well tolerated.

Complications of Vascular Disease

Vascular diseases and their sequelae increase perioperative risk for noncardiac surgical patients. In this review, the authors discuss vascular diseases, their epidemiology and pathophysiology, risk stratification, and management strategies to reduce adverse perioperative outcomes.

Clinicopathological characteristics and risk factors in elderly patients with biopsy-proven IgA nephropathy

BACKGROUND

Immunoglobulin A nephropathy (IgAN) has been well studied among young people, but few data on clinicopathological characteristics, treatment response and outcomes for elderly IgAN patients are available.

METHODS

A cohort study of elderly IgAN patients was performed. The combined endpoints of renal outcome were a 50% decline in eGFR compared with the time of renal biopsy, end-stage kidney disease and/or death. Risk factors associated with poor renal outcomes were then determined. The benefits of immunosuppressant therapies were also evaluated by Kaplan-Meier survival curve analysis.

RESULTS

This study ultimately included 126 elderly patients with IgAN. Comparison between the endpoint and non-endpoint groups indicated that patients with poor outcomes had more severe clinical features, such as worse kidney function, severe hematuria and lower albumin levels. Cox regression analysis indicated that age (HR 1.15, 95% CI 1.02-1.29, p = 0.021), male gender (HR 9.71, 95% CI 1.00-97.56, p = 0.050), and urine red blood cells (HR 1.003, 95% CI 1.000-1.006, p = 0.029) were independent risk factors for poor renal outcome in elderly IgAN patients. To explore possible reasons accounting for the predictive value of age and sex, patients were divided into two groups based on these two variables. Patients in the geriatric group had lower serum albumin, estimated glomerular filtration rate, hemoglobin and aspartate aminotransferase levels than those in the quinquagenarian group. Male patients tended to have higher hemoglobin, higher alanine aminotransferase, and lower triglycerides and cholesterol levels than female patients. To investigate different treatment responses, patients were classified into two groups depending on treatment strategies (renin-angiotensin system inhibitors and immunosuppressive therapy), and the survival analysis indicated no significant difference in kidney outcome between the two groups (p > 0.05). This result still holds after adjusting for age, sex, eGFR, hematuria, and proteinuria.

CONCLUSION

Advanced age, male, and hematuria might be independently associated with poor kidney outcomes in elderly patients with IgAN. Immunosuppressive therapy might confer no overall benefit to older IgAN patients.

Pre-microRNAs single nucleotide variants (rs3746444 A > G and rs2910164 C > G) increase the risk of ischemic stroke in the Egyptian population: a case–control study

Background

Ischemic stroke (IS) is the most leading cause of morbidity and mortality worldwide. Micro RNA (miRNA) genetic variants have been identified as a part of IS non-modifiable risk markers. This study aims to identify the possible association of rs2910164 C > G of pre-miRNA-146a and rs3746444 A > G of pre-miRNA-499 with increased IS risk. C-reactive protein (CRP) was studied as one of the mediators of the genetic disturbance in IS. The study included 100 patients with atherosclerotic IS and 100 age and sex matched healthy controls with more than one risk factor for IS. Variants were evaluated by the real-time polymerase chain reaction technique using TaqMan probes. CRP levels were assayed by immunoturbidimetry method on COBAS analyzer.

Results

Regarding rs3746444 A > G, the G allele, and its containing genotypes (GG and GG + AG) were associated with high IS incidence. Increased CRP levels were found to induce IS by GG and GG + AG genotypes, with a cut value of 7.5 mg/ L in differentiation between AA genotype and GG + AG genotypes. Combining the G allele of rs3746444 A > G with either G or C allele of rs2910164 C > G had enhanced the risk. For rs2910164 C > G, the G allele, and the combined GG + GC genotypes were associated with IS risk elevation with no correlation to CRP levels.

Conclusion

The G involving genetic variants of rs3746444 A > G and rs2910164 C > G were associated with an enhanced IS risk. CRP showed higher levels in GG and AG genotypes of rs3746444 with no relation to rs2910164 genotypes.

Adherence to antihypertensive treatment during the COVID-19 pandemic: findings from a cross-sectional study

BACKGROUND

Nonadherence to antihypertensive treatment is one of the main causes of the lack of blood pressure (BP) control. The coronavirus disease (COVID-19) pandemic imposes substantial social restriction impairing the medical care routine, which may influence adherence to the antihypertensive treatment. To assess the rate of nonadherence to antihypertensive drug treatment during the COVID-19 pandemic.

METHODS

This is a cross-sectional study evaluating hypertensive adult patients from a tertiary outpatient clinic. From March to August 2020, patients were interviewed by telephone during the social distancing period of the COVID-19 pandemic. We evaluated biosocial data, habits, attitudes, and treatment adherence using the 4-item Morisky Green Levine Scale during the social distancing. Uncontrolled BP was defined by BP ≥ 140/90 mmHg. Clinical and prescription variables for drug treatment were obtained from the electronic medical record. We performed a multivariate analysis to determine the predictors of nonadherence to BP treatment.

RESULTS

We studied 281 patients (age 66 ± 14 years, 60.5% white, 62.3% women, mean education of 9.0 ± 4 years of study). We found that 41.3% of the individuals reported poor adherence to antihypertensive drug treatment and 48.4% had uncontrolled BP. Subsample data identified that adherence was worse during the pandemic than in the previous period. The variables that were independently associated with the nonadherence during the pandemic period were black skin color (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.46-4.68), and intermittent lack of access to antihypertensive medication during the pandemic (OR, 2.56; 95% CI, 1.11-5.89).

CONCLUSIONS

Beyond traditional variables associated with poor adherence, the lack of availability of antihypertensive medications during the study underscore the potential role of pandemic on hypertension burden.

Combined influence of sedentary behaviours and chronic pain on depressive symptoms in older Korean adults with hypertension

AIMS

Depressive symptoms in hypertensive patients are linked to poor adherence to treatment. Sedentary behaviours and chronic pain can increase blood pressure and depressive symptoms, respectively. However, the impact of their coexistence on depressive symptoms in older adults with hypertension has not yet been investigated. This study aimed to identify the combined influence of sedentary behaviours and chronic pain on depressive symptoms in older adults with hypertension in Korea.

METHODS AND RESULTS

This cross-sectional study used data from the sixth Korea National Health and Nutrition Examination Survey from January to December 2014. The survey adopted multistage stratified sampling by geographical region, gender, and age. For the data analysis, a total of 573 patients with hypertension aged 65 years or older were included. Approximately, 61.0% of depressed older patients had both sedentary behaviours and chronic pain compared with patients without depressive symptoms. In multivariate logistic regression analysis, compared with patients without either sedentary behaviours or chronic pain, older adults with hypertension who presented both sedentary behaviours, and chronic pain had the highest risk of depressive symptoms (odds ratio = 13.86, 95% confidence interval = 5.87-32.71; P < 0.001).

CONCLUSION

Coexistence of sedentary behaviours and chronic pain in older hypertensive patients may lead to depressive symptoms. Evaluating both sedentary behaviours and chronic pain when assessing depressive symptoms in patients with hypertension would be beneficial in planning a patient-centred approach for controlling blood pressure. More prospective cohort studies with larger samples are required to identify the causal relationships.

Seasonal variation of ambulatory blood pressure in Chinese hypertensive adolescents

BACKGROUND

Blood pressure (BP) exhibits seasonal variation with lower levels at higher temperatures and vice versa. This phenomenon affects both sexes and all age groups. So far, only a few research studies have investigated this condition in adolescents and none of them were based on hypertensive population or ever applied ambulatory blood pressure monitor (ABPM). Therefore, we carried out the first study that used ABPM to record seasonal variation of blood pressure in hypertensive adolescents.

METHODS

From March 2018 to February 2019, 649 ABPMs from hypertensive adolescents between 13 and 17 years who were referred to wear an ABPM device in Beijing and Baoding were extracted. Seasonal change in ambulatory BP value, dipping status, and prevalence of different BP phenotypes were analyzed and compared.

RESULTS

Mean age of participants was 14.9 ± 1.5 years and 65.8% of them were boys. Of the participants, 75.3% met the criteria of overweight or obesity. From summer to winter, average 24-hour, day-time, and night-time BP showed significant rise, which was 9.8/2.8, 9.8/3.0, and 10.9/3.4 mmHg, respectively. This seasonal effect on BP was not dependent on the obesity degree. In addition, higher prevalence of nondippers and risers existed in winter while white coat hypertension was more frequent in warmer seasons.

CONCLUSION

Hypertensive adolescents showed evident seasonal change in their ABPM results, which was featured by elevated BP level and more frequent abnormal dipping patterns in winter. On the contrary, higher prevalence of white coat hypertension was found in warmer seasons. Physicians should take seasonal variation into consideration when managing adolescent hypertension.

Association between serum Klotho concentration and all-cause and cardiovascular mortality among American individuals with hypertension

BACKGROUND AND AIMS

Evidence indicates that serum Klotho concentration is associated with mortality in patients with chronic kidney disease (CKD). However, evidence on this association among people with hypertension is scarce. Therefore, we aimed to examine the association between serum Klotho concentration and all-cause and cardiovascular mortality in American patients with hypertension.

METHODS AND RESULTS

We included 6,778 participants with hypertension from the National Health and Nutrition Examination Survey (NHANES) 2007-2014. A Cox proportional hazard model was used to compute the hazard ratios (HRs) and 95% confidence intervals (CIs). The correlation between serum Klotho concentration and mortality was determined using restricted cubic spline and piecewise linear regression analyses. During 36,714 person-years of follow-up, 575 deaths were documented. Lower serum Klotho concentration was associated with increased all-cause mortality, but not cardiovascular mortality after multivariate adjustment. According to spline analysis, the correlation between serum Klotho concentration and all-cause mortality was non-linear (P < 0.001), and the threshold value was 574 pg/mL. The HR below the threshold point was 0.79 (95% CI: 0.67-0.93); no significant difference was found above the threshold point.

CONCLUSION

Higher serum Klotho concentration was associated with lower all-cause mortality, but not cardiovascular mortality in patients with hypertension with or without chronic renal impairment.

Associations of Inflammation with Risk of Cardiovascular and All-Cause Mortality in Adults with Hypertension: An Inflammatory Prognostic Scoring System

BACKGROUND

Inflammation is one of the major pathways in the progression of hypertension (HTN), and the related inflammatory markers have demonstrated certain predictive values. The current study aimed to integrate these markers to construct an inflammatory prognostic scoring (IPS) system and to assess the prognostic values of IPS in patients with HTN.

METHODS

A total of 9846 adult participants with HTN from NHANES 1999-2010 were enrolled and followed up. Demographic characteristics and the related laboratory results for the 12 inflammatory markers were collected. LASSO-COX regression, Kaplan-Meier, restricted cubic spline COX regression (RCS), receiver operator characteristic curve (ROC), and random survival forests (RSF) analysis were applied to explore the values of individual and IPS parameters.

RESULTS

At the census date of follow-up, 2387 (24.2%) were identified as all-cause deaths and 484 (4.9%) as cardiovascular deaths. All inflammatory markers showed certain prognostic values. Then, based on the LAASO analysis, LDH, ALP, LYM, NLR, MLR, SIRI, and RDW were included in the construction of the IPS system. The higher IPS had significantly worse long-term prognosis in Kaplan-Meier analysis (p log-rank <0.001). Also, IPS remained an independent prognosticator compared to the lowest quartile (All p for trend <0.001), and the ROC showed satisfactory values in the long-term prognosis of both cardiovascular and all-cause mortality. RCS further showed a linear association of IPS with cardiovascular mortality and all-cause mortality (p for non-linearity >0.05). Two different algorithms of RSF, variable importance and minimal depth, to evaluate the prognostic importance showed that IPS was the best in survival prediction.

CONCLUSION

Our results highlight that a higher IPS (system integrating the inflammatory markers) was associated with the increased risk of cardiovascular and all-cause mortality in patients with HTN, suggesting that IPS is a useful method for risk stratification in HTN.

Domestic Physical Activity and New-Onset Hypertension: A Nationwide Cohort Study in China

BACKGROUND

The relation of domestic physical activity with hypertension remains uncertain. We aimed to evaluate the prospective relation of domestic physical activity and new-onset hypertension among Chinese males and females.

METHODS

A total of 9254 adults who were free of hypertension at baseline were enrolled from the China Health and Nutrition Survey. Data on domestic physical activity were obtained by using self-reported questionnaires, and calculated as metabolic equivalent task (MET)-hours/week. Metabolic equivalent task-hours/week may account for both intensity and time spent on activities. The study outcome was new-onset hypertension, defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or diagnosed by physician or under antihypertensive treatment during the follow-up.

RESULTS

A total of 2892 participants developed hypertension during 81996 person-years of follow-up. Overall, there were reversed J-shaped associations between the domestic physical activity and new-onset hypertension in both males and females (both P values for nonlinearity < .001). Consistently, when domestic physical activity was assessed as categories (<10, 10 -< 20, 20 -< 30, 30 -< 40, 40 -< 50, 50 -< 60, 60 -<70, 70 -< 80, 80 -< 90, 90 -< 100, ≥100 MET-hours/week), compared with those with domestic physical activity < 10 MET-hours/week, the lower and similar risks of new-onset hypertension were found in participants with domestic physical activity 30 -< 90 MET-hours/week in both males and females.

CONCLUSIONS

Moderate domestic physical activity was associated with a lower risk of new-onset hypertension among both males and females.

Impact of various night-time period definitions on nocturnal ambulatory blood pressure

BACKGROUND

Several definitions of night-time BP exist for the calculation of nocturnal blood pressure (BP) based on 24-h BP measurements. How much these methods differ regarding the resulting nocturnal blood pressure values, under which circumstances these differences become clinically meaningful, and under which circumstances diary-adjusted measurements should be used preferentially remains uncertain.

METHODS

Data of 512 24-h BP recordings were analysed regarding differences in nocturnal BP based on three alternative definitions of night-time: 2300-0700 h, 0100-0500 h, and diary-adjusted measures.

RESULTS

Mean systolic nocturnal BP between 2300-0700 h was 2.5 mmHg higher than between 0100 and 0500 h and 1.6 mmHg higher than diary adjusted estimates. Up to 38.3% of individuals showed BP differences of more than 5 mmHg when comparing temporal definitions of night-time, resulting in significant proportions of individuals being re-classified as hypertensive. When diary-derived sleeping patterns differed by less than 2 h from the 2300 to 0700 h fixed time definition, mean BP discrepancies remained below 3 mmHg. Absolute time discrepancies between diary and 2300-0700 h fixed time definition of 2-4, 4-8 or at least 8 h led to SBP/DBP differences of 4.1/3.1, 6.8/6.1, and 14.5/9.1mmHg, respectively.

CONCLUSION

Average differences of nocturnal BP between varying definitions in study/cohort data are small and would be of limited relevance in many settings. However, substantial differences can be observed in individual cases, which may affect clinical decision-making in specific patients. In patients whose sleeping patterns differs by more than 2 h from defined fixed night-times, diaries should be used for adjustment.

Association of Cardiovascular Health Score Trajectory With Incident Myocardial Infarction in Hypertensive Patients

BACKGROUND

The association between changes in cardiovascular health score (CHS) over time and myocardial infarction (MI) risk in hypertensive patients remains unclear.

METHOD

This was a prospective study comprising 17 374 hypertensive patients from the Kailuan study cohort who underwent 3 surveys and were identified to be free of MI, stroke, or cancer from 2006 to 2010. CHS consisted of 7 cardiovascular health metrics (plasma glucose, total cholesterol, blood pressure, smoking, body mass index, physical activity, salt intake), ranging from 0 (worst) to 13 (best) in the study. CHS trajectories were developed during 2006 to 2010 to predict the MI risk from 2010 to 2020. Additionally, the Cox proportional hazard model was established to calculate the hazard ratio and 95% CI of incident MI in different trajectory groups.

RESULT

This study identified the 5 CHS trajectories from 2006 to 2010: low-stable (n=1161; range, 4.7-4.5), moderate-decreasing (n=3928; decreased from 6.9 to 6.0), moderate-increasing (n=1014; increased from 5.6 to 7.8), high-stable I (n=7940; range, 8.1-8.2), and high-stable II (n=3331; range, 9.2-9.7). During the median follow-up of 10.04 years, 288 incident MI cases were identified. After adjusting for potential confounders, compared with low-stable group, the hazard ratio and 95% CI of MI were 0.24 (0.15-0.40) for high-stable II, 0.36 (0.24-0.54) for high-stable I, 0.46 (0.25-0.83) for moderate-increasing, and 0.61 (0.41-0.90) for moderate-decreasing, respectively.

CONCLUSIONS

In hypertensive patients, high-stable CHS or improvement in CHS is associated with a lower risk of incident MI, when compared with low-stable CHS trajectory over time.

Headache Disorders: Does Pain Affect Blood Pressure?

PURPOSE OF REVIEW

The perspective that pain corresponds to elevated blood pressure is overly simplistic. Our objective is to investigate and debunk misconceptions regarding the effect of pain on blood pressure.

RECENT FINDINGS

While pain can increase blood pressure in the acute setting, prolonged pain and migraine's effect on blood pressure varies and can result in lower-than-expected blood pressure. Therefore, attributing pain as a sole source of elevation of blood pressure may lead to delays in diagnosing hypertension. Based on limited studies available, comorbid pain and chronic hypertension have a higher concurrence than in the general population. We will review current literature to investigate the effect of pain on blood pressure and prevalence of hypertension in chronic pain sufferers. A better understanding of pain's effect on blood pressure will help practitioners appropriately diagnose and counsel patients without disproportionately attributing high blood pressure to pain.

Traditional Chinese medicine for the treatment of diabetic kidney disease: A study-level pooled analysis of 44 randomized controlled trials

Background: Accumulating evidence suggests that traditional Chinese medicine (TCM) has significant effects on reducing 24-h urinary protein (24-h UPRO) and improves renal function indices. The current level of evidence-based medicine is still not enough due to the limitation of clinical center size and sample size. Objective: We aimed to update the current evidence on the efficacy of TCM in the treatment of diabetic kidney disease (DKD). Methods: PubMed, Embase, the Cochrane Library, and SinoMed were searched to identify randomized controlled trials (RCTs) comparing the clinical efficacy of TCM combined with Western medicine with that of Western medicine alone for the treatment of DKD. The main outcome measure was 24-h UPRO. The secondary outcomes were serum creatinine (Scr), blood urea nitrogen (BUN), glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), total cholesterol (TC), and triglyceride (TG). Meta-analyses were performed using random-effects models. The revised Cochrane risk-of-bias tool was used to assess the risk of bias. Results: A total of 44 RCTs with 3,730 participants were included. The summary estimates showed that compared with Western medicine alone, TCM combined with Western medicine significantly improved 24-h UPRO [standardized mean difference (SMD) -1.10, 95% confidence interval (CI) -1.45 to -0.74]. Moreover, TCM combined with Western medicine significantly reduced the levels of other renal function indices, including Scr (SMD -1.25, 95% CI: -1.69 to -0.81) and BUN (SMD -0.75, 95% CI: -1.10 to -0.40). TCM combined with Western medicine also showed greater benefits in reducing the levels of FBG (SMD -0.31, 95% CI: -0.47 to -0.15) and HbA1c (SMD -0.62, 95% CI: -0.89 to -0.36) in patients with DKD. In addition, superior effects on the lipid profile were noted in the TCM combined with Western medicine group in terms of TG (SMD -1.17, 95% CI: -1.76 to -0.59) and TC (SMD -0.95, 95% CI: -1.43 to -0.47). The risk of bias could have resulted from selective reports, unclear randomization methods, unblinded assignments, and some missing data. Conclusion: The results of this meta-analysis suggest that TCM combined with Western medicine has significant effects on reducing 24-h UPRO and improves renal function indices and lipid profiles compared with Western medicine alone for DKD. However, the results should be interpreted with caution due to the risk of bias of the included trials. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=213199], identifier [CRD: 42020213199].

Giant Renal Artery Aneurysm With Hydronephrosis and Severe Atrophy of the Renal Parenchyma: Case Report and Literature Review

Background:

It is known that renal artery aneurysms may lead to hydronephrosis, but utter shrinking of the renal parenchyma due to a giant renal artery aneurysm has not yet been reported. This report is of an 88-year-old woman with resistant hypertension, hydronephrosis, and renal atrophy due to a giant saccular aneurysm of the left renal artery.

Case Report:

The patient presented with 2 weeks of worsening low back pain on the left side and resistant hypertension. The discovery of a left flank mass on physical examination, lead to the ultrasound detection of a para-aortic mass and a cyst-like partially septate structure replacing the left kidney. Thereafter, a contrast-enhanced computed tomography scan revealed a giant saccular aneurysm of the left renal artery causing severe hydronephrosis with severe parenchymal thinning. The extreme parenchymal atrophy of the left kidney made it an unlikely culprit of resistant hypertension, therefore the interventional radiologist considered that an endovascular attempt to re-establish the patency of the left renal artery would have scarcely produced any benefit. Given the advanced age of the patient, the vascular surgeon considered that risk of a nephrectomy outweighed the benefit, in agreement with the patient’s unwillingness to accept an invasive intervention. Therefore, she was discharged with blood pressure lowering and pain relief medication and was thereafter lost to follow-up.

Conclusion:

To our knowledge, this is the most severe kidney parenchymal shrinking in association with a renal artery aneurysm reported in the literature.

Effectiveness of Standard vs Enhanced Self-measurement of Blood Pressure Paired With a Connected Smartphone Application: A Randomized Clinical Trial

Importance

Self-measured blood pressure (SMBP) with commercially available connected smartphone applications may help patients effectively use SMBP measurements.

Objective

To determine if enhanced SMBP paired with a connected smartphone application was superior to standard SMBP for blood pressure (BP) reduction or patient satisfaction.

Design, Setting, and Participants

This randomized clinical trial was conducted among 23 health systems participating in PCORnet, the National Patient-Centered Clinical Research Network, and included patients who reported having uncontrolled BP at their last clinic visit, a desire to lower their BP, and a smartphone. Enrollment and randomization occurred from August 3, 2019, to December 31, 2020, which was followed by 6 months of follow-up for each patient. Analysis commenced shortly thereafter.

Interventions

Eligible participants were randomly assigned to enhanced SMBP using a device that paired with a connected smartphone application (enhanced) or a standard device (standard). Participants received their device in the mail, along with web-based educational materials and phone-based support as needed. No clinician engagement was undertaken, and the study provided no special mechanisms for delivering measurements to clinicians for use in BP management.

Main Outcomes and Measures

Reduction in systolic BP, defined as the difference between clinic BP at baseline and the most recent clinic BP extracted from electronic health records at 6 months.

Results

Enrolled participants (1051 enhanced [50.0%] vs 1050 standard [50.0%]; 1191 women [56.7%]) were mostly middle-aged or older (mean [SD] age, 58 [13] years), nearly a third were Black or Hispanic (645 [31%]), and most were relatively comfortable using technology (mean [SD], 4.1 [1.1] of 5). The mean (SD) change in systolic BP from baseline to 6 months was -10.8 (18) mm Hg vs -10.6 (18) mm Hg (enhanced vs standard: adjusted difference, -0.19 mm Hg; 95% CI, -1.83 to 1.44; P = .81). Secondary outcomes were mostly null, except for documented attainment of BP control to lower than 140/<90 mm Hg, which occurred in 32% enhanced vs 29% standard groups (odds ratio, 1.15; 95% CI, 1.01-1.34). Most participants were very likely to recommend their SMBP device to a friend (70% vs 69%).

Conclusions and Relevance

This randomized clinical trial found that enhanced SMBP paired with a smartphone application is not superior to standard SMBP for BP reduction or patient satisfaction.

Trial Registration

ClinicalTrials.gov Identifier: NCT03796689.

Hypertension in Cancer Survivors: A Review of the Literature and Suggested Approach to Diagnosis and Treatment

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among cancer survivors. Hypertension, which is common among cancer survivors with a prevalence of greater than 70% by age 50, potentiates the risk for CVD in a more than additive fashion. For example, childhood cancer survivors who develop hypertension may have up to a 12 times higher risk for heart failure than survivors who remain normotensive. Studies have shown that mild valvular disease (28% incidence), cardiomyopathy (7.4%), arrhythmias (4.6%), and coronary artery disease (3.8%) are among the most common CVDs in childhood cancer survivors. Among adolescent and young adult cancer survivors, the most common reasons for cardiovascular-related hospital admission are venous/lymphatic disease (absolute excess risk 19%), cardiomyopathy and arrhythmia (15%), hypertension (13%), and ischemic heart disease (12%). In addition, cancer therapies can increase the risk for hypertension and CVD. Therefore, early detection and treatment of hypertension is essential to reducing cardiovascular morbidity and mortality among survivors.

METHODS

We present a literature review, which identified over 20 clinical trials, systemic reviews, and meta-analyses (13 clinical trials, 8 systemic reviews or meta-analyses) by searching PubMed, Google Scholar, and the Cochrane Library for relevant articles addressing hypertension in cancer survivors.

RESULTS

Although our understanding of the complex relationship between cancer therapies and CVD has grown significantly over the past 2 decades, there remain several gaps in knowledge when specifically addressing CVD in the survivor population. This review provides an up-to-date survivor-centered approach to the screening and treatment of hypertension, which considers survivor-specific cardiovascular risk, applies guideline directed therapies when appropriate, screens for survivor-specific factors that may influence antihypertensive medication selection, and finally considers the prohypertensive mechanisms of antineoplastic agents as a potential target for antihypertensive medications.

CONCLUSIONS

Screening for and treating hypertension among survivors can promote cardiovascular health in this vulnerable population.

Underuse of lifestyle recommendations in hypertension management in France: The Esteban study

Lifestyle recommendations are first‐line elements in the management of arterial hypertension. This cross‐sectional study aimed to analyze the level to which lifestyle recommendations are used in hypertension management in France, using data from the Esteban study, which was implemented by Santé Publique France, France's public health agency, from 2014 to 2016 on a representative sample of the French population. The study sample comprised 440 adult Esteban participants who were aware they had hypertension and were aged 18–74 years old. The main outcomes were the proportion of participants who received lifestyle recommendations in their hypertension management plan, and the proportion of recommendations according to the three following dimensions: physical activity, weight loss, and changes in diet. Over half (57.0%) of the 440 participants declared they did not receive lifestyle recommendations as part of their hypertension management plan in the year preceding the study. Of these, 39.0% did not receive pharmacological treatment either. Physical activity was recommended to 31.8% of sedentary participants and weight loss to 26.8% of participants with overweight or obesity. One‐fifth of the study sample (20.1%) received dietary recommendations. Of these, 69% and 10.7% were advised to limit their salt and alcohol intake, respectively. Lifestyle interventions are too rarely recommended in hypertension management plans in France. Adherence to lifestyle recommendations needs in‐depth discussion not only at the time of diagnosis but also throughout follow‐up.

Association of the Estimated Pulse Wave Velocity with Cardio-Vascular Disease Outcomes among Men and Women Aged 40-69 Years in the Korean Population: An 18-Year Follow-Up Report on the Ansung-Ansan Cohort in the Korean Genome Environment Study

The estimated pulse wave velocity (ePWV) can predict adverse cardiovascular disease (CVD) outcomes in patients with increased CVD risks. However, data on its predictive capacity for CVD outcomes in the general population are limited. This study aimed to investigate the association between the ePWV and CVD outcomes among Korean adults. Ten thousand thirty patients aged 40–69 years from the Ansung–Ansan cohort in a prospective community-based cohort study were followed up for over 18 years. The ePWV was categorized into quartiles. Cox proportional hazard models were used to estimate the risk of cardiovascular (CV) mortality and CVD outcomes (composites of CV mortality, myocardial infarction, coronary artery disease, stroke, heart failure, and peripheral artery disease). The incidence of CV mortality and CVD outcomes was 7.0% and 22.1% in the fourth (highest) ePWV quartile and 0.1% and 4.5% in the first (lowest) quartile, respectively. After relevant covariate adjustments, the patients in the fourth quartile showed a significantly higher CV mortality risk (hazard ratio (HR), 7.57; 95% confidence interval (CI), 1.83–31.25). The patients in the third and fourth quartiles had higher CVD outcome risks (third: HR, 1.61; 95% CI, 1.19–2.16; fourth: HR, 1.56; 95% CI, 1.05–2.31) than those in the first quartile. This association was more clearly observed among women than among men. An elevated ePWV is associated with CV mortality and CVD outcomes. The ePWV is expected to serve as a potential marker for identifying high-risk groups for CVD events.

Inverse association of serum carotenoid levels with prevalence of hypertension in the general adult population

Carotenoid levels are inversely associated with blood pressure (BP). This study focused on the effects of individual and combined serum carotenoids on BP and hypertension, which have not been established to date. Data from National Health and Nutrition Examination Survey (NHANES) 2001–2006 were analyzed in this cross-sectional study. Multivariate logistic, linear, and weighted quantile sum (WQS) regression analyses were applied to explore the associations of six serum carotenoids (α-carotene, β-cryptoxanthin, lutein/zeaxanthin, trans-lycopene, trans-β-carotene, and cis-β-carotene), individually and in combination, with BP/hypertension. The linearity of correlations was further assessed using restricted cubic spline (RCS) regression. A total of 11,336 adults were included for analysis. Data from multivariate models showed that all six carotenoids were independently and negatively associated with both systolic blood pressure (SBP) and diastolic blood pressure (DBP; all p < 0.05). Compared to the first quartile, the fourth quartile of α-carotene (odds ratio [OR] = 0.64 [0.52–0.77]), β-cryptoxanthin (OR = 0.74 [0.60–0.90]), trans-β-carotene (OR = 0.50 [0.40–0.61]), and cis-β-carotene (OR = 0.47 [0.35–0.64]) were significantly and inversely related to hypertension (all p < 0.05). Moreover, WQS analysis revealed that the combination of all six serum carotenoids was negatively associated with BP and hypertension (all P<0.001), among which trans-β-carotene was the most significant contributor to the protective effect against hypertension (weight, 59.50%). Dose-response analyses demonstrated a linear inverse association of all carotenoids with hypertension (p for non-linearity > 0.05). Our collective findings indicate that higher levels of all six mixed serum carotenoids are correlated with decreased prevalence of hypertension, among which β-carotene exerts the most significant effect, which may provide a basis and direction for further studies.

Self-Monitoring of Blood Pressure and Feed-back Using APP in TReatment of UnconTrolled Hypertension (SMART-BP): A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Self-monitoring of blood pressure (SMBP) is a reliable method used to assess BP accurately. However, patients do not often know how to respond to the measured BP value. We developed a mobile application-based feed-back algorithm (SMBP-App) for tailored recommendations. In this study, we aim to evaluate whether SMBP-App is superior to SMBP alone in terms of BP reduction and drug adherence improvement in patients with hypertension.

METHODS

Self-Monitoring of blood pressure and Feed-back using APP in TReatment of UnconTrolled Hypertension (SMART-BP) is a prospective, randomized, open-label, multicenter trial to evaluate the efficacy of SMBP-App compared with SMBP alone. Patients with uncomplicated essential hypertension will be randomly assigned to the SMBP-App (90 patients) and SMBP alone (90 patients) groups. In the SMBP group, the patients will perform home BP measurement and receive the standard care, whereas in the SMBP-App group, the patients will receive additional recommendations from the application in response to the obtained BP value. Follow-up visits will be scheduled at 12 and 24 weeks after randomization. The primary endpoint of the study is the mean home systolic BP. The secondary endpoints include the drug adherence, the home diastolic BP, home and office BP.

CONCLUSIONS

SMART-BP is a prospective, randomized, open-label, multicenter trial to evaluate the efficacy of SMBP-App. If we can confirm its efficacy, SMBP-App may be scaled-up to improve the treatment of hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04470284.

Prescription medication use of United States military service members by therapeutic classification

Background: This cross-sectional study investigated the prevalence of, and factors associated with, filled prescription medications (FPMs) among United States (US) service members (SMs).

Methods: A stratified random sample of active duty SMs from the Air Force, Army, Marine Corps, and Navy was obtained from military workforce records. Participants (n = 26,680) completed a questionnaire on demographics, physical characteristics, and lifestyle factors and approved access to their FPM for the previous 6 months. FPMs were obtained from the military Pharmacy Data Transaction Service that included all prescription medications dispensed at military medical treatment facilities, abroad, at retail pharmacies in the US, and/or through mail-order programs.

Results: About two-thirds (65%) of SMs had ≥1 FPM in the 6 months surveillance period. Central nervous system (CNS) agents had the highest prevalence (41%), followed by anti-infective agents (20%), eye/ear/nose/throat preparations (20%), gastrointestinal drugs (18%), autonomic drugs (17%), skin and mucous membrane agents (13%), antihistamine drugs (12%), respiratory tract agents (12%) and cardiovascular drugs (9%). Among CNS agents, overall prevalence of dispensed non-steroidal anti-inflammatory drug (NSAIDs) was 30%. The odds of any FPM was independently associated with female gender, older age, higher body mass index, former tobacco use (smoking and smokeless tobacco), lower alcohol consumption, and was highest among Army, lowest among Marine Corps personnel.

Conclusion: In this sample of SMs, dispensing of prescription medication was high, especially NSAIDs, but dispensing of cardiovascular drugs was much lower compared to the general US population, likely because of the younger age and higher level of physical activity of SMs.

Differentiated effects and determinants of home blood pressure telemonitoring: lessons from a three-year cohort in Anhui Jieshou, China

BACKGROUND

Home blood pressure telemonitoring (HBPT) is witnessing rapid diffusion worldwide. Contemporary studies documented mainly short-term (6-12 month) effects of HBPT with little data about its uptake.

OBJECTIVE

This study aims to explore 3-year use and determinants of HBPT and its interactions with systolic and diastolic blood pressure (SBP/DBP) and blood pressure (BP) control rate.

METHODS

The study used HBPT records from a 3-year cohort of 5658 hypertensive patients in Anhui Jieshou, China and data from a structured household survey of a random sample (n=3005) from the cohort. The data analysis comprised: calculation and presentation, in time-line trajectories, rates of monthly active HBPT and mean SBP/DBP for overall and subgroups of patients with varied start-month SBP/DBP; and multivariable linear, logistics and percentile regression analysis using SBP/DBP, BP control rate and yearly times of HBPT as the dependent variable respectively.

RESULTS

HBPT followed mixed changes in mean monthly SBP/DBP for varied patient groups. The magnitude of changes ranged from -43 to +39 mmHg for SBP and -27 to +15 mmHg for DBP. The monthly rates of active HBPT all manifested a rapid and then slower and slower decline. When controlled for commonly researched confounders, times of HBPT in the last year were found with decreasing correlation coefficients for SBP/DBP (being decreased from 0.10 to -0.35 and from 0.11 to -0.35 respectively) and for BP control rate (from 0.53 to -0.62).

CONCLUSIONS

HBPT had major and "target-converging" effects on SBP/DBP. The magnitude of changes was much greater than have commonly reported. BP, variation in BP and time were the most important determinants of HBPT uptake; while age, education, duration of hypertension, family history and diagnosis of hypertension complications were also linked to the uptake but at apparently weaker strength. There is a clear need for differentiated thinking over application and assessment of HBPT and for identifying and correcting/leveraging potential outdated/new opportunities or beliefs.

Chronic kidney disease after lung transplantation in a changing era

Lung transplant (LTx) physicians are responsible for highly complex post-LTx care, including monitoring of kidney function and responding to kidney function loss. Better survival of the LTx population and changing patient characteristics, including older age and increased comorbidity, result in growing numbers of LTx patients with chronic kidney disease (CKD). CKD after LTx is correlated with worse survival, decreased quality of life and high costs. Challenges lie in different aspects of post-LTx renal care. First, serum creatinine form the basis for estimating renal function, under the assumption that patients have stable muscle mass. Low or changes in muscle mass is frequent in the LTx population and may lead to misclassification of CKD. Second, standardizing post-LTx monitoring of kidney function and renal care might contribute to slow down CKD progression. Third, new treatment options for CKD risk factors, such as diabetes mellitus, proteinuria and heart failure, have entered clinical practice. These new treatments have not been studied in LTx yet but are of interest for future use. In this review we will address the difficult aspects of post-LTx renal care and evaluate new and promising future approaches to slow down CKD progression.

Progress and prospects of Sacubitril/Valsartan: Based on heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is present in nearly half of patients with heart failure. The prevalence of heart failure with normal or near-normal ejection fractions increases more rapidly than in patients with reduced ejection fractions. Angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), aldosterone antagonist, β-blocker, and calcium channel blocker have not shown significant efficacy in HFpEF clinical trials. Sacubitril/Valsartan, combined angiotensin receptor blocker (Valsartan) with neprilysin inhibitor (Sacubitril), was the first-of-its-kind angiotensin receptor-neprilysin inhibitor (ARNI) to be developed. It has shown significant efficacy on HFpEF in recent studies. It is considered that most of the current Sacubitril/Valsartan studies are still concentrated in the field of heart failure, especially heart failure with reduced ejection fraction (HFrEF). This review discusses the latest advances in cardiovascular, renal, and metabolic aspects of Sacubitril/Valsartan, mainly in HFpEF, providing more evidence for further future research on Sacubitril/Valsartan and raising issues that should be paid attention. At the same time, this review will introduce the academic consensus on Sacubitril/Valsartan in treating HFpEF in China.

Efficacy and safety of low-dose antihypertensive combination of amlodipine, telmisartan, and chlorthalidone: A randomized, double-blind, parallel, phase II trial

The aim of this clinical trial was to assess the efficacy and safety of low‐dose triple combinations of amlodipine, telmisartan, and chlorthalidone in patients with essential hypertension. After a 2‐week placebo run‐in period, 176 patients were randomized to seven treatment groups (placebo, quarter‐dose combination, third‐dose combination, half‐dose combination, amlodipine 5 mg, amlodipine 10 mg, and telmisartan 80 mg) and administered the assigned study drug orally for 8 weeks. The primary efficacy endpoint was the change in the mean sitting systolic blood pressure (BP) (MSSBP) at Week 8. The MSSBP and mean sitting diastolic BP in the quarter‐dose and half‐dose groups were significantly lower compared to the placebo and amlodipine 5 mg groups, with similar BP‐lowering effects observed compared to the amlodipine 10 mg and telmisartan 80 mg groups. However, the third‐dose group showed significant BP improvement only compared to the placebo group. A similar pattern was observed for the control rate of hypertension and response rates. Additional analysis was conducted after correcting for gender and age effects, and, as a result, the third‐dose group showed similar results with regard to the BP‐lowering effect as the quarter‐dose and half‐dose groups. In terms of safety, no special adverse events and clinically significant results were noted, and all dose groups of the triple combination are considered safe for use in essential hypertension patients. The current findings indicated that low‐dose triple combination of amlodipine, telmisartan, and chlorthalidone over 8 weeks effectively improved the BP‐lowering effect in patients with essential hypertension without any safety concerns.

Diet-related knowledge, attitudes, and behaviors among young and middle-aged individuals with high-normal blood pressure: A cross-sectional study in China

Background

Dietary modifications play an important role in the prevention and management of high-normal blood pressure (BP). The aim of this study was to investigate diet-related knowledge, attitudes, and behaviors, and the socio-demographic determinants of these, among young and middle-aged Chinese individuals with high-normal BP.

Methods

Data from the 2015 China Health and Nutrition Survey (CHNS) were analyzed in this study. A total of 1,756 subjects with high-normal BP were included. A chi-square test and binary logistic regression analysis were conducted to identify the risk factors toward diet-related knowledge, attitudes, and behaviors.

Results

A total of 37.4% of the participants knew about the Chinese Food Pagoda (CFP) or the Dietary Guidelines for Chinese Residents (DGCR). Overall, 39.8% of the subjects were classified as having adequate diet-related knowledge literacy, 27.8% reported positive diet-related attitudes to healthy eating, and 35.3% reportedly looked for nutrition knowledge. Of note, 72.4% and 80.1% of the participants reported liking to eat fruits and vegetables, respectively. Individuals with a middle school education [odds ratio (OR) = 1.784, 95% CI = 1.236-2.576], high school/vocational education (OR = 1.944, 95% CI = 1.305-2.896), and college degree or above (OR = 2.089, 95% CI = 1.341-3.322), who were living in a rural area (OR = 1.311, 95% CI = 1.048-1.639), proactively looking for nutrition knowledge (OR = 1.529, 95% CI = 1.227-1.906), and reported liking to eat vegetables (OR = 1.939, 95% CI = 1.409-2.688), were more likely to have sufficient dietary knowledge literacy. Managers (OR = 1.655, 95% CI = 1.039-2.635) were more likely to have positive dietary attitudes. Female gender (OR = 1.396, 95% CI = 1.089-1.790), high school/vocational school education (OR = 2.071, 95% CI = 1.269-3.379), college degree and above (OR = 2.207, 95% CI = 1.262-3.862), knowledge about the CFP or DGCR (OR = 8.138, 95% CI = 6.326-10.468), and sufficient dietary knowledge literacy (OR = 1.338, 95% CI = 1.050-1.705) were associated with an increased likelihood of looking for nutrition knowledge.

Conclusion

Individuals with high-normal BP, predominantly males, living in rural area, with lower education, farmers, workers, service workers, and workers in the non-government employment unit may have poor diet-related knowledge, attitudes, and behaviors.

Independent Association of 25[OH]D Level on Reduced Glutathione and TNF-α in Patients ‎with Diabetes and/or Hypertension

Purpose

Oxidative and inflammatory pathways play a significant role in the pathophysiology of a wide variety of non-communicable diseases such as type 2 diabetes mellitus (T2DM) and hypertension. However, the effect of serum 25-hydroxyvitamin D ‎‎(25[OH]D) on these pathways is still controversial. To evaluate the association of 25[OH]D on ‎antioxidant and pro-inflammatory biomarkers, reduced glutathione (GSH) and tumor ‎necrosis factor (TNF)-α, in T2DM and hypertensive patients.

Patients and Methods

This is a cross-sectional study of a consecutive sample of patients attending the the Family Medicine clinic at King Abdullah bin Abdulaziz University Hospital (KAAUH). Participants were screened for eligibility according to the following ‎criteria: aged above 18 years and diagnosed with T2DM and/or hypertension for at least one ‎year. Patients receiving any kind of vitamin D or calcium supplements within the last three ‎months were excluded, as were those with a history of ‎renal failure, cancer, liver, thyroid, or any other chronic inflammatory diseases.

Results

In total 424 T2DM and/or ‎hypertensive patients (mean age 55±12 years) were recruited. In addition to routine ‎physical and laboratory examinations, levels of serum 25[OH]D, GSH and TNF-α were ‎measured. The prevalence of 25[OH]D deficiency (<50 nmol/L) was 35.1%, which was ‎independent from GSH and TNF-α levels. In T2DM, hypertensive and patients having ‎both diseases, GSH levels were 349.3±19, 355.4±19 and 428.8±20 μmol/L, ‎respectively. Uncontrolled T2DM and hypertension patients showed significantly higher ‎GSH compared with the controlled group. ‎Males showed slightly higher level ‎of TNF-α compared with females and uncontrolled hypertensive patients had relatively ‎higher TNF-α level when evaluated against controlled hypertensive patients. ‎

Conclusion

25[OH]D level is independent of oxidative stress and inflammation, ‎assessed by levels of GSH and TNF-α, respectively, in T2DM and hypertensive Saudi ‎patients. ‎

Simultaneously measured inter-arm blood pressure difference is not associated with pulse wave velocity in a clinical dataset of at-risk hypertensive patients

Recent analysis of systolic inter-arm differences in blood pressure from the INTERPRESS-IPD Collaboration suggest an association with increased all-cause mortality, cardiovascular mortality and cardiovascular events. Previous studies have demonstrated associations with other risk parameters. We aimed to reproduce these associations in a cohort of 199 treated, at-risk hypertensive patients with pulse wave velocity (PWV) as a surrogate marker of cardiovascular (CV) damage. Simultaneously measured inter-arm blood pressure (BP) differences, 24 hour ambulatory BP and PWV were measured in 199 treated patients from a tertiary hospital hypertension outpatient clinic. Associations between systolic inter-arm BP difference and PWV were analyzed with uni- and multi-variate regression models. Out of 199 participants, 90 showed an inter-arm BP difference of more than 5 mmHg. The inter-arm difference was not associated with PWV. Furthermore, neither observed single BP measurements nor 24 hour ambulatory BP was associated with inter-arm BP differences. In our clinical patient cohort we failed to observe an association between inter-arm BP differences and PWV. Mode of assessment, study design and the sample characteristics of this treated, hypertensive cohort may have contributed to the negative findings. The limited sample size of the study poses a challenge to the detection of smaller effects in our study.