2020 International Society of Hypertension global hypertension practice guidelines

Correlation analysis of the triglyceride glucose index and heart failure with preserved ejection fraction in essential hypertensive patients

BACKGROUND

Triglyceride glucose index (TyG index) is a novel marker of insulin resistance. Studies have shown that TyG index is closely associated with the occurrence of hypertension and cardiovascular disease. However, little is known about the correlation between TyG index and the occurrence of heart failure with preserved ejection fraction (HFpEF) in hypertensive patients.

HYPOTHESIS

Our study assumes that TyG index strongly correlates with occurence of HFpEF in hypertensive patients.

METHODS

This research enrolled 559 hypertensive patients (273 patients with HFpEF and 286 without HFpEF) admitted to the Department of Cardiology of Jiading Branch of Shanghai General Hospital from 2020 to 2021 as the study subjects. Gender, age, diastolic blood pressure, systolic blood pressure (SBP), and heart rate (HR) were recorded at admission. Medication history and fasting blood samples were harvested after admission to detect laboratory index. Cardiac function and ventricular structure index were measured by echocardiography. Pearson correlation analysis was conducted to identify the correlation of TyG index with cardiac function and ventricular structure. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of TyG index in HFpEF with hypertension.

RESULTS

HFpEF patients had higher diuretic use frequencies, fasting plasma glucose, NT-proBNP, triglycerides, TyG index, left atrial diameter (LAD), left ventricular mass index (LVMI), the ratio of peak E-velocity of mitral orifice to peak velocity of early diastolic mitral annulus (E/e'), and SBP but lower ratio of peak E of early diastolic maximum blood flow velocity to peak A of late diastolic maximum blood flow velocity of mitral orifice (E/A) and average e' than non-HFpEF patients. Moreover, TyG index was correlated with LAD, left ventricular ejection fraction (LVEF), LVMI, average e', E/e', and NT-proBNP. The multivariate regression analysis suggested that TyG index, E/e', and NT-proBNP were independent risk factors for HFpEF in hypertensive patients. Compared with E/e' and NT-proBNP, the area under the ROC curve (0.778 [95% confidence interval: 0.707-0.849]) was the largest for TyG index.

CONCLUSION

TyG index is higher in HFpEF patients than in non-HFpEF patients and related to cardiac diastolic function, which strongly correlates with occurrence of HFpEF in hypertensive patients.

Standardized home blood pressure monitoring: Rationale behind the 722 protocol

Home blood pressure (HBP) has been recognized as a prognostic predictor for cardiovascular events, and integrated into the diagnosis and management of hypertension. With increasing accessibility of oscillometric blood pressure devices, HBP monitoring is easy to perform, more likely to obtain reliable estimation of blood pressures, and feasible to document long-term blood pressure variations, compared to office and ambulatory blood pressures. To obtain reliable HBP estimates, a standardized HBP monitoring protocol is essential. A consensus regarding the optimal duration and frequency of HBP monitoring is yet to be established. Based on the current evidence, the "722" protocol, which stands for two measurements on one occasion, two occasions a day (morning and evening), and over a consecutive of 7 days, is most commonly used in clinical studies and recommended in relevant guidelines and consensus documents. HBP monitoring based on the "722" protocol fulfills the minimal requirement of blood pressure measurements to achieve agreement of blood pressure classifications defined by office blood pressures and to predict cardiovascular risks. In the Taiwan HBP consensus, the frequency of repeating the "722" protocol of HBP monitoring according to different scenarios of hypertension management, from every 2 weeks to 3 months, is recommended. It is reasonable to conclude that the "722" protocol for HBP monitoring is clinically justified and can serve as a basis for standardized HBP monitoring.

Nomogram Including Serum Ion Concentrations to Screen for New-Onset Hypertension in Rural Chinese Populations Over a Short-Term Follow-up

BACKGROUND

This study aimed to establish a clinically useful nomogram to evaluate the probability of hypertension onset in the Chinese population.

METHODS AND RESULTS

A prospective cohort study was conducted in 2012-2013 and followed up in 2015 to identify new-onset hypertension in 4,123 participants. The dataset was divided into development (n=2,748) and verification (n=1,375) cohorts. After screening risk factors by lasso regression, a multivariate Cox regression risk model and nomogram were established. Among the 4,123 participants, 818 (19.8%) developed hypertension. The model identified 10 risk factors: age, waist-to-hip ratio, systolic blood pressure, diastolic blood pressure, high pulse rate, history of diabetes, family history of hypertension and stroke, intake frequency of bean products, and intensity of physical labor. The C-indices of the model in the development and validation cohorts were 0.744 and 0.768, respectively. After the inclusion of serum calcium and magnesium concentrations, the C-indices in the development and validation cohorts were 0.764 and 0.791, respectively, with areas under the curve for the updated model of 0.907 and 0.917, respectively. The calibration curve showed that the nomogram accurately predicted the probability of hypertension. The updated nomogram was clinically beneficial across thresholds of 10-60%.

CONCLUSIONS

The newly developed nomogram has good predictive ability and may effectively assess hypertension risk in high-risk rural areas in China.

Hypertension in kidney transplant recipients

Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients (KTRs) than in the general population. Hypertension is highly prevalent in KTRs and represents a major modifiable risk factor associated with adverse cardiovascular outcomes and reduced patient and graft survival. Proper definition of hypertension and recognition of special phenotypes and abnormal diurnal blood pressure (BP) patterns is crucial for adequate BP control. Misclassification by office BP is commonly encountered in these patients, and a high proportion of masked and uncontrolled hypertension, as well as of white-coat hypertension, has been revealed in these patients with the use of ambulatory BP monitoring. The pathophysiology of hypertension in KTRs is multifactorial, involving traditional risk factors, factors related to chronic kidney disease and factors related to the transplantation procedure. In the absence of evidence from large-scale randomized controlled trials in this population, BP targets for hypertension management in KTR have been extrapolated from chronic kidney disease populations. The most recent Kidney Disease Improving Global Outcomes 2021 guidelines recommend lowering BP to less than 130/80 mmHg using standardized BP office measurements. Dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers have been established as the preferred first-line agents, on the basis of emphasis placed on their favorable outcomes on graft survival. The aim of this review is to provide previous and recent evidence on prevalence, accurate diagnosis, pathophysiology and treatment of hypertension in KTRs.

Network Meta-Analysis of the Antihypertensive Effect of Traditional Chinese Exercises on Patients with Essential Hypertension

Background

In recent years, traditional Chinese exercises (TCEs) have been gradually used to reduce the blood pressure levels of patients with essential hypertension. However, there are several types of TCEs, and there is no comparative study on the antihypertensive effects of various TCEs in patients with essential hypertension.

Objective

The objective is to compare the therapeutic effects of Taijiquan (TJQ), Baduanjin (BDJ), Wuqinxi (WQX), and Yijinjing (YJJ) on essential hypertension and provide a reference for clinical treatment and scheme optimization.

Methods

The China National Knowledge Infrastructure (CNKI), Wanfang, China Scientific Journal Database, China Biology Medicine database (CBM), PubMed, Embase, Cochrane Library, and Web of Science databases were searched to collect all randomized controlled trials (RCTs) of TCEs in the treatment of essential hypertension. The search time was from the establishment of each database to November 2021. After data extraction and quality evaluation, the network meta-analysis was performed with Stata 16.0 and ADDIS 1.16.8.

Results

Finally, 45 RCTs involving 3864 patients were included. Network meta-analysis showed that YJJ had the best effect in reducing systolic blood pressure, and the difference was statistically significant [MD = -14.27, 95% CI = (-20.53∼-8.08), P < 0.05]. The best probability ranking was YJJ (P=0.736) > TJQ (P=0.203) > WQX (P=0.059) > BDJ (P=0.002). In terms of reducing diastolic blood pressure, the treatment effect of YJJ was the best, and the difference was statistically significant [MD = -7.77, 95% CI (-12.19∼-3.33), P < 0.05]. The best probability ranking was YJJ (P=0.702) > TJQ (P=0.178) > WQX (P=0.095) > BDJ (P=0.025).

Conclusion

The results showed that TCEs significantly reduced systolic and diastolic blood pressure compared with the control group, and YJJ might be the best choice. However, a larger sample, multicenter, double-blinded, high-quality RCTs are needed to make clear conclusions.

Benefits of combined exercise training on arterial stiffness and blood pressure in spontaneously hypertensive rats treated or not with dexamethasone

Dexamethasone (DEX)-induced arterial stiffness is an important side-effect, associated with hypertension and future cardiovascular events, which can be counteracted by exercise training. The aim of this study was to evaluate the mechanisms induced by combined training to attenuate arterial stiffness and hypertension in spontaneously hypertensive rats treated or not with dexamethasone. Spontaneously hypertensive rats (SHR) underwent combined training for 74 days and were treated with dexamethasone (50 µg/kg s. c.) or saline solution during the last 14 days. Wistar rats were used as controls. Echocardiographic parameters, blood pressure (BP) and pulse wave velocity (PWV), as well as histological analyses of the heart and aorta, carotid and femoral arteries were performed. At the beginning, SHR had higher BP and PWV compared with Wistar rats. After 60 days, while BP increased in sedentary SHR, combined exercise training decreased BP and PWV. After 74d, the higher BP and PWV of sedentary SHR was accompanied by autonomic imbalance to the heart, cardiac remodeling, and higher arterial collagen deposition. DEX treatment did not change these parameters. On the other hand, trained SHR had reduced BP and PWV, which was associated with better autonomic balance to the heart, reduced myocardial collagen deposition, as well as lower arterial collagen deposition. The results of this study suggest that combined training, through the reduction of aortic collagen deposition, is an important strategy to reduce arterial stiffness in spontaneously hypertensive rats, and these lower responses were maintained regardless of dexamethasone treatment.

Effect of methylenetetrahydrofolate reductase C677T polymorphism on serum folate but not vitamin B12 levels in patients with H-type hypertension

BACKGROUND

Hyperhomocysteinemia (HHcy) is a common complication in Chinese hypertensive patients and associated with methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism, folate, and vitamin B12 (Vit B12) status. This study evaluated the associations of MTHFR C677T polymorphism, folate, and Vit B12 with H-type hypertension.

METHODS AND RESULTS

887 eligible patients with essential hypertension were included. Patients were divided into two groups according to the Hcy level, the H-type hypertension group and the normal hypertension group. Related risk factors such as MTHFR polymorphism, folate and Vit B12 status were analyzed in the two groups. Age, gender, SBP, DBP, MTHFR C677T genotype, folate and Vit B12 differed significantly between H-type hypertension and normal hypertension groups (P < 0.05). MTHFR 677TT variant, gender, folate, and Vit B12 were independent risk factors for the occurrence of H-type hypertension. The risk for TT carriers was 8 times higher than that of CC and CT carriers [OR (95% CI) 8.248 (5.274-12.899)]. Male patients had almost fivefold higher odds than female patients [OR (95% CI) 4.923 (2.741-8.842)]. Folate level of patients with H-type hypertension decreased with the C to T substitution of MTFHR C677T gene (P < 0.05), while Vit B12 level was not associated with the gene (P > 0.05).

CONCLUSIONS

MTHFR 677TT variant, gender, folate, and Vit B12 were risk factors for the occurrence of H-type hypertension. Folate but not Vit B12 was associated with MTFHR C677T polymorphism in patients with H-type hypertension. Accordingly, the above factors may be considered in the prevention and treatment of hypertension.

Research on early warning of renal damage in hypertensive patients based on the stacking strategy

Background

Among the problems caused by hypertension, early renal damage is often ignored. It can not be diagnosed until the condition is severe and irreversible damage occurs. So we decided to screen and explore related risk factors for hypertensive patients with early renal damage and establish the early-warning model of renal damage based on the data-mining method to achieve an early diagnosis for hypertensive patients with renal damage.

Methods

With the aid of an electronic information management system for hypertensive out-patients, we collected 513 cases of original, untreated hypertensive patients. We recorded their demographic data, ambulatory blood pressure parameters, blood routine index, and blood biochemical index to establish the clinical database. Then we screen risk factors for early renal damage through feature engineering and use Random Forest, Extra-Trees, and XGBoost to build an early-warning model, respectively. Finally, we build a new model by model fusion based on the Stacking strategy. We use cross-validation to evaluate the stability and reliability of each model to determine the best risk assessment model.

Results

According to the degree of importance, the descending order of features selected by feature engineering is the drop rate of systolic blood pressure at night, the red blood cell distribution width, blood pressure circadian rhythm, the average diastolic blood pressure at daytime, body surface area, smoking, age, and HDL. The average precision of the two-dimensional fusion model with full features based on the Stacking strategy is 0.89685, and selected features are 0.93824, which is greatly improved.

Conclusions

Through feature engineering and risk factor analysis, we select the drop rate of systolic blood pressure at night, the red blood cell distribution width, blood pressure circadian rhythm, and the average diastolic blood pressure at daytime as early-warning factors of early renal damage in patients with hypertension. On this basis, the two-dimensional fusion model based on the Stacking strategy has a better effect than the single model, which can be used for risk assessment of early renal damage in hypertensive patients.

Reproducibility of blood pressure phenotypes identified by office and ambulatory blood pressure in treated hypertensive patients. Data from the PHYLLIS study

Previous studies have shown that white-coat and masked uncontrolled hypertension (WUCH and MUCH, respectively) are clinical conditions with very poor reproducibility over time. This is also the case for the different nighttime blood pressure (BP) patterns (dipping, nondipping, reverse dipping or extreme dipping). Whether and to what extent the phenomenon might depend on the type of antihypertensive treatment is unknown. In the present study, we addressed this issue by analyzing the data collected in the Plaque Hypertension Lipid-Lowering Italian Study (PHYLLIS), in which office and ambulatory BP were measured three times during an almost 3-year treatment period. The results showed that a limited number of WUCH or MUCH patients at an initial office measurement and 24-h systolic (S) BP measurement maintained the same status at a second set of measurements one or more years later. This was also the case for all dipping patterns, and only a minimal number of patients exhibited the same phenotype throughout all on-treatment SBP measurements. The results were similar for treatment with a thiazide diuretic or an ACE inhibitor and are in line with those of the European Lacidipine Study on Atherosclerosis (ELSA) trial, i.e., the only other available trial with multiple on-treatment office and ambulatory BP measurements, in which patients were treated with a calcium channel blocker or a beta-blocker. All the BP patterns identified in hypertensive patients treated by joint office and ambulatory BP measurements display poor reproducibility, and this is unrelated to the type of antihypertensive treatment used.

Calcium Channel Blocker Toxicity: A Practical Approach

Calcium channel blockers (CCBs) are widely prescribed medications for various clinical indications in adults and children. They are available in both immediate and long-acting formulations and are generally classified into dihydropyridines and nondihydropyridines, with nondihydropyridines having more cardioselectivity. CCB toxicity is common given the widespread use which leads to serious adverse clinical outcomes, especially in children. Severe CCB toxicities may present with life-threatening bradycardia, hypotension, hyperglycemia, and renal insufficiency. Dihydropyridine toxicity, however, may present with reflex tachycardia instead of bradycardia. Initial patient evaluation and assessment are crucial to identify the severity of CCB toxicity and design the best management strategy. There are different strategies to overcome CCB toxicity that requires precise dosing and close monitoring in various patient populations. These strategies may include large volumes of IV fluids, calcium salts, high insulin euglycemia therapy (HIET), and vasopressors. We hereby summarize the evidence behind the management of CCB toxicity and present a practical guide for clinicians to overcome this common drug toxicity.

Physical activity influences heart rate variability in young adults, regardless of dextrose ingestion

INTRODUCTION

Cardiac autonomic modulation can be altered by carbohydrate ingestion. On the other hand, some of the protective effects of physical activity may be due to its impact on the autonomic nervous system.

PURPOSE

This cross-sectional study was conducted to evaluate whether physical activity level influences heart rate variability (HRV) under fasting and mainly, after dextrose ingestion.

METHODS

Healthy adults aged 18-40 years ( n  = 92; 54.35 % women) were separated into nonactive ( n  = 47) and active groups ( n  = 45), based on the physical activity level determined by International Physical Activity Questionnaire (IPAQ) and then compared.

RESULTS

There were no significant differences ( P  > 0.05) for age, body mass, BMI, abdominal circumference, blood pressure, fasting glucose and blood glucose at 60 min after dextrose ingestion between groups. Body fat (%) was lower in the active group ( P  = 0.02). The time-domain indices (RMSSD, SDNN and pNN50) were higher in the physically active group compared to the nonactive group (main effect of group, P  < 0.01). The SDNN index was higher at 60 min after dextrose ingestion compared to fasting (main effect of time, P  ≤ 0.01). However, no HRV indices showed significantly interaction effect (group x time; P  > 0.05).

CONCLUSION

The magnitude of HRV responses to glucose was not influenced by physical activity status. Young adults who met at least the minimum physical activity recommendations showed a higher cardiac autonomic modulation, regardless of dextrose ingestion.

Management of Hypertension in the Elderly and Frail Patient

Hypertension is a frequent finding in elderly patients. Hypertension in older age can be both associated with frailty and represent a risk factor for frailty. Hypertension is recognized as a main risk factor for cardiovascular diseases such as heart failure, atrial fibrillation, and stroke and the occurrence of these diseases may provoke a decline in health status and/or worsen the degree of frailty. Blood pressure targets in hypertensive older and frail patients are not completely defined. However, specific evaluations of individual patients and their co-morbidities and assessment of domains and components of frailty, together with weighted consideration of drug use, may help in finding the appropriate therapy.

Clinical Model for the Prediction of Severe Liver Fibrosis in Adult Patients with Type II Diabetes Mellitus

Background and Objectives: Non-alcoholic fatty liver disease (NAFLD)-related severe liver fibrosis is associated with a higher risk of progressing to decompensated cirrhosis and hepatic failure and developing NAFLD-related hepatocellular carcinoma (HCC), particularly in populations with diabetes. Our pilot study aims to evaluate the performances of various noninvasive methods in predicting liver fibrosis in a population of patients with diabetes and to establish a new scoring system for the prediction of severe fibrosis (>F3). Materials and Methods: A total of 175 patients with diabetes were enrolled for liver fibrosis evaluation. Using the degree of agreement (concordance) between a noninvasive score based on serum biomarkers (NAFLD fibrosis score) and point shear-wave elastography (pSWE) as the reference method, we generated receiver operating characteristic (ROC) curves and performed a multivariate analysis to predict severe liver fibrosis. Results: In our population of patients with diabetes, gamma-glutamyltransferase (GGT), age, body mass index (BMI), the homeostatic model assessment of insulin resistance (HOMA-IR), and glycosylated hemoglobin (HbA1C) were significant predictors for the diagnosis of the F3/F4 group (area under the ROC: 0.767, 0.743, 0.757, 0.772, and 0.7, respectively; p < 0.005 for all). Moreover, the combined composite score (the sum of GGT, age, BMI, HOMA index, and HbA1C) had the highest diagnostic performance at a cut-off value of 3 (AUROC—0.899; p < 0001). The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were 91.20%, 79%, 79%, and 89%, respectively, and 89% of patients were correctly classified as having severe liver fibrosis. In contrast with the Fibrosis 4 (FIB-4) score and the AST-to-platelet ratio index (APRI), the composite score had the best accuracy in discriminating advanced fibrosis. Conclusions: The proposed composite score had a reliable and acceptable diagnostic accuracy in identifying patients with diabetes at risk of having severe fibrosis using readily available laboratory and clinical data.

Follow-up management service and health outcomes of hypertensive patients in China: A cross-sectional analysis from the national health service survey in Jiangsu province

Background

Hypertension is a major cause of early mortality worldwide. Health follow-up management services can encourage patients with hypertension to improve their health behavior and outcomes. However, a lack of studies on the relationship between specific factors of follow-up management and both subjective and objective health outcome among hypertensive patients exists. The current study investigated the relationship between service content, frequency, mode, and institutions of follow-up management and health outcomes among Chinese hypertensives.

Methods

Data were obtained from the sixth National Health Service Survey (NHSS) of Jiangsu Province, which was conducted in 2018. Descriptive statistics were used to analyze the sample characteristics and the utilization of follow-up management services. Both multiple linear regression and logistic regression were used to estimate the association of follow-up management service and other factors with hypertensives' subjective and objective health outcomes.

Result

Some respondents (19.30%) reported hypertension, and 75.36% of these patients obtained follow-up management services. Hypertensive patients' subjective health outcome self-reported health status and objective health outcome blood pressure (BP) control were found to be significantly associated with follow-up management services. The outcomes were both significantly improved by a high frequency of management services, a high level of follow-up providers, the mode of visiting healthcare facilities and/or calling, and receiving instructions on medication use. However, inquiring about patients' symptoms was negatively associated with self-reported health status and BP control. In addition, BP measurement was significantly and positively associated with hypertensive patients' self-reported health status; the patients receiving lifestyle guidance were more likely to have their BP levels under control.

Conclusions

Hypertension management strategies should further focus on the frequency of healthcare follow-up management via categorization of the follow-up services and appropriate adjustment of service delivery modes to optimize health follow-up management for hypertensives further improve their outcomes. Meanwhile, complementary policies are also needed to address other socioeconomic factors that can promote good health conditions for hypertension patients.

Characteristics of Cognitive Impairment and Their Relationship With Total Cerebral Small Vascular Disease Score in Parkinson's Disease

Background

This study aimed to investigate the characteristics of cognitive dysfunctions and their relationship with total cerebral small vascular disease (CSVD) in Parkinson’s disease (PD).

Methods

A total of 174 idiopathic PD patients who underwent brain magnetic resonance imaging (MRI) were recruited. Demographic information, vascular disease risk factors, motor function (MDS-UPDRS III score), and cognitive level (MoCA, MMSE) were collected for these patients. The total CSVD burden was scored based on lacunes, enlarged perivascular spaces (EPVS), high-grade white matter hyperintensities (WMH), and cerebral microbleeds (CMBs) for each subject.

Results

Cognitive scores on MoCA for language, delayed recall, and orientation were significantly reduced in PD patients with CSVD burden ≥ 1 than in those with CSVD burden = 0. Educational level, PDQ 39, and CSVD burden were significantly associated with MoCA scores in individuals with PD. For the whole group, the full model accounted for 33.6% variation in total MoCA scores. In which, CSVD burden explained 2.7% of the results, and the detection of lacunes, WMH, EPVS, and strictly lobar CMBs were significantly correlated with MoCA scores. The stability of the outcomes was confirmed by sensitivity analysis.

Conclusion

CSVD can independently contribute to cognitive decline in PD and cause damage in specific cognitive domains. Promoting neurovascular health may help preserve cognitive functions in PD.

Implementation of the 2018 ESC/ESH Guidelines for the management of hypertension in primary care: the HYPEDIA study

The HYPEDIA study aimed at evaluating the implementation of the 2018 European guidelines for treating hypertension in primary care. A nationwide prospective non-interventional cross-sectional study was performed in consecutive untreated or treated hypertensives recruited mainly in primary care in Greece. Participants' characteristics, office blood pressure (BP) (triplicate automated measurements, Microlife BPA3 PC) and treatment changes were recorded on a cloud platform. A total of 3,122 patients (mean age 64 ± 12.5 [SD] years, 52% males) were assessed by 181 doctors and 3 hospital centers. In 772 untreated hypertensives (25%), drug treatment was initiated in the majority, with monotherapy in 53.4%, two-drug combination in 36.3%, and three drugs in 10.3%. Angiotensin receptor blocker (ARB) monotherapy was initiated in 30%, ARB/calcium channel blocker (CCB) 20%, ARB/thiazide 8%, angiotensin converting enzyme inhibitor (ACEi)-based 19%. Of the combinations used, 97% were in single-pill. Among 977 treated hypertensives aged <65 years, 79% had BP ≥ 130/80 mmHg (systolic and/or diastolic), whereas among 1,373 aged ≥65 years, 66% had BP ≥ 140/80 mmHg. ARBs were used in 69% of treated hypertensives, CCBs 47%, ACEis 19%, diuretics 39%, beta-blockers 19%. Treatment modification was decided in 53% of treated hypertensives aged <65 years with BP ≥ 130/80 mmHg and in 62% of those ≥65 years with BP ≥ 140/80 mmHg. Renin-angiotensin system blocker-based therapy constitutes the basis of antihypertensive drug treatment in most patients in primary care, with wide use of single-pill combinations. In almost half of treated uncontrolled hypertensives, treatment was not intensified, suggesting suboptimal implementation of the guidelines and possible physician inertia.

Chinese Herbal Medicine Reduces the Risk of Heart Failure in Hypertensive Patients: A Nationwide, Retrospective, Cohort Study

Background

Hypertension (HTN) is the leading preventable risk factor for cardiovascular disease worldwide. Patients with HTN are at higher risk for heart failure (HF). The currently available therapeutic approaches for HTN do not always optimally control blood pressure or are not suitable for hypertensive patients who have a higher number of comorbidities. This study aimed to determine whether Chinese herbal medicine (CMH)-based interventions could reduce the risk of HF in hypertensive patients.

Methods

This retrospective study randomly selected 2 million enrollees from the National Health Insurance Research Database and identified 507,608 patients who were newly diagnosed with HTN in 2000–2017. After 1:1 frequency-matching by age, sex, index year, income, urbanization, duration of HTN, comorbidities and antihypertensive medications, we selected 8,912 eligible patients in each group. During 16 years of follow-up, 380 CHM users and 426 CHM non-users developed HF, representing incidence rates of 6.29 and 7.43 per 1,000 person-years, respectively.

Results

CHM users had significantly lower HF risk compared with CHM non-users (adjusted HR = 0.85, 95% CI 0.74–0.98). The markedly predominant effect was observed in those receiving CHM products for more than 180 days (adjusted HR = 0.65). The frequently prescribed formula, Jia-Wei-Xiao-Yao-San, and the single herbs Ge Gen, Huang Qi, Du Zhong, Huang Qin, and Chuan Xiong were significantly associated with lower risk of HF.

Conclusions

This population-based study revealed decreased HF risk in hypertensive patients with CHM use. These findings may provide a reference for HF prevention strategies and support the integration of CHM into clinical intervention programs that provide a favorable prognosis for hypertensive patients.

Home blood pressure monitoring schedule: optimal and minimum based on 2122 individual participants' data

OBJECTIVES

Home blood pressure (HBP) monitoring has become a primary method for hypertension diagnosis and management. This analysis aimed to investigate the optimal and minimum schedule for HBP monitoring.

METHODS

A retrospective analysis of cross-sectional data was performed, which involved HBP and 24-h ambulatory blood pressure (ABP) monitoring in adults performed within the context of clinical studies in Finland, Greece and UK. Participants with six to seven HBP monitoring days and at least 12 HBP readings were included. The stability of HBP was assessed by evaluating the average value of an increasing number of readings and its variability (SD). Its association with awake ABP was also assessed.

RESULTS

Data from 2122 participants were analysed (mean age 53.9 ± 11.3 years, males 53%, treated 34%). A progressive HBP decline was observed in succeeding days, reaching a plateau after day 3. Day 1 HBP was higher than in the next days by about 2.8/1.4 mmHg (systolic/diastolic, P < 0.001). In a 3-day HBP monitoring schedule, the exclusion of day 1 reduced average HBP and SD, with a clinically important HBP decline in 115 participants (5%) and different hypertension diagnosis in 120 participants (6%). For schedules including more than three HBP monitoring days, the exclusion of day 1 had negligible impact. The 3-day average HBP was strongly correlated with awake ABP, with a little improvement thereafter.

CONCLUSION

These data support the recommendation for 7 days of HBP monitoring with a minimum of 3 days. Readings of the first day should be discarded, particularly when the minimum 3-day monitoring schedule is obtained (average readings of second and third day).

Hypertension is associated with antibody response and breakthrough infection in health care workers following vaccination with inactivated SARS-CoV-2

Several types of vaccines have been developed to prevent the coronavirus disease 2019 (COVID-19). It is important to understand whether demographic and clinical variables affect the effectiveness of various types of vaccines. This study analysed the association between demographic/clinical factors, antibody response and vaccine effectiveness in healthcare workers vaccinated with inactivated virus.

We enrolled 101 healthcare workers who received two doses of inactivated viral vaccine (CoronaVac). Blood samples were analysed at 1, 3, and 5 months after the second dose of vaccination. Data regarding demographic characteristics, medical histories, and clinical parameters were collected by interview and medical examination. In a separate retrospective study, we analysed the incidence of vaccine breakthrough infection on 2714 healthcare workers who received two doses of inactivated viral vaccine. Medical histories and demographic data were collected using a structured self-reported questionnaire.

We found that antibody titres markedly increased at 1 month after vaccination but gradually decreased at 3–5 months post-vaccination. We observed a significant association between age (≥40 years) and antibody level, whereas sex and body mass index (BMI) exhibited no effect on antibody titres. Amongst clinical variables analysed, high blood pressure and history of hypertension were significantly correlated with lower antibody titres. Consistently, we found a significant association in the retrospective study between hypertension and the incidence of breakthrough infection.

In conclusion, our results showed that hypertension is associated with lower antibody titres and breakthrough infection following COVID-19 vaccination. Thus, blood pressure control might be important to improve the efficacy of inactivated virus vaccine.

Use of Anthropometric Indices to Identify Appropriate Cuff Shapes for Blood Pressure Measurement: Normative Data for Adults

BACKGROUND

Published evidence has shown that troncoconical cuffs improve blood pressure measurement accuracy in subjects with obesity. However, the exact shape of these cuffs according to arm size is unknown. The aim of the present study was to investigate the anthropometric characteristics of the arm in a large population in order to identify the appropriate shape of the cuff for each arm.

METHODS

The anthropometric characteristics were assessed in 729 adults with middle arm circumference ranging from 16 to 55 cm. Subjects were divided into classes of arm size and the upper-arm slant angle of the truncated cone was calculated.

RESULTS

In the whole sample, the conical shape of the arm progressively increased with increasing arm circumference (r = 0.61, P < 0.0001). Independent predictors of the conical shape were arm circumference (P < 0.0001) and length (negative relationship, P < 0.0001), and female sex (P = 0.048). Women had a slightly more pronounced conical shape of the arm (P = 0.007) than men. However, the decrease in the slant angle across the arm-size classes showed a similar trend in men and women, and in a 2-way analysis of variance there was no interactive effect between arm size and sex on the conical shape of the arm (P = 0.11). On the basis of the slant angle calculated in each arm-size class, we provide dimensions for bladders that would appropriately fit the arm within a given circumference range.

CONCLUSIONS

To properly fit the upper arm in patients with obesity cuffs should have a troncoconical shape. This study provides reference data according to arm size.

Preconception period in women and men undergoing Assisted Reproduction: A gender approach for reproductive health

OBJECTIVE

To evaluate lifestyle and risk factors playing a role in increasing the burden of cardiovascular diseases and to increase attention of clinicians who should envision a broader preconception approach in ART, not only in women but also in men.

STUDY DESIGN

In this cross-sectional study we investigated 90 Caucasian couples, referred to the Internal Medicine Clinic at the Assisted Reproductive Technology Centre, in order to better define in preconceptional period their cardiovascular risk profile, based on metabolic parameters and lifestyle behaviours.

RESULTS

We observed two-fold increase of overweight in men in comparison to women (p = 0.006). Values of waist ≥ 94 cm in men and ≥ 80 cm in women were present in 53.3% of men and 32.2% of women (p = 0.007). Similarly, values of WHR according to gender cut-off, were present in 64.4% of men and in 32.2% of women (p < 0.0001). In men we observed a significantly higher prevalence of hypertension (p = 0.02), significantly lower HDL-c (p = 0.001) and higher levels of total cholesterol (p = 0.01), LDL-c and triglycerides (p = 0.001). Sedentary behaviour was observed in about 60% of both genders. Alcohol consumption was reported by 42.2% of men and 26.7% of women (p = 0.04) and smokers were more prevalent among women (26.7%) than men (24.4%). We observed a lower adherence to Mediterranean Diet related to consumption of red meat and meat products (p = 0.02), as well as of legumes consumption (p = 0.01) in men, whereas sweet/pastries (p = 0.05) and fruits (p = 0.06) in women. Men and women with normal BMI, waist and WHR, showed a higher Mediterranean diet adherence in comparison to overweight/obese study population(p < 0.001). Finally, higher education level predicted the higher Mediterranean diet adherence in both gender (p = 0.01 for men, p = 0.03 for women).

CONCLUSIONS

This study paid attention on preconceptional health in couples planning ART. Women have a greater biological role in childbearing, whereas the role of men is underestimated. The need to conceive through ART offers a window of opportunity not only to evaluate cardiovascular profile and lifestyle factors in couples prior to conception, but also to manage comorbidities and promote health behaviours in order to improve fertility and health outcomes in both women and men at short and long-term.

Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities

Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of <140 mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP <130/80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.

Chinese expert consensus on the diagnosis and treatment of chronic heart failure in elderly patients (2021)

Heart failure is a clinical syndrome caused by ventricular insufficiency, which results in decreased activity tolerance and repeated hospitalization, seriously affecting quality of life, and it is the main cause of death in elderly people. In recent years, great progress has been made in the treatment of heart failure, but the prevalence, mortality, and readmission rate among elderly patients with heart failure remain high. Because elderly patients have multiple cardiovascular disease risk factors, coexistence of multiple diseases accompanied by multiple syndromes, multiple medications, and natural decline of body functions, the clinical diagnosis, treatment, rehabilitation, and long-term management of these patients differ from those in other populations. To facilitate clinical practice and application of clinical geriatric medicine, especially among community physicians, experts from the Cardiovascular Group, Geriatrics Branch of the Chinese Medical Association have drafted this consensus to summarize the diagnosis and treatment regimens for elderly patients with chronic heart failure and provide guidance for its clinical diagnosis and treatment in China.

Aneurysm size and blood pressure severity in patients with intracranial aneurysms and sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea is a risk factor for hypertension. Hypertension is associated with aneurysm formation, growth, and rupture of intracranial aneurysm (IA). Retrospectively, symptoms of obstructive sleep apnea are more prevalent in patients with IAs. Studies investigating the prevalence and effect of objectively measured sleep apnea in these patients are sparse. We report on the baseline data of an ongoing prospective study. We cross-sectionally analyzed whether obstructive sleep apnea was associated with larger IAs and increased need for antihypertensive medications in a population of patients with unruptured IA.

METHODS

130 adult (≥ 18 years) patients with unruptured IAs were recruited. Patients with ischemic stroke or intracranial hemorrhage within 3 months prior to screening were excluded. We assessed obstructive sleep apnea by full-night respiratory polygraphy. Aneurysm size and antihypertensive medication-as a surrogate parameter for the severity of hypertension-were compared between patients with and without obstructive sleep apnea (apnea-hypopnea index >5 events/h). Aneurysm growth and rupture rate were retrospectively analyzed.

RESULTS

101 patients completed the study protocol. Obstructive sleep apnea was diagnosed in 68.0% (17) of male and 34.2% (26) of female participants and associated with more severe hypertension (1.536 ± 0.2 vs 0.74 ± 0.1 drugs; P = .01) and larger aneurysms (6.9 ± 1.0 vs 3.8 ± 0.5 mm; P = .01).

CONCLUSIONS

Patients with obstructive sleep apnea had more antihypertensive medication and larger IAs, probably due to accelerated aneurysm growth. Sleep apnea should be considered in patients with IAs. More research is needed to investigate the effects of sleep apnea on IAs and aneurysm outcome.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Incidence and Effects of Sleep Apnea on Intracerebral Aneurysms-IESA Study; URL: https://clinicaltrials.gov/ct2/show/NCT02880059; Identifier: NCT02880059.

CITATION

Zaremba S, Albus L, Hadjiathanasiou A, Vatter H, Wüllner U, Güresir E. Aneurysm size and blood pressure severity in patients with intracranial aneurysms and sleep apnea. J Clin Sleep Med. 2022;18(6):1539-1545.

Serum uric acid concentration is associated with hyperhomocysteinemia in hypertensive Chinese adults

PURPOSE

This study is to investigate the correlation between serum uric acid levels and hyperhomocysteinemia Chinese adult patients with hypertension.

METHODS

We enrolled 981 hypertensive patients, including unmedicated hypertensives, in our study. There were 453 patients with hyperhomocysteinemia (hyperhomocysteinemia hypertension group) and 528 without it (ordinary hypertension group). We collected histories of coronary heart disease, diabetes, and smoking and tested patients' BMI, blood pressure, fasting serum uric acid, serum total cholesterol, triglycerides, low-density lipoprotein cholesterol, serum creatinine, and homocysteine. Subjects were stratified into four groups according to their serum uric acid quartiles: Q1 group, 249 cases (≤268 μmol/L); Q2 group, 245 cases (269-322 μmol/L); Q3 group, 244 cases (323-378 μmol/L); and Q4 group, 243 cases (≥379 μmol/L). We employ logistic regression analysis to investigate the relationship between serum uric acid levels and the risk of hyperhomocysteinemia in patients with hypertension.

RESULTS

We find that there were significant differences in gender distribution, serum uric acid, BMI, serum creatinine, total cholesterol, and diastolic blood pressure between the two groups (P < 0.05). The prevalence of hyperhomocysteinemia in groups Q1 through Q4 was 26.91% (67/249), 45.31% (111/245), 47.01% (117/244), and 65.02% (158/243), respectively, after adjusting for relevant factors, we find that the risk of hyperhomocysteinemia in the Q4 group was significantly higher than that in the Q1 group (odds ratio = 3.00, 95% confidence interval: 1.83-4.93).

CONCLUSION

We find evidence that an elevated serum uric acid level is an independent indicator for hyperhomocysteinemia in patients with hypertension.

Effectiveness and safety of sacubitril/valsartan for patients with hypertension and heart failure in the real-world setting: A retrospective study in China

WHAT IS KNOWN AND OBJECTIVE

Hypertension (HP) is associated with heart failure (HF). Sacubitril/valsartan (sac/val) has been approved for primary HP by China Food and Drug Administration (CFDA) in June 2021. The present study aimed to provide evidence on the effectiveness and safety of sac/val in Chinese patients complicated with HP and HF.

METHODS

This retrospective study was conducted on adult patients diagnosed with HP and HF and treated with sac/val between July 2020 and December 2020. The potential risk factors for the discontinuation events caused by sac/val-related adverse events (AEs) were explored. The data, including blood pressure (BP), cardiac indicators, corresponding values on echocardiographic parameters, unplanned visits, and AEs throughout 3-12 months, were collected.

RESULTS AND DISCUSSION

A total of 446 eligible patients were included in this study. The discontinuation events of sac/val were mainly attributed to its AEs (hypotension, hyperkalemia, and deterioration in kidney function). Univariate analysis revealed that history of chronic kidney disease, atrial fibrillation, higher values of serum creatinine, serum uric acid, serum N-terminal pro B-type natriuretic peptide, and lower estimated glomerular filtration rate were potential risk factors for discontinuation. Patients who maintained sac/val therapy throughout 3-12 months showed significantly improved values of clinical BP, cardiac indicators, and echocardiographic parameters compared to those at baseline (p < 0.0001).

WHAT IS NEW AND CONCLUSION

Sac/val was effective on BP and improved cardiac function in patients complicated with HP and HF. The physicians should focus on patients with renal dysfunction to take timely precautions to improve tolerability for sac/val.

Impact of a NDUFC2 Variant on the Occurrence of Acute Coronary Syndromes

Background

Among several potential mechanisms, mitochondrial dysfunction has been proposed to be involved in the pathogenesis of coronary artery disease (CAD). A mitochondrial complex I deficiency severely impairs cardiovascular health and contributes to CAD development. Previous evidence highlighted a key role of NDUFC2, a subunit of complex I, deficiency in the increased occurrence of renal and cerebrovascular damage in an animal model of hypertension, and of juvenile ischemic stroke occurrence in humans. Furthermore, a significant decrease of NDUFC2 mRNA was detected in peripheral blood mononuclear cells from patients experiencing acute coronary syndrome (ACS). The T allele at NDUFC2/rs23117379 variant is known to associate with reduced gene expression and mitochondrial dysfunction.

Objective

In the present study we tested the impact of the T/C NDUFC2/rs23117379 variant on occurrence of ACS in a prospective cohort of CAD patients (n = 260).

Results

Hypertension, smoking habit, diabetes and hypercholesterolemia were present in a large proportion of patients. Non-ST-elevation myocardial infarction (NSTEMI) represented the most frequent type of ACS (44%, n = 115), followed by ST-elevation myocardial infarction (STEMI) (34%, n = 88) and unstable angina (22%, n = 57). The alleles/genotypes distribution for T/C at NDUFC2/rs23117379 revealed that the TT genotype was associated with a trend toward the development of ACS at an earlier age (TT 61 ± 12, CT 65 ± 12 and CC 66 ± 11 years; p = 0.051 after adjustment for gender, hypertension, smoking habit, diabetes and hypercholesterolemia) and with a significant predictive role for ACS recurrence (hazard ratio [HR]1.671; 95% confidence interval [CI], 1.138–2.472; p = 0.009).

Conclusions

Our findings are consistent with a deleterious effect of NDUFC2 deficiency on acute coronary events predisposition and further support a role of the NDUFC2/rs23117379 variant as a genetic cardiovascular risk factor.

Global Impact of Different Blood Pressure Thresholds in 4 021 690 Participants of the May Measurement Month Initiative

BACKGROUND

Influential guidelines currently define hypertension at different thresholds of blood pressure (BP). The global May Measurement Month initiative provides a unique opportunity to estimate the potential consequences of universal lowering of BP thresholds on the prevalence of hypertension based on a large, real-world, patient-level data set.

METHODS

The average of the second and third of 3 attended BP readings after 5 minutes of rest from 4 021 690 standardized, opportunistic BP screenings in various settings of the 2017 to 2019 May Measurement Month initiatives from 104 countries were analyzed to assess the demographic and phenotypic impact of 3 defined BP thresholds.

RESULTS

The age- and sex-standardized median of the relative increase in rate of hypertension with a change of thresholds from ≥140/≥90 to ≥130/≥80 mm Hg was 72.3% (interquartile range, 59.3%-91.3%) among the participating countries. With a change from ≥140/≥90 to ≥120/≥70 mm Hg, the median range was 162.6% (interquartile range, 132.8%-202.6%). The increase in rate of hypertension was most pronounced in low-income (95.3% and 203.9%) and least pronounced in high-income countries (71.6% and 167.1%).

CONCLUSIONS

The impact of a universal application of lower BP thresholds for the definition of hypertension would have an enormous impact on the prevalence of hypertension globally with large disparities between countries and substantial heterogeneity of demographic and phenotypic patterns, which should be confirmed in dedicated population studies. While focusing on lower BP targets may constitute an opportunity for early intervention, the potential socioeconomic consequences may pose unsurmountable obstacles for most health care systems worldwide.

The Associations between Evacuation Status and Lifestyle-Related Diseases in Fukushima after the Great East Japan Earthquake: The Fukushima Health Management Survey

Background: This study aimed to investigate the association between evacuation status and lifestyle-related disease risks among Fukushima residents following the Great East Japan earthquake. Methods: Fukushima health management survey respondents were classified into non-evacuees, returnees, evacuees in lifted areas, and evacuees in banned areas. During a seven-year follow-up, 22,234 men and 31,158 women were included. Those with a history of diabetes, hypertension, or dyslipidemia at baseline were excluded. The odds ratios of risk factors (ORs) and 95% confidence intervals (CIs) for diabetes, hypertension, and dyslipidemia were calculated using a logistic regression model. Spatial autocorrelation of the prevalence of these diseases in the Fukushima area in 2017, was calculated to detect the disease prevalence status. Results: The risks of diabetes, hypertension, and dyslipidemia were higher in evacuees in banned areas than in non-evacuees; the multivariable ORs were 1.32 (95% CI: 1.19–1.46), 1.15 (1.06–1.25), and 1.20 (1.11–1.30) for diabetes, hypertension, and dyslipidemia, respectively. Returnees and evacuees in lifted areas had no increased risk of diseases. The area analyzed had a non-uniform spatial distribution of diabetes, hypertension, and hyperlipidemia, with clusters around Fukushima and Koriyama. Conclusion: Our findings imply the need for continuous support for evacuees in banned areas.

Mechanisms and Clinical Implications of Endothelial Dysfunction in Arterial Hypertension

The endothelium is composed of a monolayer of endothelial cells, lining the interior surface of blood and lymphatic vessels. Endothelial cells display important homeostatic functions, since they are able to respond to humoral and hemodynamic stimuli. Thus, endothelial dysfunction has been proposed as a key and early pathogenic mechanism in many clinical conditions. Given the relevant repercussions on cardiovascular risk, the complex interplay between endothelial dysfunction and systemic arterial hypertension has been a matter of study in recent years. Numerous articles have been published on this issue, all of which contribute to providing an interesting insight into the molecular mechanisms of endothelial dysfunction in arterial hypertension and its role as a biomarker of inflammation, oxidative stress, and vascular disease. The prognostic and therapeutic implications of endothelial dysfunction have also been analyzed in this clinical setting, with interesting new findings and potential applications in clinical practice and future research. The aim of this review is to summarize the pathophysiology of the relationship between endothelial dysfunction and systemic arterial hypertension, with a focus on the personalized pharmacological and rehabilitation strategies targeting endothelial dysfunction while treating hypertension and cardiovascular comorbidities.

Impact of sports participation on components of metabolic syndrome in adolescents: ABCD growth study

OBJECTIVES

This study aimed to analyze the impact of sports participation (12 months of practice) on the components of metabolic syndrome (MetS) in both sexes.

METHODS

This is an observational longitudinal study, a part of which is entitled "Analysis of Behaviors of Children During Growth" (ABCD Growth Study), Presidente Prudente, São Paulo, Brazil. The sample was composed of 171 adolescents (112 boys and 59 girls), divided into non-sports and sports groups. High-density lipoprotein-cholesterol (HDL-c), triglycerides, and glucose were analyzed by the colorimetric method of dry chemistry and processed biochemically. Systolic blood pressure and diastolic blood pressure were measured using an automatic device. Body fat was estimated using a densitometry scanner.

RESULTS

Adolescents who practiced sports were younger (p-value=0.001) and had a lower peak height velocity (p-value=0.001) than the non-sports group. The differences (Δ) after 12 months were of greater magnitude for the sports group when compared to the non-sports group (p-value=0.013), glucose (moderate magnitude in favor of the sports group; p-value=0.001), HDL-c (small magnitude in favor of the sports group; p-value=0.0015), and MetS (moderate magnitude in favor of the sports group; p-value=0.001).

CONCLUSIONS

The practice of sports in adolescents had a protective effect on the metabolic components of MetS.

Cardiotoxicity of BTK inhibitors: ibrutinib and beyond

INTRODUCTION

The development of Bruton<apos;>s Tyrosine Kinase (BTK) inhibitors has transformed the treatment of B-cell malignancies and other non-malignant conditions. Management of the unique cardiotoxic profile of these agents requires prompt recognition and a multi-disciplinary approach.

AREAS COVERED

The increasing indications and addition of newer agents to clinical practice and emergence of BTK inhibitor-related cardiac adverse events have complicated the management decisions for utilization of this class of therapy. We review the incidence, mechanisms, and management approaches for BTK inhibitor-related atrial fibrillation, hypertension, and ventricular arrhythmias.

EXPERT OPINION

The newer BTK inhibitor acalabrutinib represents a new standard of care in front-line chronic lymphocytic leukemia (CLL) given the results of the ELEVATE-RR trial demonstrating comparable efficacy and a more favorable toxicity profile especially with regard to cardiac adverse events as compared to ibrutinib. Often not recognized by clinicians, BTK inhibitor-induced hypertension is common and can be severe, requiring prompt recognition and initiation or adjustment of anti-hypertensive medications to prevent major adverse cardiac outcomes. Novel BTK inhibitors in development are being designed to overcome the patterns of resistance from first-generation agents and to minimize off-target kinase activity, with promising toxicity profiles in early trials.

Sex Differences in Cardiovascular Consequences of Hypertension, Obesity, and Diabetes: JACC Focus Seminar 4/7

It has long been recognized that there are significant differences between the sexes affecting prevalence, incidence, and severity over a broad range of diseases. Until the early 1990s, the limited research conducted on women's health focused primarily on diseases affecting fertility and reproduction, and women were excluded from most clinical trials. For these reasons, the prevention, diagnosis, and treatment of serious chronic diseases such as cardiovascular disease in women continue to be based primarily on findings in men, and sex-specific clinical guidelines are mostly lacking. Hypertension, obesity, and diabetes, interrelated risk factors for cardiovascular disease, differ by sex in terms of prevalence and adverse effects as well as by genetics and biology. Research is needed to understand sex differences in hypertension, obesity, and diabetes to optimally inform sex-specific prevention, diagnosis, and treatment strategies for women and men. In this way, sex-specific clinical guidelines can be developed where warranted.

Intensive Blood Pressure Treatment Goals: Evidence for Cardiovascular Protection From Observational Studies and Clinical Trials

Epidemiologic studies have consistently identified a strong, progressive relationship between blood pressure (BP) and cardiovascular disease (CVD) events, in a range of systolic BP (SBP) from as low as 90 mm Hg to as high as 180 mm Hg. Clinical trials have demonstrated greater prevention of CVD with more compared with less intensive antihypertensive drug treatment. Meta-analyses of randomized controlled trials provide strong evidence for more intensive antihypertensive drug therapy down to an SBP of 130 mm Hg, and to an SBP 120-124 mm Hg in the meta-analysis with the greatest statistical power. In the Systolic Blood Pressure Intervention Trial (SPRINT) randomization to an SBP treatment goal of <120 mm Hg compared with <140 mm Hg in persons with high CVD risk not only reduced the rate of CVD but also all-cause mortality. These benefits were noted in all of the prestated subgroups of interest, including those ≥65 years of age at baseline. In addition, cognitive impairment was less common in those randomized to the intensive compared with standard treatment. Most clinical practice guidelines recommend an SBP treatment target <130 mm Hg in adults with a high risk of CVD, which is the norm for many patients seen in clinical practice, especially those who are older, have diabetes mellitus, or chronic kidney disease.

High incidence of hypertension-mediated organ damage in a series of Chinese patients with 17α-hydroxylase deficiency

OBJECTIVE

To analyze the prevalence of hypertension-mediated organ damage (HMOD) and its relationship with enzyme activity of mutant CYP17A1 and other risk factors in patients with 17α-hydroxylase/17,20-lyase deficiency (17-OHD).

METHODS

A total of 68 patients with 17-OHD were recruited in the Peking Union Medical College Hospital from 2003 to 2021. The incidence of hypertension and HMOD was respectively analyzed. CYP17A1 sequencing was performed and the enzyme activity of mutant CYP17A1 was determined by analyzing the characteristics of mutation itself and the functional data reported previously. A logistic regression model was employed to analyze the factors related to HMOD and the specific damaged organs in 17-OHD patients.

RESULT(S)

Sixty-five patients (95.6%) exhibited hypertension, 32 of whom were diagnosed with HMOD. c.985_987delTACinsAA (p.Y329KfsX418) (53.8%) and c.1459_1467del (p. del D487_F489) (11.4%) were the top two mutations, and no correlation was found between enzyme activity of mutant CYP17A1 and HMOD. The risk of HMOD increased by 32% for each additional year of hypertension duration, 10.2-fold for each one-grade increase in hypertension level, 2.3-fold for each grade of exacerbation of hypokalemia.

CONCLUSION

Patients with 17-OHD experience a high incidence of HMOD. There was no correlation between the HMOD occurrence and enzyme activity of mutant CYP17A1. Longer duration of hypertension, more severe hypertension, and hypokalemia were independent risk factors for the occurrence of HMOD in patients with 17-OHD.

Hypertension outcomes of adrenalectomy for unilateral primary aldosteronism

PURPOSE

To evaluate laboratory and clinical results after unilateral adrenalectomy in patients with primary aldosteronism (PHA).

METHODS

A cross-sectional analysis was performed using data from patients who underwent transperitoneal laparoscopic adrenalectomy for PHA, between January 2008 and December 2019. Surgical indications were based on adrenal venous sampling without ACTH stimulation. Analyses included patient demographics; preoperative clinical, pharmacological, laboratory, and radiological data; and postoperative results assessed after a median of 4 months. Antihypertensive drug use was quantified by estimating the daily defined dose (DDD) of antihypertensive medication, thus enabling standardized comparison of dosage between the drug classes. Statistical assessments included univariable and multivariable logistic regression analysis.

RESULTS

This study enrolled 87 patients. The patients were taking 5.4 DDD of antihypertensive medication before surgery, and 3.0 DDD after surgery. Complete biochemical success of surgery was reached 67 patients (77%), 19 patients (22%) had partial biochemical success. Complete clinical success with normalization of blood pressure and withdrawal of all antihypertensive drugs was achieved in 19 patients (22%). 57 patients (65%) exhibited a reduction of DDD after surgery and/or improvement of blood pressure-partial clinical success. Thus, in 76 (87%) of all enrolled patients, surgery had an overall positive effect on hypertension control. Multivariable logistic regression showed that complete clinical success was independently associated with female gender and baseline sum of antihypertensive drugs DDD < 4.

CONCLUSION

A majority of patients undergoing unilateral adrenalectomy for PHA achieved markedly improved hypertension control, despite almost halving their antihypertensive medication. Almost a quarter of patients were cured and able to cease using all antihypertensive drugs.

Lack of Effects of Renin-Angiotensin-Aldosterone System Activity and Beta-Adrenoceptor Pathway Polymorphisms on the Response to Bisoprolol in Hypertension

PURPOSE

This study examined the effects of plasma renin activity (PRA), angiotensin II (Ang II) and aldosterone (PAC) concentrations as well as common polymorphisms in the β1-Adrenoceptor gene (ADRB1) and the G-protein α-Subunit (Gαs) protein gene the G protein α-Subunit 1 gene (GNAS) on the blood pressure (BP) and heart rate (HR) response to bisoprolol in Chinese patients with hypertension.

METHODS

Patients with sitting clinic systolic BP (SBP) 140-169 mmHg and/or diastolic BP (DBP) 90-109 mmHg after placebo run-in were treated with open-label bisoprolol 2.5 mg daily for 6 weeks. Patients diagnosed as having primary aldosteronism or renal artery stenosis were excluded. PRA, Ang II and PAC concentrations were measured after the placebo run-in and after 6 weeks of treatment. The Ser49Gly and Arg389Gly polymorphisms in ADRB1 and the c.393C > T polymorphism in GNAS were genotyped by the TaqMan® assay.

RESULTS

In 99 patients who completed the study, baseline PAC levels were significantly associated with baseline DBP and plasma potassium on univariate but not on multivariate linear regression analysis. PRA, Ang II, and PAC concentrations at baseline were not associated with changes in BP with bisoprolol treatment, but the values were all significantly reduced (PRA -0.141 ± 0.595 ng/mL/h, Ang II -2.390 ± 5.171 pmol/L and aldosterone -51.86 ± 119.1 pg/mL; all P < 0.05) following 6 weeks of bisoprolol treatment. There were no significant differences in BP or HR responses in patients with baseline PRA above or below the PRA cut-point of 0.65 ng/mL/h or the median value of 0.9 ng/ml/hour. There were no significant associations of the ADRB1 and GNAS polymorphisms with the clinic and ambulatory BP and HR responses to bisoprolol.

CONCLUSION

Baseline PRA, PAC and Ang II concentrations showed no significant association with the BP response to bisoprolol treatment, but all these parameters were reduced after 6 weeks of treatment with bisoprolol. The two common polymorphisms in ADRB1 and the c.393C > T polymorphism in GNAS had no significant association with the BP and HR response to bisoprolol in these patients.

Treating hypertension with a pill containing very low doses of four antihypertensive agents compared with standard dose irbesartan

Commentary on: Chow CK, Atkins ER, Hillis GS, et al Initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy in patients with hypertension (QUARTET): a phase 3, randomised, double-blind, active-controlled trial. Lancet 2021;398:1043-52. Series co-ordinator: Dr Teck Khong, DTB Associate Editor Clinical Pharmacology, St George's, University of London, UK.

International Guidelines for Hypertension: Resemblance, Divergence and Inconsistencies

High blood pressure is the number one killer in the world. About 1.5 billion people suffered from hypertension in 2010, and these numbers are increasing year by year. The basics of the management of high blood pressure are described in the Canadian, American, International and European guidelines for hypertension. However, there are similarities and differences in the definition, measurement and management of blood pressure between these different guidelines. According to the Canadian guidelines, normal blood pressure is less than 140/90 mmHg (systolic blood pressure/diastolic blood pressure). The AHA and ESC estimate normal blood pressure to be less than 120/80 mmHg (systolic blood pressure/diastolic blood pressure). Regarding treatments, the AHA, ISH and ESC are also in agreement about dual therapy as the first-line therapy, while Canadian recommendations retain the idea of monotherapy as the initiation of treatment. When it comes to measuring blood pressure, the four entities agree on the stratification of intervention in absolute cardiovascular risk.

[Arterial Hypertension]

Arterial hypertension affects about one third of the German population with a prevalence increasing with age up to 60 %. Globally, more than a quarter gedoppelt of the population are considered hypertensive, resulting in a total of more than one billion people. Not only due to such high prevalence, but also because of its multiple cardiovascular, renal, ocular, and cognitive complications, arterial hypertension is a leading contributor to the global burden of disease and responsible for up to 10 million deaths worldwide. Contrary to the great importance of arterial hypertension resulting from such high prevalence and immense impact on health worldwide, awareness of disease is low in affected people. Less than every second patient knows about his or her disease status and less than 40 % of patients in Europe show adequate blood pressure control with a treatment target of < 140/90 mmHg despite antihypertensive treatment. This overview of arterial hypertension, its etiology, diagnostic tools, and therapeutic options aims to improve the understanding of arterial hypertension and to facilitate the diagnostic and therapeutic approach, eventually resulting in a better and more successful handling of patients with arterial hypertension.

New onset hypertension after transplantation

It has been reported that up to 90% of organ transplant recipients have suboptimal blood pressure control. Uncontrolled hypertension is a well-known culprit of cardiovascular and overall morbidity and mortality. In addition, rigorous control of hypertension after organ transplantation is a crucial factor in prolonging graft survival. Nevertheless, hypertension after organ transplantation encompasses a broader range of causes than those identified in non-organ transplant patients. Hence, specific management awareness of those factors is mandated. An in-depth understanding of hypertension after organ transplantation remains a debatable issue that necessitates further clarification. This article provides a comprehensive review of the prevalence, risk factors, etiology, complications, prevention, and management of hypertension after organ transplantation.

A Systematic Review on Processed/Ultra-Processed Foods and Arterial Hypertension in Adults and Older People

The increase in the availability of processed and ultra-processed foods has altered the eating patterns of populations, and these foods constitute an exposure factor for the development of arterial hypertension. This systematic review analyzed evidence of the association between consumption of processed/ultra-processed foods and arterial hypertension in adults and older people. Electronic searches for relevant articles were performed in the PUBMED, EMBASE and LILACS databases. The review was conducted following the PRISMA guidelines and the Newcastle–Ottawa Scale. The search of the databases led to the retrieval of 2323 articles, eight of which were included in the review. A positive association was found between the consumption of ultra-processed foods and blood pressure/arterial hypertension, whereas insufficient evidence was found for the association between the consumption of processed foods and arterial hypertension. The results reveal the high consumption of ultra-processed foods in developed and middle-income countries, warning of the health risks of such foods, which have a high energy density and are rich in salt, sugar and fat. The findings underscore the urgent need for the adoption of measures that exert a positive impact on the quality of life of populations, especially those at greater risk, such as adults and older people.

Association between four-limb blood pressure differences and arterial stiffness: a cross-sectional study

OBJECTIVES

Although inter-arm blood pressure difference (IAD) and inter-ankle blood pressure difference (IAND) have been shown to be associated with cardiovascular disease, controversy remains. In this study, we investigated the prevalence of IAD and IAND as well as the correlation with arterial stiffness and systolic blood pressure in a large number of the Chinese population.

METHODS

The four-limb blood pressure, IAD, IAND, brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) of 12,176 participants have been measured. Multivariate logistic regression analysis was used to analyze the relationship of the increase in IAD/IAND with arterial stiffness and blood pressure. Reporting adheres to the STROBE guidelines.

RESULTS

In 12,176 participants, 1832 (15%) subjects had an IAD≥10 mmHg, 663 (5%) had an IAD≥15 mmHg, and 291 (2%) had an IAD≥20 mmHg. Correspondingly, 4548 (37%) had an IAND≥10 mmHg, 2706 (22%) had an IAND≥15 mmHg, and 1706 (14%) had an IAND≥20 mmHg. baPWV was significantly higher in those with an IAD≥10 mmHg (1881 ± 487 cm/s vs. 1943 ± 508 cm/s, P = 0.036) and IAND≥10 mmHg (1850 ± 476 cm/s vs. 1955 ± 509 cm/s, P = 0.000). Compared to others, those with IAD or IAND≥10 mmHg had higher systolic blood pressure (SBP), higher prevalence of hypertension, larger male gender ratio, bigger body mass index, higher pulse rate and lower ABI (P < 0.001 for all). A significant association with baPWV was observed for IAND≥10 mmHg (OR = 1.117; 95%CI: 1.039-1.201; P = 0.003) not for IAD≥10 mmHg (OR = 0.771; 95%CI: 0.699-0.851; P = 0.000) in multivariate logistic regression analysis.

CONCLUSIONS

Limb blood pressure differences were closely related to arterial stiffness and systolic blood pressure, allowing for a more comprehensive assessment of cardiovascular risk.

Quality of life and cognitive assessment in healthy older Asian people with early and moderate chronic kidney disease: The NAHSIT 2013–2016 and validation study

Background

Taiwan has the highest prevalence of chronic kidney disease (CKD). Impaired cognition and quality of life are significant phenomena in the late stages of CKD. We sought to obtain an overview and the attributable effect of impaired glomerular filtration on multiple domains in cognition and dimensions of quality of life for community-based healthy older adults in Taiwan.

Methods

The study was derived from the Nutrition and Health Survey in Taiwan (NAHSIT) 2013–2016, a nationwide cross-sectional study conducted to sample healthy, community-based older adults aged ≥65 years in Taiwan. Participants were categorized into four CKD groups: CKD stage 1, stage 2, stages 3a and 3b, and stages 4–5. The Mini-Mental State Examination (MMSE) and the QoL questionnaire derived from the 12-item Short Form Health Survey (SF-12) were measured. Generalized linear mixed models (GLMMs) and principal component regressions were employed for the analysis and validation, respectively.

Results

Participants with moderate CKD (stages 3a and 3b) showed deficits in global MMSE, domain orientation to time, calculation, complex commands, and role-physical and vitality in QoL questionnaires. In GLMMs, impaired eGFR per 30 mL/min/1.73 m² was associated with lower global MMSE scores (β = -0.807, standard error [SE] = 0.235, P = 0.0007), domain orientation to time (β = -0.155, SE = 0.047, P = 0.0011), calculation (β = -0.338, SE = 0.109, P = 0.0020), complex commands (β = -0.156, SE = 0.079, P = 0.0494), and role-physical (β = -2.219, SE = 0.779, P = 0.0046) dimensions of QoL.

Conclusions

Elderly Han Chinese adults with moderately impaired renal filtration could manifest cognitive deficits in orientation to time, calculation, and impaired quality of life in physical role functioning.

Associations of Renalase With Blood Pressure and Hypertension in Chinese Adults

Objective

Renalase, a novel secretory flavoprotein with amine oxidase activity, is secreted into the blood by the kidneys and is hypothesized to participate in blood pressure (BP) regulation. We investigated the associations of renalase with BP and the risk of hypertension by examining renalase single nucleopeptide polymorphism (SNPs), serum renalase levels, and renal expression of renalase in humans.

Methods

① Subjects (n = 514) from the original Baoji Salt-Sensitive Study cohort were genotyped to investigate the association of renalase SNPs with longitudinal BP changes and the risk of hypertension during 14 years of follow-up. ② Two thousand three hundred and ninety two participants from the Hanzhong Adolescent Hypertension Study cohort were used to examine the association of serum renalase levels with hypertension. Renalase expression in renal biopsy specimens from 193 patients were measured by immunohistochemistry. ③ Renalase expression was compared in hypertensive vs. normotensive patients.

Results

① SNP rs7922058 was associated with 14-year change in systolic BP, and rs10887800, rs796945, rs1935582, rs2296545, and rs2576178 were significantly associated with 14-year change in diastolic BP while rs1935582 and rs2576178 were associated with mean arterial pressure change over 14 years. In addition, SNPs rs796945, rs1935582, and rs2576178 were significantly associated with hypertension incidence. Gene-based analysis found that renalase gene was significantly associated with hypertension incidence over 14-year follow-up after adjustment for multiple measurements. ② Hypertensive subjects had higher serum renalase levels than normotensive subjects (27.2 ± 0.4 vs. 25.1 ± 0.2 μg/mL). Serum renalase levels and BPs showed a linear correlation. In addition, serum renalase was significantly associated with the risk of hypertension [OR = 1.018 (1.006–1.030)]. ③ The expression of renalase in human renal biopsy specimens significantly decreased in hypertensive patients compared to non-hypertensive patients (0.030 ± 0.001 vs. 0.038 ± 0.004).

Conclusions

These findings indicate that renalase may play an important role in BP progression and development of hypertension.