2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Sodium Intake and Target Organ Damage in Hypertension-An Update about the Role of a Real Villain

Salt intake is too high for safety nowadays. The main active ion in salt is sodium. The vast majority of scientific evidence points out the importance of sodium restriction for decreasing cardiovascular risk. International Guidelines recommend a large reduction in sodium consumption to help reduce blood pressure, organ damage, and cardiovascular risk. Regulatory authorities across the globe suggest a general restriction of sodium intake to prevent cardiovascular diseases. In spite of this seemingly unanimous consensus, some researchers claim to have evidence of the unhealthy effects of a reduction of sodium intake, and have data to support their claims. Evidence is against dissenting scientists, because prospective, observational, and basic research studies indicate that sodium is the real villain: actual sodium consumption around the globe is far higher than the safe range. Sodium intake is directly related to increased blood pressure, and independently to the enlargement of cardiac mass, with a possible independent role in inducing left ventricular hypertrophy. This may represent the basis of myocardial ischemia, congestive heart failure, and cardiac mortality. Although debated, a high sodium intake may induce initial renal damage and progression in both hypertensive and normotensive subjects. Conversely, there is general agreement about the adverse role of sodium in cerebrovascular disease. These factors point to the possible main role of sodium intake in target organ damage and cardiovascular events including mortality. This review will endeavor to outline the existing evidence.

Practical recommendations for the use of beta-blockers in chronic obstructive pulmonary disease

INTRODUCTION

Controversies regarding the use of beta-blocker in chronic obstructive pulmonary disease (COPD) have been longstanding and based on inconsistent data. COPD and cardiovascular disease have many shared risk factors and potentially overlapping pathophysiologic mechanisms. Beta-blockers, a mainstay of treatment in ischemic heart disease, congestive heart failure, and cardiac arrhythmia, remain underutilized in COPD patients despite considerable evidence of safety. Furthermore, observational studies indicated the potential benefits of beta-blockers in COPD via a variety of possible mechanisms. Recently, a randomized controlled trial of metoprolol versus placebo failed to show a reduction in COPD exacerbation risk in subjects with moderate to severe COPD and no absolute indication for beta-blocker use.

AREAS COVERED

Physiology of beta-adrenergic receptors, links between COPD and cardiovascular disease, and the role of beta-blockers in COPD management are discussed.

EXPERT COMMENTARY

Beta-blockers should not be used to treat COPD patients who do not have conditions with clear guideline-directed recommendations for their use. Vigilance is recommended in prescribing these medications for indications where another drug class could be utilized.

Prevention and management of cardiovascular disease in patients with diabetes: current challenges and opportunities

More than 100 million people in the USA have diabetes or prediabetes and are at high risk for developing cardiovascular disease. Current evidence-based guidelines support a multifactorial approach in patients with diabetes, including lifestyle intervention and pharmacological treatment of hyperglycemia, hypertension, and dyslipidemia. In addition, recent cardiovascular outcome trials demonstrated that sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists improve cardiovascular outcomes in patients with diabetes. Albeit this evidence, over 80% of patients with diabetes do not achieve the recommended treatment goals. Considering the rising burden of cardiovascular complications, there is need to improve the quality of care in patients with diabetes. In this review, we discuss the current quality of health care in patients with diabetes in the USA, identify barriers to achieve guideline-recommended treatment goals and outline opportunities for the improvement in caring for patients with diabetes.

The Associations between Liver Enzymes and Cardiovascular Risk Factors in Adults with Mild Dyslipidemia

Hypertension and dyslipidemia often occur as comorbidities, with both being strong risk factors for developing cardiovascular diseases (CVD). Abnormal liver function test could reflect a potential CVD risk even in patients with mild dyslipidemia. The aim of this study was to assess the compounding relationship between liver enzymes and cardiovascular risk factors in subjects with mild dyslipidemia. The present analysis was performed among 438 participants who had enrolled in at least one of the nine clinical studies done at the Chonbuk National University Hospital between 2009 and 2019. Significant linear increasing trends were observed in blood pressure level and other cardiovascular risk factors across quartiles of serum γ-glutamyltransferase (GGT) or alanine aminotransferase (ALT), with the increment in hypertension prevalence occurring across the quartiles of GGT and ALT. On multivariate logistic regression analyses, the odds ratios for hypertension, adjusted for smoking, drinking and obesity, in the highest quartiles of GGT, ALT, aspartate aminotransferase, and alkaline phosphatase were 3.688, 1.617, 1.372, and 1.166, respectively. Our study indicates that GGT is a superior marker for predicting CVD risk among liver enzymes. Routine screening of plasma GGT levels in patients with mild dyslipidemia will allow for early detection of CVD.

A roadmap to build a phenotypic metric of ageing: insights from the Baltimore Longitudinal Study of Aging

Over the past three decades, considerable effort has been dedicated to quantifying the pace of ageing yet identifying the most essential metrics of ageing remains challenging due to lack of comprehensive measurements and heterogeneity of the ageing processes. Most of the previously proposed metrics of ageing have been emerged from cross-sectional associations with chronological age and predictive accuracy of mortality, thus lacking a conceptual model of functional or phenotypic domains. Further, such models may be biased by selective attrition and are unable to address underlying biological constructs contributing to functional markers of age-related decline. Using longitudinal data from the Baltimore Longitudinal Study of Aging (BLSA), we propose a conceptual framework to identify metrics of ageing that may capture the hierarchical and temporal relationships between functional ageing, phenotypic ageing and biological ageing based on four hypothesized domains: body composition, energy regulation, homeostatic mechanisms and neurodegeneration/neuroplasticity. We explored the longitudinal trajectories of key variables within these phenotypes using linear mixed-effects models and more than 10 years of data. Understanding the longitudinal trajectories across these domains in the BLSA provides a reference for researchers, informs future refinement of the phenotypic ageing framework and establishes a solid foundation for future models of biological ageing.

The relationship between mean telomere length and blood pressure: results from the National Health and Nutrition Examination Surveys

Background

Recent studies have shown that telomere length has significantly relationship with different age-related diseases. However, the relationship between mean telomere length (MTL) and elevated blood pressure (BP) has been unclear. Therefore, the aim of the recent study was tried to explore the association of MLT with BP.

Methods

There were 5,981 subjects from the National Health and Nutrition Examination Surveys (NHANES, 1999–2002) was included in analysis. The MTL was measured using the quantitative polymerase chain reaction (PCR) method and expressed in telomere-to-single copy gene (T/S) ratio and grouped into quartiles. Multivariate linear [expressed in beta and 95% confidence interval (CI)], logistic regression [odds ratios (ORs) and 95% CI] analyses and smooth curve fitting were performed to evaluate the relationship between MTL, BPs and the likelihood of hypertension.

Results

The mean age of the participants was 45.2±17.3 years, including 2,923 (48.9%) males. After adjusting for potential confounders, MLT was significantly related to the prevalence of hypertension (OR: 0.12, 95% CI: 0.02, 0.94; P=0.04). Smooth curve fitting found a non-linear relationship between MTL, the levels of systolic and diastolic blood pressure (SBP/DBP) and the prevalence of hypertension. The inflection points for the smooth curve of MLT were at 0.86, 1.02 and 0.80 (T/S ratio) respectively. The betas (95% CIs) for SBP [–12.58 (–20.07, –5.09), P<0.01 and 2.25 (0.07, 4.43), P=0.04] and DBP [4.88 (1.29, 8.47), P<0.01 and –3.30 (–5.54, –1.06), P<0.01], and ORs (95% CIs) for the prevalence of hypertension [0.02 (0.001, 9.71), P=0.15 and 0.26 (0.026, 2.60), P=0.25] on the left and right of the inflection point, respectively.

Conclusions

Our findings revealed that MTL was related with SBP, DBP and the odds of hypertension in a non-linear manner.

Are Blood Pressure and Cardiovascular Stress Greater in Isometric or in Dynamic Resistance Exercise?

Medical and sports medicine associations are reluctant to endorse isometric exercise to the same extent as dynamic resistance exercise (RE). The major concern is the fear of greater increases in blood pressure (BP) that might be associated with isometric exercise. This review comprehensively presents all human studies that directly compared the magnitude of hemodynamic responses between isometric and dynamic RE. We also discuss possible mechanisms controlling BP-response and cardiovascular adjustments during both types of RE. The most prominent finding was that isometric and dynamic RE using small-muscle mass evoke equal increases in BP; however, the circulatory adjustments contributing to this response are different in dynamic and isometric RE. In contrast, studies using large-muscle mass report inconsistent results for the magnitude of BP-response between the two types of RE. Thus, when the same muscles and workloads are used, the increase in BP during isometric and dynamic RE is more comparable to what is commonly believed. However, it should be noted that only a few studies equalized the workload in two types of RE, most used small sample sizes, and all studies employed healthy participants. More studies are needed to compare the cardiovascular risks associated with isometric and dynamic RE, especially in individuals with chronic disease.

Intestinal Flora Modulates Blood Pressure by Regulating the Synthesis of Intestinal-Derived Corticosterone in High Salt-Induced Hypertension

Rationale:

High-salt diet is one of the most important risk factors for hypertension. Intestinal flora has been reported to be associated with high salt–induced hypertension (hSIH). However, the detailed roles of intestinal flora in hSIH pathogenesis have not yet been fully elucidated.

Objective:

To reveal the roles and mechanisms of intestinal flora in hSIH development.

Methods and Results:

The abovementioned issues were investigated using various techniques including 16S rRNA gene sequencing, untargeted metabolomics, selective bacterial culture, and fecal microbiota transplantation. We found that high-salt diet induced hypertension in Wistar rats. The fecal microbiota of healthy rats could dramatically lower blood pressure (BP) of hypertensive rats, whereas the fecal microbiota of hSIH rats had opposite effects. The composition, metabolism, and interrelationship of intestinal flora in hSIH rats were considerably reshaped, including the increased corticosterone level and reduced Bacteroides and arachidonic acid levels, which tightly correlated with BP. The serum corticosterone level was also significantly increased in rats with hSIH. Furthermore, the above abnormalities were confirmed in patients with hypertension. The intestinal Bacteroides fragilis could inhibit the production of intestinal-derived corticosterone induced by high-salt diet through its metabolite arachidonic acid.

Conclusions:

hSIH could be transferred by fecal microbiota transplantation, indicating the pivotal roles of intestinal flora in hSIH development. High-salt diet reduced the levels of B fragilis and arachidonic acid in the intestine, which increased intestinal-derived corticosterone production and corticosterone levels in serum and intestine, thereby promoting BP elevation. This study revealed a novel mechanism different from inflammation/immunity by which intestinal flora regulated BP, namely intestinal flora could modulate BP by affecting steroid hormone levels. These findings enriched the understanding of the function of intestinal flora and its effects on hypertension.

Leveraging the Electronic Health Records for Population Health: A Case Study of Patients With Markedly Elevated Blood Pressure

Background

The digital transformation of medical data provides opportunities to perform digital population health surveillance and identify people inadequately managed in usual care. We leveraged the electronic health records of a large health system to identify patients with markedly elevated blood pressure and characterize their follow‐up care pattern.

Methods and Results

We included 373 861 patients aged 18 to 85 years, who had at least 1 outpatient encounter in the Yale New Haven Health System between January 2013 and December 2017. We described the prevalence and follow‐up pattern of patients with at least 1 systolic blood pressure (SBP) ≥160 mm Hg or diastolic blood pressure (DBP) ≥100 mm Hg and patients with at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Of 373 861 patients included, 56 909 (15.2%) had at least 1 SBP ≥160 mm Hg or DBP ≥100 mm Hg, and 10 476 (2.8%) had at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Among patients with SBP ≥160 mm Hg or DBP ≥100 mm Hg, only 28.3% had a follow visit within 1 month (time window of follow‐up recommended by the guideline) and 19.9% subsequently achieved control targets (SBP <130 mm Hg and DBP <80 mm Hg) within 6 months. Follow‐up rate at 1 month and control rate at 6 months for patients with SBP ≥180 mm Hg or DBP ≥120 mm Hg was 31.9% and 17.2%.

Conclusions

Digital population health surveillance with an electronic health record identified a large number of patients with markedly elevated blood pressure and inadequate follow‐up. Many of these patients subsequently failed to achieve control targets.

Angiotensin III/AT2 Receptor/NHE3 Signaling Pathway in the Proximal Tubules of the Kidney: A Novel Natriuretic and Antihypertensive Mechanism in Hypertension

See Article Kemp et al

QTc Interval Predicts Disturbed Circadian Blood Pressure Variation

Background

The relationship between electrocardiographic evaluation and circadian blood pressure (BP) variation in young and middle-aged hypertensive patients remains unknown.

Methods

A total of 171 hypertensive patients were included in the study. First, patients were divided into a young and middle-aged group and an elderly group. The two groups were then separately classified into three subgroups on the basis of circadian variation of BP as dippers, non-dippers and reverse-dippers. The electrocardiographic evaluation was calculated from 12-lead electrocardiography (ECG).

Results

QTc intervals were shortest in the dippers and longest in the reverse-dippers in the young and middle-aged group (QTc dipper: 416.53±18.37ms; non-dipper: 438.30±29.71ms; reverse-dipper: 444.93±25.47ms; for dipper vs non-dipper, and dipper vs reverse-dipper P<0.05). QTc interval was found to be an independent risk factor for the non-dipper BP pattern (Odds ratio 1.049; 95% CI 1.01-1.089; P=0.012) and reverse-dipper BP pattern (Odds ratio 1.051; 95% CI 1.007-1.098; P=0.023) in young and middle-aged hypertensive patients. No significant differences in other ECG parameters were found among the three subgroups in the young and middle-aged group.

Conclusion

Our study suggested that QTc interval might serve as a risk factor for non-dipper BP pattern and reverse-dipper BP pattern in young and middle-aged hypertensive patients.

Hypertension and incident cardiovascular events following ibrutinib initiation

Ibrutinib is associated with dramatic efficacy against B-cell malignancies. Yet, it has been linked with potentially limiting cardiotoxicity, including emerging reports of profound hypertension (HTN). The long-term incidence, severity, and impact of HTN development with ibrutinib are unknown. Therefore, in 562 consecutive patients treated with ibrutinib for B-cell malignancies from 2009 through 2016, we assessed the new/incident or worsened HTN (systolic blood pressure [BP] cutoff, 130 mm Hg). Observed incident HTN rates were compared with Framingham-heart-predicted incident HTN rates. We also evaluated the relationship of HTN to the development of other major adverse cardiovascular events (MACEs), including arrhythmia, myocardial infarction, stroke, heart failure, and cardiovascular death. Further, we assessed the effects of different antihypertensive classes on ibrutinib-related HTN. Overall, 78.3% of ibrutinib users developed new or worsened HTN over a median of 30 months. New HTN developed in 71.6% of ibrutinib users, with a time to 50% cumulative incidence of 4.2 months. Among those without preceding HTN, 17.7% developed high-grade HTN (BP >160/100 mm Hg). In multivariate regression, new or worsened HTN was associated with increased MACEs (hazard ratio [HR], 2.17; 95% confidence interval [CI], 1.08-4.38). No single antihypertensive class was associated with prevention or control of ibrutinib-related HTN. However, antihypertensive initiation was associated with a lower risk of a MACE (HR, 0.40; 95% CI, 0.24-0.66). Collectively, these data suggest that ibrutinib is associated with a substantial increase in the incidence and severity of HTN, and that HTN development carries a higher risk of subsequent cardiotoxic events.

Genomics of Blood Pressure and Hypertension: Extending the Mosaic Theory Toward Stratification

The genetic architecture of blood pressure (BP) now includes more than 30 genes, with rare mutations resulting in inherited forms of hypertension or hypotension, and 1477 common single-nucleotide polymorphisms (SNPs). These signify the heterogeneity of the BP phenotype and support the mosaic theory of hypertension. The majority of monogenic syndromes involve the renin-angiotensin-aldosterone system and the adrenal glucocorticoid pathway, and a smaller fraction are due to rare neuroendocrine tumours of the adrenal glands and the sympathetic and parasympathetic paraganglia. Somatic mutations in genes coding for ion channels (KCNJ5 and CACNA1D) and adenosine triphosphatases (ATP1A1 and ATP2B3) highlight the central role of calcium signalling in autonomous aldosterone production by the adrenal gland. The per-SNP BP effect is small for SNPs according to genome-wide association studies (GWAS), and all of the GWAS-identified BP SNPs explain ∼ 27% of the 30%-50% estimated heritability of BP. Uromodulin is a novel pathway identified by GWAS, and it has now progressed to a genotype-directed clinical trial. The majority of the GWAS-identified BP SNPs show pleiotropic associations, and unravelling those signals and underpinning biological pathways offers potential opportunities for drug repurposing. The GWAS signals are predominantly from Europe-centric studies with other ancestries underrepresented, however, limiting the generalisability of the findings. In this review, we leverage the burgeoning list of polygenic and monogenic variants associated with BP regulation along with phenome-wide studies in the context of the mosaic theory of hypertension, and we explore potential translational aspects that underlie different hypertension subtypes.

Intensive vs Standard Blood Pressure Control in Adults 80 Years or Older: A Secondary Analysis of the Systolic Blood Pressure Intervention Trial

OBJECTIVES

To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function.

DESIGN

Secondary analysis.

SETTING

Systolic Blood Pressure Intervention Trial (SPRINT) PARTICIPANTS: Adults 80 years or older.

INTERVENTION

Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment).

MEASUREMENTS

We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4-m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function.

RESULTS

Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] = .66; 95% confidence interval [CI] = .49-.90), mortality (HR = .67; 95% CI = .48-.93), and MCI (HR = .70; 95% CI = .51-.96). There was a significant interaction (P < .001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR = .40; 95% CI = .28-.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI = .87-2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between-group differences in the rate of injurious falls.

CONCLUSION

In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01206062. J Am Geriatr Soc 68:496-504, 2020.

Understanding and managing cardiovascular outcomes in liver transplant recipients

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is a common cause of mortality after liver transplantation. The transplant community is focused on improving long-term survival. Understanding the prevalence of CVD in liver transplant recipients, precipitating factors as well as prevention and management strategies is essential to achieving this goal.

RECENT FINDINGS

CVD is the leading cause of death within the first year after transplant. Arrhythmia and heart failure are the most often cardiovascular morbidities in the first year after transplant which could be related to pretransplant diastolic dysfunction. Pretransplant diastolic dysfunction is reflective of presence of cirrhotic cardiomyopathy which is not as harmless as it was thought. Multiple cardiovascular risk prediction models have become available to aid management in liver transplant recipients.

SUMMARY

A comprehensive prevention and treatment strategy is critical to minimize cardiovascular morbidity and mortality after liver transplant. Weight management and metabolic syndrome control are cornerstones to any prevention and management strategy. Bariatric surgery is an underutilized tool in liver transplant recipients. Awareness of 'metabolic-friendly' immunosuppressive regimens should be sought. Strict adherence to the cardiology and endocrine society guidelines with regard to managing metabolic derangements post liver transplantation is instrumental for CVD prevention until transplant specific recommendations can be made.

Implant-Mediated Therapy of Arterial Hypertension

PURPOSE OF REVIEW

To give an overview on recent developments in permanent implant-based therapy of resistant hypertension.

RECENT FINDINGS

The American Heart Association (AHA) recently updated their guidelines to treat high blood pressure (BP). As elevated BP now is defined as a systolic BP above 120 mmHg, the prevalence of hypertension in the USA has increased from 32% (old definition of hypertension) to 46%. In the past years, device- and implant-mediated therapies have evolved and extensively studied in various patient populations. Despite an initial drawback in a randomized controlled trial (RCT) of bilateral carotid sinus stimulation (CSS), new and less invasive and unilateral systems for baroreflex activation therapy (BAT) with the BAROSTIM NEO® have been developed which show promising results in small non-randomized controlled (RCT) studies. Selective vagal nerve stimulation (VNS) has been successfully evaluated in rodents, but has not yet been tested in humans. A new endovascular approach to reshape the carotid sinus to lower BP (MobiusHD™) has been introduced (baroreflex amplification therapy) with favorable results in non-RCT trials. However, long-term results are not yet available for this treatment option. A specific subgroup of patients, those with indication for a 2-chamber cardiac pacemaker, may benefit from a new stimulation paradigm which reduces the AV latency and therefore limits the filling time of the left ventricle. The most invasive approach for resistant hypertension still is the neuromodulation by deep brain stimulation (DBS), which has been shown to significantly lower BP in single cases. Implant-mediated therapy remains a promising approach for the treatment of resistant hypertension. Due to their invasiveness, such treatment options must prove superiority over conventional therapies with regard to safety and efficacy before they can be generally offered to a wider patient population. Overall, BAROSTIM NEO® and MobiusHD™, for which large RCTs will soon be available, are likely to meet those criteria and may represent the first implant-mediated therapeutical options for hypertension, while the use of DBS probably will be reserved for individual cases. The utility of VNS awaits appropriate assessment.

Lifestyle Changes in Relation to Initiation of Antihypertensive and Lipid-Lowering Medication: A Cohort Study

Background Lifestyle modification is a key component of cardiovascular disease prevention before and concurrently with pharmacologic interventions. We evaluated whether lifestyle factors change in relation to the initiation of antihypertensive or lipid-lowering medication (statins). Methods and Results The study population comprised 41 225 participants of the FPS (Finnish Public Sector) study aged ≥40 years who were free of cardiovascular disease at baseline and responded to ≥2 consecutive surveys administered in 4-year intervals in 2000-2013. Medication use was ascertained through pharmacy-claims data. Using a series of pre-post data sets, we compared changes in body mass index, physical activity, alcohol consumption, and smoking between 8837 initiators and 46 021 noninitiators of antihypertensive medications or statins. In participants who initiated medication use, body mass index increased more (difference in change 0.19; 95% CI, 0.16-0.22) and physical activity declined (-0.09 metabolic equivalent of task hour/day; 95% CI, -0.16 to -0.02) compared with noninitiators. The likelihood of becoming obese (odds ratio: 1.82; 95% CI, 1.63-2.03) and physically inactive (odds ratio: 1.08; 95% CI, 1.01-1.17) was higher in initiators. However, medication initiation was associated with greater decline in average alcohol consumption (-1.85 g/week; 95% CI, -3.67 to -0.14) and higher odds of quitting smoking (odds ratio for current smoking in the second survey: 0.74; 95% CI, 0.64-0.85). Conclusions These findings suggest that initiation of antihypertensive and statin medication is associated with lifestyle changes, some favorable and others unfavorable. Weight management and physical activity should be encouraged in individuals prescribed these medications.

(-)-Epicatechin Reduces the Blood Pressure of Young Borderline Hypertensive Rats During the Post-Treatment Period

This study investigated the effects of (–)-epicatechin (Epi) in young male borderline hypertensive rats (BHR) during two weeks of treatment (Epi group, 100 mg/kg/day p.o.) and two weeks post treatment (PE group). Epi reduced blood pressure (BP), which persisted for two weeks post treatment. This was associated with delayed reduction of anxiety-like behaviour. Epi significantly increased nitric oxide synthase (NOS) activities in the aorta and left heart ventricle (LHV) vs. the age-matched controls without affecting the brainstem and frontal neocortex. Furthermore, Epi significantly reduced the superoxide production in the aorta and relative content of iron-containing compounds in blood. Two weeks post treatment, the NOS activities and superoxide productions in the heart and aorta did not differ from the age-matched controls. The gene expressions of the NOSs (nNOS, iNOS, eNOS), nuclear factor erythroid 2-related factor 2 (Nrf2), and peroxisome proliferator-activated receptor-γ (PPAR-γ) remained unaltered in the aorta and LHV of the Epi and PE groups. In conclusion, while Epi-induced a decrease of the rats’ BP persisted for two weeks post treatment, continuous Epi treatments seem to be necessary for maintaining elevated NO production as well as redox balance in the heart and aorta without changes in the NOSs, Nrf2, and PPAR-γ gene expressions.

Clinical applications for out-of-office blood pressure monitoring

Hypertension is one of the most common chronic diseases as well as the leading risk factor for cardiovascular disease (CVD). Efficient screening and accurate blood pressure (BP) monitoring are the basic methods of detection and management. However, with developments in electronic technology, BP measurement and monitoring are no longer limited to the physician's office. Epidemiological and clinical studies have documented strong evidence for the efficacy of out-of-office BP monitoring in multiple fields for managing hypertension and CVD. This review discusses applications for out-of-office BP monitoring, including home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM), based on recent epidemiological data and clinical studies regarding the following factors: the detection of abnormal BP phenotypes, namely, white coat hypertension and masked hypertension; stronger ability to determine the prognosis for target organ damage and mortality; better BP control; screening for hypotension; and unique approaches to identifying circadian BP patterns and BP variability.

The Vasoactive Mas Receptor in Essential Hypertension

The renin–angiotensin–aldosterone system (RAAS) has been studied extensively, and with the inclusion of novel components, it has become evident that the system is much more complex than originally anticipated. According to current knowledge, there are two main axes of the RAAS, which counteract each other in terms of vascular control: The classical vasoconstrictive axis, renin/angiotensin-converting enzyme/angiotensin II/angiotensin II receptor type 1 (AT₁R), and the opposing vasorelaxant axis, angiotensin-converting enzyme 2/angiotensin-(1-7)/Mas receptor (MasR). An abnormal activity within the system constitutes a hallmark in hypertension, which is a global health problem that predisposes cardiovascular and renal morbidities. In particular, essential hypertension predominates in the hypertensive population of more than 1.3 billion humans worldwide, and yet, the pathophysiology behind this multifactorial condition needs clarification. While commonly applied pharmacological strategies target the classical axis of the RAAS, discovery of the vasoprotective effects of the opposing, vasorelaxant axis has presented encouraging experimental evidence for a new potential direction in RAAS-targeted therapy based on the G protein-coupled MasR. In addition, the endogenous MasR agonist angiotensin-(1-7), peptide analogues, and related molecules have become the subject of recent studies within this field. Nevertheless, the clinical potential of MasR remains unclear due to indications of physiological-biased activities of the RAAS and interacting signaling pathways.

Understanding the impact of five major determinants of health (genetics, biology, behavior, psychology, society/environment) on type 2 diabetes in U.S. Hispanic/Latino families: Mil Familias - a cohort study

BACKGROUND

In the United States (U.S.), the prevalence of both diagnosed and undiagnosed type 2 diabetes (T2D) is nearly twice as high among Mexican-origin Hispanic/Latino adults compared to non-Hispanic Whites. Rates of diabetes-related complications, e.g., acute stroke and end-stage renal disease, are also higher among Hispanic/Latino adults compared to their non-Hispanic/Latino White counterparts. Beyond genetic and biological factors, it is now recognized that sociocultural influences are also important factors in determining risk for T2D and the associated complications. These influences include ethnicity, acculturation, residence, education, and economic status. The primary objective of this study is to determine the influence of the 5 major determinants of human health (genetics, biology, behavior, psychology, society/environment) on the burden of T2D for Latino families. To achieve this objective, Mil Familias (www.milfamilias.sansum.org/) is establishing an observational cohort of 1000 Latino families, with at least one family member living with T2D.

METHODS

Specially trained, bilingual Latino/a community health workers (Especialistas) recruit participant families and conduct research activities. Each individual family member will contribute data annually on over 100 different variables relating to their genetics, biology, psychology, behavior, and society/environment, creating a Latino-focused biobank ("Living Information Bank"). This observational cohort study is cross-sectional and longitudinal. Participants are divided into 4 groups: adults age ≥ 18 years with and without T2D, and children age ≥ 7 and < 18 years with and without T2D. Study activities take place through encounters between families and their Especialista. Encounters include screening/enrollment, informed consent, health promotion assessment, laboratory tests, questionnaires, physical activity monitoring, and reflection.

DISCUSSION

By creating and providing the framework for the Cohort Establishment study, we intend to inform new approaches regarding equity and excellence in diabetes research and care. We will examine the complex set of factors that contribute to the burden of diabetes in Latino families and assess if cardio-metabolic disease risks go beyond the traditional biological and genetic factors. Breaking the code on the interplay of cardio-metabolic risk factors may help not only this fast growing segment of the U.S. population, but also other high-risk populations.

TRIAL REGISTRATION

Study retrospectively registered at ClinicalTrials.gov (NCT03830840), 2/5/2019 (enrollment began 2/1/2019).

Risk Factors for Intestinal Barrier Impairment in Patients With Essential Hypertension

Background: Previous studies have indicated an association between hypertension and intestinal barrier dysfunction in mice models. The present study aims to investigate the association between hypertension and intestinal barrier impairment in humans and identify the novel potential risk factors for hypertension. Methods: Medical data from consecutive inpatients were retrospectively pooled from patient records. We compared intestinal barrier serum markers [diamine oxidase (DAO), lipopolysaccharide (LPS), and _D-lactate] between those patients with and without hypertension. Moreover, the associations between intestinal barrier markers and cardiovascular risk, hypertension history, blood pressure control, hypertensive complications, and antihypertensive medication history were also analyzed. Results: Overall, 106 hypertensive and 251 normotensive subjects were included. Patients with hypertension had a higher level of DAO (28.30 vs. 18.73%, P = 0.044) and LPS (22.64 vs. 11.16%, P = 0.005). In hypertensive patients, multivariate logistic regression analyses showed that long hypertension history (≥20 years), poor control of diastolic blood pressure, cardiac and renal complications, and use of multiple antihypertensive medications were risk factors for elevated DAO, while the use of multiple antihypertensive medications was a risk factor for elevated _D-lactate (P < 0.05). Conclusions: Hypertension is associated with impairment of intestinal barrier, especially in patients with long duration, poor blood pressure control, cardiac and renal complications, and use of multiple antihypertensive medications. The current study indicates that intestinal barrier dysfunction might be a potential predictor of hypertension.

Patient and Disease-Specific Induced Pluripotent Stem Cells for Discovery of Personalized Cardiovascular Drugs and Therapeutics

Human induced pluripotent stem cells (iPSCs) have emerged as an effective platform for regenerative therapy, disease modeling, and drug discovery. iPSCs allow for the production of limitless supply of patient-specific somatic cells that enable advancement in cardiovascular precision medicine. Over the past decade, researchers have developed protocols to differentiate iPSCs to multiple cardiovascular lineages, as well as to enhance the maturity and functionality of these cells. Despite significant advances, drug therapy and discovery for cardiovascular disease have lagged behind other fields such as oncology. We speculate that this paucity of drug discovery is due to a previous lack of efficient, reproducible, and translational model systems. Notably, existing drug discovery and testing platforms rely on animal studies and clinical trials, but investigations in animal models have inherent limitations due to interspecies differences. Moreover, clinical trials are inherently flawed by assuming that all individuals with a disease will respond identically to a therapy, ignoring the genetic and epigenomic variations that define our individuality. With ever-improving differentiation and phenotyping methods, patient-specific iPSC-derived cardiovascular cells allow unprecedented opportunities to discover new drug targets and screen compounds for cardiovascular disease. Imbued with the genetic information of an individual, iPSCs will vastly improve our ability to test drugs efficiently, as well as tailor and titrate drug therapy for each patient.

Efficacy and Safety of Sodium Tanshinone IIA Sulfonate Injection on Hypertensive Nephropathy: A Systematic Review and Meta-Analysis

Background: Sodium tanshinone IIA sulfonate (STS) injection, the extractive of traditional Chinese medicine Danshen, is supposed to be a supplementary treatment in hypertensive nephropathy. Objectives: To evaluate the efficacy and safety of STS in treatment of hypertensive nephropathy. Methods: We systematically searched China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Wan-fang database, Chinese Biomedicine Database (CBM), PubMed, Embase, Web of Science, and Cochrane Library from their inception to December 2018. All studies were screened by two reviewers according to the inclusion and exclusion criteria independently. The Cochrane Collaboration's risk tool was used to assess the methodological quality of the included studies. Reviewer Manager 5.3 was employed for statistical analysis. Results: Sixteen trials involving 1,696 patients were included. The meta-analysis results indicated a combination of STS and angiotensin receptor blockers (ARBs) was more effective than ARB monotherapy in modulating hypertensive nephropathy, as represented by improved estimated glomerular filtration rate (eGFR) [mean difference (MD) = 6.87, 95% CI (4.47, 9.28), P < 0.00001] and reduced 24 h urinary protein [MD = -0.23, 95% CI (-0.27, -0.19), P < 0.00001], serum creatinine (SCr) [MD = -21.74, 95% CI (-24.11, -19.38), P < 0.00001], cystatin-C [MD = -0.16, 95% CI (-0.24, -0.07), P = 0.0003], urinary immunoglobulin G (IgG) [MD = -0.85, 95% CI (-1.11, -0.59), P < 0.00001], and urinary transferrin [MD = -0.61, 95% CI (-1.04, -0.17), P = 0.007]. In addition, the combination therapy had better control in systolic blood pressure (SBP) [MD = -6.53, 95% CI (-8.19, -4.87), P < 0.00001] and diastolic blood pressure (DBP) [MD = -4.14, 95% CI (-5.69, -2.59), P < 0.00001]. Only three trials reported adverse events, and no adverse drug reactions were observed. Conclusions: STS combined with ARBs had a stronger effect on improving renal function in patients with primary hypertensive nephropathy than ARB monotherapy. The combination therapy also provided auxiliary hypotensive effects. Further large-scale, multicenter, and rigorously designed randomized controlled trials (RCTs) should be conducted to confirm our findings.

Comparison of the JNC7 and 2017 American College of Cardiology/American Heart Association Guidelines for the Management of Hypertension in Koreans: Analysis of Two Independent Nationwide Population-Based Studies

The optimal blood pressure (BP) guidelines in Asian populations have not been determined. We compared all-cause and cardiovascular mortality based on the Joint National Committee 7 (JNC7) and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. The National Health Insurance System-National Health Screening Cohort (NHIS-HEALS) and Korea National Health and Nutrition Examination Survey (KNHANES) were utilized. BPs were classified into three groups according to each guideline, and survival rates were analyzed with Kaplan-Meier curves and log-rank tests. Hazard ratios (HRs) were calculated using multivariable cox regression analyses, and the discriminatory ability for clinical outcomes was assessed by Harrell’s C-indexes. The JNC7 guidelines demonstrated a linear association between BP levels and survival outcomes. Adjusted HRs from the JNC7 guidelines differentiated the hypertension group (≥140/90) from the pre (130/80–139/89) and normal (<130 and <80) BP groups in clinical outcomes. In contrast, the 2017 ACC/AHA guidelines showed inconsistent survival outcomes according to BP classification (normal: <120 and <80, elevated: 120–129, and <80, and HTN: ≥130/80). According to Harrell’s C-indexes, the JNC7 guidelines had greater discrimination ability in survival outcomes in the NHIS-HEALS dataset. Our results suggest that the JNC7 guidelines are more appropriate than the 2017 ACC/AHA guidelines in Korean populations.

Detecting Lifestyle Risk Factors for Chronic Kidney Disease With Comorbidities: Association Rule Mining Analysis of Web-Based Survey Data

Background

The rise in the number of patients with chronic kidney disease (CKD) and consequent end-stage renal disease necessitating renal replacement therapy has placed a significant strain on health care. The rate of progression of CKD is influenced by both modifiable and unmodifiable risk factors. Identification of modifiable risk factors, such as lifestyle choices, is vital in informing strategies toward renoprotection. Modification of unhealthy lifestyle choices lessens the risk of CKD progression and associated comorbidities, although the lifestyle risk factors and modification strategies may vary with different comorbidities (eg, diabetes, hypertension). However, there are limited studies on suitable lifestyle interventions for CKD patients with comorbidities.

Objective

The objectives of our study are to (1) identify the lifestyle risk factors for CKD with common comorbid chronic conditions using a US nationwide survey in combination with literature mining, and (2) demonstrate the potential effectiveness of association rule mining (ARM) analysis for the aforementioned task, which can be generalized for similar tasks associated with noncommunicable diseases (NCDs).

Methods

We applied ARM to identify lifestyle risk factors for CKD progression with comorbidities (cardiovascular disease, chronic pulmonary disease, rheumatoid arthritis, diabetes, and cancer) using questionnaire data for 450,000 participants collected from the Behavioral Risk Factor Surveillance System (BRFSS) 2017. The BRFSS is a Web-based resource, which includes demographic information, chronic health conditions, fruit and vegetable consumption, and sugar- or salt-related behavior. To enrich the BRFSS questionnaire, the Semantic MEDLINE Database was also mined to identify lifestyle risk factors.

Results

The results suggest that lifestyle modification for CKD varies among different comorbidities. For example, the lifestyle modification of CKD with cardiovascular disease needs to focus on increasing aerobic capacity by improving muscle strength or functional ability. For CKD patients with chronic pulmonary disease or rheumatoid arthritis, lifestyle modification should be high dietary fiber intake and participation in moderate-intensity exercise. Meanwhile, the management of CKD patients with diabetes focuses on exercise and weight loss predominantly.

Conclusions

We have demonstrated the use of ARM to identify lifestyle risk factors for CKD with common comorbid chronic conditions using data from BRFSS 2017. Our methods can be generalized to advance chronic disease management with more focused and optimized lifestyle modification of NCDs.

Cases in Precision Medicine: A Personalized Approach to Stroke and Cardiovascular Risk Assessment in Women

Cardiovascular disease is the leading cause of death among women in the United States, and stroke is third. This article uses a case scenario to examine female sex-specific cardiovascular risk factors across the lifespan and describes a precision medicine-based approach to risk factor modification and primary prevention. It also presents recent updates to the role of genetic testing and polygenic risk scores for the prediction of stroke and cardiovascular disease.

Deportation Worry, Cardiovascular Disease Risk Factor Trajectories, and Incident Hypertension: A Community-Based Cohort Study

Background Worry about deportation has been associated with cardiovascular disease risk factors in cross-sectional research. No research has evaluated this association longitudinally or examined the association between deportation worry and incident cardiovascular disease outcomes. Methods and Results We used data from an ongoing community-based cohort of 572 women primarily of Mexican origin. We estimated associations between self-reported deportation worry and: (1) trajectories of blood pressure, body mass index, and waist circumference with linear mixed models, and (2) incident hypertension with Cox proportional hazards models. Nearly half (48%) of women reported "a lot," 24% reported "moderate," and 28% reported "not too much" deportation worry. Higher worry at baseline was associated with nonlinear systolic blood pressure and mean arterial pressure trajectories. For example, compared with not too much worry, a lot of worry was associated with a faster initial increase (β, interaction with linear year term: 4.10; 95% CI, 1.17-7.03) followed by a faster decrease in systolic blood pressure (β, interaction with quadratic year term: -0.80; 95% CI, -1.55 to -0.06). There was weak evidence of an association between deportation worry and diastolic blood pressure and no association with body mass index, waist circumference, or pulse pressure trajectories. Among 408 women without baseline hypertension, reporting a lot (hazard ratio, 2.17; 95% CI, 1.15-4.10) and moderate deportation worry (hazard ratio, 2.48; 95% CI, 1.17-4.30) were each associated with greater risk of incident hypertension compared with reporting not too much worry. Conclusions Deportation worry may contribute to widening disparities in some cardiovascular disease risk factors and outcomes over time.

Association and impact of hypertension defined using the 2017 AHA/ACC guidelines on the risk of atrial fibrillation in The Atherosclerosis Risk in Communities study

Background

Hypertension is an established risk factor for the development of atrial fibrillation (AF). We evaluated the association and population impact of hypertension, defined using the new 2017 guidelines, on risk of AF.

Methods

In this analysis, we included 14,915 participants in the Atherosclerosis Risk in Communities study without history of AF. Participants underwent blood pressure measurements at baseline and their antihypertensive medication use was assessed. Incident AF was ascertained from study electrocardiograms, hospital records and death certificates. Cox proportional models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) of AF among individuals with hypertension based on the JNC7 and 2017 ACC/AHA guidelines. Poisson models were used to obtain risk ratios and calculate population-attributable fractions (PAFs).

Results

We identified 2891 cases of incident AF during 21.4 years of mean follow-up. Prevalence of hypertension was 34 and 48% under the JNC7 and 2017 ACC/AHA definitions, respectively. HRs (95%CI) of AF in hypertensives versus non-hypertensives were 1.44 (1.32, 1.56) and 1.37 (1.26, 1.48) after multivariable adjustment under the old and new guidelines, respectively. The corresponding PAF (95%CI) using the old and new guidelines were 11% (8, 13%) and 13% (9, 16%), respectively.

Conclusions

Overall, our analysis shows that even though the prevalence of hypertension using the new criteria is 40% higher than with the old criteria, this does not translate into meaningful increases in AF attributable to hypertension. These results suggest that prevention or treatment of hypertension based on the new (versus old) guidelines may have limited impact on AF incidence.

Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients

Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130 mmHg are those of any age who are fit and have high baseline systolic BP (≥ 160 mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10 years; previous stroke or transient ischaemic attack; heart failure; and stage 3-4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic < 140 mmHg are those who have no CV disease and aged over 80 years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12 months. Treatment should never be so intense as to reduce diastolic BP to < 60 mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.

Cumulative Blood Pressure Exposure During Young Adulthood and Mobility and Cognitive Function in Midlife

BACKGROUND

High blood pressure (BP) is a known risk factor for mobility and cognitive impairment in older adults. This study tested the association of cumulative BP exposure from young adulthood to midlife with gait and cognitive function in midlife. Furthermore, we tested whether these associations were modified by cerebral white matter hyperintensity (WMH) burden.

METHODS

We included 191 participants from the CARDIA study (Coronary Artery Risk Development in Young Adults), a community-based cohort of young individuals followed over 30 years. Cumulative BP was calculated as the area under the curve (mm Hg×years) from baseline up to year 30 examination. Gait and cognition were assessed at the year 30 examination. Cerebral WMH was available at year 30 in a subset of participants (n=144) who underwent magnetic resonance imaging. Multiple linear regression models were used to assess the association of cumulative BP exposure with gait and cognition. To test effect modification by WMH burden, participants were stratified at the median of WMH and tested for interaction.

RESULTS

Higher cumulative systolic and diastolic BPs were associated with slower walking speed (both P=0.010), smaller step length (P=0.011 and 0.005, respectively), and higher gait variability (P=0.018 and 0.001, respectively). Higher cumulative systolic BP was associated with lower cognitive performance in the executive (P=0.021), memory (P=0.015), and global domains (P=0.010), and higher cumulative diastolic BP was associated with lower cognitive performance in the memory domain (P=0.012). All associations were independent of socio-demographics and vascular risk factors (body mass index, smoking, diabetes mellitus and total cholesterol). The association between cumulative BP and gait was moderated by WMH burden (interaction P<0.05). However, the relation between cumulative BP and cognitive function was not different based on the WMH burden (interaction P>0.05).

CONCLUSIONS

Exposure to higher BP levels from young to midlife is associated with worse gait and cognitive performance in midlife. Furthermore, WMH moderates the association of cumulative BP exposure with gait, but not with cognitive function in midlife. The mechanisms underpinning the impact of BP exposure on brain structure and function must be investigated in longitudinal studies using a life course approach.

Pregnancy History, Hypertension, and Cognitive Impairment in Postmenopausal Women

Purpose of Review

Risks for developing cardiovascular disease and cognitive decline increase with age. In women, these risks may be influenced by pregnancy history. This review provides an integrated evaluation of associations of pregnancy history with hypertension, brain atrophy, and cognitive decline in postmenopausal women.

Recent Findings

Atrophy in the occipital lobes of the brain was evident in women who had current hypertension and a history of preeclampsia. Deficits in visual memory in women with a history of preeclampsia are consistent with these brain structural changes. The blood velocity response to chemical and sympathoexcitatory stimuli were altered in women with a history of preeclampsia linking impairments in cerebrovascular regulation to the structural and functional changes in the brain.

Summary

Having a history of preeclampsia should require close monitoring of blood pressure and initiation of anti-hypertensive treatment in perimenopausal women. Mechanisms by which preeclampsia affects cerebrovascular structure and function require additional study.

Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes: a systematic, multinational, large-scale analysis

BACKGROUND

Uncertainty remains about the optimal monotherapy for hypertension, with current guidelines recommending any primary agent among the first-line drug classes thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and non-dihydropyridine calcium channel blockers, in the absence of comorbid indications. Randomised trials have not further refined this choice.

METHODS

We developed a comprehensive framework for real-world evidence that enables comparative effectiveness and safety evaluation across many drugs and outcomes from observational data encompassing millions of patients, while minimising inherent bias. Using this framework, we did a systematic, large-scale study under a new-user cohort design to estimate the relative risks of three primary (acute myocardial infarction, hospitalisation for heart failure, and stroke) and six secondary effectiveness and 46 safety outcomes comparing all first-line classes across a global network of six administrative claims and three electronic health record databases. The framework addressed residual confounding, publication bias, and p-hacking using large-scale propensity adjustment, a large set of control outcomes, and full disclosure of hypotheses tested.

FINDINGS

Using 4·9 million patients, we generated 22 000 calibrated, propensity-score-adjusted hazard ratios (HRs) comparing all classes and outcomes across databases. Most estimates revealed no effectiveness differences between classes; however, thiazide or thiazide-like diuretics showed better primary effectiveness than angiotensin-converting enzyme inhibitors: acute myocardial infarction (HR 0·84, 95% CI 0·75-0·95), hospitalisation for heart failure (0·83, 0·74-0·95), and stroke (0·83, 0·74-0·95) risk while on initial treatment. Safety profiles also favoured thiazide or thiazide-like diuretics over angiotensin-converting enzyme inhibitors. The non-dihydropyridine calcium channel blockers were significantly inferior to the other four classes.

INTERPRETATION

This comprehensive framework introduces a new way of doing observational health-care science at scale. The approach supports equivalence between drug classes for initiating monotherapy for hypertension-in keeping with current guidelines, with the exception of thiazide or thiazide-like diuretics superiority to angiotensin-converting enzyme inhibitors and the inferiority of non-dihydropyridine calcium channel blockers.

FUNDING

US National Science Foundation, US National Institutes of Health, Janssen Research & Development, IQVIA, South Korean Ministry of Health & Welfare, Australian National Health and Medical Research Council.

Effects of Race on Statin Prescribing for Primary Prevention With High Atherosclerotic Cardiovascular Disease Risk in a Large Healthcare System

Background

Although guidelines recommend statins with a high level of evidence for 4 primary prevention benefit groups, prescribing disparities still exist. The objective of this study was to evaluate the effects of race on statin prescribing for primary prevention.

Methods and Results

A retrospective cohort analysis of patients within a large academic health system was performed to investigate statin prescribing among primary prevention groups. The statin benefits groups were patients diagnosed with diabetes mellitus, with an low‐density lipoprotein ≥190 mg/dL, or with an atherosclerotic cardiovascular disease (ASCVD) 10‐year risk ≥7.5%. Statin prescribing was 20% in the ASCVD ≥7.5% group, followed by 37.8% in the low‐density lipoprotein ≥190 mg/dL group and 40.5% in the diabetes mellitus group. Blacks were less likely to be prescribed a statin compared with whites in the diabetes mellitus (odds ratio, 0.64; 95% CI, 0.49–0.82; P=0.001) and ASCVD ≥7.5% groups (odds ratio, 0.38; 95% CI, 0.26–0.54; P<0.0001). Blacks 60 to 69 years of age (odds ratio, 7.97; 95% CI, 3.14–20.2; P=0.003) and 70 to 79 years of age (odds ratio, 4.21; 95% CI, 1.81–9.79; P=0.008) were more likely to be prescribed a statin compared with blacks <60 years of age in the ASCVD ≥7.5% group.

Conclusions

Blacks are less likely to be prescribed statins in diabetes mellitus and ASCVD ≥7.5% groups compared with whites. Younger blacks with ASCVD risk ≥7.5% are less likely to be prescribed statins compared with older blacks. Future research should focus on tailored interventions to address statin prescribing disparities in blacks.

Modern Principles of Treatment of Uncontrolled Hypertension

Despite the current possibilities of using different classes of antihypertensive drugs that effectively reduce blood pressure and significantly improve the long-term prognosis of patients, the problem of uncontrolled arterial hypertension has not lost its importance and its solution in a particular clinical situation often remains very difficult. The term "uncontrolled arterial hypertension" can be used in all cases where arterial pressure has not been achieved. The true prevalence of uncontrolled arterial hypertension has not been established, and its study is hampered primarily by the fact that not all patients initially receive antihypertensive therapy that meets generally accepted standards. Currently, the tactics of management of patients with uncontrolled hypertension involves the use of combinations of antihypertensive drugs. Rational combinations, according to the new recommendations for the diagnosis and treatment of arterial hypertension in 2018, remain a combination of blockers of the renin-angiotensin-aldosterone system – angiotensin-converting enzyme inhibitors or receptor blockers to angiotensin with a calcium antagonist or diuretic, preferably in one tablet. With the ineffectiveness of dual therapy needs to be assigned to a third antihypertensive drug. Among the most modern antihypertensive drugs can be considered a triple fixed combination of lisinopril, amlodipine and indapamide. All the components included in the composition of the drug, has proved its high efficiency and safety. Uncontrolled arterial hypertension remains one of the most urgent problems of modern cardiology. Many aspects of it are far from unambiguously interpreted solutions and standards. Until the end, the mechanisms of the formation of uncontrolled course of hypertension remain unexplored, which, in turn, leads to a restriction of the use of drug and non-drug methods in the treatment of this pathology. Rational choice of antihypertensive therapy regimens can significantly improve the quality of treatment of this category of patients.

The relationship between eGFR slope and subsequent risk of vascular outcomes and all-cause mortality in type 2 diabetes: the ADVANCE-ON study

AIMS/HYPOTHESIS

Some studies have reported that annual change in eGFR (eGFR slope) is associated with the future risk of end-stage kidney disease, cardiovascular disease and death in general or chronic kidney disease cohorts. However, the benefits of using eGFR slopes for prediction of major clinical outcomes in diabetes are unclear.

METHODS

We used data from the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial and the ADVANCE Post-Trial Observational Study (ADVANCE-ON). After excluding the first 4 months during which an acute fall in eGFR was induced by the initiation of an ACE inhibitor and diuretic combination agent, eGFR slopes were estimated by linear mixed models, using three measurements of eGFR at 4, 12 and 24 months after randomisation over 20 months, and categorised according to quartiles. Cox regression models were used to evaluate adjusted HRs for the study's primary outcome, a composite of major renal events, major macrovascular events and all-cause mortality during the subsequent follow-up from 24 months after randomisation.

RESULTS

A total of 8,879 participants (80%) were included in this cohort. The mean age was 65.6 years (SD 6.3), the mean eGFR was 75 ml min-1 (1.73 m)-2 (SD 17) and the median urinary albumin/creatinine ratio was 14 μg/mg (interquartile range 7-38). The mean eGFR slope was -0.63 ml min-1 (1.73 m)-2 year-1 (SD 1.75). Over a median follow-up of 7.6 years following the 20-month eGFR slope ascertainment period, 2,221 participants (25%) met the primary outcome. An annual substantial decrease in eGFR (lowest 25%, <-1.63 ml min-1 [1.73 m]-2 year-1) was significantly associated with the subsequent risk of the primary outcome (HR 1.30 [95% CI 1.17, 1.43]) compared with a stable change in eGFR (middle 50%, -1.63 to 0.33). An annual substantial increase in eGFR (highest 25%, >0.33) had no significant association with the risk of the primary outcome (HR 0.96 [95% CI 0.86, 1.07]).

CONCLUSIONS/INTERPRETATION

Our study supports the utility of eGFR slope in type 2 diabetes as a surrogate endpoint for renal outcomes, as well as a prognostic factor for identifying individuals at high risk of cardiovascular disease and all-cause mortality.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov registration no. NCT00145925 and no. NCT00949286.

Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease

Background and Purpose- Nonfocal transient neurological attacks (TNAs), such as unsteadiness, bilateral weakness, or confusion, are associated with an increased risk of stroke and dementia. Cerebral ischemia plays a role in their pathogenesis, but the precise mechanisms are unknown. We hypothesized that cerebral small vessel disease is involved in the pathogenesis of TNAs and assessed the relation between TNAs and manifestations of cerebral small vessel disease on magnetic resonance imaging. Methods- We included participants from the HBC (Heart-Brain Connection) study. In this study, hemodynamic and cardiovascular contributions to cognitive impairment have been studied in patients with heart failure, carotid artery occlusion, or possible vascular cognitive impairment, as well as in a reference group. We excluded participants with a history of stroke or transient ischemic attacks. The occurrence of the following 8 TNAs was assessed with a standardized interview: unconsciousness, confusion, amnesia, unsteadiness, bilateral leg weakness, blurred vision, nonrotatory dizziness, and paresthesias. The occurrence of TNAs was related to the presence of lacunes or white matter hyperintensities (Fazekas score, ≥2; early confluent or confluent lesions) in logistic regression analysis, adjusted for age, sex, and hypertension. Results- Of 304 participants (60% men; mean age, 67±9 years), 63 participants (21%) experienced ≥1 TNAs. Lacunes and early confluent or confluent white matter hyperintensities were more common in participants with TNAs than in participants without TNAs (35% versus 20%; adjusted odds ratio, 2.32 [95% CI, 1.22-4.40] and 48% versus 27%; adjusted odds ratio, 2.65 [95% CI, 1.44-4.90], respectively). Conclusions- In our study, TNAs are associated with the presence of lacunes and early confluent or confluent white matter hyperintensities of presumed vascular origin, which indicates that cerebral small vessel disease might play a role in the pathogenesis of TNAs.

Detection of Vasodilators From Herbal Components by a Transcriptome-Based Functional Gene Module Reference Approach

Vasodilatation is one of the key therapeutic strategies for the treatment of various cardiovascular diseases with high blood pressure. Therefore, development of drugs assisting blood vessel dilation is promising. It has been proven that many drugs display definite vasorelaxant effects. However, there are very few studies that systemically explore the effective vasodilators. In this work, we build a transcriptome-based functional gene module reference approach for systematic pursuit of agents with vasorelaxant effects. We firstly curate two functional gene modules that are specifically involved in positive and negative regulation of vascular diameter based on the known gene functional interaction knowledge. Secondly, a collection of gene expression profiles following herbal component treatment are collected from a public gene expression database. Then, the correlation of the gene modules is evaluated in each herbal component–induced gene expression profile by gene set enrichment analysis. The vasorelaxant effects of the candidate compounds can be predicted and ordered by the values of a defined index. Finally, the top 10 candidate compounds are experimentally tested for their vasorelaxant effects on vessel contraction induced by Phe in aortic rings. This strategy integrating different types of technologies is expected to help to create new opportunities for the development of novel vasodilators.

Association of lifestyle factors with blood lipids and inflammation in adults aged 40 years and above: a population-based cross-sectional study in Taiwan

Background

Lifestyle factors were associated with an increased risk of cardiovascular disease (CVD) occurrence. We explored the associations between lifestyle factors and CVD risk factors, and assessed the interactive effects of lifestyle factors on CVD risk factors.

Methods

A cross-sectional data of 114,082 (57,680 men and 56,402 women) middle-aged adults and elderly in Taiwan were collected from 2001 to 2010. Logistic regression analysis was used to assess the associations between lifestyle factors and CVD risk factors. The relative excess risk due to interaction (RERI) and the attributable proportion due to interaction were used to explore the interactive effect of lifestyle factors on CVD risk factors.

Results

The interaction between alcohol consumption and smoking exhibited an excess risk of high triglycerides (RERI = 0.21; 95% CI: 0.14–0.29), and that of alcohol consumption and physical activity had an excess risk of high LDL-cholesterol (RERI = 0.11; 95% CI: 0.06–0.16) and high blood glucose (RERI = 0.05; 95% CI: 0.01–0.11). Alcohol consumption and vegetable-rich diet (intake of high vegetables with no or low meat) had an excess risk of high LDL-cholesterol and low HDL-cholesterol, but a reduced risk of high triglycerides (RERI = − 0.10; 95% CI: − 0.17 – -0.04). Smoking and physical activity had an increased risk of high blood glucose and a reduced risk of low HDL-cholesterol. Smoking and vegetable-rich diet reduced the risk of high triglycerides (RERI = − 0.11; 95% CI: − 0.18 – − 0.04), high blood glucose (RERI = − 0.14; 95% CI: − 0.21 – − 0.07) and low HDL-cholesterol (RERI = − 0.10; 95% CI: − 0.19 – -0.01).

Conclusions

The interaction between smoking, alcohol consumption, physical activity and diet were associated with lipid profile and blood glucose, hence there was an interaction between these lifestyle factors in an additive scale. Public health promotion should therefore consider multifaceted promotional activities that are likely to make a positive impact on the health status of the Taiwanese population.

Impact of the 2017 American Academy of Pediatrics Guideline on Hypertension Prevalence Compared With the Fourth Report in an International Cohort

In 2017, the American Academy of Pediatrics (AAP) updated the clinical practice guideline for high blood pressure (BP) in the pediatric population. In this study, we compared the difference in prevalence of elevated and hypertensive BP values defined by the 2017 AAP guideline and the 2004 Fourth Report and estimated the cardiovascular risk associated with the reclassification of BP status defined by the AAP guideline. A total of 47 200 children and adolescents aged 6 to 17 years from 6 countries (China, India, Iran, Korea, Poland, and Tunisia) were included in this study. Elevated BP and hypertension were defined according to 2 guidelines. In addition, 1606 children from China, Iran, and Korea who were reclassified upward by the AAP guideline compared with the Fourth Report and for whom laboratory data were available were 1:1 matched with children from the same countries who were normotensive by both guidelines. Compared with the Fourth Report, the prevalence of elevated BP defined by the AAP guideline was lower (14.9% versus 8.6%), whereas the prevalence of stages 1 and 2 hypertension was higher (stage 1, 6.6% versus 14.5%; stage 2, 0.4% versus 1.7%). Additionally, comparison of laboratory data in the case-control study showed that children who were reclassified upward were more likely to have adverse lipid profiles and high fasting blood glucose compared with normotensive children. In conclusion, the prevalence of elevated BP and hypertension varied significantly between both guidelines. Applying the new AAP guideline could identify more children with hypertension who are at increased cardiovascular risk.

Association Between High Perceived Stress Over Time and Incident Hypertension in Black Adults: Findings From the Jackson Heart Study

Background

Chronic psychological stress has been associated with hypertension, but few studies have examined this relationship in blacks. We examined the association between perceived stress levels assessed annually for up to 13 years and incident hypertension in the Jackson Heart Study, a community‐based cohort of blacks.

Methods and Results

Analyses included 1829 participants without hypertension at baseline (Exam 1, 2000–2004). Incident hypertension was defined as blood pressure≥140/90 mm Hg or antihypertensive medication use at Exam 2 (2005–2008) or Exam 3 (2009–2012). Each follow‐up interval at risk of hypertension was categorized as low, moderate, or high perceived stress based on the number of annual assessments between exams in which participants reported “a lot” or “extreme” stress over the previous year (low, 0 high stress ratings; moderate, 1 high stress rating; high, ≥2 high stress ratings). During follow‐up (median, 7.0 years), hypertension incidence was 48.5%. Hypertension developed in 30.6% of intervals with low perceived stress, 34.6% of intervals with moderate perceived stress, and 38.2% of intervals with high perceived stress. Age‐, sex‐, and time‐adjusted risk ratios (95% CI) associated with moderate and high perceived stress versus low perceived stress were 1.19 (1.04–1.37) and 1.37 (1.20–1.57), respectively (P trend<0.001). The association was present after adjustment for demographic, clinical, and behavioral factors and baseline stress (P trend=0.001).

Conclusions

In a community‐based cohort of blacks, higher perceived stress over time was associated with an increased risk of developing hypertension. Evaluating stress levels over time and intervening when high perceived stress is persistent may reduce hypertension risk.

Role of Socioeconomic Status in Hypertension among Chinese Middle-Aged and Elderly Individuals

Hypertension is an important global health concern. The relationship between hypertension and socioeconomic status (SES) has been extensively studied. However, the role of SES in hypertension is still controversial, and this kind of study is sorely lacking among Chinese middle-aged and elderly individuals. The data of this study come from the China Health and Retirement Longitudinal Survey (CHARLS) released in May 2017. A total of 21,126 people from all around China, with ages older than 45 years, were enrolled in the questionnaire survey. Hypertension was determined according to the entry in CHARLS (“Do you have doctor-diagnosed hypertension?”), and 17,676 people responded to this entry. The basic demographic and SES information were collected. Multivariate logistic regression was used to evaluate the risk factors of hypertension. Concentration index was used to measure inequality of hypertension incidence. Among the investigated middle-aged and elderly individuals, 5,177/17,676 (29.3%) had doctor-diagnosed hypertension. Multivariate logistic regression implied that individuals older than 55 years (OR 1.436, 95% CI 1.085–1.900 for age interval of 55–64 years; OR 2.032, 95% CI 1.455–2.839 for age interval of 65–74 years; OR 1.672, 95% CI 1.031–2.714 for age interval of older than 75 years), male (OR 0.038, 95% CI 0.595–0.986), overweight (OR 2.47, 95% CI 1.462–4.183), and diabetes (OR 3.159, 95% CI 2.129–4.687) were associated with hypertension. For society support, individuals in the lowest quintile were more likely to suffer hypertension. Concentration index results suggested that different income groups did not show inequality on hypertension incidence. Elder age, male, overweight, diabetes, and poor society support were suggested to be associated with hypertension incidence among middle-aged and elderly individuals in China. Our study provides implications for controlling and managing hypertension.

Estimating the Impact of Novel Digital Therapeutics in Type 2 Diabetes and Hypertension: Health Economic Analysis

BACKGROUND

Behavioral interventions can meaningfully improve cardiometabolic conditions. Digital therapeutics (DTxs) delivering these interventions may provide benefits comparable to pharmacologic therapies, displacing medications for some patients.

OBJECTIVE

Our objective was to estimate the economic impact of a digital behavioral intervention in type 2 diabetes mellitus (T2DM) and hypertension (HTN) and estimate the impact of clinical inertia on deprescribing medications.

METHODS

Decision analytic models estimated health resource savings and cost effectiveness from a US commercial payer perspective. A 3-year time horizon was most relevant to the intervention and payer. Effectiveness of the DTx in improving clinical outcomes was based on cohort studies and published literature. Health resource utilization (HRU), health state utilities, and costs were drawn from the literature with costs adjusted to 2018 dollars. Future costs and quality-adjusted life years (QALYs) were discounted at 3%. Sensitivity analyses assessed uncertainty.

RESULTS

Average HRU savings ranged from $97 to $145 per patient per month, with higher potential benefits in T2DM. Cost-effectiveness acceptability analyses using a willingness-to-pay of $50,000/QALY indicated that the intervention would be cost effective at total 3-year program costs of $6468 and $6620 for T2DM and HTN, respectively. Sensitivity analyses showed that reduced medication costs are a primary driver of potential HRU savings, and the results were robust within values tested. A resistance to deprescribe medications when a patient's clinical outcomes improve can substantially reduce the estimated economic benefits. Our models rely on estimates of clinical effectiveness drawn from limited cohort studies with DTxs and cannot account for other disease management programs that may be implemented. Performance of DTxs in real-world settings is required to further validate their economic benefits.

CONCLUSIONS

The DTxs studied may provide substantial cost savings, in part by reducing the use of conventional medications. Clinical inertia may limit the full cost savings of DTxs.

Milk and resistance exercise intervention to improve muscle function in community-dwelling older adults at risk of sarcopenia (MIlkMAN): protocol for a pilot study

INTRODUCTION

Sarcopenia is a progressive muscle disorder characterised by decline in skeletal muscle mass, strength and function leading to adverse health outcomes, including falls, frailty, poor quality of life and death. It occurs more commonly in older people and can be accelerated by poor diet and low physical activity. Intervention studies incorporating higher dietary protein intakes or protein supplementation combined with resistance exercise (RE) have been shown to limit muscle function decline. However, less is known about the role of whole foods in reducing the risk of sarcopenia. Milk is a source of high-quality nutrients, which may be beneficial for skeletal muscle. This pilot study examines the feasibility and acceptability of milk consumption with RE to improve muscle function in community-dwelling older adults at risk of sarcopenia.

METHODS AND ANALYSIS

30 older adults aged ≥65 years will be randomly allocated to three groups: 'whole milk+RE', 'skimmed milk+RE' or 'control drink+RE'. Assessments will take place in participants' homes, including screening (milk allergies, grip strength, walking speed), baseline and postintervention health and function. All participants will undertake a structured RE intervention twice a week for 6 weeks at a local gym, followed by the consumption of 500 mL of whole or skimmed milk (each ~20 g of protein) or an isocaloric control drink and another 500 mL at home. Participants' views about the study will be assessed using standardised open-ended questions. The primary outcomes include feasibility and acceptability of the intervention with recruitment, retention and intervention response rates. Analyses will include descriptive statistics, exploration of qualitative themes and intervention fidelity.

ETHICS AND DISSEMINATION

Outputs include pilot data to support funding applications; public involvement events; presentation at conferences and peer-reviewed publication.

TRIAL REGISTRATION NUMBER

ISRCTN13398279; Pre-results.

Outcome-Driven Thresholds for Ambulatory Blood Pressure Based on the New American College of Cardiology/American Heart Association Classification of Hypertension

The new American College of Cardiology/American Heart Association guideline reclassified office blood pressure and proposed thresholds for ambulatory blood pressure (ABP). We derived outcome-driven ABP thresholds corresponding with the new office blood pressure categories. We performed 24-hour ABP monitoring in 11 152 participants (48.9% women; mean age, 53.0 years) representative of 13 populations. We determined ABP thresholds resulting in multivariable-adjusted 10-year risks similar to those associated with elevated office blood pressure (120/80 mm Hg) and stages 1 and 2 of office hypertension (130/80 and 140/90 mm Hg). Over 13.9 years (median), 2728 (rate per 1000 person-years, 17.9) people died, 1033 (6.8) from cardiovascular disease; furthermore, 1988 (13.8), 893 (6.0), and 795 (5.4) cardiovascular and coronary events and strokes occurred. Using a composite cardiovascular end point, systolic/diastolic outcome-driven thresholds indicating elevated 24-hour, daytime, and nighttime ABP were 117.9/75.2, 121.4/79.6, and 105.3/66.2 mm Hg. For stages 1 and 2 ambulatory hypertension, thresholds were 123.3/75.2 and 128.7/80.7 mm Hg for 24-hour ABP, 128.5/79.6 and 135.6/87.1 mm Hg for daytime ABP, and 111.7/66.2 and 118.1/72.5 mm Hg for nighttime ABP. ABP thresholds derived from other end points were similar. After rounding, approximate thresholds for elevated 24-hour, daytime, and nighttime ABP were 120/75, 120/80, and 105/65 mm Hg, and for stages 1 and 2, ambulatory hypertension 125/75 and 130/80 mm Hg, 130/80 and 135/85 mm Hg, and 110/65 and 120/70 mm Hg. Outcome-driven ABP thresholds corresponding to elevated blood pressure and stages 1 and 2 of hypertension are similar to those proposed by the current American College of Cardiology/American Heart Association guideline.

Sex Differences in Hypertension and Stroke Risk in the REGARDS Study: A Longitudinal Cohort Study

Little is known about whether the relationship between hypertension and ischemic stroke differs by sex. We examined sex differences in the association between hypertension severity and treatment and ischemic stroke risk. We used a longitudinal cohort study in the continental United States, with oversampling of black individuals and those living in the stroke belt. We included 26 461 participants recruited from 2003 to 2007 without prevalent stroke at baseline. The main outcome was incident ischemic stroke ascertained by telephone surveillance (with physician adjudication for suspected events). Proportional hazards regression was used to assess the sex-specific association between systolic blood pressure and stroke and between classes of antihypertensive medications and stroke after adjustment for age, race, sex, and age-by-race and sex-by-treatment interaction terms. A priori, P<0.10 was considered significant for interactions. Among participants (55.4% women, 40.2% black), there were 1084 confirmed ischemic stroke events. In the adjusted model, the risk of stroke per each level of hypertension (referent/systolic blood pressure <120 mm Hg/120-129 mm Hg/130-139 mm Hg/>140 mm Hg) was higher in women (hazard ratio, 1.25; 95% CI, 1.16-1.34) than men (hazard ratio, 1.14; 95% CI, 1.05-1.23; sex-systolic blood pressure interaction term, P=0.09). Compared with no medications, with each additional class of medications, stroke risk increased by 23% (hazard ratio, 1.23; 95% CI, 1.14-1.33) for women and 21% (hazard ratio, 1.21; 95% CI, 1.12-1.31) for men (P=0.79). Further work on the biological mechanisms for sex differences in stroke risk associated with hypertension severity and a need for sex-specific clinical guidelines may be warranted.

Trends in Blood Pressure and High-Sensitivity Cardiac Troponin-T With Cardiovascular Disease: The Cardiovascular Health Study

BACKGROUND

High-sensitivity cardiac troponin T (hs-cTnT) is individually associated with incident hypertension (HTN) and cardiovascular disease (CVD) events. We hypothesize that the increases in hs-cTnT with increases in blood pressure will be related to higher incidence of CVD.

METHODS

The Cardiovascular Health Study is a longitudinal cohort of older adults. Those with hs-cTnT data and CVD risk factors at baseline and follow-up (2-3 years later) were stratified based on systolic blood pressure (SBP; optimal: <120 mm Hg, intermediate: 120-139 mm Hg, elevated: ≥140 mm Hg) and hs-cTnT (undetectable: <5 ng/l, detectable: 5-13 ng/l, elevated: ≥14 ng/l) categories. SBP and hs-cTnT were classified as increased or decreased if they changed categories between exams, and stable if they did not. Cox regression evaluated incident CVD events over an average 9-year follow-up.

RESULTS

Among 2,219 adults, 510 (23.0 %) had decreased hs-cTnT, 1,279 (57.6 %) had stable hs-cTnT, and 430 (19.4 %) had increased hs-cTnT. Those with increased hs-cTnT had a higher CVD risk with stable SBP (hazard ratio [HR]: 1.28 [1.04-1.57], P = 0.02) or decreased SBP (HR: 1.57 [1.08-2.28], P = 0.02) compared to those within the same SBP group but a stable hs-cTnT. In those with lower SBP at follow-up, there was an inverse relation between diastolic blood pressure (DBP) and risk of CVD events in those with increased hs-cTnT (HR: 0.44 per 10 mm Hg increase, P < 0.01).

CONCLUSION

An increase in hs-cTnT over time is associated with a higher risk of CVD even when the blood pressure is stable or decreases over time.

Prevalence of American Heart Association Heart Failure Stages in Black and White Young and Middle-Aged Adults: The CARDIA Study

BACKGROUND

Staging criteria for heart failure (HF) range from stage 0 (without risk) to being at risk (stage A) to presence of cardiac structural/functional abnormalities (stage B) to symptomatic/end stage (stages C/D). There are limited data on the prevalence of these stages in early adulthood and predictors of HF stage and symptoms in middle age.

METHODS AND RESULTS

The CARDIA study (Coronary Artery Risk Development in Young Adults)-a cohort of generally healthy black and white men and women-collected phenotypic, echocardiographic, and outcomes data at the year 5 and year 30 examinations when participants were 22 to 37 and 47 to 62 years of age. Prevalence of HF stages was calculated and relationship of year 5 stage to year 30 classification and outcomes was assessed. At year 5, 2189 participants had complete data. Prevalence of HF stage A/B increased from 24% to 76% in black men, from 13% to 64% in white men, from 34% to 81% in black women, and from 13% to 56% in white women. Blacks were more likely to be in any stage or with morbidity at both time points because of higher risk factor prevalence. Of 33 participants with HF or HF deaths by year 30, 21 (64%) had been in stage A or B at year 5. Only 6 participants at year 5 in stage A (at risk) improved risk status at year 30.

CONCLUSIONS

Risk for HF increased in participants from 1990 (age 22-37 years) to 2015 (age 47-62 years). Symptomatic HF or death from HF is associated with HF stage at 22 to 37 years of age. Blacks are disproportionately affected.

Incidence and risk factors of depressive symptoms in 4 years of follow-up among mid-aged and elderly community-dwelling Chinese adults: findings from the China Health and Retirement Longitudinal Study

OBJECTIVES

The purpose of this study was to examine the incidence of depressive symptoms, and determine if baseline risk factors conferred a risk for incident depressive symptoms in nationally representative sample of mid-aged and elderly Chinese adults.

DESIGN

This study was a secondary analysis of a prospective cohort from a nationally representative sample.

SETTING

Community samples were recruited from the baseline survey of the China Health and Retirement Longitudinal Study. A four-stage, stratified, cluster probability sampling strategy was used, which included 10 257 households with members aged 45 years or older and their spouse.

PARTICIPANTS

A total of 11 533 participants free of depressive symptoms at baseline were identified, and 10 288 were re-examined in either the first and/or the second follow-up surveys. The current analysis was conducted among the 10 288 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale short form.

RESULTS

The findings showed that the incidence of depressive symptoms in a 4-year follow-up was as high as 22.3%. The incidence was much higher in rural areas (25.7%) and in women (27.9%). Furthermore, participants with 1 hour longer of night-time sleep had a 10% lower risk of developing depressive symptoms. Compared with individuals who perceived their health status as poor, those who perceived their health status as excellent had a 62% lower risk of developing depressive symptoms. In addition, having diabetes (OR=1.19), chronic kidney disease (OR=1.32), chronic digestive disorders (OR=1.15) and arthritis (OR=1.43) at baseline increased the risk of depressive symptoms. However, baseline body mass index was not associated with the subsequent depressive symptoms in this population.

CONCLUSIONS

This study highlights the importance of developing an appropriate screening test to identify depressive symptoms for those who are vulnerable and ensure these individuals can receive early interventions for depressive symptoms.