Hypertension and Dyslipidemia Combined Therapeutic Approaches

Statins boost beneficial pleiotropic cardiovascular effects of cilostazol in angiotensin-II hypertensive rats

BACKGROUND AND AIMS

Hypertension is a major cause of cardiovascular (CVS) diseases. Statins exhibit a blood pressure-lowering effect independent of cholesterol. This study investigates whether combining statins with the phosphodiesterase-III inhibitor cilostazol enhances antihypertensive and cardioprotective effects.

METHODS

Hypertension was induced in rats via implanted mini-osmotic pumps releasing angiotensin II at 120 ng.kg-1.min-1 for 11 days. Hypertensive rats were treated with cilostazol (50 mg.kg-1.day-1), rosuvastatin (20 mg.kg-1.day-1), atorvastatin (50 mg.kg-1.day-1), or their combinations for seven days. Cardiovascular parameters, baroreflex sensitivity, histopathology, myocardial injury markers (creatine kinase-MB "CK-MB" and cardiac troponin I "cTnI"), and oxidative stress (catalase and malondialdehyde "MDA") were evaluated.

RESULTS

Cilostazol reduced systolic blood pressure, improved left ventricular (LV) function, and mitigated baroreflex dysfunction. Co-administration of atorvastatin enhanced these effects, with rosuvastatin showing greater improvements. The rosuvastatin/cilostazol combination significantly reduced myocardial injury, oxidative stress, and histopathological damage in the heart and aorta.

CONCLUSION

Statins, particularly rosuvastatin, enhanced cilostazol's antihypertensive and cardioprotective effects, highlighting the potential of this combination in managing hypertension and CVS diseases.

Cardiovascular disease risk factors are associated with conventional lipids and apolipoproteins in South African adults of African ancestry

BACKGROUND

Although conventional lipids (high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDLC), total cholesterol (TC) and triglycerides (TG)) are therapeutic targets to manage and prevent atherosclerotic cardiovascular disease (CVD), apolipoprotein (Apo) levels have sparked interest for their potential to improve CVD risk prediction. This study explored the relationships of traditional CVD risk factors with conventional lipids, as well as ApoA1, ApoB and its ratio (ApoB: ApoA1) in South African adults of African ancestry.

METHODS

This study included 1697 adults (aged 29 to 94) from the Prospective Urban Rural Epidemiology (PURE) study. The CVD risk markers included body mass index (BMI), physical activity index, tobacco use, dietary fat intake, γ-glutamyl transferase (γGT) and glycated haemoglobin (HbA1C). Conventional lipids were measured in serum samples using standard methodology, while ApoA1 and ApoB were measured using a multiplex magnetic bead immunoassay.

RESULTS

Stratified into tertiles of conventional lipid and Apo levels, trends emerged across multiple CVD risk markers, including BMI, tobacco use, fat intake, γGT and HbA1C levels. Higher tertiles of LDLC, TC, TG, ApoB and ApoB: ApoA1, along with the lowest tertiles of HDLC and ApoA1 exhibited higher prevalence of Type II diabetes mellitus (all p ≤ 0.024) and overweight or obesity (all except for TC, p ≤ 0.024). HDLC was negatively associated and LDLC, TC, and TG were positively associated with BMI (all p < 0.001) and HbA1C (all except for TC, p ≤ 0.005). Similarly, ApoA1 associated negatively with BMI (β=-0.067 (-0.125; -0.010), p = 0.022) and HbA1C (β=-0.071 (-0.122; -0.020), p = 0.007), while ApoB associated positively with BMI (β = 0.168 (0.117; 0.218), p < 0.001). The ApoB: ApoA1 showed positive associations with BMI (β = 0.213 (0.163; 0.263), p < 0.001) and HbA1C (β = 0.123 (0.074; 0.172), p < 0.001).

CONCLUSIONS

In South African adults of African ancestry, ApoA1, ApoB and ApoB: ApoA1 levels are associated with various established CVD risk markers and suggests that these apolipoproteins may provide additional mechanistic insights beyond the conventional lipids to understand the aetiology of early cardiometabolic disease development.

Effect of Dietary Approaches to Stop Hypertension (DASH) diet on lipid profile in individuals with overweight/ obesity: A GRADE-assessed systematic review and meta-analysis of clinical trials

BACKGROUND AND AIM

Obesity is a major nutritional disease that increases the risk of developing serious health conditions like dyslipidemia. Plant-based diets, like DASH (dietary approaches to stop hypertension), can help lower the risk of dyslipidemia. However, evidence on the effect of DASH diet on lipid profile in populations with overweight/obesity is inconsistent. This meta-analysis of controlled trials investigated the effects of the DASH diet on lipid profile in individuals with overweight/obesity.

METHODS AND RESULTS

A search for relevant studies was conducted in databases like PubMed, Web of Science, and Scopus until January 2024. The calculation of weighted-mean differences (WMDs) and 95 % confidence intervals (CIs) was performed based on the random-effects model. Sensitivity, meta-regression and publication bias analyses were also conducted. 22 eligible studies with 26 arms and 3562 participants were included. DASH diet significantly reduced total cholesterol (TC) (WMD: 5.05 mg/dl, 95 % CI: 8.78, -1.31, p = 0.008), low-density lipoprotein cholesterol (LDL-C) (WMD: 5.33 mg/dl, 95 % CI: 8.54, -2.11, p = 0.001) and very low-density lipoprotein cholesterol (VLDL-C) (WMD: 3.26, 95 % CI: 6.19, -0.34, p = 0.029) levels. Greater reductions were observed in studies with durations ≤8 weeks. All of the included studies were classified as high quality except two, which were classified as moderate quality. LDL-C and VLDL-C were categorized as high-grade evidence, while others were categorized as moderate.

CONCLUSIONS

DASH diet could improve the lipid profile of individuals with overweight/obesity by decreasing TC, LDL-C and VLDL-C levels. However, it doesn't have significant effects on high-density lipoprotein cholesterol and triglyceride levels.

Predictors of Stroke Recurrence and Outcomes in Cerebral Small Vessel Disease: A Systematic Review of the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial Findings

Cerebral small vessel disease (CSVD) plays a significant role in the development of lacunar strokes and is closely associated with cognitive decline, gait disturbances, and vascular dementia. This systematic review explores the pathophysiology and management of CSVD, with a focus on its contribution to stroke recurrence and patient outcomes. Key findings indicate that structural cardiac abnormalities, inflammatory markers, and metabolic disorders are critical predictors of stroke risk in individuals with CSVD. Structural changes in the heart, such as altered left ventricular geometry, are linked to higher stroke recurrence rates, while elevated inflammatory markers, like high-sensitivity C-reactive protein, are associated with increased vascular events. Metabolic conditions, particularly diabetes, correlate with more severe vascular abnormalities and a heightened risk of recurrent strokes and mortality. Notably, some treatment strategies, such as dual antiplatelet therapy, may inadvertently increase mortality in specific patient groups, underscoring the importance of individualized therapeutic approaches. These insights emphasize the multifactorial nature of CSVD and highlight the need for comprehensive risk assessments and targeted management strategies to improve clinical outcomes.

Sustainability assessment of the micellar optimized HPLC method for concomitant quantification of a common triple regimen for cardiovascular disorders: application to marketed formulations and in vitro dissolution testing

Hypertension and dyslipidemia are two of the most frequently co-occurring cardiovascular risk factors. The combined regimen of hydrochlorothiazide (HCTZ), rosuvastatin (ROS), and losartan (LOS) helped in the successful management of both conditions. This work's objective is to develop an eco-friendly, sensitive, simple, and reliable chromatographic method for the simultaneous estimation of HCTZ, ROS, and the LOS ternary mixture in their pure form, and pharmaceutical formulations. Utilizing sodium dodecyl sulphate (SDS) in combination with polyoxyethylene-23-lauryl ether (Brij-35) could be a greener option with minimal environmental impact in liquid chromatographic separation techniques. Therefore, a micellar HPLC protocol was optimized and validated employing a mobile phase comprising a mixture of micelles of SDS (0.15 mol L-1) and Brij-35 (0.03 mol L-1) with 0.01 M monobasic potassium phosphate buffer, pH 3.5. The cited drugs were detected at 230 nm within five minutes, using a symmetry RP-C18 column, an isocratic elution mode, and a flow speed of 1 mL min-1. Method validation was successfully performed as stated by ICH. The suggested HPLC approach was effectively applied to determine the mentioned drugs in three pharmaceutical preparations. It was also employed for monitoring their in vitro release pattern using two innovator tablet formulations, applying the USFDA guidelines. The applied procedure was evaluated and compared with previously published HPLC approaches using various metrics, including the Eco-Scale Scoring method (AES), the Green Analytical Procedure Index (GAPI), and the Analytical Greenness Calculator (AGREE) for greenness, the most current Blue Applicability Grade Index (BAGI) for blueness, and the more inclusive RGB 12 algorism for whiteness assessment.

Gallic acid: a dietary metabolite's therapeutic potential in the management of atherosclerotic cardiovascular disease

Atherosclerotic cardiovascular disease (ASCVD) causes significant morbidity and mortality globally. Most of the chemicals specifically target certain pathways and minimally impact other diseases associated with ASCVD. Moreover, interactions of these drugs can cause toxic reactions. Consequently, the exploration of multi-targeted and safe medications for treating and preventing ASCVD has become an increasingly popular trend. Gallic acid (GA), a natural secondary metabolite found in various fruits, plants, and nuts, has demonstrated potentials in preventing and treating ASCVD, in addition to its known antioxidant and anti-inflammatory effects. It alleviates the entire process of atherosclerosis (AS) by reducing oxidative stress, improving endothelial dysfunction, and inhibiting platelet activation and aggregation. Additionally, GA can treat ASCVD-related diseases, such as coronary heart disease (CHD) and cerebral ischemia. However, the pharmacological actions of GA in the prevention and treatment of ASCVD have not been comprehensively reviewed, which limits its clinical development. This review primarily summarizes the in vitro and in vivo pharmacological actions of GA on the related risk factors of ASCVD, AS, and ASCVD. Additionally, it provides a comprehensive overview of the toxicity, extraction, synthesis, pharmacokinetics, and pharmaceutics of GA,aimed to enhance understanding of its clinical applications and further research and development.

Causal relationship between dyslipidemia and diabetic neuropathy: a mendelian randomization study

Some studies have shown an association between dyslipidemia and diabetic neuropathy (DN), but the genetic association has not been clarified. Therefore, the present study aimed to investigate the genetic causal association between dyslipidemia and DN through a Mendelian randomization (MR) approach. Genetic causal associations between total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL), and high-density lipoprotein cholesterol (HDL) and DN were investigated by MR to provide a basis for the prevention and treatment of DN. Significant and independent single-nucleotide polymorphisms (SNPs) identified in genome-wide association studies were selected as instrumental variables (IVs) for MR analysis. Inverse variance weighted (IVW), MR‒Egger regression, weighted median (WME), simple mode (SM), and weighted mode (WM) methods were used to analyze causal associations. Heterogeneity and multiplicity tests were also performed and analyzed using the leave-one-out method to assess the stability of the results. Genetically predicted TC and DN (OR = 0.793, 95% CI = 0.655⁓0.961, P = 0.019) and LDL and DN (OR = 0.842, 95% CI = 0.711⁓0.998, P = 0.049) may be causally associated, but no causal associations were found between TG and DN (OR = 0.837, 95% CI = 0.631⁓1.111, P = 0.221) or between HDL and DN (OR = 1.192, 95% CI = 0.940⁓1.510, P = 0.149). TC and LDL may have genetic causal associations with DN, though no genetic causal associations were found for TG or HDL with DN. However, this study may have several limitations, and further clinical studies are needed to expand the sample size for future validation.

Analyzing lipid profiles and dyslipidemia prevalence in hypertensive patients: a cross-sectional study from primary community health institutions

Background

A significant proportion of hypertensive patients also suffer from comorbid dyslipidemia, which critically influences their treatment outcomes and overall prognosis. Given its implications, the lipid profiles of hypertensive individuals warrant increased attention for more effective clinical management.

Methods

We analyzed data from 92,443 hypertensive patients registered at primary community health institutions in 2021. Employing a cross-sectional study design, we assessed the distribution of lipid levels and the prevalence of various dyslipidemia subtypes. Stepwise forward logistic regression was used to identify factors associated with dyslipidemia, adjusting for gender, age, body size, and other relevant characteristics.

Results

According to the 2023 Chinese Guidelines for the Management of Lipids, the overall prevalence of dyslipidemia was 37.5%. Subtype analysis revealed prevalence of high total cholesterol (TC) at 11.2%, high triglycerides (TG) at 16.0%, low high-density lipoprotein cholesterol (HDL-C) at 16.0%, and high low-density lipoprotein cholesterol (LDL-C) at 10.2%. TG abnormalities were more common among males (16.8%), whereas TC abnormalities predominated in females (14.4%). Notably, hypertensive patients with diabetes had higher levels of TG compared to non-diabetics (p = 0.009). Those with stroke and liver disease comorbidities exhibited lower TG levels than their counterparts (p = 0.018 and p < 0.001, respectively). Additionally, HDL-C levels were significantly lower in hypertensives with diabetes, coronary artery disease, and central obesity (p < 0.001, p = 0.026, p < 0.001, respectively). Regression analysis indicated that dyslipidemia prevalence correlates significantly with gender, age, diabetes, coronary heart disease, stroke, family history of hypertension, body mass index (BMI), central obesity, frequency of physical activity, smoking status, regular alcohol consumption, and abdominal ultrasound findings.

Conclusion

Our study underscores the necessity of rigorous lipid monitoring and analysis of dyslipidemia-influencing factors for the development of effective health management strategies within the community. There is a critical need to examine lipid profiles comprehensively and implement targeted therapeutic interventions aimed at managing hyperlipidemia, a modifiable risk factor for cardiovascular disease.

Evaluation of Coronary Artery Calcium Score (CACS) in Dipper and Non-Dipper Hypertensive Patients with Moderate and High Cardiovascular Disease Risks

Background and Objectives: Hypertension is typically classified into two main groups, "dipper" and "non-dipper", based on nocturnal blood pressure decline. The coronary artery calcium score (CACS) is an essential biomarker used to assess the presence and severity of coronary artery disease (CAD). This study aims to demonstrate the relationship between CACS and hypertensive patients with moderate-to-high cardiovascular disease (CVD) risk classified as either dipper or non-dipper. Participants and Methods: A total of 167 patients with moderate-to-high CVD risk were divided into two subgroups: 95 patients with dipper hypertension (HT) and 72 with non-dipper hypertension. CACS was measured using coronary computed tomography angiography. Results: In the dipper HT group, there were 60 females (63.2%) and 35 males (36.8%), whereas the non-dipper HT group included 28 females (38.9%) and 44 males (61.1%) (p = 0.002). The mean age was 57 in the dipper HT group and 62 in the non-dipper HT group (p = 0.011). The mean CACS was 93 in the non-dipper HT group and 10 in the dipper HT group (p < 0.001). A history of coronary artery disease was more common in the non-dipper HT group (p = 0.003). Smoking prevalence was higher in the non-dipper HT group (31 patients, 43.1%) compared to the dipper HT group (25 patients, 26.3%) (p = 0.023). Correlation analysis showed that CACS was positively correlated with age, BMI, and HbA1c and negatively correlated with eGFR. Higher CACS values were also observed in males and patients with a history of coronary artery disease, diabetes mellitus, and hyperlipidemia. In univariate analysis, age, male sex, smoking, CAD, CACS, and elevated creatinine were identified as significant risk factors for non-dipper HT (p < 0.05). However, in multivariate analysis, only CACS emerged as a significant independent risk factor (p = 0.001), while other variables were not significant (p > 0.05). The area under the curve (AUC) for CACS was 0.759, indicating statistically significant and excellent discriminative capability (p < 0.001, 95% CI: 0.680-0.839). Conclusions: It was concluded that non-dipper hypertension is associated with higher CACS and indicates a higher cardiovascular risk for this group.

Impact of hypertension and lipid profile on cardiac function in an Iranian teaching hospital: A cross-sectional analysis

INTRODUCTION

Cardiovascular diseases (CVDs) pose a significant global health challenge and affect diverse populations. For conditions such as coronary artery disease, heart failure, and stroke prevalence, understanding the multifaceted factors contributing to CVDs is crucial. Hypertension and dyslipidemia, which are established risk factors, require further exploration, particularly in terms of their individual impact on cardiac function. This study aims to uncover associations, elucidate nuanced interplay, and provide insights for personalized interventions.

METHODS

A cross-sectional analysis, conducted at a Tehran Teaching Hospital, focused on adults admitted for suspected heart disease. The dataset included demographic information, clinical history, medications, and echocardiographic data. Statistical analysis was performed using Pearson's correlation with IBM SPSS Statistics software.

RESULTS

In this analysis of 95 individuals suspected of heart disease, aged 51 years on average, diverse blood pressure patterns with significant percentages across various hypertension stages were observed. Lipid profile analysis revealed typical lipid levels. Correlations between blood pressure, lipid parameters, and cardiac function indicated significant associations, including a negative correlation between ejection fraction and blood pressure and significant correlations between lipid profiles and adverse cardiac volume changes. Disparities in the prevalence of obesity and diabetes have highlighted potential links to hypertension.

CONCLUSIONS

This study sheds light on crucial clinical aspects of individuals with suspected heart disease, revealing patterns of obesity, varied blood pressure categories, and nuanced lipid profiles. The correlations between blood pressure, lipid parameters, and cardiac function highlight potential connections, emphasizing the importance of tailored interventions for improved cardiovascular outcomes.

Lipitension and cardiometabolic risk factors in young people

Aim. To study the relationship of lipitension and cardiometabolic risk (CMR) factors in young people.

Material and methods. The case-control study on general obesity (GO) (overweight — 33,3%, GO — 33,3%) included 191 patients (Me=35,0 [30,0-39,0] years; F/M=97(50,8%)/94(49,2%)) without cardiometabolic diseases, comparable by sex and age. The prevalence and characteristics of lipitension were studied, taking into account the features of dyslipidemia and increased blood pressure (BP). Depending on the presence of lipitension, 2 groups were identified in which the CMR factors were studied: GO and abdominal obesity (AO), visceral fat, prediabetes, insulin resistance, increased C-reactive protein (CRP), hyperuricemia, glomerular filtration rate changes. Data were processed using SPSS Statistics 26.

Results. Overall, the incidence of increased BP was 36,1%, hypertension (HTN) — 16,2%, and dyslipidemia — 73,3%. Lipitension was diagnosed in 25,1% of patients. At the same time, increased BP and HTN without combination with dyslipidemia were detected less frequently (13,1% and 5,2%, respectively). Dyslipidemia without increased BP and HTN, on the contrary, is more common (48,2%). Lipitension is more often diagnosed in men than in women — 32 (66,7%) and 16 (33,3%), p=0,005; [odds ratio=2,6; 95% confidence interval: 1,32-5,18]. In patients with lipitension, 43,8% were diagnosed with HTN, while the remaining 56,2% had BP ≥130/85 mm Hg. In the structure of dyslipidemia in lipitension, 79,2% had abnormalities in ≥2 lipid parameters, of which increased levels of low-density lipoprotein cholesterol (LDL-C) and hypercholesterolemia (78,3%) were most often detected. Persons with lipitension more often had AO (31,2%), increased glycated hemoglobin (HbA1c) >6% (39%) and insulin resistance (36,2%) than those without lipitension (p=0,026, p=0,018, p=0,044, respectively). With lipitension, a higher level of visceral fat (Me=8 [6-9] units) and HbA1c (Me=5,6 [5,1-6,0]%) was established than without it (Me=6 [4-9]U and Me=5,4 [5,1-5,9]%, respectively p=0,000 and p=0,018).

Conclusion. Increased BP and HTN are more often found in combination with dyslipidemia than as an independent risk factor. In lipitension, the largest number of patients had ≥2 lipid metabolism disorders, most often represented by increased LDL-C and hypercholesterolemia. The presence of lipitension was associated with AO, increased HbA1c, and insulin resistance.

Rosuvastatin, but not atorvastatin, enhances the antihypertensive effect of cilostazol in an acute model of hypertension

PURPOSE

Hypertensive emergency, a sudden and severe increase in blood pressure, necessitates immediate intervention to avoid end-organ damage. Cilostazol, a selective phosphodiesterase-III inhibitor, has vasodilator effect. Here, we investigated the effect of two commonly used statins, atorvastatin or rosuvastatin, on cilostazol antihypertensive activity in acute model of hypertension.

METHODS

Hypertensive emergency was induced via angiotensin II intravenous infusion (120 ng.kg-1.min-1). Rats were subjected to real-time arterial hemodynamics and electrocardiogram recording while investigated drugs were injected slowly at cumulative doses 0.5, 1, and 2 mg.kg-1, individually or in combination, followed by baroreflex sensitivity (BRS) analysis and serum electrolytes (Na+ and K+) and vasomodulators (norepinephrine (NE), and nitric oxide (NO)) assessment.

RESULTS

Cilostazol reduced systolic blood pressure (SBP), while co-injection with rosuvastatin augmented cilostazol SBP-reduction up to 30 mmHg. Compared to atorvastatin, rosuvastatin boosted the cilostazol-associated reduction in peripheral resistance, as evidenced by further decrease in diastolic, pulse, and dicrotic-notch pressures. Rosuvastatin co-injection prevented cilostazol-induced changes of ejection and non-ejection durations. Additionally, rosuvastatin coadministration produced better restoration of BRS, with an observed augmented increase in BRS indexes from spectral analysis. Greater reduction in sympathetic/parasympathetic ratio and serum NE upon rosuvastatin coadministration indicates further shift in sympathovagal balance towards parasympathetic dominance. Additionally, rosuvastatin coinjection caused a greater decrease in serum sodium, while more increase in NO indicating augmented reduction of extracellular volume and endothelial dysfunction.

CONCLUSION

Rosuvastatin boosted cilostazol's antihypertensive actions through effects on peripheral resistance, BRS, sympathovagal balance, endothelial dysfunction, and electrolytes balance, while atorvastatin did not demonstrate a comparable impact.

The effects of raspberry consumption on lipid profile and blood pressure in adults: A systematic review and meta-analysis

Research into the effects of raspberry on blood pressure and lipid profiles is inconclusive. This meta-analysis was aimed to determine whether raspberry has beneficial effects in clinical practice and to what extent these effects are associated with blood pressure and lipid profiles. A systematic literature search up to September 2023 was completed in PubMed/Medline, Scopus, and Web of Science, to identify eligible RCTs. Heterogeneity tests of the selected trials were performed using the I 2 statistic. Random effects models were evaluated based on the heterogeneity tests, and pooled data were determined as weighted mean differences with a 95% confidence interval. Eleven randomized controlled trials (with 13 arms) were eligible for this meta-analysis. Our findings revealed that Raspberry consumption had no significant effects on the blood pressure and lipid profile markers, including systolic blood pressure (SBP) (WMD, -0.37 mm Hg; 95%CI: -2.19 to 1.44; p = .68), diastolic blood pressure (DBP) (WMD, -2.14 mm Hg; 95%CI: -4.27 to 0.00; p = .05), total cholesterol (TC) (WMD, -6.83 mg/dL; 95%CI: -15.11 to 1.44; p = .10), triglycerides (TG) (WMD, -5.19 mg/dL: 95%CI: -11.76 to 1.37; p = .12), low-density lipoprotein-cholesterol (LDL-C) (WMD, -5.19 mg/dL; 95%CI: -11.58 to 1.18; p = .11), and high-density lipoprotein-cholesterol (HDL-C) (WMD, 0.82 mg/dL; 95%CI: -1.67 to 3.32; p = .51), compared to control groups. Subgroup analysis showed that raspberry consumption significantly decreased total cholesterol and LDL-C levels in people with elevated TC levels, metabolic syndrome, and andropause symptoms, as well as those older than 35, while the consumption of raspberries led to a significant increase in HDL-C levels in females, obese, under 35, and healthy individuals. Raspberry can improve lipid profile and blood pressure, but it is important to keep in mind that further research is necessary to fully understand the exact mechanism of action and a definite conclusion in this regard.

Advances in the molecular mechanisms of statins in regulating endothelial nitric oxide bioavailability: Interlocking biology between eNOS activity and L-arginine metabolism

Statins, inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A, are widely used to treat hypercholesterolemia. In addition, statins have been suggested to reduce the risk of cardiovascular events owing to their pleiotropic effects on the vascular system, including vasodilation, anti-inflammation, anti-coagulation, anti-oxidation, and inhibition of vascular smooth muscle cell proliferation. The major beneficial effect of statins in maintaining vascular homeostasis is the induction of nitric oxide (NO) bioavailability by activating endothelial NO synthase (eNOS) in endothelial cells. The mechanisms underlying the increased NO bioavailability and eNOS activation by statins have been well-established in various fields, including transcriptional and post-transcriptional regulation, kinase-dependent phosphorylation and protein-protein interactions. However, the mechanism by which statins affect the metabolism of L-arginine, a precursor of NO biosynthesis, has rarely been discussed. Autophagy, which is crucial for energy homeostasis, regulates endothelial functions, including NO production and angiogenesis, and is a potential therapeutic target for cardiovascular diseases. In this review, in addition to summarizing the molecular mechanisms underlying increased NO bioavailability and eNOS activation by statins, we also discuss the effects of statins on the metabolism of L-arginine.

Photoplethysmography for Assessing Microcirculation in Hypertensive Patients After Taking Antihypertensive Drugs: A Review

High blood pressure (BP) is a common disease and is associated with many chronic diseases. Measuring BP is essential for the treatment and management of many diseases, and therefore there is a growing need for a non-invasive, sleeveless and continuous BP monitoring device. With the development of technology, pulse waveform analysis using photoplethysmography (PPG) has become more feasible for evaluating BP. This study aimed to evaluate the changes of vascular elasticity and blood volume over time by using the characteristic parameters extracted by PPG. We reviewed the latest progress and literature on the observation of capillary network characteristics in hypertensive and non-hypertensive patients by PPG, the influence of different drugs on microcirculation characteristics in hypertensive patients with PPG, and further explored the key relationship between microcirculation and hypertension. We found that the PPG waveform produced by the fingertips of hypertensive patients is very different from that of healthy people, and the PPG waveform changes significantly during diastolic period after antihypertensive treatment. With the rapid development of medical technology, people can get more intuitive microcirculation image data, which provides beneficial help for the comprehensive understanding of hypertension.

Pharmacological Considerations in the Interpretation of Biochemical Results in Diabetic Patients with Cardiovascular Complications

Diabetes mellitus with cardiovascular diseases is often a multi-systemic disease that requires a multi-therapeutic approach which mostly poses a challenge to laboratory result interpretation. The non-availability of information on many patients due to poor referral, documentation and record keeping has resulted in isolated interpretation of laboratory result of diabetic patients with multisystemic complications. This has led to both analytical and post-analytical errors which has a negative impact on total quality of results. Therefore, this review showed the possible therapeutic treatment of a diabetic patient with cardiovascular disease and how their pharmacological role could affect laboratory result.

New Insights into Cardiovascular Diseases Treatment Based on Molecular Targets

Cardiovascular diseases (CVDs) which consist of ischemic heart disease, stroke, heart failure, peripheral arterial disease, and several other cardiac and vascular conditions are one of the most common causes of death worldwide and often co-occur with diabetes mellitus and lipid disorders which worsens the prognosis and becomes a therapeutic challenge. Due to the increasing number of patients with CVDs, we need to search for new risk factors and pathophysiological changes to create new strategies for preventing, diagnosing, and treating not only CVDs but also comorbidities like diabetes mellitus and lipid disorders. As increasing amount of patients suffering from CVDs, there are many therapies which focus on new molecular targets like proprotein convertase subtilisin/kexin type 9 (PCSK9), angiopoietin-like protein 3, ATP-citrate lyase, or new technologies such as siRNA in treatment of dyslipidemia or sodium-glucose co-transporter-2 and glucagon-like peptide-1 in treatment of diabetes mellitus. Both SGLT-2 inhibitors and GLP-1 receptor agonists are used in the treatment of diabetes, however, they proved to have a beneficial effect in CVDs as well. Moreover, a significant amount of evidence has shown that exosomes seem to be associated with myocardial ischaemia and that exosome levels correlate with the severity of myocardial injury. In our work, we would like to focus on the above mechanisms. The knowledge of them allows for the appearance of new strategies of treatment among patients with CVDs.

Cardiovascular Risk Assessment and Control in Outpatients Evaluated by 24-hour Ambulatory Blood Pressure and Different LDL-C Equations

INTRODUCTION

Office blood pressure (OBP) and low-density lipoprotein cholesterol (LDL-C) calculated by the Friedewald formula (F) are the cornerstones of the cardiovascular risk (CVR) assessment and management based on the SCORE2/SCORE2-OP model proposed by the 2021 ESC Guidelines on Cardiovascular Disease Prevention.

AIM

We compared the CVR stratification estimated by the old SCORE and the SCORE2/SCORE2-OP using OBP and ambulatory blood pressure measurement (ABPM), and we evaluated the prevalence of LDL-C control, after calculating it using three validated equations, in outpatients referred for arterial hypertension.

METHODS

A cross-sectional study on 1539 consecutive patients with valid ABPM. LDL-C was calculated using the Friedewald formula (F), its modification by Martin (M), and the Sampson (S) equation. SCORE and SCORE2/SCORE2-OP were estimated using OBP, mean daytime (+ 5 mmHg adjustment), and mean 24-hour systolic blood pressure (+ 10 mmHg adjustment). Individual CVR by 2021 ESC Guidelines (and SCORE2/SCORE2-OP) was compared to the 2019 ESC/EAS Guidelines (and SCORE). Differences in the prevalence of LDL-C control according to the three methods to calculate LDL-C were also analysed.

RESULTS

Mean age was 60 ± 12 years, with male prevalence (54%). Mean LDL-C values were 118 ± 38 mg/dL (F), 119 ± 37 mg/dL (M), and 120 ± 38 mg/dL (S), respectively. Within the same population, SCORE and SCORE2/SCORE2-OP significantly varied, but no differences emerged after comparing the average SCORE2/SCORE2-OP calculated with OBP (6% IQR 3-10), mean 24-hour systolic BP (7% IQR 4-11), and mean daytime systolic BP (7% IQR 4-11). SCORE2/SCORE2-OP and 2021 ESC Guidelines reclassified the CVR independently of the method used for BP measurement. The low-moderate risk group decreased by 32%, whereas the high and veryhighrisk groups increased by 18% and 12%, respectively. We found a significant reduction in reaching the LDL-C goals regardless of the equation used to calculate it, except for those > 65 years, in whom results were confirmed only by using the M.

CONCLUSION

SCORE2/SCORE2-OP and 2021 ESC Guidelines recommendations led to a non-negligible CVR reclassification and subsequent lack of LDL-C goal, regardless of estimating SCORE2 using OBP or ABPM. Calculating the LDL-C with the M may be the best choice in specific settings.

A Prospective Study of Lipids in Adult Women With Turner Syndrome

Context

Turner syndrome (TS) is a rare genetic syndrome with an increased mortality, mainly attributed to cardiovascular disease.

Objective

This work aimed to investigate and correlate the lipid profile in adult women with TS to clinical characteristics.

Methods

A 12-year prospective cohort study, including 4 study visits, was conducted at a specialist hospital. A total of 102 women with TS qualified for inclusion. Excluding missing variables and participants lost to follow-up, 86 women (mean age 38.1 years; range, 18.4-62.1 years) were included in this study. Fifty-three women completed the study. Repeated-measurement analysis was performed, using total cholesterol (Total-C), low-density lipoprotein (LDL), triglycerides (TGs), and high-density lipoprotein (HDL) as outcome variables and age, karyotype, body mass index (BMI), treatment with statins, antidiabetics, and hormone replacement therapy as explanatory variables. Principal component analysis (PCA) and partial least squares (PLS) analysis were performed at the first study visit.

Results

Hyperlipidemia was present in 30% of the TS cohort. Total-C increased with age (0.12 mmol/L/y; P = .016). LDL (P = .08), TGs (P = .14), and HDL (P = .24) were not associated with age. BMI significantly increased total-C (0.19 mmol/L/kg/m2; P = .006), LDL (0.63 mmol/L/kg/m2; P < .001), and TGs (0.80 mmol/L/kg/m2; P < .001) and decreased HDL (-0.59 mmol/L/kg/m2; P < .001). PCA and PLS analysis found correlations between weight and BMI and total-C, LDL, and TGs.

Conclusion

Hyperlipidemia is more prevalent in adult women with TS across adulthood compared to the background population. Total-C, LDL, TGs, and HDL were significantly associated with BMI characterizing the atherogenic profile in adult women with TS.

Effect of dietary supplementation with Diuripres® on blood pressure, vascular health, and metabolic parameters in individuals with high-normal blood pressure or stage I hypertension: The CONDOR randomized clinical study

Our aim was to evaluate if a nutritional intervention with a dietary supplement (Diuripres®) containing magnesium, standardized extract of orthosiphon, hawthorn, and hibiscus could positively affect blood pressure (BP), vascular health, and metabolic parameters in 60 individuals with high-normal BP or stage I hypertension. Participants followed a low-fat low-sodium Mediterranean diet for 4 weeks before being randomly allocated to 8-week treatment with two pills each day of either Diuripres® or placebo. Diuripres® significantly decreased systolic BP compared to placebo after 4 weeks (3.1 ± 0.8 mmHg; p < 0.05) and more consistently after 8 weeks (3.4 ± 0.9 mmHg; p < 0.05). At 8-week follow-up, after correction for multiple testing, dietary supplementation with Diuripres® was associated with significant improvements in diastolic BP (-3.1 ± 0.6 mmHg; p < 0.05), aortic BP (-4.3 ± 0.4 mmHg; p < 0.05), and high-sensitivity C-reactive protein (hs-CRP; 0.04 ± 0.01 mg/dL; p < 0.05) in comparison with baseline. The reductions in diastolic BP (--3.8 ± 0.7 mmHg; p < 0.05), aortic BP (-5.2 ± 1.0 mmHg; p < 0.05), and hs-CRP (-0.03 ± 0.01 mg/dL; p < 0.05) were also significant compared to placebo. Therefore, our study shows that dietary supplementation with Diuripres® may be useful in individuals with high-normal BP or stage I hypertension.

The Possible Effect of Dietary Fiber Intake on the Metabolic Patterns of Dyslipidemia Subjects: Cross-Sectional Research Using Nontargeted Metabolomics

BACKGROUND

Dyslipidemia is important because of its association with various metabolic complications. Numerous studies have sought to obtain scientific evidence for managing dyslipidemia patients.

OBJECTIVES

This study aims to identify differences in the nutritional traits of dyslipidemia subjects based on metabolite patterns.

METHODS

Dyslipidemia (n = 73) and control (n = 80) subjects were included. Dyslipidemia was defined as triglycerides ≥200 mg/dL, total cholesterol ≥240 mg/dL, low density lipoprotein cholesterol ≥160 mg/dL, high-density lipoprotein cholesterol <40 mg/dL (men) or 50 mg/dL (women), or lipid-lowering medicine use. Nontargeted metabolomics based on ultra-high performance liquid chromatography-mass spectrometry identified plasma metabolites, and K-means clustering was used to reconstitute groups based on the similarity of metabolomic patterns across all subjects. Then, with eXtreme Gradient Boosting, metabolites significantly contributing to the new grouping were selected. Statistical analysis was conducted to analyze traits demonstrating appreciable differences between the groups.

RESULTS

Dyslipidemia subjects were divided into 2 groups based on whether they were (n = 24) or were not (n = 56) in a similar metabolic state as the controls by K-means clustering. The considerable contribution of 4 metabolites (3-hydroxybutyrylcarnitine, 2-octenal, 1,3,5-heptatriene, and 5β-cholanic acid) to this new subset of dyslipidemia was confirmed by eXtreme Gradient Boosting. Furthermore, fiber intake was significantly higher in dyslipidemia subjects whose metabolic state was similar to that of the control than in the dissimilar group (P = 0.002). Moreover, significant correlations were observed between the 4 metabolites and fiber intake. Regression analysis determined that the ideal cutoff for fiber intake was 17.28 g/d.

CONCLUSIONS

Dyslipidemia patients who consume 17.28 g/d or more of dietary fiber may maintain similar metabolic patterns to healthy individuals, with substantial effects on the changes in the concentrations of 4 metabolites. Our findings could be applied to developing dietary guidelines for dyslipidemia patients.

Hypertension and Dyslipidemia: the Two Partners in Endothelium-Related Crime

PURPOSE OF REVIEW

The goal of this article is to characterize the endothelium's role in the development of hypertension and dyslipidemia and to point out promising therapeutic directions.

RECENT FINDINGS

Dyslipidemia may facilitate the development of hypertension, whereas the collaboration of these two silent killers potentiates the risk of atherosclerosis. The common pathophysiological denominator for hypertension and dyslipidemia is endothelial cell dysfunction, which manifests as dysregulation of homeostasis, redox balance, vascular tone, inflammation, and thrombosis. Treatment focused on mediators acting in these processes might be groundbreaking. Metabolomic research on hypertension and dyslipidemia has revealed new therapeutic targets. State-of-the-art solutions integrating interview, clinical examination, innovative imaging, and omics profiles along with artificial intelligence have been already shown to improve patients' risk stratification and treatment. Pathomechanisms underlying hypertension and dyslipidemia take place in the endothelium. Novel approaches involving endothelial biomarkers and bioinformatics advances could open new perspectives in patient management.

Advances in Treatment of Dyslipidemia

Dyslipidemias have emerged as prevalent disorders among patients, posing significant risks for the development and progression of cardiovascular diseases. These conditions are characterized by elevated levels of total cholesterol (TC), triglycerides (TGs), and low-density lipoprotein cholesterol (LDL-C). This review delves into the current treatment approach, focusing on equalizing these parameters while enhancing the overall quality of life for patients. Through an extensive analysis of clinical trials, we identify disorders that necessitate alternative treatment strategies, notably familial hypercholesterolemia. The primary objective of this review is to consolidate existing information concerning drugs with the potential to revolutionize dyslipidemia management significantly. Among these promising pharmaceuticals, we highlight alirocumab, bempedoic acid, antisense oligonucleotides, angiopoietin-like protein inhibitors, apolipoprotein C-III (APOC3) inhibitors, lomitapide, and cholesterol ester transfer protein (CETP) inhibitors. Our review demonstrates the pivotal roles played by each of these drugs in targeting specific parameters of lipid metabolism. We outline the future landscape of dyslipidemia treatment, envisaging a more tailored and effective therapeutic approach to address this widespread medical concern.

Potential antihypertensive activity of novel peptides from green basil leaves

Hypertension is among the risk factors of death globally. Novel antihypertensive peptides are alternative choices of antihypertensive assistance. This study aimed to discover novel antihypertensive peptides from green basil leaves. Two bioactive peptides with high angiotensin-converting enzyme inhibition (Asp-Leu-Ser-Ser-Ala-Pro; peptide 1) and antioxidant (Asp-Ser-Val-Ser-Ala-Ser-Pro; peptide 2) activities were gavaged to male Wistar rats induced with NG-nitro-l-arginine methyl-ester (L-NAME). L-NAME-treated rats (HT) had decreased body weights and levels of nitrite and nitrate, which are metabolites of nitric oxide. The levels of their glucose and liver function indicators increased as compared to normal rats. HT rats receiving antihypertensive drugs (HTD) showed higher low-density lipoprotein and low-density lipoprotein/high-density lipoprotein levels than HT rats. Peptide 1 seems to benefit the rat lipid profiles, liver functions, antioxidant, nitrite, nitrate, and angiotensin II peptide levels but not peptide 2. In conclusion, our findings indicate the antihypertensive potential related to vasodilation of peptides from green basil leaves.

Effect of Arabic Qahwa on Blood Pressure in Patients with Stage One Hypertension in the Eastern Region of Saudi Arabia

Hypertension (HT), which is a condition of increased blood pressure (BP), is a major health problem globally. In Saudi Arabia, morbidity and mortality rates are increasing due to HT. Arabic Qahwa (AQ) is a commonly consumed beverage in Saudi Arabia and has numerous health benefits. We conducted a randomized control trial to investigate the effect of AQ on BP among patients with HT (Stage 1). Based on the inclusion criteria, 140 patients were randomly selected, and 126 patients were followed up. After obtaining demographic information, we assessed the BP, heart rate, and lipid profile before and after the intervention of consuming four cups of AQ daily for four weeks. A paired 't' test was used with a significance level of 5%. In the AQ group, there were significant changes (p = 0.009) in systolic blood pressure (SBP), with means of 134.72 ± 3.23 and 133.14 ± 3.69 observed pre and post-test, respectively. Similarly, the diastolic blood pressure (DBP) pre- and post-test mean scores were 87.08 ± 1.8 and 85.98 ± 1.95, respectively, which also showed significance (p = 0.001). There were also significant changes (p = 0.001) observed in the lipid profile of the AQ group. In conclusion, AQ is effective in reducing SBP and DBP in patients with stage one HT.

Edible mushrooms as potential functional foods in amelioration of hypertension

Edible mushrooms are popular functional foods attributed to their rich nutritional bioactive constituent profile influencing cardiovascular function. Edible mushrooms are omnipresent in various prescribed Dietary Approaches to Stop Hypertension, Mediterranean diet, and fortified meal plans as they are rich in amino acids, dietary fiber, proteins, sterols, vitamins, and minerals. However, without an understanding of the influence of mushroom bioactive constituents, mechanism of action on heart and allergenicity, it is difficult to fully comprehend the role of mushrooms as dietary interventions in alleviating hypertension and other cardiovascular malfunctions. To accomplish this endeavor, we chose to review edible mushrooms and their bioactive constituents in ameliorating hypertension. Hypertension and cardiovascular diseases are interrelated and if the former is managed by dietary changes, it is postulated that overall heart health could also be improved. With a concise note on different edible varieties of mushrooms, a particular focus is presented on the antihypertensive potential of mushroom bioactive constituents, mode of action, absorption kinetics and bioavailability. Ergosterol, lovastatin, cordycepin, tocopherols, chitosan, ergothioneine, γ-aminobutyric acid, quercetin, and eritadenine are described as essential bioactives with hypotensive effects. Finally, safety concerns on allergens and limitations of consuming edible mushrooms with special reference to chemical toxins and their postulated metabolites are highlighted. It is opined that the present review will redirect toxicologists to further investigate mushroom bioactives and allergens, thereby influencing dietary interventions for heart health.

Therapeutic Potential of Hibiscus sabdariffa Linn. in Attenuating Cardiovascular Risk Factors

Cardiovascular diseases (CVDs) represent a broad spectrum of diseases afflicting the heart and blood vessels and remain a major cause of death and disability worldwide. CVD progression is strongly associated with risk factors, including hypertension, hyperglycemia, dyslipidemia, oxidative stress, inflammation, fibrosis, and apoptosis. These risk factors lead to oxidative damage that results in various cardiovascular complications including endothelial dysfunctions, alterations in vascular integrity, the formation of atherosclerosis, as well as incorrigible cardiac remodeling. The use of conventional pharmacological therapy is one of the current preventive measures to control the development of CVDs. However, as undesirable side effects from drug use have become a recent issue, alternative treatment from natural products is being sought in medicinal plants and is gaining interest. Roselle (Hibiscus sabdariffa Linn.) has been reported to contain various bioactive compounds that exert anti-hyperlipidemia, anti-hyperglycemia, anti-hypertension, antioxidative, anti-inflammation, and anti-fibrosis effects. These properties of roselle, especially from its calyx, have relevance to its therapeutic and cardiovascular protection effects in humans. This review summarizes the findings of recent preclinical and clinical studies on roselle as a prophylactic and therapeutic agent in attenuating cardiovascular risk factors and associated mechanisms.

Herbal medicines for the treatment of cardiovascular diseases: Benefits and risks- A narrative review

Herbal medicines (HMs) have been traditionally used for the prophylaxis/treatment of cardiovascular diseases (CVDs). Their use is steadily increasing and many patients with CVDs often combine HMs with prescribed cardiovascular medications. Interestingly, up to 70% of patients do not notify cardiologists/physicians the use of HMs and up to 90% of cardiologists/physicians may not routinely inquire them about the use of HMs. There is limited scientific evidence from well-designed clinical trials supporting the efficacy and safety of HMs and because they do not reduce morbidity and mortality are not recommended in clinical guidelines for the prophylaxis/treatment of CVDs. There is also a great deal of confusion about the identification, active constituents and mechanisms of action of HMs; the lack of standardization and quality control (contaminations, adulterations) represent other sources of concern. Furthermore, the widespread perception that unlike prescription drugs HMs are safe is misleading and some HMs can cause clinically relevant adverse events and interactions, particularly when used with narrow therapeutic index prescribed cardiovascular drugs (antiarrhythmics, antithrombotics, digoxin). Cardiologists/physicians can no longer ignore the problem. They must improve their knowledge about the HMs their patients consume to provide the best advice and prevent adverse reactions and drug interactions. This narrative review addresses the putative mechanisms of action, suggested clinical uses and safety of most commonly used HMs, the pivotal role of cardiologists/physicians to protect consumers and the main challenges and gaps in evidence related to the use of HMs in the prophylaxis and treatment of CVDs.

An Expert Opinion on the Role of the Rosuvastatin/Amlodipine Single Pill Fixed Dose Combination in Cardiovascular Prevention

Current cardiovascular disease prevention strategies are based on the management of cardiovascular risk as a continuum, redefining the therapeutic goals for each individual based on the estimated global risk profile. Given the frequent clustering of the principal cardiovascular risk factors, such as hypertension, diabetes and dyslipidaemia, in the same individual, patients are required to take multiple drugs to achieve therapeutic targets. The adoption of single pill fixed dose combinations may contribute to achieve better control of blood pressure and cholesterol compared to the separate administration of the individual drugs, mostly due to better adherence related to therapeutic simplicities. This paper reports the outcomes of an Expert multidisciplinary Roundtable. In particular, the rational and potential clinical use of the single pill fixed dose combination "Rosuvastatin-Amlodipine" for the management of concomitant hypertension/hypercholesterolemia in different clinical fields are discussed. This Expert Opinion also illustrates the importance of an early and effective management of total cardiovascular risk, highlights the substantial benefits of combining blood pressure and lipid-lowering treatments in a single-pill fixed dose combination and attempts to identify and overcome the barriers to the implementation in clinical practice of the fixed dose combinations with dual targets. This Expert Panel identifies and proposes the categories of patients who may benefit the most from this fixed dose combination.

Self-Reported Coffee Consumption and Central and Peripheral Blood Pressure in the Cohort of the Brisighella Heart Study

Even though coffee consumption has been clearly related to a number of benefits to the cardiovascular system, its effect on blood pressure (BP) has not been fully elucidated. In this sub-analysis of the Brisighella Heart Study (BHS), we compared central and peripheral BP values in a sub-cohort of 720 men (47.9%) and 783 women (52.1%) reporting the drinking of different amounts of coffee each day, for whom a full set of clinical, laboratory and hemodynamic parameters was available. According to our observations, moderate coffee drinking was associated to either higher levels of systolic BP (SBP) compared to those with heavy coffee consumption or lower SBP than that in the non-coffee drinking group (p-value for trend <0.05). In particular, people who drank 2 cups of coffee per day and people who drank >3 cups per day had lower SBP than non-coffee drinkers by 5.2 ± 1.6 mmHg (p = 0.010) and 9.7 ± 3.2 mmHg, respectively (p = 0.007). Similar trends were also observed for peripheral pulse pressure (PP), aortic BP and aortic PP. In the age-adjusted multiple linear regression model, negative predictors of SBP, PP, aortic BP and aortic PP were the estimated glomerular filtration rate (eGFR), female sex and coffee consumption. Positive predictors included body mass index (BMI) and low-density lipoprotein cholesterol (LDL-C). Then, our findings show that regular coffee drinking is associated with lower SBP, PP, aortic BP and aortic PP, but with similar arterial stiffness.

The Association Between Dietary Inflammatory Index (DII) and Risk of Hypertension: A Case-Control Study

INTRODUCTION

Hypertension (HTN) is a common risk factor for various medical diseases. Recently, there is growing evidence focusing on the potential inflammatory properties of food in the developing HTN risk. However, limited data are indicating the link between the dietary inflammatory index score (DII) and HTN risk.

AIM

This study aimed to investigate the relationship between DII score and HTN risk in middle-aged people.

METHODS

This case-control study was performed on 945 middle-aged participants (376 subjects with HTN and 569 control group). Usual dietary intakes were collected using a validated semi-quantitative food frequency questionnaire. The dietary inflammatory index (DII) for each participant was calculated with a standardized procedure, and the relationship between the risk of HTN and the DII score was investigated.

RESULTS

The multi-adjusted regression analysis showed that subjects with the higher DII score had a 1.61 times greater chance of developing HTN than individuals in the lowest ones (95% CI 1.07-2.65). Interestingly, after conducting a sex-based analysis, there was no significant relationship between DII score and risk of HTN in middle-aged women (95% CI 0.38-1.61). However, middle-aged men in the highest quartile of DII had greater (2.91 times) odds of HTN compared to the lowest quarter of DII (95% CI 1.52-5.23).

CONCLUSION

The findings of this study suggested that adherence to a diet with a high inflammatory index could increase the risk of HTN in middle-aged men by approximately 2.9 times. However, following a diet with a high DII score had no significant relationship with HTN risk in middle-aged women.