Treatment of Hypertension in Patients With Coronary Artery Disease

Mobile-HR: An Ophthalmologic-Based Classification System for Diagnosis of Hypertensive Retinopathy Using Optimized MobileNet Architecture

Hypertensive retinopathy (HR) is a serious eye disease that causes the retinal arteries to change. This change is mainly due to the fact of high blood pressure. Cotton wool patches, bleeding in the retina, and retinal artery constriction are affected lesions of HR symptoms. An ophthalmologist often makes the diagnosis of eye-related diseases by analyzing fundus images to identify the stages and symptoms of HR. The likelihood of vision loss can significantly decrease the initial detection of HR. In the past, a few computer-aided diagnostics (CADx) systems were developed to automatically detect HR eye-related diseases using machine learning (ML) and deep learning (DL) techniques. Compared to ML methods, the CADx systems use DL techniques that require the setting of hyperparameters, domain expert knowledge, a huge training dataset, and a high learning rate. Those CADx systems have shown to be good for automating the extraction of complex features, but they cause problems with class imbalance and overfitting. By ignoring the issues of a small dataset of HR, a high level of computational complexity, and the lack of lightweight feature descriptors, state-of-the-art efforts depend on performance enhancement. In this study, a pretrained transfer learning (TL)-based MobileNet architecture is developed by integrating dense blocks to optimize the network for the diagnosis of HR eye-related disease. We developed a lightweight HR-related eye disease diagnosis system, known as Mobile-HR, by integrating a pretrained model and dense blocks. To increase the size of the training and test datasets, we applied a data augmentation technique. The outcomes of the experiments show that the suggested approach was outperformed in many cases. This Mobile-HR system achieved an accuracy of 99% and an F1 score of 0.99 on different datasets. The results were verified by an expert ophthalmologist. These results indicate that the Mobile-HR CADx model produces positive outcomes and outperforms state-of-the-art HR systems in terms of accuracy.

The baseline and repeated measurements of DBP to assess in-hospital mortality risk among critically ill patients with acute myocardial infarction: A retrospective cohort study

Changes in diastolic blood pressure (DBP) are common in patients with acute myocardial infarction (AMI). The relationship between the dynamic change of DBP and in-hospital mortality among patients with AMI remains unclear. This study aimed to explore the importance of DBP during disease development among patients with AMI. We performed a retrospective cohort study involving patients from the Medical Information Mart for Intensive Care III database, which included > 40,000 patients admitted to the intensive care unit (ICU). Overall, 3209 adult AMI admissions were identified. We extracted the clinical and laboratory information in the patients with AMI. Cox proportional hazards models were used to evaluate the prognostic values of baseline DBP. We used the generalized additive mixed model (GAMM) to compare trends in DBP over time among survivors and non-survivors, after adjusting for potential confounders. During the ICU stay, 189 patients died (mortality rate, 6.36%). The age of each non-survivor together with the variations in DBP over time from admission to the time of death is of great importance to the scientific community. Cox multivariable regression analysis displayed that after adjusting for confounding factors, ascended baseline DBP was an important hazard factor for hospital deaths (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03; P = .003). Based on GAMM, DBP in the death group was markedly lower than that of the surviving group. Moreover, the difference between the two groups showed an increasing trend within 3 days after ICU admission. After adjusting for various variables, the results were stable. DBP significantly contributed to in-hospital mortality among patients with AMI. There was a nonlinear correlation between baseline DBP and in-hospital mortality among patients with AMI, and the DBP of the non-survivors decreased within the first 3 days after ICU admission. However, the causality cannot be deduced from our data.

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management

OBJECTIVE

We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI.

METHODS

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013.

RESULTS

Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%).

CONCLUSIONS

The main effects were not statistically significant.

PRACTICAL IMPLICATIONS

Completing the full dose of the intervention may be essential to experience the intervention effect.

CLINICAL TRIAL REGISTRATION

The unique identifier is NCT00901277 (http://www.

CLINICALTRIALS

gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).

Therapeutic mechanism of Curcuma aromatica Salisb. rhizome against coronary heart disease based on integrated network pharmacology, pharmacological evaluation and lipidomics

Curcuma aromatica Salisb. rhizome (CASR) has multifunctional characteristics worldwide and a long history of use as a botanical drug with. Currently, it is often used clinically to treat coronary heart disease (CHD) caused by blood stasis syndrome. However, the therapeutic mechanism of CASR in the treatment of CHD remains poorly understood. In study, the main chemical constituents of CASR were analyzed using UPLC-Q-TOF-MS/MS. Then, its potential therapeutic mechanism against CHD was predicted. Subsequently, pharmacological evaluation was performed using CHD rat model. Finally, a lipidomics approach was applied to explore the different lipid metabolites to verify the regulation of CASR on lipid metabolism disorders in CHD. A total of 35 compounds was identified from CASR. Seventeen active components and 51 potential targets related to CHD were screened by network pharmacology, involving 13 key pathways. In vivo experiments showed that CASR could significantly improve myocardial infarction, blood stasis, and blood lipid levels and regulate the PI3K/AKT/mTOR signaling pathway in CHD rats. Lipidomics further showed that CASR could regulate abnormal sphingolipid, glycerophospholipid, and glycerolipid metabolism in CHD rats. The therapeutic mechanism of CASR against CHD was initially elucidated and included the regulation of lipid metabolism. Its effects may be attributed to active ingredients, such as curzerene, isoprocurcumenol, and (+)-curcumenol. This study reveals the characteristics of multi-component and multi-pathway of CASR in the treatment of CHD, which provides a basis for the follow-up development and utilization of CASR.

Machine Learning and Electrocardiography Signal-Based Minimum Calculation Time Detection for Blood Pressure Detection

Objective

Measurement and monitoring of blood pressure are of great importance for preventing diseases such as cardiovascular and stroke caused by hypertension. Therefore, there is a need for advanced artificial intelligence-based systolic and diastolic blood pressure systems with a new technological infrastructure with a noninvasive process. The study is aimed at determining the minimum ECG time required for calculating systolic and diastolic blood pressure based on the Electrocardiography (ECG) signal. Methodology. The study includes ECG recordings of five individuals taken from the IEEE database, measured during daily activity. For the study, each signal was divided into epochs of 2-4-6-8-10-12-14-16-18-20 seconds. Twenty-five features were extracted from each epoched signal. The dimension of the dataset was reduced by using Spearman's feature selection algorithm. Analysis based on metrics was carried out by applying machine learning algorithms to the obtained dataset. Gaussian process regression exponential (GPR) machine learning algorithm was preferred because it is easy to integrate into embedded systems.

Results

The MAPE estimation performance values for diastolic and systolic blood pressure values for 16-second epochs were 2.44 mmHg and 1.92 mmHg, respectively.

Conclusion

According to the study results, it is evaluated that systolic and diastolic blood pressure values can be calculated with a high-performance ratio with 16-second ECG signals.

The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.

Clinical Utility of Amplification Refractory Mutation System-Based PCR and Mutation-Specific PCR for Precise and Rapid Genotyping of Angiotensin-Converting Enzyme 1 (ACE1-rs4646996 D>I) and Angiotensin-Converting Enzyme 2 (ACE2-rs4240157T>C) Gene Variations in Coronary Artery Disease and Their Strong Association with Its Disease Susceptibility and Progression

Background: Experimental clinical and research studies demonstrated that the renin−angiotensin system (RAS) affects the pathogenesis of atherosclerosis and the prognosis of coronary heart disease (CHD). The results show that ACE2 (angiotensin I-converting enzyme 2) might act as a protective protein for cardiovascular diseases; however, only a few studies in human populations have been carried out. The aim of this study was to develop, optimize, and validate a direct T-ARMS-based PCR assay for the precise and rapid genotyping of ACE1-rs4646996 D>I and ACE2-rs4240157T>C and study their association with coronary artery disease susceptibility and progression. Methodology: This study included 149 consecutive coronary artery disease patients and 150 healthy controls. We utilized T-ARMS for the precise and rapid genotyping of ACE2-rs4240157; rs4646994. Results: Our results indicated that the ACE1-rs4646996 D>I genotypes observed between CAD cases and controls were statistically significant (p < 0.008) and, similarly, the ACE2-rs4240157T>C genotypes observed were significant (p < 0.0001). Moreover, the frequency of the D allele (ACE1-D>I) and C allele (ACE2-rs4240157T>C) was found to be higher among CAD patients than the HC. Our results indicated that in the codominant model, the ACE2-ID genotype was strongly associated with increased CAD susceptibility in a codominant model with an OR of 2.37, (95%) CI = (1.023−5.504), and p < 0.04. Similarly, the ACE2-DD genotype was strongly associated with an increased CAD susceptibility with an OR of 3.48, (95%) CI = (1.49 to 8.117), and p < 0.003. Similarly, in allelic comparison, the D allele was strongly associated with CAD susceptibility with an OR of 1.59, (95%) CI = (1.12−2.24), and p < 0.003. Our results revealed that there was a significant correlation between ACE2-I/D genotypes and hypertension, T2D, and obesity (p < 0.05). The results of ACE2 rs4240157 genotyping indicated a strong association in the codominant model with an increased CAD susceptibility with an OR of 3.62, (95%) CI = (2.027 to 6.481), and p < 0.0001. Similarly, in a dominant inheritance model, a strong association is observed between the ACE2 rs4240157 (CT+CC) genotype with an OR of 6.34, (95%) CI = (3.741 to 10.749), and p < 0.0001. In allelic comparison, the T allele was strongly associated with CAD susceptibility with an OR of 5.56, (95% CI = (3.56 to 7.17), and p < 0.0001. Similarly, our results revealed that there was a significant association of the ACE2-rs4240157T>C genotypes with Triglycerides (mg/dL), HDL-C (mg/dL), total Cholesterol (mg/dL), and C-reactive protein (mg/L) in CAD. Conclusion: It was indicated that the ARMS technique and MS-PCR assay proved to be fast, accurate, and reliable for ACE2-rs4240157T>C and ACE1-rs4646996 D>I, respectively, and can be used as a potential molecular tool in the diagnosis of genetic diseases in undeveloped and developing countries—where there might be a shortage of medical resources and supplies. ACE1-I>D genotypes were strongly associated with T2D, hypertension, and obesity (p < 0.002). Besides the ACE2-rs4240157 CT heterozygosity genotype, the T allele was strongly associated with CAD susceptibility. Future longitudinal studies in different ethnic populations with larger sample sizes are recommended to validate these findings

An Automatic Detection and Classification System of Five Stages for Hypertensive Retinopathy Using Semantic and Instance Segmentation in DenseNet Architecture

The stage and duration of hypertension are connected to the occurrence of Hypertensive Retinopathy (HR) of eye disease. Currently, a few computerized systems have been developed to recognize HR by using only two stages. It is difficult to define specialized features to recognize five grades of HR. In addition, deep features have been used in the past, but the classification accuracy is not up-to-the-mark. In this research, a new hypertensive retinopathy (HYPER-RETINO) framework is developed to grade the HR based on five grades. The HYPER-RETINO system is implemented based on pre-trained HR-related lesions. To develop this HYPER-RETINO system, several steps are implemented such as a preprocessing, the detection of HR-related lesions by semantic and instance-based segmentation and a DenseNet architecture to classify the stages of HR. Overall, the HYPER-RETINO system determined the local regions within input retinal fundus images to recognize five grades of HR. On average, a 10-fold cross-validation test obtained sensitivity (SE) of 90.5%, specificity (SP) of 91.5%, accuracy (ACC) of 92.6%, precision (PR) of 91.7%, Matthews correlation coefficient (MCC) of 61%, F1-score of 92% and area-under-the-curve (AUC) of 0.915 on 1400 HR images. Thus, the applicability of the HYPER-RETINO method to reliably diagnose stages of HR is verified by experimental findings.

Learning and non-learning algorithms for cuffless blood pressure measurement: a review

The machine learning approach has gained a significant attention in the healthcare sector because of the prospect of developing new techniques for medical devices and handling the critical database of chronic diseases. The learning approach has potential to analyze complex medical data, disease diagnosis, and patient monitoring system, and to monitor e-health record. Non-invasive cuffless blood pressure (CLBP) measurement secured a significant position in the patient monitoring system. From a few recent decades, the importance of cuffless technology has been perceived towards continuous monitoring of blood pressure (BP) and supplementary efforts have been made towards its continuous monitoring. However, the optimal method that measures BP unambiguously and continuously has not yet emerged along with issues like calibration time, accuracy and long-term estimation of BP with miniaturizing hardware. The present study provides an insight into several learning algorithms along with their feature selection models. Various challenges and future improvements towards the current state of machine learning in healthcare industries are discussed in the present review. The bottom line of this study is to provide a comprehensive perspective of the machine learning approach of CLBP for the generation of highly precise predictive models for continuous BP measurement.

The Association of IL-6, TNFα and CRP Gene Polymorphisms with Coronary Artery Disease in a Tunisian Population: A Case-Control study

Coronary artery disease is an inflammatory disease. Systemic markers of inflammation such as Interleukin-6, Tumor Necrosis Factor alpha and C-reactive protein have previously been shown to be associated with increased risk of cardiovascular events. The aim of the present study is to assess the role of variants in the IL-6 (- 174 G/C), TNFα (- 308 A/G) and CRP (+ 1059G/C) genes as susceptibility markers for CAD in a Tunisian population. The investigation was conducted as a case-control study involving 204 patients and 400 age-gender matched controls. Genotyping was performed using polymerase chain reaction and restriction fragment length polymorphism analysis. There are significant differences between CAD patients and the control group with regard to BMI (p < 10^-3) and family history of CAD (p < 10^-3). The CAD patients are more likely to have a history of smoking (p < 10^-3), have a higher value of TC (p = 0.003), LDLc (p = 0.016), hs-CRP (p = 0.01), IL6 (p < 10^-3) and TNFα (p = 0.038). Our analysis showed significant differences between cases and controls in genotypic distribution of IL6-174CC (p = 0.003; OR = 7.71 CI (1.58-37.56)), TNFα - 308 AA (p = 0.004; OR = 2.95 (1.57-5.51)) and CRP + 1059 CC (p < 10^-3; OR = 5.40 (2.30-12.68)). However, we failed to find an association between the different genotypes and the inflammatory markers levels. Our results suggest that the presence of IL-6 (- 174 G/C), TNFα (-308 A/G) and CRP (+ 1059G/C) polymorphisms, may be considered to be a risk factor for CAD in Tunisian population.

Methylation Profile of miR-9-1 and miR-9-1/-9-3 as Potential Biomarkers of Diabetic Retinopathy

AIMS

Analysis of the relationship between the methylation profile of miR-9-1 or miRs -9-1 / -9-3 and diabetic retinopathy.

BACKGROUND

Diabetic Retinopathy (DR) is a frequent complication of Diabetes mellitus and it has a decisive impact on the quality of life, as it is one of the biggest causes of blindness in the adult population. Levels of microRNA-9 have been shown to be related to diabetes but little is known about its involvement with DR in humans.

OBJECTIVE

To analyze the relationship between the methylation profile of miR-9-1 or miRs -9-1/-9-3 and DR.

METHODS

103 patients diagnosed with diabetes for 5 to 10 years were analyzed. The data were categorized according to clinical, biochemical, lifestyle and anthropometric parameters. DNA extracted from leukocyte samples was used to determine the methylation profile of miRs-9-1 and -9-3 using a specific methylation PCR assay.

RESULTS

miR-9-1 methylation was related to diabetic retinopathy, indicating that methylation of this miR increases the chances of presenting retinopathy up to 5 times. In our analyses, diabetics with lower levels of creatinine and CRP showed significant reductions (99% and 97%) in presenting DR. Methylation of both miRs-9-1 and 9-3 methylated increases the chances of presenting DR by 8 times; in addition, a sedentary lifestyle can increase the risk for the same complication by up to 6 times.

CONCLUSION

Our results suggest that both methylation of miR-9-1 and e miRs-9-1 / 9-3 favors DR in patients with diabetes in a period of 5 to 10 years of diagnosis.

Chronic resveratrol consumption prevents hypertension development altering electrophysiological currents and Ca2+ signaling in chromaffin cells from SHR rats

Resveratrol (RESV) is one of the most abundant polyphenol-stilbene compounds found in red wine with well-established cardioprotective and antihypertensive effects. Hyperactivity of the sympathoadrenal axis seems to be one of the major contributing factors in the pathogenesis of human essential hypertension. Alterations in outward voltage-dependent potassium currents (I_K) and inward voltage-dependent sodium (I_Na), calcium (I_Ca) and nicotinic (I_ACh) currents, CCs excitability, Ca²⁺ homeostasis, and catecholamine exocytosis were previously related to the hypertensive state. This raised the issue of whether in vivo long-term RESV treatment can directly act as a modulator of Ca²⁺ influx or a regulator of ion channel permeability in CCs. We monitored outward and inward currents, and cytosolic Ca²⁺ concentrations ([Ca²⁺]_c) using different pharmacological approaches in CCs from normotensive (WKY) and hypertensive (SHR) animals chronically exposed to trans-RESV (50 mg/L/v.o, 28 days). The long-term RESV treatment prevented the increase of the systolic blood pressure (SBP) in SHR, without reversion of cardiac hypertrophy. We also found an increase of the outward I_K, reduction in inward I_Na,I_Ca, and I_ACh, and the mitigation of [Ca²⁺]_c overload in CCs from SHR at the end of RESV treatment. Our data revealed that electrophysiological alterations of the CCs and in its Ca²⁺ homeostasis are potential new targets related to the antihypertensive effects of long-term RESV treatment.

Blood pressure distribution and control in coronary patients from 24 European countries in the European Society of Cardiology EURoObservational Research Programme European survey of cardiovascular disease prevention and diabetes. EUROASPIRE IV Registry

BACKGROUND

Hypertension is the most prevalent major independent risk factor for developing coronary heart disease (CHD). The present analysis aimed to assess blood pressure (BP) distribution and factors associated with insufficient BP control in coronary patients from 24 countries participating in the European Society of Cardiology (ESC) EURoObservational Research Programme (EORP) EUROASPIRE IV survey.

METHODS

EUROASPIRE IV is a cross-sectional study conducted in 2012-2013 in patients aged 80 years or less hospitalized for CHD with a follow-up visit at a median of 16 months later. Logistic regression analysis was applied to confirm factors associated with BP control defined as less than 140/90 mmHg for nondiabetic patients and less than 140/85 mmHg for diabetic patients.

RESULTS

A total of 7998 patients (response rate, 48.7%) attended the follow-up visit. Complete data were available in 7653 participants (mean age 62.5 ± 9.6 years). The BP goal was achieved in 57.6%. Patients failing to achieve the BP goal were older, had higher BMI, had more often a history of coronary artery bypass grafting (CABG) and reported diabetes more frequently. Logistic regression confirmed the following independent significant predictors of not achieving the BP goal: a history of diabetes [odds ratio (OR) 1.75], obesity (OR 1.70 vs. normal BMI), overweight (OR 1.28 vs. normal BMI), age at least 65 years (OR 1.53) and CABG as the index event (OR 1.26 vs. acute MI).

CONCLUSION

EUROASPIRE IV found insufficient BP control in a large proportion of patients with stable CHD, with diabetes, increased BMI, older age and CABG as the index event being independent predictors of poor BP control.

Exploring the mechanism of TCM formulae in the treatment of different types of coronary heart disease by network pharmacology and machining learning

Traditional Chinese medicine (TCM) has long been used in the clinical treatment of coronary heart disease (CHD). TCM is characterized by syndrome-based medication, which is, using different TCM formulae for different syndromes. However, the underlying mode of action remains unclear. In this work, we utilized network pharmacology and machine learning to explore the mechanism of eight classic TCM formulae in the treatment of different types of CHD. First, by integrating multiple databases, a total of 669 potential bioactive compounds and 581 targets of the eight formulae were screened. Then, the effectiveness of these formulae on CHD was evaluated using two network-based indicators. The results showed that each formula's targets were significantly correlated with CHD associated genes and overlapped with the targets of 9 classes of drugs for cardio vascular diseases (CVD) to some degree. Next, from 5 different levels, i.e., herb, symptom, compound, target, and pathway level, we systematically compared the eight formulae using network clustering and hierarchical clustering. We found that all the formulae could be grouped into five clusters and the clustering results were approximately consistent at different levels. All the formulae were involved in 7 pathways closely related to CHD and may exhibit the common effect of relieving angina. Formulae in the same group collectively regulated some unique pathways and suggest further specific indications. For example, the three formulae used for Qi stagnation and blood stasis, Qi deficiency and blood stasis, and Qi-Yin deficiency syndromes acted on two special pathways (TNF signaling pathway, NF-kappa B signaling pathway) and may exert anti-inflammatory and immune-enhancing effects; the two formulae for Yin deficiency of heart and kidney, and Yang deficiency of heart and kidney syndromes regulated two special pathways (PPAR signaling pathway, thyroid hormone signaling pathway) in endocrine system and could improve renal function. Subsequently, we designed a rank algorithm, which integrated network topology with biological function, to identify important targets of these formulae. The results were consistent with the multi-level clustering results. At last, our literature mining validated about 20 % putative targets, as well as clustering results and effects of the formulae by experimental evidences. This study explained the medication patterns and scientific significance of TCM formulae on different types of CHD from perspective of systems biology. It may facilitate the understanding of different types of CHD described by traditional Chinese medicine from the perspectives of modern biology.

Development of a Multistep Hypertension Quality Improvement Program in an Academic General Medicine Practice

Hypertension is a common problem and a major risk factor for cardiovascular disease. It is unclear whether efforts to control blood pressure (BP) known to be effective in integrated healthcare systems can be successfully implemented in an academic setting. We describe our experience implementing a multistep quality improvement program within an academic general medicine practice aimed at improving BP among patients with uncontrolled hypertension. Ensuring medical assistants were correctly measuring BP provided the basis for accurate data entry into the electronic medical record (EMR); our EMR-based registry data allowed us to feedback primary care provider (PCP) level data on BP control for panel management, which resulted in improvements in BP for a substantial proportion of patients, particularly for those with more practice visits. However, due to PCP, patient, and system barriers, our initial attempt to integrate a pharmacist into our team for hypertension management was only successful for a small number of patients who engaged in pharmacist in-person visits. Future improvement efforts will focus on addressing the barriers to more intensive BP management, integrating lessons from this experience. As chronic disease management shifts to a population-based model, team change will be a necessary component for achieving clinical improvement.

Warranty period of normal stress myocardial perfusion imaging in hypertensive patients: A parametric survival analysis

BACKGROUND

We evaluated the warranty period of a normal stress myocardial perfusion single-photon emission computed tomography (MPS) in hypertensive patients.

METHODS AND RESULTS

A total of 471 consecutive hypertensive patients with suspected coronary artery disease and normal perfusion at stress MPS were followed for a mean of 76 ± 21 months. Endpoint events were cardiac death or nonfatal myocardial infarction. With Cox analysis, age (hazard ratio 1.1, P < .005) and stress test type (hazard ratio 2.7, P < .005) were independent predictors of events. With parametric Weibull analysis, patients ≤60 years old undergoing exercise stress test remained at low risk for the entire length of follow-up, while the highest probability of events and the major risk acceleration were observed in those > 60 years old who underwent pharmacologic stress test. In patients undergoing exercise test, peak systolic blood pressure (BP; hazard ratio 1.1, P < .005) emerged as predictor of events, and only subjects with peak systolic BP < 160 mmHg remained at low risk for the entire length of follow-up. In contrast, for patients with peak systolic BP ≥180 mmHg, the time to achieve a cumulative cardiac risk level of 3% was 18 months.

CONCLUSIONS

In hypertensive patients, the warranty period of a normal stress MPS varies according to stress type and peak systolic BP. A normal stress MPS can be considered reassuring in subjects ≤60 years old who performed exercise stress test and a peak systolic BP < 160 mmHg.

A clinical trial on the effect of a multifaceted intervention on blood pressure control and medication adherence in patients with uncontrolled hypertension

BACKGROUND

Hypertension (HTN) is the key risk factor for cardiovascular diseases (CVDs). The purpose of this study was to determine the effect of a multifaceted intervention on blood pressure (BP) control and medication adherence (MA) among patients with uncontrolled HTN.

METHODS

A randomized controlled clinical trial study was conducted on 72 patients in the emergency ward who were selected through convenience sampling method. They were randomly divided into intervention and control groups. The studied multifaceted intervention includes motivational interviews and 90 minutes of training sessions, use of a drug reminder box, family support, and 4 phone call follow-ups. The8-Item Morisky Medication Adherence Scale (MMAS-8) was used before and after the intervention. BP was measured in both groups before and after the intervention and compared between them.

RESULTS

No significant difference existed between the two groups in terms of MA and systolic and diastolic BP before the study. The differences between the mean changes in post-intervention systolic (-25.75 ± 19.39 vs. -2.88 ± 11.92 mmHG; P < 0.001) and diastolic (-6.18 ± 8.87 vs. -1.06 ± 8.70 mmHg; P = 0.010) BP in the intervention and control groups were statistically significant. The mean changes in post-intervention MA in the intervention and control group was 2.91 ± 1.64 and -0.36 ± 1.15, respectively; this difference was statistically significant (P < 0.001).

CONCLUSION

The studied multifaceted intervention promoted MA and reduced systolic and diastolic BP. Thus, the use of this method as a supplementary treatment is recommended after patient discharge.

Managing Hypertension in the elderly: What's new?

Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world. Hypertension is a major risk factor for cardiovascular events and mortality in the elderly. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling persons aged 65 years and older with an average systolic blood pressure of 130 ​mm Hg or higher or a diastolic blood pressure of 80 ​mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 ​mm Hg For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment. Randomized clinical trials need to be performed in frail elderly patients with hypertension living in nursing homes. Elderly frail persons with prevalent and frequent falls, marked cognitive impairment, and multiple comorbidities requiring multiple antihypertensive drugs also need to be included in randomized clinical trials. Data on patients older than 85 years treated for hypertension are also sparse. These patients need clinical trial data. Finally, the effect of different antihypertensive drugs on clinical outcomes including serious adverse events needs to be investigated in elderly frail patients with hypertension and different comorbidities.

Managing the elderly patient with hypertension: current strategies, challenges, and considerations

Introduction: Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world.Areas covered: An extensive literature review of articles and clinical trials on PUBMED on the topic of hypertension in the elderly from 1976 through January 2020 was conducted. This review article discusses clinical trials on treatment of hypertension in the elderly, the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, the 2018 European Society of Cardiology/European Society of Hypertension guidelines, and the treatment of hypertension and of resistant hypertension in the elderly.Expert opinion: The 2017 ACC/AHA hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mm Hg. For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment.

Cornea: A Window to White Matter Changes in Stroke; Corneal Confocal Microscopy a Surrogate Marker for the Presence and Severity of White Matter Hyperintensities in Ischemic Stroke

PURPOSE

The presence of white matter hyperintensities (WMH) on MRI imaging confers an increased risk of stroke, dementia, and death. Corneal confocal microscopy (CCM) can detect nerve injury non-invasively and may be a useful surrogate marker for WMH. The objective is to determine whether corneal nerve pathology identified using CCM is associated with the presence of WMH in patients with acute ischemic stroke.

METHODS

This is a cross-sectional study where 196 consecutive individuals with acute ischemic stroke were enrolled and underwent neurological examination, MRI brain imaging and CCM. Participants underwent blinded quantification of WMH and corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD) and corneal nerve fiber length (CNFL).

RESULTS

The prevalence of hypertension [P = .013] was significantly higher and CNFD [P = .031] was significantly lower in patients with WMH compared to those without WMH. CNFD and CNFL were significantly lower in patients with DM without WMH [P = .008, P = .019] and in patients with DM and WMH [P = .042, P = .024] compared to patients without DM or WMH, respectively. In a multivariate model, a 1-unit decrease in the CNFD increased the risk of WMH by 6%, after adjusting for age, DM, gender, dyslipidemia, metabolic syndrome, smoking, and HbA1c. DM was associated with a decrease in all CCM parameters but was not a significant independent factor associated with WMH.

CONCLUSIONS

CCM demonstrates corneal nerve pathology, which is associated with the presence of WMH in participants with acute ischemic stroke. CCM may be a useful surrogate imaging marker for the presence and severity of WMHs.

Short-Chain Fatty Acid Propionate Protects From Hypertensive Cardiovascular Damage

Supplemental Digital Content is available in the text.

Background:

Arterial hypertension and its organ sequelae show characteristics of T cell–mediated inflammatory diseases. Experimental anti-inflammatory therapies have been shown to ameliorate hypertensive end-organ damage. Recently, the CANTOS study (Canakinumab Antiinflammatory Thrombosis Outcome Study) targeting interleukin-1β demonstrated that anti-inflammatory therapy reduces cardiovascular risk. The gut microbiome plays a pivotal role in immune homeostasis and cardiovascular health. Short-chain fatty acids (SCFAs) are produced from dietary fiber by gut bacteria and affect host immune homeostasis. Here, we investigated effects of the SCFA propionate in 2 different mouse models of hypertensive cardiovascular damage.

Methods:

To investigate the effect of SCFAs on hypertensive cardiac damage and atherosclerosis, wild-type NMRI or apolipoprotein E knockout–deficient mice received propionate (200 mmol/L) or control in the drinking water. To induce hypertension, wild-type NMRI mice were infused with angiotensin II (1.44 mg·kg^–1·d^–1 subcutaneous) for 14 days. To accelerate the development of atherosclerosis, apolipoprotein E knockout mice were infused with angiotensin II (0.72 mg·kg^–1·d^–1 subcutaneous) for 28 days. Cardiac damage and atherosclerosis were assessed using histology, echocardiography, in vivo electrophysiology, immunofluorescence, and flow cytometry. Blood pressure was measured by radiotelemetry. Regulatory T cell depletion using PC61 antibody was used to examine the mode of action of propionate.

Results:

Propionate significantly attenuated cardiac hypertrophy, fibrosis, vascular dysfunction, and hypertension in both models. Susceptibility to cardiac ventricular arrhythmias was significantly reduced in propionate-treated angiotensin II–infused wild-type NMRI mice. Aortic atherosclerotic lesion area was significantly decreased in propionate-treated apolipoprotein E knockout–deficient mice. Systemic inflammation was mitigated by propionate treatment, quantified as a reduction in splenic effector memory T cell frequencies and splenic T helper 17 cells in both models, and a decrease in local cardiac immune cell infiltration in wild-type NMRI mice. Cardioprotective effects of propionate were abrogated in regulatory T cell–depleted angiotensin II–infused mice, suggesting the effect is regulatory T cell–dependent.

Conclusions:

Our data emphasize an immune-modulatory role of SCFAs and their importance for cardiovascular health. The data suggest that lifestyle modifications leading to augmented SCFA production could be a beneficial nonpharmacological preventive strategy for patients with hypertensive cardiovascular disease.

The Relationship Between Lipid Metabolism and The Level of Albuminuria with Single Nucleotide Polymorphism -204A>C [rs 3808607] CYP7A1 Gene in Patients with Type 2 Diabetes Mellitus and Diabetic Nephropathy

Background and aims. The purpose of our study was to determine the features of diabetic nephropathy, to identify the relationship between the level of albumin excretion, urine and lipid profile, genotype variants of the CYP7A1 gene in people with type 2 diabetes and diabetic nephropathy.

Material and methods. Patients were divided into three groups. Normoalbinuria was detected in group I, and II - microalbuminuria, and III -macroalbuminuria. Determination of albumin to creatinine ratio was more accurate, although more expensive method. We examined single nucleotide polymorphism -204A> C [rs 3808607] of the promoter region of the CYP7A1 gene.

Results. It was established that homozygotes by the major allele with genotype AA had lower values of albuminuria, atherogenic lipoproteins, total cholesterol, triglycerides and higher levels of anti-atherogenic lipoproteins than patients with AС and СС genotypes.

Conclusion. The СС genotype was most unfavorable in the prognostic plan, since homozygotes for this minor allele were characterized by higher values of albuminuria, total cholesterol, triglycerides, and lower values of high-density lipoprotein

Novel Therapeutic Approaches Targeting the Renin-Angiotensin System and Associated Peptides in Hypertension and Heart Failure

Despite the success of renin-angiotensin system (RAS) blockade by angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor (AT1R) blockers, current therapies for hypertension and related cardiovascular diseases are still inadequate. Identification of additional components of the RAS and associated vasoactive pathways, as well as new structural and functional insights into established targets, have led to novel therapeutic approaches with the potential to provide improved cardiovascular protection and better blood pressure control and/or reduced adverse side effects. The simultaneous modulation of several neurohumoral mediators in key interconnected blood pressure-regulating pathways has been an attractive approach to improve treatment efficacy, and several novel approaches involve combination therapy or dual-acting agents. In addition, increased understanding of the complexity of the RAS has led to novel approaches aimed at upregulating the ACE2/angiotensin-(1-7)/Mas axis to counter-regulate the harmful effects of the ACE/angiotensin II/angiotensin III/AT1R axis. These advances have opened new avenues for the development of novel drugs targeting the RAS to better treat hypertension and heart failure. Here we focus on new therapies in preclinical and early clinical stages of development, including novel small molecule inhibitors and receptor agonists/antagonists, less conventional strategies such as gene therapy to suppress angiotensinogen at the RNA level, recombinant ACE2 protein, and novel bispecific designer peptides.

Benefits and harms of lower blood pressure treatment targets: systematic review and meta-analysis of randomised placebo-controlled trials

OBJECTIVES

To assess the effect of antihypertensive treatment in the 130-140 mm Hg systolic blood pressure range.

DESIGN

Systematic review and meta-analysis.

INFORMATION SOURCES

PubMed, CDSR and DARE were searched for the systematic reviews, which were manually browsed for clinical trials. PubMed and Cochrane Central Register of Controlled Trials were searched for trials directly in February 2018.

ELIGIBILITY CRITERIA

Randomised double-blind trials with ≥1000 patient-years of follow-up, comparing any antihypertensive agent against placebo.

DATA EXTRACTION AND RISK OF BIAS

Two reviewers extracted study-level data, and assessed risk of bias using Cochrane Collaborations risk of bias assessment tool, independently.

MAIN OUTCOMES AND MEASURES

Primary outcomes were all-cause mortality, major cardiovascular events and discontinuation due to adverse events. Secondary outcomes were cardiovascular mortality, myocardial infarction, stroke, heart failure, hypotension-related adverse events and renal impairment.

RESULTS

Eighteen trials, including 92 567 participants (34% women, mean age 63 years), fulfilled the inclusion criteria. Primary preventive antihypertensive treatment was associated with a neutral effect on all-cause mortality (relative risk 1.00, 95% CI 0.95 to 1.06) and major cardiovascular events (1.01, 0.96 to 1.06), but an increased risk of discontinuation due to adverse events (1.23, 1.03 to 1.47). None of the secondary efficacy outcomes were significantly reduced, but the risk of hypotension-related adverse events increased with treatment (1.71, 1.32 to 2.22). In coronary artery disease secondary prevention, antihypertensive treatment was associated with reduced risk of all-cause mortality (0.91, 0.83 to 0.99) and major cardiovascular events (0.85, 0.77 to 0.94), but doubled the risk of adverse events leading to discontinuation (2.05, 1.62 to 2.61).

CONCLUSION

Primary preventive blood pressure lowering in the 130-140 mm Hg systolic blood pressure range adds no cardiovascular benefit, but increases the risk of adverse events. In the secondary prevention, benefits should be weighed against harms.

PROSPERO REGISTRATION NUMBER

CRD42018088642.

Implications of the New 2017 American College of Cardiology/American Heart Association Guidelines for Hypertension

Automated validated devices should be used for measuring blood pressure (BP). The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines recommend that a systolic BP between 120-129 mmHg with a diastolic BP less than 80 mmHg should be treated with lifestyle measures. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for secondary prevention of cardiovascular events in persons with clinical cardiovascular disease and an average systolic BP of ≥130 mmHg or an average diastolic BP≥80 mmHg. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease ≥ 10% and an average systolic BP ≥130 mmHg or an average diastolic BP ≥80 mmHg. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease of < 10% and an average systolic BP ≥140 mmHg or an average diastolic BP ≥ 90 mmHg. These guidelines recommend initiating antihypertensive drug therapy with 2 first-line drugs from different classes either as separate agents or in a fixed-dose combination in persons with a BP ≥140/90 mmHg or with a BP > 20/10 mmHg above their BP target. White coat hypertension must be excluded before starting treatment with antihypertensive drugs in persons with hypertension at low risk for atherosclerotic cardiovascular disease. Antihypertensive drug treatment for different disorders is discussed.

Continuous Blood Pressure Monitoring as a Basis for Ambient Assisted Living (AAL) - Review of Methodologies and Devices

Blood pressure (BP) is a bio-physiological signal that can provide very useful information regarding human's general health. High or low blood pressure or its rapid fluctuations can be associated to various diseases or conditions. Nowadays, high blood pressure is considered to be an important health risk factor and major cause of various health problems worldwide. High blood pressure may precede serious heart diseases, stroke and kidney failure. Accurate blood pressure measurement and monitoring plays fundamental role in diagnosis, prevention and treatment of these diseases. Blood pressure is usually measured in the hospitals, as a part of a standard medical routine. However, there is an increasing demand for methodologies, systems as well as accurate and unobtrusive devices that will permit continuous blood pressure measurement and monitoring for a wide variety of patients, allowing them to perform their daily activities without any disturbance. Technological advancements in the last decade have created opportunities for using various devices as a part of ambient assisted living for improving quality of life for people in their natural environment. The main goal of this paper is to provide a comprehensive review of various methodologies for continuous cuff-less blood pressure measurement, as well as to evidence recently developed devices and systems for continuous blood pressure measurement that can be used in ambient assisted living applications.

Systematic Review for the 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Objective

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

Methods

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

Results

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Low Diastolic Blood Pressure Is Associated With Angina in Patients With Chronic Coronary Artery Disease

BACKGROUND

In patients with coronary artery disease (CAD), low diastolic blood pressure (DBP) is associated with increased risk of myocardial infarction, but its association with angina is unknown.

OBJECTIVES

The goal of this study was to examine the association of low DBP and angina in patients with CAD.

METHODS

The study assessed the frequency of angina (measured by using the Seattle Angina Questionnaire-Angina Frequency score) according to DBP in patients with known CAD from 25 U.S. cardiology clinics. Hierarchical logistic regression was used to test the association between DBP and angina, with a spline term for DBP to assess nonlinearity.

RESULTS

Among 1,259 outpatients with CAD, 411 (33%) reported angina in the prior month, with higher rates in the lowest DBP quartile (40 to 64 mm Hg: 37%). In the unadjusted model, DBP was associated with angina with a J-shaped relationship (p = 0.017, p for nonlinearity = 0.027), with a progressive increase in odds of angina as DBP decreased below ∼70 to 80 mm Hg. This association remained significant after sequential adjustment for demographic characteristics (p = 0.002), comorbidities (p = 0.002), heart rate (p = 0.002), systolic blood pressure (p = 0.046), and antihypertensive antianginal medications (p = 0.045).

CONCLUSIONS

In patients with chronic CAD, there seemed to be an association between lower DBP and increased odds of angina. If validated, these findings suggest that clinicians should consider less aggressive blood pressure control in patients with CAD and angina.

Pharmacological management of hypertension in the elderly and frail populations

INTRODUCTION

Cardiovascular disease is a leading cause of mortality in the elderly. Hypertension is an important modifiable risk factor that contributes to cardiovascular morbidity and mortality. The prevalence of hypertension is known to increase with age, and hypertension has been associated with an increase in risk for cardiovascular disease in the elderly. There is a wealth of evidence that supports aggressive control of blood pressure to lower cardiovascular risk in the general population. However, there are limited data to guide management of hypertension in the elderly and frail patient subgroups. These subgroups are inadequately treated due to lack of clarity regarding blood pressure thresholds, treatment targets, comorbidities, frailty, drug interactions from polypharmacy, and high cost of care. Areas covered: We review the current evidence behind the definition, goals, and treatments for hypertension in the elderly and frail and outline a strategy that can be used to guide antihypertensive pharmacotherapy in this population. Expert commentary: Lower blood pressure to < 130/80 mm Hg in elderly patients if tolerated and promote use of combination therapy if the blood pressure is > 20/10 mm Hg over the goal blood pressure. Antihypertensive treatment regimens must be tailored to each individual based on their comorbidities, risk for adverse effects, and potential drug interactions ( Figure 1 ).

The Treatment Effect of an ACE-Inhibitor Based Regimen with Perindopril in Relation to Beta-Blocker use in 29,463 Patients with Vascular Disease: a Combined Analysis of Individual Data of ADVANCE, EUROPA and PROGRESS Trials

INTRODUCTION

In everyday practice, angiotensin converting enzyme inhibitors and beta-blockers are cornerstone treatments in patients with (cardio-)vascular disease. Clear data that evaluate the effects of the combination of these agents on morbidity and mortality are lacking.

METHODS

In this retrospective pooled analysis of three large perindopril outcome trials (ADVANCE, EUROPA, PROGRESS), clinical outcomes were evaluated in 29,463 patients with vascular disease. Multivariate Cox regression analyses were performed in patients randomized to a perindopril-based regimen or placebo (treatment effect), and data were stratified according to background beta-blocker treatment. The primary endpoint was a composite of cardiovascular mortality, non-fatal myocardial infarction, and stroke.

RESULTS

The cumulative incidence of the primary endpoint over mean follow-up of 4.0 years (Sd 1.0) was significantly lower in the beta-blocker/perindopril group (9.6%; 545/5700 patients) as compared to beta-blocker/placebo (11.8%; 676/5718 patients) (p < 0.01). Adding perindopril to existing beta-blocker treatment reduced the relative risk of the primary endpoint by 20% (hazard ratio (HR) 0.80; 95% confidence interval (CI) 0.71-0.90), non-fatal myocardial infarction by 23% (HR 0.77; 95% CI 0.65-0.91), and all-cause mortality by 22% (HR 0.78; 95% CI 0.68-0.88) as compared to placebo. Significant treatment benefit was not observed for stroke (HR 0.93; 95% CI 0.75-1.15). Significance was maintained for the primary endpoint and cardiovascular endpoints when data were further stratified by baseline hypertension. However, the mortality benefit was only observed in patients with hypertension with background beta-blocker use.

CONCLUSIONS

These data suggest that the beneficial cardioprotective effects of perindopril treatment are additive to the background beta-blockers use.

Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk

Aims

Optimal blood pressure for prevention of cardiovascular (CV) events in patients with Type 2 diabetes mellitus (T2DM) remains uncertain and there is concern for increased risk with low diastolic blood pressure (DBP). This study analysed the association between blood pressure and CV outcomes in high-risk patients with T2DM.

Methods and results

Patients with T2DM and elevated CV risk were enrolled in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus-Thrombolysis in Myocardial Infarction 53 trial. Cardiovascular outcomes were compared in the biomarker subgroup (n = 12 175) after stratification by baseline systolic blood pressure (SBP) and DBP. Adjusted risk was calculated by blood pressure stratum using clinical covariates plus N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin-T (hsTnT). Trends were tested using linear and quadratic models. Adjusted risk of the composite endpoint of CV death, myocardial infarction (MI), or ischaemic stroke showed U-shaped relationships with baseline SBP and DBP (Pquadratic ≤ 0.01) with nadirs at SBP 130-140 or DBP 80-90 mmHg. Diastolic blood pressure <60 mmHg was associated with increased risk of MI (adjusted hazard ratio 2.30; 95% confidence interval 1.50-3.53) relative to DBP 80-90 mmHg. Adjusted odds of hsTnT concentration ≥14 ng/L showed U-shaped relationships with SBP and DBP (Pquadratic ≤ 0.01). The relationships between low DBP, elevated hsTnT, and increased MI remained after exclusion of patients with prior heart failure or NT-proBNP >median, suggesting that the relationship was not due to confounding from diagnosed or undiagnosed heart failure.

Conclusions

In patients with diabetes and elevated CV risk, even after extensive adjustment for underlying disease burden, there was a persistent association for low DBP with subclinical myocardial injury and risk of MI.

Systematic Review for the 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (i.e., angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Impact of hypertension on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection

INTRODUCTION

Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD.

METHODS

In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up.

RESULTS

The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients.

CONCLUSIONS

Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.

Systemic and specific effects of antihypertensive and lipid-lowering medication on plasma protein biomarkers for cardiovascular diseases

A large fraction of the adult population is on lifelong medication for cardiovascular disorders, but the metabolic consequences are largely unknown. This study determines the effects of common anti-hypertensive and lipid lowering drugs on circulating plasma protein biomarkers. We studied 425 proteins in plasma together with anthropometric and lifestyle variables, and the genetic profile in a cross-sectional cohort. We found 8406 covariate-protein associations, and a two-stage GWAS identified 17253 SNPs to be associated with 109 proteins. By computationally removing variation due to lifestyle and genetic factors, we could determine that medication, per se, affected the abundance levels of 35.7% of the plasma proteins. Medication either affected a single, a few, or a large number of protein, and were found to have a negative or positive influence on known disease pathways and biomarkers. Anti-hypertensive or lipid lowering drugs affected 33.1% of the proteins. Angiotensin-converting enzyme inhibitors showed the strongest lowering effect by decreasing plasma levels of myostatin. Cell-culture experiments showed that angiotensin-converting enzyme inhibitors reducted myostatin RNA levels. Thus, understanding the effects of lifelong medication on the plasma proteome is important both for sharpening the diagnostic precision of protein biomarkers and in disease management.

Systematic Review for the 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.