Potential U.S. Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline

Sodium Intake and Cause-Specific Mortality Among Predominantly Low-Income Black and White US Residents

IMPORTANCE

Epidemiologic evidence regarding the outcomes of dietary sodium intake on mortality remains limited for low-income individuals, particularly Black people.

OBJECTIVE

To investigate the associations of excessive dietary sodium with all-cause and cause-specific mortality among predominantly low-income Black and White Americans.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included participants aged 40 to 79 years from the Southern Community Cohort Study who were recruited at Community Health Centers in 12 southeastern states from 2002 to 2009. Analyses were conducted between March 2022 and June 2023.

EXPOSURES

Dietary sodium intake was assessed using a validated food frequency questionnaire at baseline.

MAIN OUTCOMES AND MEASURES

Multivariable-adjusted Cox regression was used to estimate hazard ratios (HRs) and 95% CIs for mortality outcomes (all-cause, cardiovascular disease [CVD], coronary heart disease [CHD], stroke, heart failure, cancer, and other) associated with sodium intake. Nonlinear associations and population-attributable risk (PAR) of the mortality burden associated with excess sodium were further assessed.

RESULTS

Among the 64 329 participants, 46 185 (71.8%) were Black, 18 144 (28.2%) were White, and 39 155 (60.9%) were female. The mean (SD) age at study enrollment was 51.3 (8.6) years for Black participants and 53.3 (9.3) years for White counterparts. Mean (SD) dietary sodium intake was 4512 (2632) mg/d in Black individuals and 4041 (2227) mg/d in White individuals; 37 482 Black individuals (81.2%) and 14 431 White individuals (79.5%) exceeded the current dietary recommendations of 2300 mg/d. During a median (IQR) follow-up of 13.8 (11.3-15.8) years, 17 811 deaths were documented, including 5701 from CVD. After adjustment for potential confounders, in Black individuals, HRs per 1000-mg increase in daily sodium intake were 1.07 (95% CI, 1.03-1.10) and 1.08 (95% CI, 1.02-1.14) for deaths from total CVD and CHD, respectively; while in White individuals, the corresponding HRs were 1.08 (95% CI, 1.02-1.14) and 1.13 (95% CI, 1.03-1.23). No significant associations were found for cancer mortality. PAR estimates suggest that sodium intake above the recommended threshold may account for 10% of total CVD, 13% of CHD, and 30% of heart failure deaths in this low-income southern population.

CONCLUSIONS AND RELEVANCE

In this cohort study of 64 329 low-income Americans, nearly 80% of study participants consumed sodium exceeding the current recommended daily amount, which was associated with 10% to 30% of CVD mortality. Public health programs targeted to reduce sodium intake among this underserved population may be beneficial.

Hypertension Among Cohort of Persons With Human Immunodeficiency Virus Initiated on a Dolutegravir-Based Antiretroviral Regimen in Ghana

Background

Dolutegravir (DTG), a new antiretroviral drug, is being integrated into antiretroviral regimens for people with human immunodeficiency virus (PWH) in Ghana. There is little evidence of the effect of DTG on blood pressure (BP) levels in sub-Saharan Africa, especially West Africa. Our aim was to assess the incidence and predictors of hypertension (HTN) among PWH initiated on a DTG-based antiretroviral regimen in Ghana.

Methods

An observational multicenter longitudinal study was conducted among PWH in Ghana from 2020 to 2022. BPs of nonhypertensive patients with BP ≤120/80 mm Hg at baseline were measured at 3, 6, 12, and 18 months post-DTG initiation. The primary outcome of the study was incidence of HTN, defined as BP ≥140/90 mm Hg. Kaplan-Meier estimator was used to estimate risk of developing HTN. Cox proportional hazards model with robust standard errors was used to estimate hazard ratios (HRs).

Results

HTN prevalence among PWH screened was 37.3% (1366/3664). The incidence of de novo HTN among nonhypertensive PWH at 72 weeks was 598.4 per 1000 person-years (PY) (95% confidence interval [CI], 559.2-640.3) with incidence proportion of 59.90 (95% CI, 57.30-62.44). A quarter of those with de novo HTN developed it by month 6. Obesity (adjusted HR [aHR], 1.27 [95% CI, 1.05-1.54]), abnormal serum urea (aHR, 1.53 [95% CI, 1.27-1.85]), and low high-density lipoprotein (aHR, 1.45 [95% CI, 1.22-1.72]) were risk factors for HTN.

Conclusions

Incidence of HTN was high among PWH on DTG. There is a need to monitor BP for HTN in adult PWH as well as traditional risk factors to reduce the burden of HTN and its complications.

Prevalence and associated factors of undiagnosed hypertension among women aged 15-49 years in India: an analysis of National Family Health Survey-4 data

Hypertension is a major risk factor for cardiovascular diseases globally. Fortunately, there is a vast armamentarium of effective therapeutic options at our disposal so undiagnosed hypertension represents a missed opportunity. In a previous analysis [1] of the NFHS-4 dataset for the prevalence and risk factors for undiagnosed hypertension and its associated risk factors among Indian women aged 15-49 years, we had overestimated prevalence by inclusion of self-reported cases. We have since retracted when this anomaly was highlighted [2]. We have now re-analyzed the same database and here present these data. The current analysis shows that the overall prevalence of undiagnosed hypertension was 8.05% among women aged 15-49 years in India. In rural areas, it was 7.89% compared with 8.38% for urban areas. Factors associated with undiagnosed hypertension in rural and urban areas were age, BMI, wealth quintiles, educational level, religion, caste and geographical zones. Nearly half the women aged 15-49 years in India with hypertension are unaware and this has implications for personal and reproductive health.

Comparison of the Omron HeartGuide to the Welch Allyn ProBP 3400 blood pressure monitor

Hypertension affects approximately 100 million U.S. adults and is the leading single contributing risk factor to all-cause mortality. Accurate blood pressure (BP) measurement is essential in the treatment of BP, and a number of devices exist for monitoring. Recently, a new watch-type design was released, the Omron HeartGuide (BP8000), with claims to provide clinically accurate BP measurement while also tracking activity and sleep similar to smart watches. The aim of this research was done in two studies: (1) evaluation of the HeartGuide device for measurement of resting BP and heart rate (HR); and (2) assessment of the HeartGuide for BP, HR, step-counting and sleep monitoring during activities of daily living. Study 1 compared the Omron HeartGuide to the previously validated Welch Allyn ProBP 3400 following a modified version of the Universal Standard for validation of BP measuring devices set by the AAMI/ESH/ISO. While resting HR measured by the HeartGuide was similar to Welch Allyn measures, both systolic and diastolic BP were significantly lower ( P ≤0.001), with differences of 10.4 (11.1) and 3.2 (10.0) mmHg, respectively. Study 2 compared HeartGuide measures to Welch Allyn measures for BP, HR, steps and sleep during various body positions (supine, seated, standing), physiological stressors (cold pressor test, lower body submersion, exercise), and free-living. The HeartGuide significantly underestimated BP though provided accurate HR during most conditions. It also significantly underestimated steps, but reported sleep measures similar to those subjectively reported. Based on the significant differences between the HeartGuide and Welch Allyn, our data indicate the HeartGuide is not a suitable replacement for existing BP monitors.

Lost in Translation: Why Are Rates of Hypertension Control Getting Worse Over Time?

Treatment of hypertension to decrease rates of cardiovascular disease is the most well studied and most broadly applicable treatment in cardiovascular prevention. Blood pressure can be measured anywhere, not just in a physician's office; medications are readily available, inexpensive, and have highly favorable benefit/harm ratios with relatively minimal side effects; and stepped medication regimens can be prescribed in algorithmic fashion by a variety of practitioners. Yet overall hypertension control rates in the United States have never exceeded 60%, and the last 5-10 years have seen decreased, rather than increased, rates of control. Here, I describe the scale of this massive failure to deliver on the promise of preventive hypertension care; outline the populations most affected and the contemporaneous events that have impacted hypertension control; discuss the disparate paths of hypertension science and health care delivery; and highlight novel interventions, approaches, and future opportunities to bend the curve back toward improvements in hypertension control.

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

Background

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines newly classified 31 million US adults as having stage 1 hypertension. The ACC/AHA guidelines recommend behavioral change without pharmacology for the low-risk portion of this group. However, the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achievable by evidence-based dietary improvements, sustained weight loss, adequate physical activity, and alcohol moderation remain unquantified. We estimated the effect of systolic BP (SBP) control and behavioral changes on 10-year CVD outcomes and costs.

Methods

We used the CVD Policy Model to simulate CVD events, mortality, and healthcare costs among US adults aged 35-64. We simulated interventions on a target population, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: defined as untreated SBP 130-139 mmHg and diastolic BP <90 mmHg; no history of CVD, diabetes, or chronic kidney disease; and low 10-year risk of CVD. We used published meta-analyses and trials to estimate the effects of behavior modification on SBP. We assessed the extent to which intermittent healthcare utilization or partial uptake of nonpharmacologic therapy would decrease CVD events prevented.

Results

Controlling SBP to <130 mmHg among the estimated 8.8 million U.S. adults (51% women) in the target population could prevent 26,100 CVD events, avoid 2,900 deaths, and save $1.6 billion in healthcare costs over 10 years. The Dietary Approaches to Stop Hypertension (DASH) diet could prevent 16,000 CVD events among men and 12,000 among women over a decade. Other nonpharmacologic interventions could avert between 3,700 and 19,500 CVD events. However, only 5.5 million (61%) of the target population regularly utilized healthcare where recommended clinician counseling could occur.

Conclusions

As only two-thirds of U.S. adults with Stage 1 hypertension regularly receive medical care, substantial benefits to cardiovascular health and associated costs may only stem from policies that promote widespread adoption and sustained adherence of nonpharmacologic therapy. Future work should quantify the population-level costs, benefits, and efficacy of improving the food system and local infrastructure on health behavior change.

Prognosis of Systolic Pressure 130 to 139 According to Risk. A Prospective Cohort Study Between 1992 and 2019

BACKGROUND

Guidelines recommend pharmacological treatment for systolic blood pressure (SBP) of 130 to 139 mm Hg in secondary prevention. However, uncertainty persists in primary prevention in low cardiovascular risk patients (CVR).

METHODS

Cohort study representative of the general population of Albacete/Southeast Spain. We examined 1029 participants with untreated blood pressure and free of cardiovascular disease, followed-up during 1992 to 2019. Cox regression modeled the association of SBP with cardiovascular morbidity and mortality (outcome-1) and cardiovascular morbidity and all-cause mortality (outcome-2).

RESULTS

Participants' mean age was 44.8 years (53.8%, women; 77.1% at low-CVR); 20.3% had SBP 120 to 129; 13.0% 130 to 139 at low-CVR and 3.4% at high-CVR; and 27.4% ≥140 mm Hg. After a 25.7-year median follow-up, 218 outcome-1 and 302 outcome-2 cases occurred. Unadjusted hazard ratios of outcome-1 for these increasing SBP categories (versus <120) were 2.72, 2.27, 11.54, and 7.52, respectively; and 2.69, 2.32, 10.55, and 7.34 for outcome-2 (all P<0.01). After adjustment for other risk factors, hazard ratio (95% CI) of outcome-1 were 1.49 (0.91-2.44), 1.65 (0.94-2.91, P=0.08), 1.36 (0.72-2.57), and 1.82 (1.15-2.88), respectively, and 1.39 (0.91-2.11), 1.69 (1.05-2.73), 1.09 (0.63-1.88), and 1.64 (1.11-2.41) for outcome-2. Compared with 130 to 139 at low-CVR, hazard ratio for 130 to 139 at high-CVR was 4.85 for outcome-1 (P<0.001) and 4.43 for outcome-2 (P<0.001).

CONCLUSIONS

In this primary prevention population of relatively young average age, untreated SBP of 130 to 139 mm Hg at low-CVR had long-term prognostic value and might benefit from stricter SBP targets. High-CVR patients had nonsignificant higher risk (limited sample size) but 4-fold greater risk when compared with low-CVR. Overall, results indicate the importance of risk stratification, supporting risk-based decision-making.

Increased blood pressure after nonsevere COVID-19

BACKGROUND

Various sequelae have been described after nonsevere coronavirus disease 2019 (COVID-19), but knowledge on postacute effects on blood pressure is limited.

METHODS

This is a cross-sectional analysis of blood pressure profiles in individuals after nonsevere COVID-19 compared with matched population-based individuals without prior COVID-19. Data were derived from the ongoing and prospective Hamburg City Health Study, a population-based study in Hamburg, Germany, and its associated COVID-19 program, which included individuals at least 4 months after COVID-19. Matching was performed by age, sex, education, and preexisting hypertension in a 1 : 4 ratio.

RESULTS

Four hundred and thirty-two individuals after COVID-19 (mean age 56.1 years) were matched to 1728 controls without prior COVID-19 (56.2 years). About 92.8% of COVID-19 courses were mild or moderate, only 7.2% were hospitalized, and no individual had been treated on an intensive care unit. Even after adjustment for relevant competing risk factors, DBP [+4.7 mmHg, 95% confidence interval (95% CI) 3.97-5.7, P  < 0.001] was significantly higher in individuals after COVID-19. For SBP, a trend towards increased values was observed (+1.4 mmHg, 95% CI -0.4 to 3.2, P  = 0.120). Hypertensive blood pressures at least 130/80 mmHg (according to the ACC/AHA guideline) and at least 140/90 mmHg (ESC/ESH guideline) occurred significantly more often in individuals after COVID-19 than matched controls (odds ratio 2.0, 95% CI 1.5-2.7, P  < 0.001 and odds ratio 1.6, 95% CI 1.3-2.0, P  < 0.001, respectively), mainly driven by changes in DBP.

CONCLUSION

Blood pressure is higher in individuals after nonsevere COVID-19 compared with uninfected individuals suggesting a significant hypertensive sequela.

Decreased retinal and choroidal endothelial surface molecules in spontaneously hypertensive rats

Hypertension is associated with changes in the retina and choroid, with resulting consequences of increased vascular permeability and microhemorrhages. To date, very little information is available regarding the changes in the retinal and choroidal endothelial surface layer. In this study, we have examined changes in protein expression of several molecules including platelet endothelial cell adhesion molecule-1 (PECAM-1), vascular endothelial cadherin (VE-cadherin), glypican-1, and syndecan-1, in spontaneously hypertensive rats (SHR) compared to control normotensive Wistar Kyoto (WKY) rats. In male SHR vs WKY rat retinas, decreases were found for VE-cadherin and syndecan-1; whereas in female retinas, decreases were found for PECAM-1, glypican-1, and syndecan-1. In male SHR vs WKY rat choroid, we found an increase in glypican-1, but choroidal syndecan-1 was decreased in SHR in both males and females. Therefore, decreases in SHR of both retinal and choroidal syndecan-1 were found in both males and females. These losses of syndecan-1 were accompanied by an increase in plasma levels of the proteoglycan, indicating possible systemic endothelial shedding. In contrast, plasma levels of glypican-1 decreased. Interestingly, in normotensive WKY rats, retinal levels of all four endothelial surface molecules were higher in females than in males, in some cases, by substantial amounts. In summary, a number of changes occur in endothelial surface molecules in SHR, with some changes being sex-dependent; it is possible that the loss of these molecules contributes to the vascular dysfunction that occurs in hypertensive retina and choroid.

Hypertension medication from guidelines to practice: A cohort study in western Iran

PURPOSE

Hypertension (HTN) is one of the most common risk factors for non-communicable chronic diseases. The aim of the current study is to evaluate the prescribing patterns of antihypertensive medications in Kermanshah Province, west of Iran.

METHODS

The Ravansar Non-Communicable Diseases (RaNCD) cohort study is the first Kurdish community-based study; subjects' age ranged from 35 to 65 years. In order to examine the use of medications to control blood pressure, participants were asked to bring all prescribed medications to the study center. Treatments were compared with 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) Guidelines for the management of arterial HTN.

RESULTS

From a total of 10 040 participants in RaNCD cohort, 1575 (15.7%) individuals were hypertensive, of whom, 1271 (80.7%) people were aware of their condition. From 1153 (73.20%) people under treatment, 840 (72.8%) had their HTN properly controlled. The most common medications used to treat HTN were losartan (27.5%), metoprolol (14.3%), and captopril (11.9%). Regardless of type of treatment, 49.3% of all patients have received the medication for l 6 ≥ years. The most commonly used drugs were β-blockers and angiotension receptor blockers as 620 (31.0%) and 612 (30.6%), respectively. Multivariable analysis showed that female gender, those receive ≥3 antihypertensive agents, and using preferred combinations were associated with a better blood pressure control. In addition, the probability of hypertension control was less likely with increasing duration of treatment (i.e >6 years) and in obese patients with ≥35 kg/m2 .

CONCLUSIONS

Even though adherence to the international guidelines was acceptable, improvements can be made for better control of HTN. Therefore, it is imperative to educate healthcare professionals on improving their selection of antihypertensive medications and combination therapy for hypertensive patients.

Novel signaling axis of FHOD1-RNF213-Col1α/Col3α in the pathogenesis of hypertension-induced tunica media thickening

Hypertension-induced tunica media thickening (TMT) is the most important fundamental for the subsequent complications like stroke and cardiovascular diseases. Pathogenically, TMT originates from both vascular smooth muscle cells (VSMCs) hypertrophy due to synthesizing more amount of intracellular contractile proteins and excess secretion of extracellular matrix. However, what key molecules are involved in the pathogenesis of TMT is unknown. We hypothesize that formin homology 2 domain-containing protein 1 (FHOD1), an amply expressed mediator for assembly of thin actin filament in VSMCs, is a key regulator for the pathogenesis of TMT. In this study, we found that FHOD1 expression and its phosphorylation/activation were both upregulated in the arteries of three kinds of hypertensive rats. Ang-II induced actin filament formation and hypertrophy through activation and upregulation of FHOD1 in VSMCs. Active FHOD1-mediated actin filament assembly and secretions of collagen-1α/collagen-3α played crucial roles in Ang-II-induced VSMCs hypertrophy in vitro and hypertensive TMT in vivo. Proteomics demonstrated that activated FL-FHOD1 or its C-terminal diaphanous-autoregulatory domain significantly upregulated RNF213 (ring finger protein 213), a 591-kDa cytosolic E3 ubiquitin ligase with its loss-of-functional mutations being a susceptibility gene for Moyamoya disease which has prominent tunica media thinning in both intracranial and systemic arteries. Mechanistically, activated FHOD1 upregulated its downstream effector RNF213 independently of its classical pathway of decreasing G-actin/F-actin ratio, transcription, and translation, but dependently on its C-terminus-mediated stabilization of RNF213 protein. FHOD1-RNF213 signaling dramatically promoted collagen-1α/collagen-3α syntheses in VSMCs. Our results discovered a novel signaling axis of FHOD1-RNF213-collagen-1α/collagen-3α and its key role in the pathogenesis of hypertensive TMT.

Cardiovascular health and proximity to urban oil drilling in Los Angeles, California

BACKGROUND

Although ~18 million people live within a mile from active oil and gas development (OGD) sites in the United States, epidemiological research on how OGD affects the health of nearby urban residents is sparse. Thousands of OGD sites are spread across Los Angeles (LA) County, California, home to the largest urban oil production in the country. Air pollution and noise from OGD may contribute to cardiovascular morbidity.

OBJECTIVE

We examined the association between proximity to OGD and blood pressure in a diverse cohort of residents in LA.

METHODS

We recruited residents in South LA who lived <1 km from an OGD site. We collected three blood pressure measurements for each participant and used the second and third measurements to calculate averages for systolic blood pressure (SBP) and diastolic blood pressure (DBP) separately. We conducted multivariable linear regression to examine the relationship between distance to OGD sites and continuous SBP and DBP, adjusting for BMI, smoking status, distance to freeway, sex, age, and use of antihypertension medications, with a random effect for household. We examined effect measure modification by BMI category and smoking category.

RESULTS

Among the 623 adult participants, we found that for every 100 meter increase in distance from the OGD site, DBP was reduced by an average of 0.73 mmHg (95% CI: -1.26, -0.21) in this population. We observed stronger effects of proximity to OGD site on DBP among never smokers and among participants with a healthy BMI. The associations observed between proximity to OGD site and SBP were weaker but followed the same patterns as those for DBP.

IMPACT

Our study suggests that living near urban oil drilling sites is significantly associated with greater diastolic blood pressure in urban Los Angeles communities. This research improves understanding of impacts from living nearby drilling operations on the health and welfare of this community, which is critical to inform public health relevant strategies.

Self-Perception of Aging and Hypertension in a Cohort of Sexual Minority

Objectives To determine whether self-perception of aging is an important marker of health and hypertension among older sexual minority men. Methods We evaluated associations between self-perception of aging (chronologic-subjective age discrepancy and aging satisfaction) and hypertension among 1,180 sexual minority men (51.6% with HIV/48.4% without HIV) from the Multicenter AIDS Cohort Study using a manifest Markov chain model adjusted for HIV status, age, race/ethnicity, education, smoking status, inhaled nitrite use, diabetes, dyslipidemia, kidney and liver disease. Results The overall prevalence of hypertension increased from 73.1% to 82.6% over three years of follow-up. Older age discrepancy (aOR (adjusted odds ratio): 1.13 95% CI: 0.35-3.69) and low aging satisfaction (aOR: 0.88; 95% CI: 0.31-2.52) were not associated with an increased prevalence of hypertension, regardless of HIV status. Discussion More than 80% of sexual minority men had a diagnosis of hypertension but self-perception of aging was not predictive of incident hypertension.

Trends in antihypertensive drug utilization in British Columbia, 2004-2019: a descriptive study

BACKGROUND

Clinical guidelines for hypertension were updated with lower blood pressure targets following new studies in 2015; the real-world impact of these changes on antihypertensive drug use is unknown. We aimed to describe trends in antihypertensive drug utilization from 2004 to 2019 in British Columbia.

METHODS

We conducted a longitudinal study to describe the annual prevalence and incidence rate of use of 5 antihypertensive drug classes (thiazides, angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers [ARBs], calcium channel blockers and β-blockers) among BC residents aged 30-75 years. We also conducted a cohort study to compare the risk of discontinuation and switch or add-on therapy between incident users of the above drug classes. We used linkable administrative health databases from BC. We performed a Fine-Gray competing risk analysis to estimate subhazard ratios.

RESULTS

Among BC residents aged 30-75 years (population: 2 376 282 [2004] to 3 014 273 [2019]), the incidence rate of antihypertensive drug use decreased from 23.7 per 1000 person-years in 2004 to 18.3 per 1000 person-years in 2014, and subsequently increased to 22.6 per 1000 person-years in 2019. The incidence rate of thiazide use decreased from 8.9 per 1000 person-years in 2004 to 3.2 per 1000 person-years in 2019, and incidence rates for the other drug classes increased. Incident users receiving thiazide monotherapy had an increased risk of discontinuing any antihypertensive treatment compared with ACE inhibitor monotherapy (subhazard ratio 0.96, 95% confidence interval [CI] 0.95-0.97), ARB monotherapy (subhazard ratio 0.84, 95% CI 0.81-0.87) and thiazide combination with ACE inhibitor or ARB (subhazard ratio 0.86, 95% CI 0.84-0.88), and had the highest risk of switching or adding on.

INTERPRETATION

First-line use of thiazides continued to decrease despite a marked increase in incident antihypertensive therapy following updated guidelines; incident users receiving ARB monotherapy were least likely to discontinue, and incident users receiving thiazide monotherapy were more likely to switch or add on than users of other initial monotherapy or combination. Further research is needed on the factors influencing treatment decisions to understand the differences in trends and patterns of antihypertensive drug use.

Risk factors for heart, cerebrovascular, and kidney diseases: evaluation of potential side effects of medications to control hypertension, hyperglycemia, and hypercholesterolemia

Background

Heart disease (HD), cerebrovascular disease (CBD), and kidney disease (KD) are serious diseases worldwide. These diseases constitute the leading causes of death worldwide and are costly to treat. An analysis of risk factors is necessary to prevent these diseases.

Data and Methods

Risk factors were analyzed using data from 2,837,334, 2,864,874, and 2,870,262 medical checkups obtained from the JMDC Claims Database. The side effects of medications used to control hypertension (antihypertensive medications), hyperglycemia (antihyperglycemic medications), and hypercholesterolemia (cholesterol medications), including their interactions, were also evaluated. Logit models were used to calculate the odds ratios and confidence intervals. The sample period was from January 2005 to September 2019.

Results

Age and history of diseases were found to be very important factors, and the risk of having diseases could be almost doubled. Urine protein levels and recent large weight changes were also important factors for all three diseases and made the risks 10%-30% higher, except for KD. For KD, the risk was more than double for individuals with high urine protein levels. Negative side effects were observed with antihypertensive, antihyperglycemic, and cholesterol medications. In particular, when antihypertensive medications were used, the risks were almost doubled for HD and CBD. The risk would be triple for KD when individuals were taking antihypertensive medications. If they did not take antihypertensive medications and took other medications, these values were lower (20%-40% for HD, 50%-70% for CBD, and 60%-90% for KD). The interactions between the different types of medications were not very large. When antihypertensive and cholesterol medications were used simultaneously, the risk increased significantly in cases of HD and KD.

Conclusion

It is very important for individuals with risk factors to improve their physical condition for the prevention of these diseases. Taking antihypertensive, antihyperglycemic, and cholesterol medications, especially antihypertensive medications, may be serious risk factors. Special care and additional studies are necessary to prescribe these medications, particularly antihypertensive medications.

Limitations

No experimental interventions were performed. As the dataset was comprised of the results of health checkups of workers in Japan, individuals aged 76 and above were not included. Since the dataset only contained information obtained in Japan and the Japanese are ethnically homogeneous, potential ethnic effects on the diseases were not evaluated.

Hypertension Statistics for US Adults: An Open-Source Web Application for Analysis and Visualization of National Health and Nutrition Examination Survey Data

BACKGROUND

Data from the US National Health and Nutrition Examination Survey are freely available and can be analyzed to produce hypertension statistics for the noninstitutionalized US population. The analysis of these data requires statistical programming expertise and knowledge of National Health and Nutrition Examination Survey methodology.

METHODS

We developed a web-based application that provides hypertension statistics for US adults using 10 cycles of National Health and Nutrition Examination Survey data, 1999 to 2000 through 2017 to 2020. We validated the application by reproducing results from prior publications. The application's interface allows users to estimate crude and age-adjusted means, quantiles, and proportions. Population counts can also be estimated. To demonstrate the application's capabilities, we estimated hypertension statistics for noninstitutionalized US adults.

RESULTS

The estimated mean systolic blood pressure (BP) declined from 123 mm Hg in 1999 to 2000 to 120 mm Hg in 2009 to 2010 and increased to 123 mm Hg in 2017 to 2020. The age-adjusted prevalence of hypertension (ie, systolic BP≥130 mm Hg, diastolic BP≥80 mm Hg or self-reported antihypertensive medication use) was 47.9% in 1999 to 2000, 43.0% in 2009 to 2010, and 44.7% in 2017 to 2020. In 2017 to 2020, an estimated 115.3 million US adults had hypertension. The age-adjusted prevalence of controlled BP, defined by the 2017 American College of Cardiology/American Heart Association BP guideline, among nonpregnant US adults with hypertension was 9.7% in 1999 to 2000, 25.0% in 2013 to 2014, and 21.9% in 2017 to 2020. After age adjustment and among nonpregnant US adults who self-reported taking antihypertensive medication, 27.5%, 48.5%, and 43.0% had controlled BP in 1999 to 2000, 2013 to 2014, and 2017 to 2020, respectively.

CONCLUSIONS

The application developed in the current study is publicly available at https://bcjaeger.shinyapps.io/nhanesShinyBP/ and produced valid, transparent and reproducible results.

Perinatal intermittent hypoxia increases early susceptibility to ANG II-induced hypertension in adult male but not in female Sprague-Dawley rats

Prenatal, perinatal, and adulthood exposure to chronic intermittent hypoxia (IH) increases blood pressure in rodents. Males exposed to chronic IH have higher blood pressure versus females. However, it is unknown if this same-sex difference exists with acute perinatal IH. We tested the hypothesis that acute perinatal IH increases baseline blood pressure and enhances sensitivity to angiotensin II (ANG II)-induced hypertension in male Sprague-Dawley rats. Male and female pups were randomized to control (room air) or IH (10 min of ∼10% O2 for 3 times/day) for the first 8 days of life. IH decreased oxygen saturation, as confirmed via a pulse oximeter. Pups were weaned at postnatal day 21. Blood pressure was measured via telemetry beginning at 14 wk of age and analyzed separately into light and dark phases to assess circadian rhythm. Osmotic minipumps to deliver ANG II were implanted at 15 wk of age. Perinatal IH exposure did not alter baseline blood pressure. One week of ANG II treatment increased blood pressure in light and dark periods in males exposed to IH versus control; there was no effect in females. Blood pressure among the groups was comparable following 2 wk of ANG II infusion. Perinatal IH did not change the circadian rhythm. Following ANG II treatment, indexes of renal injury were measured. Perinatal IH did not alter kidney size, structure, nephron number, or creatinine clearance. These data indicate that acute perinatal IH enhances early ANG II-induced hypertension in males, independent of nephron loss or decreases in body weight or kidney function.NEW & NOTEWORTHY The impact of acute intermittent hypoxia (IH) in early life on blood pressure in adulthood is unknown. This study used a new model exposing female and male rat pups to acute IH in the first 8 days of life, without exposing the dam. Although baseline blood pressure was not altered in adulthood, IH increased susceptibility to angiotensin II hypertension only in males, supporting increased susceptibility of males exposed to IH to a second cardiovascular stressor.

Rationale and Design of the Groceries for Black Residents of Boston to Stop Hypertension Among Adults Without Treated Hypertension (GoFresh) Trial

BACKGROUND

Poor diet quality significantly contributes to hypertension disparities affecting Black adults. While the Dietary Approaches to Stop Hypertension (DASH) eating pattern lowers blood pressure (BP), access to DASH-patterned groceries is a major barrier for residents of urban food deserts.

METHODS

The Groceries for Black Residents of Boston to Stop Hypertension among Adults without Treated Hypertension (GoFresh) study is one of five projects in the RESTORE Network, an AHA-funded initiative focused on hypertension prevention. GoFresh is testing whether online, dietitian-assisted, home-delivered, DASH-patterned groceries lowers BP among Black adults with elevated BP. This individual-level, parallel-arm trial will enroll up to 176 Black adults with SBP (systolic blood pressure) between 120 and <150 mm Hg residing in Boston-area communities with reduced grocery store access. Following randomization, half of the participants will be assigned to weekly sessions with a dietitian who will assist participants in ordering DASH-patterned groceries online for home delivery; the remainder will receive a $500 monthly stipend. Both interventions will last 3 months, followed by a 9-month maintenance phase.

RESULTS

The primary outcome is the difference in SBP after 3 months. Secondary outcomes include a change in 24-hour ambulatory BP, body mass index, 24-hour urine sodium and potassium, hemoglobin A1C, lipids, fruit and vegetable intake, and saturated fat intake. Qualitative interviews with 45 participants 6 months after baseline assessments will determine barriers and facilitators to long-term maintenance of DASH-patterned grocery shopping.

DISCUSSION

Findings from this study will inform ongoing work on scalable interventions to prevent hypertension among Black adults with implications for public and healthcare-based food supplementation programs.

TRIAL REGISTRATION

NCT05121337. Registered on 16 November 2021, at ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/NCT05121337.

Low Energy Availability (LEA) and Hypertension in Black Division I Collegiate Athletes: A Novel Pilot Study

The purpose of this study was to investigate the relationship between low energy availability (LEA) and nutritional content with high blood pressure (HBP) in African American Division I athletes. Twenty-three D1 African American pre-season athletes were recruited to participate. HBP was defined as >120 systolic blood pressure (BP) and <80 diastolic BP. Athletes self-reported nutritional intake using a non-consecutive 3-day food recall which was then reviewed by a sports dietitian. LEA was evaluated as total energy intake-total daily energy expenditure (TDEE), which was predicted. Additionally, micronutrients were evaluated. A statistical analysis relied on Spearman correlation (R), standardized mean difference with 95% confidence interval, mean ± SD, and odds ratios (OR). Correlation values were categorized: 0.20-0.39 = low; 0.40-0.69 = moderate; 0.70-1.0 = strong. A moderate relationship was observed between HBP and LEA (R = 0.56) with 14/23 having HBP. Of the 14 athletes observed with HBP, 78.5% (11/14) were calorically deficient (-529 ± 695 kcal) with an OR of 7.2. Micronutrient intake deficiencies were ubiquitous among the 23 HBP athletes: poly-unsaturated fatty acid -29.6%; omega-3 -26.0%; iron -46.0%; calcium -25.1%; and sodium -14.2%, amongst others. LEA and micronutrient deficiencies may contribute to HBP in Black D1 athletes, which has been shown to be the most common modifiable risk factor to decrease the risk of sudden cardiac death.

Association of Early Adulthood Hypertension and Blood Pressure Change With Late-Life Neuroimaging Biomarkers

Importance

The association between hypertension developed before midlife and late-life brain health is understudied and, because of the cardioprotective benefits of estrogen before menopause, may differ by sex.

Objective

To assess the association of early adulthood hypertension and blood pressure (BP) change with late-life neuroimaging biomarkers and examine potential sex differences.

Design, Setting, and Participants

This cohort study used data from the Study of Healthy Aging in African Americans (STAR) and Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study, which were harmonized longitudinal cohorts of racially and ethnically diverse adults aged 50 years and older from the San Francisco Bay area and Sacramento Valley in California. The STAR was conducted from November 6, 2017, to November 5, 2021, and the KHANDLE study was conducted from April 27, 2017, to June 15, 2021. The current study included 427 participants from the KHANDLE and STAR studies who received health assessments between June 1, 1964, and March 31, 1985. Regional brain volumes and white matter (WM) integrity were measured via magnetic resonance imaging between June 1, 2017, and March 1, 2022.

Exposures

Hypertension status (normotension, transition to hypertension, and hypertension) and BP change (last measure minus first measure) were assessed at 2 multiphasic health checkups (MHCs; 1964-1985) in early adulthood (ages 30-40 years).

Main Outcomes and Measures

Regional brain volumes and WM integrity were measured using 3T magnetic resonance imaging and z standardized. General linear models adjusted for potential confounders (demographic characteristics and study [KHANDLE or STAR]) were used to assess the association of hypertension and BP change with neuroimaging biomarkers. Sex interactions were tested.

Results

Among 427 participants, median (SD) ages were 28.9 (7.3) years at the first MHC, 40.3 (9.4) years at the last MHC, and 74.8 (8.0) years at neuroimaging. A total of 263 participants (61.6%) were female and 231 (54.1%) were Black. Overall, 191 participants (44.7%) had normotension, 68 (15.9%) transitioned to hypertension, and 168 (39.3%) had hypertension. Compared with participants who had normotension, those who had hypertension and those who transitioned to hypertension had smaller cerebral volumes (hypertension: β = -0.26 [95% CI, -0.41 to -0.10]; transition to hypertension: β = -0.23 [95% CI, -0.44 to -0.23]), with similar differences in cerebral gray matter volume (hypertension: β = -0.32 [95% CI, -0.52 to -0.13]; transition to hypertension: β = -0.30 [95% CI, -0.56 to -0.05]), frontal cortex volume (hypertension: β = -0.43 [95% CI, -0.63 to -0.23]; transition to hypertension: β = -0.27 [95% CI, -0.53 to 0]), and parietal cortex volume (hypertension: β = -0.22 [95% CI, -0.42 to -0.02]; transition to hypertension: β = -0.29 [95% CI, -0.56 to -0.02]). Participants with hypertension also had smaller hippocampal volume (β = -0.22; 95% CI, -0.42 to -0.02), greater ventricular volumes (lateral ventricle: β = 0.44 [95% CI, 0.25-0.63]; third ventricle: β = 0.20 [95% CI, 0.01-0.39]), larger free water volume (β = 0.35; 95% CI, 0.18-0.52), and lower fractional anisotropy (β = -0.26; 95% CI, -0.45 to -0.08) than those who had normotension. Holding hypertension status constant, a 5-mm Hg increase in systolic BP was associated with smaller temporal cortex volume (β = -0.03; 95% CI, -0.06 to -0.01), while a 5-mm Hg increase in diastolic BP was associated with smaller parietal cortex volume (β = -0.06; 95% CI, -0.10 to -0.02). The negative association of hypertension and BP change with regional brain volumes appeared stronger in men than women for some regions.

Conclusions and Relevance

In this cohort study, early adulthood hypertension and BP change were associated with late-life volumetric and WM differences implicated in neurodegeneration and dementia. Sex differences were observed for some brain regions whereby hypertension and increasing BP appeared more detrimental for men. These findings suggest that prevention and treatment of hypertension in early adulthood is important for late-life brain health, particularly among men.

On-treatment blood pressure and cardiovascular mortality in adults with repaired coarctation of aorta

BACKGROUND

Although, hypertension is common in adults with repaired coarctation of aorta (COA), there are no data about on-treatment blood pressure (BP), and its relationship to outcomes in this population. The purpose of this study was to determine the relationship between on-treatment BP and cardiovascular mortality in adults with repaired COA.

METHODS

Retrospective study of adults with repaired COA on antihypertensive therapy (n = 461, age 39 ± 11). All BP measurements obtained within the first 3 years were averaged to determine the on-treatment BP, and the patients were stratified into BP quartiles using the cut-off points from the guidelines.

RESULTS

Being in the upper systolic BP (SBP) quartiles (SBP 120-129, 130-139 and ≥140) was associated with higher risk of cardiovascular mortality (HR 1.05, 95%CI 1.01-1.07, HR 1.12, 95%CI 1.04 to 1.15 and HR 1.39, 95%CI 1.13 to 1.59), as compared to being the lowest SBP quartile. We observed a 7% increase in the risk of cardiovascular mortality for every 5 mmHg increase in SBP, and a 4% increase in risk of cardiovascular mortality for every 5 mmHg increase in DBP.

CONCLUSIONS

Collectively, these data suggest that even s less severe form of hypertension SBP (120-129 mmHg) was not benign, and perhaps should be considered for antihypertensive therapy. A randomized controlled clinical trial is required to determine whether this group of patients (SBP 120 to 129 mmHg) would benefit from antihypertensive therapy, and to determine the optimal type and intensity of antihypertensive therapy in this population.

Adolescent Relational Roots of Adult Blood Pressure: A Fourteen-Year Prospective Study

Intensity in adolescent romantic relationships was examined as a long-term predictor of higher adult blood pressure in a community sample followed from age 17 to 31. Romantic intensity in adolescence--measured via quantity of time spent alone with a partner and duration of the relationship--was predicted by parents' psychologically controlling behavior, and was in turn found to predict higher resting adult systolic and diastolic blood pressure even after accounting for relevant covariates. The prediction to adult blood pressure was partially mediated via conflict in non-romantic adult friendships and intensity in adult romantic relationships. Even after accounting for these mediators, however, a direct path from adolescent romantic intensity to higher adult blood pressure remained. Neither family income in adolescence nor trait measures of personality assessed in adulthood accounted for these findings. Results are interpreted both as providing further support for the view that adolescent social relationship qualities have substantial long-term implications for adult health, as well as suggesting a potential physiological mechanism by which adolescent relationships may be linked to adult health outcomes.

Efficacy and safety of a quadruple ultra-low-dose treatment for hypertension (QUARTET USA): Rationale and design for a randomized controlled trial

BACKGROUND

Over half of patients with elevated blood pressure require multi-drug treatment to achieve blood pressure control. However, multi-drug treatment may lead to lower adherence and more adverse drug effects compared with monotherapy.

OBJECTIVE

The Quadruple Ultra-low-dose Treatment for Hypertension (QUARTET) USA trial was designed to evaluate whether initiating treatment with ultra-low-dose quadruple-combination therapy will lower office blood pressure more effectively, and with fewer side effects, compared with initiating standard dose monotherapy in treatment naive patients with SBP < 180 and DBP < 110 mm Hg and patients on monotherapy with SBP < 160 and DBP < 100 mm Hg.

METHODS/DESIGN

QUARTET USA was a prospective, randomized, double-blind trial (ClinicalTrials.gov NCT03640312) conducted in federally qualified health centers in a large city in the US. Patients were randomly assigned (1:1) to either ultra-low-dose quadruple combination therapy or standard dose monotherapy. The primary outcome was mean change from baseline in office systolic blood pressure at 12-weeks, adjusted for baseline values. Secondary outcomes included measures of blood pressure change and variability, medication adherence, and health related quality of life. Safety outcomes included occurrence of serious adverse events, relevant adverse drug effects, and electrolyte abnormalities. A process evaluation aimed to understand provider experiences of implementation and participant experiences around side effects, adherence, and trust with clinical care.

DISCUSSION

QUARTET USA was designed to evaluate whether a novel approach to blood pressure control would lower office blood pressure more effectively, and with fewer side effects, compared with standard dose monotherapy. QUARTET USA was conducted within a network of federally qualified healthcare centers with the aim of generating information on the safety and efficacy of ultra-low-dose quadruple-combination therapy in diverse groups that experience a high burden of hypertension.

The impact of lifestyle guidance intervention on health outcomes among Japanese middle-aged population with metabolic syndrome: A regression discontinuity study

Metabolic syndrome (MetS) prevalence has increased globally with considerable morbidity and economic burden at both individual and national levels. Japan is the first and only country that has introduced a nationwide lifestyle guidance intervention program to manage and control MetS. We conducted a quasi-experiment approach-regression discontinuity design-to evaluate the impact of this intervention on health outcomes at the population level. We retrospectively collected data of adults aged ≥35 years who participated in health checkups in 2015. Age in 2015 was used as the assignment variable, and an age of 40 years old was the threshold because those with MetS aged ≥40 were required to receive lifestyle guidance intervention. Among 26,772 MetS adults, those who received the intervention had significant reductions in obesity measurements (bodyweight, waist circumference, and body mass index [BMI]) after 1 year of this intervention. Blood pressure was also significantly reduced in men after 1 year of undertaking the intervention. The results were similar when including demographic, socioeconomic, and behavioral covariates and using alternative functional forms to estimate the impact, or when bandwidths around intervention thresholds were changed. Our results showed that lifestyle guidance intervention for MetS has an important impact on weight loss and blood pressure reduction at the population level. This intervention could address the high burden of obesity and cardiovascular diseases in Japan and other countries with an unmet need for MetS prevention and management.

Network meta-analysis of sacubitril/valsartan for the treatment of essential hypertension

Aim

Sacubitril/valsartan has been demonstrated to reduce blood pressure in hypertensive patients, but the best dose remains unclear. We performed this network meta-analysis to determine the comparative efficacy and safety of three available doses of sacubitril/valsartan (i.e., 100, 200, and 400 mg).

Methods and results

We searched four databases for relevant studies published before January 2022. Mean systolic and diastolic blood pressures in the sitting position (msSBP and msDBP) and ambulatory condition (24-h maSBP and maDBP) and adverse events (AEs) were assessed. Nine randomized controlled trials (RCTs) involving 5474 patients were included. Sacubitril/valsartan 200 mg once daily was slightly better than 400 mg once daily in lowering 24-h maDBP (MD, 1.31 mmHg; 95% CI 0.61–2.01 mmHg), slightly better than 100 mg once daily in lowering 24-h maSBP (MD, − 3.70 mmHg; 95% CI  − 6.22 to − 1.18 mmHg) and 24-h maDBP (MD, − 2.98; 95% CI − 5.11 to − 0.85), and slightly better than Valsartan 160 mg once daily in lowering 24-h maSBP (MD, − 3.23 mmHg; 95% CI, − 5.25 to − 1.21). 400 mg once daily of sacubitril/valsartan was better than 200 mg once daily in lowering msDBP (MD, − 9.38 mmHg; 95% CI − 17.79 to − 0.97 mmHg). Interestingly, 400 mg once daily of sacubitril/valsartan had fewer trial-specified AEs than 200 mg once daily (OR, 0.74; 95%CI 0.55–0.99). There was no statistical difference for the remaining comparisons.

Conclusions

In hypertensive patients, 200 mg once daily of sacubitril/valsartan may exert a greater reduction in ambulatory blood pressure than 100 mg once daily and 200 mg once daily may not be inferior to 400 mg once daily. Moreover, it is not clear that sacubitril/valsartan lowers blood pressure more than an angiotensin receptor blocker. Further trials are required to determine the incremental value of sacubitril/valsartan as an anti-hypertensive agent.

Graphical abstract

Heart diseases, hypertension and effects of antihypertensive medications: Is hypertension a true risk factor of heart diseases?

Background

Heart diseases (HD) are the leading cause of deaths in the world. Many studies have been done on the relationships among hypertension, HD and antihypertensive medications. Most of the studies find that hypertension is a significant risk factor of HD, but there are some studies in which hypertension is not a risk factor. As antihypertensive medications are routinely prescribed to prevent HD, it is necessary to evaluate the effects of these and other risk factors of HD.

Data and methods

The relationship between hypertension and HD was analyzed using 6,773,464 medical checkups obtained from the JMDC Claims Database obtained from January 2005 to September 2019. Factors potentially affecting HD, including blood pressures (BP) and usage of antihypertensive medications, were evaluated using 2,861,769 observations. To avoid the causality problem, probit models were used to analyze the probability of an individual who had no history of HD at year t developing HD by year t + 1.

Results

A positive relation between systolic blood pressure (SBP) and HD was found in the equation without any other covariates. However, the significant relation between HD and BP disappeared when the models contained various other factors as covariates. When a 10-year age or longer interval was used in the model, a positive relation between the two variables was found, suggesting that SBP works as a proxy variable. Taking antihypertensive medications greatly increases the probability of developing HD in the next year. Higher levels of cholesterols decrease the probability of developing HD.

Conclusion

Unlike many previous studies, no significant relationship between HD and hypertension was found in the models containing multiple covariates. The accepted relation might actually be spurious, and it is important to select covariates carefully. Taking antihypertensive medications appears to increase the probability of developing HD in the next year, suggesting the need for further research and greater caution in the use of antihypertensive medications.

Renal Sympathetic Denervation for Hypertension

Arterial hypertension is the most prevalent global modifiable risk factor for cardiovascular morbidity and mortality. Despite the availability of numerous pharmacologic treatments, many patients do not achieve guideline-recommended blood pressure targets. Therefore, renal sympathetic denervation (RDN), a process in which catheter-directed techniques are used to ablate portions of the renal artery to reduce sympathetic activity, has been extensively investigated as a complementary and nonpharmacologic approach for the treatment of arterial hypertension. This review seeks to discuss the pathophysiological rationale of this strategy, to survey its history and development, and to highlight the current clinical evidence and possible future directions of its employment. In sum, RDN has demonstrated itself to be a safe and well-tolerated endovascular intervention that can reliably contribute to improved blood pressure control and, perhaps ultimately, significant cardiovascular prognosis.

Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations

The 2017 American College of Cardiology/American Heart Association and 2018 European Society of Cardiology/European Society of Hypertension clinical practice guidelines for management of high blood pressure/hypertension are influential documents. Both guidelines are comprehensive, were developed using rigorous processes, and underwent extensive peer review. The most notable difference between the 2 guidelines is the blood pressure cut points recommended for the diagnosis of hypertension. There are also differences in the timing and intensity of treatment, with the American College of Cardiology/American Heart Association guideline recommending a somewhat more intensive approach. Overall, there is substantial concordance in the recommendations provided by the 2 guideline-writing committees, with greater congruity between them than their predecessors. Additional harmonization of future guidelines would help to underscore the commonality of their core recommendations and could serve to catalyze changes in practice that would lead to improved prevention, awareness, treatment, and control of hypertension, worldwide.

Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines

The 2017 American College of Cardiology/American Heart Association and 2018 European Society of Cardiology/European Society of Hypertension clinical practice guidelines for management of high blood pressure/hypertension are influential documents. Both guidelines are comprehensive, were developed using rigorous processes, and underwent extensive peer review. The most notable difference between the 2 guidelines is the blood pressure cut points recommended for the diagnosis of hypertension. There are also differences in the timing and intensity of treatment, with the American College of Cardiology/American Heart Association guideline recommending a somewhat more intensive approach. Overall, there is substantial concordance in the recommendations provided by the 2 guideline-writing committees, with greater congruity between them than their predecessors. Additional harmonization of future guidelines would help to underscore the commonality of their core recommendations and could serve to catalyze changes in practice that would lead to improved prevention, awareness, treatment, and control of hypertension, worldwide.

Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations

The 2017 American College of Cardiology/American Heart Association and 2018 European Society of Cardiology/European Society of Hypertension clinical practice guidelines for management of high blood pressure/hypertension are influential documents. Both guidelines are comprehensive, were developed using rigorous processes, and underwent extensive peer review. The most notable difference between the 2 guidelines is the blood pressure cut points recommended for the diagnosis of hypertension. There are also differences in the timing and intensity of treatment, with the American College of Cardiology/American Heart Association guideline recommending a somewhat more intensive approach. Overall, there is substantial concordance in the recommendations provided by the 2 guideline-writing committees, with greater congruity between them than their predecessors. Additional harmonization of future guidelines would help to underscore the commonality of their core recommendations and could serve to catalyze changes in practice that would lead to improved prevention, awareness, treatment, and control of hypertension, worldwide.

State-of-the-Art Review: Evidence on Red Meat Consumption and Hypertension Outcomes

Hypertension (HTN) is a well-established risk factor for cardiovascular diseases (CVDs), including ischemic heart disease, stroke, heart failure, and atrial fibrillation. The prevalence of HTN, as well as mortality rates attributable to HTN, continue to increase, particularly in the United States and among Black populations. The risk of HTN involves a complex interaction of genetics and modifiable risk factors, including dietary patterns. In this regard, there is accumulating evidence that links dietary intake of red meat with a higher risk of poorly controlled blood pressure and HTN. However, research on this topic contains significant methodological limitations, which are described in the review. The report provided below also summarizes the available research reports, with an emphasis on processed red meat consumption and how different dietary patterns among certain populations may contribute to HTN-related health disparities. Finally, this review outlines potential mechanisms and provides recommendations for providers to counsel patients with evidence-based nutritional approaches regarding red meat and the risk of HTN, as well as CVD morbidity and mortality.

Risk of Mild Cognitive Impairment or Probable Dementia in New Users of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors: A Secondary Analysis of Data From the Systolic Blood Pressure Intervention Trial (SPRINT)

Importance

The cardiovascular and renal outcomes of angiotensin-II receptor blocker (ARB) and angiotensin-converting enzyme inhibitor (ACEI) treatment are well-known; however, few studies have evaluated initiation of these agents and cognitive impairment.

Objective

To emulate a target trial to evaluate the cognitive outcomes of initiating an ARB- vs ACEI-based antihypertensive regimen in individuals at risk for mild cognitive impairment (MCI) and probable dementia (PD).

Design, Setting, and Participants

Active comparator, new-user observational cohort study design using data from the Systolic Blood Pressure Intervention Trial (SPRINT), conducted November 2010 through July 2018. Marginal cause-specific hazard ratios (HRs) and treatment-specific cumulative incidence functions were estimated with inverse probability (IP) weighting to account for confounding. Participants were using neither an ARB nor ACEI at baseline. Data analysis was conducted from April 7, 2021, to April 26, 2022.

Exposures

New users of ARB vs ACEI during the first 12 months of trial follow-up.

Main Outcomes and Measures

Composite of adjudicated amnestic MCI or PD.

Results

Of 9361 participants, 727 and 1313 new users of an ARB or ACEI, respectively, with well-balanced baseline characteristics between medication exposure groups after inverse probability weighting (mean [SD] age, 67 [9.5] years; 1291 ]63%] male; 240 [33%] Black; 89 [12%] Hispanic; 383 [53%] White; and 15 [2%] other race or ethnicity. In the primary analysis, during a median follow-up of 4.9 years, the inverse probability-weighted rate of amnestic MCI or PD was 4.3 vs 4.6 per 100 person-years among participants initiating ARB vs ACEI (HR, 0.93; 95% CI, 0.76-1.13). In subgroup analyses, new users of an ARB vs ACEI had a lower rate of amnestic MCI or PD among those in the standard systolic blood pressure treatment arm (HR, 0.61; 95% CI, 0.41-0.91) but not in the intensive arm (HR, 1.17; 95% CI, 0.90-1.52) (P = .007 for interaction).

Conclusions and Relevance

In this observational cohort study of US adults at high cardiovascular disease risk, there was no difference in the rate of amnestic MCI or PD among new users of an ARB compared with ACEI, although 95% CIs were wide.

Influence of Sex, BMI, and Skin Color on the Accuracy of Non-Invasive Cuffless Photoplethysmography-Based Blood Pressure Measurements

Vital signs obtained by photoplethysmography-based devices might be influenced by subcutaneous fat and skin color. This observational comparison study aimed to test the accuracy of blood pressure (BP) measurements between a photoplethysmography-based device and cuff-based BP device in ambulatory individuals, coming for a routine BP checkup. Systolic BP (SBP) and diastolic BP (DBP) measurements were stratified based on sex, BMI (<25; 25 ≤BMI<30; 30 ≤kg/m²), and skin color (types 1–3 and 4–6 by the Fitzpatrick scale). A total of 1548 measurements were analyzed. Correlations of SBP and DBP between the devices among males/females were between 0.914–0.987 (p < 0.001), and Bland-Altman analysis showed a bias of less than 0.5 mmHg for both sexes. Correlations of SBP and DBP between the devices among BMI groups were between 0.931–0.991 (p < 0.001), and Bland-Altman analysis showed a bias of less than 1 mmHg for all. Correlations of SBP and DBP between the devices among the skin color groups were between 0.936–0.983 (p < 0.001), and Bland-Altman analysis showed a bias of less than 1 mmHg for all. This study shows similar and high agreements between BP measurements obtained using a PPG-based non-invasive cuffless BP device and a cuff-based BP device across sex, BMI, and skin color groups.

Blood Pressure and Glycemic Control Among Ambulatory US Adults With Heart Failure: National Health and Nutrition Examination Survey 2001 to 2018

BACKGROUND

Multisociety guidelines recommend a goal systolic blood pressure (BP) <130 mm Hg and a hemoglobin A1c (HbA1c) <8% in patients with heart failure (HF), regardless of ejection fraction. Few studies have described BP and glycemic control in ambulatory patients with HF and racial and ethnic disparities in this subset of the population.

METHODS

We evaluated prevalence of uncontrolled BP and HbA1c in non-Hispanic Black, non-Hispanic White, and Mexican American adults aged ≥20 years with self-reported HF (National Health and Nutrition Examination Surveys: 2001-2018). Prevalence ratios (95% CI) for uncontrolled BP and HbA1c were calculated by race and ethnicity and adjusted for sex, age, treatment, and socioeconomic status. In secondary analyses, we examined trends in the prevalence of uncontrolled BP and HbA1c.

RESULTS

Uncontrolled BP was present in 48% (95% CI, 49%-56%) of adults with HF (representing 2.3 million people). Non-Hispanic Black participants had a higher prevalence of uncontrolled BP compared with non-Hispanic White participants (53% [48%-58%] compared with 47% [43%-51%], P<0.05). In adjusted models, non-Hispanic Black participants were 1.19 (1.02-1.39) times more likely to have uncontrolled BP than non-Hispanic White participants. Overall, uncontrolled HbA1c was found in 8% (6%, 10%) with no differences by race and ethnicity. Prevalence of uncontrolled BP improved over time but uncontrolled risk factors remained high-2017 to 2018: 41% (36%, 47%) and 7% (5%, 12%) had uncontrolled BP and HbA1c, respectively.

CONCLUSIONS

We document an unacceptably high prevalence of uncontrolled BP and HbA1c in a nationally representative, ambulatory HF sample with significant differences in BP control by race and ethnicity.

Angiotensin Type-2 Receptors: Transducers of Natriuresis in the Renal Proximal Tubule

Angiotensin II (Ang II) type-2 receptors (AT₂R) are expressed in the adult kidney, prominently in renal proximal tubule cells (RPTCs), and play an important role in opposing renal sodium (Na⁺) retention induced by Ang II stimulation of Ang II type-1 receptor (AT₁R). Natriuresis induced by AT₁R blockade is due at least in part to AT₂R activation and whole body deletion of AT₂Rs reduces the natriuretic response to increased blood pressure (BP). The major endogenous AT₂R agonist mediating the natriuretic response is Ang III, the Ang II heptapeptide metabolite generated by aminopeptidase A, and the principal nephron site mediating inhibition of Na⁺ reabsorption by the AT₂R is the renal proximal tubule (RPT). AT₂Rs induce natriuresis via a bradykinin, nitric oxide and cyclic GMP (cGMP) signaling cascade. Recent studies demonstrated a key role for protein phosphatase 2A (PP2A) in the AT₂R-mediated natriuretic response upstream of cGMP. By inducing natriuresis, AT₂Rs lower BP in the Ang II-infusion model of hypertension. PP2A activation and the natriuretic response to AT₂R stimulation are defective in spontaneously hypertensive rats, a model of primary hypertension in humans. AT₂R agonists are candidates for proximal tubule natriuretic agents in Na⁺ and fluid retention disorders.

Potential impact of systematic and random errors in blood pressure measurement on the prevalence of high office blood pressure in the United States

The authors examined the proportion of US adults that would have their high blood pressure (BP) status changed if systolic BP (SBP) and diastolic BP (DBP) were measured with systematic bias and/or random error versus following a standardized protocol. Data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES; n = 5176) were analyzed. BP was measured up to three times using a mercury sphygmomanometer by a trained physician following a standardized protocol and averaged. High BP was defined as SBP ≥130 mm Hg or DBP ≥80 mm Hg. Among US adults not taking antihypertensive medication, 32.0% (95%CI: 29.6%,34.4%) had high BP. If SBP and DBP were measured with systematic bias, 5 mm Hg for SBP and 3.5 mm Hg for DBP higher and lower than in NHANES, the proportion with high BP was estimated to be 44.4% (95%CI: 42.6%,46.2%) and 21.9% (95%CI 19.5%,24.4%). Among US adults taking antihypertensive medication, 60.6% (95%CI: 57.2%,63.9%) had high BP. If SBP and DBP were measured 5 and 3.5 mm Hg higher and lower than in NHANES, the proportion with high BP was estimated to be 71.8% (95%CI: 68.3%,75.0%) and 48.4% (95%CI: 44.6%,52.2%), respectively. If BP was measured with random error, with standard deviations of 15 mm Hg for SBP and 7 mm Hg for DBP, 21.4% (95%CI: 19.8%,23.0%) of US adults not taking antihypertensive medication and 20.5% (95%CI: 17.7%,23.3%) taking antihypertensive medication had their high BP status re-categorized. In conclusions, measuring BP with systematic or random errors may result in the misclassification of high BP for a substantial proportion of US adults.

Blood Pressure and Glaucomatous Progression in a Large Clinical Population

PURPOSE

To investigate the effect of systemic arterial blood pressure (BP) on rates of progressive structural damage over time in glaucoma.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 7501 eyes of 3976 subjects with glaucoma or suspected of glaucoma followed over time from the Duke Glaucoma Registry.

METHODS

Linear mixed models were used to investigate the effects of BP on the rates of retinal nerve fiber layer (RNFL) loss from spectral-domain OCT (SD-OCT) over time. Models were adjusted for intraocular pressure (IOP), gender, race, diagnosis, central corneal thickness (CCT), follow-up time, and baseline disease severity.

MAIN OUTCOME MEASURE

Effect of mean arterial pressure (MAP), systolic arterial pressure (SAP), and diastolic arterial pressure (DAP) on rates of RNFL loss over time.

RESULTS

A total of 157 291 BP visits, 45 408 IOP visits, and 30 238 SD-OCT visits were included. Mean rate of RNFL change was -0.70 μm/year (95% confidence interval, -0.72 to -0.67 μm/year). In univariable models, MAP, SAP, and DAP during follow-up were not significantly associated with rates of RNFL loss. However, when adjusted for mean IOP during follow-up, each 10 mmHg reduction in mean MAP (-0.06 μm/year; P = 0.007) and mean DAP (-0.08 μm/year; P < 0.001) but not SAP (-0.01 μm/year; P = 0.355) was associated with significantly faster rates of RNFL thickness change over time. The effect of the arterial pressure metrics remained significant after additional adjustment for baseline age, diagnosis, sex, race, follow-up time, disease severity, and corneal thickness.

CONCLUSIONS

When adjusted for IOP, lower MAP and DAP during follow-up were significantly associated with faster rates of RNFL loss, suggesting that levels of systemic BP may be a significant factor in glaucoma progression.

Association of Differences in Treatment Intensification, Missed Visits, and Scheduled Follow-up Interval With Racial or Ethnic Disparities in Blood Pressure Control

Importance

Black patients with hypertension often have the lowest rates of blood pressure (BP) control in clinical settings. It is unknown to what extent variation in health care processes explains this disparity.

Objective

To assess whether and to what extent treatment intensification, scheduled follow-up interval, and missed visits are associated with racial and ethnic disparities in BP control.

Design, Setting, and Participants

In this cohort study, nested logistic regression models were used to estimate the likelihood of BP control (defined as a systolic BP [SBP] level <140 mm Hg) by race and ethnicity, and a structural equation model was used to assess the association of treatment intensification, scheduled follow-up interval, and missed visits with racial and ethnic disparities in BP control. The study included 16 114 adults aged 20 years or older with hypertension and elevated BP (defined as an SBP level ≥140 mm Hg) during at least 1 clinic visit between January 1, 2015, and November 15, 2017. A total of 11 safety-net clinics within the San Francisco Health Network participated in the study. Data were analyzed from November 2019 to October 2020.

Main Outcomes and Measures

Blood pressure control was assessed using the patient's most recent BP measurement as of November 15, 2017. Treatment intensification was calculated using the standard-based method, scored on a scale from -1.0 to 1.0, with -1.0 being the least amount of intensification and 1.0 being the most. Scheduled follow-up interval was defined as the mean number of days to the next scheduled visit after an elevated BP measurement. Missed visits measured the number of patients who did not show up for visits during the 4 weeks after an elevated BP measurement.

Results

Among 16 114 adults with hypertension, the mean (SD) age was 58.6 (12.1) years, and 8098 patients (50.3%) were female. A total of 4658 patients (28.9%) were Asian, 3743 (23.2%) were Black, 3694 (22.9%) were Latinx, 2906 (18.0%) were White, and 1113 (6.9%) were of other races or ethnicities (including American Indian or Alaska Native [77 patients (0.4%)], Native Hawaiian or Pacific Islander [217 patients (1.3%)], and unknown [819 patients (5.1%)]). Compared with patients from all racial and ethnic groups, Black patients had lower treatment intensification scores (mean [SD], -0.33 [0.26] vs -0.29 [0.25]; β = -0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; β = 0.35; P < .001). In contrast, Asian patients had higher treatment intensification scores (mean [SD], -0.26 [0.23]; β = 0.02; P < .001) and fewer missed visits (mean [SD], 0.2 [0.7] visits; β = -0.20; P < .001). Black patients were less likely (odds ratio [OR], 0.82; 95% CI, 0.75-0.89; P < .001) and Asian patients were more likely (OR, 1.13; 95% CI, 1.02-1.25; P < .001) to achieve BP control than patients from all racial or ethnic groups. Treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in BP control among Black patients and 26% and 13% of the difference among Asian patients.

Conclusions and Relevance

This study's findings suggest that racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in BP control, and racial and ethnic differences in visit attendance may also play a role. Ensuring more equitable provision of treatment intensification could be a beneficial health care strategy to reduce racial and ethnic disparities in BP control.

Multiple Social Vulnerabilities to Health Disparities and Hypertension and Death in the REGARDS Study

Social vulnerabilities increase the risk of developing hypertension and lower life expectancy, but the effect of an individual's overall vulnerability burden is unknown. Our objective was to determine the association of social vulnerability count and the risk of developing hypertension or dying over 10 years and whether these associations vary by race. We used the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) and included participants without baseline hypertension. The primary exposure was the count of social vulnerabilities defined across economic, education, health and health care, neighborhood and built environment, and social and community context domains. Among 5425 participants of mean age 64±10 SD years of which 24% were Black participants, 1468 (31%) had 1 vulnerability and 717 (15%) had ≥2 vulnerabilities. Compared with participants without vulnerabilities, the adjusted relative risk ratio for developing hypertension was 1.16 (95% CI, 0.99-1.36) and 1.49 (95% CI, 1.20-1.85) for individuals with 1 and ≥2 vulnerabilities, respectively. The adjusted relative risk ratio for death was 1.55 (95% CI, 1.24-1.93) and 2.30 (95% CI, 1.75-3.04) for individuals with 1 and ≥2 vulnerabilities, respectively. A greater proportion of Black participants developed hypertension and died than did White participants (hypertension, 38% versus 31%; death, 25% versus 20%). The vulnerability count association was strongest in White participants (P value for vulnerability count×race interaction: hypertension=0.046, death=0.015). Overall, a greater number of socially determined vulnerabilities was associated with progressively higher risk of developing hypertension, and an even higher risk of dying over 10 years.

Hypertension Prevalence, Awareness, and Control Among Parents of School-Aged Children in the United Arab Emirates

BACKGROUND

Increased blood pressure (BP) is a major cardiovascular disease risk factor. The study aimed to determine the prevalence and predictors of hypertension and its awareness and control among parents of school-aged children in the United Arab Emirates (UAE).

METHODS

A total of 605 parents participated in this cross-sectional study. Information on socio-demographics, lifestyle factors, and history of chronic disease were collected through an adapted version of the World Health Organization STEPS questionnaire. Fasting blood glucose samples, BP measurements, body mass index (BMI), and waist and hip circumference were obtained using standard measurement protocols. Prevalence of hypertension was identified in the cohorts by defining hypertension using the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines (BP≥130/80 mmHg) and the World Health Organization-International Society of Hypertension Guidelines Orchid (BP≥140/90 mmHg) in association with antihypertensive medication use.

RESULTS

The mean age of participants was 42.9±7.9 years. The prevalence of hypertension was 37.2% (95% CI: 33.5-41.2) and 18.0% (95% CI: 15.2-21.3), using the 2017 and the previous WHO definitions, respectively. Little over half of the sample (51.5%) who were aware of having hypertension reported using antihypertensive medications. Of those reporting the use of antihypertensive medications in the past two days, 13 of 33 patients (39.4%) had their hypertension under control (<140/90 mmHg). The independent correlates of hypertension included age [(adjusted odds ratio (AOR): 1.09 (1.05-1.13], male sex [AOR: 2.48 (1.41-4.34], college or higher education [AOR: 0.22 (0.09-0.56)], family history of hypertension [AOR: 2.03 (1.17-3.53)], obesity [AOR: 3.15 (1.24-7.12)], and moderate or vigorous physical activity [AOR: 0.50 (0.26-0.98)].

CONCLUSION

Hypertension is prevalent among parents of school-going children. Improving lifestyle, health literacy, and introducing innovative models to raise awareness and education about hypertension are essential to achieve sustainable development goals (SDGs).

Hypertensive Aspects of Cardiometabolic Disorders Are Associated with Lower Brain Microstructure, Perfusion, and Cognition

BACKGROUND

Cardiometabolic disorders (hypertension, diabetes) are key modifiable risk factors for Alzheimer's disease and related disorders. They often co-occur; yet, the extent to which they independently affect brain structure and function is unclear.

OBJECTIVE

We hypothesized their combined effect is greater in associations with cognitive function and neuroimaging biomarkers of white matter (WM) health and cerebral perfusion in a diverse older adult cohort.

METHODS

Participants aged 50-85 years received: clinical evaluation, oral glucose tolerance testing, neuroimaging, cognitive testing, and adjudication. Neuroimaging included: T1 (gray [GM]/WM segmentation, regional volumes/thicknesses); FLAIR (WM hyperintensity volume [WMHv]; arterial spin labeling (cerebral blood flow); diffusion tensor imaging (fractional anisotropy [FA]); and neurite orientation dispersion and density imaging (Free Water). Hypertension (HTN) and impaired glucose tolerance (IGT) were staged and cardiometabolic status was categorized (HTN only, IGT only, IGT+HTN, neither). Multivariable linear regression modeled associations with cognitive and neuroimaging measures (covariates: age, gender, race).

RESULTS

MRI was available for 478 participants (35% mild cognitive impairment, 10% dementia) with mean age 70±8 years, 74% with HTN, 61% with IGT, and 15% self-identified as Black/African-American. IGT+HTN was significantly associated with cognitive impairment, higher WM Free Water and WMHv, lower FA, and lower GM perfusion compared to neither factor. HTN alone was associated with poorer cognition and lower GM perfusion. Cardiometabolic factors were not associated with GM macrostructure (volumes, temporal lobe cortical thickness) or cognitive status.

CONCLUSION

HTN and its co-occurrence with IGT (HTN+IGT) were associated with lower global cognitive performance and reduced GM perfusion and impaired WM microstructure.

Catheter-Based Renal Denervation Therapy: Evolution of Evidence and Future Directions

Motivated by the persistence of uncontrolled blood pressure and its public health impact, the development and evaluation of device-based therapies for hypertension has advanced at an accelerated pace to complement pharmaceutical and lifestyle intervention strategies. Countering widespread interest from early studies, the lack of demonstrable efficacy for renal denervation (RDN) in a large, sham-controlled randomized trial motivated revision of trial design and conduct to account for confounding variables of procedural technique, medication variability, and selection of both patients and end points. Now amidst varied trial design and methods, several sham-controlled, randomized trials have demonstrated clinically meaningful reductions in blood pressure with RDN. With this momentum, additional studies are underway to position RDN as a potential part of standard therapy for the world's leading cause of death and disability. In parallel, further studies will address unresolved issues including durability of blood pressure lowering and reduction in antihypertensive medications, late-term safety, and impact on clinical outcomes. Identifying predictors of treatment effect and surveys of patient-reported outcomes and treatment preferences are also evolving areas of investigation. Aside from confirmatory studies of safety and effectiveness, these additional studies will further inform patient selection, expand experience with RDN in broader populations with hypertension, and provide guidance to how RDN may be incorporated into treatment pathways.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Decreased CSF Dynamics in Treatment-Naive Patients with Essential Hypertension: A Study with Phase-Contrast Cine MR Imaging

BACKGROUND AND PURPOSE

Arterial sclerosis resulting from hypertension slows CSF transportation in the perivascular spaces, showing the intrinsic relationship between the CSF and the blood vasculature. However, the exact effect of hypertension on human CSF flow dynamics remains unclear. The present study aimed to evaluate CSF flow dynamics in treatment-naive patients with essential hypertension using phase-contrast cine MR imaging.

MATERIALS AND METHODS

The study included 60 never-treated patients with essential hypertension and 60 subjects without symptomatic atherosclerosis. CSF flow parameters, such as forward flow volume, forward peak velocity, reverse flow volume, reverse peak velocity, average flow, and net flow volume, were measured with phase-contrast cine MR imaging. Differences between the 2 groups were assessed to determine the independent determinants of these CSF flow parameters.

RESULTS

Forward flow volume, forward peak velocity, reverse flow volume, reverse peak velocity, and average flow in the patients with hypertension significantly decreased (all, P < .05). Increasing systolic blood pressure was significantly associated with lower forward flow volume (β = -0.44 mL/mL/mm Hg; 95% CI, -0.83 to -0.06 mL/mL/mm Hg), forward peak velocity (β = -0.50 cm/s/mm Hg; 95% CI, -0.88 to -0.12 cm/s/mm Hg), reverse flow volume (β = -0.61 mL/mL/mm Hg; 95% CI, -0.97 to -0.26 mL/mL/mm Hg), reverse peak velocity (β = -0.55 cm/s/mm Hg; 95% CI, -0.91-0.18 cm/s/mm Hg), and average flow (β = -0.50 mL/min/mm Hg; 95% CI, -0.93 to -0.08 mL/min/mm Hg).

CONCLUSIONS

The CSF flow dynamics in patients with hypertension are decreased, and increasing systolic blood pressure is strongly associated with lower CSF flow dynamics.

Traditional Chinese Medicine Injections Combined With Antihypertensive Drugs for Hypertensive Nephropathy: A Network Meta-Analysis

Background: Hypertension, a risk factor for cardiovascular events, is often associated with chronic kidney disease. This is called hypertensive nephropathy (HN), which negatively affects physical fitness and body mass, leading to economic burden. Traditional Chinese medicine injections (TCMIs) are common traditional Chinese-patent medicine preparations in China. There was a lack of evidence to prove which TCMIs combine with ADs (TCMIs+ADs) may be a therapeutic option for HN. Thus, we systematically reviewed the efficacy and safety of various TCMIs + ADs in patients with HN.

Methods: We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, and VIP information resource integration service platform databases for relevant Chinese- and English-language randomized controlled trials (RCTs) published from database inception until May 2021. Literature screening, data extraction, and quality assessment was performed by two reviewers independently but using the same criteria. We performed the effect modeling to analyze the data for all outcomes and ranked each intervention using the P-score. Furthermore, sensitivity analysis, meta-regression, and funnel plots were used to test the stability, heterogeneity, and publication bias, respectively.

Results: We included 69 RCTs with 6373 patients and including six TCMIs + ADs. Network analysis indicated that the ginkgo leaf extract and dipyridamole combined with ADs (GLED + ADs) was the most efficacious in terms of 24-h urinary protein excretion [mean difference (MD) = −0.70, 95% confidence interval (CI): −0.82 to −0.58; P-score = 1] and systolic blood pressure (MD = −12.95, 95% CI: −21.03 to −4.88; P-score = 0.88), whereas the salvianolate combined with ADs (SA + ADs) showed the highest effectiveness for diastolic blood pressure (MD = −6.88, 95% CI: −10.55 to −3.21; P-score = 0.9). Based on the combined P-score of network meta-analysis results (88% and 85.26%) and sensitivity analysis results (72% and 71.54%), the biplots showed that the GLED + ADs was the most efficacious intervention in all TCMIs + ADs for primary outcomes, followed by the SA + ADs and sodium tanshinone IIA sulfonate combined with ADs (STS + ADs). There was no significant difference in terms of safety between TCMIs + ADs and ADs alone.

Conclusion: Of all the TCMIs + ADs, GLED + ADs, SA + ADs, and STS + ADs may demonstrate a higher efficacy than ADs alone for HN. Weighing with the potential benefits and limitations in methodology, potential heterogeneity and outcomes, we should use various TCMIs with caution in clinical practice. Nevertheless, additional high-quality RCTs are warranted and future research should focus on the clinical value of core outcomes to confirm the effectiveness and safety of TCMIs for HN.

Systematic Review Registration: clinicaltrials.gov, identifier CRD42020205358

Isometric Exercise Training: A Review of Hypothesized Mechanisms and Protocol Application in Persons with Hypertension

According to the American Heart Association 116.4 million, or 46% of US adults are estimated to have hypertension. Although, traditional moderate intensity aerobic exercise training is associated with reducing blood pressure by 5-8 mmHg, barriers to this modality of exercise training exist. Thus, the purpose of this review is to evaluate the mechanisms and incorporation of isometric exercise training (IET) as an adjunctive mode of exercise in a population with HTN. Based upon the articles reviewed from the years 2000-2020 which incorporated IET and provided clear protocols lasting 4 or more weeks, meaningful reductions in blood pressure occurred following IET (SBP, -9.7 ± 3.3 mmHg; DBP, -4.8 ± 2.6 mmHg) which support the need to increase adoption of this exercise form into practice to help treat hypertension. Specifically, an IET program of 12-20 minutes per day, 3 times per week, could improve blood pressure reduction in those with hypertension. IET has the potential to produce significant and clinically meaningful blood pressure reductions and could serve as an adjunctive exercise modality alongside the established exercise prescription for those with hypertension.

Klotho and SIRT1 changes from pre-diabetes to diabetes and pre-hypertension to hypertension

BACKGROUND

Hypertension and diabetes are among the most important risk factors of cardiovascular diseases. Klotho and SIRT1 are known as anti-aging factors with beneficial effects on cardiovascular system. In this study we investigated the serum Klotho and SIRT1 levels in pre-diabetic and pre-hypertensive individuals and then in diabetic and hypertensive patients to see their relationship with these diseases.

METHOD

229 individuals divided into six groups with similar gender and age distribution 1-Control (normal BP and FBS) 2-pre-diabetic (FBS between 100 and 125 mg/dl) 3-diabetic (FBS ≥ 126 mg/dl), 4-pre-hypertensive (SBP 120-139 or DBP 80-89 mm Hg) 5-hypertensive (SBP ≥ 140 or DBP ≥ 90 mm Hg), and 6-patients with combined hypertension/diabetes. Serum levels of Klotho and SIRT1 were measured by ELISA method.

RESULTS

Serum Klotho and STRT1 levels decreased in pre-diabetes and returned to normal in diabetic patients. Their concentration increased in pre-hypertension and recovered to normal in hypertension. In the physiologic range of FBS there is a negative correlation between Klotho and SIRT1 with FBS. When pathologic ranges of FBS added to analysis, the negative correlation abolished/U shaped. Also an inverse U shape correlation observed between Klotho and SIRT1 with MAP in the range of normal to hypertensive BP levels. There was an overall positive relationship between the serum levels of Klotho and SIRT1 themselves.

CONCLUSION

The serum levels of the anti-aging proteins Klotho and SIRT1 increases or reduces at the onset of the disease, as a compensatory mechanism, but as the disease progresses their level recovers.

Hypertension-induced cognitive impairment: from pathophysiology to public health

Hypertension affects two-thirds of people aged >60 years and significantly increases the risk of both vascular cognitive impairment and Alzheimer's disease. Hypertension compromises the structural and functional integrity of the cerebral microcirculation, promoting microvascular rarefaction, cerebromicrovascular endothelial dysfunction and neurovascular uncoupling, which impair cerebral blood supply. In addition, hypertension disrupts the blood-brain barrier, promoting neuroinflammation and exacerbation of amyloid pathologies. Ageing is characterized by multifaceted homeostatic dysfunction and impaired cellular stress resilience, which exacerbate the deleterious cerebromicrovascular effects of hypertension. Neuroradiological markers of hypertension-induced cerebral small vessel disease include white matter hyperintensities, lacunar infarcts and microhaemorrhages, all of which are associated with cognitive decline. Use of pharmaceutical and lifestyle interventions that reduce blood pressure, in combination with treatments that promote microvascular health, have the potential to prevent or delay the pathogenesis of vascular cognitive impairment and Alzheimer's disease in patients with hypertension.