2020 International Society of Hypertension global hypertension practice guidelines

Left Ventricular Hypertrophy in Women With a History of Preeclampsia

BACKGROUND

As a hypertensive disorder of pregnancy, preeclampsia is associated with increased cardiovascular morbidity and mortality later in life. Since early signs of myocardial affection could indicate a higher risk of future cardiovascular disease manifestations, we investigated whether women with prior preeclampsia have a higher prevalence of left ventricular hypertrophy compared with women from the general population and to what extent chronic hypertension affects any potential difference.

METHODS

In a cohort study, women aged 40 to 55 years with prior preeclampsia were compared with age- and parity-matched women from the general population. They underwent a research cardiac computed tomography, and the primary outcome was left ventricular hypertrophy, defined as a left ventricular mass index >30 g/m2.7.

RESULTS

In 679 women with prior preeclampsia and 672 controls (median age, 47 years), we found a higher prevalence of left ventricular hypertrophy (14.0% versus 6.4%) in the preeclampsia group with an odds ratio of 1.62, 95% CI (1.07-2.46), P=0.024, median of 15 years (range, 0-28) after pregnancy, after adjustment for cardiovascular risk factors, including chronic hypertension. Left ventricular hypertrophy was more frequent among women with preeclampsia with (26.2% versus 15.6%) and without (5.5% versus 2.4%) chronic hypertension, and a mediation analysis showed that chronic hypertension explained 22% of the association between preeclampsia and left ventricular hypertrophy.

CONCLUSIONS

Women with prior preeclampsia had a 2-fold higher prevalence of left ventricular hypertrophy compared with women from the general population, and preeclampsia was independently associated with left ventricular hypertrophy, regardless of the presence of cardiovascular risk factors, including chronic hypertension.

REGISTRATION

URL: https://www.clinicalTrials.gov; Unique identifier: NCT03949829.

A randomized controlled pilot study investigating adherence to blood pressure diaries with personal pictures in stroke follow-up care

INTRODUCTION

Blood pressure (BP) management is essential in secondary stroke prevention. Strategies to ensure continuous home BP monitoring are needed. Few studies investigated factors influencing adherence to home BP management. Therefore, we designed a pilot study to investigate the feasibility of keeping BP diaries (BPDs) with personal images.

METHODS

In this prospective trial, we randomized persons with a diagnosis of stroke or transient ischemic attack into two groups: (i) 10 patients received a personalized BPD with pictures of their choosing and (ii) 10 patients received a BPD without photographs. We instructed participants in both groups to document their BP at home twice daily over 28 days. Adherence was defined as the number of BP measurements performed relative to the maximum number of recommended measurements. We assessed patient reported outcomes as exploratory endpoints.

RESULTS

We found no statistically significant difference in mean adherence between the control group (64%) and the intervention group (69%). The BP was within the recommended range and precision of documentation was high in both groups, without statistically significant differences. Patient reported outcomes such as depression scores did not differ significantly between study groups.

CONCLUSION

Our findings underline the relevance to investigate aspects of adherence to home BP management suggesting the inclusion of patient-provided pictures to be feasible.

Maternal and Neonatal Outcomes in Gestational Hypertension for Delivery at 37 versus 38 to 40 Weeks

This study aimed to compare neonatal and maternal outcomes for mothers with gestational hypertension delivered at 37 weeks' gestation compared with 38 to 40 weeks.Single-center, retrospective chart review of women with gestational hypertension delivered between 370/7 and 406/7 weeks' gestation over a 29-month period.A total of 337 mother-infant dyads with gestational hypertension were included: 194 delivered at 37 weeks' gestation (cohort 1) and 143 delivered at 38 to 40 weeks' gestation (cohort 2). Preeclampsia developed in 12% of cohort 1 and 8% of cohort 2 (p = 0.242). No significant differences in severe hypertensive-related complications were found between the cohorts. Neonatal outcomes including neonatal intensive care unit admission, respiratory support, phototherapy, and length of stay were all more frequent in cohort 1.For women with gestational hypertension, delivery at 38 to 40 weeks was not associated with increased maternal complications but was associated with fewer neonatal complications when compared with delivery at 37 weeks. · Gestational hypertension is a common complication of pregnancy.. · Mothers with gestational hypertension are often induced early.. · Neonatal adverse outcomes increase with early delivery.. · Optimal timing of delivery for pregnancies complicated by gestational hypertension is unknown..

Empagliflozin in resistant hypertension and heart failure with preserved ejection fraction: the EMPEROR-Preserved trial

BACKGROUND AND AIMS

Hypertension has a high prevalence in heart failure with preserved ejection fraction (HFpEF), which can be controlled, uncontrolled, or even resistant. The effects of empagliflozin on systolic blood pressure (SBP), time in target range, incidence of hypertensive urgencies, and studied cardiovascular and renal outcomes in different hypertension categories and after treatment with empagliflozin in the EMPEROR-Preserved trial were explored.

METHODS

A total of 5533 patients were studied and the population was separated into resistant (resHTN), uncontrolled (uctrHTN), and controlled (ctrHTN) hypertension. The effect of SBP on outcomes and treatment effects of empagliflozin were explored. Analyses were done with Cox regression analyses adjusted for demographic and clinical confounders and with a mixed model for repeated measures.

RESULTS

Empagliflozin reduced SBP in resHTN slightly more than in the other categories in the first weeks, while thereafter there were no significant differences. The modest reduction in SBP resulted in a moderate increase in time at target and reduced hypertensive urgencies. The primary endpoint was more prevalent in resHTN (P = .0358), but the treatment effect of empagliflozin on the primary endpoint was similar in resHTN, uctrHTN, and ctrHTN (P for interaction = .92) as was the improvement of the estimated glomerular filtration rate slope (P for interaction = .95) and change in quality of life by empagliflozin.

CONCLUSIONS

In HFpEF, the prevalence of resHTN is high and is associated with frequently higher outcome rates compared with ctrHTN and uctrHTN. The treatment effect was not modified by hypertension categories. This indicates that in HFpEF, moderate modifications of blood pressure do not affect overall outcomes and treatment effects of empagliflozin.

Assessing the Impact of Hypertension on Health-Related Quality of Life: Insights from Sociodemographic, Economic, and Clinical Features Using SF-36

Background: Hypertension significantly impacts the health-related quality of life (HRQoL) of patients. This study evaluates the influence of sociodemographic, economic, and clinical features on HRQoL among hypertensive patients using the 36-Item Short Form Survey (SF-36). Method: A cross-sectional study was conducted at a public health center in Khamis Mushayt, Saudi Arabia, where 209 adult hypertensive patients were surveyed using simple random sampling. Data were collected through a structured questionnaire covering sociodemographic and clinical details, and multiple linear regression was used to analyze the associations between variables and the SF-36 domains. Results: Of the 209 participants, 122 (58.4%) were female and 87 (41.6%) were male. Complications and multiple antihypertensive medications were linked to poorer physical functioning and general health (p < 0.05). Salt restriction improved physical functioning (B = 12.339, p = 0.008), and exercise reduced body pain (B = -8.487, p = 0.038). Middle-income patients had higher vitality (B = 7.632, p = 0.038) and social functioning (B = 16.465, p = 0.035). Higher-income individuals showed lower social functioning (B = -12.323, p = 0.022). Conclusions: Age, income, marital status, and complications were key determinants of HRQoL in hypertensive patients. Lifestyle interventions like exercise and salt restriction improve physical functioning and reduce pain, while psychological and social support are vital for mental health. Tailored interventions addressing clinical and psychosocial support are crucial for optimizing HRQoL in this population.

Validation of the Microlife BP3T01-1B blood pressure monitoring device in adults and adolescents according to the ISO 81060-2:2018 protocol

BACKGROUND

Accurate measurement of blood pressure (BP) is crucial for the diagnosis and ongoing management of hypertension. Only devices that have been validated using an established protocol should be used to measure BP. The aim of this study was to validate the Microlife BP3T01-1B, an automated upper-arm BP measuring device, according to the DIN EN ISO 81060-2:2018-11 (ANSI/AAMI/ISO 81060-2:2018) standard protocol.

METHODS

BP measurements were performed in 85 adults and adolescents (age range: 13-86 years) using the same-arm sequential method of the DIN EN ISO 81060-2:2018-11 protocol, alternating between the test device and a reference mercury sphygmomanometer.

RESULTS

A total of 255 valid comparisons were available for the analysis of criterion 1. The mean ± SD difference between the test device and the reference device values was -2.56 ± 7.53 mmHg for SBP and -3.10 ± 5.65 mmHg for DBP. The mean differences met the pass criterion of less than or equal to ±5 mmHg and the SD values met the pass criterion of ≤8 mmHg. All 85 participants were included in the analysis of criterion 2. The mean ± SD intraindividual difference between the test and reference devices was -2.56 ± 6.15 mmHg for SBP and -3.10 ± 4.85 mmHg for DBP. Both were within the required pass range of SD ≤6.43 mmHg for SBP and SD ≤6.20 mmHg for DBP.

CONCLUSION

The Microlife BP3T01-1B BP monitoring device fulfilled the criteria of the DIN EN ISO 81060-2:2018-11 (ANSI/AAMI/ISO 81060-2:2018) protocol in a general population and can be recommended for the measurement of BP in adults and adolescents.

Diuretics in patients with chronic kidney disease

Diuretic drugs act on electrolyte transporters in the kidney to induce diuresis and are often used in chronic kidney disease (CKD), given that nephron loss creates a deficit in the ability to excrete dietary sodium, which promotes an increase in plasma volume. This rise in plasma volume is exacerbated by CKD-induced systemic and intra-renal activation of the renin-angiotensin-aldosterone-system, which further limits urinary sodium excretion. In the absence of a compensatory decrease in systemic vascular resistance, increases in plasma volume induced by sodium retention can manifest as a rise in systemic arterial blood pressure. Management of sodium and volume overload in patients with CKD is therefore typically based on restriction of dietary sodium intake and the use of diuretic agents to enhance urinary sodium excretion. Thiazide and thiazide-type diuretics are foundational therapies for the management of hypertension, whereas loop diuretics are often needed for volume overload, which might also require combination therapies. Mineralocorticoid receptor antagonists have an important role in the management of diuretic-resistant volume overload or treatment-resistant hypertension. Additionally, diuretics can be used for the diagnosis of kidney diseases and in the management of hyperkalaemia or hypokalaemia, hyponatraemia, hypercalcaemia and hypomagnesaemia.

Correlation between myocardial work and disease activity in rheumatoid arthritis patients with preserved left ventricular ejection fraction: a retrospective study based on non-invasive pressure-strain loop：

BACKGROUND

Early cardiac damage is very common in RA patients, but it is usually subclinical. Therefore, finding a non-invasive method for the early detection and treatment of cardiac damage in autoimmune diseases is particularly important.diac dam RA ，。，。 OBJECTIVE: To evaluate left ventricular function changes in rheumatoid arthritis (RA) patients with preserved left ventricular ejection fraction (LVEF) using left ventricular pressure-strain loop (LV-PSL) technology and to explore the correlation between myocardial work (MW) and disease activity.- （LV-PSL） （LVEF） （RA） ， （MW） 。 METHODS: A total of 62 RA patients with preserved LVEF, treated at Wujin Hospital Affiliated with Jiangsu University from January 2021 to September 2023, were included. Patients were categorized into low (25), medium (18), and high (19) disease activity groups based on the 28 joint disease activity score (DAS28). A control group of 29 healthy individuals was also established. LV-PSL technology assessed left ventricular global longitudinal strain (GLS) and MW parameters: global constructive work (GCW), global wasted work (GWW), global work index (GWI), and global work efficiency (GWE). Correlations between MW parameters, GLS, LVEF, and DAS28 scores were analyzed. 2021 1 20239 62 LVEF RA 。 28 （DAS28） （25） 、 （18） （19） 。 29 。LV-PSL （GLS） MW ： （GCW）、 （GWW）、 （GWI） （GWE）。 MW 、 GLS 、 LVEF DAS28 。 RESULTS: There were no significant differences in general data between study and control groups (p > 0.05). However, laboratory indicators (RF, CRP, ESR) showed significant differences (p < 0.05). GWI, GCW, GWE, and GLS were significantly lower in the high disease activity group compared to controls (p < 0.05). GWI, GCW, and GWE were positively correlated with LVEF and absolute GLS, while GWW correlated negatively with LVEF (p < 0.05). （p > 0.05）。， （RF、CRP、ESR） （p < 0.05）。， GWI、GCW、GWE GLS （p < 0.05）。GWI、GCW GWE LVEF GLS ， GWW LVEF （p < 0.05）。 （p > 0.05）。， （RF、CRP、ESR） （p < 0.05）。， GWI、GCW、GWE GLS （p < 0.05）。GWI、GCW GWE LVEF GLS ， GWW LVEF （p < 0.05）。 CONCLUSION: RA disease activity is closely associated with impaired myocardial work. LV-PSL technology effectively monitors myocardial function abnormalities in RA patients, providing valuable insights for clinical management. Key Points • Myocardial work is significantly impaired in RA patients with high disease activity. • Left ventricular pressure-strain loop (LV-PSL) technology effectively assesses cardiac function in this patient population. • Increased disease activity correlates with reduced myocardial work parameters.

Effects of obstructive sleep apnea on nocturnal changes in blood pressure - a retrospective study

To explore the effects of obstructive sleep apnea (OSA) on nocturnal changes in blood pressure (BP), we enrolled 2037 participants who underwent polysomnography (PSG) between 2019 and 2020 and examined BP changes before and after sleep. BP was measured in the evening and the following morning using an electronic wrist sphygmomanometer in the supine position. The severity of OSA was determined by PSG and graded based on the apnea/hypopnea index (AHI). Participants with OSA (AHI ≥ 5 events/h) had significantly higher morning systolic BP (SBP) and diastolic BP (DBP) compared to their evening measurements. BP values, whether measured in the evening or the morning, as well as the nocturnal changes (differences between morning and evening values), showed significant correlations with the AHI for both SBP and DBP, even after adjusting for confounders such as age, sex, body mass index, and the presence of comorbidities, including hypertension, heart failure, coronary artery disease, diabetes, renal disorder, and cerebrovascular attack. After standardization, the extent of nocturnal changes in DBP was greater than SBP, especially among participants with severe OSA. In a logistic regression model with serial multivariate adjustments, OSA was found to be independently associated with morning hypertension, particularly in individuals with moderate to severe OSA.

Factors influencing self-report adherence to treatment in a sample of patients with hypertension in the west Pomeranian Voivodeship of Poland

Background/objectives

One of the major challenges in managing hypertension is non-adherence to treatment recommendations. This issue poses a significant barrier to effectively controlling blood pressure and preventing related cardiovascular complications. The main objective of this study was to demonstrate the level of adherence to therapeutic recommendations by hypertensive patients, and to determine how socio-demographic and medical variables affect adherence.

Methods

The study was conducted among 205 patients with diagnosed hypertension hospitalized in the West Pomeranian Voivodeship. The study used a diagnostic survey method, a survey technique, and a self-administered questionnaire and the Adherence to Refills and Medication Scale.

Results

The overall score for the ARMS questionnaire was 24.32, which is 2.03 points per question and indicates that adherence to therapeutic recommendations among the hypertensive patients surveyed was at a good level. Based on the collected data, it was shown that the older the age, the worse the adherence was. In addition, urban residents adhered to therapeutic recommendations less frequently than other respondents.

Conclusion

Patients with diabetes were more likely to be non-compliant than patients without diabetes. And respondents with diagnosed CHF were more likely to adhere to recommendations than other respondents. Age, occupational activity and place of residence influenced adherence to treatment recommendations among hypertensive patients surveyed.

Intensive Blood Pressure Strategy on Cardiovascular Diseases in Patients With Metabolic Syndrome: Post Hoc Analysis of a Clinical Trial

BACKGROUND

Blood pressure (BP) management in patients with metabolic syndrome is complex, and optimal targets remain debated. The CRHCP (China Rural Hypertension Control Project) trial demonstrated that intensive BP control reduces cardiovascular events. This secondary analysis assessed its efficacy in patients with hypertension and metabolic syndrome.

METHODS AND RESULTS

This a post hoc analysis of a cluster randomized trial (NCT03527719) across 3 Chinese provinces; 18 076 hypertensive patients with metabolic syndrome were followed up for 3 years. Intervention groups received multifaceted BP management by nonphysician health care professionals aiming for <130/80 mm Hg BP under physician supervision. The primary outcome of major adverse cardiovascular events included stroke, myocardial infarction, heart failure, and death from cardiovascular causes, during a 3-year follow-up. A total of 18 076 participants (median [range] age, 63 [54-72] years; 13 056 [72.2%] women) were enrolled in 2 clusters and were adjudicated for the primary outcome (control, 9337; intervention, 8739). At the end of the 3-year follow-up, the mean systolic/diastolic BP was 126.3/73.0 mm Hg in the intervention group versus 147.3/82.0 mm Hg in the usual care group. Compared with the usual care group, the intervention group had a lower rate of major adverse cardiovascular events (1.58% versus 2.42% per year; hazard ratio [HR], 0.65 [95% CI, 0.57-0.74]; P<0.001), as well as stroke (HR, 0.68 [95% CI, 0.55-0.83]; P=0.015), myocardial infarction (HR, 0.70 [95% CI, 0.51-0.97]; P=0.034), death from cardiovascular causes (HR, 0.67 [95% CI, 0.47-0.96]; P=0.029), and death from all causes (HR, 0.82 [95% CI, 0.71-0.94]; P=0.005).

CONCLUSIONS

Intensive BP control (<130/80 mm Hg) by trained nonphysician community health care professionals effectively reduces cardiovascular events in patients with hypertension and metabolic syndrome.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03527719.

A Randomized Controlled Trial on the Efficacy and Safety of a Calcium-Channel Blocker and an Angiotensin-Converting Enzyme Inhibitor in Chinese and European Patients with Hypertension

BACKGROUND

In a post hoc analysis of a multinational, randomized trial, we investigated whether the efficacy and safety of nifedipine-gastrointestinal therapeutic system (GITS) and ramipril differed between Chinese and European patients with hypertension.

METHODS

Previously treated (after 2-week washout) and untreated patients with clinic blood pressure (BP) ≥ 140/90 mmHg (systolic/diastolic), daytime ambulatory BP ≥ 135/85 mmHg and standard deviation of home systolic BP > 7 mmHg, and/or daytime BP > 12 mmHg were randomly assigned to treatment based on nifedipine-GITS 30 mg or ramipril 10 mg for 12 months. Clinic, ambulatory and home BP were measured at baseline, 10 weeks and 12 months after randomization.

RESULTS

A total of 67 Chinese and 101 European patients were analyzed and they differed in age (50.9 vs. 54.6 years, respectively), body mass index (24.5 vs. 27.0 kg/m2), clinic diastolic BP (87.9 vs. 92.5 mmHg), heart rate (75.0 vs. 70.8 beats/minute), and nighttime diastolic BP (79.3 vs. 75.9 mmHg) (all P < 0.05). However, within each ethnicity, patients were comparable for clinical characteristics between the nifedipine-GITS and ramipril groups (P > 0.05). In both the Chinese and European patients, BP was similarly reduced with nifedipine-GITS and ramipril, except that daytime systolic/diastolic BP reductions were 7.4/4.1 mmHg greater in the ramipril than nifedipine-GITS group in Chinese (P = 0.02). The safety profile differed between the Chinese and European patients (P for drug*ethnicity interaction ≤ 0.05) for all adverse events (lower incidence on nifedipine-GITS in Chinese), ankle edema (higher on nifedipine-GITS in Europeans), and dry cough (higher on ramipril in Chinese).

CONCLUSION

In the Chinese and European patients with hypertension, nifedipine-GITS and ramipril had similar BP lowering efficacy, but different safety profile and tolerability.

CLINICAL TRIALS REGISTRATION

Identifier at clinicaltrials.gov NCT02499822 (Registration date: 16 July 2015).

Bioequivalence Study of Single-Pill Capsule Formulation of Amlodipine Plus Benazepril in Healthy Chinese Subjects Under Fasting and Fed Conditions

Background

The aim of the study was to evaluate the pharmacokinetic (PK) properties and safety profiles of test and reference amlodipine/benazepril capsules under both fasting and fed states, determine the bioequivalence between the two formulations, and provide sufficient evidence for new drug application.

Subjects and Methods

The bioequivalence study was conducted utilizing a randomized, open-label design, involving two formulations administered in a single-dose format. Healthy Chinese participants who met the eligibility criteria were administered a single dose of the test or reference amlodipine/benazepril capsule. Blood samples were taken serially for up to 168 hours post-administration during each period, and the plasma levels of amlodipine, benazepril, and benazeprilat were measured using high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method. For bioequivalence evaluation, geometric mean ratios comparing the pharmacokinetic parameters of the test drug with those of the reference drug were calculated along with their corresponding 90% confidence intervals. Safety assessments were conducted throughout the duration of the study.

Results

The PK parameters of the test formulation were found to be comparable to those of the reference formulation under both fasting and fed conditions. The 90% confidence intervals (CIs) for the geometric mean ratios comparing the test and reference formulations for the peak concentration (Cmax), the area under the curve from time zero to the last measurable concentration (AUC0-t), and the area under the curve from time zero to observed infinity (AUC0-∞) of amlodipine, benazepril, and benazeprilat fell within the range of 80.00% to 125.00% in both groups. Both formulations were well tolerated by participants, with no serious adverse events reported throughout the trial.

Conclusion

The pharmacokinetic bioequivalence between the test and reference formulation in healthy individuals was confirmed under both fasting and fed states, meeting regulatory standards set for the study. Both drug formulations demonstrated safety and tolerability.

Mean arterial pressure differences between cuff oscillometric and invasive blood pressure

Differences between automated cuff oscillometric blood pressure (BP) and invasive measurements are well described, but the causes are not fully understood. Automated BP devices record cuff oscillometric mean arterial pressure (MAP) as a key measurement step that is presumed to be accurate, but if not, could create error in cuff systolic (SBP) and diastolic BP (DBP) estimations. This has never been determined and was the aim of the study. Data from five studies with similar protocols were analysed (N = 262 patients undergoing coronary angiography, 61 ± 11 years, 65% male). Cuff oscillometric MAP was measured using five different models of automated cuff BP devices simultaneous to invasively measured MAP (fluid-filled or solid-state catheters). Cuff SBP and DBP were estimated by device-specific algorithms. Differences (∆) were calculated as cuff-invasive aortic BP. There were significant associations between ∆MAP and ∆SBP in four out of five devices (unstandardised β range = 0.42-1.04). The ∆MAP explained 6-52% of the variance in ∆SBP. In the same four devices, there were significant associations between ∆MAP and ∆DBP (unstandardised β range = 0.57-0.97) and ∆MAP explained 35-52% of the variance in ∆DBP. In conclusion, there are differences between cuff oscillometric MAP and invasive MAP which are associated with ∆SBP and ∆DBP. Further research is required to improve cuff oscillometric BP and greater transparency needed to understand algorithms used in these devices.

Association between low-dose ionizing radiation and hypertension: a cohort study in China

OBJECTIVE

The association between high-dose ionizing radiation and the incidence of hypertension is well-established, whereas the impact of low-dose ionizing radiation (<20 mSv) on hypertension remains uncertain. The aim of this study is to assess the risk of hypertension among petroleum workers workers following long-term exposure to low-dose ionizing radiation (<20 mSv).

METHODS

The study began in July 2013 and was followed up to December 2019. The subjects were petroleum and petrochemical workers in Karamay, Xinjiang (n = 2658). The radiation type is ionizing radiation (X-rays, γ-rays), with a dose range of 0-110.84 mSv. This study identifies hypertension cases based on the "Chinese Guidelines for the Prevention and Treatment of Hypertension". logistic regression is the primary statistical methods employed in this study.

RESULTS

Compared with the unexposed group, long-term low-dose ionizing radiation exposure is a risk factor for the incidence of hypertension (RR = 2.09, 95% CI = 1.40-3.06). middle (5.17-20.00 mSv) (RR = 2.70, 95% CI = 1.39-4.99), cutoff (20.00-48.33 mSv) (RR = 3.02, 95% CI = 1.38-6.13) and high cumulative exposure dose (48.33-110.84 mSv) (RR = 3.05, 95% CI = 1.46-5.96) are all associated with the incidence of hypertension, and the risk of hypertension increases with the increase of exposure dose. Low (>0-5.17 mSv), middle (5.17-20.00 mSv), cutoff (20.00-48.33 mSv)and high cumulative exposure dose (48.33-110.84 mSv) systolic and diastolic blood pressure increase with the increase of cumulative exposure dose (P < 0.05).

CONCLUSIONS

This study found that low-dose ionizing radiation (<20 mSv) is associated with the incidence of hypertension among petroleum workers. The cumulative exposure dose is related to the risk of hypertension in petroleum workers, as well as to their systolic and diastolic blood pressure.

Improving Therapeutic Adherence and Reducing Therapeutic Inertia in the Management of People with Cardiometabolic Diseases: A Call-to-Action from the Middle East

Hypertension, dyslipidemia, and type 2 diabetes are highly prevalent and poorly controlled cardiometabolic diseases in the Middle East. Therapeutic non-adherence and therapeutic inertia are major contributors to this suboptimal disease control. Regardless of the cardiometabolic disease, evidence-based solutions may be used to improve therapeutic non-adherence and overcome inertia, and thereby help to alleviate the heavy burden of cardiovascular disease in the Middle East. Such solutions include the routine and early use of single-pill combinations, educational initiatives for patients, and multidisciplinary team-based care. This article highlights these and other potential solutions for therapeutic non-adherence and inertia, as discussed at the 2024 Evidence in the Cardiometabolic Environment (EVIDENT) Summit. There is now a 'call-to-action' from healthcare providers and other stakeholder groups to ensure that the solutions discussed at this meeting are implemented within health systems in the Middle East to significantly improve cardiovascular outcomes.Infographic available for this article.

Blood pressure measurement technique in clinical practice in the NHS Greater Glasgow and Clyde

Blood pressure (BP) measurement is a common procedure conducted in various disciplines and is widely available on clinical reports. The diagnosis and management of hypertension require reliable measurement of BP in outpatient clinics. Published studies suggest the standardised method for BP measurement is difficult to apply in routine clinical practice. This study aimed to assess the current practice of BP measurement in outpatient clinics in relevant secondary care clinical specialties across the 15 separate hospital sites of the NHS Greater Glasgow and Clyde region (population 1.2 million) compared to the recommended standardised method. An online questionnaire was developed and disseminated to the supervising clinician of each of 268 regular outpatient clinics. The questionnaire focused on the standardised BP method (patient preparation, environment, and BP measurement technique). The questionnaire was returned for 110 clinics. 73 (66.4%) of the participating clinics measure BP routinely and these formed the basis for further analysis. 3 clinics (4.1%) apply all components of the standardised BP method. 5 (6.9%) clinics deliver advice to patients prior to clinic attendance on how to prepare for BP measurement. 61 (83.6%) of participating clinics have a dedicated quiet environment for BP measurement. 50 (68.5%) clinics always place the cuff on bare upper arm and 63.0% use a cuff size appropriate to upper arm circumference. In a wide range of secondary care out-patient clinic settings, we found that BP measurement rarely adheres to the recommended standards. This has important implications for the quality of treatment decisions that are based on BP measurement.

The role of single-pill ACE inhibitor/ccb combination for hypertension: an Algerian view via the nominal group technique

Around one-third of adults in Algeria have hypertension, but > 40% are unaware they have the disease, and of those receiving treatment, only ~ 20-30% have adequate blood pressure (BP) control. Recommended starting treatment is an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker plus a calcium channel blocker (CCB) or diuretic. A single-pill combination of perindopril/amlodipine (ACEi/CCB) recently became available in Algeria. Twelve Algerian hypertension experts reviewed the clinical evidence regarding this therapeutic combination to determine its potential role for hypertension management in Algeria. The evidence indicated that this combination reduces cardiovascular outcomes and visit-to-visit BP variability, effectively controls 24-hour BP, and is well tolerated. In conclusion, the perindopril/amlodipine SPC provides a valuable new treatment option for hypertension in Algeria.

ASSOCIATION BETWEEN OBESITY AND ALTERATIONS IN PHOTORECEPTOR-RETINAL PIGMENT EPITHELIUM-CHORIOCAPILLARIS COMPLEX IN HEALTHY EYES

PURPOSE

To investigate the effect of obesity on alterations in the photoreceptor-retinal pigment epithelium (RPE)-choriocapillaris complex.

METHODS

Two hundred and twenty participants with varying body mass index were enrolled and categorized into three groups: normal weight, overweight, and obese. Retinal and choroidal images were obtained using swept-source optical coherence tomography. Automatic segmentation was used for image analysis, evaluating retina thickness parameters such as retinal nerve fiber layer, ganglion cell layer and inner plexiform layer, inner nuclear layer, outer plexiform layer, outer nuclear layer, myoid and ellipsoid zone, outer segment of photoreceptors, RPE, and choroidal parameters including choroidal thickness, luminal area, stromal area, total choroidal area, choroidal vascular index, and choriocapillaris flow void percentage. Differences in photoreceptor-RPE-choriocapillaris complex among the groups and their correlation with body mass index were explored.

RESULTS

Compared with the control subjects, participants with obesity exhibited thinner myoid and ellipsoid zone and outer segment of photoreceptors, increased choriocapillaris flow void percentage, and thicker RPE. Correlation analysis revealed a negative correlation between body mass index and myoid and ellipsoid zone (r = -0.17, P = 0.01) and outer segment of photoreceptors (r = -0.16, P = 0.02), whereas a positive correlation was observed with RPE (r = 0.15, P = 0.00).

CONCLUSION

Individuals with obesity may present with a thinner myoid and ellipsoid zone and outer segment of photoreceptors, thicker RPE, and reduced choriocapillaris perfusion, suggesting potential damage to the photoreceptor-RPE-choriocapillaris complex. These alterations in the photoreceptor-RPE-choriocapillaris complex alterations could serve as potential biomarkers for monitoring early pathologic and physiologic changes associated with obesity.

Risk factors for chronic hypertension 5 years after a pregnancy complicated by preeclampsia: a systematic review and meta-analysis

Approximately 30% of women with a history of preeclampsia develop chronic hypertension within 10 years of pregnancy. This systematic review summarizes risk factors before, during, and immediately after pregnancy for the development of chronic hypertension 5 years after preeclampsia. Databases were searched with terms 'preeclampsia' and 'postpartum hypertension' or 'cardiovascular disease' up to 30th October 2023. Observational studies reporting chronic hypertension more than 5 years after preeclampsia were included. Quality was assessed using the Newcastle-Ottawa scale. Wherever possible, a meta-analysis was conducted. Twenty-one cohort and five case-control studies, with a median quality score of 8/10, were included, involving 197 793 patients and reporting 32 risk factors. Preeclampsia in a subsequent pregnancy is associated with chronic hypertension [risk ratio (RR) 2.26, 95% confidence interval (CI) 1.59-3.22, n = 45 626]. Other significant risk factors include early-onset of preeclampsia (<34 weeks gestation), maternal BMI, blood pressure, diabetes, and family history of hypertension.

Glycemic Targets and Prevention of Complications

CONTEXT

Complications of diabetes mellitus have significant impacts on morbidity, mortality, quality of life, and health costs for individuals. Setting and achieving glycemic targets to prevent these complications is a top priority when managing diabetes. However, patients often already have complications when diagnosed with diabetes mellitus. Therefore, methods to prevent disease progression become a crucial component of diabetes management. The purpose of this article is to review glycemic targets and methods of screening and managing diabetes-related complications.

EVIDENCE ACQUISITION

A PubMed review of the literature pertaining to diabetes mellitus, glycemic targets, microvascular complications, and macrovascular complications was conducted. We reviewed articles published between 1993 and 2024. Guidelines published by nationally recognized organizations in the fields of diabetes, nephrology, and cardiology were referenced. Public health statistics obtained by the Center for Disease Control and Prevention and the National Kidney Foundation were used.

EVIDENCE SYNTHESIS

Achieving glycemic targets and screening for diabetes-related complications at appropriate intervals remains the key factor for early detection and intervention. An algorithmic approach to glycemic management based on individual risk factors is beneficial in choosing pharmacotherapy.

CONCLUSION

The consequences of diabetes-related complications can be detrimental. However, achieving and maintaining glycemic targets combined with diligent screening, reduction of risk factors, and prompt treatment can halt disease progression.

Development of a curriculum to educate religious leaders about blood pressure using community-based participatory research and educational theory in Mwanza, Tanzania

Hypertension is a leading cause of premature mortality in Tanzania, but low trust and awareness of biomedical healthcare and prioritization of spiritual over physical health hinders uptake of care. Religious leaders are highly respected community members and are eager to collaborate with health professionals. Few community health worker training programs utilize evidence-based pedagogical recommendations in combination with theology specific to their students' backgrounds. Our team of health research professionals and religious leaders developed a curriculum to teach local religious leaders to address and screen their communities for hypertension.We use a Community Based Participatory Research framework and evidence-based educational strategies (Kern's framework for medical education, Bloom's learning domains, and Knowles adult learning principles) to build a curriculum optimized to partner with religious leaders. Previously assessed attitudes toward and knowledge of hypertension in the community determined objectives and content, and religious leaders on the team determined appropriate religious aspects to incorporate. Through an evidence-based process, we hope to maximize efficacy of the intervention.Recognizing religious leaders as unique learners, we utilize well-tested educational theory and strategies to create a comprehensive curriculum prioritizing student input. The curriculum aligns with adult learning theories, is culturally tailored to meet the needs of the communities involved and equips religious leaders to promote blood pressure management through screening and lifestyle interventions. The curriculum addresses healthcare through a religious lens, fostering trust between healthcare professionals, patients, and religious leaders through interdisciplinary collaboration.

Sex-specific Associations of Aldosterone and Renin With Body Composition: A Population-based Cohort Study

CONTEXT

Renin-angiotensin-aldosterone system (RAAS) activation is closely linked to obesity; however, the sex-specific associations between RAAS activity and body composition among individuals without obesity are not well understood.

OBJECTIVE

To investigate the associations of aldosterone and renin with body composition according to sex in the general population.

DESIGN

Population-based cohort study.

SETTING

Québec (Canada).

PARTICIPANTS

Adults aged 40 to 69 years enrolled in CARTaGENE between 2009 and 2010 (N = 3687).

EXPOSURES

Plasma aldosterone and renin concentrations.

MAIN OUTCOME MEASURES

Body composition assessed via anthropometrics (waist circumference and waist-to-hip ratio), bioelectrical impedance (lean body mass, fat mass, and muscle mass), and cardiac magnetic resonance imaging (epicardial and pericardial adipose tissue volumes).

RESULTS

The mean (SD) age and body mass index were 55 (8) years and 27.3 (4.8) kg/m2, respectively. Among males, higher aldosterone and renin were associated with increased waist circumference, increased waist-to-hip ratio, increased fat mass, decreased lean body mass, and decreased muscle mass (P < .05). Aldosterone (P = .02), but not renin (P = .43), was associated with increased ectopic cardiac adiposity in males. In contrast, higher renin (P < .05), but not aldosterone (P ≥ .05), was associated with increased waist circumference, increased waist-to-hip ratio, and increased cardiac adiposity in females. Among females, higher renin and aldosterone were associated with increased fat mass (P < .05) but were not associated with lean body mass or muscle mass (P ≥ .05). All aforementioned associations were independent of body weight.

CONCLUSION

Independent of body weight, increased RAAS activity is associated with unfavorable differences in body composition; however, the strength and pattern of association varies by sex.

Associations of Systemic Immune-Inflammation Index With Mortality Risk Among Adults in Diabetic Kidney Disease, NHANES 1999 to 2018

OBJECTIVES

Immune-inflammation plays a crucial role in the pathogenesis of diabetic kidney disease (DKD), but an exact assessment of indicators remains undefined. In this study we address the link between systemic immune-inflammation index (SII) and mortality risk in DKD, and we explore the effect of sex disparities.

METHODS

Data from patients with DKD from the National Health and Nutritional Examination Surveys (NHANES, 1999 to 2018) were studied and their causes of death were identified from NHANES-related files. A weighted Cox model was used to evaluate hazard ratios for all-cause, cardiovascular, and cardiocerebrovascular mortality, and these associations were visualized by smoothing curves.

RESULTS

The average SII was 634.20 (103/μL). There were 1,283 deaths recorded during 273,422 person months (396 were cardiovascular related and 461 were cardiocerebrovascular related). Higher SIIs in the fifth quintile were significantly associated with increased mortality (p<0.01). SII trends showed an increased risk of all-cause mortality of >697.0 (103/μL), cardiovascular risk of >717.8 (103/μL), and cardiocerebrovascular risk of >650.0 (103/μL). In men, mortality increased when SII reached 500 to 660 (103/μL) and 700 to 760 (103/μL) for women.

CONCLUSIONS

There was a significant association between higher SII and increased risk of all-cause, cardiovascular, and cardiocerebrovascular mortality in DKD patients. In addition, although men had lower SII, their mortality was higher than that of women.

Interactions Between BMP2/BMP4 Gene Polymorphisms and Fluoride Exposure on Essential Hypertension: A Cross-Sectional Study in China

(1) Objective: To evaluate the relationship between fluoride exposure, interactions of BMP2/BMP4 gene polymorphisms, and fluoride exposure on essential hypertension. (2) Methods: A cross-sectional study was conducted among 725 participants in a high-fluoride region of Shanxi Province, China. Urinary fluoride concentrations were measured as indicators of fluoride exposure. Hypertension was diagnosed based on standard guidelines. BMP2 (rs1005464) and BMP4 (rs17563) polymorphisms were genotyped. Logistic regression and interaction models were performed to evaluate associations and interactions between fluoride exposure, gene polymorphisms, and hypertension. (3) Results: Higher urinary fluoride concentrations were significantly associated with an increased risk of hypertension, exhibiting a dose-dependent relationship. The rs1005464 (G > A) polymorphism of BMP2 was identified as a protective factor against hypertension in individuals with the AG + AA genotype. Significant interactions were observed between the BMP2 rs1005464 and BMP4 rs17563 polymorphisms, influencing hypertension risk. Additionally, both multiplicative and additive interactions between high fluoride exposure and the BMP4 rs17563 polymorphism were identified, highlighting the combined impact of environmental and genetic factors on hypertension. (4) Conclusions: Fluoride exposure is positively associated with hypertension. BMP2 gene polymorphisms affect the risk of hypertension, and BMP4 gene polymorphisms may modify the impact of fluoride on hypertension.

Anxiety disorder, depression and coronary artery disease: associations and modification by genetic susceptibility

BACKGROUND

Associations of anxiety disorder and depression with coronary artery disease (CAD) are heterogeneous between populations. This study investigated how genetic susceptibility to CAD alters these associations with incident CAD, comparing and combining anxiety disorder and depression.

METHODS

This is a prospective cohort study using UK Biobank. Diagnoses of anxiety disorder and depression were ascertained through linked hospital admission data. Incident CAD was ascertained through hospital admission and death certificate data after baseline. CAD polygenic risk score (PRSCAD) was obtained from CARDIoGRAMplus4 and categorised into low, intermediate, and high. Cox proportional hazard models were used to examine associations between anxiety disorder and depression and CAD.

RESULTS

Both anxiety disorder (HR 2.31, 95% CI 1.92-2.78) and depression (HR 2.15, 95% CI 1.90-2.24) were associated with CAD after adjusting for sociodemographic confounders. There was an addictive interaction between depression and PRSCAD (RERI 0.97, 95% CI 0.12-1.81) such that the association between depression and CAD was strongest among those with a high PRSCAD whilst there was no such evidence for anxiety disorder. Anxiety disorder only (HR 1.68, 95% 1.16-2.44), depression only (HR 2.13, 95% CI 1.72-2.64), and concomitant anxiety disorder and depression (HR 3.85, 95% CI 2.48-5.98) were associated with CAD even among people with a low PRSCAD. Adjusting for potential mediators attenuated all these associations across PRS categories.

CONCLUSIONS

CAD genetic susceptibility might partly contribute to the clustering of depression and CAD but does not provide a full explanation, nor does it explain the association between anxiety disorder and CAD. Therefore, other mechanisms should be explored.

Racial and gender inequities in the control of arterial hypertension in ELSA-Brasil: An intersectional approach

This study investigated the association of the intersectional categories of gender-race/color with inadequate blood pressure (BP) control in Brazilian adults using antihypertensive drugs to treat hypertension. This is a cross-sectional analysis conducted with 4448 participants living with hypertension from visit 2 (2012-2014) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) undergoing pharmacological treatment. The association of the intersectional categories - White woman, Brown woman, Black woman, White man, Brown man, Black man - with inadequate BP control (systolic BP levels ≥140 mmHg and/or diastolic BP levels ≥90mmH) was estimated by the prevalence ratio (PR) and 95% confidence interval (95% CI) obtained by generalized linear models with Poisson distribution, adjusted covariates. The age-standardized prevalence of inadequate BP control ranged from 18.9% (White women) to 35.6% (Black men). After adjusting for sociodemographic characteristics, health-related behavior, health conditions, and the class number of antihypertensive medications, compared to White women, Black men (PR: 1.49 95% CI: 1.26-1.75), Brown men (PR: 1.42 95% CI: 1.18-1.72), Black women (PR: 1.36 95% CI: 1.12-1.65), and White men (PR: 1.32 95% CI: 1.09-1.60) showed poorer BP control. Results corroborate a higher prevalence of inadequate BP control in Black and Brown men. Furthermore, this intersectional approach evidenced that the prevalence of inadequate BP control in Black women is higher than that in White men, when compared to White women. Findings highlight that, for the development of more equitable BP control strategies, one must consider the specificities of socially marginalized intersectional groups, especially Black men and women.

Trends in antihypertensive use among privately insured hypertensive clients in Ghana

The objective of the study was to describe the patterns of antihypertensive medicines (AHM) in a selected national population in Ghana. The claims data for all privately insured patients in Ghana over three years to 2018 were analysed. The classes of medicines used, the dose by time, gender and age, and generic status were examined. In addition, the use in Defined Daily Dose (DDD) per 1000 population per day was estimated. Classes of AHM prescribed were CCB, ARB, ACEI, diuretics, and BB. Amlodipine, nifedipine, losartan, lisinopril, and bendroflumethiazide accounted for 74% of all use. The most widely used single CCB was amlodipine 3.92 DDD/1,000 population/day in 2016, 3.92 DDD/1,000 population/day in 2017, and 4.92 DDD/1,000 population/day in 2018. In those aged 51-60 years, use of CCB in women (74.0 DDD/1,000 population/day) was almost twice that of men (38.3 DDD/1,000 population/day). The top ten medicines accounted for 93% of all single medicine products in 2018. Most single medicine products was generic (76.5% in 2016; 79.9% in 2017 and 83.1% in 2018) whiles most fixed combination products were branded (73.0% in 2016; 89.7% in 2017 and 91.3% in 2018). The patterns of AHM use are clinically expected although the Ghana Standard Treatment guidelines are not directive about lines of treatment.

Association of the panimmune-inflammatory value (PIV) with all-cause and cardiovascular mortality in maintenance hemodialysis patients: a propensity score matching retrospective study

PURPOSE

The panimmune-inflammatory value (PIV) is a novel inflammatory indicator. However, its role in maintenance hemodialysis (MHD) remains unclear. Our goal was to explore the predictive value of PIV for cardiovascular and all-cause mortality in MHD patients.

METHODS

In this retrospective cohort study, 507 patients receiving MHD between November 2017 and December 2022 were enrolled. The PIV value was calculated as follows: neutrophil count × monocyte count × platelet count/lymphocyte count. Patients were divided into two groups on the basis of the median PIV. Propensity score matching (PSM) was used to adjust for imbalances in baseline information between groups. Kaplan‒Meier curves, Cox regression, the Fine‒Gray competing risk model, and restricted cubic spline (RCS) curves were used to analyze the relationship between PIV and mortality.

RESULTS

By the end of follow-up, 126 deaths had occurred, 91 of which were due to cardiovascular disease. The Kaplan‒Meier curves demonstrated that MHD patients with higher PIV levels had a poorer prognosis for all-cause death (p = 0.019). PIV levels were linked to all-cause death in multivariate Cox proportional risk regression (HR = 1.76; 95% CI 1.14, 2.72; p = 0.011). The Fine‒Gray model revealed a greater cumulative incidence of cardiovascular death in the higher PIV group (p = 0.035). PIV levels were linked to cardiovascular mortality in the Fine‒Gray competing risk model (HR = 2.06; 95% CI 1.25, 3.42; p = 0.005). The RCS revealed a nonlinear relationship between PIV and mortality risk (p < 0.05). Using 63 years of age as the threshold, we observed a multiplicative interaction effect between age and PIV for all-cause mortality (p = 0.006).

CONCLUSION

In MHD patients, PIV is an independent hazard factor for cardiovascular-related mortality and all-cause mortality.

Initial treatment with a single capsule containing half-dose quadruple therapy vs standard-dose dual therapy in hypertensive patients (QUADUAL): a randomized, blinded, crossover trial

BACKGROUND

Guidelines recognized dual combination in initial antihypertensive therapy. Studies found that low-dose quadruple combination were superior to monotherapy. However, whether low-dose quadruple therapy is better than dual combination is unknown.

METHODS

A randomized blinded crossover trial was conducted to compare the efficacy and safety of low-dose quadruple antihypertensives (irbesartan 75 mg + metoprolol 23.75 mg + amlodipine 2.5 mg + indapamide 1.25 mg) with standard-dose dual antihypertensives (irbesartan 150 mg + amlodipine 5 mg), both in a single pill, in the initial treatment of patients with mild to moderate hypertension. Patients were randomly assigned in a 1:1 ratio to two crossover sequences. Each sequence received four-weeks of either half-dose quadruple antihypertensives or standard-dose dual antihypertensives, followed by a two-week washout and crossover for four-weeks. Participants and researchers were blinded. The main outcomes were the reduction of blood pressure and safety outcomes. Analyses were per intention to treat.

RESULTS

A total of 90 eligible participants were randomized between July 13, 2022, and April 20, 2023. The mean age was 43.88 years (SD 10.31), and 25.6% were women. The mean baseline 24-h blood pressure was 145.59/93.84 mm Hg. Compared to the standard-dose dual treatment, the half-dose quadruple treatment resulted in a further reduction in mean 24-h blood pressure by 4.72/4.17 mm Hg (P < 0.001 for both systolic and diastolic blood pressure), mean daytime blood pressure by 5.52/4.73 mm Hg (P < 0.001 for both), mean nighttime blood pressure by 2.37/2.25 mm Hg (P = 0.034 and 0.014, respectively), and mean office blood pressure by 2.91/1.73 mm Hg (P < 0.001 and 0.014, respectively). Apart from significant increases of fasting blood glucose (P = 0.029) and blood uric acid (P < 0.001) in the half-dose quadruple group, no other adverse events or changes in laboratory values differed significantly between the two treatments.

CONCLUSIONS

Initiating treatment with half-dose quadruple combination therapy was more effective in lowering blood pressure than standard-dose dual therapy. The safety of half-dose quadruple therapy was comparable.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05377203.

The influence of fetal sex on maternal blood pressure in pregnancy

Background

Pregnancy with a male fetus carries a higher risk of term pre-eclampsia than pregnancy with a female fetus. Based on evidence that maternal blood pressure (BP) may be raised in pregnancies with Beckwith-Wiedemann syndrome (fetal overgrowth), a possible contributing factor to the association between male sex and term pre-eclampsia is that males grow faster, reaching ~130 g higher birth weight, on average, than females. The association between fetal sex and maternal BP in healthy pregnancies is not known. We hypothesized that male sex would be associated with higher maternal BP in healthy pregnancies, and that this association would be explained by birth weight differences between males and females.

Methods and findings

We tested the association between fetal sex and maternal systolic (SBP) and diastolic blood pressure (DBP), measured at ~28 weeks of gestation, in a meta-analysis of five different cohorts of mother-child pairs (n up to 109,842). Maternal BP was analyzed as both a continuous and dichotomized (high BP: yes or no) outcome. Linear regression models were constructed with and without adjustment for birth weight to assess whether any difference in maternal BP was explained by the difference in birth weight between male and female babies. Lastly, we constructed a fetal genetic score for birth weight using 186 own-birth-weight-associated single-nucleotide polymorphisms (SNPs) to test whether birth-weight-raising-alleles in the fetus were associated with maternal BP in pregnancy (n up to 32,232). Both maternal SBP and DBP were higher in pregnancy when carrying a male fetus compared to a female fetus (mean difference 0.35 mmHg [95%CI: 0.15-0.55] and 0.35 mmHg [95%CI: 0.21-0.49], for SBP and DBP, respectively). An independent effect of fetal sex remained when including birth weight but attenuated slightly (0.22 mmHg [95%CI: 0.02-0.42] and 0.31 mmHg [95%CI: 0.17-0.45], for SBP and DBP respectively). A positive effect estimate was found for odds of experiencing high maternal BP given pregnancy with a male fetus, but confidence intervals were wide (OR 1.05 [95%CI: 0.98-1.12]). No evidence for an association was found between a fetal birth weight genetic score and SBP or DBP when conditioned on maternal genotype.

Conclusions

We found strong evidence to support a small effect of male fetal sex on higher maternal BP in pregnancy and that larger fetal size at birth does not contribute to a substantial part of this association. Our findings do not indicate a difference in maternal BP that would warrant changes to routine monitoring in clinical practice but do suggest that male sex may be a contributing risk factor for BP-related complications.

Association of dietary quality and mortality in the non-alcoholic fatty liver disease and advanced fibrosis populations: NHANES 2005-2018

Background

Nonalcoholic fatty liver disease (NAFLD) has emerged as a significant global health concern, with advanced fibrosis increasing mortality risks. Despite the abundance of dietary guidelines for managing NAFLD, the precise impact of diet quality on mortality among individuals with advanced fibrosis remains elusive. This study aims to explore the influence of five dietary quality indexes on mortality among NAFLD patients and advanced fibrosis patients.

Methods

This study utilized data from the National Health and Nutrition Examination Survey (NHANES) spanning from 2005 to 2018 to assess dietary quality based on the Alternate Mediterranean Diet (aMED), Healthy Eating Index-2020 (HEI-2020), Dietary Approach to Stop Hypertension (DASH), Alternate Healthy Eating Index (AHEI), and Dietary Inflammatory Index (DII). Weighted Cox proportional hazard regression models along with restricted cubic splines and subgroup analyses were employed in this study.

Results

The analysis encompassed 3,634 NAFLD patients. After a median follow-up of 89 months, it was found that higher scores on the aMED (HR 0.814, 95% CI 0.681-0.972), HEI-2020 (HR 0.984, 95% CI 0.972-0.997), DASH (HR 0.930, 95% CI 0.883-0.979), and AHEI (HR 0.980, 95% CI 0.966-0.995) were associated with lower mortality risks, while DII scores (HR 1.280, 95% CI 1.098-1.493) indicated an increased risk of mortality. Additionally, a nonlinear relationship was identified solely between AHEI scores and all-cause mortality in NAFLD patients. Notably, among patients with advanced fibrosis, HEI-2020 as a categorical variable (T3: HR 0.519, 95% CI 0.280-0.964), DASH as a continuous variable (continuous: HR 0.921, 95% CI 0.849-0.999), AHEI (continuous: HR 0.971, 95% CI 0.945-0.997; T2: HR 0.545, 95% CI 0.310-0.960; T3: HR 0.444, 95% CI 0.245-0.804), and DII (continuous: HR 1.311, 95% CI 1.121-1.534; T3: HR 2.772, 95% CI 1.477-5.202) exhibited significant associations with all-cause mortality. Subgroup analyses revealed an interaction between AHEI scores and sex among NAFLD patients, where higher AHEI scores correlated with lower all-cause mortality in females, but no such association was observed in males. For other dietary quality, subgroup analyses indicated that their relationships with mortality were robust.

Conclusion

Our study suggests that a high-quality diet could potentially mitigate mortality risk in both NAFLD and advanced fibrosis patients.

Identification and preliminary validation of biomarkers associated with mitochondrial and programmed cell death in pre-eclampsia

Background

The involvement of mitochondrial and programmed cell death (mtPCD)-related genes in the pathogenesis of pre-eclampsia (PE) remains inadequately characterized.

Methods

This study explores the role of mtPCD genes in PE through bioinformatics and experimental approaches. Differentially expressed mtPCD genes were identified as potential biomarkers from the GSE10588 and GSE98224 datasets and subsequently validated. Hub genes were determined using support vector machine, least absolute shrinkage and selection operator, and Boruta based on consistent expression profiles. Their performance was assessed through nomogram and artificial neural network models. Biomarkers were subjected to localization, functional annotation, regulatory network analysis, and drug prediction. Clinical validation was conducted via real-time quantitative polymerase chain reaction (RT-qPCR), immunofluorescence, and Western blot.

Results

Four genes [solute carrier family 25 member 5 (SLC25A5), acyl-CoA synthetase family member 2 (ACSF2), mitochondrial fission factor (MFF), and phorbol-12-myristate-13-acetate-induced protein 1 (PMAIP1)] were identified as biomarkers distinguishing PE from normal controls. Functional analysis indicated their involvement in various biological pathways. Immune analysis revealed associations between biomarkers and immune cell activity. A regulatory network was informed by biomarker expression and database predictions, in which KCNQ1OT1 modulates ACSF2 expression via hsa-miR-200b-3p. Drug predictions, including clodronic acid, were also proposed. Immunofluorescence, RT-qPCR, and Western blot confirmed reduced expression of SLC25A5, MFF, and PMAIP1 in PE, whereas ACSF2 was significantly upregulated.

Conclusion

These four mtPCD-related biomarkers may play a pivotal role in PE pathogenesis, offering new perspectives on the disease's diagnostic and mechanistic pathways.

The association between body roundness index and new-onset hyperuricemia in Chinese population: the Kailuan cohort study

BACKGROUND

This study aimed to investigate the potential relationship between the newly defined adiposity metric, the Body Roundness Index (BRI), which assesses central obesity, and the development of new-onset hyperuricemia.

METHODS

In the Kailuan cohort study from 2006 to 2019, 91,804 eligible participants were included. A multivariate Cox regression model was used to test the correlation between BRI and hyperuricemia. At the same time, the restricted cubic spline was applied to solve the dose-response relationship between BRI and the risk of hyperuricemia.Then, stratified analysis was carried out using multivariate Cox regression according to age, sex, hs-CRP level, TG level, education level, smoking status and hypertension status.

RESULTS

The results showed that the risk of new-onset hyperuricemia was significantly increased in the highest quartile compared with the lowest quartile. After adjusting for confounders, compared with Q1, the HR (95% CI) for new-onset hyperuricemia was 1.24 (1.18-1.30), 1.32 (1.25-1.40), and 1.40 (1.29-1.52) for Q2, Q3, and Q4, respectively. Restricted cubic spline analysis showed a J-curve relationship between baseline BRI levels and new-onset hyperuricaemia. Age, sex, hs-CRP level, TG level, income level, education level, smoking, and hypertension each had a multiplicative interaction with BRI at baseline.

CONCLUSION

We found that elevated BRI increased the risk of developing new-onset hyperuricaemia. In addition, the association between elevated BRI and the risk of new-onset hyperuricemia showed dependency on age, sex, hs-CRP level, TG level, education level, smoking status and hypertension status.

miR-26a-5p/ADAM17-Mediated Proteolysis of TREM2 Regulates Neuroinflammation in Hypertensive Mice Following Lead Exposure

Hypertension is not merely a vascular disorder but a significant risk factor for neural impairment. Moreover, healthcare for the hypertensive population with environmental or occupational pollutants has become an issue of increasing concern in public health. As a traditional neurotoxic heavy metal, Pb exposure results in neuroinflammation as well as neurodegenerative diseases. The current study aimed to investigate the mechanisms of neuroinflammation in hypertensive mice exposed to Pb. We demonstrated that hypertension exacerbated Pb-induced neuroinflammation in the prefrontal cortex (PFC), hippocampus, and hypothalamus, as evidenced by increased levels of proinflammatory cytokines (IL-6 and TNF-α) and decreased levels of anti-inflammatory cytokines (CD206 and IL-10). Additionally, hypertension enhanced the neuroinflammatory response in microglia, as indicated by similar changes in cytokine expression in an in vitro cell model. Importantly, we found that TREM2, a key regulator of microglial inflammation, was downregulated in hypertensive mice with Pb exposure. This decline in TREM2 expression was associated with increased proteolysis of TREM2 by a disintegrin and metalloproteases 10 (ADAM10) as well as a disintegrin and metalloproteases 17 (ADAM17), in which ADAM17 was verified as the main cleavage enzyme in terms of TREM2 proteolytic cleavage in hypertensive mice following Pb exposure. Furthermore, we identified miR-26a-5p as a potential regulator of ADAM17 expression, suggesting a potential mechanism for the downregulation of TREM2 in this context. Our findings provided new insights into the complex interplay between hypertension, Pb exposure, and neuroinflammation as well as highlight the potential role of TREM2, ADAM17, and miR-26a-5p as therapeutic targets for neuroinflammation in hypertensive populations with Pb exposure.

Diagnostic and therapeutic challenges in implementing hypertension management after kidney transplantation

PURPOSE OF REVIEW

Evidence for blood pressure (BP) measurement and hypertension management in kidney transplant recipients (KTR) remains lacking.

RECENT FINDINGS

Accurate BP measurement technique is a critical component of hypertension management, and 24-h ambulatory BP monitoring remains the gold standard for diagnosis of hypertension in KTR. BP target at different periods posttransplant is uncertain, but likely higher than that in nontransplant patients given factors related to long-standing uremic milieu and kidney transplantation such as vascular calcification altering transplant renal hemodynamic and allograft perfusion and immunosuppression. Dividing BP target into immediate, early, and late posttransplant periods can guide differential diagnoses of hypertension and BP control with a target SBP less than 160 mmHg in general and BP 115-135/65-85 mmHg for adult KTR receiving pediatric kidneys during the immediate posttransplant period, 130/80 mmHg during early and late posttransplant periods. Calcium channel blockers were shown to have favorable graft outcomes. Novel antihypertensive medications for resistant and refractory hypertension and device-based therapies are limited due to KTR's ineligibility for participating in clinical trials.

SUMMARY

In KTR, BP measurement and monitoring practice should follow the standard clinical practice guideline for nontransplant patients by considering posttransplant factors and immunosuppressive state. Novel treatment options required further studies.

2024 Latin American Society of Hypertension guidelines on the management of arterial hypertension and related comorbidities in Latin America

Hypertension is responsible for more than two million deaths due to cardiovascular disease annually in Latin America (LATAM), of which one million occurs before 70 years of age. Hypertension is the main risk factor for cardiovascular morbidity and mortality, affecting between 20 and 40% of LATAM adults. Since the publication of the 2017 LASH hypertension guidelines, reports from different LATAM countries have confirmed the burden of hypertension on cardiovascular disease events and mortality in the region. Many studies in the region have reported and emphasized the dramatically insufficient blood pressure control. The extremely low rates of awareness, treatment, and control of hypertension, particularly in patients with metabolic disorders, is a recognized severe problem in LATAM. Earlier implementation of antihypertensive interventions and management of all cardiovascular risk factors is the recognized best strategy to improve the natural history of cardiovascular disease in LATAM. The 2024 LASH guidelines have been developed by a large group of experts from internal medicine, cardiology, nephrology, endocrinology, general medicine, geriatrics, pharmacology, and epidemiology of different countries of LATAM and Europe. A careful search for novel studies on hypertension and related diseases in LATAM, together with the new evidence that emerged since the 2017 LASH guidelines, support all statements and recommendations. This update aims to provide clear, concise, accessible, and useful recommendations for health professionals to improve awareness, treatment, and control of hypertension and associated cardiovascular risk factors in the region.

Interaction between 24 h Urinary Free Cortisol and Obesity in Hypertension-Mediated Organ Damage in Patients with Untreated Hypertension

Background

Given the close relationship between excessive cortisol secretion and obesity, as well as their intimate associations with cardiometabolic sequelae, this study aimed to evaluate whether elevated cortisol levels and obesity are independently and potentially interactively related to hypertension-mediated organ damage (HMOD) in patients with untreated hypertension.

Methods

A total of 936 untreated hypertensive patients were recruited. Body mass index (BMI), 24-hour urinary free cortisol (24 h UFC), and HMOD indicators, including left ventricular hypertrophy (LVH), carotid intima-media thickness (CIMT), and albuminuria, were assessed. Multivariate logistic regression was conducted to evaluate the associations of HMOD indicators with 24 h UFC and obesity. Generalized linear models were used to test for the interaction effects of obesity in the associations between log 24 h UFC levels and HMOD indicators.

Results

Compared to non-obese patients, those who were obese had a greater left ventricular mass index (LVMI), greater CIMT, a higher level of 24-hour urinary albumin (24 h UALB) and more frequent albuminuria (all p < 0.05). In the obese group, elevated 24 h UFC was significantly associated with LVH (odds ratio (OR) = 2.53; 95% CI: 1.02-6.31, p = 0.044) and albuminuria (OR = 3.13; 95% CI: 1.31-7.43, p = 0.01), after multivariate adjusting. There was a significant interactive effect of obesity on the association between 24 h UFC and LVH and albuminuria (all p for interaction <0.05). A significant correlation was observed between 24 h UFC and LVMI in obese and non-obese patients. Conversely, the correlations of 24 h UFC and log 24 h UALB were found only in obese patients but not in non-obese patients.

Conclusions

Elevated 24 h UFC levels were associated with higher severity of HMOD, including more frequent LVH, albuminuria, and greater CIMT. Additionally, obesity modified the effects of 24 h UFC on both LVH and albuminuria.

Systemic Immune-Inflammatory Index as a Prognostic Biomarker in Patients with Heart Failure: A Comprehensive Analysis

ObjectiveThis study aimed to assess the prognostic significance of the Systemic Immune-Inflammatory Index (SII) in chronic heart failure (CHF) patients and evaluate its potential as a predictive biomarker.MethodsA retrospective analysis was conducted on 2748 CHF patients from the First Affiliated Hospital of Xinjiang Medical University from 2012 to 2022. The primary outcome was all-cause mortality (ACM), with readmission rates as secondary endpoints. An optimal SII cutoff value of 916.68 was determined for predicting ACM.ResultsElevated SII levels were significantly correlated with an increased risk of ACM in CHF patients across all left ventricular ejection fraction (LVEF) categories. The high SII group had a 43.8% increased risk of ACM compared to the low SII group.ConclusionSII is a significant prognostic biomarker in CHF, independent of traditional risk factors, highlighting its importance in risk stratification and clinical decision-making, and necessitating further investigation in prospective studies.

Commentary on the 2021 update of the KDIGO clinical practice guideline for management of blood pressure in chronic kidney disease

The 2021 KDIGO clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provided significant practice-changing recommendations for the care of both adult and paediatric CKD patients not receiving dialysis. The purpose of this review is to contextualise these recommendations and evaluate their applicability to the Australian and New Zealand context. Key updates presented in this guideline relate to measurement techniques, with a strong recommendation for standardised office BP measurement, as opposed to routine office BP measurement. Standardised measurement is more nuanced, compared to routine measurement, in terms of patient preparation, technique, timing, and duration of measurement, which may produce more accurate measurements but may require restructuring of clinical appointments and retraining of staff. The target systolic BP level for non-dialysis, non-transplant adult CKD patients suggested is <120 mmHg. The lifestyle and pharmacological interventions for lowering BP include regular exercise, a low-sodium diet, and renin-angiotensin-system (RAS) inhibitors in patients with comorbid diabetes or albuminuria. This commentary identifies several patient subgroups requiring further investigation and clinical guidance, including diabetic CKD, dialysis and transplant recipients with CKD, and paediatric CKD, and highlights the importance of further exploring the effect of SGLT2 inhibitors on high BP in CKD patients.

Hypertension and orthostatic hypotension in the elderly: a challenging balance

Hypertension and orthostatic hypotension (OH) frequently coexist in the older population, both stemming from impaired blood pressure (BP) regulation. Managing hypertension in patients with OH presents a significant clinical challenge, particularly in frail older adults who are also prone to falls. Hypertension treatment is often suboptimal in this population due to concerns over the potential increased risk of falls associated with treatment. However, current clinical guidelines provide limited guidance on managing this complex issue. This review explores the pathophysiology of hypertension and OH, reviews existing guidelines, and examines the evidence surrounding hypertension management in patients with OH. Additionally, we provide an overview of research focused on frail older adults and offer expert-opinion-based recommendations for the management of hypertension and OH in routine clinical practice.

Assessment of total carotid plaque area progression in patients with chronic kidney disease. Good practices for decision-making

BACKGROUND

Chronic kidney disease (CKD) increases cardiovascular risk, however, traditional cardiovascular risk factors cannot entirely explain it. A real-world investigation examined the concept that renal function decline is linked to carotid total plaque area progression, which strongly confirms cardiovascular risk. We analyzed CKD patients in stages 1-3 to find risk factor relationships before the onset of severe CKD.

METHODS

We monitored 328 patients for 16 ± 5 months. Participants were classified at baseline by estimated glomerular filtration rate (eGFR) stage: G1 (≥ 90), G2 (60-89), and G3 (30-59 ml/min/1.73m2). Ultrasound-guided total plaque area tracked atherosclerosis. Age, sex, blood pressure, lipids, and HbA1c were covariates. Total plaque area and variables were measured on day 1 and at the conclusion of observation. We used a multilevel mixed effects model to assess biological and behavioral factors on total plaque area progression in the general population. For validation, this research was conducted on 73 CKD patients with optimal traditional cardiovascular risk factor management during 15 ± 5 months.

RESULTS

Multiple analyses showed an inverse relationship between eGFR decline and total plaque area progression [β-exponent = 0.99 (95% CI = 0.98-0.99)], regardless of age, lipid profile, blood pressure, smoking, diabetes, or hypertension. The correlation remained significant in the 73-patient sample with optimal traditional cardiovascular risk factor management (β-exponent = 0.99; 95% CI 0.97-0.99). Although traditional cardiovascular risk factor management was excellent, total plaque area increased considerably in G2-G3 patients compared to G1.

CONCLUSIONS

CKD, total plaque area, and eGFR are inversely correlated, independent of traditional cardiovascular risk factors, suggesting that non-traditional mechanisms are responsible for resistant atherosclerosis. The combination of eGFR and total plaque area may be useful in identifying high-risk patients.

Tissue sodium in patients with rheumatoid arthritis: a novel potential driver of hypertension in autoimmunity

Patients with rheumatoid arthritis (RA) have increased hypertension. Tissue sodium may contribute to development and progression of hypertension through immune cell activation. This study aimed to determine if skin sodium content is: 1) higher in RA versus control participants, and 2) associated with blood pressure and disease activity. This cross-sectional study included 32 patients with RA and 33 control participants. Lower leg skin sodium content was measured using magnetic resonance imaging. Ambulatory 24-h blood pressure measurements were obtained, and disease activity was assessed by Disease Activity Score-28 for RA with CRP (DAS28-CRP). Skin sodium content was higher in RA versus control participants (14.22 [12.82, 18.04] vs 12.41 [10.67, 14.55] mmol/L), p = 0.005. Every 1 mmol/l increase in skin sodium was associated with a 1.05 mmHg (95% CI 0.29, 1.82 mmHg, p = 0.009) increase in average 24-h systolic blood pressure in patients with RA, but this relationship was not present in control participants. Skin sodium was not associated with DAS28-CRP or its components. Skin sodium is increased in RA versus control participants and is correlated with 24-h and diurnal systolic blood pressure in patients with RA but not in control participants. Skin sodium content may help explain increased hypertension in patients with RA.

Vascular Endothelium at the Molecular Level: From Fundamental Knowledge Toward Medical Implementation

The concept of multiple physiologic roles played by a single layer of endothelium on the intimal face of blood vessels started gaining recognition in the 1960s [...].

Sleep quality and incident hypertension

INTRODUCTION AND OBJECTIVES

Poor sleep quality poses significant public health challenges worldwide. This study aimed to investigate the association between sleep quality and the risk of hypertension.

METHODS

The study analyzed 284 250 adults from the UK Biobank (UKB) and 6104 participants from the English Longitudinal Study of Ageing (ELSA) without hypertension at baseline. The exposure of interest was sleep quality, which was evaluated based on questionnaires. Participants were divided into 3 groups based on the assessment of sleep quality. Sleep duration was assessed by self-reported sleep hours by each participant. The primary endpoint was new onset hypertension.

RESULTS

In the UKB cohort, participants with poor sleep quality showed a significantly higher risk of hypertension than those with healthy sleep quality (HR, 1.277; 95%CI, 1.21-1.346]. The results from the ELSA cohort effectively validated those from the UKB cohort; participants with poor sleep quality had a notably heightened risk of hypertension (HR, 1.264; 95%CI, 1.02-1.566). Prolonging sleep duration was associated with a decrease in the risk of hypertension in individuals with intermediate or healthy sleep quality. Although several factors were independently associated with a lower risk of hypertension (P<.001), the association between sleep quality and an increased risk of hypertension remained significant regardless of genetic susceptibility to hypertension (P for interaction=.067).

CONCLUSIONS

Considering the genetic predisposition to hypertension, poor sleep quality is associated with an elevated risk of hypertension. In intermediate or healthy levels of sleep quality, prolonging sleep duration is linked to a reduced risk of hypertension.

Effects of high-intensity interval and moderate-intensity continuous training on ambulatory blood pressure and cardiovascular outcomes in older adults with hypertension (HEXA Study): study protocol for a randomised trial

INTRODUCTION

Approximately two-thirds of Brazilian older adults have hypertension. Aerobic training is the first-line non-pharmacological therapy for hypertension. However, the effects of different aerobic training approaches on ambulatory blood pressure in older adults are uncertain. Here, we present the study protocol for the HEXA Study, which aims to investigate the effects of high-intensity interval (HIIT) and moderate-intensity continuous training (MICT) on 24-hour ambulatory blood pressure and cardiovascular outcomes in older adults with hypertension.

METHODS AND ANALYSIS

This is a single-centre, randomised, three-arm, parallel superiority trial with a 1:1:1 ratio. The trial is conducted with blinded outcome assessors and statistical analysts. 66 inactive older adults with hypertension aged 60-80 years without a history of major adverse cardiovascular events will be randomly assigned to one of the following groups: (1) HIIT (3 months; 3× week); (2) MICT (3 months; 3× week); (3) health education programme (control; 3 months; 1× week). Exercise training sessions involve rating of perceived exertion-based outdoor moderate walking, brisk walking and/or jogging. The primary outcome is 24-hour ambulatory blood pressure. Secondary cardiovascular outcomes are resting blood pressure, cardiorespiratory fitness, pulse wave velocity, carotid intima-media thickness, heart rate variability and cardiac function/structure. All outcomes are measured at baseline and after a 3-month period. In addition, feelings of pleasure/displeasure, adherence and safety are reported.

ETHICS AND DISSEMINATION

All procedures were approved by the Research Ethics Committee of the Onofre Lopes University Hospital (protocol, CAAE 07191019.8.0000.5292) and are executed in compliance with the Declaration of Helsinki. Additionally, the procedures adhered to Resolution 466/2012 issued by the Brazilian National Health Council for research involving human subjects.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ID: RBR-4ntszb).

Abdominal fat accumulation increases the risk of high blood pressure: evidence of 47,037 participants from Chinese and US national population surveys

AIMS

This study aims to ascertain whether abdominal fat accumulation evaluated by waist circumference increases the risk of hypertension using the nationwide population.

METHODS

We enrolled 47,037 participants from the China Health and Nutrition Survey (CHNS), China Health and Retirement Longitudinal Study (CHARLS), and National Health, and Nutrition Examination Survey (NHANES). The adjusted logistic regression model was used to examine the relationship between waist circumference and prevalent hypertension. 9445 participants without baseline hypertension from the CHNS and CHARLS were followed up to investigate the association between waist circumference and onset hypertension. The association was evaluated using a Cox regression model and restricted cubic spline. Furthermore, Mendelian randomization was employed to explore causal inferences.

RESULTS

In the baseline survey, waist circumference demonstrated a notable correlation with hypertension, presenting an odds ratio (with 95% confidence intervals) of 1.34 (1.28 ~ 1.40). After a mean follow-up of 3.8 years for participants without baseline hypertension, 2,592 (27.5%) developed hypertension. In the pooled analysis, the Cox regression showed that every 10 cm increase in waist circumference was associated with 20% (95% CI: 13% ~ 27%) elevated risk of new-onset hypertension. Restricted cubic splines indicated a pronounced linear dose-response relationship. A subgroup analysis affirmed the persisting association between waist circumference and hypertension onset even in those with normal BMI. The Mendelian randomization method revealed a significant causative association between waist circumference and hypertension.

CONCLUSION

Elevated waist circumference stands as an independent risk factor for hypertension, even in those with normal BMI. Our results provide evidence supporting the routine measure for waist circumference.

The Mediating Role of Depressive Symptoms and Treatment Burden on Health-Related Quality of Life Among Multimorbid Patients With Hypertension: A Multi-Group Analysis

Multimorbidity negatively affects health-related quality of life (HRQoL), though the underlying mechanism remained unclear. This study aims to investigate the mediating role of depressive symptoms and multimorbidity treatment burden (MTB) in the association between disease burden and HRQoL in multimorbid patients with hypertension and to determine differences in mediating effects between and within age groups (< 60 years vs. 60 and above). Disease burden, depressive symptoms, MTB, and HRQoL were assessed by self-reported questionnaires. We conducted path analysis with all subjects and multi-group path analyses with two age groups. Results from the path analysis with all subjects (n = 498) showed a significant direct effect of disease burden on HRQoL and a significant indirect effect via depressive symptoms and MTB. No significant differences in mediating effects were found between age groups. However, in the older patients, depressive symptoms had a greater indirect effect than MTB. Our results underscore the importance of addressing both depressive symptoms and MTB in interventions tailored to the patient's age.