Highlights of the 2019 Japanese Society of Hypertension Guidelines and perspectives on the management of Asian hypertensive patients

Gender and Sex-Based Differences in Hypertension Risk Factors Among Non-Hispanic Asian Adults in the United States

INTRODUCTION

The prevalence of hypertension (HTN) is rising at an accelerated rate, and it remains the primary factor contributing to cardiovascular illnesses. Sex can serve as an influencing factor, leading to variations in the factors affecting HTN.

OBJECTIVE

This study aimed to investigate gender and sex differences in the prevalence of HTN and explore the associations between HTN and 4 categories of risk factors: demographics, habits or lifestyle, body measurement, and laboratory blood results among non-Hispanic Asians in the United States.

METHODS

This secondary analysis included non-Hispanic Asian adults aged 18 years or older from the 2017 to 2018 National Health and Nutrition Examination Surveys.

RESULTS

Among the 815 participants, 35% of men (140 of 399) and 37% (154 of 416) of women had HTN ( P = .610). The mean age for men is 46.03 ± 16.9 years, whereas the mean age for women is 49.24 ± 16.8 years. After regression analysis, advancing age, increased body mass index, and increased serum uric acid were significant predictors of HTN in both sexes. However, men developed HTN earlier compared with women. Marital status and increased fasting glucose were only significant in men. Compared with their never-married counterparts, men who were currently married or living with a partner had lower odds of having HTN (odds ratio, 0.28; P = .034).

CONCLUSIONS

There was no significant difference in the prevalence of HTN between the sexes. Age, body mass index, and serum uric acid were significant risk factors in both men and women. Meanwhile, marital status and fasting glucose were only significant in men.

Long-term changes in carotid intima-media thickness according to baseline blood pressure level: J-STARS Echo study

BACKGROUND AND AIMS

We aimed to investigate long-term changes in carotid intima-media thickness (IMT) based on baseline blood pressure (BP) levels in non-cardioembolic stroke patients.

METHODS

Patients aged 45-80 years with dyslipidemia who were not on statins before enrollment and had experienced a non-cardioembolic stroke were assigned to either the pravastatin group or the control group in a randomized trial. Patients were classified into three groups according to BP levels: normal BP (N-group: systolic BP [sBP] <140 mmHg and diastolic BP [dBP] <90 mmHg), highly elevated BP (G2 group: sBP ≥160 mmHg or dBP ≥100 mmHg), and mildly elevated BP (G1 group: the remaining patients). Mixed effect models were used to examine differences in slope of mean carotid IMT increases annually over the 5-year observation period among three groups, and for two groups divided based on whether they were above or below certain BP cut-off levels set at every 1 mmHg, ranging between 139 and 161 mmHg for sBP, and 89-101 mmHg for dBP.

RESULTS

Of 792 patients, baseline mean carotid IMT in the G1-group (0.908 ± 0.152 mm) and G2-group (0.905 ± 0.145 mm) was significantly higher than the N-group (0.870 ± 0.153 mm) (P < 0.01, for both respectively). Although there was no significant difference in the increase among three groups (P = 0.091), the increase in patients above sBP 154, 159 and 160 mmHg or dBP 101 mmHg at baseline was higher than others (P < 0.05 for all).

CONCLUSIONS

High baseline BP correlated with a high baseline carotid IMT and its subsequent 5-year increase in non-cardioembolic stroke patients.

CLINICAL TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov.

UNIQUE IDENTIFIER

NCT00361530.

Comparing International Guidelines for the Remission of Hypertension After Bariatric Surgery

BACKGROUND/OBJECTIVES

Obesity remains a global health concern and is associated with increased risk of type 2 diabetes, hypertension, and cardiovascular disease overall. Dissimilar hypertension guidelines are available for clinicians, namely those prepared by the American Heart Association (AHA) and the European Society of Cardiology (ESC), which may lead to distinctive appreciation of health outcomes of patients with obesity after bariatric and metabolic surgery, such as hypertension remission. The main goal of this study was to compare the effects of applying stricter (AHA) versus looser (ESC) blood pressure criteria on hypertension diagnosis pre-bariatric surgery and remission assessment one year post-op.

METHODS

A retrospective analysis of clinical data from patients who underwent surgical treatment for obesity at a single university hospital was performed. To evaluate the hypertension improvement or remission, two different types of blood pressure (BP) categorization were considered (based on AHA and ESC guidelines), in which each patient would fit according to their BP values pre- (m0) and 12 months postoperative (m12).

RESULTS

From a sample of 153 patients submitted for surgical treatment of obesity, more patients were considered with hypertension based on the AHA guideline (130 vs. 102; p < 0.001), while a higher rate of hypertension remission at 12 months after bariatric surgery was observed when following the ESC guideline (58.82 vs. 53.08%). Baseline patients' clinical characteristics based on each hypertension outcome were mostly independent of the guideline used (p > 0.05), where only age and systolic blood pressure were relatively higher in "ESC groups".

CONCLUSIONS

We conclude that only minor differences exist between the two guidelines used. If evaluated based on ESC guidelines, it is expected that less patients are considered with hypertension, and the remission rate may be, at least numerically, higher.

A Prospective Study on Lifestyle Factors, Body Mass Index Changes, and Lipitension Risk in Japanese Young and Middle-Aged Women

Background: This study investigates how lifestyle factors and westernization contribute to obesity and examines the influence of body mass index (BMI) changes and lifestyle factors on "lipitension," a significant risk factor for heart disease and metabolic syndrome. Methods: This prospective study focused on women aged 20-64 without pre-existing hypertension and dyslipidemia who underwent regular medical checkups between April 2016 and March 2022. Anthropometric measurements and blood pressure, along with low-density lipoprotein, high-density lipoprotein, and triglycerides levels, were assessed. Results: Over an average 46.5-month follow-up, 11.5% of initially healthy young and middle-aged women developed lipitension. Categorizing participants based on BMI changes revealed stable (63.8%), decreased (12.5%), and increased (23.8%) groups within this 11.5%. Increased BMI is linked with a heightened hazard risk for lipitension. Women with increased BMI who refrained from snacking (aHR [95% confidence interval (CI)] = 2.750 [1.433-5.279]), avoided late-night eating (aHR [95% CI] = 1.346 [1.032-1.754]), and engaged in alcohol consumption (aHR [95% CI] = 2.037 [1.138-3.646]) showed an elevated risk. Conversely, within the decreased BMI group, behaviors like skipping breakfast (aHR [95% CI] = 0.190 [0.047-0.764]), eating quickly (aHR [95% CI] = 0.457 [0.215-0.972]), and not eating late (aHR [95% CI] = 0.665 [0.467-0.948]) were associated to a reduced lipitension. Subgroup analysis for women with BMI <23 revealed specific behaviors influencing lipitension risk in both BMI-increased and BMI-stable groups. Conclusion: Customized interventions, including for women with BMI <23, enhance heart health, mitigating global lifestyle diseases and obesity.

Nonalcoholic Fatty Liver Disease in Japan Continue to Increase Even after the Launch of Specific Health Checkups

Objective To examine the trends and relationships between nonalcoholic fatty liver disease (NAFLD) and hypertension, type 2 diabetes mellitus (T2DM), and dyslipidemia from fiscal year (FY) 2008, when specific health checkups (SHCs) were initiated in Japan, to FY 2019 and the relationship between NAFLD trends and dietary nutrition. Methods A total of 48,332 participants (25,121 men and 23,211 women) diagnosed with NAFLD who underwent health checkups, including ultrasonography, from FY 2008 to FY 2019 were included. A fatty liver was diagnosed using ultrasonography. The dietary nutrient intake status was based on data from the National Health and Nutrition Survey, Japan. Results Over 12 years, NAFLD prevalence increased from 26.9% to 43.1% in men (p<0.0001) and from 9.9% to 17.9% in women (p<0.0001) in all body mass index (BMI) groups except for obese II (according to the World Health Organization Asia-Pacific criteria) in men and underweight in women and almost all age groups. T2DM prevalence increased in men (from 9.0% to 10.7%, p=0.0234), and obesity and higher waist circumference rates increased in women (from 16.0% to 18.0%, p=0.0059 and from 8.1% to 10%, respectively, p=0.0006). The dietary nutrient intake increased with regard to the total fat, fat/energy ratio, saturated fatty acids, monounsaturated fatty acids, and n6/n3 fatty acid ratio in both men and women, and these nutrient trends were correlated with NAFLD prevalence (all p≤0.0005). Conclusion In Japan, NAFLD increased in both men and women regardless of the BMI and age, even after starting SHCs. An unbalanced fat intake may be one of the major reasons for this increase.

Vascular Ultrasound for In Vivo Assessment of Arterial Pathologies in a Murine Model of Atherosclerosis and Aortic Aneurysm

Vascular diseases like atherosclerosis and abdominal aortic aneurysm (AAA) are common pathologies in the western world, promoting various potentially fatal conditions. Here, we evaluate high-resolution (HR) ultrasound in mouse models of atherosclerosis and AAA as a useful tool for noninvasive monitoring of early vascular changes in vivo. We used Apolipoprotein E-deficient (ApoE-/-) mice as an atherosclerosis model and induced AAA development by the implementation of Angiotensin II-releasing osmotic minipumps. HR ultrasound of the carotid artery or the abdominal aorta was performed to monitor vascular remodeling in vivo. Images were analyzed by speckle tracking algorithms and correlated to histological analyses and subsequent automated collagen quantification. Consistent changes were observed via ultrasound in both models: Global radial strain (GRS) was notably reduced in the AAA model (23.8 ± 2.8% vs. 12.5 ± 2.5%, p = 0.01) and in the atherosclerotic mice (20.6 ± 1.3% vs. 15.8 ± 0.9%, p = 0.02). In mice with AAA, vessel distensibility was significantly reduced, whereas intima-media thickness was increased in atherosclerotic mice. The area and collagen content of the tunica media were increased in diseased arteries of both models as measured by automated image analysis of Picrosirius Red-stained aortic sections. Correlation analysis revealed a strong correlation of multiple parameters, predicting early vascular damage in HR ultrasound and histological examinations. In conclusion, our findings underscore the potential of HR ultrasound in effectively tracing early alterations in arterial wall properties in murine models of atherosclerosis and AAA.

Pancreas transplantation improves the quality of life of Japanese type 1 diabetes patients with diabetic kidney disease

OBJECTIVES

Type 1 diabetes mellitus (T1DM) patients with diabetic kidney disease-induced kidney failure have a significantly impaired quality of life (QOL), resulting in a high level of physical, mental, and social anxiety. In this study, we evaluated the QOL of T1DM patients on the list for pancreas transplantation (PTx) at their registration, and determined whether PTx improved their QOL.

METHODS

There were 58 patients (men/women, 22/36; mean age, 42.8±8.0 years) with T1DM and who were registered on the waiting list for PTx. Quantitative QOL assessment was performed using the Medical Health Survey Short Form (SF-36) version 2. Changes in the QOL before and after PTx were also examined in 24 of these patients.

RESULTS

The mean value of each endpoint and the summary score of the SF-36 physical (PCS), mental (MCS), and role (RCS) components were all below the national normal level at PTx registration. No significant difference in QOL scores was observed in the intergroup comparison of 35 patients on dialysis, 13 patients without dialysis, and ten patients after kidney transplantation. The 24 patients who underwent PTx showed improvement in PCS, MCS, and most SF-36 scores.

CONCLUSION

T1DM patients waiting for PTx had a decreased QOL, regardless of dialysis, and PTx improved their QOL.

Inconsistent Control Status of Office, Home, and Ambulatory Blood Pressure All Taken Using the Same Device: The HI-JAMP Study Baseline Data

BACKGROUND

Inconsistencies between the office and out-of-office blood pressure (BP) values (described as white-coat hypertension or masked hypertension) may be attributable in part to differences in the BP monitoring devices used.

METHODS

We studied consistency in the classification of BP control (well-controlled BP vs. uncontrolled BP) among office, home, and ambulatory BPs by using a validated "all-in-one" BP monitoring device. In the nationwide, general practitioner-based multicenter HI-JAMP study, 2,322 hypertensive patients treated with antihypertensive drugs underwent office BP measurements and 24-hour ambulatory BP monitoring (ABPM), consecutively followed by 5-day home BP monitoring (HBPM), for a total of seven BP measurement days.

RESULTS

Using the thresholds of the JSH2019 and ESC2018 guidelines, the patients with consistent classification of well-controlled status in the office (<140 mmHg) and home systolic BP (SBP) (<135 mmHg) (n = 970) also tended to have well-controlled 24-hour SBP (<130 mmHg) (n = 808, 83.3%). The patients with the consistent classification of uncontrolled status in office and home SBP (n = 579) also tended to have uncontrolled 24-hour SBP (n = 444, 80.9%). Among the patients with inconsistent classifications of office and home BP control (n = 803), 46.1% had inconsistent ABPM-vs.-HBPM out-of-office BP control status. When the 2017 ACC/AHA thresholds were applied as an alternative, the results were essentially the same.

CONCLUSIONS

The combined assessment of the office and home BP is useful in clinical practice. Especially for patients whose office BP classification and home BP classification conflict, the complementary clinical use of both HBPM and ABPM might be recommended.

2021 Taiwan Stroke Society Guidelines of blood pressure control for ischemic stroke prevention

BACKGROUND

Since the publication of the 2015 Taiwan Stroke Society Blood Pressure for Treatment and Prevention of Stroke Guideline (2015 TSS BP Guideline), several new clinical studies have addressed whether a stricter blood pressure (BP) target would be effective for stroke prevention.

METHODS

TSS guideline consensus group provides recommendations on BP targets for stroke prevention based on updated evidences.

RESULTS

The present guideline covers five topics: (1) diagnosis of hypertension; (2) BP control and primary prevention of ischemic stroke; (3) BP control and secondary prevention of ischemic stroke; (4) BP control and secondary prevention of large artery atherosclerosis ischemic stroke; and (5) BP control and secondary prevention of small vessel occlusion ischemic stroke.

CONCLUSION

The BP target for most stroke patients with hypertension is <130/80 mm Hg.

The Association of Dietary Intake, Oral Health, and Blood Pressure in Older Adults: A Cross-Sectional Observational Study

Hypertension is related to impaired mastication that causes malnutrition, declining the general health of older adults. This study assessed the role of dietary intake in the relationship between oral health and blood pressure. Eight hundred ninety-four adults aged ≥65 years who independently lived in rural regions of Japan participated in this study. Hypertension was classified according to the guidelines of the Japanese Society of Hypertension. The oral condition was evaluated by analyzing the remaining teeth, occlusal force, posterior occlusal support, masticatory performance, oral moisture, and oral bacterial level. Dietary intake was assessed using a brief self-administered dietary history questionnaire. Mann-Whitney U, chi-square, Kruskal-Wallis tests, and logistic regression analyses were used to elucidate the factors related to hypertension. Normotensive, hypertensive, and history of hypertension were observed in 30.9%, 23.8%, and 45.3% of the participants, respectively. The factors significantly associated with the hypertension were age, body mass index, posterior occlusal support condition, and sodium-to-potassium ratio related to salt intake and/or vegetable intake. Participants without posterior occlusion significantly had higher risk of hypertension (odds ratio = 1.72). This study suggested that there was an association between oral health and hypertension, while the loss of occlusal support may influence nutritional intake conditions.

STEP to blood pressure management of elderly hypertension: evidence from Asia

With a rapidly aging population, adequate blood pressure (BP) control is critical for hypertension management and prevention of cardiovascular events. Impressive cardiovascular benefits have been observed with intensive BP control (SBP target, <120 mmHg) in the SPRINT (Systolic Blood Pressure Intervention Trial) study, even in patients 75 years of age or older. A most recent meta-analysis including 51 randomized trials with over 350,000 participants from the BPLTTC (The Blood Pressure Lowering Treatment Trialists’ Collaboration) showed that BP lowering is effective in older people for reducing major cardiovascular events. The STEP (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) study—a multicenter, randomized, controlled trial conducted in China, provided important evidence that intensive BP treatment (SBP target, 110 mmHg to <130 mmHg) benefits older hypertensive patients (aged 60–80 years) and reduced the incidence of cardiovascular events than standard treatment (target 130 mmHg to <150 mmHg). Because Asian people have a higher burden of hypertension and stroke than Caucasian people, intensive BP treatment has more advantages in reducing the risk of cardiovascular events including stroke in Asian hypertensive patients than in Caucasian people. Home BP monitoring is helpful to facilitate hypertension management for older patients. It should also be noted that clinical decision-making should be on a patient basis, such as fragility, diabetes, stroke, and other comorbidities, with tailored BP targets. Here we review the important clinical trials of BP control in elderly hypertension, interpretate the main findings of STEP, and also discuss the perspectives of managing hypertension in Asia.

Lifestyle- and comorbidity-related factors for the prescription of proton pump inhibitors after Helicobacter pylori eradication in Japan

Background and Aim

The aim of the present study was to examine the lifestyle‐ and comorbidity‐related determinant factors of the prescription of proton pump inhibitors (PPIs) for patients in whom Helicobacter pylori has been eradicated, and to evaluate the relationship between PPI prescription and the severity of endoscopic esophagitis.

Methods

This retrospective study included patients who underwent H. pylori eradication from May 2012 to September 2016 at Saiseikai Karatsu Hospital. All patients received upper gastrointestinal endoscopy before H. pylori eradication. Patients with open peptic ulcers and/or malignant diseases were excluded, and a final total of 389 patients were evaluated. Medical records were reviewed to determine the prescription of PPIs after H. pylori eradication, lifestyle‐related factors, and comorbidities. Lifestyle‐related factors were confirmed by a questionnaire.

Results

PPIs were administered to 124 of 389 patients (31.9%). The only lifestyle‐related risk factor for the prescription of PPIs after H. pylori eradication was older age (P < 0.01). Hypertension increased the prescription of PPIs (P = 0.034). The prescription of PPIs was not influenced by the presence of grade A esophagitis, whereas the PPI prescription rate was significantly increased in patients with grades B/C/D endoscopic esophagitis (P < 0.01). The grade of chronic gastritis before H. pylori eradication had no effect on the prescription of PPIs.

Conclusion

The lifestyle‐ and comorbidity‐related risk factors for the prescription of PPIs after H. pylori eradication were older age and hypertension, while mild endoscopic esophagitis had no influence on PPI prescription.

Association of Serum High-Density Lipoprotein Cholesterol with High Blood Pressures at Checkup: Results of Kanagawa Investigation of Total Checkup Data from the National Database-9 (KITCHEN-9)

BACKGROUND

although high-density lipoprotein has cardioprotective effects, the association between serum high-density lipoprotein cholesterol (HDL-C) and hypertension is poorly understood. Therefore, we investigated whether high and low concentrations of HDL-C are associated with high blood pressure (HBP) using a large healthcare dataset.

METHODS

in a community-based cross-sectional study of 1,493,152 Japanese people (830,669 men and 662,483 women) aged 40-74 years who underwent a health checkup, blood pressures automatically measured at healthcare center were investigated in nine HDL-C groups (20-110 mg/dL or over).

RESULTS

crude U-shaped relationship were observed between the nine HDL-C and blood pressures in both men and women. Logistic regression analysis showed left-to-right inverted J-shaped relationships between HDL-C and odds ratios for HBP (≥140/90 mmHg and/or pharmacotherapy), with lower limits of 90-99 mg/dL in both sexes, which were unchanged after adjusting for confounding factors. However, further adjustment for body mass index and serum triglyceride concentration revealed positive linear associations between HDL-C and HBP, although blunt U-shaped associations remained in nonalcohol drinkers.

CONCLUSION

both low and extremely high HDL-C concentrations are associated with HBP. The former association might be dependent on excess fat mass concomitant with low HDL-C, whereas the latter association may be largely dependent on frequent alcohol consumption.

Comparison of guidelines for the management of hypertension: Similarities and differences between international and Asian countries; perspectives from HOPE-Asia Network

Guidelines on the management of hypertension have been developed by various professional bodies and institutions to primarily address the issues of diagnosis, treatment, and control in order to rationalize and improve the management of hypertension. Hypertension guidelines across the world have recently been updated following the new and controversial lower blood pressure threshold of ≥130/80 mmHg for the diagnosis of hypertension adopted by the Americans. While there are differences between the major as well as between the Asian national guidelines, there were also many similarities. This paper discusses and highlights the differences and similarities between the major international guidelines of the American College of Cardiology/American Heart Association, of the European Society of Cardiology/European Society of Hypertension, and of the International Society of Hypertension and also compares them with the Asian guidelines.

Profiles Combining Muscle Atrophy and Neutrophil-to-Lymphocyte Ratio Are Associated with Prognosis of Patients with Stage IV Gastric Cancer

We aimed to investigate the impact of muscle atrophy and the neutrophil-to-lymphocyte ratio (NLR), a sub-clinical biomarker of inflammation and nutrition, on the prognosis of patients with unresectable advanced gastric cancer. We retrospectively enrolled 109 patients with stage IV gastric cancer (median age 69 years; female/male 22%/78%; median observational period 261 days). Independent factors and profiles for overall survival (OS) were determined by Cox regression analysis and decision-tree analysis, respectively. OS was calculated using the Kaplan–Meier method. The prevalence of muscle atrophy was 82.6% and the median NLR was 3.15. In Cox regression analysis, none of factors were identified as an independent factor for survival. The decision-tree analysis revealed that the most favorable prognostic profile was non-muscle atrophy (OS rate 36.8%). The most unfavorable prognostic profile was the combination of muscle atrophy and high NLR (OS rate 19.6%). The OS rate was significantly lower in patients with muscle atrophy and high NLR than in patients with non-muscle atrophy (1-year survival rate 28.5% vs. 54.7%; log-rank test p = 0.0014). In conclusion, “muscle atrophy and high NLR” was a prognostic profile for patients with stage IV gastric cancer. Thus, the assessment of muscle mass, subclinical inflammation, and malnutrition may be important for the management of patients with stage IV gastric cancer.

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.