Isolated diastolic hypertension. A favorable finding among young and middle-aged hypertensive subjects

Blood pressure response to extended-release naltrexone in heroin and prescription opioid users and its implications for cardiovascular morbidity

BACKGROUND

Consuming opioid agonists is a risk factor for cardiovascular disease particularly in intravenous heroin users. The monthly injectable extended-release opioid antagonist, naltrexone (XR-NTX) is an effective treatment for opioid use disorder. The impact of opioid receptor blockade through XR-NTX on blood pressure, a critical risk factor for cardiovascular morbidity, has not yet been characterized.

METHODS

The study evaluated the change in blood pressure during XR-NTX treatment among 14 patients who predominately used intravenous heroin and 24 patients who used prescription oral opioids, all with opioid use disorder. Blood pressure was measured in each patient immediately before the first XR-NTX injection and ∼two weeks after the first injection. The change in diastolic and systolic pressure was compared between the heroin users and the prescription opioids users using analysis of variance.

RESULTS

XR-NTX treatment was associated with significant decreases in diastolic blood pressure in the heroin group, but not in the prescription opioids group. Systolic blood pressure values in the heroin users showed a decline at trend level only.

CONCLUSIONS

Further research is warranted to replicate our findings and to determine whether XR-NTX effect is relatively specific to blood pressure or generalizes to other components of metabolic syndrome. Distinguishing between heroin and prescription opioid users could shed light on the unique clinical and pharmacological profiles of opioid drugs, particularly regarding their cardiovascular safety. This information can be useful in developing personalized therapeutic strategies based on the route of opioid administration.

Effects of hypertension diagnoses on alcohol consumption among Chinese Adults—A Two-dimensional regression discontinuity analysis

Exploiting the fact that hypertension is diagnosed when a person’s blood pressure reading exceeds a medically specified threshold (90 mmHg for diastolic blood pressure or 140 mmHg for systolic blood pressure), this study estimates the effect of a first-ever hypertension diagnosis on Chinese adults’ alcohol consumption using a two-dimensional regression discontinuity design. Analyzing data on 10,787 adults from the China Health and Nutrition Survey, our estimation reveals that hypertension diagnoses based on diastolic blood pressure readings exert a number of desirable effects. Hypertensive adults’ drinking frequency and the incidence of excessive drinking among them were reduced by 1.2 times/week and 17.9 percentage points, respectively, about three years after the diagnosis. Meanwhile, their beer and Chinese spirits (Baijiu) intakes were reduced by 518.6 ml/week and 194.8 ml/week, respectively. Interestingly, we also found modest evidence that hypertension diagnoses based on diastolic blood pressure readings increase Chinese adults’ wine intake, suggesting a substitution pattern upon hypertension diagnoses. In contrast, based on systolic blood pressure readings, no significant effects of hypertension diagnoses on alcohol consumption were found.

Elevated On-Treatment Diastolic Blood Pressure and Cardiovascular Outcomes in the Presence of Achieved Systolic Blood Pressure Targets

BACKGROUND AND OBJECTIVES

This study aimed to investigate the association between cardiovascular events and 2 different levels of elevated on-treatment diastolic blood pressures (DBP) in the presence of achieved systolic blood pressure targets (SBP).

METHODS

A nation-wide population-based cohort study comprised 237,592 patients with hypertension treated. The primary endpoint was a composite of cardiovascular death, myocardial infarction, and stroke. Elevated DBP was defined according to the Seventh Report of Joint National Committee (JNC7; SBP <140 mmHg, DBP ≥90 mmHg) or to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) definitions (SBP <130 mmHg, DBP ≥80 mmHg).

RESULTS

During a median follow-up of 9 years, elevated on-treatment DBP by the JNC7 definition was associated with an increased risk of the occurrence of primary endpoint compared with achieved both SBP and DBP (adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 1.05-1.24) but not in those by the 2017 ACC/AHA definition. Elevated on-treatment DBP by the JNC7 definition was associated with a higher risk of cardiovascular mortality (aHR, 1.42; 95% CI, 1.18-1.70) and stroke (aHR, 1.19; 95% CI, 1.08-1.30). Elevated on-treatment DBP by the 2017 ACC/AHA definition was only associated with stroke (aHR, 1.10; 95% CI, 1.04-1.16). Similar results were seen in the propensity-score-matched cohort.

CONCLUSION

Elevated on-treatment DBP by the JNC7 definition was associated a high risk of major cardiovascular events, while elevated DBP by the 2017 ACC/AHA definition was only associated with a higher risk of stroke. The result of study can provide evidence of DBP targets in subjects who achieved SBP targets.

The effects of a hypertension diagnosis on health behaviors: A two-dimensional regression discontinuity analysis

This paper explores how a diagnosis of hypertension might affect a person's health-related behaviors. The analysis uses a two-dimensional regression discontinuity design because hypertension is diagnosed when a person's systolic or diastolic blood pressure (SBP or DBP) surpasses a pre-established threshold. We find that those closely above the SBP threshold significantly adjusted their lifestyle, such as reducing daily fat intake and quitting smoking, while those just surpassing the DBP cutoff did not. Further mechanism analysis suggests that the possibility of constraints, rather than education and income gradients, does more to explain the disparate behaviors of subjects near the SBP and DBP thresholds. Those around the DBP threshold generally have tighter work schedules and undertake more competitive jobs, which hinder them from improving their lifestyle. Overall, our findings complement the existing literature by posing a new perspective for understanding people's potential reluctance to adjust their behavior.

Prevalence, Predictors, Progression, and Prognosis of Hypertension Subtypes in the Framingham Heart Study

Background The epidemiology of hypertension subtypes has not been well characterized in the recent era. Methods and Results We delineated the prevalence, predictors, progression, and prognostic significance of hypertension subtypes in 8198 Framingham Heart Study participants (mean age, 46.5 years; 54% women). The prevalence of hypertension subtypes was as follows: nonhypertensive (systolic blood pressure [SBP] <140 mm Hg and diastolic blood pressure [DBP] <90 mm Hg), 79%; isolated systolic hypertension (ISH; SBP ≥140 mm Hg and DBP <90 mm Hg), 8%; isolated diastolic hypertension (SBP <140 mm Hg and DBP ≥90 mm Hg), 4%; and systolic-diastolic hypertension (SDH; SBP ≥140 mm Hg and DBP ≥90 mm Hg), 9%. The prevalence of ISH and SDH increased with age. Analysis of a subsample of nonhypertensive participants demonstrated that increasing age, female sex, higher heart rate, left ventricular mass, and greater left ventricular concentricity were predictors of incident ISH and SDH. Higher baseline DBP was associated with the risk of developing isolated diastolic hypertension and SDH, whereas higher SBP was associated with all 3 hypertension subtypes. On follow-up (median, 5.5 years), isolated diastolic hypertension often reverted to nonhypertensive BP (in 42% of participants) and ISH progressed to SDH (in 26% of participants), whereas SDH frequently transitioned to ISH (in 20% of participants). During follow-up (median, 14.6 years), 889 participants developed cardiovascular disease. Compared with the nonhypertensive group (referent), ISH (adjusted hazard ratio [HR], 1.57; 95% CI, 1.30-1.90) and SDH (HR, 1.66; 95% CI, 1.36-2.01) were associated with increased cardiovascular disease risk, whereas isolated diastolic hypertension was not (HR, 1.03; 95% CI, 0.68-1.57). Conclusions Hypertension subtypes vary in prevalence with age, are dynamic during short-term follow-up, and exhibit distinctive prognoses, underscoring the importance of blood pressure subphenotyping.

Isolated Diastolic Hypertension and Risk of Cardiovascular Events: A Systematic Review and Meta-Analysis of Cohort Studies With 489,814 Participants

Background: The association between isolated diastolic hypertension (IDH) and cardiovascular events has been inconsistently reported. This meta-analysis of cohort studies was designed to investigate the effect of the 2018 European Society of Cardiology (ESC) definition of IDH on the risk of composite cardiovascular events, cardiovascular mortality, all-cause mortality, and all strokes including ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to July 6, 2021. Cohort studies that investigated the association between IDH and cardiovascular events risk, compared to normotension, were included. Pooled hazard ratios (HRs) and 95% CIs were calculated using a random-effects models and heterogeneity was evaluated using Q-test and I ² statistic. The robustness of the associations was identified using sensitivity analysis. The methodological quality of the studies was assessed using the Newcastle-Ottawa scale. Publication bias was assessed using funnel plot, trim-and-fill method, Begg's test, and Egger's test. Results: A total of 15 cohort studies (13 articles) including 489,814 participants were included in this meta-analysis. The follow-up period ranged from 4.3 to 29 years. IDH was significantly associated with an increased risk of composite cardiovascular events (HR 1.28, 95% CI: 1.07-1.52, p = 0.006), cardiovascular mortality (HR 1.45, 95% CI: 1.07-1.95, p = 0.015), all strokes (HR 1.44, 95% CI: 1.04-2.01, p = 0.03), and HS (HR 1.64, 95% CI: 1.18-2.29, p = 0.164), but not associated with all-cause mortality (HR 1.20, 95% CI: 0.97-1.47, p = 0.087) and IS (HR 1.56, 95% CI: 0.87-2.81, p = 0.137). Subgroup analysis further indicated that IDH in the younger patients (mean age ≤ 55 years) and from Asia were significantly associated with an increased risk of composite cardiovascular events, while the elderly patients (mean age ≥ 55 years), Americans, and Europeans were not significantly associated with an increased risk of composite cardiovascular events. Conclusion: This meta-analysis provides evidence that IDH defined using the 2018 ESC criterion is significantly associated with an increased risk of composite cardiovascular events, cardiovascular mortality, all strokes and HS, but not significantly associated with all-cause death and IS. These findings also emphasize the importance for patients with IDH to have their blood pressure within normal, especially in the young adults and Asians. Trial Registration: PROSPERO, Identifier: CRD42021254108.

Isolated diastolic hypertension and target organ damage: Findings from the STANISLAS cohort

BACKGROUND

Isolated diastolic hypertension (IDH) is defined as diastolic blood pressure (DBP) ≥80 mmHg and systolic blood pressure (SBP) <130 mmHg according to 2017 ACC/AHA guidelines. The effective cardiovascular risk linked to IDH is debated.

HYPOTHESIS

IDH might contribute marginally to hypertension-related target organ damage (TOD) development.

METHODS

In this cross-sectional analysis 1605 subjects from the STANISLAS cohort, a large familiar longitudinal study from Eastern France, were included. Participants were categorized according to average values at 24-h ABP recording as having normal BP (SBP < 130/DBP < 80 mmHg); combined hypertension (SBP ≥130/DBP ≥80 mmHg or on antihypertensive treatment); IDH (SBP <130/DBP >80 mmHg); isolated systolic hypertension (ISH: SBP ≥130/DBP <80 mmHg). The association between hypertension status and TOD was assessed by multivariable-adjusted logistic models.

RESULTS

Using normotension as reference, IDH was not significantly associated with NTproBNP levels (adjusted odds ratio [OR] 1.04 [95%CI 0.82;1.32], p = .750), microalbuminuria (OR 0.99 [0.69; 1.42], p = .960), diastolic dysfunction (OR 1.53 [0.88; 2.68], p = .130), left ventricular (LV) mass index (OR per 10 g/m2 increase 1.07 [0.95; 1.21], p = .250), LV longitudinal strain (global: OR 1.07 [0.99; 1.14], p = .054; subendocardial: OR 1.06 [0.99; 1.13], p = .087), carotid intima media thickness (OR 1.27 [0.79; 2.06], p = .320), reduced ankle-brachial index (<0.9; OR 1.59 [0.19; 13.55], p = .670) and pulse wave velocity (PWV; OR 1.07 [0.93; 1.23], p = .360). In contrast, combined hypertension and ISH were independently associated with LV mass index and PWV increase (all p ≤ .01).

CONCLUSIONS

IDH was not significantly associated with TOD. Further studies are needed to clarify the clinical role of IDH. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01391442.

A cohort study and meta-analysis of isolated diastolic hypertension: searching for a threshold to guide treatment

AIMS

Whether isolated diastolic hypertension (IDH), as defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline, is associated with cardiovascular disease (CVD) has been disputed. We aimed to further study the associations of IDH with (i) subclinical CVD in the form of coronary artery calcium (CAC), (ii) incident systolic hypertension, and (iii) CVD events.

METHODS AND RESULTS

We used multivariable-adjusted logistic and Cox regression to test whether IDH by 2017 ACC/AHA criteria (i.e. systolic blood pressure <130 mmHg and diastolic blood pressure ≥80 mmHg) was associated with the above outcomes in the Multi-Ethnic Study of Atherosclerosis (MESA). In a random-effects meta-analysis of the association between IDH and CVD events, we combined the MESA results with those from seven other previously published cohort studies. Among the 5104 MESA participants studied, 7.5% had IDH by the 2017 ACC/AHA criteria. There was no association between IDH and CAC [e.g. adjusted prevalence odds ratio for CAC >0 of 0.88 (95% CI 0.66, 1.17)]. Similarly, while IDH was associated with incident systolic hypertension, there was no statistically significant associations with incident CVD [hazard ratio 1.19 (95% CI 0.77, 1.84)] or death [hazard ratio 0.94 (95% CI 0.65, 1.36)] over 13 years in MESA. In a stratified meta-analysis of eight cohort studies (10 037 843 participants), the 2017 IDH definition was also not consistently associated with CVD and the relative magnitude of any potential association was noted to be numerically small [e.g. depending on inclusion criteria applied in the stratification, the adjusted hazard ratios ranged from 1.04 (95% CI 0.98, 1.10) to 1.09 (95% 1.03, 1.15)].

CONCLUSION

The lack of consistent excess in CAC or CVD suggests that emphasis on healthy lifestyle rather than drug therapy is sufficient among the millions of middle-aged or older adults who now meet the 2017 ACC/AHA criteria for IDH, though they require follow-up for incident systolic hypertension. These findings may not extrapolate to adults younger than 40 years, motivating further study in this age group.

Midlife Hypertension and Alzheimer's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Hypertension is an established risk factor for stroke and vascular dementia but recent meta-analyses examining the association between Alzheimer's disease (AD) and hypertension have found no significant association. These meta-analyses included short term studies starting in late life which may have obscured the real effect of midlife hypertension.

OBJECTIVE

To examine the association of AD with midlife hypertension, by including only studies with a sufficiently long follow up duration.

METHODS

Relevant studies were found by searches of MEDLINE, EMBASE, and PubMed. Study outcomes were grouped by measures of blood pressure and definition of hypertension (e.g., systolic hypertension > 140 mmHg or > 160 mmHg). We assessed pooled effect estimates using random effects models and heterogeneity of pooled estimates through the I2 statistic.

RESULTS

Literature search found 3,426 publications of which 7 were eligible studies. There was a significant association between systolic hypertension (>160 mm Hg) and AD (HR 1.25, 95CI 1.06 - 1.47, p = 0.0065). Similarly, for systolic hypertension > 140 mm Hg, there was a smaller but still significant association (HR 1.18, 95CI 1.02 - 1.35, p = 0.021). For diastolic hypertension, all four studies found no significant associations between diastolic hypertension and AD, and these data could not be pooled due to heterogeneity in reporting.

CONCLUSIONS

Our study found that midlife stage 1 and stage 2 systolic hypertension is associated with increased risk of AD by 18 and 25%, respectively, although no association was found for diastolic hypertension. It is likely that assertive control of systolic hypertension starting in midlife is important to preventing AD.

Isolated diastolic hypertension as defined by the 2017 American College of Cardiology/American Heart Association blood pressure guideline and incident cardiovascular events in Chinese

OBJECTIVE

The new arterial hypertension guidelines by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) changed the definition of isolated diastolic hypertension (IDH). We assessed and compared in a Chinese population the IDH prevalence, newly defined by the 2017 ACC/AHA guidelines versus the former definition by the Joint National Committee 7 (JNC7) criteria, and examined longitudinal associations of IDH with cardiovascular disease (CVD) outcomes.

METHODS

The prospective community-based Kailuan Study included participants aged 18-98 years who underwent a detailed medical examination at baseline in 2006/2007 and who were biennially re-examined till 2017. History of antihypertensive medication at baseline was an exclusion criterion.

RESULTS

The study population consisted of 87 346 individuals (mean age: 50.9 years; range: 18-98 years). Prevalence of IDH was 7.79% [95% confidence interval (CI): 7.62, 7.97] by JNC7 guidelines and 24.72% (95% CI: 24.43, 25.01) by 2017 ACC/AHA criteria [difference: 19.93% (95% CI: 16.81, 17.04)]. Applying the 2017 ACC/AHA guidelines, the prevalence of IDH-recommended antihypertensive therapy was 7.73% (95% CI: 7.55, 7.90). In multivariable analysis, IDH by JNC7 criteria was significantly associated with incident myocardial infarction [n = 93 events; hazard ratio: 1.30 (95 CI: 1.02, 1.66)], cerebral hemorrhage [n = 73 events; hazard ratio: 1.79 (95% CI: 1.35, 2.38)], and total CVD [n = 373 events; hazard ratio: 1.15 (95% CI: 1.02, 1.30)], when compared with normotension. IDH based on 2017 ACC/AHA guidelines was associated with incident cerebral hemorrhage [n = 129 events; hazard ratio: 1.47 (95% CI: 1.12, 1.94)] and total CVD [n = 828 events; hazard ratio: 1.13 (95% CI: 1.02, 1.26)].

CONCLUSION

In this adult Chinese community, 2017 ACC/AHA-defined IDH was associated with the incidence of cerebral hemorrhage and total CVD, and as compared with JNC7-defined IDH, it was more prevalent.

Abnormal cardiac and metabolic measures correlate significantly with lower performance and activity in overweight chronic liver disease

People with Hepatitis C (HCV) and non-alcoholic fatty liver disease (NAFLD) in the United States follow national trends toward a sedentary lifestyle and are increasingly at risk for hypertension. The intent of this study was to identify potential correlates of exercise tolerance in people with two types of chronic liver disease (CLD)-NAFLD and HCV. Measures included cardiac output, oxygen consumption and stroke volume, blood pressure, distance walked in 6 minutes, clinical laboratory tests, and medications influencing the autonomic nervous system, patient self-reports of activity, fatigue, and health-related quality of life (HRQL). A total of 67 patients completed the 6-minute walk test [45.1% Female, Age 51.7 ± 8.0 years, Body Mass Index 32.8 ± 5.9, 60% HCV]. At baseline, 70% had either diastolic (DBP) or systolic blood pressure outside normal range. Performance and cardiorespiratory measures correlated strongly with one another, but not with activity. Patients with abnormal DBP reported significantly lower maximum activity (MAS; r = -.254, P = .041, CI = -0.51 to -0.010; MAS 70.6 vs 82.5), significantly higher DBP post-6-minute walk test (r = .524, P = .0001, CI = 0.287-0.762) and significantly lower overall HRQL items related to physical domains (r = .273, P = .029, CI = -0.518 to -0.029). Mental-domain HRQL and depression measures did not correlate significantly with blood pressure. This study reports a significant correlation between both pre-hypertensive and hypertensive DBP, poor physical-domain self-reports, HRQL, and performance in CLD patients.

Association between body mass index and hypertension subtypes in Indian and United States adults

The purpose of this cross-sectional, secondary analysis was to determine the association between BMI & lipids and hypertension subtype in U.S. and Indian adults. Obese BMI was significantly associated with isolated diastolic hypertension (IDH) compared to low/normal BMI (relative risk ratio [95% CI]; U.S.: 4.33 [2.88,6.52]; India: 2.51 [2.41,2.60]). Furthermore, BMI was more strongly associated with IDH than other hypertension subtypes in U.S. and non-obese Indian adults. In obese Indian adults, we observed higher odds of isolated systolic hypertension until the 6th decade, and systo-diastolic hypertension thereafter. Triglyceride levels were associated with IDH in U.S. adults (1.94 [1.43,2.63]).

Isolated Diastolic Hypertension in the UK Biobank: Comparison of ACC/AHA and ESC/NICE Guideline Definitions

The 2017 American College of Cardiology/American Heart Association guideline defines hypertension as a blood pressure ≥130/80 mm Hg, whereas the 2018 European Society of Cardiology (ESC) and 2019 National Institute for Health and Care Excellence (NICE) guidelines use a ≥140/90 mm Hg threshold. Our objective was to study the associations between isolated diastolic hypertension (IDH), diagnosed using these 2 blood pressure thresholds, and cardiovascular disease (CVD) in a large cohort of UK adults. We analyzed data from UK Biobank, which enrolled participants between 2006 and 2010 with follow-up through March 2019. We excluded persons with systolic hypertension or baseline CVD. We defined incident CVD as a composite of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. We used Cox regression to quantify associations between IDH and CVD, as well as the individual outcomes included in the composite outcome. We studied 151 831 participants with normal systolic blood pressure (mean age 54 years, 40% male). Overall, 24.5% had IDH by the American College of Cardiology/American Heart Association definition compared with 6% by the ESC/NICE definition. Compared with normal diastolic blood pressure, IDH by the American College of Cardiology/American Heart Association definition was not significantly associated with CVD risk (hazard ratio, 1.08 [95% CI, 0.98-1.18]) whereas IDH by the ESC/NICE definition was significantly associated with a modest increase in CVD (hazard ratio, 1.15 [95% CI, 1.04-1.29]). Similar results were found by sex and among participants not taking baseline antihypertensives. Furthermore, neither IDH definition was associated with the individual outcomes of nonfatal myocardial infarction or stroke. In conclusion, the proportion of UK Biobank participants with IDH was significantly higher by the American College of Cardiology/American Heart Association definition compared with the ESC/NICE definitions; however, only the ESC/NICE definition was statistically associated with increased CVD risk.

The clinical significance of isolated diastolic hypertension

The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by others. It is also more common in the young subjects who are at low CV risk and quite rare in the older subjects, who are at increased CV risk. Treatment of IDH in the older subjects could increase the CV complications due to a J-curve effect and, in addition, could increase the incidence of stroke from further lowering the normal systolic blood pressure (SBP). Very low SBP and DBP cannot be sustained by the cerebral blood flow autoregulation and could lead to cerebral ischemia. In order to get a better perspective of the current status of the treatment of IDH, a review of the English language literature of the available studies was conducted and 12 papers with pertinent information were retrieved. The analysis of results from these studies suggests that IDH is associated with adverse CV events in younger persons and it should be treated. In contrast, the prevalence of IDH is low in older subjects and is not associated with adverse CV events in the majority of cases. Thus, its further lowering should be avoided to prevent further decrease in normal SBP and prevent the onset of adverse CV events. However, the decision to treat IDH in older subjects should be individualized.

Association of Isolated Diastolic Hypertension as Defined by the 2017 ACC/AHA Blood Pressure Guideline With Incident Cardiovascular Outcomes

IMPORTANCE

In the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline, the definition of hypertension was lowered from a blood pressure (BP) of greater than or equal to 140/90 to greater than or equal to 130/80 mm Hg. The new diastolic BP threshold of 80 mm Hg was recommended based on expert opinion and changes the definition of isolated diastolic hypertension (IDH).

OBJECTIVE

To compare the prevalence of IDH in the United States, by 2017 ACC/AHA and 2003 Joint National Committee (JNC7) definitions, and to characterize cross-sectional and longitudinal associations of IDH with outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analyses of the National Health and Nutrition Examination Survey (NHANES 2013-2016) and longitudinal analyses of the Atherosclerosis Risk in Communities (ARIC) Study (baseline 1990-1992, with follow-up through December 31, 2017). Longitudinal results were validated in 2 external cohorts: (1) the NHANES III (1988-1994) and NHANES 1999-2014 and (2) the Give Us a Clue to Cancer and Heart Disease (CLUE) II cohort (baseline 1989).

EXPOSURES

IDH, by 2017 ACC/AHA (systolic BP <130 mm Hg, diastolic BP ≥80 mm Hg) and by JNC7 (systolic BP <140 mm Hg, diastolic BP ≥90 mm Hg) definitions.

MAIN OUTCOMES AND MEASURES

Weighted estimates for prevalence of IDH in US adults and prevalence of US adults recommended BP pharmacotherapy by the 2017 ACC/AHA guideline based solely on the presence of IDH. Risk of incident atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD) in the ARIC Study.

RESULTS

The study population included 9590 adults from the NHANES (mean [SD] baseline age, 49.6 [17.6] years; 5016 women [52.3%]) and 8703 adults from the ARIC Study (mean [SD] baseline age, 56.0 [5.6] years; 4977 women [57.2%]). The estimated prevalence of IDH in the NHANES was 6.5% by the 2017 ACC/AHA definition and 1.3% by the JNC7 definition (absolute difference, 5.2% [95% CI, 4.7%-5.7%]). Among those newly classified as having IDH, an estimated 0.6% (95% CI, 0.5%-0.6%) also met the guideline threshold for antihypertensive therapy. Compared with normotensive ARIC participants, IDH by the 2017 ACC/AHA definition was not significantly associated with incident ASCVD (n = 1386 events; median follow-up, 25.2 years; hazard ratio [HR], 1.06 [95% CI, 0.89-1.26]), HF (n = 1396 events; HR, 0.91 [95% CI, 0.76-1.09]), or CKD (n = 2433 events; HR, 0.98 [95% CI, 0.65-1.11]). Results were also null for cardiovascular mortality in the 2 external cohorts (eg, HRs of IDH by the 2017 ACC/AHA definition were 1.17 [95% CI, 0.87-1.56] in the NHANES [n = 1012 events] and 1.02 [95% CI, 0.92-1.14] in CLUE II [n = 1497 events]).

CONCLUSIONS AND RELEVANCE

In this analysis of US adults, the estimated prevalence of IDH was more common when defined by the 2017 ACC/AHA BP guideline compared with the JNC7 guideline. However, IDH was not significantly associated with increased risk for cardiovascular outcomes.

β-blockers: Their new life from hypertension to cancer and migraine

The pharmacological class of β-blockers includes a plea of molecules with largely different pharmacokinetic and pharmacodynamic characteristics with a protective effect that may span far beyond the cardiovascular system. Although all these compounds share the pharmacological blockade of the adrenergic receptors, each of them is characterized by specific pharmacological properties, including selectivity of action depending on the adrenergic receptors subtypes, intrinsic sympathomimetic activity (ISA), lipid solubility, pharmacokinetic profile, and also other ancillary properties that impact their clinical effect. Their use in the treatment of hypertension has been extensively debated and at the moment a class indication is not present. However, in specific niche of patients, such as in those young individuals in which hypertension is mainly driven by a sympathetic hyperactivation, strong evidence pose β-Blockers as a highly reasonable first-line treatment. Lipophilic β-blockers, specifically propranolol and metoprolol, can cross the Blood Brain Barrier and have a Class A indication for the prophylactic treatment of migraine attacks. Moreover, since β-adrenergic receptors affect the proliferative process of both cancer and immune cells, their blockade has been associated with metastasis reduction in several epithelial and solid organ tumors posing β-Blockers as a new attractive, inexpensive and relatively safe therapeutic strategy in patients with several types of cancer. However, further dedicated prospective, randomized, placebo-controlled studies are needed to determine the real efficacy of these compounds.

Isolated diastolic hypertension and its risk factors in semi-rural population of South India

Background

Isolated diastolic hypertension (IDH) has been actively discussed for the last two decades because of its prevalence in a younger population and its association with cardiovascular disease. Furthermore, the association of IDH is significant in South Asian Countries such as India because relatively younger populations are known to have a higher risk of cardiovascular events.

Objective

The objective of this study is to find prevalence of IDH and its risk correlates in a semiurban population of South Indian state of Andhra Pradesh.

Methods

Data were collected using the modified World Health Organization - STEPwise approach to Surveillance (WHO STEPS) questionnaire for 16,636 individuals from a group of villages under Thavanampalle Mandal. Collated data were analyzed for prevalence and risk factors of IDH.

Results

Prevalence of IDH was found to be 4.0% with mean age of 46.0 (±SD 13.6) years and a relatively higher prevalence in men (5.3%) as compared with women (3.2%). The prevalence of IDH peaked in the fifth decade of life (40–49 years of age) and declined thereafter. Among various risk factors that were analyzed for their association with IDH, only age, body weight, and body mass index retained their significance in multivariate binary logistic regression analysis.

Conclusion

There is a significant prevalence of IDH below 50 years of age in the semiurban population of South India. As IDH in young and middle age is known to be associated with increased risk of cardiovascular events and end organ involvement, it highlights need for study and development of effective IDH management strategies to reduce associated morbidity and mortality.

Differential Control Rate of Systolic and Diastolic Blood Pressure among Korean Adults with Hypertension: the Sixth Korean National Health and Nutrition Examination Survey, 2013-2015 (KNHANES VI)

Background and Objectives

Discrepancy in blood pressure (BP) control rate may be owed to different risk factors associated with elevated systolic and diastolic BP (SBP and DBP).

Methods

In a nationally representative survey of Korean population with BP measurements, a total of 5,100 participants with hypertension was included in the analyses. Three separate types of control rates were calculated: SBP, DBP, and (combined) S&DBP among all participants with hypertension and participants with treated hypertension, separately. Control rates were compared across sex and age groups. Multivariable logistic regression was used to identify demographic factors associated with SBP, DBP, and S&DBP control rates, separately.

Results

In total, SBP, DBP, and S&DBP control rates were 63.0%, 63.7%, and 42.5% among all hypertension patients, and 77.5%, 87.4%, and 71.6% among treated hypertension patients. Men aged 40–49 years with hypertension and 30–39 years treated for hypertension had the highest SBP control rate (74.6% and 96.2%), which decreased by older age. Inversely, DBP control rate progressively increased with older age. SBP control rate among women with hypertension was the highest in 40–49 years (67.0%) but without linear trend by age group. Interestingly, both combined and DBP control rates were noticeably low among women aged 50–59 years. Women with body mass index ≥25 were at higher odds of having controlled SBP. Lower DBP control rate was observed in men with lower education level, higher household income, and heavy drinkers.

Conclusions

Separate examination of control rates demonstrated different sex- and age-differential trends, which would have been overlooked in combined control rates.

Richer, wiser and in better health? The socioeconomic gradient in hypertension prevalence, unawareness and control in South Africa

The socioeconomic gradient in chronic conditions is clear in the poorest and wealthiest of countries, but extant evidence on this relationship in low- and middle-income countries is inconclusive. We use data gathered between 2008 and 2012 from a nationally representative sample of over 10,000 South African adults, and objective health measures to analyse the differential effects of education, income and other factors on the prevalence of hypertension, individuals' awareness and control of hypertensive status. Prevalence of hypertension is high at 38% among women and 34% among men. 59% of hypertensive individuals are unaware of their status. We find prevalence and unawareness of hypertension are a public health concern across all income groups in South Africa. Higher income is however associated with effective control amongst men. Completing secondary education is associated with 7 mmHg lower blood pressure only in a small sub-group of women but is associated with 22 percentage point higher likelihood of effective hypertension control amongst women. We conclude that poorer and less educated individuals are particularly at high risk of cardiovascular disease in South Africa.

Isolated diastolic hypertension and incident heart failure in community-dwelling older adults: Insights from the Cardiovascular Health Study

BACKGROUND

Isolated systolic hypertension and isolated diastolic hypotension are common in older adults and associated with a higher risk of incident heart failure (HF). However, little is known about the prevalence and impact of isolated diastolic hypertension in this population.

METHODS

In the Cardiovascular Health Study (CHS), of the 5776 community-dwelling older adults ≥65years who had data on baseline systolic and diastolic blood pressure (SBP and DBP), 28 had isolated diastolic hypertension (DBP ≥90mmHg and SBP <140mmHg). From the 5748 without isolated diastolic hypertension, we excluded those with SBP ≥120mmHg (n=4451), DBP 80-89mmHg (n=20), DBP <60mmHg (n=425), normal BP taking anti-hypertensive medications (n=311), normal BP taking no anti-hypertensive medications but with history of hypertension (n=38), and baseline HF (n=5). The final cohort of 524 participants included 27 with isolated diastolic hypertension.

RESULTS

Patients (n=524) had a mean (±SD) age of 71 (±5) years, 58% were women and 9% African American. There were no significant between-group age or sex differences; 37% of those with isolated diastolic hypertension (versus 7% without) were African American. Incident HF occurred in 19% and 7% of participants with and without isolated diastolic hypertension, respectively (multivariable-adjusted hazard ratio {HR}, 4.65; 95% confidence interval {CI}, 1.09-19.90; p=0.038). There was a trend toward higher cardiovascular mortality (HR, 4.59; 95% CI, 0.92-23.88; p=0.063).

CONCLUSION

Among community-dwelling older adults, isolated diastolic hypertension is rare and is associated with higher risk for incident HF and cardiovascular mortality.

The association of adiposity, physical fitness, vitamin D levels and haemodynamic parameters in young Saudi females

Objectives

In this study, we assessed the possible association of adiposity, physical fitness, vitamin D levels and haemodynamic parameters as intermediate risk factors for cardiovascular health in young Saudi women.

Methods

A total of 87 young healthy Saudi women were recruited in this cross-sectional study during 2014–2015. The body weight, height, waist and hip circumference, and plasma 25-hydroxyvitamin D (25[OH] D) levels were measured. The exercise stress test was performed to determine the pulse rate, blood pressure (BP), ECG, and VO_2max. Multiple linear regression models were generated for the resting (r) and maximum (m) diastolic (D) and systolic (s) arterial BP and pulse rate (PR), adiposity markers, VO_2max, and plasma levels of 25(OH) D.

Results

A multiple linear regression model was significant for the rDBP, mDBP, rSBP, and mSBP with adjusted R² (6.5, 10.2, 8.3, and 4.5%, respectively). Except for VO_2max in the mDBP model, none of the included risk factors were significant according to the t-test.

Conclusion

This study showed the association of high adiposity and decreased physical fitness with haemodynamic parameters in young Saudi women. An exaggerated exercise DBP might predict future cardiovascular risk in unfit young women.

Hypertension subtypes and risk of cardiovascular diseases in a Mongolian population, inner Mongolia, China

BACKGROUND

There have been no reports about the effects of hypertension subtypes on the future cardiovascular events among Mongolian people, China.

METHODS AND RESULTS

From June 2003 to July 2012, we conducted a prospective study to assess the association of hypertension subtypes with future risk of cardiovascular events including stroke and coronary heart disease among a Mongolian cohort of 2589 adults in China. According to the baseline blood pressure levels, the subjects were divided into those with normal blood pressure, prehypertension, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and combined systolic and diastolic hypertension (SDH). Cox proportional hazards models were used to evaluate the association between blood pressure subtypes and risk of cardiovascular diseases. After adjustment for age and gender, hazard ratios (95% confidence intervals) of cardiovascular diseases were 1.75 (0.92-3.33), 2.11 (0.95-4.70), 2.14 (1.01-4.56) and 5.31 (2.86-9.77) for pre-hypertension, ISH, IDH and SDH, respectively, compared with normal blood pressure. Furthermore, after adding other cardiovascular risk factors to adjustment, hazard ratios (95% confidence intervals) of cardiovascular diseases were 1.74 (0.92-3.31), 2.00 (0.88-4.54), 2.20 (1.02-4.74) and 4.92 (2.62-9.26) for pre-hypertension, ISH, IDH and SDH, respectively, compared with the normal blood pressure group.

CONCLUSIONS

IDH and SDH were significantly associated with the increased risk of cardiovascular diseases; this study suggests that carefully monitoring and actively treating the subjects with IDH should be an important strategy for CVD prevention among Mongolian population.

Cardiovascular risks associated with diastolic blood pressure and isolated diastolic hypertension

Hypertension is a major reversible risk factor for cardiovascular complications. According to recent guidelines, hypertension can be subdivided into isolated diastolic, isolated systolic, and systolic and diastolic mixed hypertension using proposed thresholds of various blood pressure components. In the present article, we reviewed the association of cardiovascular outcomes with diastolic blood pressure versus systolic blood pressure and with isolated diastolic hypertension versus systolic and mixed hypertension in observational prospective cohort studies and large-scale individual data-based meta-analysis. Blood pressure was measured either in the clinic or at home or under ambulatory conditions for 24 h in cohort studies. To illustrate the treatment effect of diastolic blood pressure lowering, we also reviewed randomized placebo-controlled outcome trials in diastolic hypertension.

CONCLUSIONS

The risks conferred by diastolic and systolic blood pressure, irrespective of the methods of blood pressure measurement, are age-dependent. Diastolic blood pressure and isolated diastolic hypertension drive coronary risk in younger subjects, whereas systolic blood pressure is the predominant risk indicator in older people. Reversibility of the risk by diastolic BP lowering treatment in randomized trials confirms that diastolic hypertension is a risk factor that must be treated.

Hypertension Subtypes among Hypertensive Patients in Ibadan

Background. Certain hypertension subtypes have been shown to increase the risk for cardiovascular morbidity and mortality and may be related to specific underlying genetic determinants. Inappropriate characterization of subtypes of hypertension makes efforts at elucidating the genetic contributions to the etiology of hypertension largely vapid. We report the hypertension subtypes among patients with hypertension from South-Western Nigeria. Methods. A total of 1858 subjects comprising 76% female, hypertensive, aged 18 and above were recruited into the study from two centers in Ibadan, Nigeria. Hypertension was identified using JNCVII definition and was further grouped into four subtypes: controlled hypertension (CH), isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH). Results. Systolic-diastolic hypertension was the most prevalent. Whereas SDH (77.6% versus 73.5%) and IDH (4.9% versus 4.7%) were more prevalent among females, ISH (10.1% versus 6.2%) was higher among males (P = 0.048). Female subjects were more obese (P < 0.0001) and SDH was prevalent among the obese group. Conclusion. Gender and obesity significantly influenced the distribution of the hypertension subtypes. Characterization of hypertension by subtypes in genetic association studies could lead to identification of previously unknown genetic variants involved in the etiology of hypertension. Large-scale studies among various ethnic groups may be needed to confirm these observations.

Ambulatory hypertension subtypes and 24-hour systolic and diastolic blood pressure as distinct outcome predictors in 8341 untreated people recruited from 12 populations

BACKGROUND

Data on risk associated with 24-hour ambulatory diastolic (DBP24) versus systolic (SBP24) blood pressure are scarce.

METHODS AND RESULTS

We recorded 24-hour blood pressure and health outcomes in 8341 untreated people (mean age, 50.8 years; 46.6% women) randomly recruited from 12 populations. We computed hazard ratios (HRs) using multivariable-adjusted Cox regression. Over 11.2 years (median), 927 (11.1%) participants died, 356 (4.3%) from cardiovascular causes, and 744 (8.9%) experienced a fatal or nonfatal cardiovascular event. Isolated diastolic hypertension (DBP24≥80 mm Hg) did not increase the risk of total mortality, cardiovascular mortality, or stroke (HRs≤1.54; P≥0.18), but was associated with a higher risk of fatal combined with nonfatal cardiovascular, cardiac, or coronary events (HRs≥1.75; P≤0.0054). Isolated systolic hypertension (SBP24≥130 mm Hg) and mixed diastolic plus systolic hypertension were associated with increased risks of all aforementioned end points (P≤0.0012). Below age 50, DBP24 was the main driver of risk, reaching significance for total (HR for 1-SD increase, 2.05; P=0.0039) and cardiovascular mortality (HR, 4.07; P=0.0032) and for all cardiovascular end points combined (HR, 1.74; P=0.039) with a nonsignificant contribution of SBP24 (HR≤0.92; P≥0.068); above age 50, SBP24 predicted all end points (HR≥1.19; P≤0.0002) with a nonsignificant contribution of DBP24 (0.96≤HR≤1.14; P≥0.10). The interactions of age with SBP24 and DBP24 were significant for all cardiovascular and coronary events (P≤0.043).

CONCLUSIONS

The risks conferred by DBP24 and SBP24 are age dependent. DBP24 and isolated diastolic hypertension drive coronary complications below age 50, whereas above age 50 SBP24 and isolated systolic and mixed hypertension are the predominant risk factors.

School performance affects adolescent blood pressure

Hypertension is a risk factor in many cardiovascular or cerebrovascular diseases. Adolescent hypertension may develop into adult hypertension. Examining the aetiologic factors of adolescent hypertension is crucial in its prevention and in managing its possible complications. The predominant view of aetiologic factors includes heredity, overweight/obesity, insulin resistance, gestational hypertension, diet, and intrauterine growth retardation. This article reported that children's academic grades in schools were positively correlated with adolescent blood pressure.

C-reactive protein predicts systolic blood pressure and pulse pressure but not diastolic blood pressure: the Cardiovascular Disease Risk Factors Two-Township Study

OBJECTIVE

Inflammation has been associated with cardiovascular events and mortality, using C-reactive protein (CRP) as a marker. We examined whether the baseline serum concentration of CRP can independently predict the development of hypertension or future systolic or diastolic blood pressure (BP) in a community-based population in Taiwan.

METHODS

A study population sample was recruited in cycle 2 (1990-1993) of the CardioVascular Disease risk FACtors Two-township Study (CVDFACTS) and was followed to 1994-1997. A total of 2,113 nondiabetic adults with normal BP were enrolled for the study of incident hypertension. Hypertension was defined as a systolic blood pressure (SBP) ≥ 140 mm Hg, a diastolic blood pressure (DBP) ≥ 90 mm Hg, or the use of antihypertensive drugs. Cox regression and linear regression analyses were used to evaluate the association between baseline serum concentrations of CRP measured with a high-sensitivity assay and the development of hypertension and future SBP/DBP and pulse pressure (PP).

RESULTS

During the follow-up period of a median of 3.27 years, 145 participants developed incident hypertension. The incidence rates of hypertension by tertile of increasing CRP were 9.3, 19.0, and 33.0 per 1,000 person-years (P for trend < 0.01). In the multivariate model adjusted for age, gender, and prehypertension, baseline CRP remained significantly predictive of incident hypertension. The concentration of CRP was associated with SBP and PP, but not with DBP.

CONCLUSION

Inflammation is associated with future SBP in the Taiwanese population.

Blood pressure tracking over the adult life course: patterns and correlates in the Framingham heart study

The extent to which select vascular risk factors differentially influence blood pressure (BP) is incompletely understood. Thus, we used multilevel modeling to analyze serial BP measurements using 21 732 person-observations obtained on Framingham Heart Study participants (mean age, 38 years, 52% women; 4993 unique individuals) over a 28-year period. We related longitudinal tracking of each BP measure (systolic BP, diastolic BP, mean arterial pressure, and pulse pressure) to age, sex, body mass index, smoking, diabetes mellitus, total/high-density lipoprotein cholesterol ratio, and heart rate. In multivariable-adjusted analyses, we observed that older age, male sex, greater body mass index, and higher heart rate were positively associated with increase in all BP measures (P<0.0001). Notably, higher total/high-density lipoprotein cholesterol ratio was associated with greater mean arterial pressure (P<0.01). Conversely, diabetes mellitus and smoking were associated with higher pulse pressure (P<0.01). We also observed effect modification by sex: the increase in pulse pressure with age and body mass index was more pronounced in women compared with men (P<0.0001). All BP measures tracked at higher levels in both men and women with multiple vascular risk factors. Taken together, our longitudinal observations in a large community-based sample demonstrate a greater pulsatile load in women than in men with increasing age. We also observed a differential impact of select vascular risk factors on the individual components of BP, underscoring distinct regulation of these measures over the life course.

Hypertension in the metabolic syndrome

Increased blood pressure is considered an important component of metabolic syndrome. More than 85% of those with metabolic syndrome, even in the absence of diabetes, have elevated blood pressure (BP) or hypertension. The association of elevated BP with the metabolic syndrome is strongly linked through the causative pathway of obesity. Hypertension is the leading metabolic syndrome risk factor that predisposes to increased cardiovascular morbidity and mortality, and is additionally an important risk factor for development of chronic kidney disease in the presence of obesity, the metabolic syndrome, and microalbuminuria. Control of blood pressure in persons with the metabolic syndrome may prevent a significant number of coronary heart disease events. The primary modality of treatment is lifestyle intervention with reduced caloric intake and increased physical activity. Pharmacologic intervention is indicated on the basis of the severity of BP elevation, associated cardiovascular risk factors, and the presence of target organ damage.

The importance of diastolic blood pressure in predicting cardiovascular risk

Brachial systolic blood pressure (SBP) is the overall best predictor of future cardiovascular risk for the entire hypertensive population; however, there is much that can be learned from assessing diastolic blood pressure (DBP) in relation to simultaneous levels of SBP, because the former is not distorted by pressure amplification. Low DBP in very young adults (mean age 20 years), presenting as isolated systolic hypertension (ISH), results from elevation in stroke volume and/or arterial stiffness. This subtype of hypertension has a marked male predominance, occurs twice as frequently as essential hypertension, and is potentially not a benign condition. In contrast, isolated diastolic hypertension (IDH) in young adults (mean age of 40 years) with IDH occurs predominantly in men with a high prevalence of metabolic syndrome. Indeed, persons with IDH frequently evolve into systolic-diastolic hypertension and are potentially at increased risk for future diabetes and cardiovascular complications. The older age population with ISH and low DBP (mean age >/=60 years of age) has a high prevalence of left ventricular hypertrophy, increased ventricular-arterial stiffness, and a tendency for diastolic dysfunction and heart failure. Finally, concordant very high DBP, especially in older persons, defines potential hypertensive urgencies, emergencies, secondary forms of hypertension, and other high peripheral resistance states.

Prevalence of isolated diastolic hypertension and associated risk factors among adults in Kanpur, India

BACKGROUND

Isolated diastolic hypertension (IDH) is a largely unrecognized subtype of hypertension, more commonly seen in the younger age group.

AIMS

(1) To determine the prevalence of IDH in the adult population of Kanpur district. (2) To study the associated risk factors of IDH.

METHODS

A community-based cross-sectional study was conducted in 801 subjects, aged 20 years and above, using multistage stratified random sampling technique.

RESULTS

The prevalence of IDH was 4.5%, which was 6.2% in men and 3.1% in women. A significant proportion of IDH was seen in the 40-49 years age group. Multivariate logistic regression analysis of the associated risk factors showed that gender, physical activity and BMI were significantly associated with IDH.

CONCLUSION

Isolated diastolic hypertension is an emerging problem in developing countries. IDH is more common among men, sedentary individuals and those with a higher BMI.

[Isolated systolic hypertension. An independent disease]

Hypertension can be classified based on certain criteria, such as severity, existence of specific end-organ damage, or the dominant blood pressure subphenotype so that isolated diastolic hypertension (IDH), mixed systolic-diastolic hypertension (SDH), and isolated systolic hypertensive (ISH) states can be defined. The FRAMINGHAM study was the first to demonstrate a continuous increase of systolic blood pressure with age and a peak of diastolic pressure between 55 and 65 years of age. This results not only in a high prevalence of hypertension of approximately 50-80% beyond the age of 60 but also in a disproportionately high increase in isolated systolic hypertension. ISH develops either as a new condition mostly from the group of primary high-normal blood pressure or secondly through burnout of existing systolic-diastolic hypertension with highly progressive vascular ageing.The pathophysiological background lies in remodeling processes in the macrovascular and microvascular compartments with stiffening of conduit and peripheral arterial vessels. In clinical practice these processes are easy to measure by determining pulse wave velocity (PWV), the augmentation index, and pulse pressure. These parameters are closely related to cardiovascular and cerebrovascular morbidity and mortality ISH is not only a hypertension subphenotype but often indicates significant organ damage or may even be considered to be a secondary form of hypertension characterized by remodeled and stiffened arterial vessel walls and this condition is difficult to treat. It appears therefore that ISH warrants special therapeutic strategies with a focus on antiproliferative, antistiffening, anti-atherosclerotic, and vasodilating actions. As a result of the available data from the results of treatment studies it appears that renin-angiotensin system (RAS) blockers and calcium channel blockers (CCBs) are the preferred drugs for treatment of this condition.

Hypothesis: it is time to reconsider phenotypes in hypertension

The study of genes and mechanisms associated with hypertension is hampered by the heterogeneity of hypertensive patients. Refining the definition of hypertension is a potential means of improving the clarity of mechanistic studies, but the lack of intermediate phenotypes hinders the assessment of causal relationships. Looking at younger individuals and hemodynamic subsets of hypertension is one such refinement. The authors argue that the separate analysis of patients with isolated diastolic hypertension, predominantly diastolic hypertension, and isolated systolic hypertension in the young in combination with common biomarkers may be an initial step to decrease heterogeneity within patient subsets, thus providing new avenues for genetic and pathophysiological studies.

The study of aortic stiffness in different hypertension subtypes in dialysis patients

The aim of this study was to validate whether differences in aortic stiffness are responsible for the differences in cardiovascular mortality among hypertension subtypes. Twenty hundred and fifty continuous ambulatory peritoneal dialysis patients were included in the present study. They were classified into four groups: normotensives (n=92) with systolic blood pressure (SBP) <140 mmHg and diastolic blood pressure (DBP) <90 mmHg; isolated systolic hypertensives (ISH, n=84) with SBP > or =140 mmHg and DBP <90 mmHg; isolated diastolic hypertensives (IDH, n=21) with SBP <140 mmHg and DBP > or =90 mmHg; and systolic-diastolic hypertensives (SDH, n=53) with SBP > or =140 mmHg and DBP > or =90 mmHg. Aortic stiffness was assessed by pulse pressure, central pressure parameters and pulse wave velocity. The IDH group had more male patients and a lower mean age than the other groups. The percentage of diabetes in the ISH group was higher than that in the other groups. The comparisons of aortic stiffness showed that the ISH and SDH groups had higher aortic stiffness than the normotension and IDH groups. The aortic stiffness in the ISH group was also higher than that in the SDH group, but there was no significant difference in aortic stiffness between the normotension and IDH groups. In conclusion, this study showed that aortic stiffness was significantly different among different hypertension subtypes, which might be an underlying cause of the differences in cardiovascular mortality among the hypertension subtypes.

Stepwise increase in the prevalence of isolated systolic hypertension with the stages of chronic kidney disease

BACKGROUND

Hypertension is common in patients with chronic kidney disease (CKD), and isolated systolic hypertension (ISH) accounts for most patients with inadequate blood pressure (BP) control. However, it remains unclear whether the prevalence of ISH would increase with the advancement of CKD.

METHODS

CKD patients of stages 3, 4 and 5 were recruited (n = 324). Based on office systolic BP (SBP) and diastolic BP (DBP), they were classified into any of the four hypertensive subtypes: normotension (SBP/DBP <140/90 mmHg), isolated diastolic hypertension (IDH, SBP <140 mmHg and DBP >or=90 mmHg), ISH (SBP >or=140 mmHg and DBP <90 mmHg) and systolic-diastolic hypertension (SDH, SBP/DBP >or=140/90 mmHg).

RESULTS

The control rate was 45.7% at stage 3, which decreased with the advancement of CKD (control rate was 51.9%, 40.4% and 38.6% in stage 3, 4 and 5, respectively; P < 0.05). The prevalence of IDH changed from 5.0% to 5.3% and 0% from stage 3 to 4 and 5, while there was no significant change in the prevalence of SDH (15.0%, 14.9% and 15.7% at stage 3, 4 and 5, respectively). There was a stepwise increase in the prevalence of ISH with the stages of CKD (it was 28.1%, 39.4% and 45.7% in stage 3, 4 and 5, respectively). Logistic regression showed that age and CKD stages [compared with stage 3, stage 4 and 5 had 2.57 (95% CI 1.04-6.33) and 3.68 (95% CI 1.09-12.47) folds higher risk to develop ISH, respectively] were independent predictors of ISH.

CONCLUSION

The prevalence of ISH increased correspondingly with advanced stages of CKD, which may partially contribute to the increased cardiovascular mortality during the progress of CKD.

Blood pressure categories, hypertensive subtypes, and the metabolic syndrome

BACKGROUND

Elevated blood pressure (BP) is one element of metabolic syndrome (MetS); however, the relation of various BP categories and hypertension subtypes to the likelihood of having MetS is not well defined.

METHODS

We determined the odds of MetS, defined by the National Cholesterol Education Program, in various BP categories from a cross-sectional study of 5968 individuals aged at least 18 years and untreated for hypertension (weighted to 124.7 million) in the National Health and Nutrition Examination Survey, 1999-2002. Nonhypertensive BP categories were optimal, normal, and high-normal BP, according to JNC-VI classification. Hypertension consisted of three subtypes: isolated diastolic hypertension (IDH), systolic-diastolic hypertension (SDH), and isolated systolic hypertension (ISH).

RESULTS

Among those with hypertension and MetS, 25.3% had IDH, 20.2% had SDH, and 54.5% had ISH. The MetS prevalence in nontreated persons was 5.8% for optimal BP, 9.1% for normal BP, 38.2% for high-normal BP, 45.9% for IDH, 44.3% for SDH, and 43.9% for ISH. Risk factor odds ratios (95% confidence intervals; reference group, optimal BP), adjusted for age, sex, total cholesterol, and smoking, were 1.6 (1.2-2.2) for normal BP, 9.4 (6.9-12.7) for high-normal BP, 14.7 (8.9-24.0) for IDH, 12.2 (7.2-20.8) for SDH, and 10.2 (7.0-14.9) for ISH (all P < 0.01); odds ratios were higher for women in all categories.

CONCLUSIONS

Despite having the lowest mean age, IDH subtype is associated with greatest likelihood of MetS. The high frequency of ISH in the hypertensive population, however, makes ISH the most common hypertensive subtype in persons with MetS.

What is the most important component of blood pressure: systolic, diastolic or pulse pressure?

PURPOSE OF REVIEW

Diastolic blood pressure has traditionally been considered the most important component of blood pressure and the primary target of antihypertensive therapy. However, over 30 years ago important epidemiological studies pointed out the importance of systolic blood pressure, and research during the 1990s has strengthened this view. Unlike diastolic blood pressure, systolic blood pressure increases progressively with age, and in the ageing societies elevated systolic pressure is the most common form of hypertension. The characteristic changes of systolic and diastolic blood pressure with age lead to increases in pulse pressure (systolic minus diastolic), which has emerged as a new, potentially independent risk factor. In this review we compare the relative importance of various blood pressure components.

RECENT FINDINGS

Generally, in studies in which readings of systolic and diastolic blood pressure have been compared, systolic blood pressure has been a better predictor of risk. Moreover, isolated systolic hypertension predicts risk better than isolated diastolic hypertension, and the treatment of both isolated systolic hypertension and combined hypertension has reduced cardiovascular events. There are no treatment studies of isolated diastolic hypertension. Pulse pressure reflects stiffening of large arteries and is associated with several cardiovascular risk factors. Pulse pressure also predicts events in epidemiologic studies, but elucidation of an independent role is hampered by the close correlation between pulse pressure and systolic blood pressure.

SUMMARY

Epidemiological and treatment studies suggest that systolic blood pressure should be the primary target of antihypertensive therapy, although consideration of systolic and diastolic pressure together improves risk prediction. The greatest practical concern at the moment is the undertreatment of hypertension, especially systolic, and total cardiovascular risk.

Isolated diastolic hypertension, pulse pressure, and mean arterial pressure as predictors of mortality during a follow-up of up to 32 years

OBJECTIVE

To compare mortality associated with various blood pressure components in middle-aged men during up to 32 years of follow-up.

DESIGN

A prospective cohort study.

SETTING

Helsinki, Finland.

PARTICIPANTS

We studied 3267 initially healthy men, aged 30-45 years, who participated in health check-ups from 1964 onwards.

MAIN OUTCOME MEASURES

Cox regression was used to relate baseline blood pressure components to all-cause (n = 701) and cardiovascular disease (CVD) mortality (n = 325).

RESULTS

Systolic (SBP) and diastolic (DBP) blood pressures, pulse pressure and mean arterial pressure singly predicted CVD mortality. With SBP 160 mmHg and DBP 90 mmHg as cut-off values, four blood pressure subgroups were identified: normotension (n = 1919), isolated systolic hypertension (ISH, n = 17), isolated diastolic hypertension (IDH, n = 1013), and combined systolic and diastolic hypertension (SDH, n = 318). IDH was subdivided into IDH-1 with SBP 140-159 mmHg (n = 667) and IDH-2 with SBP less than 140 mmHg (n = 346). With normotension as reference, only SDH and IDH-1 predicted CVD mortality [relative risk (RR) 2.71, 95% confidence interval (CI) 2.00 to 3.66, and RR 1.39, 95% CI 1.04 to 1.87, respectively]. Risk with IDH-2 (RR 1.14, 95% CI 0.77 to 1.69) was not statistically significant. SDH and IDH-1, but not IDH-2, were also associated with increased all-cause mortality risk. Use of antihypertensive medication did not explain the results.

CONCLUSION

These results demonstrate the often neglected role of SBP in predicting long-term CVD risk in middle-aged men. When SBP is less than 140 mmHg, IDH is not associated with significantly increased risk of mortality. Administrative guidelines, which affect population health, should also take due note of SBP.

Pulse pressure: a predictor of cardiovascular mortality among young normotensive subjects

Wide pulse pressure has been associated with increased cardiovascular disease events among hypertensive subjects. To test the hypothesis that this association also exists among normotensive subjects, data from the first National Health and Nutritional Examination Survey and the 1992 Epidemiological Follow-up Study were analyzed. The study group included 7346 participants, aged 25-74 years, with baseline blood pressure levels <140/90 mmHg and without a history of hypertension. Deaths from cardiovascular disease and all other causes were determined. At entry, mean age and blood pressure level were 43.4 years and 118/76 mmHg. During an average follow-up period of 17.4 years, there were 1443 (19.6%) deaths, 557 of them ascribed to cardiovascular disease. Age-race-adjusted cardiovascular mortality was significantly higher for those in the highest quartile of pulse pressure (> or = 50 mmHg). However, after stratification into age <55 years and > or = 55 years, and controlling for other cardiovascular risk factors, increased pulse pressure was associated with cardiovascular mortality only in younger men and women. In these subjects, men and women with pulse pressures > or = 48, and > or = 46 mmHg, respectively, had a relative risk (95% confidence in terval) of 2.35 (1.21-4.38) and 2.90 (1.34-4.98) for cardiovascular mortality with those with pulse pressures of less than 36 and 34 mmHg, respectively (p < 0.05) as reference. While systolic blood pressure by itself was a weaker predictor of cardiovascular mortality than pulse pressure, diastolic and mean arterial pressure were not predictive at all. No measure of blood pressure was related to mortality in those aged > or = 55 years. In conclusion, among young subjects, but not older normotensive persons, at very low risk of cardiovascular disease, a wide pulse pressure is associated with increased cardiovascular mortality.

Mean blood pressure, pulse pressure and grade of hypertension in untreated hypertensive patients with sleep-related breathing disorder

OBJECTIVE

To test the hypothesis that sleep-related breathing disorder (SRBD) is associated with increasing severity of cardiovascular risk markers.

DESIGN

A cross-sectional study of sleep laboratory patients.

SETTING

University Hospital Sleep Disorders Centre.

PATIENTS

We studied 591 patients referred for a sleep study, all of them without a history of systemic hypertension.

INTERVENTIONS

Clinical interview, two unattended sleep studies, and assessment of office blood pressure, cholesterol concentration, alcohol and nicotine consumption and daytime blood gases.

MAIN OUTCOME MEASURE

Post-hoc analysis of different cardiovascular risk markers: mean blood pressure, pulse pressure, and the type and grade of systemic hypertension.

RESULTS

Patients were classified as normotensive (blood pressure < 140/90 mmHg, n = 228) or hypertensive (blood pressure > or = 140/90 mmHg, n = 363) according to office blood pressure measurements. Mixed (systolic and diastolic) hypertension was the most common type of hypertension (n = 182), followed by isolated diastolic hypertension (n = 101), borderline isolated systolic hypertension (n = 70), and isolated systolic hypertension (n = 10). The frequency of mixed hypertension increased with SRBD activity (P < 0.05) and respiratory disturbance index (RDI; the number of breathing disorders per hour of estimated sleep time) was increased in those with mixed hypertension compared with those with normotension (24.8 compared with 15.7; t test: P < 0.01). In hypertensive patients classified as having grades 1 -3 of hypertension (n = 265, 80 and 18, respectively), there was a progressive increase in RDI (18.9, 27.2 and 30.3, respectively, P < 0.01). Mean blood pressure increased significantly with RDI. Pulse pressure increased significantly with age (P < 0.001), but was unrelated to the degree of SRBD.

CONCLUSION

We conclude that mean blood pressure and the severity of hypertension, but not pulse pressure, increase with the severity of the SRBD.

Excess mortality associated with increased pulse pressure among middle-aged men and women is explained by high systolic blood pressure

OBJECTIVE

To assess the risk of death from coronary heart disease, stroke, all cardiovascular diseases and all-cause mortality associated with pulse pressure among the middle-aged population.

METHODS AND DESIGN

A prospective 15-year follow-up cohort study was conducted of two independent cross-sectional random samples of the population who participated in baseline surveys in 1972 or 1977. Each survey included a self-administered questionnaire with questions on smoking and antihypertensive drug treatment, measurements of height, weight and blood pressure and the determination of the serum cholesterol concentration. Multivariate analyses were performed by using Cox proportional hazard models.

SETTING

The provinces of North Karelia and Kuopio in eastern Finland

PARTICIPANTS

Men and women aged 45-64 years with no history of myocardial infarction or stroke at the time of the baseline survey were selected. In total 4333 men and 5270 women took part in this follow-up study.

RESULTS

The relative risk of coronary heart disease, stroke, cardiovascular disease and all-cause mortality increased with the increasing pulse pressure in individuals aged 45-64 years independent of the diastolic blood pressure level. Only in women with diastolic blood pressure > or = 95 mmHg was the relative risk of fatal stroke not statistically significant. After adjustment for systolic blood pressure, the positive association between mortality and increasing pulse pressure disappeared.

CONCLUSION

Increasing pulse pressure is a predictor of death from coronary heart disease, stroke, cardiovascular disease and all causes in men and women aged 45-64 years, but the increase in risk is entirely associated with the increase in systolic blood pressure.

Target blood pressure for antihypertensive therapy in patients with proteinuric renal disease

The Modification of Diet in Renal Disease (MDRD) study showed for the first time that controlling blood pressure is critically important in slowing the progression of proteinuric renal disease (24-h proteinuria of 1.0 g or more). Furthermore, it was found that the greater proteinuria, the more important it was to achieve excellent blood pressure control. The MDRD analysis also suggested that this paradigm may be particularly important for blacks with proteinuric renal disease. Surprisingly, the MDRD data showed that a blood pressure of 125/75 mm Hg was superior to a blood pressure of 135/85 mm Hg in slowing the progression of renal disease. Thus, so-called hypercontrol of blood pressure is needed to slow the progression of proteinuric renal disease. Studies in patients with diabetic glomerulosclerosis also have provided evidence as to the importance of achieving the low blood pressure goal to slow the progression of the glomerulopathy. In summary, strict control of blood pressure (125/75 mm Hg or less, if tolerated) is recommended to slow the progression of proteinuric renal disease. Furthermore, the greater the proteinuria, the more important it is to achieve this target blood pressure to slow the progression of renal disease.

Hypertension in the elderly

The decade of the 1990s has clarified the perspective on treating hypertension in the elderly and provided a wealth of evidence to assist in the treatment of elevated blood pressure in older persons. Despite this wealth of information, important questions remain about treatment of hypertension in the elderly.