Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg

Cumulative blood pressure predicts risk of cardiovascular outcomes in middle-aged and older population

BACKGROUND

Cardiovascular disease (CVD) remains a major health concern globally, contributing to a considerable disease burden. However, few studies have considered long-term cumulative blood pressure (cBP) exposure in middle-aged and older population in China. The aim of this study was to investigate whether long-term cBP was associated with subsequent cardiovascular outcomes among participants without CVD at baseline in Chinese over 45 years old.

METHODS

6435 participants in China of the CHARLS (The China Health and Retirement Longitudinal Study) were included. Cumulative BP was calculated as the area under the curve using measurements from wave 1 (2011) to wave 2 (2013). Outcomes included CVD, heart disease and stroke.

RESULTS

During a median follow-up period of 5 years, 1101 CVD events, 826 heart disease, and 351 stroke were recorded. Each 1-SD increase in cumulative systolic blood pressure (cSBP), cumulative diastolic blood pressure (cDBP), and cumulative mean arterial pressure (cMAP) was associated with increased risk of CVD (HR, 1.12; 95%, 1.05-1.20, HR, 1.14; 95%, 1.07-1.22, HR, 1.14; 95%, 1.07-1.22), heart disease (HR, 1.05; 95%, 0.97-1.13, HR, 1.09; 95%, 1.01-1.17, HR, 1.08; 95%, 1.00-1.16) and stroke (HR, 1.35; 95%, 1.21-1.51, HR, 1.31; 95%, 1.17-1.46, HR, 1.36; 95%, 1.22-1.51). The relationship between cBP and CVD has only been found in people younger than 60 years of age. A significant association was observed for cumulative pulse pressure (cPP) with stroke (HR, 1.23; 95%, 1.10-1.38). None nonlinear relationships were identified (p-nonlinear > .05). For the prediction of cardiovascular outcomes, cBP load outperformed baseline BP in terms of C statistics (p < .001).

CONCLUSIONS

Long-term cSBP, cDBP and cMAP were associated with subsequent CVD and only found in people younger than 60 years of age, whereas cPP was associated with stroke only across all ages. Cumulative BP may provide a better prediction of cardiovascular outcomes compared with single BP measurement. Efforts are required to control long-term BP in assessing cardiovascular risks.

Increased arterial stiffness and left ventricular remodelling as markers of masked hypertension: findings from the PAMELA population

BACKGROUND

The value of the association of arterial stiffness with left ventricular concentric remodelling/left ventricular hypertrophy (LVH) assessed by echocardiography, for prediction of masked hypertension defined by office and ambulatory blood pressure monitoring (ABPM) in the general population is largely undefined. We investigated this topic in the participants to the Pressioni Monitorate E Loro Associazioni (PAMELA) study.

METHODS

The study included 272 participants (153 normotensives and 119 with masked hypertension) who attended the second and third survey of the PAMELA study performed after 10 and 25 years from the initial evaluation. Data collection included medical history, physical examination, blood tests, office, ABPM, echocardiographic and Cardio-Ankle Vascular Index (CAVI) measurements.

RESULTS

Compared to normotensive individuals, participants with masked hypertension were younger, had significantly higher office, home, mean 24-h, day-time, night-time SBP/DBP and heart rate. The likelihood of having masked hypertension, was approximately more than two-fold higher [odds ratio (OR) = 2.29, confidence interval (CI): 1.01-5.31, P  = 0.04] in participants with increased CAVI and left ventricular remodelling/LVH compared to their counterparts without organ damage. This association showed a unique value in identifying masked hypertension compared to both isolated markers of organ damage (OR = 1.69, P  = 0.15 for increased CAVI and OR = 0.82, P  = 0.80 for left ventricular remodelling/LVH), after adjusting for age, sex, office SBP/DBP, antihypertensive treatment and diabetes.

CONCLUSION

The present study offers a new piece of evidence of the key value of looking for both vascular and cardiac organ damage to unmask MH and improve its clinical management in the general population.

Association of psychiatric history with hypertension among adults who present for metabolic and bariatric surgery

BACKGROUND

Psychiatric diagnoses are common among adults with severe obesity (body mass index [BMI] ≥40 kg/m2) and may be associated with hypertension.

OBJECTIVES

To determine the association between lifetime and current psychiatric diagnoses, separately, with hypertension, uncontrolled blood pressure (BP), and systolic BP (SBP) among adults with severe obesity undergoing metabolic and bariatric surgery (MBS).

SETTING

Academic medical center.

METHODS

Outcomes were identified from electronic medical records. Psychiatric diagnoses were assessed by clinical interview and included any bipolar and related disorder or depressive disorders, anxiety, alcohol use disorder, substance use disorder, post-traumatic stress disorder, and eating disorders. Adjusted odds ratios for the association between psychiatric diagnoses and hypertension and uncontrolled BP, separately, were calculated using logistic regression. Linear regression was used to determine the association of psychiatric diagnoses with SBP. Models were adjusted for age, sex, race, and BMI.

RESULTS

There were 281 participants with mean age of 40.5 years (standard deviation = 10.9) and BMI of 45.9 kg/m2 (standard deviation = 6.2). Participants were predominantly women (86.5%) and Black (57.2%). Overall, 44.8% had hypertension and 32.5% of these individuals had uncontrolled BP. The adjusted odds ratios for hypertension was higher (2.95; 95% confidence interval 1.48-5.87) and SBP was greater (3.50 mm Hg; P = .048) among participants with a lifetime diagnosis of anxiety compared with those without. Participants with any current psychiatric diagnosis had a higher SBP compared to those who did not have a current psychiatric diagnosis (3.62 mm Hg; P = .029).

CONCLUSIONS

A diagnosis of anxiety during the lifetime of patients undergoing MBS was associated with almost three times increased odds of hypertension.

Cost-Effectiveness of Salt Substitution and Antihypertensive Drug Treatment in Chinese Prehypertensive Adults

BACKGROUND

Recent guidelines recommend antihypertensive drug treatment for prehypertensive individuals with blood pressure between 130/80 and 139/89 mm Hg. This study evaluates the cost-effectiveness of 3 interventions in Chinese prehypertensive adults: salt substitution, antihypertensive drug treatment, and their combination.

METHODS

We developed a Markov cohort model to estimate cardiovascular disease (CVD) events, costs, and quality-adjusted life years (QALYs) over a lifetime. Data from the China Kadoorie Biobank informed the simulation. Costs and utilities were drawn from published sources. We evaluated the cost-effectiveness of salt substitution alone, antihypertensive drug treatment alone, and a combination of the 2, focusing on the overall prehypertensive population, those at high CVD risk, and different starting ages (40, 50, 60, and 70 years). Incremental cost-effectiveness ratios (ICERs) were calculated per QALY gained.

RESULTS

Salt substitution at age 40 years is the only cost-effective strategy for prehypertensive individuals, with an ICER of $6413.62/QALY. For those at high CVD risk, the combination intervention starting at age 40 years is most cost-effective, with an ICER of $2913.30/QALY. Interventions initiated at younger ages yielded greater CVD reductions and lower ICERs. For example, a combined intervention at age 40 years reduces CVD events by 5.3% with an ICER of $2913.30/QALY, compared with 4.9% and $32 635.33/QALY at age 70 years. These results were consistent across sensitivity analyses.

CONCLUSIONS

In China, replacing usual salt with a salt substitute is more cost-effective than treating prehypertensive individuals over the age of 40 years with antihypertensive drugs. Furthermore, starting intervention at a younger age in prehypertensive adults can result in even greater cost savings.

mHealth Intervention for Elevated Blood Pressure Among College Students: Single-Arm Intervention Study

BACKGROUND

Current evidence reveals a growing pattern of hypertension among young adults, significantly increasing their risk for cardiovascular disease later in life. Young adults, particularly those of college age, often develop risk factors related to lifestyle choices in diet, exercise, and alcohol consumption. Developing useful interventions that can assist with screening and possible behavioral modifications that are suitable and appealing to college-aged young adults could help with early identification and intervention for hypertension. Recent studies indicate mobile health (mHealth) apps are acceptable and effective for communication and message delivery among this population.

OBJECTIVE

The purpose of this study was to examine the feasibility of using a mobile smartphone delivery system that provides tailored messages based on participant self-measured blood pressure (BP) with college-aged young adults.

METHODS

Using a single-arm intervention, pilot study design, the mHealth to Optimize BP Improvement (MOBILE) intervention was implemented with college students aged 18 years to 39 years who had systolic BP >120 mm Hg and diastolic BP ≥80 mm Hg. Participants were required to measure their BP daily for 28 days, submit the readings to the app, and receive preset educational text messages tailored to their BP value and related to encouraging healthy lifestyle modifications. Changes in a participant's BP was evaluated using a mixed regression model, and a postintervention survey evaluated their perspectives on the mHealth intervention.

RESULTS

The participants' (N=9) mean age was 22.64 (SD 4.54) years; 56% (5/9) were overweight, and 11% (1/9) were obese. The average daily participation rate was 86%. Of the 9 participants, 8 completed the survey, and all indicated the intervention was easy to use, found it increased awareness of their individual BP levels, indicated the text messages were helpful, and reported making lifestyle changes based on the study intervention. They also provided suggestions for future implementation of the intervention and program. Overall, no significant changes were noted in BP over the 28 days.

CONCLUSIONS

The mHealth-supported MOBILE intervention for BP monitoring and tailored text messaging was feasible to implement, as our study indicated high rates of participation and acceptability. These encouraging findings support further development and testing in a larger sample over a longer time frame and hold the potential for early identification and intervention among college-aged adults, filling a gap in current research.

Satisfaction with local healthcare services and medical need among hypertensive patients: a nationwide study

BACKGROUND

Investigating the factors associated with unmet medical needs is important since it can reflect access to healthcare. This study examined the relationship between the unmet medical needs of patients with hypertension and their satisfaction with the healthcare services available in their neighborhoods.

METHODS

Data were from the 2021 Korean Community Health Survey. The sample included individuals aged 19 years who were diagnosed with hypertension. The main outcome measure was unmet medical need. The relationship between the outcome measure and independent variables were analyzed using multivariate logistic regressions, along with a subgroup analysis based on whether patients were currently receiving treatment for hypertension.

RESULTS

Unmet medical needs were found in 4.3% of the study participants. A higher likelihood of unmet medical needs was found in individuals not satisfied with the healthcare services at proximity (adjusted OR = 1.69, 95% CI: 1.49-1.92) compared to those satisfied with services nearby. Similar tendencies were found regardless of whether individuals were currently receiving treatment for hypertension, although larger differences were found between groups in participants who were currently not receiving treatment.

CONCLUSIONS

The findings infer the need to consider patient satisfaction with nearby healthcare services in implementing public health policies that address unmet medical need in patients with hypertension.

Estimated Population Health Benefits of Intensive Systolic Blood Pressure Treatment Among SPRINT-Eligible US Adults

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated an intensive (<120 mm Hg) vs. standard (<140 mm Hg) systolic blood pressure (SBP) goal lowered cardiovascular disease (CVD) risk. Estimating the effect of intensive SBP lowering among SPRINT-eligible adults most likely to benefit can guide implementation efforts.

METHODS

We studied SPRINT participants and SPRINT-eligible participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study and National Health and Nutrition Examination Surveys (NHANES). A published algorithm of predicted CVD benefit with intensive SBP treatment was used to categorize participants into low, medium, or high predicted benefit. CVD event rates were estimated with intensive and standard treatment.

RESULTS

Median age was 67.0, 72.0, and 64.0 years in SPRINT, SPRINT-eligible REGARDS, and SPRINT-eligible NHANES participants, respectively. The proportion with high predicted benefit was 33.0% in SPRINT, 39.0% in SPRINT-eligible REGARDS, and 23.5% in SPRINT-eligible NHANES. The estimated difference in CVD event rate (standard minus intensive) was 7.0 (95% confidence interval [CI] 3.4-10.7), 8.4 (95% CI 8.2-8.5), and 6.1 (95% CI 5.9-6.3) per 1,000 person-years in SPRINT, SPRINT-eligible REGARDS participants, and SPRINT-eligible NHANES participants, respectively (median 3.2-year follow-up). Intensive SBP treatment could prevent 84,300 (95% CI 80,800-87,920) CVD events per year in 14.1 million SPRINT-eligible US adults; 29,400 and 28,600 would be in 7.0 million individuals with medium or high predicted benefit, respectively.

CONCLUSIONS

Most of the population health benefit from intensive SBP goals could be achieved by treating those characterized by a previously published algorithm as having medium or high predicted benefit.

Systolic Blood Pressure and Cardiovascular Risk in Normotensive Adults

OBJECTIVE

To examine the association of systolic blood pressure (SBP) and cardiovascular risk in normotensive adults.

PATIENTS AND METHODS

This study analyzed data from 7 prospective cohorts between September 29, 1948, and December 31, 2018. Complete information on history of hypertension and baseline blood pressure measurements were required for inclusion. We excluded individuals younger than 18 years old, those with a history of hypertension, and patients with baseline SBP measurements of less than 90 mm Hg or 140 mm Hg or higher. Cox proportional hazards regression and restricted cubic spline models were used to evaluate the hazards of cardiovascular outcomes.

RESULTS

A total of 31,033 participants were included. The mean ± SD age was 45.3±14.8 years, 16,693 of the participants (53.8%) were female, and the mean ± SD SBP was 115.8±11.7. Over a median follow-up of 23.5 years, 7005 cardiovascular events occurred. Compared with those who had SBP levels of 90 to 99 mm Hg, participants with SBP levels of 100 to 109, 110 to 119, 120 to 129, and 130 to 139 mm Hg experienced 23% (hazard ratio [HR], 1.23; 95% CI, 1.07 to 1.42), 53% (HR, 1.53; 95% CI, 1.33 to 1.76), 87% (HR, 1.87; 95% CI, 1.62 to 2.16), and 117% (HR, 2.17; 95% CI, 1.87 to 2.52) increased risks of cardiovascular events, respectively. Compared with follow-up SBP of 90 to 99 mm Hg, the HRs for cardiovascular events were 1.25 (95% CI, 1.02 to 1.54), 1.93 (95% CI, 1.58 to 2.34), 2.55 (95% CI, 2.09 to 3.10), and 3.39 (95% CI, 2.78 to 4.14), respectively, for follow-up SBP levels of 100 to 109, 110 to 119, 120 to 129, and 130 to 139 mm Hg.

CONCLUSION

In adults without hypertension, there is a stepwise increase in risk of cardiovascular events, with increasing SBP starting at levels as low as 90 mm Hg.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Response of circulating metabolites to an oral glucose challenge and risk of cardiovascular disease and mortality in the community

Background

New biomarkers to identify cardiovascular disease (CVD) risk earlier in its course are needed to enable targeted approaches for primordial prevention. We evaluated whether intraindividual changes in blood metabolites in response to an oral glucose tolerance test (OGTT) may provide incremental information regarding the risk of future CVD and mortality in the community.

Methods

An OGTT (75 g glucose) was administered to a subsample of Framingham Heart Study participants free from diabetes (n = 361). Profiling of 211 plasma metabolites was performed from blood samples drawn before and 2 h after OGTT. The log2(post/pre) metabolite levels (Δmetabolites) were related to incident CVD and mortality in Cox regression models adjusted for age, sex, baseline metabolite level, systolic blood pressure, hypertension treatment, body mass index, smoking, and total/high-density lipoprotein cholesterol. Select metabolites were related to subclinical cardiometabolic phenotypes using Spearman correlations adjusted for age, sex, and fasting metabolite level.

Results

Our sample included 42% women, with a mean age of 56 ± 9 years and a body mass index of 30.2 ± 5.3 kg/m². The pre- to post-OGTT changes (Δmetabolite) were non-zero for 168 metabolites (at FDR ≤ 5%). A total of 132 CVD events and 144 deaths occurred during median follow-up of 24.9 years. In Cox models adjusted for clinical risk factors, four Δmetabolites were associated with incident CVD (higher glutamate and deoxycholate, lower inosine and lysophosphatidylcholine 18:2) and six Δmetabolites (higher hydroxyphenylacetate, triacylglycerol 56:5, alpha-ketogluturate, and lower phosphatidylcholine 32:0, glucuronate, N-monomethyl-arginine) were associated with death (P < 0.05). Notably, baseline metabolite levels were not associated with either outcome in models excluding Δmetabolites. The Δmetabolites exhibited varying cross-sectional correlation with subclinical risk factors such as visceral adiposity, insulin resistance, and vascular stiffness, but overall relations were modest. Significant Δmetabolites included those with established roles in cardiometabolic disease (e.g., glutamate, alpha-ketoglutarate) and metabolites with less defined roles (e.g., glucuronate, lipid species).

Conclusions

Dynamic changes in metabolite levels with an OGTT are associated with incident CVD and mortality and have potential relevance for identifying CVD risk earlier in its development and for discovering new potential therapeutic targets.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01647-w.

Reduction in blood pressure for elevated blood pressure/stage 1 hypertension according to the ACC/AHA guideline and cardiovascular outcomes

Aims

Few studies have examined the relationship of blood pressure (BP) change in adults with elevated BP or stage 1 hypertension according to the ACC/AHA guideline with cardiovascular outcomes. We sought to identify the effect of BP change among individuals with elevated BP or stage 1 hypertension on incident heart failure (HF) and other cardiovascular diseases (CVDs).

Methods and results

We conducted a retrospective cohort study including 616,483 individuals (median age 46 years, 73.7% men) with elevated BP or stage 1 hypertension based on the ACC/AHA BP guideline. Participants were categorized using BP classification at one-year as normal BP (n = 173,558), elevated BP/stage 1 hypertension (n = 367,454), or stage 2 hypertension (n = 75,471). The primary outcome was HF, and the secondary outcomes included (separately) myocardial infarction (MI), angina pectoris (AP), and stroke. Over a mean follow-up of 1,097 ± 908 days, 10,544 HFs, 1,317 MIs, 11,070 APs, and 5,198 strokes were recorded. Compared with elevated BP/stage 1 hypertension at one-year, normal BP at one-year was associated with a lower risk of developing HF (HR:0.89, 95% CI:0.85-0.94), whereas stage 2 hypertension at one-year was associated with an elevated risk of developing HF (HR:1.43, 95% CI:1.36-1.51). This association was also present in other cardiovascular outcomes including MI, AP, and stroke. The relationship was consistent in all subgroups stratified by age, sex, baseline BP category, and overweight/obesity.

Conclusion

A one-year decline in BP was associated with the lower risk of HF, MI, AP, and stroke, suggesting the importance of lowering BP in individuals with elevated BP or stage 1 hypertension according to the ACC/AHA guideline to prevent the risk of developing CVD.

New wrinkles in hypertension management 2022

PURPOSE OF REVIEW

High blood pressure (BP) is the world's leading risk factor for cardiovascular disease (CVD) and death. This review highlights findings during the past 18 months that apply to the management of high BP in adults in the context of the 2017 American College of Cardiology/American Heart Association (AHA) BP guideline.

RECENT FINDINGS

A comprehensive meta-analysis of clinical trials that employed a novel statistical method identified a substantially linear relationship between dietary sodium intake and BP, strongly supporting the AHA daily dietary sodium intake recommendation of less than 1500 mg/day but suggesting that any reduction in sodium intake is likely to be beneficial. Among adults with hypertension, use of a salt substitute (containing reduced sodium and enhanced potassium) led to striking reductions in CVD outcomes. Young adults with stage 1 hypertension and a low 10-year atherosclerotic CVD risk score should be started on a 6-month course of vigorous lifestyle modification; if their BP treatment goal is not achieved, a first-line antihypertensive agent should be added to the lifestyle modification intervention. In patients with stage 4 renal disease, the thiazide-like diuretic chlorthalidone (as add-on therapy) lowered BP markedly compared with placebo. Nonsteroidal mineralocorticoid receptor antagonists (MRAs) represent a new class of MRA that has been shown to lower BP and provide significant CVD protection. In Chinese adults aged 60-80 years at baseline, intensive BP control with a SBP target of 110-129 compared with 130-149 mmHg reduced CVD events with minimal side effects.

SUMMARY

Recent findings have advanced our knowledge of hypertension management, clarifying, amplifying and supporting the 2017 ACC/AHA BP guideline recommendations.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prevalence of Cardiometabolic Syndrome and its Association With Body Shape Index and A Body Roundness Index Among Type 2 Diabetes Mellitus Patients: A Hospital-Based Cross-Sectional Study in a Ghanaian Population

Cardiometabolic syndrome (MetS) is closely linked to type 2 diabetes mellitus (T2DM) and is the leading cause of diabetes complications. Anthropometric indices could be used as a cheap approach to identify MetS among T2DM patients. We determined the prevalence of MetS and its association with sociodemographic and anthropometric indices among T2DM patients in a tertiary hospital in the Ashanti region of Ghana. A comparative cross-sectional study was conducted among 241 T2DM outpatients attending the Komfo Anokye Teaching Hospital (KATH) and the Kumasi South Hospital for routine check-up. Sociodemographic characteristics, clinicobiochemical markers, namely, systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), and glycated hemoglobin (HbA1C) were measured. Anthropometric indices, namely, body mass index (BMI), Conicity index (CI), body adiposity index (BAI), A body shape index (ABSI), body roundness index (BRI), Waist-to-hip ratio (WHR), and Waist-to-height ratio (WHtR) were computed based on either the Height, Weight, Waist circumference (WC) or Hip circumference (HC) of the patients. Metabolic syndrome (MetS) was classified using the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria. Data entry and analysis were done using Excel 2016 and SPSS version 25.0 respectively. Of the 241 T2DM patients, 99 (41.1%) were males whereas 144 (58.9%) were females. The prevalence of cardiometabolic syndrome (MetS) was 42.7% with dyslipidemia and hypertension recording a prevalence of 6.6 and 36.1%, respectively. Being a female T2DM patient [aOR = 3.02, 95%CI (1.59-5.76), p = 0.001] and divorced [aOR = 4.05, 95%CI (1.22-13.43), p = 0.022] were the independent sociodemographic predictors of MetS among T2DM patients. The 4th quartile for ABSI and 2nd to 4th quartiles for BSI were associated with MetS on univariate logistic regression (p <0.05). Multivariate logistic regression identified the 3rd quartile (aOR = 25.15 (2.02-313.81), p = 0.012) and 4th quartile (aOR = 39.00, 95%CI (2.68-568.49), p = 0.007) for BRI as the independent predictors of MetS among T2DM. The prevalence of cardiometabolic syndrome is high among T2DM patients and this was influenced by female gender, being divorced, and increased BRI. Integration of BRI as part of routine assessment could be used as early indicator of cardiometabolic syndrome among T2DM patients.

Association between cumulative blood pressure in early adulthood and right ventricular structure and function in middle age: The CARDIA study

OBJECTIVE

Cumulative blood pressure (BP) exposure is a known risk factor for cardiovascular disease. This study sought to investigate the association between cumulative BP from early adulthood to middle age and right ventricular (RV) structure and function in middle age.

METHODS

We included 2844 participants from the CARDIA study (Coronary Artery Risk Development in Young Adults). Cumulative BP over the 30-years follow-up was defined as the sum of the product of mean BP for each pair of consecutive examinations and the time interval between these two consecutive examinations in years. RV structure and function were assessed by echocardiography. The main analyses utilized logistic and linear regression models.

RESULTS

In fully adjusted models, higher cumulative systolic BP was independently associated with lower tricuspid annular plane systolic excursion (TAPSE), right ventricular peak systolic velocity (RVS'), right ventricular early diastolic velocity (RVe'), and higher pulmonary arterial systolic pressure. Higher cumulative diastolic BP was independently associated with smaller RV basal diameter, lower TAPSE, RVS', and RVe'. For categorical analyses of RV dysfunction, cumulative systolic BP was not related to systolic dysfunction. Per 1-SD increase in cumulative systolic BP was associated with a higher risk of diastolic dysfunction, while an increase in cumulative diastolic BP was associated with a higher risk of systolic dysfunction and diastolic dysfunction.

CONCLUSIONS

Cumulative exposure to increased BP from early adulthood to middle age was associated with incipient RV systolic and diastolic dysfunction in middle age. Exposure to higher diastolic BP levels from early adulthood to middle age was associated with a smaller RV basal diameter in middle age.

Incorporation of Retinal Arteriolosclerosis into Risk Stratification of Blood Pressure Category According to the 2017 ACC/AHA Blood Pressure Guideline

Aim: We investigated whether retinal arteriolosclerosis (RA) could be used for cardiovascular disease (CVD) risk stratification of individuals categorized according to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Blood Pressure (BP) guideline.

Methods: We studied 291,522 participants without a history of CVD and not taking any BP-lowering medications from the JMDC Claims Database. RA was defined as Keith–Wagener–Barker system grade ≥ 1. Each participant was classified into one of the six groups: (1) normal or elevated BP without RA, (2) normal or elevated BP with RA, (3) stage 1 hypertension without RA, (4) stage 1 hypertension with RA, (5) stage 2 hypertension without RA, and (6) stage 2 hypertension with RA.

Results: Median (interquartile range) age was 46 (40–53) years, and 141,397 (48.5%) of the participants were men. During a mean follow-up of 1,223±830 days, 527 myocardial infarction (MI), 5,718 angina pectoris, 2,890 stroke, and 5,375 heart failure (HF) events occurred. Multivariable Cox regression analyses revealed that the risk of CVD increased with BP category, and this association was pronounced by the presence of RA. Compared with normal or elevated BP without RA, the hazard ratios (HRs) for MI (HR 1.17, 95% CI 0.93–1.47) were higher in stage 1 hypertension without RA. The HRs for MI further increased in stage 1 hypertension with RA (1.86 [1.17–2.95]). This association was present in stroke and HF.

Conclusion: Incorporation of the assessment for RA may facilitate the CVD risk stratification of people classified based on the 2017 ACC/AHA BP guideline, particularly for those categorized in stage 1 hypertension.

Randomized controlled trial of stress reduction with meditation and health education in black men and women with high normal and normal blood pressure

BACKGROUND

Black men and women suffer from disparities in morbidity and mortality from hypertension, cardiovascular disease, and currently, COVID-19. These conditions are associated with social determinants of health and psychosocial stress. While previous trials demonstrated that stress reduction with meditation lowered BP in the grade I range in Black adults, there is a paucity of evidence for high normal and normal BP.

OBJECTIVE

This randomized controlled trial was conducted to evaluate the effect of stress reduction with the Transcendental Meditation (TM) technique in Black adults with high normal BP and normal BP using international classifications.

METHODS

A total of 304 Black men and women with high normal (130-139/85-89 mm Hg) and normal BP (120-129/80-84 mm Hg) were randomized to either TM or health education (HE) groups. BP was recorded at 3, 6, 9, 12, 24, 30 and 36 months after baseline. Linear mixed model analysis was conducted to compare the BP change between TM and HE participants in the high-normal BP and normal-BP groups. Survival analysis for hypertensive events was conducted.

RESULTS

After an average of 19.9 ± 11.1 months follow-up, TM participants in the high-normal BP group showed significantly lower posttest SBP (-3.33 mm Hg, p = 0.045). There was no difference in DBP (-0.785 mm Hg, p = 0.367) compared to HE participants. In the normal BP group, the SBP and DBP were not different between the TM and HE participants. The hazard ratio for hypertensive events was 0.52 (p = 0.15) in the high normal BP group (7 TM vs 13 HE) with no difference in the normal BP group.

CONCLUSION

This RCT found that meditation lowered systolic BP in Black men and women with high normal BP but not in normal BP participants. These results may be relevant to reducing health disparities in CVD and related co-morbidities.

Long-term cumulative blood pressure in young adults and incident heart failure, coronary heart disease, stroke, and cardiovascular disease: The CARDIA study

AIMS

Cumulative blood pressure (BP) is a measure that incorporates the severity and duration of BP exposure. The prognostic significance of cumulative BP in young adults for cardiovascular diseases (CVDs) in comparison to BP severity alone is, however, unclear.

METHODS AND RESULTS

We investigated 3667 Coronary Artery Risk Development in Young Adults participants who attended six visits over 15 years (year-0 (1985-1986), year-2, year-5, year-7, year-l0, and year-15 exams). Cumulative BP was calculated as the area under the curve (mmHg × years) from year 0 through year 15. Cox models assessed the association between cumulative BP (year 0 through year 15), current BP (year 15), and BP change (year 0 and year 15) and CVD outcomes. Mean (standard deviation) age at year 15 was 40.2 (3.6) years, 44.1% were men, and 44.1% were African-American. Over a median follow-up of 16 years, there were 47 heart failure (HF), 103 coronary heart disease (CHD), 71 stroke, and 191 CVD events. Cumulative systolic BP (SBP) was associated with HF (hazard ratio (HR) = 2.14 (1.58-2.90)), CHD (HR = 1.49 (1.19-1.87)), stroke (HR = 1.81 (1.38-2.37)), and CVD (HR = 1.73 (1.47-2.05)). For CVD, the C-statistic for SBP (year 15) was 0.69 (0.65-0.73) and change in C-statistic with the inclusion of SBP change and cumulative SBP was 0.60 (0.56-0.65) and 0.72 (0.69-0.76), respectively. For CVD, using year-15 SBP as a reference, the net reclassification index (NRI) for cumulative SBP was 0.40 (p < 0.0001) and the NRI for SBP change was 0.22 (p = 0.001).

CONCLUSIONS

Cumulative BP in young adults was associated with the subsequent risk of HF, CHD, stroke, and CVD. Cumulative BP provided incremental prognostic value and improved risk reclassification for CVD, when compared to single BP assessments or changes in BP.

Level of systolic blood pressure within the normal range and risk of cardiovascular events in the absence of risk factors in Chinese

The risk of cardiovascular disease (CVD) at currently defined normal systolic blood pressure (SBP) levels in individuals without CVD risk factors is not well examined. We evaluated whether higher systolic blood pressure within the range considered normal is associated with a higher CVD risk in Chinese without traditional CVD risk factors. The community-based study included 25,529 individuals (mean age:47.3 ± 12.3 years;range:18–95 years) with a baseline SBP of 90–129 mmHg, who were free of CVD and traditional CVD risk factors, and who were re-examined in biennial intervals. During a mean follow-up of 10.6 ± 1.49 years (maximum. 11.5 years), 847 CVD events occurred. CVD incidence per 1000 person-years increased with higher baseline SBP levels (SBP,90–99 mmHg:1.45;100–109 mmHg:2.15;110–119 mmHg:3.06; and 120–129 mmHg:3.80). After adjusting for CVD risk factors, the categorical Cox regression suggested that the CVD risk was not statistically significant for study participants with a baseline SBP level of 100–109 mmHg, 110–119 mmHg, and 120–129 mmHg compared with those with a baseline SBP level of 90–99 mmHg. If CVD risk factors including blood pressure categories which developed during follow-up were included in a time-dependent Cox regression analysis, the normal baseline SBP was still not associated with incident CVDs. A SBP between 90 and 129 mmHg was not associated with an increased CVD risk in a healthy population.

Progress and Research Priorities in Imaging Genomics for Heart and Lung Disease: Summary of an NHLBI Workshop

Imaging genomics is a rapidly evolving field that combines state-of-the-art bioimaging with genomic information to resolve phenotypic heterogeneity associated with genomic variation, improve risk prediction, discover prevention approaches, and enable precision diagnosis and treatment. Contemporary bioimaging methods provide exceptional resolution generating discrete and quantitative high-dimensional phenotypes for genomics investigation. Despite substantial progress in combining high-dimensional bioimaging and genomic data, methods for imaging genomics are evolving. Recognizing the potential impact of imaging genomics on the study of heart and lung disease, the National Heart, Lung, and Blood Institute convened a workshop to review cutting-edge approaches and methodologies in imaging genomics studies, and to establish research priorities for future investigation. This report summarizes the presentations and discussions at the workshop. In particular, we highlight the need for increased availability of imaging genomics data in diverse populations, dedicated focus on less common conditions, and centralization of efforts around specific disease areas.

Sex and body mass index dependent associations between serum 25-hydroxyvitamin D and pulse pressure in middle-aged and older US adults

High pulse pressure (PP) is a valid indicator of arterial stiffness. Many studies have reported that vitamin D concentration is inversely associated with vascular stiffening. This association may differ depending on sex and body mass index (BMI). This study investigated the associations between vitamin D and PP and evaluated whether these associations differ according to sex and BMI, using data for individuals aged ≥ 50 years from the National Health and Nutrition Examination Survey (NHANES) 2007-2010. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were used as biomarkers of vitamin D levels. High PP was defined as ≥ 60 mmHg. Total 25(OH)D concentrations were dose-dependently associated with lower odds ratios (ORs) for high PP (p-trend = 0.01), after controlling for sociodemographic, behavioral, and dietary factors. When stratified by sex, there was a dose-dependent association between total 25(OH)D concentrations and lower risk of high PP (p-trend < 0.001) in females, but not in males. When stratified by BMI, there was a dose-dependent association between total 25(OH)D concentrations and lower risk of high PP (p-trend < 0.001) in non-overweight subjects, but not in overweight subjects. Improving the vitamin D status could delay elevation of PP and vascular stiffening in female and non-overweight subjects.

Blood pressure and long-term subclinical cardiovascular outcomes in low-risk young adults: Insights from Hanzhong adolescent hypertension cohort

Stage 1 hypertension, newly defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline, has been the subject of significant interest globally. This study aims to assess the impact of the new blood pressure (BP) stratum on subsequent subclinical cardiovascular outcomes in low-risk young adults. This longitudinal study consisted of 1020 young adults (47.7% female; ages 18-23 years) free of cardiovascular disease from the Hanzhong Adolescent Hypertension Cohort with up to 25-year follow-up since 1992-1995. Outcomes were available through June 2017. Young adults with stage 1 hypertension accounted for 23.7% of the cohort. When it comes to middle adulthood, subjects with early life stage 1 hypertension were more likely to experience BP progression, and they had a 1.61-fold increased risk of high-risk brachial-ankle pulse wave velocity (baPWV) and a 2.92-fold risk of left ventricular hypertrophy (LVH) comparing with their normotensive counterparts. Among participants without any active treatment in midlife, the risk associated with stage 1 hypertension for BP progression was 2.25 (95% confidence interval [CI] = 1.41-3.59), high-risk baPWV was 1.58 (95% CI = 1.09-2.79), LVH was 2.75 (95% CI = 1.16-6.48), and subclinical renal damage (SRD) was 1.69 (95% CI = 1.02-2.82) compared with the normal BP group. Overall, young adults with stage 1 hypertension had significantly higher risks for midlife subclinical cardiovascular outcomes than normotensive subjects. BP management targeting low-risk young adults is of importance from both clinical and public health perspectives.

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Improving Stroke Risk Prediction in the General Population: A Comparative Assessment of Common Clinical Rules, a New Multimorbid Index, and Machine-Learning-Based Algorithms

BACKGROUND

 There are few large studies examining and predicting the diversified cardiovascular/noncardiovascular comorbidity relationships with stroke. We investigated stroke risks in a very large prospective cohort of patients with multimorbidity, using two common clinical rules, a clinical multimorbid index and a machine-learning (ML) approach, accounting for the complex relationships among variables, including the dynamic nature of changing risk factors.

METHODS

 We studied a prospective U.S. cohort of 3,435,224 patients from medical databases in a 2-year investigation. Stroke outcomes were examined in relationship to diverse multimorbid conditions, demographic variables, and other inputs, with ML accounting for the dynamic nature of changing multimorbidity risk factors, two clinical risk scores, and a clinical multimorbid index.

RESULTS

 Common clinical risk scores had moderate and comparable c indices with stroke outcomes in the training and external validation samples (validation-CHADS₂: c index 0.812, 95% confidence interval [CI] 0.808-0.815; CHA₂DS₂-VASc: c index 0.809, 95% CI 0.805-0.812). A clinical multimorbid index had higher discriminant validity values for both the training/external validation samples (validation: c index 0.850, 95% CI 0.847-0.853). The ML-based algorithms yielded the highest discriminant validity values for the gradient boosting/neural network logistic regression formulations with no significant differences among the ML approaches (validation for logistic regression: c index 0.866, 95% CI 0.856-0.876). Calibration of the ML-based formulation was satisfactory across a wide range of predicted probabilities. Decision curve analysis demonstrated that clinical utility for the ML-based formulation was better than that for the two current clinical rules and the newly developed multimorbid tool. Also, ML models and clinical stroke risk scores were more clinically useful than the "treat all" strategy.

CONCLUSION

 Complex relationships of various comorbidities uncovered using a ML approach for diverse (and dynamic) multimorbidity changes have major consequences for stroke risk prediction. This approach may facilitate automated approaches for dynamic risk stratification in the significant presence of multimorbidity, helping in the decision-making process for risk assessment and integrated/holistic management.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The Molecular Basis of Predicting Atherosclerotic Cardiovascular Disease Risk

Atherosclerotic cardiovascular disease (ASCVD) proceeds through a series of stages: initiation, progression (or regression), and complications. By integrating known biology regarding molecular signatures of each stage with recent advances in high-dimensional molecular data acquisition platforms (to assay the genome, epigenome, transcriptome, proteome, metabolome, and gut microbiome), snapshots of each phase of atherosclerotic cardiovascular disease development can be captured. In this review, we will summarize emerging approaches for assessment of atherosclerotic cardiovascular disease risk in humans using peripheral blood molecular signatures and molecular imaging approaches. We will then discuss the potential (and challenges) for these snapshots to be integrated into a personalized movie providing dynamic readouts of an individual's atherosclerotic cardiovascular disease risk status throughout the life course.

Montelukast Use Decreases Cardiovascular Events in Asthmatics

Cysteinyl leukotrienes are proinflammatory mediators with a clinically established role in asthma and a human genetic and preclinical role in cardiovascular pathology. Given that cardiovascular disease has a critical inflammatory component, the aim of this work was to conduct an observational study to verify whether the use of a cysteinyl leukotriene antagonist, namely, montelukast, may protect asthmatic patients from a major cardiovascular event and, therefore, represent an innovative adjunct therapy to target an inflammatory component in cardiovascular disease. We performed an observational retrospective 3-year study on eight hundred adult asthmatic patients 18 years or older in Albania, equally distributed into two cohorts, exposed or nonexposed to montelukast usage, matched by age and gender according to information reported in the data collection. Patients with a previous history of myocardial infarction or ischemic stroke were excluded. In summary, 37 (4.6%) of the asthmatic patients, 32 nonexposed, and five exposed to montelukast suffered a major cardiovascular event during the 3-year observation period. All the cardiovascular events, in either group, occurred among patients with an increased cardiovascular risk. Our analyses demonstrate that, independent from gender, exposure to montelukast remained a significant protective factor for incident ischemic events (78% or 76% risk reduction depending on type of analysis). The event-free Kaplan–Meier survival curves confirmed the lower cardiovascular event incidence in patients exposed to montelukast. Our data suggest that there is a potential preventative role of montelukast for incident cardiac ischemic events in the older asthmatic population, indicating a comorbidity benefit of montelukast usage in asthmatics by targeting cysteinyl leukotriene-driven cardiac disease inflammation.

Blood Pressure States Transition Inference Based on Multi-State Markov Model

The investigation of risk factors associated with hypertension patients has been extensively studied in the past decades. However, the pattern of natural progressive trajectories to hypertension from nonhypertensive states was rarely explored. In this study, we are interested in discovering the underlying transition patterns between different blood pressure states, namely normal state, elevated state, and hypertensive state among the working population in the United States. A multi-state Markov model was built based on 88,966 clinical records from 34,719 participants we collected during the worksite preventive screening from 2012 to 2018. We first investigated the various risk factors, and we found that body mass index (BMI) is the most critical factor for developing new-onset hypertension. The transition probabilities, survival probabilities, and sojourn time of each state were derived given different levels of BMI, age groups, and gender categories. We found the underweight participants are more likely to remain in the current nonhypertensive states within 3 years, while extremely obese participants have a higher probability of developing hypertension. We discovered the distinct transition patterns among male and female participants. On average, the sojourn time in the normal state for normal-weight participants is 4.33 years for females and 2.18 years for their male counterparts. For the extremely obese participants, the average sojourn time in the normal state is 1.38 years for females and 0.71 years for males. In the end, a web-based graphical user interface (GUI) application was developed for clinicians to visualize the impact of behavioral interventions on delaying the progression of hypertension. Our analysis can provide a unique insight into hypertension research and proactive interventions.

Hypertension (Blood Pressure) and Lifetime Risk of Target Organ Damage

PURPOSE OF REVIEW

The purpose of this review is to describe the long-term or lifetime relationship between blood pressure and target organ damage. The use of the term "blood pressure" as opposed to hypertension is purposeful. The risk of cardiovascular disease from blood pressure begins below the levels of blood pressure defined as hypertension by contemporary definitions.

RECENT FINDINGS

An important recent publication that bears on this topic was the 2017 ACC/AHA Blood Pressure Management Guidelines. The redefinition of hypertension and blood pressure treatment goal to 130/80 mmHg and the decision to rely almost exclusively on data from event-based randomized controlled clinical trials, which led to a recommendation for lifestyle therapy only for most with stage 1 hypertension, were important. A report from the CARDIA study demonstrated significant risk for cardiovascular disease at 20 years for stage 1 hypertension. Based on all evidence, clinicians should consider the use of medication for stage 1 hypertension in those uncontrolled on lifestyle therapy.

Visit-to-Visit Blood Pressure Variability, Coronary Atheroma Progression, and Clinical Outcomes

Importance

Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events, but mechanisms and therapeutic implications underlying this association are not well understood.

Objective

To examine the association of intraindividual BPV, coronary atheroma progression, and clinical outcomes using serial intravascular ultrasonography.

Design, Setting, and Participants

Post hoc patient-level analysis of 7 randomized clinical trials conducted from 2004 to 2016 involving 3912 patients in multicenter, international, clinic-based primary and tertiary care centers. Adult patients with coronary artery disease who underwent serial intravascular ultrasonography in the setting of a range of medical therapies were included. Data were analyzed between November 2017 and March 2019.

Exposures

Visit-to-visit BPV measured using intraindividual standard deviation over 3, 6, 12, 18, and 24 months.

Main Outcomes and Measures

Percent atheroma volume (PAV) progression and major adverse cardiovascular events (defined as death, myocardial infarction, stroke, urgent revascularization for acute coronary syndrome, and hospitalization for unstable angina).

Results

Of 3912 patients, the mean (SD) age was 58 (9) years, 1093 (28%) were women, and 3633 (93%) were white . Continuous change in PAV was significantly associated with systolic BPV (β, .049; 95% CI, 0.021-0.078; P = .001), diastolic BPV (β, .031; 95% CI, 0.002-0.059; P = .03), and pulse pressure variability (β, .036; 95% CI, 0.006-0.067; P = .02), without a signal for differential effect greater than or less than a mean BP of 140/90 mm Hg. The PAV progression as a binary outcome was significantly associated with systolic BPV (odds ratio, 1.09; 95% CI, 1.01-1.17; P = .02) but not diastolic BPV (odds ratio, 1.04; 95% CI, 0.97-1.11; P = .30) or pulse pressure variability (odds ratio, 1.03; 95% CI, 0.96-1.10; P = .47). Survival curves revealed a significant stepwise association between cumulative major adverse cardiovascular events and increasing quartiles of systolic BPV (Kaplan-Meier estimates for quartiles 1-4: 6.1% vs 8.5% vs 10.1% vs 12.0%, respectively; log-rank P <.001). These distinct stepwise associations were not seen with diastolic BPV or pulse pressure variability.

Conclusions and Relevance

Greater BPV, particularly systolic BPV, is significantly associated with coronary atheroma progression and adverse clinical outcomes. These data suggest maintaining stable blood pressure levels may be important to further improve outcomes in patients with coronary disease.

To whom recommend intensive treatment for hypertension?

Arterial hypertension is the main identifiable cardiovascular risk factor, and although the benefit of blood pressure reduction is universally acknowledged, the scientific community has long been divided over the therapeutic blood pressure targets to be reached, also considering the estimated overall cardiovascular risk and the presence of individual risk factors and associated comorbidities. During the last few years, numerous clinical studies and meta-analyses, in particular, the SPRINT study, have been published, demonstrating the advantages of an intensive antihypertensive treatment, over a target blood pressure value (<140/90 mmHg), in the reduction of major cardiovascular events, myocardial infarction, stroke, heart failure, and all-causes cardiovascular mortality. Stemming from these results the major International Guidelines revisited the therapeutic objectives, recommending blood pressure value <130/80 mmHg for the vast majority of hypertensive patients until the age of 65 and suggesting a reduction of the target also in the elderly. Numerous studies and meta-analyses demonstrated that the reduction of the risk of coronary or cerebral events, and of all-causes cardiovascular mortality, is independent from the baseline value of blood pressure and the individual estimated risk. It has been also demonstrated that an early institution of antihypertensive treatment is associated with a faster realization of the recommended targets, and consequent significant benefits in terms of reduction of the incidence of myocardial infarction, heart failure, and major cardiovascular events, particularly when blood pressure control is achieved during the first 6 months of treatment, and even better during first 3 months. Other studies outlined that combination therapy with two or more drugs, mainly in a single pill configuration, are superior in reaching the recommended therapeutic targets. This is the reason why this strategy is strongly supported by the European Society of Cardiology/European Society of Hypertension (ESC/ESH) 2018 Guidelines, specifically the use of renin-angiotensin-aldosterone system inhibitors [angiotensin-converting enzyme (ACE) inhibitors and Sartans], in combination with calcium antagonist and/or thiazide diuretics, with the option to add antagonist of mineralcorticoid receptors, when an adequate blood pressure control has not been reached, or other classes of drugs, such as beta-blockers, when specific clinical indications are present, first and foremost ischaemic cardiomyopathy or heart failure. The newly proposed therapeutic goals are particularly important in high-risk patients, such as patients with previous cardiovascular events, diabetes mellitus, renal insufficiency, and patients older than 65 years of age.

Natural language processing of lifestyle modification documentation

Lifestyle modification, including diet, exercise, and tobacco cessation, is the first-line treatment of many disorders including hypertension, obesity, and diabetes. Lifestyle modification data are not easily retrieved or used in research due to their textual nature. This study addresses this knowledge gap using natural language processing to automatically identify lifestyle modification documentation from electronic health records. Electronic health record notes from hypertension patients were analyzed using an open-source natural language processing tool to retrieve assessment and advice regarding lifestyle modification. These data were classified as lifestyle modification assessment or advice and mapped to a coded standard ontology. Combined lifestyle modification (advice and assessment) recall was 99.27 percent, precision 94.44 percent, and correct classification 88.15 percent. Through extraction and transformation of narrative lifestyle modification data to coded data, this critical information can be used in research, metric development, and quality improvement efforts regarding care delivery for multiple medical conditions that benefit from lifestyle modification.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Hypertension Drug Therapy

Hypertension is still the number one global killer. No matter what causes are, lowering blood pressure can significantly reduce cardiovascular complications, cardiovascular death, and total death. Unfortunately, some hypertensive individuals simply do not know having hypertension. Some knew it but either not being treated or treated but blood pressure does not achieve goal. The reasons for inadequate control of blood pressure are many. One important reason is that we are not very familiar with antihypertensive agents and less attention has been paid to comorbidities, complications as well as the hypertension-modified target organ damage in patients with hypertension. The right antihypertensive drug was not given to the right hypertensive patients at right time. This reviewer studied comprehensively the literature, hopefully that the review will help improve antihypertensive drug selection and antihypertensive therapy.

Effectiveness of mobile phone-based self-management interventions for medication adherence and change in blood pressure in patients with coronary heart disease: A systematic review and meta-analysis

AIMS

The aim of this study was to synthesise and evaluate the effectiveness of mobile phone-based self-management interventions for medication adherence and change in blood pressure in patients with coronary heart disease.

METHODS

Relevant randomised controlled trials evaluating mobile phone-based self-management interventions for medication adherence and/or change in blood pressure in coronary heart disease patients were identified by searching six electronic databases (PubMed, Cochrane, CINAHL, ProQuest, Scopus and EMBASE) from January 2008 to January 2019. The trials were screened, data were extracted and quality was assessed by two independent reviewers. Meta-analyses were performed for different outcomes while narrative syntheses were conducted for studies that could not be pooled or when there was the presence of high heterogeneity.

RESULTS

Fifteen trials were included in this review, of which 11 of these trials were meta-analysed. Mobile phone-based self-management interventions were associated with a statistically significant reduction in diastolic blood pressure (combined mean difference of -1.99 (95% confidence interval (CI) -3.20 to -0.78; P=0.0001)). However, the combined effect on medication adherence (medium size effect of d=0.72 (95% CI -0.32 to 1.75; P=0.17)) and change in systolic blood pressure (combined mean difference of -1.08 (95% CI -5.51 to 3.35; P=0.63)) was not statistically significant. There was significant heterogeneity among the trials reviewed.

CONCLUSION

Mobile phone-based self-management interventions have the potential to improve self-management and adherence in patients with coronary heart disease but better designed, conducted and reported trials are needed to demonstrate this.

Incorporation of Biomarkers Into Risk Assessment for Allocation of Antihypertensive Medication According to the 2017 ACC/AHA High Blood Pressure Guideline: A Pooled Cohort Analysis

BACKGROUND

Risk for atherosclerotic cardiovascular disease was a novel consideration for antihypertensive medication initiation in the 2017 American College of Cardiology/American Heart Association Blood Pressure (BP) guideline. Whether biomarkers of chronic myocardial injury (high-sensitivity cardiac troponin T ≥6 ng/L] and stress (N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≥100 pg/mL) can inform cardiovascular (CV) risk stratification and treatment decisions among adults with elevated BP and hypertension is unclear.

METHODS

Participant-level data from 3 cohort studies (Atherosclerosis Risk in Communities Study, Dallas Heart Study, and Multiethnic Study of Atherosclerosis) were pooled, excluding individuals with prevalent CV disease and those taking antihypertensive medication at baseline. Participants were analyzed according to BP treatment group from the 2017 American College of Cardiology/American Heart Association BP guideline and those with high BP (120 to 159/<100 mm Hg) were further stratified by biomarker status. Cumulative incidence rates for CV event (atherosclerotic cardiovascular disease or heart failure), and the corresponding 10-year number needed to treat to prevent 1 event with intensive BP lowering (to target systolic BP <120 mm Hg), were estimated for BP and biomarker-based subgroups.

RESULTS

The study included 12 987 participants (mean age, 55 years; 55% women; 21.5% with elevated high-sensitivity cardiac troponin T; 17.7% with elevated NT-proBNP) with 825 incident CV events over 10-year follow-up. Participants with elevated BP or hypertension not recommended for antihypertensive medication with versus without either elevated high-sensitivity cardiac troponin T or NT-proBNP had a 10-year CV incidence rate of 11.0% and 4.6%, with a 10-year number needed to treat to prevent 1 event for intensive BP lowering of 36 and 85, respectively. Among participants with stage 1 or stage 2 hypertension recommended for antihypertensive medication with BP <160/100 mm Hg, those with versus without an elevated biomarker had a 10-year CV incidence rate of 15.1% and 7.9%, with a 10-year number needed to treat to prevent 1 event of 26 and 49, respectively.

CONCLUSIONS

Elevations in high-sensitivity cardiac troponin T or NT-proBNP identify individuals with elevated BP or hypertension not currently recommended for antihypertensive medication who are at high risk for CV events. The presence of nonelevated biomarkers, even in the setting of stage 1 or stage 2 hypertension, was associated with lower risk. Incorporation of biomarkers into risk assessment algorithms may lead to more appropriate matching of intensive BP control with patient risk.

Sex differences in masked hypertension: the Coronary Artery Risk Development in Young Adults study

OBJECTIVE

To evaluate the association of sex with masked hypertension, defined by out-of-clinic hypertension based on ambulatory blood pressure monitoring (ABPM) among adults without hypertension based on blood pressure (BP) measured in the clinic, after adjusting for potential confounders.

METHODS

We evaluated sex differences in the prevalence of masked hypertension and the difference between awake, or alternatively 24-h, ambulatory BP and clinic BP using multivariable adjusted models among 658 participants who underwent 24-h ABPM and had clinic SBP/DBP less than 140/90 mmHg during the Year 30 Exam of the Coronary Artery Risk Development in Young Adults study.

RESULTS

The mean age ± standard deviation (SD) of the participants was 54.8 ± 3.7 years, 58.4% were women, and 58.2% were black. The prevalence of any masked hypertension was 37.5% among women and 60.6% among men. In a model including adjustment for demographics, cardiovascular risk factors, antihypertensive medication, and clinic BP, the prevalence ratios (95% confidence intervals) comparing men versus women were 1.39 (1.18-1.63) for any masked hypertension, and 1.60 (1.28-1.99), 1.71 (1.36-2.15), and 1.40 (1.13-1.73) for masked awake, 24-h and asleep hypertension, respectively. In a fully adjusted model, the differences between mean awake ambulatory BP and clinic BP were 2.75 [standard error (SE) 0.92] mmHg higher for SBP and 3.61 (SE 0.58) mmHg higher for DBP among men compared with women.

CONCLUSION

The prevalence of masked hypertension on ABPM was high in both men and women. Male sex was an independent predictor of masked hypertension.

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

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

Relation between the Updated Blood Pressure Classification according to the American College of Cardiology/American Heart Association Guidelines and Carotid Intima-Media Thickness

American College of Cardiology/American Heart Association recently updated their guidelines for hypertension, and lowered the threshold of normal blood pressure (BP). However, the validity of the updated guidelines remains controversial. We investigated the relation between the revised BP classification and carotid intima-media thickness, using a community-based cohort. We examined 1,241 subjects who underwent health check-ups at our institute. They were divided into 3 groups based on their BP levels: normal blood pressure (sBP <130 mm Hg and dBP <80 mm Hg, n = 556); stage 1 hypertension (130 mm Hg ≤sBP <140 mm Hg or 80 mm Hg ≤ dBP <90 mm Hg, n = 236); and stage 2 hypertension (sBP ≥140 mm Hg or dBP ≥90 mm Hg, including subjects prescribed with antihypertensive medications, n = 449). With an increase in BP, increase in the mean age, proportion of males, and prevalence of CVD risk factors was seen. The prevalence of carotid plaque, defined as intima-media thickness ≥1.1 mm, also increased with increase in BP. After adjustment with covariates, higher BP was seen to be associated with carotid plaque presence. Atherosclerotic changes are present in stage 1 hypertension even in the healthy population, suggesting the importance of aggressive antihypertensive treatment based on the updated American College of Cardiology/American Heart Association guidelines.

Hypertension

Recent guidelines on diagnosis and management of high blood pressure (BP) include substantial changes and several new concepts compared with previous guidelines. These are reviewed and their clinical implications are discussed in this article. The goal is to provide a practical reference to assist clinicians with up-to-date management of patients with high BP. Important issues include new diagnostic thresholds, out-of-office BP monitoring, intensified treatment goals, and a different approach to resistant hypertension. Finally, differences among guidelines, the persistent controversies that have led to them, and their implications for clinical practice are discussed.

Prevention and Control of Hypertension: JACC Health Promotion Series

Hypertension, the leading risk factor for cardiovascular disease, originates from combined genetic, environmental, and social determinants. Environmental factors include overweight/obesity, unhealthy diet, excessive dietary sodium, inadequate dietary potassium, insufficient physical activity, and consumption of alcohol. Prevention and control of hypertension can be achieved through targeted and/or population-based strategies. For control of hypertension, the targeted strategy involves interventions to increase awareness, treatment, and control in individuals. Corresponding population-based strategies involve interventions designed to achieve a small reduction in blood pressure (BP) in the entire population. Having a usual source of care, optimizing adherence, and minimizing therapeutic inertia are associated with higher rates of BP control. The Chronic Care Model, a collaborative partnership among the patient, provider, and health system, incorporates a multilevel approach for control of hypertension. Optimizing the prevention, recognition, and care of hypertension requires a paradigm shift to team-based care and the use of strategies known to control BP.

Cumulative blood pressure from early adulthood to middle age is associated with left atrial remodelling and subclinical dysfunction assessed by three-dimensional echocardiography: a prospective post hoc analysis from the coronary artery risk development in young adults study

Aims

To evaluate the association of cumulative blood pressure (BP) from young adulthood to middle age with left atrial (LA) structure/function as assessed by three-dimensional echocardiography (3DE) in a large longitudinal bi-racial population study.

Methods and results

We conducted a prospective post hoc analysis of individuals enrolled at the Coronary Artery Risk Development in Young Adults, which is a multi-centre bi-racial cohort with 30 years of follow-up. Cumulative systolic and diastolic BP levels were defined by summing the product of average millimetres of mercury and the years between each two consecutive clinic visits over 30 years of follow-up. Multivariable linear regression analyses were used to assess the relationship between cumulative systolic and diastolic BP with 3DE LA structure and function, adjusting for demographics and traditional cardiovascular risk factors. A total of 1033 participants were included, mean age was 55.4 ± 3.5 years, 55.2% women, 43.9% blacks. Cumulative systolic BP had stronger correlations than cumulative diastolic BP. Higher cumulative systolic BP was independently associated with higher 3D LA volumes: maximum (β = 1.74, P = 0.004), pre-atrial contraction (β = 1.87, P < 0.001), minimum (β = 0.76, P = 0.04), total emptying (β = 0.98, P = 0.006), active emptying (β = 1.12, P < 0.001), and lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.02). Higher cumulative diastolic BP was independently associated with higher 3D LA active emptying volume (β = 0.66, P = 0.002), lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.004), and higher magnitude 3D LA late diastolic strain rate (β = -0.04, P = 0.05).

Conclusion

Higher cumulative BP from early adulthood throughout middle age was associated with adverse LA remodelling evaluated by 3D echocardiography.