Isolated Diastolic Hypertension in the IDACO Study: An Age-Stratified Analysis Using 24-Hour Ambulatory Blood Pressure Measurements

Cardiovascular Risk in Patients With Treated Isolated Diastolic Hypertension and Isolated Low Diastolic Blood Pressure

BACKGROUND

The prognosis of high or markedly low diastolic blood pressure (DBP) with normalized on-treatment systolic blood pressure on major adverse cardiovascular events (MACEs) is uncertain. This study examined whether treated isolated diastolic hypertension (IDH) and treated isolated low DBP (ILDBP) were associated with MACEs in patients with hypertension.

METHODS AND RESULTS

A total of 7582 patients with on-treatment systolic blood pressure <130 mm Hg from SPRINT (Systolic Blood Pressure Intervention Trial) were categorized on the basis of average DBP: <60 mm Hg (n=1031; treated ILDBP), 60 to 79 mm Hg (n=5432), ≥80 mm Hg (n=1119; treated IDH). MACE risk was estimated using Cox proportional-hazards models. Among the SPRINT participants, median age was 67.0 years and 64.9% were men. Over a median follow-up of 3.4 years, 512 patients developed a MACE. The incidence of MACEs was 3.9 cases per 100 person-years for treated ILDBP, 1.9 cases for DBP 60 to 79 mm Hg, and 1.8 cases for treated IDH. Comparing with DBP 60 to 79 mm Hg, treated ILDBP was associated with an 1.32-fold MACE risk (hazard ratio [HR], 1.32, 95% CI, 1.05-1.66), whereas treated IDH was not (HR, 1.18 [95% CI, 0.87-1.59]). There was no effect modification by age, sex, atherosclerotic cardiovascular disease risk, or cardiovascular disease history (all P values for interaction >0.05).

CONCLUSIONS

In this secondary analysis of SPRINT, among treated patients with normalized systolic blood pressure, excessively low DBP was associated with an increased MACE risk, while treated IDH was not. Further research is required for treated ILDBP management.

Cumulative Diastolic Blood Pressure Burden in Normal Systolic Blood Pressure and Cardiovascular Disease

BACKGROUND

The clinical significance of isolated diastolic hypertension defined by the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines remains inconsistent. We examined whether long-term diastolic burden predicts the first major adverse cardiovascular event in participants with sustained and untreated normal systolic BP.

METHODS

The Mass General Brigham Biobank is a New England health care-based cohort recruited between 2010 and 2021. A total of 15 979 participants aged 18 to 64 years and without prior cardiovascular disease, antihypertensives, or high systolic BP were studied. The cumulative diastolic burden was determined as the area under the curve for diastolic BP (DBP) ≥80 mm Hg over 5 years before enrollment. Major adverse cardiovascular event was defined as a composite of first incident ischemic heart disease, stroke, heart failure, or all-cause death.

RESULTS

Of the 15 979 participants, mean (SD) age at enrollment was 47.6 (14.3) years, 11 950 (74.8%) were women, and the mean (SD) systolic BP and DBP were 118.0 (12.9) and 72.2 (9.3) mm Hg, respectively. Over a median (interquartile range) follow-up of 3.5 (1.8-5.4) years, 2467 (15.4%) major adverse cardiovascular events occurred. Using Cox proportional hazards regression, each SD increase in cumulative DBP was independently associated with a hazard ratio (95% CI) of 1.06 (1.02-1.10) without effect modification by sex (P=0.65), age (P=0.46), or race/ethnicity (P=0.24). In addition to traditional risk factors, cumulative DBP modestly improved the discrimination C index (95% CI) from 0.74 (0.72-0.75) to 0.75 (0.74-0.76; likelihood ratio test, P=0.037).

CONCLUSIONS

Among individuals with normal systolic BP, cumulative DBP may augment cardiovascular disease risk stratification beyond a single DBP measure and traditional risk factors.

Isolated Diastolic Hypertension and Kidney and Cardiovascular Outcomes in CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study

Rationale & Objective

The clinical significance of isolated diastolic hypertension in patients with chronic kidney disease (CKD) is unclear. We assessed the prevalence of isolated diastolic hypertension and its association with adverse kidney and cardiovascular outcomes in participants in the Chronic Renal Insufficiency Cohort (CRIC) study.

Study Design

Prospective cohort study.

Setting & Population

CRIC study participants with complete baseline data on systolic blood pressure (SBP) and diastolic BP (DBP) (N=5,621).

Exposure

Isolated diastolic hypertension defined as SBP ≤ 130 mm Hg and DBP >80 mm Hg.

Reference Group

Normotension, defined as SBP ≤ 130 mm Hg and DBP ≤ 80 mm Hg.

Outcomes

Composite kidney events (50% decline in estimated glomerular filtration rate or onset of kidney failure), composite cardiovascular events (myocardial infarction, heart failure, stroke, or peripheral arterial disease), and all-cause mortality.

Analytical Approach

Cox proportional hazards models adjusted for demographic, health behavior, and clinical covariates.

Results

Of the 5,621 participants, 347 (6.2%) had isolated diastolic hypertension. Among the 347 participants with isolated diastolic hypertension, there was no association between isolated diastolic hypertension and the composite kidney outcome (HR, 1.17; 95% CI, 0.93-1.47; P = 0.18), composite cardiovascular events (HR, 0.91; 95% CI, 0.65-1.27; P = 0.58), or all-cause mortality (HR, 0.82; 95% CI, 0.57-1.19; P = 0.30).

Limitations

Older age of cohort and low number of participants of Asian ethnicity limit generalizability of findings. A relatively small sample size is inadequate to detect modest associations with outcomes.

Conclusions

Isolated diastolic hypertension was not associated with the risk of adverse kidney and cardiovascular events in participants with CKD.

Plain Language Summary

Clinicians frequently encounter patients with kidney disease who have controlled systolic blood pressure (BP) but high diastolic BP and do not know whether they should intensify BP treatment in an attempt to control the diastolic BP. We examined whether having controlled systolic BP but uncontrolled diastolic BP leads to worse heart and kidney outcomes in patients with chronic kidney disease. We did not find any such association. However, our study was relatively small and had a number of limitations. Till larger studies confirm or refute this finding, we recommend not increasing blood pressure medications to improve the diastolic BP control if the systolic BP is already well controlled in patients with chronic kidney disease.

Are Overweight and Obesity Risk Factors for Developing Metabolic Syndrome or Hypertension after a Preeclamptic Event?

OBJECTIVE

To identify the determinants and risks associated with developing hypertension and metabolic syndrome in the first year postpartum in women who experienced preeclampsia.

METHODS

A cohort study was conducted, involving women who had experienced preeclampsia (PE) recently. The control group was women with the same characteristics but a healthy pregnancy. The variables analyzed were somatometry, disease history, pre-pregnancy body mass index (Pre-BMI), and Third Adult Treatment Panel updated (ATP III) metabolic syndrome (MS) data (blood pressure, obesity, triglycerides, high-density lipoproteins, and fasting glucose). These variables were measured at 3, 6, and 12 months postpartum.

RESULTS

Women with a history of PE exhibited higher systolic and diastolic blood pressure than women without PE. The risk of developing isolated diastolic arterial hypertension at 3 and 12 months of follow-up was two to eight times greater in women with a history of PE. Factors associated with having higher blood pressure levels were preeclampsia, insulin resistance, age, and BMI. Neither the pre-BMI index nor gestational weight gain (GWG) had any effect on blood pressure in any of the three assessments. Women with preeclampsia had a 5- to 8-fold increased risk of developing MS (which could be explained not only by the history of preeclampsia but also by the history of pre-pregnancy obesity). However, PE was not identified as a risk factor at the six-month evaluation and was only explained by pre-pregnancy obesity and overweight.

CONCLUSIONS

Obesity and overweight, as well as preeclampsia, were strongly associated with the development of hypertension and metabolic syndrome during the first year following childbirth.

Reduction in blood pressure for people with isolated diastolic hypertension and cardiovascular outcomes

AIMS

Isolated diastolic hypertension (IDH) is a largely underrated risk factor for cardiovascular disease (CVD). It is currently unclear whether a reduction in blood pressure (BP) is associated with CVD events among adults with IDH. We aimed to elucidate the relationship between BP reduction and incident CVD in individuals with IDH.

METHODS AND RESULTS

We retrospectively analysed the data of 71 297 individuals with IDH. Isolated diastolic hypertension was defined as systolic BP of < 140 mmHg and diastolic BP (DBP) of ≥90 mmHg (median age, 48 years; 83.1% men; median DBP, 92 mmHg). None of the participants took BP-lowering medications or had a history of CVD at baseline. Blood pressure was measured at baseline and 1-year follow-up, and participants were categorized into two groups based on DBP at 1 year (≥90 or < 90 mmHg). The primary outcome was a composite endpoint that included myocardial infarction, stroke, and all-cause death. Over a mean follow-up period of 1100 ± 859 days, 1317 composite CVD endpoints were recorded. Participants with DBP of < 90 mmHg at 1 year were at a lower risk of composite CVD events [hazard ratio (HR): 0.75, 95% confidence interval (CI): 0.67-0.83] than those with DBP of ≥90 mmHg at 1 year. A reduction in DBP per 5 mmHg during the 1-year follow-up was associated with a lower composite CVD event risk (HR: 0.92, 95% CI: 0.89-0.95). The results remained consistent across a multitude of sensitivity analyses.

CONCLUSION

Our analysis of a large-scale epidemiological dataset demonstrated a relationship of reduction in DBP with a reduced risk for CVD events in individuals with IDH.

Hemodynamic profiles of arterial hypertension with ambulatory blood pressure monitoring

Blood pressure (BP) measurements obtained during a twenty-four-hour ambulatory blood pressure monitoring (24 h ABPM) have not been reliably applied to extract arterial hemodynamics. We aimed to describe the hemodynamic profiles of different hypertension (HT) subtypes derived from a new method for total arterial compliance (C_t) estimation in a large group of individuals undergoing 24 h ABPM. A cross-sectional study was conducted, which included patients with suspected HT. Cardiac output, C_t, and total peripheral resistance (TPR) were derived through a two-element Windkessel model without having a pressure waveform. Arterial hemodynamics were analyzed according to HT subtypes in 7434 individuals (5523 untreated HT and 1950 normotensive controls [N]). The individuals mean age was 46.2 ± 13.0 years; 54.8% were male, and 22.1% were obese. In isolated diastolic hypertension (IDH), the cardiac index (CI) was greater than that in normotensive (N) controls (CI: IDH vs. N mean difference 0.10 L/m/m²; CI 95% 0.08 to 0.12; p value <0.001), with no significant clinical difference in C_t. Isolated systolic hypertension (ISH) and divergent systolic-diastolic hypertension (D-SDH) had lower C_t values than nondivergent HT subtype (C_t: divergent vs. nondivergent mean difference -0.20 mL/mmHg; CI 95% -0.21 to -0.19 mL/mmHg; p value <0.001). Additionally, D-SDH displayed the highest TPR (TPR: D-SDH vs. N mean difference 169.8 dyn*s/cm^-5; CI 95% 149.3 to 190.3 dyn*s/cm^-5; p value <0.001). A new method is provided for the simultaneous assessment of arterial hemodynamics with 24 h ABPM as a single diagnostic tool, which allows a comprehensive assessment of arterial function for hypertension subtypes. Main hemodynamic findings in arterial HT subtypes with regard to C_t and TPR. The 24 h ABPM profile reflects the state of C_t and TPR. Younger individuals with IDH present with a normal C_t and frequently increased CO. Patients with ND-SDH maintain an adequate C_t with a higher TPR, while subjects with D-SDH present with a reduced C_t, high PP and high TPR. Finally, the ISH subtype occurs in older individuals with significantly reduced C_t, high PP and a variable TPR proportional to the degree of arterial stiffness and MAP values. There was an observed increase in PP with age in relation to the changes in C_t (see also text). SBP: systolic blood pressure; DBP: diastolic blood pressure; MAP: mean arterial pressure; PP: pulse pressure; N: normotension; HT: hypertension; IDH: isolated diastolic hypertension; ND-SDH: nondivergent systole-diastolic hypertension; D-SDH: divergent systolic-diastolic hypertension; ISH: isolated systolic hypertension; C_t: total arterial compliance; TPR: total peripheral resistance; CO: cardiac output; 24 h ABPM: 24 h ambulatory blood pressure monitoring.

Hypertension in China: epidemiology and treatment initiatives

The past two to three decades have seen a steady increase in the prevalence of hypertension in China, largely owing to increased life expectancy and lifestyle changes (particularly among individuals aged 35-44 years). Data from the China hypertension survey conducted in 2012-2015 revealed a high prevalence of grade 3 hypertension (systolic blood pressure ≥180 mmHg and diastolic blood pressure ≥110 mmHg) in the general population, which increased with age to up to 5% among individuals aged ≥65 years. The risk profile of patients with hypertension in China has also been a subject of intense study in the past 30 years. Dietary sodium and potassium intake have remained largely the same in China in the past three decades, and salt substitution strategies seem to be effective in reducing blood pressure levels and the risk of cardiovascular events and death. However, the number of individuals with risk factors for hypertension and cardiovascular disease in general, such as physical inactivity and obesity, has increased dramatically in the same period. Moreover, even in patients diagnosed with hypertension, their disease is often poorly managed owing to a lack of patient education and poor treatment compliance. In this Review, we summarize the latest epidemiological data on hypertension in China, discuss the risk factors for hypertension that are specific to this population, and describe several ongoing nationwide hypertension control initiatives that target these risk factors, especially in the low-resource rural setting.

Prevention of cardiorenal damage: importance of albuminuria

Chronic kidney disease (CKD) is projected to become a leading global cause of death by 2040, and its early detection is critical for effective and timely management. The current definition of CKD identifies only advanced stages, when kidney injury has already destroyed &gt;50% of functioning kidney mass as reflected by an estimated glomerular filtration rate &lt;60 mL/min/1.73 m2 or a urinary albumin/creatinine ratio &gt;six-fold higher than physiological levels (i.e. &gt; 30 mg/g). An elevated urinary albumin-excretion rate is a known early predictor of future cardiovascular events. There is thus a ‘blind spot’ in the detection of CKD, when kidney injury is present but is undetectable by current diagnostic criteria, and no intervention is made before renal and cardiovascular damage occurs. The present review discusses the CKD ‘blind spot’ concept and how it may facilitate a holistic approach to CKD and cardiovascular disease prevention and implement the call for albuminuria screening implicit in current guidelines. Cardiorenal risk associated with albuminuria in the high-normal range, novel genetic and biochemical markers of elevated cardiorenal risk, and the role of heart and kidney protective drugs evaluated in recent clinical trials are also discussed. As albuminuria is a major risk factor for cardiovascular and renal disease, starting from levels not yet considered in the definition of CKD, the implementation of opportunistic or systematic albuminuria screening and therapy, possibly complemented with novel early biomarkers, has the potential to improve cardiorenal outcomes and mitigate the dismal 2040 projections for CKD and related cardiovascular burden.

A personal history of research on hypertension From an encounter with hypertension to the development of hypertension practice based on out-of-clinic blood pressure measurements

In the 1970s, many people had severe hypertension and related cardiovascular and cerebrovascular diseases; however, antihypertensive treatments were not available at the time. The author encountered such conditions during the initial exposure to medicine. The author subsequently entered the field of hypertension medicine to prevent such conditions and engaged in hypertension research for more than 50 years. The author's central interest was the physiological and clinical aspects of blood pressure (BP) variability. Out-of-clinic BP measurements were the focus of clinical research. It was anticipated that self-measurement of BP at home (HBP) would improve medical practice surrounding hypertension. To establish evidence-based hypertension medicine, the Ohasama study (an epidemiology based on HBP) was conducted. The study provided firm evidence of the clinical significance of HBP and diagnostic criteria for hypertension and normotension. To establish target HBP levels for antihypertensive therapy, the Hypertension Objective treatment based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study (a prospective intervention study) was also conducted. Application of HBP measurements expanded to obstetric, clinical pharmacology, pathophysiology, and genetic studies. During these studies, crucial information on the clinical significance of BP variability (such as circadian and day-by-day variation of BP, nocturnal BP, white-coat hypertension, and masked hypertension) was established. Finally, the author described the priority of HBP over clinic-measured BP for the diagnosis of hypertension in the 2014 Japanese Society of Hypertension Guidelines. In this article, the author's history of hypertension research, from the first encounter with hypertension to the construction of guidelines on hypertension, is reviewed.

Isolated Diastolic Hypertension and Risk of Cardiovascular Disease: Controversies in Hypertension - Pro Side of the Argument

Isolated diastolic hypertension (IDH), defined as diastolic blood pressure in the hypertensive range but systolic blood pressure not in the hypertensive range, is not uncommon (<20%) among adults with hypertension. IDH often manifests in concurrence with other cardiovascular risk factors. Individuals with IDH tend to have lower awareness of their hypertension compared with those with both systolic and diastolic hypertension. IDH appears to be a largely underrated risk factor for cardiovascular disease events, which may be explained by inconsistent association of IDH with cardiovascular disease events. The inconsistency suggests that IDH is heterogeneous. One size does not seem to fit all in the clinical management of individuals with IDH. Rather than treating IDH as a monolithic low-risk condition, detailed phenotyping in the context of individual comprehensive cardiovascular risk would seem to be most useful to assess an individual's expected net benefit from therapy. In this review, we highlight that the clinical relevance of IDH differs by individual clinical characteristics, and elucidate groups of individuals with IDH that should be wary of cardiovascular disease risks.

Age-Dependent Relationship of Hypertension Subtypes With Incident Heart Failure

Background The prevalence of hypertension subtypes changes with age. However, little is known regarding the age-dependent association of hypertension subtypes with incident heart failure (HF). Methods and Results We conducted an observational cohort study including 2 612 570 people (mean age, 44.0 years; 55.0% men). No participants were taking blood pressure-lowering medications or had a known history of cardiovascular disease. Participants were categorized as aged 20 to 49 years (n=1 825 756), 50 to 59 years (n=571 574), or 60 to 75 years (n=215 240). We defined stage 1 hypertension as systolic blood pressure (SBP) 130 to 139 mm Hg or diastolic blood pressure (DBP) 80 to 89 mm Hg and stage 2 hypertension as SBP ≥140 mm Hg or DBP ≥90 mm Hg. Among participants with stage 2 hypertension, isolated diastolic hypertension was defined as SBP <140 mm Hg and DBP ≥90 mm Hg, isolated systolic hypertension as SBP ≥140 mm Hg and DBP <90 mm Hg, and systolic diastolic hypertension as SBP ≥140 mm Hg and DBP ≥90 mm Hg. During a mean follow-up of 1205±934 days, 43 415 HF, 4807 myocardial infarction, 45 365 angina pectoris, 22 179 stroke, and 10 420 atrial fibrillation events occurred. Although the incidence of HF and other cardiovascular disease events increased with age, hazard ratios and relative risk reductions of each hypertension subtype for HF decreased with age. An age-dependent relationship between hypertension subtypes and incident HF was similarly observed in both men and women. Conclusions The contribution of isolated diastolic hypertension, isolated systolic hypertension, and systolic diastolic hypertension to the development of HF and other cardiovascular disease events was attenuated with age, suggesting that preventive efforts for blood pressure control could provide a greater benefit in younger individuals.

Association between high-mobility group box 2 and subclinical hypertension-mediated organ damage in young adults

Background:

Hypertension-mediated organ damage (HMOD) is an emerging problem among young adults. The potential role of chronic immune-mediated inflammation in the pathogenesis of HMOD is increasingly being recognized. High-mobility group box 2 (HMGB2) is known for its role in the modulation of innate immunity and exerts signaling functions that affect various inflammatory diseases. However, the association between HMGB2 and HMOD in young adults remains unclear.

Objectives:

The aim of this study was to explore the association between HMGB2 and subclinical HMOD in young adults.

Design:

This is a cross-sectional study.

Methods:

Body composition, carotid ultrasound, carotid-femoral PWV (cf-PWV) measures, echocardiography, serum HMGB2 levels, and serum classic cardiometabolic risk factors were measured in 988 untreated young adults. We estimated the risk related to serum HMGB2 using multivariable-adjusted linear and logistic regression models. Then, we conducted a pathway overrepresentation analysis to examine which key biological pathways may be linked to serum HMGB2 in young adults with HMOD.

Results:

Among the 988 untreated young adults, we identified four distinct hypertension phenotypes: normotension (40.0%), white-coat hypertension (16.0%), masked hypertension (20.9%), and sustained hypertension (23.1%). High levels of serum HMGB2 were related to increased carotid intima-media thickness (cIMT) and left ventricular mass index (LVMI), higher cf-PWV and blood pressure, and a lower estimated glomerular filtration rate (eGFR). Linear regression analysis showed that serum HMGB2 was positively associated with cf-PWV and negatively associated with eGFR in all patients. Multivariate analysis showed that high levels of serum HMGB2 were associated with high odds of subclinical HMOD (damage in at least one organ). Biological pathway analysis indicated that patients with high serum HMGB2 levels had increased activity of pathways, related to endothelial dysfunction, inflammatory processes, and atherosclerosis.

Conclusion:

High serum concentrations of HMGB2 are associated with an increased risk of subclinical HMOD in untreated young adults.