Office blood pressure threshold of 130/80 mmHg better predicts uncontrolled out-of-office blood pressure in apparent treatment-resistant hypertension

The objective of this study was to compare the diagnostic accuracy of office blood pressure (BP) threshold of 140/90 and 130/80 mmHg for correctly identifying uncontrolled out‐of‐office BP in apparent treatment‐resistant hypertension (aTRH). We analyzed 468 subjects from a prospectively enrolled cohort of patients with resistant hypertension in South Korea (clinicaltrials.gov: NCT03540992). Resistant hypertension was defined as office BP ≥ 130/80 mmHg with three different classes of antihypertensive medications including thiazide‐type/like diuretics, or treated hypertension with four or more different classes of antihypertensive medications. We conducted different types of BP measurements including office BP, automated office BP (AOBP), home BP, and ambulatory BP. We defined uncontrolled out‐of‐office BP as daytime BP ≥ 135/85 mmHg and/or home BP ≥ 135/85 mmHg. Among subjects with office BP < 140/90 mmHg and subjects with office BP < 130/80 mmHg, 66% and 55% had uncontrolled out‐of‐office BP, respectively. The prevalence of controlled and masked uncontrolled hypertension was lower, and the prevalence of white‐coat and sustained uncontrolled hypertension was higher, with a threshold of 130/80 mmHg than of 140/90 mmHg, for both office BP and AOBP. The office BP threshold of 130/80 mmHg was better able to diagnose uncontrolled out‐of‐office BP than 140/90 mmHg, and the net reclassification improvement (NRI) was 0.255. The AOBP threshold of 130/80 mmHg also revealed better diagnostic accuracy than 140/90 mmHg, with NRI of 0.543. The office BP threshold of 130/80 mmHg showed better than 140/90 mmHg in terms of the correspondence to out‐of‐office BP in subjects with aTRH.

Blood pressure levels and cardiovascular risk according to age in patients with diabetes mellitus: a nationwide population-based cohort study

Background

Little is known about age-specific target blood pressure (BP) in hypertensive patients with diabetes mellitus (DM). The aim of this study was to determine the BP level at the lowest cardiovascular risk of hypertensive patients with DM according to age.

Methods

Using the Korean National Health Insurance Service database, we analyzed patients without cardiovascular disease diagnosed with both hypertension and DM from January 2002 to December 2011. Primary end-point was composite cardiovascular events including cardiovascular death, myocardial infarction and stroke.

Results

Of 241,148 study patients, 35,396 had cardiovascular events during a median follow-up period of 10 years. At the age of < 70 years, the risk of cardiovascular events was lower in patients with BP < 120/70 mmHg than in those with BP 130–139/80–89 mmHg. At the age of ≥ 70, however, there were no significant differences in the risk of cardiovascular events between patients with BP 130–139/80–89 mmHg and BP < 120/70 mmHg. The risk of cardiovascular events was similar between patients with BP 130–139/80–89 mmHg and BP 120–129/70–79 mmHg, and it was significantly higher in those with BP ≥ 140/90 mmHg than in those with BP 130–139/80–89 mmHg at all ages.

Conclusions

In a cohort of hypertensive patients who had DM but no history of cardiovascular disease, lower BP was associated with lower risk of cardiovascular events especially at the age of < 70. However, low BP < 130–139/80–89 mmHg was not associated with decreased cardiovascular risk, it may be better to keep the BP of 130–139/80–89 mmHg at the age of ≥ 70.

Efficacy and Tolerability of Pitavastatin Versus Pitavastatin/Fenofibrate in High-risk Korean Patients with Mixed Dyslipidemia: A Multicenter, Randomized, Double-blinded, Parallel, Therapeutic Confirmatory Clinical Trial

PURPOSE

Dyslipidemia is an important risk factor for cardiovascular disease (CVD). Statins are known to effectively reduce not only low-density lipoprotein cholesterol (LDL-C) level but also death and nonfatal myocardial infarction due to coronary heart disease. The risk for CVD from atherogenic dyslipidemia persists when elevated triglyceride (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels are not controlled with statin therapy. Therefore, statin/fenofibrate combination therapy is more effective in reducing CVD risk. Here, we assessed the efficacy and tolerability of pitavastatin/fenofibrate combination therapy in patients with mixed dyslipidemia and a high risk for CVD.

METHODS

This multicenter, randomized, double-blind, parallel-group, therapeutic-confirmatory clinical trial evaluated the efficacy and tolerability of fixed-dose combination therapy with pitavastatin/fenofibrate 2/160 mg in Korean patients with a high risk for CVD and a controlled LDL-C level (<100 mg/dL) and a TG level of 150-500 mg/dL after a run-in period with pitavastatin 2 mg alone. In the 8-week main study, 347 eligible patients were randomly assigned to receive pitavastatin 2 mg with or without fenofibrate 160 mg after a run-in period. In the extension study, patients with controlled LDL-C and non-HDL-C (<130 mg/dL) levels were included after the completion of the main study. All participants in the extension study received the pitavastatin/fenofibrate combination therapy for 16 weeks for the assessment of the tolerability of long-term treatment.

FINDINGS

The difference in the mean percentage change in non-HDL-C from baseline to week 8 between the combination therapy and monotherapy groups was -12.45% (95% CI, -17.18 to -7.72), and the combination therapy was associated with a greater reduction in non-HDL-C. The changes in lipid profile, including apolipoproteins, fibrinogen, and high-sensitivity C-reactive protein from baseline to weeks 4 and 8 were statistically significant with combination therapy compared to monotherapy at all time points. Furthermore, the rates of achievement of non-HDL-C and apolipoprotein B targets at week 8 in the combination therapy and monotherapy groups were 88.30% versus 77.98% (P = 0.0110) and 78.94% versus 68.45% (P = 0.0021), respectively. The combination therapy was well tolerated, with a safety profile similar to that of statin monotherapy.

IMPLICATIONS

In these Korean patients with mixed dyslipidemia and a high risk for CVD, combination therapy with pitavastatin/fenofibrate was associated with a greater reduction in non-HDL-C compared with that with pitavastatin monotherapy, and a significantly improvement in other lipid levels. Moreover, the combination therapy was well tolerated, with a safety profile similar to that of statin monotherapy. Therefore, pitavastatin/fenofibrate combination therapy could be effective and well tolerated in patients with mixed dyslipidemia. ClinicalTrials.gov identifier: NCT03618797.

Massive pulmonary thromboembolism combined with transient thyrotoxicosis in an 18 year old girl

Background

Pulmonary thromboembolism (PTE) is thought to usually stem from deep vein thrombosis (DVT). However, evidence of DVT could not be found in many cases. Furthermore, transient thyrotoxicosis is a rare but potentially life–threatening emergency involving a systemic hypercoagulable state. We report on an 18 year-old-girl with transient thyrotoxicosis with massive PTE without DVT.

Case presentation

An 18-year-old girl was admitted to the hospital with syncope. Patient had no history of trauma, any known underlying disease or oral contraceptives use. Chest computed tomography (CT) showed massive PTE in both central pulmonary arteries and diffuse goiter. However, a low extremity Doppler sonogram did not detect DVT. To manage the PTE, we administered low molecular weight heparin. On the other hands, thyroid function test indicated a state of thyrotoxicosis. In addition, patient had a partial protein S deficiency but no other immunologic abnormality. Therefore, the patient was diagnosed with massive PTE, thyrotoxicosis, and partial protein S deficiency. Patient was discharged with oral warfarin and methimazole. A follow-up echocardiogram obtained 3 months after anticoagulation therapy demonstrated normal dimensions and systolic function. After thyrotoxicosis was treated with methimazole for a month, a euthyroid state was achieved and the goiter decreased to a normal size. The methimazole was gradually tapered off and stopped at 4 months. At a 6-month follow up visit, PTE and pulmonary hypertension had disappeared but the patient still had a partial protein S deficiency. We decided to stop all medication with careful monitoring. During a 4-year follow-up period after the episode, she was asymptomatic without any evidence of recurrent systemic thromboembolism or hyperthyroidism.

Conclusions

Early recognition and appropriate treatment of PTE combined with transient thyrotoxicosis were vital to preventing other complications.

The effect of alcohol dose on the development of hypertension in Asian and Western men: systematic review and meta-analysis

BACKGROUND/AIMS

There are inconsistencies in the effects of low to moderate dose alcohol consumption on the development of hypertension in adult men. We hypothesized that a region-specific effect might participate in this heterogeneity.

METHODS

We conducted a systematic review and meta-analysis to evaluate the effect of alcohol dose on hypertension incidence using contemporary data through December 2017. Subjects were categorized according to their level of alcohol consumption as non-drinkers (reference) and low- (0.01 to 20.0 g/day), moderate- (20.1 to 40.0 g/day), moderate- to high- (40.1 to 60.0 g/day), and high-dose (> 60.0 g/day) drinkers. We defined hypertension as a blood pressure ≥ 140/90 mmHg and/or the use of anti-hypertensive drugs.

RESULTS

In total, 11 articles (seven Asian and four Western) were selected for our analysis. Among Asian men, a significantly elevated risk was observed even in the low alcohol dose group in comparison with the group with no alcohol consumption, and the risk increased in a dose-dependent manner (pooled relative risks [95% confidence intervals (CI)]: 1.25 [1.13 to 1.38], 1.48 [1.27 to 1.72], 1.75 [1.43 to 2.15], and 1.78 [1.51 to 2.09]). Among Western men, a similar dose-response relationship was noted in general (p for subgroup difference > 0.1), but a significantly elevated risk was evident only in the high-dose group (pooled relative risks [95% CI]: 1.22 [0.85 to 1.74], 1.57 [0.90 to 2.75], 1.47 [0.44 to 4.91], and 1.49 [1.02 to 2.18]).

CONCLUSION

Even low doses of alcohol can lead to the development of hypertension, particularly in Asian men. Our findings could serve as additional evidence for developing an appropriate preventive strategy in each region.

Is the use of RAS inhibitors safe in the current era of COVID-19 pandemic?

Antihypertensive drugs are one of the most widely used pharmacologic agent in the world and it is predominantly used in the elderly subjects. Pneumonia is the most common cause of death in the extremely old subject. During infection and its complication such as sepsis, hypotension could be exacerbated by antihypertensive drugs because homeostasis mechanisms such as sodium balance, renin angiotensin aldosterone system and/or sympathetic nervous system can be mitigated by antihypertensive drug therapy. Severe Acute Respiratory Syndrome-Coronavirus-1 and 2 viral surface protein is known to attach angiotensin converting enzyme 2 (ACE2) on the cell membrane to facilitate viral entry into the cytoplasm. Despite the theoretical concerns of increased ACE2 expression by Renin-Angiotensin-Aldosterone system (RAS) blockade, there is no evidence that RAS inhibitors are harmful during COVID-19 infection and have in fact been shown to be beneficial in animal studies. Therefore, it is recommended to maintain RAS blockade during the current corona virus pandemic.

Effect of Fimasartan versus Valsartan and Olmesartan on Office and Ambulatory Blood Pressure in Korean Patients with Mild-to-Moderate Essential Hypertension: A Randomized, Double-Blind, Active Control, Three-Parallel Group, Forced Titration, Multicenter, Phase IV Study (Fimasartan Achieving Systolic Blood Pressure Target (FAST) Study)

Purpose

Head-to-head comparison of the blood pressure (BP) lowering effect of fimasartan versus valsartan, with olmesartan as a reference, on office blood pressure and ambulatory BP.

Patients and Methods

Of the 369 randomly assigned patients in this study, 365 hypertensive patients were referred as the full analysis set and divided into 3 groups with a 3:3:1 ratio (fimasartan group: 155, valsartan group: 157, olmesartan group: 53). After the 2-week single-blind placebo run-in period, initial standard doses of 60-mg fimasartan, 80-mg valsartan, and 10-mg olmesartan were administered for 2 weeks, then forcibly up-titrated higher doses (fimasartan 120 mg, valsartan 160 mg, olmesartan 20 mg) were given for 4 weeks. ABP was measured before and after the 6-week treatment. Primary endpoint was reduction of sitting office systolic BP (SiSBP) of fimasartan compared to valsartan after 6 weeks. Secondary endpoints were reduction of sitting office diastolic BP (SiDBP) and 24 hrs, day-time, and night-time mean systolic and diastolic ABP (ASBP, ADBP) after 6 weeks.

Results

Patients’ mean age was 58.34±7.68 years, and 289 patients were male (79.18%). After the 6-week treatment, SiSBP reduction of fimasartan and valsartan were −16.26±15.07 and −12.81±13.87 (p=0.0298) and SiDBP were −7.63±9.67 and −5.14±8.52 (p=0.0211). Reductions in 24 hrs mean ASBP were −15.22±13.33 and −9.45±12.37 (p=0.0009), and ADBPs were −8.74±7.55 and −5.98±7.85 (p=0.0140). Reductions of night-time ASBPs were −16.80±15.81 and −10.32±14.88 (p=0.0012), and those of night-time ADBPs were −8.89±9.93 and −5.55±9.70 (p=0.0152). Reduction of BP in olmesartan group did not demonstrate significant difference with fimasartan group in all end-points.

Conclusion

Fimasartan 120-mg treatment demonstrated superior efficacy in reduction of SiSBP, SiDBP, and 24 hrs ASBP and ADBP compared to valsartan 160 mg. Reduction of night-time ASBP from baseline was largest in fimasartan group, suggesting that fimasartan may be effective for recovering dipping pattern.

NCT number

NCT02495324 (Fimasartan Achieving SBP Target (FAST) study).

Predictors of Significant Coronary Artery Disease in Patients with Cerebral Artery Atherosclerosis

OBJECTIVE

There are few existing data on the status of coronary artery disease (CAD) in patients with atherosclerosis of the cerebral artery detected by brain imaging studies. We aimed to analyze the predictors of asymptomatic angiographically significant CAD detected by simultaneous cerebral and coronary angiography.

METHODS

This retrospective cohort study screened data obtained between August 2009 and April 2019; 11,047 patients underwent cerebral angiography for atherosclerotic change (>50% stenosis or aneurysm) seen in brain magnetic resonance angiography (MRA) or computed tomography angiography (CTA) at a single center by endovascular neurosurgeon's decision. Of these, 700 patients including 622 patients who underwent simultaneous coronary and cerebral angiography and 78 patients who underwent coronary angiography within a month were enrolled. We investigated the characteristics and predictors of angiographically significant CAD (>50% stenosis). Furthermore, we also analyzed the major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, myocardial infarction, and stroke for 5 years.

RESULTS

The frequency of significant CAD was 59% (413/700), the mean age was 68.9 ± 10.3 years, and 60.6% were male. During mean follow-up of 50 months, the MACCE rate of our whole cohort was significantly higher in the CAD group (21.5%) than in the non-CAD group (14.6%; hazard ratio 1.65, 95% CI 1.17-2.33, p value = 0.005). Considering that the embolic stroke is less associated with atherosclerotic change, our predictive model of significant CAD was made without embolic stroke (n = 599). In our multivariate model 2 including univariate <0.1, the independent predictors of significant CAD were male (OR 1.62, 95% CI 1.11-2.35, p = 0.012), diabetes mellitus (OR 1.81, 95% CI 1.22-2.68, p = 0.003), previous stroke (OR 1.63, 95% CI 1.02-2.60, p = 0.039), low ankle-brachial index (ABI; <0.9; OR 3.25, 95% CI 1.21-8.73, p = 0.019), left ventricular ejection fraction (EF) <50% on echocardiography (OR 2.82, 95% CI 1.25-6.35, p = 0.012), troponin I or T positive (OR 2.76, 95% CI 1.69-4.53, p < 0.001), and complex features on cerebral angiography (OR 2.73, 95% CI 1.78-4.19, p < 0.001).

CONCLUSIONS

Accurate coronary evaluation by coronary angiography might be considered when patients with atherosclerotic cerebral artery detected on brain MRA or CTA planned cerebral angiography were male or have diabetes mellitus, previous stroke, low ABI (<0.9), left ventricular EF <50% on echocardiography, troponin I or T positivity, and complex features on cerebral angiography.

P5728Association of systolic blood pressure and cardiovascular outcomes at different age groups in the healthy general population: a nationwide prospective cohort study

Background

Uncertainties remain regarding the effect of blood pressure on various cardiovascular outcomes in different age groups.

Purpose

We aimed to identify 1) whether a systolic blood pressure (SBP) of 130–139 mm Hg elevates cardiovascular disease (CVD) mortality and 2) whether SBP shows a linear association with cause-specific CVD mortality in all age groups among individuals without known hypertension and CVD.

Methods

We used the Korean National Health Insurance sample data (n=429,220). Participants were categorized into three groups by age (40–59, 60–69, and 70–80 years).

Results

A positive and graded association was generally observed between SBP and overall and cause-specific CVD mortality regardless of age, except for ischemic heart disease (IHD) mortality in those aged 70–80 years. Among those aged 70–80, the hazard ratios (HRs) (95% CIs) for overall CVD mortality were 1.08 (0.92–1.28), 1.14 (0.97–1.34), and 1.34 (1.14–1.58) for SBP values of 120–129, 130–139, and 140–149 mm Hg, respectively, compared to SBP <120 mm Hg. For total stroke mortality, the corresponding HRs were 1.29 (1.02–1.64), 1.37 (1.09–1.72), and 1.52 (1.20–1.93), while for IHD mortality, the corresponding HRs were 0.90 (0.64–1.26), 0.86 (0.62–1.19), and 1.29 (0.93–1.78). Nonlinear associations were significant for IHD (Fig 1).

Figure 1

Conclusion

In the elderly Korean population, SBPs of 130–139 mm Hg elevated total stroke mortality, but not IHD mortality, compared to normal BP, and a linear association was not observed for IHD mortality in the range <140 mm Hg. Regarding an appropriate diagnostic cutoff for hypertension, an individualized approach considering each person's organ susceptibility is needed for the elderly population.

Acknowledgement/Funding

None

Effects of sarcopenia, body mass indices, and sarcopenic obesity on diastolic function and exercise capacity in Koreans

AIMS

Obesity induces left ventricular diastolic dysfunction and ultimately causes heart failure. Sarcopenic obesity is common in heart failure with preserved ejection fraction (HFpEF). However, the precise mechanism by which sarcopenic obesity is related to HFpEF is poorly understood. We aimed to evaluate the combined effect of sarcopenia (SP) and obesity on left ventricular diastolic function and exercise capacity.

METHODS

This study included 733 healthy subjects who underwent health check-ups in a tertiary hospital in Korea. All participants were categorized into four groups: non-SP/non-obese, SP/non-obese, non-SP/obese, and SP/obese. Comprehensive echocardiography with cardiopulmonary exercise testing was performed. Diastolic dysfunction was defined as an E/e' ratio ≥ 10.

RESULTS

Across SP and obesity groups, a gradual decrease in e' velocity and an increase in the E/e' ratio was noted after adjustment for age and sex. Furthermore, a gradual decrease in percent-predicted peak VO₂ was observed across the groups. In the multivariate logistic regression analysis, the SP/obese group had the highest risk for diastolic dysfunction (OR 4.27, 95% CI 2.41-7.57), followed by the non-SP/obese group (OR 2.88, 95% CI 1.57-5.29) and the SP/non-obese group (OR 1.90, 95% CI 1.01-3.56) compared with the reference (non-SP/non-obese) group even after controlling for various confounders.

CONCLUSION

Sarcopenic obesity was associated with impaired diastolic function and decreased exercise capacity, suggesting a possible mechanism by which sarcopenic obesity contributes to the development of HFpEF.

2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension

The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.

2018 Korean society of hypertension guidelines for the management of hypertension: part III-hypertension in special situations

Treatment of hypertension improves cardiovascular, renal, and cerebrovascular outcomes. However, the benefit of treatment may be different according to the patients’ characteristics. Additionally, the target blood pressure or initial drug choice should be customized according to the special conditions of the hypertensive patients. In this part III, we reviewed previous data and presented recommendations for some special populations such as diabetes mellitus, chronic kidney disease, elderly people, and cardio-cerebrovascular disease.

2018 Korean Society of Hypertension guidelines for the management of hypertension: part I-epidemiology of hypertension

The Korean Society of Hypertension guideline defines hypertension as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, where the effectiveness of pharmacological treatment has been established. It is confirmed that higher blood pressure levels are associated with increased risk of cardiovascular disease and mortality also in the Korean population. About one third of Korean adults aged 30 years or older are estimated to have hypertension, and the prevalence of hypertension gradually increases as the age increases. The awareness, treatment, and control rates of hypertension are generally improving in Korea, but more efforts are required to increase awareness and treatment among younger patients with hypertension and to improve lifestyle modification compliance at all ages. More studies are required to determine the magnitude and impact of white coat hypertension and masked hypertension in the Korean population.

Clinical Benefit of Treatment of Stage-1, Low-Risk Hypertension

Evidence about the benefits of treating uncomplicated, low-risk, stage-1 hypertension is lacking. The study aimed to investigate the association between mean blood pressure (BP) and clinical outcomes, and to determine optimal BPs in treated, low-risk, stage-1 hypertension. From the National Health Insurance Service Health Examination Database, patients with stage-1 hypertension between 2005 and 2006 were selected. They had a systolic BP of 140 to 159 mm Hg or diastolic BP of 90 to 99 mm Hg. Patients were grouped as controlled (mean BP <140/90 mm Hg; n=99 301) and uncontrolled (mean BP ≥140/90 mm Hg; n=49 460) according to their mean BP recorded during the follow-up health examination. All-cause mortality and cardiovascular outcomes were examined. Mean BPs in the controlled and uncontrolled groups were 131.1/80.9 and 144.6/86.8 mm Hg, respectively. Controlled BP was associated with significantly lower risks of all-cause mortality, all stroke, hemorrhagic stroke, ischemic stroke, and end-stage renal disease. Subgroup analysis demonstrated benefits of controlled BP in hypertensive patients aged <50 years for all-cause mortality, all stroke, hemorrhagic stroke, ischemic stroke, and end-stage renal disease, with no significant interaction according to age. The BP associated with the lowest risk of all-cause mortality was 120 to <130 mm Hg (systolic BP) and 70 to <80 mm Hg (diastolic BP). There was an increased risk of myocardial infarction in patients with mean systolic BP <120 mm Hg and diastolic BP <80 mm Hg. BP <140/90 mm Hg was associated with a significant reduction in the risk of mortality, stroke, and end-stage renal disease, with the lowest mortality risk at BP ranges of 120 to <130 and 70 to <80 mm Hg.

Effect of physical activity on the cardiometabolic profiles of non-obese and obese subjects: Results from the Korea National Health and Nutritional Examination Survey

Background

Physical inactivity is an important but often neglected risk factor for various cardiovascular diseases. We hypothesized that physical inactivity might have deleterious effects on metabolic health in obese and non-obese subjects.

Methods

We evaluated the effect of physical activity on the cardiometabolic profiles of a nationwide cohort of non-obese and obese individuals who did not have overt cardiovascular diseases. A total of 3,830 study subjects were divided into two groups based on their body mass index (BMI). Within each BMI group, participants were divided according to their physical activity level. To ascertain their cardiometabolic profiles, we collected data regarding the homeostasis model assessment-estimated insulin resistance (HOMA-IR) index, high-density lipoprotein (HDL)-cholesterol level, systolic blood pressure, heart rate, and high-sensitivity C-reactive protein (hsCRP) level.

Results

Physically inactive subjects demonstrated markedly elevated HOMA-IR index and heart rates in each BMI category, even after adjustments for baseline covariates. They also tended to have worse profiles for HDL-cholesterol, systolic blood pressure, and hsCRP levels. A significant elevation in cardiometabolic risk was noted across the four physical activity/obesity groups (p<0.05). HOMA-IR index was largely affected by obesity, but within each BMI category, physical inactivity independently elevated the risk for worsening insulin resistance. In addition, physical inactivity significantly increased the risk of elevated heart rate in both non-obese and obese individuals. Notably, the detrimental effect of physical activity on heart rate was not modified by obesity.

Conclusions

Physical activity was associated with favorable cardiometabolic risk profiles with regard to insulin resistance status and heart rate level in both BMI groups. Our results suggest that increasing physical activity could be a helpful strategy for improving the cardiometabolic health in the Korean population, regardless of obesity status.

Efficacy of a fixed dose combination of irbesartan and atorvastatin (Rovelito®) in Korean adults with hypertension and hypercholesterolemia

Purpose

Coexistence of hypertension (HTN) and hypercholesterolemia is a major synergistic and modifiable risk factor for cardiovascular disease (CVD). Thus, a fixed-dose combination (FDC) of anti-HTN drugs and statins may be useful for treating CVD. This study evaluated the efficacy of an FDC of irbesartan and atorvastatin (Rovelito^®) in Korean patients.

Patients and methods

Patients with HTN and hypercholesterolemia were screened for this prospective, observational, descriptive, multi-center, phase IV study. Eligible patients were administered with Rovelito for 3 months. Dose adjustment was allowed based on the physician’s discretion. Blood pressure (BP) goal was <140/90 mmHg, and blood lipid goal was based on Adult Treatment Panel III. Compliance with therapeutic lifestyle modification and safety of the study drugs were evaluated.

Results

Of the 2,777 patients enrolled in this study, 931 were analyzed for clinical efficacy. BP and low-density lipoprotein cholesterol (LDL-C) goals were achieved in 801 (86.04%) and 797 (85.61%) patients, respectively. For the BP goal, higher baseline BP and higher body mass index were risk factors for treatment failure. For LDL-C goal, baseline LDL-C level, number of concomitant drugs, smoking status, and alcohol consumption were risk factors for treatment failure. Of the 931 participants, 694 (74.54%) achieved the treatment goals for both BP and LDL-C. Smoking status, alcohol consumption, number of concomitant drugs, and higher baseline LDL-C and BP levels were risk factors for treatment failure in both BP and LDL-C goals. Adherence with Rovelito was 97.90%±5.79%, and incidence of adverse events was 4.19% (116).

Conclusion

FDC of irbesartan and atorvastatin (Rovelito) could be extremely helpful in treating patients with both HTN and hypercholesterolemia. Poor metabolic profiles were risk factors for poor treatment response and the reason for choosing Rovelito. Therapeutic lifestyle modification should still be underscored despite the 75% treatment success rate with Rovelito for both conditions.

Controversies in the 2017 ACC/AHA Hypertension Guidelines: Who Can Be Eligible for Treatments Under the New Guidelines? - An Asian Perspective

Until the 2017 ACC/AHA Hypertension Guidelines were released, the target blood pressure (BP) for adults with hypertension (HTN) was 140/90 mmHg in most of the guidelines. The new 2018 ESC/ESH, Canadian, Korean, Japan, and Latin American hypertension guidelines have maintained the <140/90 mmHg for the primary target in the general population and encourage reduction to <130/80 if higher risk. This is more in keeping with the 2018 American Diabetes Association guidelines. However, the 2017 ACC/AHA guidelines classify HTN as BP ≥130/80 mmHg and generally recommend target BP levels below 130/80 mmHg for hypertensive patients independently of comorbid disease or age. Although the new guidelines mean that more people (nearly 50% of adults) will be diagnosed with HTN, the cornerstone of therapy is still lifestyle management unless BP cannot be lowered to this level; thus, more people will require BP-lowering medications. To date, there have been many controversies about the definition of HTN and the target BP. Targeting an intensive systolic BP goal can increase the adverse effects of multiple medications and the cardiovascular disease risk by excessively lowering diastolic BP, especially in patients with high risk, including those with diabetes, chronic kidney disease, heart failure, and coronary artery disease, and the elderly. In this review, we discuss these issues, particularly regarding the optimal target BP.

Low plasma renin activity is an independent predictor of near-term incidence of hypertension in Asian populations

BACKGROUND

Plasma renin activity is involved in the regulation of body salt content and blood pressure. However, there is a paucity of data regarding the association between low or high plasma renin activity and the development of hypertension.

METHOD

We investigated the relation of baseline plasma renin activity to increases in blood pressure and the incidence of hypertension after four years in 2,146 non-hypertensive individuals from a community-based Korean population (mean age, 50 years), 58% of whom were women. We defined an "increase in blood pressure" as an increment of systolic blood-pressure ≥ 10 mmHg or initiation of antihypertensive drugs and defined "hypertension" as a systolic blood pressure of 140 mm Hg or higher, a diastolic blood pressure of 90 mm Hg or higher, or the use of antihypertensive medications.

RESULTS

After 4 years, the increase in blood pressure had increased in 27.9% of the participants, and hypertension had developed in 17.9%. After adjustment, the lowest sex-specific tertile of plasma renin activity was an independent risk factor of an elevation in blood pressure (Adjusted Odds Ratio 1.37, 95% confidence interval 1.07-1.74, p = 0.011) and hypertension (Adjusted Odds Ratio 1.84, 95% confidence interval 1.36-2.50, p < 0.001) compared to the highest sex-specific tertile. The associations between the plasma renin activity and blood-pressure outcomes were evident in adults with especially high urine sodium excretion.

CONCLUSION

Low plasma renin activity was associated with the development of hypertension in the middle-aged Asian population, especially in peoples with high sodium intake.

Heart Rate and Bone Mineral Density in Older Women with Hypertension: Results from the Korea National Health and Nutritional Examination Survey

OBJECTIVES

To determine whether high heart rate is associated with low bone mineral density (BMD) in older women with hypertension.

DESIGN

Retrospective cohort study.

SETTING

Population-based study conducted in Korea (Korea National Health and Nutritional Examination Survey 2009-10).

PARTICIPANTS

Postmenopausal women aged 60 and older with hypertension (N=981) divided into 2 groups according to resting heart rate, with a cut-off value of 80 bpm, which has been found to be associated with osteoporosis.

MEASUREMENTS

BMD profiles and clinical and laboratory data were collected. Osteoporosis was defined as a T-score of -2.5 or less, according to World Health Organization criteria.

RESULTS

BMD was significantly lower in participants with a high heart rate, even after adjustment for age, diabetes mellitus, white blood cell count, and fasting glucose and triglyceride levels. The prevalence of osteoporosis was also significantly higher in those participants. In multivariate logistic regression analysis, the group with high heart rate was 1.7 times as likely (95% confidence interval=1.2-2.3) to have osteoporosis as those with a lower heart rate, independent of age, body mass index, comorbidities, and laboratory findings.

CONCLUSION

High heart rate is independently associated with lower BMD in older women with hypertension; proactive surveillance of BMD could be helpful when managing older women with hypertension and a high heart rate.

Visit-to-visit variability of systolic blood pressure predicts all-cause mortality in patients received percutaneous coronary intervention with drug-eluting stents

Blood pressure (BP) and its variability are associated with atherosclerotic disease and cardiovascular events. The prognostic implications of outpatient clinic visit-to-visit blood pressure variability (BPV) are unknown in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). A total of 1,463 patients undergoing PCI with DES were consecutively enrolled from January 2009 to December 2013. We analyzed the 1,234 patients, who measured clinic BP more than three times during the first year after PCI. The BPV is determined by standard deviation of systolic and diastolic BP, and coefficient of variation. Median follow-up duration was 905 days (interquartile range 529-1,310 days). All patients were divided into two groups according to the coefficient of variation of systolic BP (CVSBP); high CVSBP group (> 8.78, n = 617) and low CVSBP group (≤ 8.78, n = 617). High CVSBP group had significantly higher all-cause mortality (7.9% versus 3.1%, p < 0.001) and composite of all-cause mortality, myocardial infarction, and stroke (13.1% versus 6.2%, p < 0.001). In multivariate logistic regression analysis for prediction of all-cause mortality, and composite of all-cause mortality, myocardial infarction, and stroke after PCI with DES, hazard ratios of high CVSBP group were 2.441 (95% of confidence interval 1.042-5.718, p = 0.040), and 1.980 (95% of confidence interval 1.125-3.485, p = 0.018). The higher visit-to-visit BPV is associated higher mortality in patients undergoing PCI with DES. The clinic measured visit-to-visit BPV may serve as a predictor of all-cause mortality after PCI with DES.

Dipeptidyl peptidase 4 inhibitor attenuates obesity-induced myocardial fibrosis by inhibiting transforming growth factor-βl and Smad2/3 pathways in high-fat diet-induced obesity rat model

Obesity-induced myocardial fibrosis may lead to diastolic dysfunction and ultimately heart failure. Activation of the transforming growth factor (TGF)-βl and its downstream Smad2/3 pathways may play a pivotal role in the pathogenesis of obesity-induced myocardial fibrosis, and the antidiabetic dipeptidyl peptidase 4 inhibitors (DPP4i) might affect these pathways. We investigated whether DPP4i reduces myocardial fibrosis by inhibiting the TGF-β1 and Smad2/3 pathways in the myocardium of a diet-induced obesity (DIO) rat model. Eight-week-old male spontaneously hypertensive rats (SHRs) were fed either a normal fat diet (chow) or a high-fat diet (HFD) and then the HFD-fed SHRs were randomized to either the DPP4i (MK-0626) or control (distilled water) groups for 12weeks. At 20weeks old, all the rats underwent hemodynamic and metabolic studies and Doppler echocardiography. Compared with the normal fat diet (chow)-fed SHRs, the HFD-fed SHRs developed a more intense degree of hyperglycemia and dyslipidemia and showed a constellation of left ventricular (LV) diastolic dysfunction, and exacerbated myocardial fibrosis, as well as activation of the TGF-β1 and Smad2/3 pathways. DPP4i significantly improved the metabolic and hemodynamic parameters. The echocardiogram showed that DPP4i improved the LV diastolic dysfunction (early to late ventricular filling velocity [E/A] ratio, 1.49±0.21 vs. 1.77±0.09, p<0.05). Furthermore, DPP4i significantly reduced myocardial fibrosis and collagen production by the myocardium and suppressed TGF-β1 and phosphorylation of Smad2/3 in the heart. In addition, DPP4i decreased TGF-β1-induced collagen production and TGF-β1-mediated phosphorylation and nuclear translocation of Smad2/3 in rat cardiac fibroblasts. In conclusion, DPP4 inhibition attenuated myocardial fibrosis and improved LV diastolic dysfunction in a DIO rat model by modulating the TGF-β1 and Smad2/3 pathways.

The impact of preload on 3-dimensional deformation parameters: principal strain, twist and torsion

Background

Strain analysis is feasible using three-dimensional (3D) echocardiography. This approach provides various parameters based on speckle tracking analysis from one full-volume image of the left ventricle; however, evidence for its volume independence is still lacking.

Methods

Fifty-eight subjects who were examined by transthoracic echocardiography immediately before and after hemodialysis (HD) were enrolled. Real-time full-volume 3D echocardiographic images were acquired and analyzed using dedicated software. Two-dimensional (2D) longitudinal strain (LS) was also measured for comparison with 3D strain values.

Results

Longitudinal (pre-HD: −24.57 ± 2.51, post-HD: −21.42 ± 2.15, P < 0.001); circumferential (pre-HD: −33.35 ± 3.50, post-HD: −30.90 ± 3.22, P < 0.001); and radial strain (pre-HD: 46.47 ± 4.27, post-HD: 42.90 ± 3.61, P < 0.001) values were significantly decreased after HD. The values of 3D principal strain (PS), a unique parameter of 3D images, were affected by acute preload changes (pre-HD: −38.10 ± 3.71, post-HD: −35.33 ± 3.22, P < 0.001). Twist and torsion values were decreased after HD (pre-HD: 17.69 ± 7.80, post-HD: 13.34 ± 6.92, P < 0.001; and pre-HD: 2.04 ± 0.86, post-HD:1.59 ± 0.80, respectively, P < 0.001). The 2D LS values correlated with the 3D LS and PS values.

Conclusion

Various parameters representing left ventricular mechanics were easily acquired from 3D echocardiographic images; however, like conventional parameters, they were affected by acute preload changes. Therefore, strain values from 3D echocardiography should be interpreted with caution while considering the preload conditions of the patients.