A hypertensive response to exercise is prominent in patients with obstructive sleep apnea and hypertension: a controlled study

Blood pressure (BP) behavior during exercise is not clear in hypertensive patients with obstructive sleep apnea (OSA). The authors studied 57 men with newly diagnosed essential hypertension and untreated OSA (apnea-hypopnea index [AHI] ≥5) but without daytime sleepiness (Epworth Sleepiness Scale score ≤10), and an equal number of hypertensive controls without OSA matched for age, body mass index, and office systolic BP. All patients underwent ambulatory BP measurements, transthoracic echocardiography, and exercise treadmill testing according to the Bruce protocol. A hypertensive response to exercise (HRE) was defined as peak systolic BP ≥210 mm Hg. Patients with OSA and control patients had similar ambulatory and resting BP, ejection fraction, and left ventricular mass. Peak systolic BP was significantly higher in patients with OSA (197.6±25.6 mm Hg vs 187.8±23.6 mm Hg; P=.03), while peak diastolic BP and heart rate did not differ between groups. Furthermore, an HRE was more prevalent in patients with OSA (44% vs 19%; P=.009). Multiple logistic regression revealed that an HRE is independently predicted by both the logAHI and minimum oxygen saturation during sleep (odds ratio, 3.94; confidence interval, 1.69-9.18; P=.001 and odds ratio, 0.94; confidence interval, 0.89-0.99; P=.02, respectively). Exaggerated BP response is more prevalent in nonsleepy hypertensives with OSA compared with their nonapneic counterparts. This finding may have distinct diagnostic and prognostic implications.

Soluble receptor for advanced glycation end-product levels are related to albuminuria and arterial stiffness in essential hypertension

BACKGROUND AND AIMS

Emerging evidence suggests that the soluble receptor for advanced glycation end-products (sRAGE) is implicated in the development of vascular disease. We investigated the interrelationships of sRAGE with albumin to creatinine ratio (ACR) and arterial stiffness in essential hypertension.

METHODS AND RESULTS

In 309 untreated non-diabetic hypertensives, ACR values were determined as the mean of three non-consecutive morning spot urine samples and aortic stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (c-f PWV). In all subjects, venous blood sampling was performed for the estimation of sRAGE levels. Patients with low (n = 155) compared to those with high sRAGE values (n = 154) had greater 24-h systolic BP (140 ± 8 vs. 134 ± 7 mmHg, p < 0.0001), exhibited higher ACR (36.3 ± 51.6 vs. 17.2 ± 1.2 mg g(-1), p < 0.0001) and c-f PWV (8.3 ± 1.5 vs. 7.8 ± 1.1 m s(-1), p = 0.003), independently of confounding factors. Multiple regression analyses revealed that age, male sex, 24-h systolic BP and sRAGE were the 'independent correlates' of ACR (R(2) = 0.493, p < 0.0001), while age, 24-h systolic BP and sRAGE were the 'independent correlates' of c-f PWV (R(2) = 0.428, p < 0.0001).

CONCLUSION

In hypertensives, decreased sRAGE levels are accompanied by pronounced albuminuria and arterial stiffening. The association of sRAGE with ACR and c-f PWV suggests involvement of sRAGE in the progression of hypertensive vascular damage.

Catheter-based renal sympathetic denervation for the treatment of resistant hypertension: first experience in Greece with significant ambulatory blood pressure reduction

We describe the first two cases in Greece of catheter-based renal sympathetic denervation (RSD) by means of radiofrequency ablation. The procedure was performed on middle-aged men with long-standing resistant hypertension (office blood pressure, BP 195/115 mmHg and ambulatory BP 190/110 mmHg; office BP 170/95 mmHg and ambulatory BP 151/87 mmHg) under optimal medical therapy. The percutaneous RSD was completed successfully, and led to a significant reduction in both office and ambulatory BP at 3 weeks, with no vascular complications, while renal function remained unaltered. These cases of RSD suggest that renal nerve ablation for the treatment of resistant hypertension constitutes an effective and safe therapeutic modality, accompanied by significant reduction of ambulatory BP, and broadening of its clinical use in our country is of clinical importance.

Periodontitis and coronary artery disease: a questioned association between periodontal and vascular plaques

Periodontitis is a bacterially-induced, localized chronic inflammatory disease destroying both the connective tissue and the supporting bone of the teeth. In the general population, severe forms of the disease demonstrate a prevalence of almost 5%, whereas initial epidemiological evidence suggests an association between periodontitis and coronary artery disease (CAD). Both the infectious nature of periodontitis and the yet etiologically unconfirmed infectious hypothesis of CAD, question their potential association. Ephemeral bacteremia, systemic inflammation and immune-pathological reactions constitute a triad of mechanisms supporting a cross-talk between periodontal and vascular damage. To which extent each of these periodontitis-mediated components contribute to vascular damage still remains uncertain. More than twenty years from the initial epidemiological association, the positive weight of evidence remains still alive but rather debated, because of both the presence of many uncontrolled confounding factors and the different assessment of periodontal disease. From the clinical point of view, advising periodontal prevention or treatment targeting on the prevention of CAD it is unjustified. By contrast, oral hygiene including periodontal health might contribute to the overall well-being and healthy lifestyle and hence as might at least partially contribute to cardiovascular prevention.

Metabolic syndrome and exaggerated blood pressure response to exercise in newly diagnosed hypertensive patients

Background: Running evidence supports a prognostic value of an exaggerated blood pressure response to exercise (EBPR). The impact of the metabolic syndrome (MS) on EBPR in hypertensive patients has not been investigated.

Design: A cross-sectional study in the setting of an outpatient hypertension clinic.

Methods: In total, 325 non-diabetic patients with newly diagnosed hypertension were divided into two groups based on the presence ( n = 95) or absence ( n = 230) of the MS as defined with NCEP-ATP III criteria. All subjects underwent ambulatory blood pressure monitoring, echocardiography and exercise treadmill testing.

Results: Hypertensive patients with MS exhibited higher prevalence of EBPR (by 17%, p = 0.002) and peak exercise systolic BP (by 10.4 mmHg, p = 0.001) irrespectively of confounders. Metabolic equivalents were higher in hypertensives with MS (by 0.6 ml/kg/min, p = 0.048), but the difference lost significance after adjusting for confounders, including body mass index. Logistic regression analysis identified the MS as an independent predictor of an EBPR ( p = 0.016). Hypertensive patients with MS had a 2.3-fold risk of exhibiting EBPR compared to those without MS. However, individual components of MS altogether as well as each one separately failed to predict EBPR.

Conclusions: Presence of MS in newly diagnosed hypertensive patients is associated with increased peak exercise BP and a higher frequency of EBPR over and above its separate elements.

Periodontitis and blood pressure: the concept of dental hypertension

Chronic periodontitis is a common inflammatory disorder that is being contemplated as a risk factor for atherosclerotic complications. Current epidemiological evidence also supports its potential association with increases in blood pressure levels and hypertension prevalence. Furthermore, data from cross-sectional studies suggest that in hypertensive subjects periodontitis may enhance the risk and degree of target organ damage. A possible pathogenetic background of an effect of periodontitis on blood pressure should include the systemic generalization of the local oral inflammation, the role of the host immune response, the direct microbial effect on the vascular system and alterations in endothelial function. Inversely, the concept of hypertension unfavorably affecting periodontal tissues cannot be excluded. The two conditions share multiple common risk factors that should be readily controlled for when assessing a possible association. Thoroughly designed prospective and interventional trials are needed in order to determine the impact of periodontitis on blood pressure regulation and incident hypertension and its integration in the clinical approach of both dental and hypertensive patients.

Resistant hypertension and obstructive sleep apnea: the sparring partners

Enhanced target organ damage and cardiovascular morbidity represent common issues observed in both resistant hypertension and obstructive sleep apnea. Common pathophysiological features and risk factors justify their coexistence, especially in individuals with increased upper-body adiposity. Impaired sodium handling, sympathetic activation, accelerated arterial stiffening, and impaired cardiorenal hemodynamics contribute to drug-resistant hypertension development in obstructive sleep apnea. Effective CPAP therapy qualifies as an effective "add-on" to the underlying antihypertensive pharmacological therapy, and emerging evidence underlines the favorable effect of mineralocorticoid antagonists on both resistant hypertension and obstructive sleep apnea treatment.

Periodontal disease severity and urinary albumin excretion in middle-aged hypertensive patients

To address whether periodontal disease indexes are associated with urinary albumin-to-creatinine ratio (UACR) in conditions of high and low systemic inflammation as reflected by levels of high-sensitivity C-reactive protein (hs-CRP) in untreated hypertensive patients, we studied 242 hypertensive patients 51 ± 9 years old (24-hour systolic/diastolic blood pressure [BP] 132 ± 10/83 ± 8 mm Hg) with varying severity of periodontal disease evaluated by 3 periodontal disease indexes (PDIs) (i.e., mean clinical loss of attachment, maximum probe depth, and gingival bleeding index). Patients underwent BP measurements, echocardiography, and periodontal examination, and from fasting blood samples we assessed metabolic profile and hs-CRP. From 2 nonconsecutive overnight spot urine samples we evaluated UACR. With respect to median hs-CRP and UACR levels (1.67 mg/L and 10 mg/g, respectively), the total population was divided into patients with low-UACR/low-hs-CRP (n = 65), low-UACR/high-hs-CRP (n = 63), high-UACR/low-hs-CRP (n = 51), and high-UACR/high-hs-CRP (n = 63). PDIs differed among the 4 groups, and those with high UACR had significantly higher 24-hour systolic BP compared to those with low UACR. UACR was determined by all periodontal disease indexes, hs-CRP, and the interaction of each periodontal disease index with hs-CRP. In addition, mean clinical loss of attachment was the strongest determinant of the high-UACR/high-hs-CRP pattern among all studied periodontal disease indexes. In conclusion, in untreated middle-aged hypertensive patients, periodontal disease indexes and hs-CRP have a synergistic effect on UACR levels independently of the underlying hemodynamic load.