2020 International Society of Hypertension Global Hypertension Practice Guidelines

Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey

Background

The impact of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for diagnosis and management of hypertension on the prevalence of hypertension in India is unknown.

Methods

We analyzed data from the Cardiac Prevent 2015 survey to estimate the change in the prevalence of hypertension. The JNC8 guidelines defined hypertension as a systolic blood pressure of ≥140 ​mmHg or diastolic blood pressure of ≥90 ​mmHg. The 2017 ACC/AHA guidelines define hypertension as a systolic blood pressure of ≥130 ​mmHg or diastolic blood pressure of ≥80 ​mmHg. We standardized the prevalence as per the 2011 census population of India. We also calculated the prevalence as per the World Health Organization (WHO) World Standard Population (2000–2025).

Results

Among 180,335 participants (33.2% women), the mean age was 40.6 ​± ​14.9 years (41.1 ​± ​15.0 and 39.7 ​± ​14.7 years in men and women, respectively). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%) and 2,878 (1.6%) participants belonged to age group 18–19, 20–44, 45–54, 55–64, 65–74 and ​≥ ​75 years respectively. The prevalence of hypertension according to the JNC8 and 2017 ACC/AHA guidelines was 29.7% and 63.8%, respectively- an increase of 115%. With the 2011 census population of India, this suggests that currently, 486 million Indian adults have hypertension according to the 2017 ACC/AHA guidelines, an addition of 260 million as compared to the JNC8 guidelines.

Conclusion

According to the 2017 ACC/AHA guidelines, 3 in every 5 Indian adults have hypertension.

Do the combined blood pressure effects of exercise and antihypertensive medications add up to the sum of their parts? A systematic meta-review

Objective

To compare the blood pressure (BP) effects of exercise alone (EXalone), medication alone (MEDSalone) and combined (EX+MEDScombined) among adults with hypertension.

Data sources

PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus and the Cochrane Library.

Eligibility criteria

Randomised controlled trails (RCTs) or meta-analyses (MAs) of controlled trials that: (1) involved healthy adults>18 year with hypertension; (2) investigated exercise and BP; (3) reported preintervention and postintervention BP and (4) were published in English. RCTs had an EX+MEDScombined arm; and an EXalone arm and/or an MEDSalone arm; and MAs performed moderator analyses.

Design

A systematic network MA and meta-review with the evidence graded using the Physical Activity Guidelines for Americans Advisory Committee system.

Outcome

The BP response for EXalone, MEDSalone and EX+MEDScombined and compared with each other.

Results

Twelve RCTs qualified with 342 subjects (60% women) who were mostly physically inactive, middle-aged to older adults. There were 13 qualifying MAs with 28 468 participants (~50% women) who were mostly Caucasian or Asian. Most RCTs were aerobic (83.3%), while the MAs involved traditional (46%) and alternative (54%) exercise types. Strong evidence demonstrates EXalone, MEDSalone and EX+MEDScombined reduce BP and EX+MEDScombined elicit BP reductions less than the sum of their parts. Strong evidence indicates EX+MEDScombined potentiate the BP effects of MEDSalone. Although the evidence is stronger for alternative than traditional types of exercise, EXaloneelicits greater BP reductions than MEDSalone.

Conclusions

The combined BP effects of exercise and medications are not additive or synergistic, but when combined they bolster the antihypertensive effects of MEDSalone.

PROSPERO registration number

The protocol is registered at PROSPERO CRD42020181754.

Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial

OBJECTIVE

The HOME BP (Home and Online Management and Evaluation of Blood Pressure) trial aimed to test a digital intervention for hypertension management in primary care by combining self-monitoring of blood pressure with guided self-management.

DESIGN

Unmasked randomised controlled trial with automated ascertainment of primary endpoint.

SETTING

76 general practices in the United Kingdom.

PARTICIPANTS

622 people with treated but poorly controlled hypertension (>140/90 mm Hg) and access to the internet.

INTERVENTIONS

Participants were randomised by using a minimisation algorithm to self-monitoring of blood pressure with a digital intervention (305 participants) or usual care (routine hypertension care, with appointments and drug changes made at the discretion of the general practitioner; 317 participants). The digital intervention provided feedback of blood pressure results to patients and professionals with optional lifestyle advice and motivational support. Target blood pressure for hypertension, diabetes, and people aged 80 or older followed UK national guidelines.

MAIN OUTCOME MEASURES

The primary outcome was the difference in systolic blood pressure (mean of second and third readings) after one year, adjusted for baseline blood pressure, blood pressure target, age, and practice, with multiple imputation for missing values.

RESULTS

After one year, data were available from 552 participants (88.6%) with imputation for the remaining 70 participants (11.4%). Mean blood pressure dropped from 151.7/86.4 to 138.4/80.2 mm Hg in the intervention group and from 151.6/85.3 to 141.8/79.8 mm Hg in the usual care group, giving a mean difference in systolic blood pressure of -3.4 mm Hg (95% confidence interval -6.1 to -0.8 mm Hg) and a mean difference in diastolic blood pressure of -0.5 mm Hg (-1.9 to 0.9 mm Hg). Results were comparable in the complete case analysis and adverse effects were similar between groups. Within trial costs showed an incremental cost effectiveness ratio of £11 ($15, €12; 95% confidence interval £6 to £29) per mm Hg reduction.

CONCLUSIONS

The HOME BP digital intervention for the management of hypertension by using self-monitored blood pressure led to better control of systolic blood pressure after one year than usual care, with low incremental costs. Implementation in primary care will require integration into clinical workflows and consideration of people who are digitally excluded.

TRIAL REGISTRATION

ISRCTN13790648.

Review of Clinical Trials on the Effects of Tai Chi Practice on Primary Hypertension: The Current State of Study Design and Quality Control

The modulation of Tai Chi in physiological function and psychological status attracts sustaining attention. This paper collected original articles regarding the effects of Tai Chi practice on modulating primary hypertension from 7 electronic databases (PubMed, Excerpta Medica Database, Cochrane Library, Web of Science, Chinese Knowledge Resource Integrated Database, Wanfang Database, and China Science and Technology Journal Database) from their dates of origin to October 1st, 2020. A total of 45 articles were included. The literature analyses have shown that the benefits of Tai Chi practice for blood pressure management have been identified in all of the included 45 studies, and Tai Chi exercise has shown significant efficacy in improving hypertension clinical symptoms and quality of life, compared to the majority of control interventions, though there are also some methodological issues, including small sample sizes, lack of exact randomization methods and quality control criteria, and lack of specific standards used to measure the characteristics of Tai Chi practice. In the future, the inclusion of additional design standards, stricter quality controls, and evaluation measures for the features of Tai Chi practice is required in trials evaluating its effects on hypertension.

Single-pill combination of cilnidipine, an l-/n-type calcium channel blocker, and valsartan reduces the day-by-day variability of morning home systolic blood pressure in patients with treated hypertension: A sub-analysis of the HOPE-combi survey

We examined the effects of a fixed‐dose single‐pill combination of cilnidipine (10 mg), an L‐/N‐type calcium channel blocker, and valsartan (80 mg) (SPC of Cil/Val) on the day‐by‐day variability of morning home systolic blood pressure (MHSBP) in 616 patients with treated hypertension for 12 months as a sub‐analysis of the HOPE‐Combi survey, multicentral, post‐marketing, and prospective observational survey. The SPC of Cil/Val was administrated once a day in the morning. The SPC of Cil/Val decreased the standard deviation (SD, from 6.3 ± 4.8 to 5.1 ± 3.8 mmHg, p < .01), coefficient of variation (from 4.3 ± 3.2 to 3.8 ± 2.9%, p < .05), average real variability (ARV, from 7.9 ± 6.6 to 6.3 ± 5.1 mmHg, p < .01), and the difference between maximum and minimum (MMD, from 11.9 ± 9.2 to 9.7 ± 7.2 mmHg, p < .01) of MHSBP. The variability of MHSBP increased with age; however, this was not increased in patients ≥70 years at the baseline. In elderly patients (≥70 years, N = 283), the SPC of Cil/Val decreased the SD (from 6.9 ± 5.6 to 5.6 ± 4.4 mmHg, p < .01), ARV (from 8.6 ± 7.7 to 6.9 ± 5.7 mmHg, p < .05), and MMD (from 13.2 ± 10.7 to 10.7 ± 8.3 mmHg, p < .01) of MHSBP at 12 months; the reduction in these MHSBP variability parameters was comparable to that in adults <70 years. These results suggest that the SPC of Cil/Val is effective in reducing day‐by‐day variability of MHSBP in elderly patients.

Risk Stratification and Management of Arterial Hypertension and Cardiovascular Adverse Events Related to Cancer Treatments: An Oncology Network from Piedmont and Aosta Valley (North-Western Italy) Consensus Document

Cancer patients receiving a potentially cardiotoxic oncologic therapy have an increased risk of cardiovascular adverse events (CVAEs), especially in presence of concomitant arterial hypertension (AH). Therefore, cancer patients should be evaluated before, during and after cardiotoxic treatments, to early identify new-onset or worsening AH or CVAEs. An expert panel of oncology networks from Piedmont and Aosta Valley (North-Western Italy) aimed to provide recommendations to support health professionals in selecting the best management strategies for patients, considering the impact on outcome and the risk–benefit ratio of diagnostic/therapeutic tools. We proposed an useful document for evaluating and managing AH related to cancer treatments. Patients should be divided into 4 cardiovascular (CV) risk groups before starting potentially cardiotoxic therapies: patients with low/moderate risk who should be entirely evaluated by oncologists and patients with high/very high risk who should be referred to a cardiologist or arterial hypertension specialist. According to the CV risk class, every patient should be followed up during cancer treatment to monitor any possible CV complications. Adequate control of AH related to antineoplastic treatments is crucial to prevent severe CVAEs. In the presence of high-profile risk or lack of response to anti-hypertensive therapy, the patients should be managed with a cardiovascular-oncology expert center.

The role of dietary salt and alcohol use reduction in the management of hypertension

Introduction: Despite the improved treatment protocol of hypertension, the magnitude of the disease and its related burden remains raised. Hypertension makes up the leading cause of stroke, kidney disease, arterial disease, eye disease, and cardiovascular disease (CVD) growth. Areas covered: This review provides the overview of the role of dietary salt and alcohol use reduction in the management of hypertension, a brief history of alcohol, the vascular endothelium functions, the effects of alcohol use on blood pressure (BP), the mechanisms of alcohol, brief history of salt, the effects of dietary salt intake on BP, and the mechanisms of salt. Expert opinion: Studies found that high dietary salt intake and heavy alcohol consumption have a major and huge impact on BP while both of them have been identified to increase BP. Also, they raise the risk of hypertension-related morbidity and mortality in advance. On the other way, the dietary salt and alcohol use reduction in the management of hypertension are significant in the control of BP and its related morbidity and mortality. Further, studies suggested that the dietary salt and alcohol use reductions are the cornerstone in the management of hypertension due to their significance as part of comprehensive lifestyle modifications.

Relacorilant, a Selective Glucocorticoid Receptor Modulator, Induces Clinical Improvements in Patients With Cushing Syndrome: Results From A Prospective, Open-Label Phase 2 Study

INTRODUCTION/PURPOSE

Relacorilant is a selective glucocorticoid receptor modulator (SGRM) with no progesterone receptor activity. We evaluated the efficacy and safety of relacorilant in patients with endogenous Cushing syndrome (CS).

MATERIALS AND METHODS

A single-arm, open-label, phase 2, dose-finding study with 2 dose groups (NCT02804750, https://clinicaltrials.gov/ct2/show/NCT02804750) was conducted at 19 sites in the U.S. and Europe. Low-dose relacorilant (100-200 mg/d; n = 17) was administered for 12 weeks or high-dose relacorilant (250-400 mg/d; n = 18) for 16 weeks; doses were up-titrated by 50 mg every 4 weeks. Outcome measures included proportion of patients with clinically meaningful changes in hypertension and/or hyperglycemia from baseline to last observed visit. For patients with hypertension, clinical response was defined as a ≥5-mmHg decrease in mean systolic or diastolic blood pressure, measured by a standardized and validated 24-h ABPM. For patients with hyperglycemia, clinical response was defined ad-hoc as ≥0.5% decrease in HbA1c, normalization or ≥50-mg/dL decrease in 2-h plasma glucose value on oral glucose tolerance test, or decrease in daily insulin (≥25%) or sulfonylurea dose (≥50%).

RESULTS

35 adults with CS and hypertension and/or hyperglycemia (impaired glucose tolerance or type 2 diabetes mellitus) were enrolled, of which 34 (24 women/10 men) received treatment and had postbaseline data. In the low-dose group, 5/12 patients (41.7%) with hypertension and 2/13 patients (15.4%) with hyperglycemia achieved response. In the high-dose group, 7/11 patients (63.6%) with hypertension and 6/12 patients (50%) with hyperglycemia achieved response. Common (≥20%) adverse events included back pain, headache, peripheral edema, nausea, pain at extremities, diarrhea, and dizziness. No drug-induced vaginal bleeding or hypokalemia occurred.

CONCLUSIONS

The SGRM relacorilant provided clinical benefit to patients with CS without undesirable antiprogesterone effects or drug-induced hypokalemia.

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Pharmacologic management of nocturnal polyuria: a contemporary assessment of efficacy, safety, and progress toward individualized treatment

This narrative review synthesizes current evidence on the medical management of nocturnal polyuria, including antidiuretic replacement therapy as well as other emerging modalities, with particular emphasis on areas of active investigation and future research directions. Relative to earlier formulations, the pharmacological profiles of novel desmopressin acetate nasal spray and orally disintegrating tablet formulations appear favorable in optimizing the balance between efficacy and safety. Additionally, several highly selective small-molecule arginine vasopressin 2 receptor agonists are under active development, while appropriately timed short-acting diuretics, pharmacotherapy for hypertension, nonsteroidal anti-inflammatory drugs, and sex hormone replacement therapy are also a focal point of extensive ongoing nocturnal polyuria research. Emerging laboratory technologies now make feasible a sub-stratification of nocturnal polyuria patients into substrate-based phenotypes for individualized treatment. An increasingly refined understanding of the pathogenesis of nocturnal polyuria, and arginine vasopressin dysregulation in particular, has also introduced new opportunities for point-of-care testing in patients with nocturnal polyuria.

The Renin-Angiotensin System, Hypertension, and SARS-CoV-2 Infection: a Review

PURPOSE OF REVIEW

This review focuses on the associations between the renin-angiotensin system, hypertension, and severe acute respiratory syndrome (SARS-COV-2) infection. A brief prelude on the current state of affairs with COVID-19 is given. In addition to an overview of ACE2, Ang II, and Ang (1-7), this review presents a brief statement on hypertension, including the function of enzymes involved in the control of hypertension, cardiovascular disease, diabetes mellitus, and other malignancies.

RECENT FINDINGS

There is currently no data in support of the concerns raised with the use of ACEIs/ARBs. Many researchers have voiced concerns that the use of ACEIs and ARBs may increase tissue ACE2 levels. These researchers therefore recommend that individuals on ACEIs/ARB's medications withhold such antihypertensive drugs, unless advised by their physicians to do so. SARS-CoV-2 uses ACE2 receptors as the port of entry to human hosts. ACE2 and ACE are different enzymes and ACE inhibitors do not inhibit ACE2. Therefore, the use of ARB's or ACEIs should not be discontinued if an individual is infected by SARS-CoV-2. Further studies are required to investigate the effect of ACEIs and ARBs on ACE2 expression and COVID-19.

Blood Pressure Tracking From Childhood to Adulthood

Hypertension is the most common non-communicable disease among adults and is the most important modifiable risk factor for premature cardiovascular disease. The increasing worldwide burden of hypertension is a major global health issue. Early prevention with lifestyle modification or pharmaceutical treatment reduces the incidence of hypertension and the risk of subsequent cardiovascular disease. Therefore, identification of young persons at risk for hypertension has the obvious benefit of providing a chance for early intervention. Previous studies have demonstrated the positive association of elevated childhood blood pressure with hypertension in adulthood. Accumulated evidence also indicates the possibility that elevated pediatric blood pressure is associated with increased risk of future cardiovascular disease. In this article, we review the tracking of blood pressure from childhood to adulthood and emphasize the importance of pediatric blood pressure monitoring and control for predicting and preventing adult hypertension and cardiovascular disease.

Effectiveness of Perindopril/Indapamide Single-Pill Combination in Uncontrolled Patients with Hypertension: A Pooled Analysis of the FORTISSIMO, FORSAGE, ACES and PICASSO Observational Studies

INTRODUCTION

Our objective was to determine the effectiveness of a perindopril/indapamide (Per/Ind) single-pill combination (SPC) in a broad range of patient profiles, including subgroups with varying hypertension severity, age and cardiovascular risk profiles.

METHODS

Patient data from four large prospective observational studies (FORTISSIMO, FORSAGE, PICASSO, ACES) were pooled. In each study, patients already treated for hypertension were switched to Per/Ind 10/2.5 mg SPC and systolic and diastolic blood pressure (SBP/DBP) measured at the 1-month (M1) and 3-month (M3) visits. Study endpoints included change in SBP and DBP from baseline to M1 and M3 and the percentage of patients achieving BP control (SBP/DBP < 140/90 mmHg for patients without diabetes or < 140/85 mmHg for patients with diabetes).

RESULTS

A total of 16,763 patients were enrolled and received Per/Ind (94% received the full dose of 10/2.5). Mean patient age was 61.4 years (36% were ≥ 65 years old), 57% were women, and 16% had isolated systolic hypertension (ISH). Mean baseline office SBP/DBP was 162/94 mmHg, and mean duration of hypertension was 11 years. Cardiovascular risk factors and comorbid conditions were common in this population. Significant mean reductions in SBP (- 23 mmHg) and DBP (- 11 mmHg) were observed at M1 compared with baseline (P < 0.001), which were maintained at M3 (- 30 mmHg and - 14 mmHg, respectively). At M3, BP control was achieved by 70% of patients (78% for ISH). In patients with SBP ≥ 180 mmHg at baseline (grade III hypertension), the mean SBP/DBP decrease was - 51/- 20 mmHg and 53% achieved BP control. Per/Ind was well tolerated with an overall rate of adverse events of 1.3%, most frequently cough and dizziness at rates of 0.3% and 0.2%, respectively.

CONCLUSION

In this hypertensive population including difficult-to-control patient subgroups, switching to Per/Ind 10/2.5 mg SPC led to rapid and important reductions in BP. BP control was achieved in 70% of patients overall in an everyday practice context.

A Case-Control Study of Peripartum Cardiomyopathy Using the Rochester Epidemiology Project

Background:

The incidence of peripartum cardiomyopathy (PPCM) is known through referral center databases that may be affected by referral, misclassification, and other biases. We sought to determine the community-based incidence and natural history of PPCM using the Rochester Epidemiology Project.

Methods and Results:

Incident cases of PPCM occurring between January 1, 1970, and December 31, 2014, were identified in Olmsted County, Minnesota. A total of 15 PPCM cases were confirmed yielding an incidence of 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Clinical information, disease characteristics, and outcomes were extracted from medical records in a 27-county region of the Rochester Epidemiology Project including Olmsted County and matched in a 1:2 ratio with pregnant women without PPCM. A total of 48 women were identified with PPCM in the expanded 27-county region. There was 1 death and no transplants over a median of 7.3 years of follow-up. Six of the 23 women with subsequent pregnancies developed recurrent PPCM, all of whom recovered. Migraine and anxiety were identified as novel possible risk factors for PPCM.

Conclusions:

The population-based incidence of PPCM was 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Cardiovascular outcomes were generally excellent in this community cohort.

Global Public Health Guidelines on Physical Activity and Sedentary Behavior for People Living With Chronic Conditions: A Call to Action

Background: In 2020, the World Health Organization (WHO) released global guidelines on physical activity (PA) and sedentary behavior, for the first time providing population-based recommendations for people living with selected chronic conditions. This article briefly presents the guidelines, related processes and evidence, and, importantly, considers how they may be used to support research, practice, and policy. Methods: A brief overview of the scope, agreed methods, selected chronic conditions (adults living with cancer, hypertension, type 2 diabetes, and human immunodeficiency virus), and appraisal of systematic review evidence on PA/sedentary behavior is provided. Methods were consistent with World Health Organization protocols for developing guidelines. Results: Moderate to high certainty evidence (varying by chronic condition and outcome examined) supported that PA can reduce the risk of disease progression or premature mortality and improve physical function and quality of life in adults living with chronic conditions. Direct evidence on sedentary behavior was lacking; however, evidence extrapolated from adult populations was considered applicable, safe, and likely beneficial (low certainty due to indirectness). Conclusions: Clinical and public health professionals and policy makers should promote the World Health Organization 2020 global guidelines and develop and implement services and programs to increase PA and limit sedentary behavior in adults living with chronic conditions.

sGC stimulation lowers elevated blood pressure in a new canine model of resistant hypertension

Therapy-resistant hypertension is a serious medical problem, causing end-organ damage, stroke, and heart failure if untreated. Since the standard of care fails in resistant hypertension patients, there is still a substantial unmet medical need for effective therapies. Active stimulation of soluble guanylyl cyclase via novel soluble guanylyl cyclase stimulators might provide an effective treatment option. To test this hypothesis, we established a new experimental dog model and investigated the effects of the soluble guanylyl cyclase-stimulator BAY 41-2272. In beagle dogs, a resistant hypertension phenotype was established by combining unilateral renal wrapping with the occlusion of the renal artery in the contralateral kidney. The most frequently used antihypertensive drugs were administered orally, either alone or in combination, and their acute effect on telemetric measured blood pressure was assessed and compared with that of BAY 41-2272. The chosen disease stimulus led to a moderate and stable increase in blood pressure. Even high doses of standard-of-care antihypertensives only slightly decreased blood pressure. In contrast, the administration of the soluble guanylyl cyclase stimulator BAY 41-2272 as standalone therapy led to a dose-dependent reduction in blood pressure (-14.1 ± 1.8 mmHg). Moreover, BAY 41-2272 could also further decrease blood pressure in addition to a triple combination of standard-of-care antihypertensives (-28.6 ± 13.2 mmHg). BAY 41-2272 was highly efficient as a standalone treatment in resistant hypertension but was also effective in addition to standard-of-care treatment. These data strongly suggest that soluble guanylyl cyclase stimulators might provide an effective pharmacologic therapy for patients with resistant hypertension.

Hypertension Clinical Practice Guidelines (ISH, 2020): What Is New?

OBJECTIVE

In May 2020, the International Society of Hypertension (ISH) published "Practice Guidelines for the Management of Hypertension." The ISH 2020 guidelines were developed based on evidence criteria (i) to be used globally, (ii) to be fit for application in low-middle-income and high-income settings, and (iii) to be concise, simple, and easy to use by clinicians, nurses, and community health workers, as appropriate. The defined purpose was to adhere to the current evidence and develop a balanced proposal for global use in line with the ISH mission.

METHODOLOGY

Multiple novel approaches have been included keeping in mind about lifestyle modification and flexibility in treatment options.

RESULTS AND CONCLUSIONS

The ISH 2020 guidelines are practical and physician friendly. It also proves immensely helpful for low-resource countries without national guidelines on the management of hypertension.

Prices of combination medicines and single-molecule antihypertensive medicines in India's private health care sector

More than half of patients with hypertension require two or more medicines to control blood pressure. Combinations of anti‐hypertensive medicines are available as Single Pill Combinations (SPCs) or Single Agent Pills (SAPs). SPCs of two or more anti‐hypertensive medicines facilitate simpler dosing schedules, decrease pill burden, increase adherence to medicine, and simplify procurement and distribution. Despite this, equivalent combinations of separate pills (SAPs) are often prescribed instead of SPCs under the assumption that SAPs are priced lower. This study compared prices of anti‐hypertensive SPCs and equivalent SAPs in the private health care sector of India. High sales volume anti‐hypertensive SPCs and SAPs were selected from 2018 private sector pharmaceutical sales data. SPCs and SAPs price information was collected from online pharmacy websites between November 2019 and January 2020. Anti‐hypertensive SPCs represent approximately 39.1% of India's private sector anti‐hypertensive drug market. Multiple manufacturers produce the same top‐selling SPCs, suggesting a viable and competitive market. A comparison of SPCs and SAPs across different manufacturers showed that the lowest prices of both SPCs and the sum of component SAPs were nearly identical across different manufacturers. An analysis of dual‐drug SPCs and SAPs by the same manufacturer showed that most manufacturers (five of six) had priced their SPCs higher than SAPs. These observations suggest that the price of SPCs could be lowered to match the combined price of the component SAPs, and manufacturing costs and market forces do not present a barrier to the implementation of anti‐hypertensive SPCs.

Digital Health in Cardiac Rehabilitation and Secondary Prevention: A Search for the Ideal Tool

Digital health is becoming more integrated in daily medical practice. In cardiology, patient care is already moving from the hospital to the patients' homes, with large trials showing positive results in the field of telemonitoring via cardiac implantable electronic devices (CIEDs), monitoring of pulmonary artery pressure via implantable devices, telemonitoring via home-based non-invasive sensors, and screening for atrial fibrillation via smartphone and smartwatch technology. Cardiac rehabilitation and secondary prevention are modalities that could greatly benefit from digital health integration, as current compliance and cardiac rehabilitation participation rates are low and optimisation is urgently required. This viewpoint offers a perspective on current use of digital health technologies in cardiac rehabilitation, heart failure and secondary prevention. Important barriers which need to be addressed for implementation in medical practice are discussed. To conclude, a future ideal digital tool and integrated healthcare system are envisioned. To overcome personal, technological, and legal barriers, technological development should happen in dialog with patients and caregivers. Aided by digital technology, a future could be realised in which we are able to offer high-quality, affordable, personalised healthcare in a patient-centred way.

Guidelines for the design and conduct of human clinical trials on ingestion-time differences - chronopharmacology and chronotherapy - of hypertension medications

Current hypertension guidelines fail to provide a recommendation on when-to-treat, thus disregarding relevant circadian rhythms that regulate blood pressure (BP) level and 24 h patterning and medication pharmacokinetics and pharmacodynamics. The ideal purpose of ingestion-time (chronopharmacology, i.e. biological rhythm-dependent effects on the kinetics and dynamics of medications, and chronotherapy, i.e. the timing of pharmaceutical and other treatments to optimize efficacy and safety) trials should be to explore the potential impact of endogenous circadian rhythms on the effects of medications. Such investigations and outcome trials mandate adherence to the basic standards of human chronobiology research. In-depth review of the more than 150 human hypertension pharmacology and therapeutic trials published since 1974 that address the differential impact of upon-waking/morning versus at-bedtime/evening schedule of treatment reveals diverse protocols of sometimes suboptimal or defective design and conduct. Many have been "time-of-day," i.e. morning versus evening, rather than circadian-time-based, and some relied on wake-time office BP rather than around-the-clock ambulatory BP measurements (ABPM). Additionally, most past studies have been of too small sample size and thus statistically underpowered. As of yet, there has been no consensual agreement on the proper design, methods and conduct of such trials. This Position Statement recommends ingestion-time hypertension trials to follow minimum guidelines: (i) Recruitment of participants should be restricted to hypertensive individuals diagnosed according to ABPM diagnostic thresholds and of a comparable activity/sleep routine. (ii) Tested treatment-times should be selected according to internal biological time, expressed by the awakening and bed times of the sleep/wake cycle. (iii) ABPM should be the primary or sole method of BP assessment. (iv) The minimum-required features for analysis of the ABPM-determined 24 h BP pattern ought to be the asleep (not "nighttime") BP mean and sleep-time relative BP decline, calculated in reference to the activity/rest cycle per individual. (v) ABPM-obtained BP means should be derived by the so-called adjusted calculation procedure, not by inaccurate arithmetic averages. (vi) ABPM should be performed with validated and calibrated devices at least hourly throughout two or more consecutive 24 h periods (48 h in total) to achieve the highest reproducibility of mean wake-time, sleep-time and 48 h BP values plus the reliable classification of dipping status. (vii) Calculation of minimum required sample size in adherence with proper statistical methods must be provided. (viii) Hypertension chronopharmacology and chronotherapy trials should preferably be randomized double-blind, randomized open-label with blinded-endpoint, or crossover in design, the latter with sufficient washout period between tested treatment-time regimens.

Assessment of Medication Adherence and Related Factors in Hypertensive Patients: The Role of Beliefs About Medicines

Low medication adherence is one of the leading causes that affect the achievement of target levels for hypertension. Identifying modifiable factors associated with low adherence is crucial. This study aims to assess medication adherence and the role of beliefs about medicines on medication adherence among hypertensive patients.This cross-sectional study was conducted with 200 hypertension patients.Data were collected using the Morisky-Green-Levine Medication Adherence Scale, and the Beliefs about Medicines Questionnaire [BMQ-Turkish Translation (BMQ-T)]. It was found that the BMQ-T subscales of Specific Concern (β = 0.358, p = .027) and General Overuse (β = 0.552, p = .011) had an independent predictor effect on medication adherence scores. In this study, the patients who thought that drugs were overused and had concerns about this were seen to be less adherent with the medication. With regard to patients who use antihypertensive drugs but have uncontrolled blood pressure, their beliefs about drugs should not be ignored when evaluating adherence with drug therapy.

How should we measure blood pressure? Implications of the fourth blood pressure measurement in office blood pressure

According to the European Hypertension Guidelines regarding office blood pressure measurements (OBPMs), the mean between second/third or third/fourth OBPM should be taken if the first two readings differ by ≤10 or >10 mmHg, respectively. Our aim was to explore the value of the fourth OBPM and determine whether a simplified OBPM procedure is feasible without loss of quality. In this cross‐sectional study, four standard OBPMs were taken. The mean of the second/third OBPM (S2S3/D2D3) and third/fourth OBPM (S3S4/D3D4) for systolic/diastolic values was calculated. Correlation, agreement, and differences regarding BP classification were explored for the entire cohort and subsets with a difference between the first/second OBPM (S1S2/D1D2) ≤10 and >10 mmHg. Overall (n = 802) and for the subsets with an S1S2 (n = 596) and D1D2 (n = 742) difference ≤10 mmHg, S3S4/D3D4 was in median 0.5 mmHg lower than S2S3/D2D3, respectively (p < .0005 for all). In participants with an S1S2 (n = 206) and D1D2 (n = 60) difference >10 mmHg, S3S4/D3D4 differed numerically from S2S3/D2D3, respectively (p > .1 for all). Overall and for all subsets with an S1S2/D1D2 difference ≤10/>10 mmHg, less subjects were numerically classified as hypertensive with S3S4/D3D4 than with S2S3/D2D3 (p > .04), but BP reclassification occurred in both directions in 1.0%‐10.0%, depending on the cohort. In conclusion, the third/fourth OBPM results in lower BP values than the second/third measurement, regardless of the difference between first/second OBPM, whereby BP reclassifications occurred in both directions. Therefore, the cutoff of >10 versus ≤10mmHg difference between first/second OBPM to implement a fourth BPM harbors the risk of distorted results. We therefore recommend using the second/third BPM for standardized OBPM.

Trial registration: Registered on clinicaltrials.gov (NCT02552030).

Anti-Hypertensive Potential and Epigenetics of Angiotensin II type 2 Receptor (AT2R)

BACKGROUND

Renin angiotensin system (RAS) is a critical pathway involved in blood pressure regulation. Octapeptide, angiotensin II (Ang II), is a biologically active compound of RAS pathway which mediates its action by binding to either angiotensin II type 1 receptor (AT1R) or angiotensin II type 2 receptor (AT2R). Binding of Ang II to AT1R facilitates blood pressure regulation, whereas AT2R is primarily involved in wound healing and tissue remodeling.

OBJECTIVES

Recent studies have highlighted the additional role of AT2R to counterbalance the detrimental effects of AT1R. Activation of angiotensin II type 2 receptor using AT2R agonist has shown the effect on natriuresis and release of nitric oxide. Additionally, AT2R activation has been found to inhibit angiotensin converting enzyme (ACE) and enhance angiotensin receptor blocker (ARB) activity. These findings highlight the potential of AT2R as a novel therapeutic target against hypertension.

CONCLUSION

The potential role of AT2R highlights the importance of exploring additional mechanisms that might be crucial for AT2R expression. Epigenetic mechanisms, including DNA methylation and histone modification, have been explored vastly with relation to cancer, but the role of such mechanisms in the expression of AT2R has recently gained interest.

Angiotensin receptor neprilysin inhibitor as a novel antihypertensive drug: Evidence from Asia and around the globe

Hypertension is a worldwide epidemic that continues to grow, with a subset of patients responding poorly to current treatment available. This is especially relevant in Asia, which constitutes 61% of the global population. Hypertension in Asia is a unique entity that is often salt‐sensitive, nocturnal, and systolic predominant. Sacubitril/valsartan is a first‐in‐class angiotensin receptor neprilysin inhibitor that was first used in heart failure with reduced ejection fraction. Sacubitril inhibits neprilysin, a metallopeptidase that degrades natriuretic peptides (NPs). NPs exert sympatholytic, diuretic, natriuretic, vasodilatory, and insulin‐sensitizing effects mostly via cyclic guanosine monophosphate (cGMP)‐mediated pathways. As an antihypertensive agent, sacubitril/valsartan has outperformed angiotensin II receptor type 1 blockers (ARBs), with additional reductions of office systolic blood pressures ranging between 5 and 7 mmHg, in multiple studies in Asia and around the globe. The drug was well tolerated even in the elderly or those with chronic kidney disease. Its mechanisms of actions are particularly attractive for treatment of hypertension in Asia. Sacubitril/valsartan offers a novel, dual class, single‐molecule property that may be considered as first‐line antihypertensive therapy. Further investigations are needed to validate its safety for long‐term use and to explore other potentials such as in the management of insulin resistance and obesity, which often coexist with hypertension in Asia.

Genomic Association of Single Nucleotide Polymorphisms with Blood Pressure Response to Hydrochlorothiazide among South African Adults with Hypertension

This study described single nucleotide polymorphisms (SNPs) in hydrochlorothiazide-associated genes and further assessed their correlation with blood pressure control among South African adults living with hypertension. A total of 291 participants belonging to the Nguni tribes of South Africa on treatment for hypertension were recruited. Nineteen SNPs in hydrochlorothiazide pharmacogenes were selected and genotyped using MassArray. Uncontrolled hypertension was defined as blood pressure ≥140/90 mmHg. The association between genotypes, alleles and blood pressure response to treatment was determined by conducting multivariate logistic regression model analysis. The majority of the study participants were female (73.19%), Xhosa (54.98%) and had blood pressure ≥140/90 mmHg (68.73%). Seventeen SNPs were observed among the Xhosa tribe, and two (rs2070744 and rs7297610) were detected among Swati and Zulu participants. Furthermore, alleles T of rs2107614 (AOR = 6.69; 95%CI 1.42–31.55; p = 0.016) and C of rs2776546 (AOR = 3.78; 95%CI 1.04–13.74; p = 0.043) were independently associated with uncontrolled hypertension, whilst rs2070744 TC (AOR = 38.76; 95%CI 5.54–270.76; p = 0.00023), CC (AOR = 10.44; 95%CI 2.16–50.29; p = 0.003) and allele T of rs7297610 (AOR = 1.86; 95%CI 1.09–3.14; p = 0.023) were significantly associated with uncontrolled hypertension among Zulu and Swati participants. We confirmed the presence of SNPs associated with hydrochlorothiazide, some of which were significantly associated with uncontrolled hypertension in the study sample. Findings open doors for further studies on personalized therapy for hypertension in the country.

Association Between Pulse Pressure and Carotid Intima-Media Thickness Among Low-Income Adults Aged 45 Years and Older: A Population-Based Cross-Sectional Study in Rural China

Worldwide, the stroke burden remains severe, especially for people in low socioeconomic groups. Atherosclerosis is a leading cause of stroke that is attracting increasingly greater attention. Blood pressure, including pulse pressure (PP) and systolic (SBP) and diastolic (DBP) blood pressures, is a traditional risk factor for atherosclerosis; its association with carotid intima-media thickness (CIMT) has also been widely studied. However, published studies have not reported on the relationship between PP and CIMT in low-income adults. Thus, this study investigated the relationship between PP and CIMT in a low-income population, in China. A total of 3,789 people, aged ≥45 years and without histories of stroke or cardiovascular disease, were recruited into this study. B-mode ultrasonography was performed to determine CIMTs. Demographic characteristics, physical examination data, previous medical histories, and laboratory test results were collected for each study participant. Multiple linear regression models were used to analyze the association between CIMT and PP. The mean CIMT was 567.1 μm (males, 583.5 μm; females, 555.7 μm). The SBP, DBP, PP, and mean arterial pressure (MAP) values were all positively correlated with CIMT, in the univariate analysis; PP and MAP showed the strongest correlations. In addition, in three multiple linear regression models, PP was shown to be significantly associated with CIMT; each 1-mm Hg increase in PP resulted in a CIMT increase of ≥0.41 μm (all P < 0.001). Our results demonstrated that, when compared with SBP, DBP, and MAP, PP may be the best predictor of CIMT. Thus, controlling blood pressure, especially PP levels, is vital to decreasing the prevalence of atherosclerosis, especially in this low socioeconomic status population in China.

A Multicenter Study of Neutrophil-to-Lymphocyte Ratio in Primary Aldosteronism

Background

Hypertensive patients with primary aldosteronism (PA) have a higher risk of cardiovascular complications than those with blood pressure-matched essential hypertension. The excess cardiovascular consequences of PA can be attributed to the proinflammatory effect of excessive aldosterone and mineralocorticoid receptor activation in a range of peripheral tissues and cell types. The neutrophil-to-lymphocyte ratio (NLR) is a widely available marker of inflammation which has been shown to predict cardiovascular outcome in the general population. This study aims to evaluate the use of NLR as a potential biomarker of PA and PA severity.

Methods

Patients with PA (n = 355) were identified from 2 large PA databases in Australia and China, while controls (n = 222) were patients with hypertension who were referred for assessment but did not meet the diagnostic criteria for PA. The NLR was retrospectively collected from routine full blood examination, prior to commencement of targeted treatment for PA.

Results

The NLR did not differ between PA patients and hypertensive controls (median 2.3 and 2.4, P = 0.563). However, among patients with PA, the NLR was positively correlated with baseline and post-saline aldosterone levels (r = 0.22 and P < 0.001 for both) and negatively correlated with serum potassium (r = -0.15, P = 0.006). Furthermore, in a logistic regression analysis of data from patients with PA, the NLR predicted the presence of comorbid chronic kidney disease (CKD) (defined as estimated glomerular filtration rate <60 mL/min/1.73m²) with an odds ratio of 1.5 (P = 0.003).

Conclusion

While the NLR did not distinguish PA from controls, it was a marker of PA severity, being associated with aldosterone concentration as well as the presence of CKD. A prospective study is needed to further clarify the role of NLR in predicting end-organ damage associated with PA.

Clinical characteristics of patients with alcohol dependence comorbid with hypertension among regular drinkers: An internet-based, cross-sectional study in Japan

While evidence suggests a strong association between alcohol and hypertension, little is known about the profile of patients with alcohol dependence comorbid with hypertension. This study aimed to clarify the clinical characteristics and health problems of this population through a web-based questionnaire survey using a research company's panel of adults in Japan. Of 20 000 regular drinkers, 176 on treatment for hypertension and with alcohol dependence (confirmed and/or an Alcohol Use Disorders Identification Test score ≥15 points) were included. Participants were asked about their health-related quality of life, work productivity, blood pressure (BP) control, receipt of brief interventions, and awareness of their alcohol dependence. Results were compared between the BP-controlled and BP-uncontrolled groups. The mean EQ-5D utility score was 0.838 in the entire population, and 0.786 vs. 0.892 in the groups (p < 0.0001). When 133 'employed' participants were compared, productivity loss was more apparent in the BP-uncontrolled group (presenteeism, 27.3% vs. 6.1%, p < 0.0001; absenteeism, 10.7% vs. 1.0%, p = 0.0003). The rate of dissatisfaction with BP control was 55.1% in the entire population (most [76.3%] of those dissatisfied considered alcohol a cause of inadequate BP control), ~78% in the uncontrolled group, and ~34% in the controlled group. Of those previously advised to reduce drinking or abstain from alcohol (60.2% of all participants), 63% (BP-uncontrolled group) and 55% (BP-controlled group) decreased their drinking. Though more than twice as many participants thought themselves to be alcohol-dependent in the BP-uncontrolled group than in the controlled group (41% vs. 15%), most (59% vs. 85%) showed no self-awareness of alcohol dependence. Patients with alcohol dependence comorbid with hypertension had impaired health status and reduced work productivity. They thought alcohol was the most common cause of inadequate BP control. Treatment beyond brief interventions is needed to enhance their awareness of alcohol dependence and their motivation to reduce drinking.

The 2020 International Society of Hypertension global hypertension practice guidelines - key messages and clinical considerations

The International Society of Hypertension (ISH) has recently developed practice guidelines for the management of hypertension in adults aged ≥18 years. Conceptually, the 2020 ISH Guidelines are closer to the 2018 ESC/ESH Guidelines rather than to the 2017 ACC/AHA Guidelines. The ISH Guidelines have two distinctive features when compared with the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines. First, they are written in a concise and easy-to-read style; second, they focuses on practical issues related to the management of hypertension in 'high-income' as well as in 'low-income' countries, where there is limited access to resources for the diagnosis and treatment of hypertension. In our opinion, the 2020 ISH Guidelines share with the 2018 ESC/ESH Guidelines an important limitation which may impair the retention of these key aspects of Guidelines by physicians, with consequent difficult adoption in clinical practice. It consists in the definition of several blood pressure targets in relation to age, target organ damage and concomitant disease. We believe that results of randomized clinical trials and meta-analysis do not support the recommendation of differential BP targets, as well as of rigid 'safety boundaries'. This review critically examines similarities and differences across the three major Hypertension Guidelines, which include the definition of hypertension, drug treatment, and blood pressure targets, with emphasis on key messages relevant for clinical practice.

Postnatal Enalapril to Improve Cardiovascular Function Following Preterm Preeclampsia (PICk-UP):: A Randomized Double-Blind Placebo-Controlled Feasibility Trial

Hypertensive disease in pregnancy is associated with future cardiovascular disease and, therefore, provides an opportunity to identify women who could benefit from targeted interventions aimed at reducing cardiovascular morbidity. This study focused on the highest-risk group, women with preterm preeclampsia, who have an 8-fold risk of death from future cardiovascular disease. We performed a single-center feasibility randomized controlled trial of 6 months' treatment with enalapril to improve postnatal cardiovascular function. Echocardiography and hemodynamic measurements were performed at baseline (<3 days), 6 weeks, and 6 months postdelivery on 60 women. At randomization, 88% of women had diastolic dysfunction, and 68% had concentric remodeling/hypertrophy. No difference was seen in total vascular resistance (P=0.59) or systolic function (global longitudinal strain: P=0.14) between groups at 6 months. However, women treated with enalapril had echocardiographic measurements consistent with improved diastolic function (E/E'[the ratio of early mitral inflow velocity and early mitral annular diastolic velocity]: P=0.04) and left ventricular remodeling (relative wall thickness: P=0.01; left ventricular mass index: P=0.03) at 6 months, compared with placebo. Urinary enalapril was detectable in 85% and 63% of women in the enalapril arm at 6 weeks and 6 months, respectively. All women responded positively to taking enalapril in the future. Our study confirmed acceptability and feasibility of the study protocol with a recruitment to completion rate of 2.2 women per month. Importantly, postnatal enalapril treatment was associated with improved echocardiographic measurements; these early improvements have the potential to reduce long-term cardiovascular disease risk. A definitive, multicenter randomized controlled trial is now required to confirm these findings. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT03466333.

Clinical characteristics and risk factors for mortality of patients with COVID-19 in a large data set from Mexico

PURPOSE

The purpose of this study was to assess clinical characteristics and risk factors for mortality of patients with coronavirus disease 2019 (COVID-19) from Mexico, given that it currently is in active community transmission.

METHODS

Multivariate logistic regression model and Kaplan-Meier survival curves were fitted to study odds of death of characteristics and comorbidities in patients with COVID-19 in Mexico.

RESULTS

Age, sex, and the most frequent comorbidities diabetes, obesity, and hypertension were significantly associated to the risk of death by COVID-19 (P < .0001). Smoking habit was not identified as a risk factor for death. Less-frequent comorbidities such as chronic obstructive pulmonary disease, chronic kidney disease, and patients with immunosuppressed conditions also showed a significant risk for death (P < .0001). Hospitalized patients and those with pneumonia had serious risks for mortality (P < .0001), and more attention to specific conditions might be considered during clinical admission.

CONCLUSIONS

A more vulnerable positive patient is depicted by a male patient, older than 41 years, which increases their risk with more prevalent comorbidities such as diabetes, hypertension, and obesity. Some implications on outcomes are discussed.

Diagnostic Comparability and Interchangeability Between Daytime Ambulatory Blood Pressure Monitoring and 24-Hour Ambulatory Blood Pressure Monitoring in Detecting Masked Hypertension

Background The primary aim of this study was to evaluate the level of diagnostic overlap between daytime ambulatory blood pressure (BP) monitoring (DT-ABPM) and 24-hour ambulatory BP monitoring (24-h ABPM) in detecting masked hypertension (MH). Methods This is a prospective study that was performed in a sample of 196 soldiers aged between 21 and 50 years (without a history of hypertension) undergoing ABPM testing. The diagnosis of MH based on DT-ABPM defined as (office blood pressure (OBP) <140/90 and DT-ABPM ≥135/85) was compared with the 24-h ABPM defined as (OBP <140/90 mm Hg and 24-h ABPM ≥130/80 mm Hg). We critically analyzed the results to see the agreement between the two methods. Results The number of subjects classified as having MH based on both DT-ABPM and 24-h ABPM, only on 24-h ABPM, and only on DT-ABPM were 11 (5.6%), 29 (14.8%), and 18 (9.2%), respectively. The sensitivity, specificity, and positive and negative predictive values for DT-ABPM in detecting MH were: sensitivity = 100% (95% CI: 97.82% - 100%), specificity = 62.07% (95% CI: 42.26% - 79.31%), PPV = 93.82% (95% CI: 90.50% - 96.03%), and NPV = 100%, respectively. The level of agreement between DT-ABPM and 24-h ABPM in diagnosing MH was 94.4% and discordance in 5.6% (11/196); (kappa=0.736, p < 0.001). Conclusion The sensitivity, specificity, positive and negative predictive values all showed agreement between the two BP methods to confirm the diagnoses of MH. DT-ABPM can be used as an alternative to the 24-h ABPM. DT-ABPM eliminates sleep disturbance attributable to ABPM and maximizes patient compliance with the ABPM test. A further larger trial is needed for more confirmation and to affect the guidelines for using daytime ABPM.

Blood Pressure Changes in 1610 Subjects With and Without Antihypertensive Medication During Long-Term Fasting

Background

We investigated daily blood pressure (BP) changes during fasting periods ranging from 4 to 41 (10.0±3.8) days in a cohort of 1610 subjects, including 920 normotensive, 313 hypertensive nonmedicated, and 377 hypertensive medicated individuals.

Methods and Results

Subjects underwent a multidisciplinary fasting program with a daily intake of ≈250 kcal. Weight and stress scores decreased during fasting, and the well‐being index increased, documenting a good tolerability. BP mean values decreased from 126.2±18.6/81.4±11.0 to 119.7±15.9/77.6±9.8 mm Hg (mean change, −6.5/3.8 mm Hg). BP changes were larger for hypertensive nonmedicated subjects (>140/90 mm Hg) and reduced by 16.7/8.8 mm Hg. This reduction reached 24.7/13.1 mm Hg for hypertensive nonmedicated subjects (n=76) with the highest BP (>160/100 mm Hg). In the normotensive group, BP decreased moderately by 3.0/1.9 mm Hg. Interestingly, we documented an increase of 6.3/2.2 mm Hg in a subgroup of 69 female subjects with BP <100/60 mm Hg. In the hypertensive medicated group, although BP decreased from 134.6/86.0 to 127.3/81.3 mm Hg, medication was stopped in 23.6% of the subjects, whereas dosage was reduced in 43.5% and remained unchanged in 19.4%. The decrease in BP was larger in subjects fasting longer. Baseline metabolic parameters, such as body mass index and glucose levels, as well as age, can be used to predict the amplitude of the BP decrease during fasting with a machine learning model.

Conclusions

Long‐term fasting tends to decrease BP in subjects with elevated BP values. This effect persisted during the 4 days of stepwise food reintroduction, even when subjects stopped their antihypertensive medication.

Registration

URL: https://www.drks.de/drks_web/; Unique identifier: DRKS00010111.

Contemporary Strategies to Manage High Blood Pressure in Patients with Coexistent Resistant Hypertension and Heart Failure With Reduced Ejection Fraction

Resistant hypertension (RH) represents an advanced subtype of hypertension that is complex to diagnose and treat. Compared with general hypertension, RH increases the risk patients will develop more advanced cardiovascular complications, including heart failure with reduced ejection fraction (HFrEF). As expected, the prevalence of RH has increased since the introduction of lower blood pressure targets included in the recent 2017 American blood pressure guidelines. The array of pharmacotherapies available to treat both hypertension and HFrEF has also expanded within the past decade. However, the efficacy of these cutting-edge pharmacotherapies has not come without a more advanced understanding of the important adjunct role non-pharmacological therapies play in helping with the management of both hypertension and HFrEF. In this review, we provide a summary of the latest pharmacological and non-pharmacological strategies that can be used to initiate treatment and optimize long-term blood pressure control in patients with coexistent RH and HFrEF.

A Modified Recommended Food Score Is Inversely Associated with High Blood Pressure in Korean Adults

Hypertension is associated with an increase in cardiovascular disease and mortality. The interplay between dietary intake—especially sodium intake—and high blood pressure highlights the importance of understanding the role of eating patterns on cardiometabolic risk factors. This study investigates the relationship between a modified version of the Recommended Food Score (RFS) and hypertension in 8389 adults aged 19–64 years from the Korea National Health and Nutrition Examination Survey 2013–2015. A dish-based, semi-quantitative, 112-item food frequency questionnaire was used to assess dietary intakes. Modified RFS (mRFS) is based on the reported consumption of foods recommended in the Dietary Approaches to Stop Hypertension (DASH) diet modified for Korean foods. High blood pressure included hypertension and prehypertension, also known as stage 1 hypertension. Men and women with the highest quintile of mRFS had a 27.2% (OR: 0.728, 95% CI: 0.545–0.971, p-trend = 0.0289) and 32.9% (OR: 0.671, 95% CI: 0.519–0.867, p-trend = 0.0087) lower prevalence of high blood pressure than those with the lowest quintile of mRFS, respectively. Our finding suggests that a higher mRFS may be associated with a lower prevalence of high blood pressure among the Korean adult population.

Effect and Acceptability of Mindfulness-Based Stress Reduction Program on Patients With Elevated Blood Pressure or Hypertension: A Meta-Analysis of Randomized Controlled Trials

The mindfulness-based stress reduction program (MBSR) may reduce blood pressure (BP) in patients with hypertension or elevated BP. However, some important parameters (such as asleep BP) have not been investigated in previous reviews, and a well-conducted meta-analysis is lacking. This meta-analysis investigates the effect and acceptability of MBSR on patients with elevated BP or hypertension. Relevant articles were searched in multiple databases, including MEDLINE, EMBASE, and APA PsycInfo. Included studies were randomized controlled trials that involved patients with an elevated BP, had a control group, and investigated the effect of MBSR. The mean office and out-of-office (including 24-hour, daytime, and asleep) systolic BP and diastolic BP, psychological outcomes (depression/anxiety/stress), and dropout rate were compared between the MBSR arm and the control arm using a random-effects model. Quality assessment was conducted based on the Cochrane risk-of-bias tool. Twelve studies were included, and only one was considered having low risk of bias. MBSR decreased the office systolic BP and diastolic BP by 6.64 and 2.47 mm Hg at postintervention, respectively; the reduction in diastolic BP was sustained until 3 to 6 months after the recruitment. Our meta-analyses did not find a significant reduction in out-of-office BP after MBSR. MBSR reduced depressive, anxiety, and stress symptoms. The dropout rate from MBSR arm was 15% and was similar to that of control arm. The current evidence is limited by lack of high-quality and adequately powered trials with long-term follow-up. Furthermore, out-of-office BP was only reported by few trials.

[Cardiovascular preventive recommendations. PAPPS 2020 update]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: Epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; Cardiovascular (CV) risk tables and recommendations for the calculation of CV risk; Main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; Indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation. The quality of testing and the strength of the recommendation are included in the main recommendations.

Renovascular Hypertension

Renovascular hypertension (RVH) is relatively common but underrecognized cause of resistant hypertension in clinical practice. Most patients with RVH have suboptimal control of hypertension in spite of being on multiple anti hypertensive medications. Prompt diagnosis and management is crucial to prevent long term morbidity and mortality. Initial evaluation by primary care physicians can expedite this to improve patient outcomes by co-managing hypertension specialists. In addition to pharmacologic and nonpharmacologic measures, some patients may benefit from angioplasty. This article discusses various definitions of hypertension, approach to diagnosis of RVH, and management. Data from clinical trials are discussed with evidence-based medicine practice recommendations.

Antihypertensive Effects of Gynura divaricata (L.) DC in Rats with Renovascular Hypertension

Gynura divaricata (L.) DC (Compositae) (GD) could be found in various parts of Asia. It has been used as a traditional medicine to treat diabetes, high blood pressure, and other diseases, but its effects have not yet been scientifically confirmed. Therefore, we aimed at determining whether GD could affect renal function regulation, blood pressure, and the renin-angiotensin-aldosterone system (RAAS). Cardio-renal syndrome (CRS) is a disease caused by the interaction between the kidney and the cardiovascular system, where the acute or chronic dysfunction in one organ might induce acute or chronic dysfunction of the other. This study investigated whether GD could improve cardio-renal mutual in CRS type 4 model animals, two-kidney one-clip (2K1C) renal hypertensive rats. The experiments were performed on the following six experimental groups: control rats (CONT); 2K1C rats (negative control); OMT (Olmetec, 10 mg/kg/day)-treated 2K1C rats (positive control); and 2K1C rats treated with GD extracts in three different doses (50, 100, and 200 mg/kg/day) for three weeks by oral intake. Each group consisted of 10 rats. We measured the systolic blood pressure weekly using the tail-cuff method. Urine was also individually collected from the metabolic cage to investigate the effect of GD on the kidney function, monitoring urine volume, electrolyte, osmotic pressure, and creatinine levels from the collected urine. We observed that kidney weight and urine volume, which would both display typically increased values in non-treated 2K1C animals, significantly decreased following the GD treatment (###p < 0.001 vs. 2K1C). Osmolality and electrolytes were measured in the urine to determine how renal excretory function, which is reduced in 2K1C rats, could be affected. We found that the GD treatment improved renal excretory function. Moreover, using periodic acid-Schiff staining, we confirmed that the GD treatment significantly reduced fibrosis, which is typically increased in 2K1C rats. Thus, we confirmed that the GD treatment improved kidney function in 2K1C rats. Meanwhile, we conducted blood pressure and vascular relaxation studies to determine if the GD treatment could improve cardiovascular function in 2K1C rats. The heart weight percentages of the left atrium and ventricle were significantly lower in GD-treated 2K1C rats than in non-treated 2K1C rats. These results showed that GD treatment reduced cardiac hypertrophy in 2K1C rats. Furthermore, the acetylcholine-, sodium nitroprusside-, and atrial natriuretic peptide-mediated reduction of vasodilation in 2K1C rat aortic rings was also ameliorated by GD treatment (GD 200 mg/kg/day; p < 0.01, p < 0.05, and p < 0.05 vs. 2K1C for vasodilation percentage in case of each compound). The mRNA expression in the 2K1C rat heart tissue showed that the GD treatment reduced brain-type natriuretic peptide and troponin T levels (p < 0.001 and p < 0.001 vs. 2K1C). In conclusion, this study showed that GD improved the cardiovascular and renal dysfunction observed in an innovative hypertension model, highlighting the potential of GD as a therapeutic agent for hypertension. These findings indicate that GD shows beneficial effects against high blood pressure by modulating the RAAS in the cardio-renal syndrome. Thus, it should be considered an effective traditional medicine in hypertension treatment.

Renin inhibitors versus angiotensin converting enzyme (ACE) inhibitors for primary hypertension

BACKGROUND

Renin inhibitors (RIs) reduce blood pressure more than placebo, with the magnitude of this effect thought to be similar to that for angiotensin converting enzyme (ACE) inhibitors. However, a drug's efficacy in lowering blood pressure cannot be considered as a definitive indicator of its effectiveness in reducing mortality and morbidity. The effectiveness and safety of RIs compared to ACE inhibitors in treating hypertension is unknown.

OBJECTIVES

To evaluate the benefits and harms of renin inhibitors compared to ACE inhibitors in people with primary hypertension.

SEARCH METHODS

The Cochrane Hypertension Group Information Specialist searched the following databases for randomized controlled trials up to August 2020: the Cochrane Hypertension Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers about further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

We included randomized, active-controlled, double-blinded studies (RCTs) with at least four weeks follow-up in people with primary hypertension, which compared renin inhibitors with ACE inhibitors and reported morbidity, mortality, adverse events or blood pressure outcomes. We excluded people with proven secondary hypertension.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the included trials, evaluated the risks of bias and entered the data for analysis.

MAIN RESULTS

We include 11 RCTs involving 13,627 participants, with a mean baseline age from 51.5 to 74.2 years. Follow-up duration ranged from four weeks to 36.6 months. There was no difference between RIs and ACE inhibitors for the outcomes: all-cause mortality: risk ratio (RR) 1.05, 95% confidence interval (CI) 0.93 to 1.18; 5 RCTs, 5962 participants; low-certainty evidence; total myocardial infarction: RR 0.86, 95% CI 0.22 to 3.39; 2 RCTs, 957 participants; very low-certainty evidence; adverse events: RR 0.98, 95% CI 0.93 to 1.03; 10 RTCs, 6007 participants;  moderate-certainty evidence; serious adverse events: RR 1.21, 95% CI 0.89 to 1.64; 10 RTCs, 6007 participants; low-certainty evidence; and withdrawal due to adverse effects: RR 0.85, 95% CI 0.68 to 1.06; 10 RTCs, 6008 participants; low-certainty evidence. No data were available for total cardiovascular events, heart failure, stroke, end-stage renal disease or change in heart rate. Low-certainty evidence suggested that RIs reduced systolic blood pressure: mean difference (MD) -1.72, 95% CI -2.47 to -0.97; 9 RCTs, 5001 participants;  and diastolic blood pressure: MD -1.18, 95% CI -1.65 to -0.72; 9 RCTs, 5001 participants,  to a greater extent than ACE inhibitors, but we judged this to be more likely due to bias than a true effect.  AUTHORS' CONCLUSIONS: For the treatment of hypertension, we have low certainty that renin inhibitors (RI) and angiotensin converting enzyme (ACE) inhibitors do not differ for all-cause mortality and myocardial infarction. We have low to moderate certainty that they do not differ for adverse events. Small reductions in blood pressure with renin inhibitors compared to ACE inhibitors are of low certainty.  More independent, large, long-term trials are needed to compare RIs with ACE inhibitors, particularly assessing morbidity and mortality outcomes, but also on blood pressure-lowering effect.

Clinical assessment and management of liver fibrosis in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is among the most frequent etiologies of cirrhosis worldwide, and it is associated with features of metabolic syndrome; the key factor influencing its prognosis is the progression of liver fibrosis. This review aimed to propose a practical and stepwise approach to the evaluation and management of liver fibrosis in patients with NAFLD, analyzing the currently available literature. In the assessment of NAFLD patients, it is important to identify clinical, genetic, and environmental determinants of fibrosis development and its progression. To properly detect fibrosis, it is important to take into account the available methods and their supporting scientific evidence to guide the approach and the sequential selection of the best available biochemical scores, followed by a complementary imaging study (transient elastography, magnetic resonance elastography or acoustic radiation force impulse) and finally a liver biopsy, when needed. To help with the selection of the most appropriate method a Fagan′s nomogram analysis is provided in this review, describing the diagnostic yield of each method and their post-test probability of detecting liver fibrosis. Finally, treatment should always include diet and exercise, as well as controlling the components of the metabolic syndrome, +/- vitamin E, considering the presence of sleep apnea, and when available, allocate those patients with advanced fibrosis or high risk of progression into clinical trials. The final end of this approach should be to establish an opportune diagnosis and treatment of liver fibrosis in patients with NAFLD, aiming to decrease/stop its progression and improve their prognosis.

The Cardiotonic Steroid Marinobufagenin Is a Predictor of Increased Left Ventricular Mass in Obesity: The African-PREDICT Study

The endogenous Na+/K+-ATPase inhibitor, marinobufagenin (MBG), strongly associates with salt intake and a greater left ventricular mass index (LVMi) in humans and was shown to promote cardiac fibrosis and hypertrophy in animals. The adverse effects of MBG on cardiac remodeling may be exacerbated with obesity, due to an increased sensitivity of Na+/K+-ATPase to MBG. This study determined whether MBG is related to the change in LVMi over time in adults with a body mass index (BMI) ≥30 kg/m2 (obese) and <30 kg/m2 (non-obese). The study followed 275 healthy participants (aged 20-30 years) from the African-Prospective study on the Early Detection and Identification of Cardiovascular disease and Hypertension (African-PREDICT) study over 4.5 years. At baseline, we measured 24 h urine MBG excretion. MBG levels were positively associated with salt intake. LVMi was determined by two-dimensional echocardiography at baseline and after >4.5 years. With multivariate adjusted analyses in obese adults (N = 56), we found a positive association of follow-up LVMi (Adjusted (Adj.) R2 = 0.35; Std. β = 0.311; p = 0.007) and percentage change in LVMi (Adj. R2 = 0.40; Std. β = 0.336; p = 0.003) with baseline MBG excretion. No association of LVMi (Adj. R2 = 0.37; p = 0.85) or percentage change in LVMi (Adj. R2 = 0.19; p = 0.68) with MBG excretion was evident in normal weight adults (N = 123). These findings suggest that obese adults may be more sensitive to the adverse cardiac effects of MBG and provide new insight into the potential role of dietary salt, by way of MBG, in the pathogenesis of cardiac remodeling in obese individuals.