Hypertension Across a Woman's Life Cycle

Tracking and Transition Probability of Blood Pressure From Childhood to Midadulthood

Importance

Despite its relevance for pediatric blood pressure (BP) screening, the long-term predictive utility and natural progression of pediatric BP classification remain understudied.

Objective

To evaluate BP tracking from childhood to midadulthood using the American Academy of Pediatrics (AAP) thresholds and estimate transition probabilities among BP classifications over time considering multiple time points.

Design, Setting, and Participants

The analyses were performed in 2023 using data gathered from September 1980 to August 2018 within the longitudinal Cardiovascular Risk in Young Finns Study. Participants had BP examined 9 times over 38 years, from childhood (aged 6-12 years) or adolescence (15-18 years) to young adulthood (21-27 years), late young adulthood (30-37 years), and midadulthood (39-56 years).

Exposures

BP classifications (normal, elevated, hypertension) were based on AAP guidelines for children and adolescents and the 2017 American College of Cardiology/American Heart Association guidelines for adults.

Main Outcomes and Measures

Outcomes were BP classifications at follow-up visits. Tracking coefficients were calculated using generalized estimated equations. Transition probabilities among BP classifications were estimated using multistate Markov models.

Results

This study included 2918 participants (mean [SD] baseline age, 10.7 [5.0] years; 1553 female [53.2%]). Over 38 years, the tracking coefficient (odds ratio [OR]) for maintaining elevated BP/hypertension was 2.16 (95% CI, 1.95-2.39). Males had a higher probability than females of progressing to and maintaining hypertension and a lower probability of reverting to normal BP from childhood to midadulthood (transition probability: from normal BP to stage 2 hypertension, 0.20; 95% CI, 0.17-0.22 vs 0.08; 95% CI, 0.07-0.10; maintaining stage 2 BP, 0.32; 95% CI, 0.27-0.39 vs 0.14; 95% CI, 0.09-0.21; from stage 2 hypertension to normal BP, 0.23; 95% CI, 0.19-0.26 vs 0.58; 95% CI, 0.52-0.62. For both sexes, the probability of transitioning from adolescent hypertension to normal BP in midadulthood was lower (transition probability, ranging from 0.16; 95% CI, 0.14-0.19 to 0.44; 95% CI, 0.39-0.48) compared with childhood hypertension (transition probability, ranging from 0.23; 95% CI, 0.19-0.26 to 0.63; 95% CI, 0.61-0.66). The probability of maintaining normal BP sharply decreased in the first 5 to 10 years, stabilizing thereafter. Children with normal BP generally maintained this status into adolescence (male: transition probability, 0.64; 95% CI, 0.60-0.67; female: transition probability, 0.81; 95% CI, 0.79-0.84) but decreased by young adulthood (male: transition probability, 0.41; 95% CI, 0.39-0.44; female: transition probability, 0.69; 95% CI, 0.67-0.71).

Conclusion and Relevance

Results of this cohort study reveal an enduring association of childhood and adolescent BP (AAP thresholds) with later BP. Although childhood normal BP tends to be maintained into adolescence, the probability of reverting to and sustaining normal BP decreases notably from adolescence to young adulthood. The findings of this study underscore the importance of prevention to maintain normal BP starting in childhood, suggesting adolescence as a potential critical period. The results suggest the potential for less frequent screenings for children with initially normal BP.

Meeting clean air targets could reduce the burden of hypertension among women of reproductive age in India

BACKGROUND

Air pollution is one of the leading risk factors for hypertension globally. However, limited epidemiological evidence exists in developing countries, specifically with indigenous health data and for fine particulate matter (PM2.5) composition. Here, we addressed this knowledge gap in India.

METHODS

Using a logistic regression model, we estimated the association between hypertension (systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) prevalence among women of reproductive age (WRA, 15-49 years) from the fifth round of the National Family Health Survey and long-term exposure to PM2.5 and its composition, after adjusting for confounders. We also explored the moderating effects of socioeconomic indicators through a multiplicative interaction with PM2.5.

RESULTS

Hypertension prevalence increased by 5.2% (95% uncertainty interval: 4.8%-5.7%) for every 10 μg/m3 increase in ambient PM2.5 exposure. Significant moderating effects were observed among smokers against nonsmokers and for various sociodemographic parameters. Among PM2.5 species, every interquartile range increase in black carbon (BC) and sulphate exposure was significantly associated with higher odds of hypertension than for organic carbon and dust. We estimated that achieving the National Clean Air Program target and World Health Organization air quality guidelines can potentially reduce hypertension prevalence by 2.42% and 4.21%, respectively.

CONCLUSION

Our results demonstrate that increasing ambient PM2.5 exposure is associated with a higher prevalence of hypertension among WRA in India. The risk is not uniform across various PM2.5 species and is higher with BC and sulphate. Achieving clean air targets can substantially reduce the hypertension burden in this population.

High sodium, rather than high blood pressure, induces immune cell activation and renal infiltration in ovariectomized adult Wistar rats

We used an animal model of salt-sensitive hypertension (SSH) in which ovariectomized (oVx) rats developed hypertension with high salt (HS) intake. Hypertension is accompanied by changes in the percentage of CD4+ T lymphocytes, immune CD45+ cell infiltration into renal tissue, and changes in Na+, K+- ATPase (NKA) expression in both renal tissue and peripheral blood mononuclear cells (PBMCs). To determine whether the observed changes resulted from HS intake, high blood pressure, or both, hydralazine (HDZ) was used to lower blood pressure. The oVx HS rats received two HDZ schedules either to prevent or to treat hypertension. NKA was overexpressed in the kidneys of all oVx groups and in PBMCs of oVx HS rats. This pattern was not altered with HDZ treatment. Changes in CD4+ T lymphocytes and renal infiltration of CD45+ cells were not reversed either. High salt, but not high blood pressure, induces immune cell activation and renal infiltration. Overexpressed NKA is the primary event, and HS is the perturbation to the system in this model of SSH, which resembles the postmenopausal state.

Cardiometabolic risk factors in women: what's sauce for the goose is not sauce for the gander

PURPOSE OF REVIEW

The aim of this review was to discuss cardiometabolic risk factors that affect women.

RECENT FINDINGS

Recent calls to action to address cardiometabolic risk factors specific to women relate to increasing evidence of sex-specific differences in patient-related, drug-related, and socio-demographic factors leading to sub-optimal care of women.

SUMMARY

Certain aspects of common modifiable cardiovascular risk factors (e.g. smoking, hypertension, dyslipidaemia and diabetes) affect female individuals more adversely. Additionally, there are risk factors or enhancers that particularly affect cardiometabolic health in women [e.g. premature menopause, polycystic ovarian syndrome (PCOS), familial partial lipodystrophy, socio-cultural factors]. Understanding these risk factors may provide insight on how to improve cardiometabolic outcomes in women.

The Association Between National Institutes of Health Stroke Scale Score and Clinical Outcome in Patients with Large Core Infarctions Undergoing Endovascular Treatment

INTRODUCTION

This study aimed to analyze the association between baseline National Institutes of Health Stroke Scale (NIHSS) scores and clinical outcomes in patients with large core infarctions undergoing endovascular treatment (EVT), a relationship that remains unclear.

METHODS

Data were obtained from the MAGIC study, a prospective multicenter cohort study focusing on patients with acute large core ischemic stroke. This analysis evaluated the impact of NIHSS scores on EVT outcomes in patients with large core infarctions. Primary outcome metrics included favorable outcomes (modified Rankin Scale [mRS] of 0-3 at 90 days), while secondary outcomes encompassed shifts in mRS scores, functional independence (mRS score of 0-2), mRS score of 0-4, and successful recanalization rates. Adverse events considered were symptomatic intracranial hemorrhage (sICH) and mortality.

RESULTS

A total of 490 patients were enrolled in this study. Higher baseline NIHSS scores were inversely correlated with favorable outcomes (adjusted odds ratio [OR] in model 3, 0.848 [0.797-0.903], P < 0.001), particularly in patients with NIHSS scores above 20 (adjusted OR in model 3, 0.518 [0.306-0.878] vs. 0.290 [0.161-0.523]). Regarding adverse events, higher baseline NIHSS scores significantly correlated with increased 90-day mortality rates (adjusted OR in model 3, 1.129 [1.072-1.189], P < 0.001). This correlation became insignificant when baseline NIHSS scores exceeded 22. Additionally, baseline NIHSS scores partially mediated the association between age (indirect effect = - 0.0005, 19.39% mediated) and sex (indirect effect = 0.0457, 25.08% mediated) with the primary outcome.

CONCLUSIONS

The findings indicate that higher baseline NIHSS scores correlate with poorer outcomes and increased mortality, particularly when scores exceed 20. Moreover, age and sex indirectly influence favorable outcomes through their association with baseline NIHSS scores.

Global, regional and national temporal trends in prevalence for cardiovascular diseases in women of childbearing age, from 1990 to 2019: An age-period-cohort analysis

Background

Epidemiological studies on cardiovascular diseases (CVD) among women of childbearing age (WCBA) remain scarce. Our research aims to delineate the prevalence trends of CVD within this population over the past three decades, considering age, period, and birth cohort dynamics.

Methods

Estimates of CVD prevalence for WCBA, along with their 95% uncertainty intervals (UI), were extracted from the Global Burden of Diseases 2019 (GBD2019). An age-period-cohort (APC) model was utilized to assess the annual percentage change (net drifts) in overall prevalence, annual percentage changes in prevalence for individual age groups (local drifts), and fitted longitudinal age-specific rates adjusted for age effects and period/cohort relative risks (period/cohort effect).

Results

In 2019, the global prevalence of CVD among WCBA was 53.42 million (95% UI: 47.77 to 60.18). Eight countries recorded a prevalence exceeding one million, accounting for 54.17% of the global CVD prevalence in WCBA. Over the past 30 years, the annual net drift in CVD prevalence among the global WCBA was 0.27% (95% CI: 0.25 to 0.29). This value was 0.01% (95% CI: 0.04 to 0.06) in regions with a high sociodemographic index (SDI) and 0.21% (95% CI: 0.19 to 0.22) in those with a low SDI. Seventy-seven countries demonstrated an increasing trend in CVD prevalence, while 53 showed a decrease, and 74 remained relatively stable. Notably, as shown in local drift, there was a rise in CVD prevalence among adolescents aged 15-19 and adults aged 40-49 in regions categorized by five distinct SDI levels. This drift varied by SDI regions. Regions with a high SDI consistently had elevated period risks throughout the study duration, while other regions had lower period risks until 2000-2004 and displayed increased adverse period risks. The prevalence in low-middle and low SDI regions manifested detrimental trends, whereas other regions demonstrated an initial decline followed by a surge in successive birth cohorts.

Conclusions

Resources dedicated to CVD care for WCBA are largely insufficient, especially in low SDI regions. Thus, there is an urgent need to allocate cardiovascular healthcare resources variably across different SDI regions, aiming to diminish risks among successively younger birth cohorts. Throughout this endeavor, the formulation of targeted policies and the judicious distribution of resources are essential to reduce risks for women across all age groups.

Perimenopause in women with rheumatologic diseases: a spotlight on an under-addressed transition

Abundant research has been published describing the effects invoked during menopause across different organ systems. Changing levels of estrogen and progesterone result in bidirectional alterations of immune cell pathways. Overall, the net trend dampens immunoregulation and promotes inflammation. In paradigmatic rheumatologic diseases, the combined effect is far from predictable. While some features may abate during menopause, studies have shown a general increased frequency toward disease exacerbation. Similarly, while impossible to isolate the ramifications of menopause in women with fibromyalgia, a tendency toward enhanced symptoms is unquestionably apparent. Furthermore, the comorbidities accrued by increasing age and the consequences of long-term medication use may also confound this picture. Periodic rheumatologic visits are warranted, with clinical assessments directed toward a multi-disciplinary approach. Ultimately, while an arsenal of effective tools is available for caring for these women and their underlying conditions, more studies are needed to better clarify how the different stages surrounding perimenopause affect subpopulations with rheumatic diseases and fibromyalgia-related disorders so that clinical course can be predicted and addressed prior to the emergence of symptomatology.

Basic Mechanisms of Brain Injury and Cognitive Decline in Hypertension

Dementia affects almost 50 million adults worldwide, and remains a major cause of death and disability. Hypertension is a leading risk factor for dementia, including Alzheimer disease and Alzheimer disease-related dementias. Although this association is well-established, the mechanisms underlying hypertension-induced cognitive decline remain poorly understood. By exploring the mechanisms mediating the detrimental effects of hypertension on the brain, studies have aimed to provide therapeutic insights and strategies on how to protect the brain from the effects of blood pressure elevation. In this review, we focus on the basic mechanisms contributing to the cerebrovascular adaptions to elevated blood pressure and hypertension-induced microvascular injury. We also assess the cellular mechanisms of neurovascular unit dysfunction, focusing on the premise that cognitive impairment ensues when the dynamic metabolic demands of neurons are not met due to neurovascular uncoupling, and summarize cognitive deficits across various rodent models of hypertension as a resource for investigators. Despite significant advances in antihypertensive therapy, hypertension remains a critical risk factor for cognitive decline, and several questions remain about the development and progression of hypertension-induced cognitive impairment.

Role of Female Sex Hormones and Immune Response in Salt-Sensitive Hypertension Development: Evidence from Experimental Models

PURPOSEOF REVIEW

Female sex hormones have systemic effects unrelated to their reproductive function. We describe experiences of different research groups and our own, on aspects related to the importance of female sex hormones on blood pressure (BP) regulation and salt-sensitivity-mediated BP response and salt sensitivity without alterations in BP, as well as renal sodium handling and interactions with the immune system.

RECENT FINDINGS

Changes in sodium intake in normotensive premenopausal women cause more BP variations than in men. After menopause, women often develop arterial hypertension (HT) with a profile of sodium sensitivity. Besides, experimental results have shown that in adult rat models resembling the postmenopausal hormonal state induced by ovariectomy, controlling BP is not enough to avoid renal and other tissue infiltration with immune cells, which does not occur when sodium intake is low or normal. Therefore, excess sodium promotes an inflammatory state with the involvement of immune cells. The evidence of activation of adaptive immunity, besides changes in T cell subpopulations, includes changes in sodium transporters and receptors. More studies are needed to evaluate the particular sodium sensitivity of women and its meaning. Changes in lifestyle and sodium intake reduction are the main therapeutic steps. However, to face the actual burden of salt-sensitive HT in postmenopausal women and its associated inflammatory/immune changes, it seems reasonable to work on immune cell activity by considering the peripheral blood mononuclear cell phenotypes of molecules and transport proteins related to sodium handle, both to screen for and treat cell activation.

Pregnancy in end-stage kidney disease: Great news that needs to be handled carefully

Compared to women with normal kidney function, women with end-stage kidney disease (ESKD) are much less likely to become pregnant, but more likely to have a complicated pregnancy. While renal transplantation remains the best option for women who desire to have a child, pregnancy on dialysis should be considered an option for those who may not receive a transplant during their reproductive years. Many physicians do not encounter a pregnant patient with ESKD during their nephrology training, and may not feel prepared to provide care for such patients in a busy practice. In this paper, we briefly provide an overview of the most significant practical points related to management of a pregnant patient with ESKD through a real-life case with twin pregnancy. The two key elements in management of these patients would be an intensified hemodialysis regimen and a multidisciplinary team that can provide frequent, regular, and multifaceted assessments.