Pre-hypertension: Is it an inflammatory state?

Inflammation index SIRI is associated with increased all-cause and cardiovascular mortality among patients with hypertension

Background

Inflammation plays an essential role in the pathogenesis of hypertension. A novel inflammatory biomarker systemic inflammatory response index (SIRI) is related with all-cause and cardiovascular (CVD) mortality, while the role of SIRI in hypertension patients is unclear.

Methods

A total of 21,506 participants with hypertension were recruited in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018. SIRI was calculated as the neutrophil count ^* monocyte count/lymphocyte count. Hypertension was defined according to the examination of blood pressure, prescription, and self-reported physician diagnosis. Survival status was followed through 31 December 2019. The non-linear relationship was assessed using restricted cubic spline analysis. The association of all-cause mortality with SIRI was evaluated using the Kaplan-Meier curve and the weighted Cox regression analysis. The predictive abilities were assessed with Receiver operating curve.

Results

During 189,063 person-years of follow-up, 5,680 (26.41%) death events were documented, including 1,967 (9.15%) CVD related deaths. A J-shaped association was observed between SIRI and all-cause and CVD mortality. The Kaplan-Meier curve indicated the all-cause and CVD mortality risks were higher in high SIRI quartiles compared with lower SIRI quartiles. After adjusting for all covariates, the SIRI was positively associated with the all-mortality risk with HR = 1.19 (1.15, 1.22), and CVD mortality with HR = 1.19 (1.15, 1.24). The result was robust in subgroup analysis and sensitivity analysis.

Conclusion

Elevated SIRI level is associated with increased all-cause and CVD mortality among patients with hypertension. SIRI is considered as a potential inflammatory biomarker in the clinical practice. Further large-scale cohort studies are required to confirm our findings.

Supplementation of Water-Soluble Vitamins Reduces Hyperhomocysteinemia, Insulin Resistance, and High-Sensitivity C-reactive Protein in Prehypertension Subjects

BACKGROUND

Prehypertensives are at higher risk of developing cardiovascular diseases. Hyperhomocysteinemia, insulin resistance, and increased high-sensitivity C-reactive protein (hs-CRP) are independent risk factors for the development of cardiovascular complications. In prehypertensives, specific therapeutic approaches can be implemented at the earliest to prevent the onset of overt hypertension. So the present study was performed to study the effect of supplementation of water-soluble vitamins on cardiovascular risk factors like homocysteine, insulin resistance, and C-reactive protein in prehypertensive subjects.

METHODS

Sixty prehypertensive subjects were recruited into the study based on inclusion and exclusion criteria and randomized into two groups of 30 each. One group was given a placebo and the other was given water-soluble vitamins for four months. Serum homocysteine, insulin, homeostatic model assessment of insulin resistance (HOMA-IR), and hs-CRP were assayed.

RESULTS

After four months of treatment with water-soluble vitamins, there was a significant decrease in levels of serum homocysteine, hs-CRP, and HOMA-IR when compared to placebo treatment. After four months of treatment, there was a significant decrease in the levels of hs-CRP, homocysteine, and HOMA-IR in groups treated with water-soluble vitamins compared to the basal levels.

CONCLUSION

In subjects with prehypertension, supplementation of water-soluble vitamins decreases the level of homocysteine, insulin resistance, and hs-CRP.

Negative association between lipoprotein associated phospholipase A2 activity and baroreflex sensitivity in subjects with high normal blood pressure and a positive family history of hypertension

The relationship between baroreflex sensitivity (BRS) and inflammatory vascular biomarker Lipoprotein associated phospholipase A2 (Lp-PLA2) in subjects with high normal blood pressure (HNBP, prehypertensives) with a positive family history of hypertension (FHH+) and hypertension history free control subjects (FHH-) was evaluated. A total of 24 HNBP participants (age 39.5 ± 2.5 years, 18 male/ 6 female) were studied. 14 HNBP subjects FHH+ were compared to 10 HNBP participants FHH-, being of similar age and body mass index. BRS (ms/mmHg) was determined by the sequence and spectral methods (five-minute non-invasive beat-to-beat recording of blood pressure and RR interval, controlled breathing at a frequency of 0.33 Hz). Venous blood was analyzed for Lp-PLA2 biomarker of vascular inflammation and atherothrombotic activity. A significant negative correlation between spontaneous BRS obtained by both methods and systolic blood pressure (BP) was present (BRS spect r = -0.54, P<0.001, BRS seq r = -0.59, P<0.001). BRS obtained by sequence and spectral methods were reduced in HNBP FHH+ compared to the group of HNBP FHH- (P = 0.0317 BRS seq, P = 0.0395 BRS spect). Lp-PLA2 was significantly higher in HNBP FHH+ compared to FHH- controls (P<0.05). Lp-PLA2 was negatively correlated with BRS obtained by sequence method (r = -0.798, R2 = 0.636, P<0.001) in the HNBP FHH+ subjects. These findings demonstrate that reduced baroreflex sensitivity, as a marker of autonomic dysfunction, is associated with vascular inflammation, predominantly in otherwise healthy participants with a positive family history of hypertension who could predispose to increased risk of hypertension. We conclude that our transversal study suggests that a lowbaroreflex sensitivity could be an early sign of autonomic dysfunction even in the prehypertensive period, and to corroborate these findings, a longitudinal study is needed.

Is Office Blood Pressure Measurement Reliable in Obese Adolescents?

BACKGROUND

Although it is not reflected in the OBP measurement in obese children, ambulatory BP changes are known to occur. MH, non-dipper pattern and nocturnal hypertension have been reported to increase in obese children. On the other hand, the factors that indicate a high risk of hypertension are still unclear. The aim of our study is to especially detect masked hypertension by 24-hour BP measurement in obese adolescents and to evaluate the relationship of masked hypertension with metabolic syndrome parameters, anthropometric measurements and hepatosteatosis in these patients.

METHODS

A total of 63 adolescents diagnosed with obesity were evaluated between January 2019 and December 2019. Office blood pressure was measured for all children, and all of them underwent ABPM. Patients with and without hypertension in ABPM were compared in terms of clinical and laboratory findings.

RESULTS

The mean age was 14.0 ± 1.7 years, females composed 49.2% of the study population. Office blood pressure measurement revealed hypertension in 4 (6.3%) patients and prehypertension in 15 (23.8%) patients. Thirteen patients (20.9%) were diagnosed with masked hypertension, white coat hypertension was diagnosed in 3 (4.7%) patients. Abnormal ABPM patterns were found to be significantly more frequent in patients with severely obesity (with obesity: 26.4% vs severe obesity: 55.6%, p = 0.03) and patients with a higher waist circumference and waist circumference/height ratio.

CONCLUSION

The prevalence of masked hypertension in obese adolescents has been found to be quite high. Therefore, we recommend ABPM in adolescents with high waist circumference/height ratio and severe obesity, even if their office blood pressure measurements are normal.

Prehypertension and risk of cardiovascular diseases: a meta-analysis of 47 cohort studies

OBJECTIVE

To assess the association of prehypertension (SBP 120-139 mmHg and/or DBP 80-89 mmHg) and total cardiovascular diseases (CVDs), coronary heart disease (CHD), myocardial infarction (MI), and stroke.

METHODS

PubMed, Embase, and Web of Science were searched for articles published up to 7 November 2018. Normal range BP was considered SBP less than 120 mmHg and DBP less than 80 mmHg. RRs and 95% CIs were pooled using fixed-effects models. Meta-regression was conducted to estimate the heterogeneity among subgroups.

RESULTS

We included 27 articles (47 studies including 491 666 study participants) in the analysis. Prehypertension was associated with total CVDs (RR 1.40, 95% CI 1.34-1.46), CHD (1.40, 1.28-1.52), MI (1.86, 1.50-2.32), and stroke (1.66, 1.56-1.76). Risk of total CVDs, MI, and stroke was increased with low-range prehypertension (low-range: SBP 120-129 mmHg and/or DBP 80-84 mmHg) versus normal BP - RR 1.42 (95% CI 1.29-1.55), 1.43 (1.10-1.86), and 1.52 (1.27-1.81), respectively - and risk of total CVDs, CHD, MI, and stroke was increased with high-range prehypertension (high-range: SBP 130-139 mmHg and/or DBP 85-89 mmHg) - RR 1.81 (95% CI 1.56-2.10), 1.65 (1.13-2.39), 1.99 (1.59-2.50), and 1.99 (1.68-2.36), respectively. The population-attributable risk for the association of total CVDs, CHD, MI, and stroke with prehypertension was 12.09, 13.26, 24.60, and 19.15%, respectively.

CONCLUSION

Prehypertension, particularly high-range, is associated with increased risk of total CVDs, CHD, MI, and stroke. Effective control of prehypertension could prevent more than 10% of CVD cases.

Impact of Prehypertension on the Risk of Major Adverse Cardiovascular Events in a Chinese Rural Cohort

BACKGROUND

The study was performed to investigate the impact of prehypertension defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) on the risk of major adverse cardiovascular events (MACE) in a Chinese rural cohort.

METHODS

The epidemiological prospective cohort study included 38,765 participants aged ≥35 years followed for a median of 12.5 years-divided into normal BP (n = 7,366), prehypertension (n = 18,095), and hypertension groups (n = 13,304)-were enrolled for the final analysis. Follow-up for MACE including cardiovascular disease (CVD) death, stroke and myocardial infarction (MI) was conducted. Adjusted Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

The age and sex-adjusted incidence of MACE and its subtypes rose progressively with elevation of BP levels (P < 0.001). After adjusting multivariable Cox proportional hazards, significant increases were observed from the prehypertensive group for incident MACE (HR = 1.337, 95% CI: 1.186-1.508, P < 0.001), CVD mortality (HR = 1.331, 95% CI: 1.109-1.597, P = 0.002), and stroke (HR = 1.424, 95% CI：1.237-1.639, P < 0.001) but not MI (P > 0.05) compared with normal BP.

CONCLUSION

Prehypertensive individuals had a greater risk of incident MACE, CVD mortality, and stroke, implying that improvements in BP monitoring and early intervention in individuals with prehypertension in rural China are urgently needed.

Inflammation and Apparent Treatment-Resistant Hypertension in Patients With Chronic Kidney Disease

Apparent treatment-resistant hypertension (ATRH) is highly prevalent and associated with cardiovascular disease risk in patients with chronic kidney disease. We analyzed the association of inflammatory biomarkers with ATRH and its complications in patients with chronic kidney disease. ATRH was defined as blood pressure ≥140/90 mm Hg while taking ≥3 antihypertensive medications or blood pressure <140/90 mm Hg while taking ≥4 medications. Analyses included 1359 CRIC study (Chronic Renal Insufficiency Cohort) participants with ATRH and 2008 hypertensive participants without. Logistic regression was used to examine cross-sectional associations of inflammatory biomarkers and ATRH adjusting for demographic, lifestyle, and clinical risk factors and treatments. Cox proportional hazards models were used to assess the impact of inflammatory biomarkers on associations of ATRH with composite cardiovascular disease and mortality beyond conventional risk factors. Multivariable-adjusted odds ratio (95% CI) of ATRH for the highest tertile versus the lowest tertile of inflammatory biomarker levels was 1.29 (95% CI, 1.05-1.59) for IL (interleukin)-6, 1.49 (95% CI, 1.20-1.85) for TNF-α (tumor necrosis factor-α), and 0.77 (95% CI, 0.63-0.95) for TGF-β (transforming growth factor-β). High-sensitivity CRP (C-reactive protein), fibrinogen, IL-1β, and IL-1 receptor antagonist were not significantly associated with ATRH. Adding inflammatory biomarkers to Cox models did not attenuate the significant association of ATRH with cardiovascular disease and mortality. Our findings show higher levels of IL-6 and TNF-α and lower levels of TGF-β were independently associated with odds of ATRH. Targeting specific inflammatory pathways may improve blood pressure control in patients with chronic kidney disease.

Sympathoexcitation and impaired arterial baroreflex sensitivity are linked to vascular inflammation in individuals with elevated resting blood pressure

Elevated Resting Blood Pressure (ERBP) in the prehypertensive range is associated with increased risk of hypertension and cardiovascular disease, the mechanisms of which remain unclear. Prior studies have suggested that ERBP may be associated with overactivation and dysregulation of the sympathetic nervous system (SNS). We hypothesized that compared to normotensives (≤120/80 mmHg), ERBP (120/80-139/89 mmHg) has higher SNS activity, impaired arterial baroreflex sensitivity (BRS), and increased vascular inflammation. Twenty-nine participants were studied: 16 otherwise healthy individuals with ERBP (blood pressure (BP) 130 ± 2/85 ± 2 mmHg) and 13 matched normotensive controls (mean BP 114 ± 2/73 ± 2 mmHg). We measured muscle sympathetic nerve activity (MSNA), beat-to-beat BP, and continuous electrocardiogram at rest and during arterial BRS testing via the modified Oxford technique. Blood was analyzed for the following biomarkers of vascular inflammation: lipoprotein-associated phospholipase A2 (Lp-PLA2), E-selectin, and intercellular adhesion molecule 1 (ICAM-1). Resting MSNA burst frequency (22 ± 2 vs. 16 ± 2 bursts/min, P = 0.036) and burst incidence (36 ± 3 vs. 25 ± 3 bursts/100 heart beats, P = 0.025) were higher in ERBP compared to controls. Cardiovagal BRS was blunted in ERBP compared to controls (13 ± 2 vs. 20 ± 3 msec/mmHg, P = 0.032), while there was no difference in sympathetic BRS between groups. Lp-PLA2 (169 ± 8 vs. 142 ± 9 nmol/min/mL, P = 0.020) and E-selectin (6.89 ± 0.6 vs. 4.45 ± 0.51 ng/mL, P = 0.004) were higher in ERBP versus controls. E-selectin (r = 0.501, P = 0.011) and ICAM-1 (r = 0.481, P = 0.015) were positively correlated with MSNA, while E-selectin was negatively correlated with cardiovagal BRS (r = -0.427, P = 0.030). These findings demonstrate that individuals with ERBP have SNS overactivity and impaired arterial BRS that are linked to biomarkers of vascular inflammation.

VEGF-C attenuates renal damage in salt-sensitive hypertension

Salt-sensitive hypertension is a major risk factor for renal impairment leading to chronic kidney disease. High-salt diet leads to hypertonic skin interstitial volume retention enhancing the activation of the tonicity-responsive enhancer-binding protein (TonEBP) within macrophages leading to vascular endothelial growth factor C (VEGF-C) secretion and NOS3 modulation. This promotes skin lymphangiogenesis and blood pressure regulation. Whether VEGF-C administration enhances renal and skin lymphangiogenesis and attenuates renal damage in salt-sensitive hypertension remains to be elucidated. Hypertension was induced in BALB/c mice by a high-salt diet. VEGF-C was administered subcutaneously to high-salt-treated mice as well as control animals. Analyses of kidney injury, inflammation, fibrosis, and biochemical markers were performed in vivo. VEGF-C reduced plasma inflammatory markers in salt-treated mice. In addition, VEGF-C exhibited a renal anti-inflammatory effect with the induction of macrophage M2 phenotype, followed by reductions in interstitial fibrosis. Antioxidant enzymes within the kidney as well as urinary RNA/DNA damage markers were all revelatory of abolished oxidative stress under VEGF-C. Furthermore, VEGF-C decreased the urinary albumin/creatinine ratio and blood pressure as well as glomerular and tubular damages. These improvements were associated with enhanced TonEBP, NOS3, and lymphangiogenesis within the kidney and skin. Our data show that VEGF-C administration plays a major role in preserving renal histology and reducing blood pressure. VEGF-C might constitute an interesting potential therapeutic target for improving renal remodeling in salt-sensitive hypertension.

The effect of dexmedetomidine on the perioperative hemodynamics and postoperative cognitive function of elderly patients with hypertension: Study protocol for a randomized controlled trial

INTRODUCTION

Cognitive dysfunction after surgery, a common clinical manifestation of postoperative psychonosema. It usually occurs after heart surgery, hip replacement, mandibular fractures, and other major operations. Dexmedetomidine can exert sedative, analgesic, anxiolytic effect, inhibits the sympathetic activity, maintains hemodynamic balance, helps reduce the amount of anesthetic agents, and relatively slightly depresses respiration. Preoperative administration of dexmedetomidine for sedation has been reported to reduce the incidence of acute postoperative delirium. But currently there is no study on the effect of dexmedetomidine on the postoperative cognitive function of elderly patients with essential hypertension.

METHODS/DESIGN

This study is a prospective, single-center, double-blind controlled clinical trial. Elderly patients aged between 60 and 80 years old, diagnosed with primary hypertension for 1 year or longer will be included, and randomized into 2 groups. Patients in observational group will be given a loading dose of dexmedetomidine at 0.8 μg/kg, pumped for over 10 minutes. Although patients in control group will be pumped of the same volume of normal saline within 10 minutes, before the induction of anesthesia. Minimental state examination and levels of interleukin-6, tumor necrosis factor alpha, and C-reactive protein will be set as primary endpoints. Baseline characteristics of patients will be summarized by groups and compared using Chi-square or Fisher exact tests for categorical variables and 2-sample t tests or Wilcoxon rank sum test for the continuous variables. Repeated measurement analysis of covariance model will also be used for the comparison of endpoints between 2 groups.

CONCLUSION

The present study is designed to investigate the effect of the application of dexmedetomidine on postoperative myocardial injury and postoperative cognitive dysfunction, also to explore the association between inflammatory factors and postoperative cognitive function. With this study, we are expecting to find out an appropriate anesthesia method for elderly people with hypertension to alleviate the postoperative adverse effects caused by medical treatments.

TRIALS REGISTRATION

This study was registered on Chinese Clinical Trial Registry (http://www.chictr.org.cn/) with the ID ChiCTR-IPR-16009156.

Associations of urinary sodium and sodium to potassium ratio with hypertension prevalence and the risk of cardiovascular events in patients with prehypertension

The aim of this study was to investigate the effects of urinary sodium and sodium to potassium ratio on inflammatory cytokines, hypertension, and cardiovascular disease in patients with prehypertension. The authors observed 627 patients with prehypertension in the General Hospital of Shenyang Military Region. Rank correlation analysis revealed that interleukin 6 expression exhibited significant positive correlations with urinary sodium (R = .13) and sodium to potassium ratio (R = .13). The multivariate-adjusted hazard ratio of 24-hour urinary sodium was 1.01 (95% confidence interval, 1.00 - 1.01) for hypertension and 1.01 (95% confidence interval, 1.00 - 1.02) for cardiovascular disease, whereas the hazard ratio for 24-hour urinary sodium to potassium ratio was 1.13 (95% confidence interval, 1.08 - 1.19) for hypertension and 1.10 (95% confidence interval, 1.04 - 1.17) for cardiovascular disease. The study suggests that a high-salt diet may lead to increased interleukin 6 levels and may contribute to hypertension. In addition, a high sodium to potassium ratio and high sodium levels are associated with increased risks of cardiovascular disease and hypertension in patients with prehypertension.

Effect of Intensive Periodontal Therapy on Blood Pressure and Endothelial Microparticles in Patients With Prehypertension and Periodontitis: A Randomized Controlled Trial

BACKGROUND

Although some studies show a positive association between periodontitis and blood pressure (BP) elevation, research on the effect of intensive periodontal treatment on decline in BP levels and endothelial microparticles (EMPs) without any antihypertensive management is lacking. Therefore, the present clinical trial explores whether intensive periodontal therapy would lower BP levels and EMPs of patients with prehypertension with periodontitis.

METHODS

From a total 107 patients, 95 underwent randomization (47 assigned to control-treatment [CT] group and 48 assigned to intensive-treatment [IT] group) and completed the trial. Patients received intervention for 4 consecutive weeks and were followed for 6 months. Levels of BP and EMPs were evaluated at baseline and 1, 3, and 6 months after intervention.

RESULTS

Periodontal conditions were significantly improved (P <0.05) 6 months after intensive periodontal treatment. In parallel, the primary outcomes including systolic and diastolic BP and EMPs were markedly reduced in the IT group compared with the CT group (absolute difference: 12.57 and 9.65 mm Hg and 581.59/μL, respectively; 95% confidence intervals: 10.45 to 14.69, 7.06 to 12.24, and 348.12 to 815.06, respectively; P <0.05). Reduction in BP levels and EMPs was related to improvement in probing depth (r = 0.358, 0.363, and 0.676, respectively, by the Pearson product-moment correlation; P = 0.009, 0.008, and P <0.001, respectively).

CONCLUSION

To the best knowledge of the authors, the present study demonstrates for the first time that intensive periodontal intervention without any antihypertensive medication therapy may be an effective means to lower levels of BP and EMPs in patients with prehypertension with periodontitis.

It's time to redefine inflammation

Inflammation has been defined for many years as the response to tissue injury and infection. We are now forced to reconsider this definition by the avalanche of reports that molecules and cells associated with inflammation are activated or expressed in high concentration in a large variety of states in the absence of tissue injury or infection. Modest increases in concentration of C-reactive protein, a circulating marker of inflammation, have been reported to be associated with an astounding number of conditions and lifestyles felt to be associated with poor health; these conditions represent or reflect minor metabolic stresses. In recent years we have learned that inflammation is triggered by sentinel cells that monitor for tissue stress and malfunction-deviations from optimal homeostasis-and that molecules that participate in the inflammatory process play a role in restoring normal homeostasis. Accordingly, we suggest that inflammation be redefined as the innate immune response to potentially harmful stimuli such as pathogens, injury, and metabolic stress.-Antonelli, M., Kushner, I. It's time to redefine inflammation.

Double positivity of the IgG isotype of both anticardiolipin and anti-β2gpI antibodies is associated with the highest number of vascular impairment parameters in patients with primary antiphospholipid syndrome: preliminary data

Although numerous studies investigated the association between homocysteine (Hcy), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP) and apolipoproteins (apo_s) with thrombosis and/or recurrent pregnancy losses, studies that analyzed the abovementioned parameters and multiple positivity of antiphospholipid antibodies (aPL Abs) in patients with primary antiphospholipid syndrome (PAPS) are lacking. Therefore, the aim of this study was to analyze the presence of various combinations of the abovementioned parameters and their associations with clinical and/or serological features of PAPS. High-pressure liquid chromatography (HPLC) was used for determination of Hcy, while apoAI, apoB, and lipoprotein (Lp) (a) concentrations were estimated by immunonephelometry. High-sensitivity C-reactive protein (hsCRP) was measured by immunoturbidimetry. Apo (a), TNF-α, and aPL Abs were measured by ELISA. Various combinations of analyzed parameters (Hcy/CRP/TNF/apoAI/apoB/apo (a)/Lp (a)) were not associated with a single presence of either aPL Abs. Double positivity for both isotypes of anticardiolipin (aCL) Abs (IgG + IgM) was associated with the increased apoB levels. The presence of the IgG isotype of both aCL + anti-beta2 glycoprotein I (aβ2gpI) Abs was associated with the highest number of analyzed parameters (i.e., increased levels of hsCRP, Lp (a), and apo (a)). The presence of the IgG isotype of both aCL + aβ2gpI Abs was associated with the highest number of vascular impairment parameters in patients with PAPS, and this combination confers the highest risk for the recurrence of thrombotic episodes. This is the first report that analyzed the association between various combinations of vascular impairment parameters with multiple aPL Ab positivity. Our results provide a rationale for further investigations of therapeutic approaches for PAPS patients.

Polyphenols: a Promising Nutritional Approach to Prevent or Reduce the Progression of Prehypertension

Diet plays a crucial role in maintaining healthy blood pressure. Functional foods are increasingly popular among health-conscious consumers to reduce cardiovascular risk factors and improve vascular health. In particular, dietary polyphenols represent an extraordinary inventory of structurally different compounds that may represent promising candidate chemical entities to prevent or delay the onset of hypertension. In recent years, it has been recognized that prehypertension may be a predictor of clinical hypertension and consequently of cardiovascular risk. Moreover, prehypertension status is associated with increased levels of several inflammatory markers and it is also characterized by structural changes, including endothelial dysfunction and arteriolar hypertrophy. Despite the low bioavailability of polyphenols and the lack of clinical data from nutritional intervention studies, the antihypertensive role of polyphenols to control blood pressure and reduce inflammation and endothelial dysfunction has been subject of recent debate. The purpose of this article is to discuss the potential benefits of dietary polyphenols as a promising and effective nutritional strategy for the management of prehypertension.