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Starr MC, Wilson AC. Systemic Hypertension in Infants with Bronchopulmonary Dysplasia. Curr Hypertens Rep 2022; 24:193-203. [PMID: 35266097 DOI: 10.1007/s11906-022-01179-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Neonatal hypertension is increasingly recognized as improvements in neonatal intensive care have led to increased survival of premature infants. Among infants with bronchopulmonary dysplasia (BPD), the rates of hypertension are much higher than the general neonatal population. However, the etiology and pathophysiology of this increased risk of hypertension in neonates with lung disease remain unclear. RECENT FINDINGS Among infants with bronchopulmonary dysplasia, the rates of hypertension are much higher than the general neonatal population. New studies suggest outcomes in neonates with BPD with hypertension are usually good, with resolution of hypertension in most infants with lung disease. Several potential mechanisms of hypertension in this patient population have been recently proposed. This review focuses on the recent epidemiologic data on prevalence of hypertension in neonates with bronchopulmonary dysplasia, reviews the typical clinical course, and discusses available strategies for management of infants with bronchopulmonary dysplasia that develop hypertension.
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Affiliation(s)
- Michelle C Starr
- Riley Hospital for Children, 410 W 10th Street, Suite 2000A, Indianapolis, IN, 46202, USA.
- Indiana University School of Medicine, Health Information & Translational Sciences, 410 W 10th Street, Suite 2000A, Indianapolis, IN, 46202, USA.
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, IN, USA.
| | - Amy C Wilson
- Riley Hospital for Children, 410 W 10th Street, Suite 2000A, Indianapolis, IN, 46202, USA
- Indiana University School of Medicine, Health Information & Translational Sciences, 410 W 10th Street, Suite 2000A, Indianapolis, IN, 46202, USA
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2
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Abstract
The blood pressure (BP) of neonates, especially those born premature, changes rapidly over the first days and weeks of life. Neonatal BPs may be affected by maternal factors, perinatal factors or events, and intrinsic or extrinsic infant factors. Unfortunately, the effect of many maternal health and disease states has only been studied in small numbers or has shown conflicting results. Many events around the time of delivery have the potential to influence the neonatal BP, and while definitive studies are often lacking, some observational data support physiological expectations. The strongest determinants of neonatal BP are the infant factors of gestational age at birth, birth weight, and postmenstrual age. Understanding the expected pattern of BP changes, identifying the potential influencing factors, and accurately measuring the BP are all essential to determine whether there is a BP abnormality present but are also more complex in the neonatal population. This review describes the evidence for maternal conditions, perinatal events, and infant factors to affect neonatal BP. It also explains what is currently known about the changing BP patterns in neonates including those born preterm. In addition, by examining the physiological process of hemodynamic adaptation to the extrauterine environment and compensatory cardiovascular responses, we can gain insight into the expected and unexpected vascular responses, making the variability of neonatal BP seem a little more predictable.
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Affiliation(s)
- Janis M Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
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3
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Abstract
Hypertension in neonates is increasingly recognized because of improvements in neonatal intensive care that have led to improved survival of premature infants. Although normative data on neonatal blood pressure remain limited, several factors appear to be important in determining blood pressure levels in neonates, especially gestational age, birth weight and maternal factors. Incidence is around 1% in most studies and identification depends on careful blood pressure measurement. Common causes of neonatal hypertension include umbilical catheter associated thrombosis, renal parenchymal disease, and chronic lung disease, and can usually be identified with careful diagnostic evaluation. Given limited data on long-term outcomes and use of antihypertensive medications in these infants, clinical expertise may need to be relied upon to decide the best approach to treatment. This review will discuss these concepts and identify evidence gaps that should be addressed.
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Affiliation(s)
- Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, And Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA.
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Chatmethakul T, Roghair RD. Risk of hypertension following perinatal adversity: IUGR and prematurity. J Endocrinol 2019; 242:T21-T32. [PMID: 30657741 PMCID: PMC6594910 DOI: 10.1530/joe-18-0687] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
Consistent with the paradigm shifting observations of David Barker and colleagues that revealed a powerful relationship between decreased weight through 2 years of age and adult disease, intrauterine growth restriction (IUGR) and preterm birth are independent risk factors for the development of subsequent hypertension. Animal models have been indispensable in defining the mechanisms responsible for these associations and the potential targets for therapeutic intervention. Among the modifiable risk factors, micronutrient deficiency, physical immobility, exaggerated stress hormone exposure and deficient trophic hormone production are leading candidates for targeted therapies. With the strong inverse relationship seen between gestational age at delivery and the risk of hypertension in adulthood trumping all other major cardiovascular risk factors, improvements in neonatal care are required. Unfortunately, therapeutic breakthroughs have not kept pace with rapidly improving perinatal survival, and groundbreaking bench-to-bedside studies are urgently needed to mitigate and ultimately prevent the tsunami of prematurity-related adult cardiovascular disease that may be on the horizon. This review highlights our current understanding of the developmental origins of hypertension and draws attention to the importance of increasing the availability of lactation consultants, nutritionists, pharmacists and physical therapists as critical allies in the battle that IUGR or premature infants are waging not just for survival but also for their future cardiometabolic health.
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Affiliation(s)
- Trassanee Chatmethakul
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Robert D Roghair
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Starr MC, Flynn JT. Neonatal hypertension: cases, causes, and clinical approach. Pediatr Nephrol 2019; 34:787-799. [PMID: 29808264 PMCID: PMC6261698 DOI: 10.1007/s00467-018-3977-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/12/2018] [Accepted: 05/01/2018] [Indexed: 12/24/2022]
Abstract
Neonatal hypertension is increasingly recognized as dramatic improvements in neonatal intensive care, advancements in our understanding of neonatal physiology, and implementation of new therapies have led to improved survival of premature infants. A variety of factors appear to be important in determining blood pressure in neonates, including gestational age, birth weight, and postmenstrual age. Normative data on neonatal blood pressure values remain limited. The cause of hypertension in an affected neonate is often identified with careful diagnostic evaluation, with the most common causes being umbilical catheter-associated thrombosis, renal parenchymal disease, and chronic lung disease. Clinical expertise may need to be relied upon to decide the best approach to treatment in such patients, as data on the use of antihypertensive medications in this age group are extremely limited. Available data suggest that long-term outcomes are usually good, with resolution of hypertension in most infants. In this review, we will take a case-based approach to illustrate these concepts and to point out important evidence gaps that need to be addressed so that management of neonatal hypertension may be improved.
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Affiliation(s)
- Michelle C. Starr
- Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Joseph T. Flynn
- Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA, USA
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6
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Bates ML, Welch BT, Randall JT, Petersen-Jones HG, Limberg JK. Carotid body size measured by computed tomographic angiography in individuals born prematurely. Respir Physiol Neurobiol 2018; 258:47-52. [PMID: 29803761 DOI: 10.1016/j.resp.2018.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE We tested the hypothesis that the carotid bodies would be smaller in individuals born prematurely or exposed to perinatal oxygen therapy when compared individuals born full term that did not receive oxygen therapy. METHODS A retrospective chart review was conducted on patients who underwent head/neck computed tomography angiography (CTA) at the Mayo Clinic between 10 and 40 years of age (n = 2503). Patients were identified as premature ( < 38 weeks) or receiving perinatal oxygen therapy by physician completion or billing codes (n = 16 premature and n = 7 receiving oxygen). Widest axial measurements of the carotid body images captured during the CTA were performed. RESULTS Carotid body visualization was possible in 43% of patients and 52% of age, sex, and body mass index (BMI)-matched controls but only 17% of juvenile preterm subjects (p = .07). Of the carotid bodies that could be visualized, widest axial measurements of the carotid bodies in individuals born prematurely (n = 7, 34 ± 4 weeks gestation, birth weight: 2460 ± 454 g; average size: 2.5 ± 0.2 cm) or individuals exposed to perinatal oxygen therapy (n = 3, 38 ± 2 weeks gestation, Average size: 2.2 ± 0.1 cm) were not different when compared to controls (2.3 ± 0.2 cm and 2.3 ± 0.2 cm, respectively, p > 0.05). CONCLUSIONS Carotid body size, as measured using CTA, is not smaller in adults born prematurely or exposed to perinatal oxygen therapy when compared to sex, age, and BMI-matched controls. However, carotid body visualization was lower in juvenile premature patients. The decreased ability to visualize the carotid bodies in these individuals may be a result of their prematurity.
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Affiliation(s)
- Melissa L Bates
- Department of Health and Human Physiology, USA; Abboud Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Brian T Welch
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Jess T Randall
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Jacqueline K Limberg
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Steinbrekera B, Roghair R. Modeling the impact of growth and leptin deficits on the neuronal regulation of blood pressure. J Endocrinol 2016; 231:R47-R60. [PMID: 27613336 PMCID: PMC5148679 DOI: 10.1530/joe-16-0273] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 09/08/2016] [Indexed: 12/15/2022]
Abstract
The risk of hypertension is increased by intrauterine growth restriction (IUGR) and preterm birth. In the search for modifiable etiologies for this life-threatening cardiovascular morbidity, a number of pathways have been investigated, including excessive glucocorticoid exposure, nutritional deficiency and aberration in sex hormone levels. As a neurotrophic hormone that is intimately involved in the cardiovascular regulation and whose levels are influenced by glucocorticoids, nutritional status and sex hormones, leptin has emerged as a putative etiologic and thus a therapeutic agent. As a product of maternal and late fetal adipocytes and the placenta, circulating leptin typically surges late in gestation and declines after delivery until the infant consumes sufficient leptin-containing breast milk or accrues sufficient leptin-secreting adipose tissue to reestablish the circulating levels. The leptin deficiency seen in IUGR infants is a multifactorial manifestation of placental insufficiency, exaggerated glucocorticoid exposure and fetal adipose deficit. The preterm infant suffers from the same cascade of events, including separation from the placenta, antenatal steroid exposure and persistently underdeveloped adipose depots. Preterm infants remain leptin deficient beyond term gestation, rendering them susceptible to neurodevelopmental impairment and subsequent cardiovascular dysregulation. This pathologic pathway is efficiently modeled by placing neonatal mice into atypically large litters, thereby recapitulating the perinatal growth restriction-adult hypertension phenotype. In this model, neonatal leptin supplementation restores the physiologic leptin surge, attenuates the leptin-triggered sympathetic activation in adulthood and prevents leptin- or stress-evoked hypertension. Further pathway interrogation and clinical translation are needed to fully test the therapeutic potential of perinatal leptin supplementation.
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MESH Headings
- Adiposity
- Adult
- Animals
- Animals, Newborn
- Disease Models, Animal
- Female
- Fetal Growth Retardation/drug therapy
- Fetal Growth Retardation/metabolism
- Fetal Growth Retardation/physiopathology
- Hormone Replacement Therapy
- Humans
- Hypertension/etiology
- Hypertension/metabolism
- Hypertension/prevention & control
- Hypothalamus/metabolism
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/metabolism
- Infant, Premature, Diseases/physiopathology
- Leptin/deficiency
- Leptin/genetics
- Leptin/metabolism
- Leptin/therapeutic use
- Male
- Mice
- Nerve Tissue Proteins/agonists
- Nerve Tissue Proteins/metabolism
- Neurodevelopmental Disorders/drug therapy
- Neurodevelopmental Disorders/metabolism
- Neurodevelopmental Disorders/physiopathology
- Pregnancy
- Receptors, Leptin/agonists
- Receptors, Leptin/metabolism
- Recombinant Proteins/metabolism
- Recombinant Proteins/therapeutic use
- Signal Transduction
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Affiliation(s)
- Baiba Steinbrekera
- Stead Family Department of PediatricsCarver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Robert Roghair
- Stead Family Department of PediatricsCarver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Peotta V, Rahmouni K, Segar JL, Morgan DA, Pitz KM, Rice OM, Roghair RD. Neonatal growth restriction-related leptin deficiency enhances leptin-triggered sympathetic activation and central angiotensin II receptor-dependent stress-evoked hypertension. Pediatr Res 2016; 80:244-51. [PMID: 27049292 PMCID: PMC4990468 DOI: 10.1038/pr.2016.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/28/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neonatal growth restriction (nGR) leads to leptin deficiency and increases the risk of hypertension. Previous studies have shown nGR-related hypertension is normalized by neonatal leptin (nLep) and exacerbated by psychological stress. With recent studies linking leptin and angiotensin signaling, we hypothesized that nGR-induced nLep deficiency increases adult leptin sensitivity; leading to leptin- or stress-induced hypertension, through a pathway involving central angiotensin II type 1 receptors. METHODS We randomized mice with incipient nGR, by virtue of their presence in large litters, to vehicle or physiologic nLep supplementation (80 ng/g/d). Adult caloric intake and arterial pressure were monitored at baseline, during intracerebroventricular losartan infusion and during systemic leptin administration. RESULTS nGR increased leptin-triggered renal sympathetic activation and hypertension with increased leptin receptor expression in the arcuate nucleus of the hypothalamus; all of those nGR-associated phenotypes were normalized by nLep. nGR mice also had stress-related hyperphagia and hypertension, but only the stress hypertension was blocked by central losartan infusion. CONCLUSION nGR leads to stress hypertension through a pathway that involves central angiotensin II receptors, and nGR-associated leptin deficiency increases leptin-triggered hypertension in adulthood. These data suggest potential roles for preservation of neonatal growth and nLep supplementation in the prevention of nGR-related hypertension.
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Affiliation(s)
- Veronica Peotta
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Kamal Rahmouni
- Department of Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, IA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Jeffrey L. Segar
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Donald A. Morgan
- Department of Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Kate M. Pitz
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Olivia M. Rice
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Robert D. Roghair
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
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Oral oestrogen reverses ovariectomy-induced morning surge hypertension in growth-restricted mice. Clin Sci (Lond) 2016; 130:613-23. [PMID: 26795436 DOI: 10.1042/cs20150693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 01/21/2016] [Indexed: 11/17/2022]
Abstract
Perinatal growth restriction (GR) is associated with heightened sympathetic tone and hypertension. We have previously shown that naturally occurring neonatal GR programmes hypertension in male but not female mice. We therefore hypothesized that intact ovarian function or post-ovariectomy (OVX) oestrogen administration protects GR female mice from hypertension. Utilizing a non-interventional model that categorizes mice with weanling weights below the tenth percentile as GR, control and GR adult mice were studied at three distinct time points: baseline, post-OVX and post-OVX with oral oestrogen replacement. OVX elicited hypertension in GR mice that was significantly exacerbated by psychomotor arousal (systolic blood pressure at light to dark transition: control 122 ± 2; GR 119 ± 2; control-OVX 116 ± 3; GR-OVX 126 ± 3 mmHg). Oestrogen partially normalized the rising blood pressure surge seen in GR-OVX mice (23 ± 7% reduction). GR mice had left ventricular hypertrophy, and GR-OVX mice in particular had exaggerated bradycardic responses to sympathetic blockade. For GR mice, a baseline increase in baroreceptor reflex sensitivity and high frequency spectral power support a vagal compensatory mechanism, and that compensation was lost following OVX. For GR mice, the OVX-induced parasympathetic withdrawal was partially restored by oestrogen (40 ± 25% increase in high frequency spectral power, P<0.05). In conclusion, GR alters cardiac morphology and cardiovascular regulation. The haemodynamic consequences of GR are attenuated in ovarian-sufficient or oestrogen-replete females. Further investigations are needed to define the role of hormone replacement therapy targeted towards young women with oestrogen deficiency and additional cardiovascular risk factors, including perinatal GR, cardiac hypertrophy and morning surge hypertension.
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Novel single nucleotide polymorphism markers for low dose aspirin-associated small bowel bleeding. PLoS One 2013; 8:e84244. [PMID: 24367646 PMCID: PMC3867469 DOI: 10.1371/journal.pone.0084244] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 11/13/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Aspirin-induced enteropathy is now increasingly being recognized although the pathogenesis of small intestinal damage induced by aspirin is not well understood and related risk factors have not been established. AIM To investigate pharmacogenomic profile of low dose aspirin (LDA)-induced small bowel bleeding. METHODS Genome-wide analysis of single nucleotide polymorphisms (SNPs) was performed using the Affymetrix DMET™ Plus Premier Pack. Genotypes of candidate genes associated with small bowel bleeding were determined using TaqMan SNP Genotyping Assay kits and direct sequencing. RESULTS In the validation study in overall 37 patients with small bowel bleeding and 400 controls, 4 of 27 identified SNPs: CYP4F11 (rs1060463) GG (p=0.003), CYP2D6 (rs28360521) GG (p=0.02), CYP24A1 (rs4809957) T allele (p=0.04), and GSTP1 (rs1695) G allele (p=0.04) were significantly more frequent in the small bowel bleeding group compared to the controls. After adjustment for significant factors, CYP2D6 (rs28360521) GG (OR 4.11, 95% CI. 1.62 -10.4) was associated with small bowel bleeding. CONCLUSIONS CYP4F11 and CYP2D6 SNPs may identify patients at increased risk for aspirin-induced small bowel bleeding.
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Abstract
PURPOSE OF REVIEW Continued interest in neonatal hypertension has led to generation of new data on normal blood pressure (BP) values in neonates, identification of new causes of hypertension in the neonatal period, and improved insights into therapy. RECENT FINDINGS Normal BP in neonates depends on a variety of factors, including gestational age, postnatal age, and birth weight, and may be influenced by other antenatal conditions. The incidence of neonatal hypertension is low, and it is most often seen in infants with concurrent conditions such as chronic lung disease (CLD) or renal disease, or in those that have undergone umbilical arterial catheterization. Although few data exist on efficacy and safety of antihypertensive medications in neonates, a wide variety of medications have been utilized in those who do require treatment. Hypertension resolves over time in most infants, although robust long-term outcome data are lacking. SUMMARY Our understanding of neonatal hypertension continues to evolve. Although better data are available on normal BP and the incidence of hypertension, we still need studies focused on appropriate treatment and long-term prognosis.
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