A blunted decrease in nocturnal blood pressure is independently associated with increased aortic stiffness in patients with resistant hypertension

The time-course augmentation of perivascular space enlargement in the basal ganglia among a community-dwelling elder population

PURPOSE

We examined whether time-course augmentation of perivascular space enlargement in the basal ganglia (BG-PVS) reflected cerebral small vessel disease (CSVD) severity by considering white matter hyperintensity lesion (WMHL) as an indicator for CSVD.

MATERIALS AND METHODS

This study population included 416 older participants from a community-based cohort. They participated in magnetic resonance imaging (MRI) studies more than once during the study period. The grades for BG-PVS and WMHL were evaluated by visual rating scales; BG-PVS time-course augmentation in 4-9 years was also evaluated. At baseline, the participants were asked about their smoking and drinking history, and medical history. They also underwent a blood examination and their office blood pressure (BP) examination. In addition, 24-h ambulatory BP monitoring was also performed within the study period.

RESULTS

Of the 416 participants, 48 participants (11.5%) had BG-PVS time-course augmentation. The participants with BG-PVS augmentation had significantly lower LDL levels, hyper-nighttime BP, and lower nighttime BP fall in univariate analysis (p = 0.03, p = 0.03, p = 0.003, respectively). In multivariate analysis, lower nighttime BP fall and male sex showed significance (p = 0.02, 0.03, respectively). Additionally, BG-PVS time-course augmentation was significantly associated with subsequent WMHL severity in univariate analysis (p < 0.001), which remained significant in multivariate analysis adjusted by imaging and demographic factors (p = 0.03). In multivariate analysis, additionally adjusted by the clinical factors, the significance disappeared (p = 0.07).

CONCLUSION

This study revealed that the lower nighttime BP fall in ambulatory blood pressure monitoring was a factor significantly associated with BG-PVS augmentation. Moreover, the BG-PVS time-course augmentation would be a notable finding that was associated with the subsequent WMHL.

Aortic Stiffness Is Associated With Higher Nighttime Ambulatory Blood Pressure in Middle-Aged and Older Adults

PURPOSE

The objective of this study was to determine the relationship between aortic stiffening and brachial and central ambulatory blood pressure (AMBP) in a nonclinical sample of middle-aged and older adults (MA/O). We hypothesized aortic stiffness would be positively associated with 24-hr, daytime, and nighttime brachial and central AMBP.

METHODS

Fifty-one participants aged ≥50 yr (21 males and 30 females, mean age 63.4 ± 9.0 yr) with a body mass index <35 kg/m2 who also had a resting brachial blood pressure (BP) <160/100 mmHg with or without BP medications were recruited for this cross-sectional analysis. All participants underwent measures of aortic stiffness (carotid-femoral pulse wave velocity [cfPWV]) and 24-hr AMBP monitoring. Bivariate correlations assessed the relationship between cfPWV, brachial, and central AMBP. Partial correlations were used to independently adjust for traditional cardiovascular disease (CVD) risk factors including age, sex, waist circumference, glucose, and augmentation index normalized to heart rate 75 bpm, a surrogate measure of arterial stiffness, and in a multivariable combined model.

RESULTS

Nighttime brachial systolic BP (r = 0.31) and central systolic BP (r = 0.30) were correlated with cfPWV in the multivariable combined model (P≤ .05). Nighttime brachial pulse pressure and central pulse pressure were correlated with cfPWV after independently adjusting for all CVD risk factors (P≤ .05, all) but not when combined in the multivariable model (P> .05).

CONCLUSIONS

Higher nighttime brachial and central AMBP with older age are related, in part, to greater aortic stiffening. Therefore, interventions to lower or prevent aortic stiffening may also lower nighttime BP in MA/O adults to lower CVD risk.

Nocturnal systolic blood pressure dipping and progression of chronic kidney disease

The relationship between declining nocturnal blood pressure (BP) and adverse cardiovascular outcomes is well-recognized. However, the relationship between diurnal BP profile and the risk of chronic kidney disease (CKD) progression is unclear. Herein, we examined the association between nocturnal systolic SBP (SBP) dipping and CKD progression in 1061 participants at the Cardiovascular and Metabolic Disease Etiology Research Center-High Risk (CMERC-HI). The main exposure was diurnal systolic BP (SBP) profile and diurnal SBP difference ([nighttime SBP-daytime SBP] × 100/daytime SBP). The primary outcome was CKD progression, defined as a composite of ≥ a 50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy. During 4749 person-years of follow-up (median, 4.8 years), the composite outcome occurred in 380 (35.8%) participants. Compared to dippers, the hazard ratios (HRs) for the risk of adverse kidney outcomes were 1.02 (95% confidence interval [CI], 0.64-1.62), 1.30 (95% CI, 1.02-1.66), and 1.40 (95% CI, 1.03-1.90) for extreme dipper, non-dipper, and reverse dipper, respectively. In a continuous modeling, a 10% increase in diurnal SBP difference was associated with a 1.21-fold (95% CI, 1.07-1.37) higher risk of CKD progression. Thus, decreased nocturnal SBP decline was associated with adverse kidney outcomes in patients with CKD. Particularly, patients with non-dipping and reverse dipping patterns were at higher risk for CKD progression than those with a dipping pattern.

Cross-sectional associations between short and mid-term blood pressure variability, cognition, and vascular stiffness in older adults

Background

High blood pressure variability (BPV), particularly in older age, appears to be an independent risk factor for incident dementia. The current study aimed to investigate the association between different BPV measures (short- and mid-term BPV including circadian patterns) and cognitive functioning as well as vascular stiffness measures to better understand the role that BPV plays in cognitive impairment.

Methods

70 older adults (60-80-year-olds) without dementia completed a cognitive test battery and had their blood pressure (BP) assessed via a 24-hour ambulatory BP monitor (divided into sleep and wake for short-term BPV) and 4-day morning and evening home-based BP monitor (for day-to-day BPV). Arterial stiffness was evaluated via pulse wave analysis and pulse wave velocity (PWV) and cerebrovascular pulsatility was assessed via transcranial doppler sonography of the middle cerebral arteries.

Results

High systolic as well as diastolic short- and mid-term BPV were associated with poorer cognitive functioning, independent of the mean BP. Higher short-term BPV was associated with poorer attention and psychomotor speed, whilst day-to-day BPV was negatively linked with executive functioning. Circadian BP patterns (dipping and morning BP surge) showed no significant relationships with cognition after adjusting for covariates. Higher systolic short-term BPV was associated with higher arterial stiffness (PWV) and higher diastolic day-to-day BPV was linked with lower arterial stiffness. No significant associations between BPV measures and cerebrovascular pulsatility were present.

Conclusion

High BPV, independently of the mean BP, is associated with lower cognitive performance and increased arterial stiffness in older adults without clinically-relevant cognitive impairment. This highlights the role of systolic and diastolic BPV as a potential early clinical marker for cognitive impairment.

Nondipping blood pressure pattern predicts cardiovascular events and mortality in patients with atherosclerotic peripheral vascular disease

BACKGROUND

Patients with peripheral vascular disease (PVD) are often underdiagnosed and undertreated. Nocturnal nondipping blood pressure (BP) pattern, as diagnosed by ambulatory BP monitoring (ABPM), is associated with increased cardiovascular risk, but has not been studied in patients with PVD. We aimed to investigate if a nondipping BP pattern predicts cardiovascular events or all-cause death in outpatients with PVD.

METHODS

Consecutive outpatients with carotid or lower-extremity PVD were examined with 24-hour ABPM (n = 396). Nondipping was defined as a < 10% fall in systolic BP level during night-time. We used Cox regression models adjusting for potential confounders. We also evaluated the incremental prognostic value of dipping status in the COPART risk score. Our primary composite outcome was cardiovascular events or all-cause death.

RESULTS

In the cohort (mean age 70; 40% women), 137 events occurred during a 5.1-year median follow-up; incident rate of 7.35 events per 100 person-years. Nondipping was significantly associated with outcome (hazard ratio 1.55, 95% CI 1.07-2.26, p = 0.021) in a fully adjusted model. When adding nondipping to the risk markers in the COPART risk score, the model fit significantly improved (χ2 7.91, p < 0.005) and the C-statistic increased from 0.65 to 0.67.

CONCLUSION

In a cohort of outpatients with PVD, nondipping was an independent risk factor for future cardiovascular events or mortality and seemed to be a strong predictor in patients with carotid artery disease but not in lower-extremity PVD. Additional studies are needed to evaluate the clinical utility of ABPM for improved prevention in these high-risk patients. (ClinicalTrials.gov Identifier: NCT01452165).

Impact of thoracic endovascular aortic repair following blunt traumatic thoracic aortic injury on blood pressure

BACKGROUND

Blunt traumatic thoracic aortic injuries (BTAIs) are associated with a high mortality rate. Thoracic endovascular aortic repair (TEVAR) is the most frequently used surgical strategy in patients with BTAI, as it offers good short- and middle-term results. Previous studies have reported an abnormally high prevalence of hypertension (HT) in these patients. This work aimed to describe the long-term prevalence of HT and provide a comprehensive evaluation of the biomechanical, clinical, and functional factors involved in HT development.

METHODS

Twenty-six patients treated with TEVAR following BTAI with no history of HT at the time of trauma were enrolled. They were matched with 37 healthy volunteers based on age, sex, and body surface area and underwent a comprehensive follow-up study, including cardiovascular magnetic resonance, 24-hour ambulatory blood pressure monitoring, and assessment of carotid-femoral pulse wave velocity (cfPWV, a measure of aortic stiffness) and flow-mediated vasodilation.

RESULTS

The mean patient age was 43.5 ± 12.9 years, and the majority were male (23 of 26; 88.5%). At a mean of 120.2 ± 69.7 months after intervention, 17 patients (65%) presented with HT, 14 (54%) had abnormal nighttime blood pressure dipping, and 6 (23%) high cfPWV. New-onset HT was related to a more proximal TEVAR landing zone and greater distal oversizing. Abnormal nighttime blood pressure was related to high cfPWV, which in turn was associated with TEVAR length and premature arterial aging.

CONCLUSIONS

HT frequently occurs otherwise healthy subjects undergoing TEVAR implantation after BTAI. TEVAR stiffness and length, the proximal landing zone, and distal oversizing are potentially modifiable surgical characteristics related to abnormal blood pressure.

Abnormal Circadian Blood Pressure Variation is Associated with SYNTAX Scores in Hospitalized Patients with Acute Coronary Syndrome

BACKGROUND

Blunted nocturnal blood pressure (BP) reduction, referred to as non-dipper hypertension, is a strong predictor of cardiovascular morbidity and mortality.

OBJECTIVES

This study aimed to investigate the relationship between non-dipper hypertension and the severity and complexity of coronary artery disease using SYNTAX score in hospitalized patients with acute coronary syndrome.

METHODS

A total of 306 consecutive patients with acute coronary syndrome were screened. Patients who were clinically stable and admitted to the intermediate intensive care unit at least 24 hours after angiography and/or successful revascularization. After the exclusion criteria, 141 patients (34 female and 107 male; mean age 61 ± 11 years) were included. Non-dipper hypertension has been defined as a 0% to 10% decrease in average systolic BP at nighttime compared to daytime, measured at hourly intervals using the same automatic BP measuring device on bedside monitors (Vismo PVM-2701; Nihon Kohden Corp., Tokyo, Japan). SYNTAX score was calculated with an online calculator. The independent predictors of SYNTAX score were assessed using multivariable logistic regression analysis. P < 0.05 was considered statistically significant.

RESULTS

The patients with non-dipper hypertension had higher SYNTAX score than the patients with dipper hypertension (11.12 ± 6.41 versus 6.74 ± 6.45, p < 0.0001). In a multivariable logistic regression model, non-dipper hypertension status (odds ratio: 5.159; 95% confidence interval: 2.246 to 11.852, p < 0.001), sex (p = 0.012) and low-density lipoprotein cholesterol (p = 0.008) emerged as independent predictors of high SYNTAX score.

CONCLUSIONS

The results of our study provide a possible additional mechanism linking abnormal circadian BP profile with coronary artery disease severity and complexity in patients with acute coronary syndrome.

Prognostic Value of Changes in Aortic Stiffness for Cardiovascular Outcomes and Mortality in Resistant Hypertension: a Cohort Study

The prognostic importance of changes in aortic stiffness for the occurrence of adverse cardiovascular outcomes and mortality has never been investigated in patients with resistant hypertension. We aimed to evaluate it in a prospective cohort of 442 resistant hypertension individuals. Changes in aortic stiffness were assessed by 2 carotid-femoral pulse wave velocity (CF-PWV) measurements performed over a median time interval of 4.7 years. Multivariate Cox analysis examined the associations between changes in CF-PWV (evaluated as continuous variables and categorized into quartiles and as increased/persistently high or reduced/persistently low) and the occurrence of total cardiovascular events (CVEs), major adverse CVEs, and cardiovascular/all-cause mortalities. During a median follow-up of 4.1 years after the second CF-PWV measurement, there were 49 total CVEs (42 major adverse CVEs) and 53 all-cause deaths (32 cardiovascular). As continuous variables, increments in absolute and relative changes in CF-PWV were associated with higher risks of CVEs and major adverse CVEs occurrence, but not of mortality. Divided into quartiles of CF-PWV changes, risks increased in the third and fourth quartile subgroups in relation to the reference first quartile subgroup (those with greatest CF-PWV reductions) for all outcomes. Patients who either increased or persisted with high CF-PWV had excess risks of cardiovascular morbidity/mortality, with hazard ratios ranging from 2.7 to 3.0, in relation to those who reduced or persisted with low CF-PWV values. In conclusion, reducing or preventing progression of aortic stiffness was associated with significant cardiovascular protection in patients with resistant hypertension, suggesting that it may be an additional clinical target of antihypertensive treatment.

Is there any true distinction in extreme dipping versus nondipping or dipping phenotype regarding hypertension-mediated organ damage in newly diagnosed and never-treated hypertensive patients?

Dipping phenomena is defined as nocturnal BP fall >10% during 24-h ambulatory blood pressure (BP) monitoring (ABPM) which carries a favorable cardiovascular risk (CVR) prognosis due to reduced 24-h hypertension burden. To date, extreme dipping phenotype (defined as BP decrease ≥20%) has led to controversial prognostic results regarding CVR. We aimed to explore hypertension-mediated organ damage (HMOD) in extreme dippers compared to the other dipping phenotypes (nondipping, dipping). From 490 consecutive patients with newly diagnosed never-treated arterial hypertension (mean age 51 ± 11 years, 294 males) subjected to 24-h ABPM, we studied 52 extreme dippers, 52 age- and gender-matched nondippers, and 52 age- and gender-matched dippers. All patients were subjected to arterial stiffness (PWV), 24-h microalbumin levels, carotid intima-media thickness (cIMT), diastolic dysfunction (E/Ea), and left ventricular mass index (LVMI) evaluation. ANOVA analysis found no differences regarding HMOD between groups. Multiple regression analysis revealed the following independent direct relationships between: (i) office SBP and PWV in nondippers (β = 0.35, p = 0.01) and extreme dippers (β = 0.49, p < 0.001), (ii) office SBP and E/Ea in extreme dippers (β = 0.39, p = 0.007), (iii) 24-h diurnal and nocturnal SBP and E/Ea in dippers (β = 0.40, p = 0.004, β = 0.39, p = 0.005, and β = 0.40, p = 0.004, respectively), and (iv) 24-h and nocturnal SBP and LVMI in nondippers (β = 0.29, p = 0.04 and β = 0.36, p = 0.009, respectively). In the early phases of untreated-arterial hypertension disease, extreme dipping phenotype in middle-aged hypertensives does not imply an adverse or favorable prognosis regarding the incidence of HMOD either as continuous variables or as abnormal HMOD compared to other dipping phenotypes.

Defining the nocturnal period in 24-h ambulatory blood pressure monitoring: a comparison of three methods

OBJECTIVES

The purpose of our study was to compare three definitions of ambulatory blood pressure (BP) nocturnal period and to assess their agreement in determining nocturnal BP dipping patterns.

METHODS

We investigated 69 subjects with metabolic syndrome, aged 50-55 years. In all subjects, we assessed 24-h BP monitoring, electrocardiogram and actigraphy profiles. The nocturnal period was defined in three ways: as a fixed narrow nighttime period from 01:00 to 06:00, as a self-reported sleeping period and as a disappearance and onset of physical activity recorded by the actigraph.

RESULTS

Our study revealed a significant discrepancy between the self-reported and actigraphy-based nocturnal periods (P < 0.001). In addition, different definitions of the nighttime yielded significant differences in determining nondipping, extreme dipping and dipping BP patterns, the identification of the latter being affected the most. The actigraphy-based approach best aligned with the fixed-time determination of the nocturnal period: Cohen's kappa coefficient for the nondipping pattern was 0.78 (0.58-1), for the dipping pattern 0.75 (0.59-0.91) and for the extreme dipping pattern 0.81 (0.65-0.97). In comparison to the self-reported determination of the nocturnal period, using the actigraphy-based approach resulted in reclassifying the nocturnal BP pattern in 20.3% of subjects.

CONCLUSIONS

The lack of agreement between fixed-time, self-reported and actigraphy-based determinations of the nighttime period affects the identification of the nocturnal BP patterns. In comparison to the self-reported nocturnal period estimation, the actigraphy-based approach results in the reclassification of BP dipping status in every fifth subject.

Supine blood pressure—A clinically relevant determinant of vascular target organ damage in hypertensive patients

Night‐time blood pressure (BP) is an important predictor of cardiovascular outcomes. Its assessment, however, remains challenging due to limited accessibility to ambulatory BP devices in many settings, costs, and other factors. We hypothesized that BP measured in a supine position during daytime may perform similarly to night‐time BP when modeling their association with vascular hypertension‐mediated organ damage (HMOD). Data from 165 hypertensive patients were used who as part of their routine clinic workup had a series of standardized BP measurements including seated attended office, seated and supine unattended office, and ambulatory BP monitoring. HMOD was determined by assessment of kidney function and pulse wave velocity. Correlation analysis was carried out, and univariate and multivariate models were fitted to assess the extent of shared variance between the BP modalities and their individual and shared contribution to HMOD variables. Of all standard non‐24‐hour systolic BP assessments, supine systolic BP shared the highest degree of variance with systolic night‐time BP. In univariate analysis, both systolic supine and night‐time BP were strong determinants of HMOD variables. In multivariate models, supine BP outperformed night‐time BP as the most significant determinant of HMOD. These findings indicate that supine BP may not only be a clinically useful surrogate for night‐time BP when ambulatory BP monitoring is not available, but also highlights the possibility that unattended supine BP may be more closely related to HMOD than other BP measurement modalities, a proposition that requires further investigations in prospective studies.

Prognostic Impact of Aortic Stiffness in Patients With Resistant Hypertension

The prognostic importance of aortic stiffness in patients with resistant hypertension has never been investigated. We aimed to evaluate it for the occurrence of adverse cardiovascular outcomes and mortality in a prospective cohort of resistant hypertensive patients. Aortic stiffness was assessed by carotid-femoral pulse wave velocity (cf-PWV) at baseline in 891 resistant hypertensive patients who were followed-up for a median of 7.8 years. Multivariate Cox analysis examined the associations between cf-PWV and the occurrence of total cardiovascular events (CVE), major adverse CVEs, and cardiovascular and all-cause mortalities. The improvement in risk stratification was assessed by C statistics and the integrated discrimination improvement index. During follow-up, 138 patients had a CVE (123 major adverse CVE) and 142 patients died (91 from cardiovascular causes). The cf-PWV, analyzed either as a continuous or as a categorical variable, predicted all cardiovascular and mortality outcomes. Patients with increased aortic stiffness (cf-PWV ≥10 m/s after correction for the white-coat effect, or uncorrected directly measured ≥11 m/s) had a significant 2.2- to 2.6-fold increased risk of CVEs and mortality, after adjustments for other risk factors, including 24-hour ambulatory blood pressures and dipping patterns. Aortic stiffness significantly improved cardiovascular risk stratification, with integrated discrimination improvement indices ranging from 13% (for total CVEs) to 18% (for major adverse CVE). In conclusion, increased aortic stiffness predicts adverse cardiovascular outcomes and mortality and improves cardiovascular risk stratification in resistant hypertensive patients. cf-PWV measurement should be included into the routine clinical management of resistant hypertension.

Nocturnal blood pressure dipping is similar in rheumatoid arthritis patients as compared to a normal population

OBJECTIVE

Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory disorder which further doubles the risk of developing cardiovascular disease. Some studies suggest that in RA patients, the prevalence of hypertension increases due to prednisolone use, clinical status, genetic factors, and physical inactivity. On the other hand, dipper and non-dipper status in RA patients compared to non-RA subjects has not been investigated to our knowledge. Purpose of the study is to investigate whether non-dipper status is more deteriorated in RA patients.

METHODS

Sixty-five RA patients and 61 age-sex-matched control patients were evaluated in this cross-sectional study. Patients were classified according to 24-h ambulatory blood pressure monitoring results. Patients with previous hypertension diagnosis, coronary artery disease, and abnormal kidney function were excluded.

RESULTS

Mean age of the study sample was 53.7 ± 12.3 years and 40.5% were male. There was no significant difference between groups in terms of basic demographic characteristics. Leukocyte counts (p = 0.001), neutrophil counts (p = 0.001), and red cell distribution width (p = 0.000) were significantly higher in the RA group. ABPM results indicate no significant difference between RA patients and the control group in terms of daytime systolic and diastolic blood pressure, nighttime systolic and diastolic blood pressure, and average systolic and diastolic blood pressure results (p > 0.05). There was no statistical difference regarding the non-dipper status of patient groups (p = 0.412). Nocturnal blood pressure dipping was significantly similar between groups (p = 0.980).

CONCLUSION

In conclusion, RA patients have similar values in terms of nocturnal blood pressure dipping and hypertension diagnosis as compared to normal population.

Arterial (Aortic) Stiffness in Patients with Resistant Hypertension: from Assessment to Treatment

PURPOSE OF REVIEW

The purpose of the review is to examine whether measurement of aortic stiffness could be especially value-adding for risk stratification and treatment among patients with resistant hypertension (RH).

RECENT FINDINGS

Adverse arterial remodeling and increased aortic stiffness is associated with RH, and it may be of additional clinical benefit to measure aortic stiffness in these patients. However, there is insufficient evidence to determine whether aortic stiffness is excessively high relative to the level of blood pressure (BP) among people with RH. This issue needs resolution as it could help refine management decisions guided by aortic stiffness. If conventional antihypertensive therapy fails to lower BP in patients with RH, there is good rationale for effectiveness of spironolactone as add on therapy, and this should also improve aortic stiffness. Lifestyle intervention with exercise and diet should be additionally efficacious towards improving BP and aortic stiffness in patients with RH, but there is limited data in this patient population. For better characterization on the effects of BP treatment on aortic stiffness, measures of central aortic BP may help refine management decisions above and beyond conventional arm cuff BP. There is strong evidence to support the use of aortic stiffness as a tool to aid risk stratification in hypertension management. Although there is a theoretical basis for special additional benefit of measuring aortic stiffness in patients with RH (as distinct from uncomplicated hypertension), at this time, there is inadequate data available to make definitive conclusions and is an area for future investigation.

Hemoglobin A1c and C-reactive protein are independently associated with blunted nocturnal blood pressure dipping in obesity-related prediabetes

Blunted nocturnal dipping in blood pressure (BP) is associated with increased cardiovascular disease (CVD) risk in middle-aged/older adults. The prevalence of blunted nocturnal BP dipping is higher in persons with obesity and diabetes, conditions that are also associated with elevated aortic stiffness and inflammation. Therefore, we hypothesized that elevated glycemia, inflammation and aortic stiffness would be inversely associated with the magnitude of nocturnal systolic BP dipping among middle-aged/older adults with obesity at high CVD risk. Twenty-four hour ambulatory BP monitoring, aortic stiffness (carotid-femoral pulse wave velocity, CF-PWV), hemoglobin A1c (HbA1c) and inflammation (C-reactive protein, CRP) were measured in 86 middle-aged/older adults with obesity and at least one other CVD risk factor (age 40-74 years; 34 male/52 female; body mass index=36.7±0.5 kg m^-2; HbA1c=5.7±0.04%). In the entire cohort, CRP (β=0.40±0.20, P=0.04), but not HbA1c or CF-PWV was independently associated with systolic BP dipping percent (Model R²=0.07, P=0.12). In stratified (that is, presence or absence of prediabetes) multiple linear regression analysis, HbA1c (β=6.24±2.6, P=0.02) and CRP (β=0.57±0.2, P=0.01), but not CF-PWV (β=0.14± 2.6, P=0.74), were independently associated with systolic BP dipping percent (Model R²=0.32, P<0.01) in obese adults with prediabetes but were absent in obese adults without prediabetes (Model R²=0.01 P=0.95). However, nocturnal systolic BP dipping percent (P=0.65), CF-PWV (P=0.68) and CRP (P=0.59) were similar between participants with and without prediabetes. These data suggest that impaired long-term glycemic control and higher inflammation may contribute partly to blunted BP dipping in middle-aged/older adults with obesity-related prediabetes.

Impact of the Management of Type B Aortic Dissection on the Long-Term Blood Pressure

Ambulatory blood pressure (BP) measurement (ABPM) is recommended to assess optimal BP control, and we studied its influence after an acute type B aortic dissection (ATBAD). We retrospectively collected data from 111 patients with ATBAD from January 2004 to September 2014. Controlled BP group was defined according to a 24-hour BP under 130/80 mm Hg during chronic phase. The population consisted of 85 men, with a mean age of 61 ± 13 years and mean body mass index of 28 ± 6 kg/m². The median delay between ambulatory BP measurement and ATBAD was 2 (0.3 to 4) months. The mean 24-hour BP of the entire population was 124/71 ± 15/8.8 mm Hg. BP was not controlled in 41 patients (37%). The treatment score at discharge was 3.9 ± 1.4. The mean glomerular filtration rate was 83 ± 28 ml/min/1.73 m², with no difference between groups. Visceral stent implantation in the acute phase (odds ratio [OR] 3.857 [1.199 to 12.406], p = 0.023), higher left ventricular ejection fraction (OR 1.092 [1.005 to 1.187], p = 0.038), and higher platelet count at discharge (OR 1.064 [1.018 to 1.112], p = 0.006) were identified as predictors of good BP control by multivariate analysis. The analysis showed that nighttime systolic BP was associated with aortic events during follow-up (hazard ratio [HR] 5.2 [1.01 to 27.2], p = 0.049), particularly for a threshold of 124 mm Hg or more (HR 1.967 [1.052 to 3.678], p = 0.0341). Nighttime pulse pressure showed also its significance (HR 20.1 [1.4 to 282.7], p = 0.026). In conclusion, subclinical renal malperfusion revascularization seems to improve BP control. A greater nighttime systolic BP was associated with the risk of new aortic events during follow-up.

Forearm Resistance-Vessel Dilatation Function During Reactive Hyperemia in Patients With Resistant Hypertension

BACKGROUND

Forearm blood flow (FBF) measured during reactive hyperemia by venous-occlusion plethysmography assesses resistance-vessel dilatation function but has never been investigated in resistant hypertension. The aim was to evaluate the independent correlates of forearm resistance-vessel function parameters in resistant hypertensives.

METHODS

In a cross-sectional study, 274 resistant hypertensives performed 24-hour ambulatory blood pressure (BP) monitoring, 2D-echocardiography, aortic pulse wave velocity, and venous-occlusion plethysmography with baseline and hyperemic FBF and vascular resistance measurements. A subsample of 103 patients also performed ultrasonographic brachial artery endothelial function examination. Independent correlates of baseline and hyperemic vascular parameters were assessed by multiple linear regressions.

RESULTS

Median (interquartile range) baseline FBF was 3.1 (2.4-4.0) ml/min/100ml of tissue, and during hyperemia mean FBF rose to 7.0 (5.2-9.4) ml/min/100ml of tissue. Baseline FBF and resistance were independently associated with left ventricular mass index (partial correlations -0.14 and 0.13, respectively), whereas hyperemic parameters were independently associated with body mass index (BMI) (inversely for FBF, partial correlation: -0.18 to -0.21) and with the nocturnal BP fall (directly for FBF, partial correlation: 0.12-0.15), after adjustments for age, sex, mean arterial pressure, and baseline vascular parameters. In a separate analysis, a larger brachial artery diameter was associated with higher hyperemic FBF, but there were no associations between resistance-vessel and conduit-vessel dilatation function parameters.

CONCLUSION

In patients with resistant hypertension, left ventricular mass was the only correlate of baseline FBF and resistance, whereas higher BMI and lower nocturnal BP fall were independently associated with lower FBF and higher resistance during reactive hyperemia.

Predictive Performance of Echocardiographic Parameters for Cardiovascular Events Among Elderly Treated Hypertensive Patients

BACKGROUND

Hypertension leads to cardiac structural and functional changes, commonly assessed by echocardiography. In this study, we assessed the predictive performance of different echocardiographic parameters including left ventricular hypertrophy (LVH) on future cardiovascular outcomes in elderly hypertensive patients without heart failure.

METHODS

Data from LVH substudy of the Second Australian National Blood Pressure trial were used. Echocardiograms were performed at entry into the study. Cardiovascular outcomes were identified over short term (median 4.2 years) and long term (median 10.9 years). LVH was defined using threshold values of LV mass (LVM) indexed to either body surface area (BSA) or height(2.7): >115/95g/m(2) (LVH-BSA(115/95)) or ≥49/45g/m(2.7) (LVH-ht(49/45)) in males/females, respectively, and ≥125g/m(2) (LVH-BSA(125)) or ≥51g/m(2.7) (LVH-ht(51)) for both sexes.

RESULTS

In the 666 participants aged ≥65 years in this analysis, LVH prevalence at baseline was 33%-70% depending on definition; and after adjusting for potential risk factors, only LVH-BSA(115/95) predicted both short- and long-term cardiovascular outcomes. Participants having LVH-BSA(115/95) (69%) at baseline had twice the risk of having any first cardiovascular event over the short term (hazard ratio, 95% confidence interval: 2.00, 1.12-3.57, P = 0.02) and any fatal cardiovascular events (2.11, 1.21-3.68, P = 0.01) over the longer term. Among other echocardiographic parameters, LVM and LVM indexed to either BSA or height(2.7) predicted cardiovascular events over both short and longer term.

CONCLUSIONS

In elderly treated hypertensive patients without heart failure, determining LVH by echocardiography is highly dependent on the methodology adopted. LVH-BSA(115/95) is a reliable predictor of future cardiovascular outcomes in the elderly.

Blood pressure reverse dipping may associate with stable coronary artery disease in patients with essential hypertension: a cross-sectional study

The dipping variations of circadian blood pressure (BP) correlate closely with target-organ damages and cardiovascular events. The aim of this study was to investigate the relationship between BP reverse dipping and the prevalence of stable coronary artery disease (sCAD) in hypertensive patients. Clinical data and the results of 24-hour ambulatory BP monitoring (ABPM) were obtained from 718 hypertensive patients (390 males, mean age 59.6 ± 13.8 years) in a single centre in Northern China. Reverse dipping pattern was defined as nocturnal systolic BP (SBP) was higher than daytime SBP. A logistic regression model was applied to explore the independent risk factors of sCAD. The patients with BP reverse dipping accounted for 31.5% in sCAD group and 19.5% in control group (P < 0.05). In multivariate analysis, BP reverse dipping remained significantly associated with the prevalence of sCAD (Odds ratio [OR], 1.772; p = 0.027). Furthermore, the circadian decline rate of SBP was independently associated with sCAD (OR, 0.975; p = 0.043). The hypertensive patients with reverse BP dipping were found to be more frequently suffering from sCAD. BP reverse dipping examined with 24-hour ABPM may indicate sCAD.

Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis

The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.

Cardiac Organ Damage and Arterial Stiffness in Autonomic Failure: Comparison With Essential Hypertension

Autonomic failure (AF) is characterized by orthostatic hypotension, supine hypertension, and increased blood pressure (BP) variability. AF patients develop cardiac organ damage, similarly to essential hypertension (EH), and have higher arterial stiffness than healthy controls. Determinants of cardiovascular organ damage in AF are not well known: both BP variability and mean BP values may be involved. The aim of the study was to evaluate cardiac organ damage, arterial stiffness, and central hemodynamics in AF, compared with EH subjects with similar 24-hour BP and a group of healthy controls, and to evaluate determinants of target organ damage in patients with AF. Twenty-seven patients with primary AF were studied (mean age, 65.7±11.2 years) using transthoracic echocardiography, carotid-femoral pulse wave velocity, central hemodynamics, and 24-hour ambulatory BP monitoring. They were compared with 27 EH subjects matched for age, sex, and 24-hour mean BP and with 27 healthy controls. AF and EH had similar left ventricular mass (101.6±33.3 versus 97.7±28.1 g/m(2), P=0.59) and carotid-femoral pulse wave velocity (9.3±1.8 versus 9.2±3.0 m/s, P=0.93); both parameters were significantly lower in healthy controls (P<0.01). Compared with EH, AF patients had higher augmentation index (31.0±7.6% versus 26.1±9.2%, P=0.04) and central BP values. Nighttime systolic BP and 24-hour systolic BP predicted organ damage, independent of BP variability. AF patients develop hypertensive heart disease and increased arterial stiffness, similar to EH with comparable mean BP values. Twenty-four-hour and nighttime systolic BP were determinants of cardiovascular damage, independent of BP variability.

Cardiovascular and renal complications in patients with resistant hypertension

With an increased prevalence, resistant hypertension is recognized as an entity with a high cardiovascular morbidity and mortality. In a large cohort of patients with resistant hypertension, the crude incidence rate of total cardiovascular events reached 4.32 per 100 patient-years of follow-up (19.6 %), with a cardiovascular mortality of 8.3 % (incidence rate of 1.72 per 100 patient-years). Cardiovascular event rates are significantly higher in resistant hypertensives compared with non-resistant (18.0 % versus 13.5 %). In the same way, the prevalence of established cardiovascular and renal disease, as the asymptomatic organ damage (represented by left ventricular hypertrophy, carotid wall thickening, arterial stiffness, and microalbuminuria) is higher in these patients. Many studies have demonstrated a strong association between damage to these organs with higher blood pressure levels, the diagnosis of true resistant hypertension, and refractory hypertension. All efforts should be employed in order to control blood pressure and also to regress and/or prevent subclinical cardiovascular and renal damage. The focus should be on prevention of cardiovascular and renal complications, improving the prognosis of resistant hypertension.

A reduced heart rate variability is independently associated with a blunted nocturnal blood pressure fall in patients with resistant hypertension

BACKGROUND

A blunted nocturnal blood pressure (BP) fall is a marker of worse cardiovascular outcomes, and autonomic imbalance may be involved. The objective was to evaluate the associations between the nocturnal BP fall and heart rate variability (HRV) parameters in resistant hypertension.

DESIGN AND METHODS

In a cross-sectional analysis, 424 resistant hypertensive patients performed 24-h ambulatory BP and Holter monitoring, and 221 patients also performed polysomnography. Time-domain HRV parameters evaluated were the standard deviation of all normal RR intervals (SDNN), the standard deviation of the averaged normal RR intervals for all 5-min segments (SDANN), the root mean square of differences between adjacent R-R intervals (rMSSD) and the percentage of adjacent R-R intervals that varied by more than 50 ms (pNN50). Multivariate linear and logistic regressions assessed associations between the nocturnal BP fall and HRV parameters.

RESULTS

Two hundred and sixty-six patients (63%) presented a nondipping pattern. These patients had lower SDNN and SDANN than normal dipping patients, but equal rMSSD and pNN50. On multivariate analysis, after adjustments for several confounders, a reduced SDNN (<70 ms) implied a 2.9 to 3.4-fold [95% confidence interval (CI) 1.2-8.5] and a reduced SDANN (<50 ms) a 3.7 to 4.2-fold (95% CI 1.5-11.4) higher odds of having a nondipping pattern. Further adjustment for the presence and severity of obstructive sleep apnoea did not change the results.

CONCLUSION

Reduced SDNN and SDANN, two HRV parameters that mainly reflect sympathetic overactivity, were independently associated with a blunted nocturnal BP fall in resistant hypertension. These relationships offer insight into physiopathological mechanisms linking the circadian BP variability to cardiovascular outcomes.

Resistant hypertension and target organ damage

Cardiovascular (CV) complications such as myocardial infarction, heart failure, stroke and renal failure are related to both the degree and the duration of blood pressure (BP) increase. Resistant hypertension (RH) is associated with a higher risk of CV complications and a higher prevalence of target organ damage (TOD). The relationship between CV disease and TOD can be bidirectional. Elevated BP in RH may cause CV structural and functional alterations, and the development or persistence of left ventricular hypertrophy, aortic stiffness, atherosclerotic plaques, microvascular disease and renal dysfunction, may render hypertension more difficult to control. Specifically, RH is related to several conditions, including obesity, sleep apnea, diabetes, metabolic syndrome and hyperaldosteronism, characterized by an overexpression of humoral and hormonal factors that are involved in the development and maintenance of TOD. Optimal therapeutic strategies, including pharmacological treatment and innovative invasive methodologies, have been shown to achieve adequate BP control and induce the regression of TOD, thereby potentially improving patient prognosis.

Prognostic factors in resistant hypertension: implications for cardiovascular risk stratification and therapeutic management

Resistant hypertension (RH) is defined as uncontrolled office blood pressure (BP) in spite of the use of at least three antihypertensive medications. Although its condition has a high prevalence, it is still understudied, and its prognosis is not well established. Some prospective studies evaluated the prognostic value of ambulatory BP monitoring, ECG and renal parameters. They pointed out that ambulatory BPs are important predictors of cardiovascular morbidity and mortality, whereas office BP has no prognostic value. The diagnosis of true RH and the nondipping pattern are also valuable predictors of cardiovascular outcomes. Moreover, several ECG (prolonged ventricular repolarization, serial changes in the strain pattern and left ventricular hypertrophy) and renal parameters (albuminuria and reduced glomerular filtration rate) are also powerful cardiovascular risk markers in RH. These markers and others yet unexplored, such as arterial stiffness and serum biomarkers, may improve cardiovascular risk stratification in these very high-risk patients.

Prevalence and associated factors of subclinical hypercortisolism in patients with resistant hypertension

BACKGROUND

Subclinical hypercortisolism is a secondary cause of hypertension that had never been evaluated in resistant hypertensive patients, a subgroup of general hypertensive individuals with an expected high prevalence of secondary hypertension.

METHODS

Four hundred and twenty-three patients with resistant hypertension and ages up to 80 years were screened for the presence of subclinical hypercortisolism by morning serum cortisol after a midnight 1 mg dexamethasone suppression test (DST). Those with morning cortisol of at least 50  nmol/l had hypercortisolism confirmed by two salivary cortisol of at least 3.6  nmol/l collected at 2300  h. Statistical analysis included bivariate tests between those with positive and negative screening test and with and without confirmed hypercortisolism, and logistic regressions to assess their independent correlates.

RESULTS

One hundred and twelve patients (prevalence 26.5%, 95% confidence interval 22.0-31.9%) had the screening test positive for suspected hypercortisolism. None had overt Cushing syndrome. Patients with positive screening were older, more frequently males, had higher prevalences of diabetes and target-organ damage and higher nighttime SBPs than patients with normal screening test results. Thirty-four patients (total prevalence 8.0%, 95% confidence interval: 5.7-11.2%) had confirmed hypercortisolism. Independent correlates of a positive DST were older age (P = 0.007), male sex (P = 0.012) and presence of cardiovascular diseases (P = 0.002) and chronic kidney disease (P = 0.016). Correlates of confirmed subclinical hypercortisolism were older age (P = 0.020), diabetes (P = 0.06) and a nondipping pattern on ambulatory blood pressure monitoring (P = 0.04).

CONCLUSION

Patients with resistant hypertension had a relatively high prevalence of subclinical hypercortisolism, and its presence is associated with several markers of worse cardiovascular prognosis.

Left ventricular geometry and diastolic function in the hypertensive heart: impact of age

BACKGROUND AND AIM

The impact of aging on the relationship between left ventricular (LV) mass/geometry and diastolic function as assessed by updated echocardiographic methods, such as tissue Doppler, is poorly defined. We investigated this issue in a cohort of hypertensive patients.

METHODS

A total of 660 hypertensives (mean age 65 ± 13 years, 48% men) with preserved LV systolic function underwent a comprehensive echo-Doppler examination for routine clinical indications. For the present analysis, the subjects have been divided in two age groups (<65 or ≥65 years).

RESULTS

Overall, 61% of subjects fulfilled the criteria for LVH, 18% for left atrial (LA) enlargement and 11% for altered LV filling index. Concentric LV geometry was 1.4-fold higher in older hypertensives than in younger counterparts; also the prevalence of LA enlargement and altered LV filling was 2.0- and 1.9-fold higher in the former group, respectively. In older hypertensives, at variance from younger ones, neither LV mass nor relative wall thickness (RWT), a continuous index of LV geometry, were independently correlated to conventional as well as tissue Doppler LV diastolic indexes.

CONCLUSIONS

Our findings suggest the relationship between cardiac hypertrophy and diastolic function in hypertensive subjects is affected by aging-associated factors unrelated to the amount of LV mass as assessed by standard echocardiography.

Prevalence of left-ventricular hypertrophy in hypertension: an updated review of echocardiographic studies

Left-ventricular hypertrophy (LVH) is a cardinal manifestation of hypertensive organ damage associated with an increased cardiovascular (CV) risk. We reviewed recent literature on the prevalence of LVH, as assessed by echocardiography, in order to offer an updated information on the magnitude of subclinical alterations in LV structure in contemporary human hypertension. A MEDLINE search using key words 'left ventricular hypertrophy', 'hypertension', 'echocardiography' and 'cardiac organ damage' was performed in order to identify relevant papers. Full articles published in English language in the last decade, (1 January 2000-1 December 2010), reporting studies in adult or elderly individuals, were considered. A total of 30 studies, including 37,700 untreated and treated patients (80.3% Caucasian, 52.4% men, 9.6% diabetics, 2.6% with CV disease) were considered. LVH was defined by 23 criteria; its prevalence ranged from 36% (conservative criteria) to 41% (less conservative criteria) in the pooled population. LVH prevalence was not different between women and men (range 37.9-46.2 versus 36.0-43.5%, respectively). Eccentric LVH was more frequent than concentric hypertrophy (range 20.3-23.0 versus 14.8-15.8, respectively, P<0.05); concentric phenotype was found in a consistent fraction (20%) of both genders. Despite the improved management of hypertension in the last two decades, LVH remains a highly frequent biomarker of cardiac damage in the hypertensive population. Our analysis calls for a more aggressive treatment of hypertension and related CV risk factors leading to LVH.

Ambulatory blood pressure monitoring in resistant hypertension

ABPM constitutes a valuable tool in the diagnosis of RH. The identification of white coat RH and masked hypertension (which may fulfill or not the definition of RH) is of great importance in the clinical management of such patients. Moreover, the various ABPM components such as average BP values, circadian BP variability patterns, and ambulatory BP-derived indices, such as ambulatory arterial stiffness index (AASI), add significantly to the risk stratification of RH. Lastly, ABPM may indicate the need for implementation of specific therapeutic strategies, such as chronotherapy, that is, administration-time dependent therapy, and the evaluation of their efficacy.

Resistant hypertension and left ventricular hypertrophy: an overview

Available data on subclinical cardiac damage in resistant hypertension (RH) are rather scanty. Thus, we sought to review the literature focusing on the association between RH and left ventricular hypertrophy (LVH). A MEDLINE search was performed to identify relevant articles using the key words "resistant hypertension, " "refractory hypertension," "left ventricular hypertrophy," "cardiac damage," and "left ventricular dysfunction." Full articles published in the English language in the last two decades (December 1, 1989, to July 31, 2010) reporting studies in adult or elderly individuals, were considered. Checks of the reference lists of selected articles complemented the electronic search. A total of 11 cross-sectional and longitudinal studies, including 3325 patients attending outpatient hypertension clinics, were considered. Prevalence rates of echocardiographic LVH, as assessed by updated criteria, ranged from 55% to 75% of patients with RH, peaking to 91% in the subgroup with concomitant electrocardiographic (ECG) LV strain. Reduction in ECG-LVH induced by treatment showed a relevant beneficial impact on cardiovascular prognosis. These data support the view that initial and on-treatment assessment of LVH in patients with RH is important for cardiovascular risk monitoring and therapeutic strategies decision-making.

[Evaluation of blood pressure control by ambulatory blood pressure monitoring and study of factors associated with poor blood pressure control in 300 treated hypertensive type 2 diabetic patients]

Hypertension is frequently associated with type 2 diabetes and is often difficult to control.

AIM

Evaluate the frequency of controlled hypertension in our type 2 diabetic patients with known and treated hypertension and determine the factors associated with poor blood pressure control.

SUBJECTS AND METHODS

Prospective study concerning 300 type 2 diabetic patients with a known and treated hypertension, sex-ratio: 0.64, mean age: 61.2±9.1 years (37-86). All subjects underwent physical examination, biological investigations and a 24 hours ambulatory blood pressure monitoring (ABPM).

RESULTS

Hypertension was well controlled in 70 patients (23.3%). The concordance rate between clinical measure of blood pressure and ABPM was 70.3%. Subjects with uncontrolled hypertension were older (61.8±8.9 vs 59.1±9.3 years, P<0.05), more frequently of male sex (sex-ratio: 0.77 vs 0.34, P<0.01), smokers (36.4 vs 21.7%, P<0.05) and with abdominal adiposity (P<0.05). Duration of diabetes, body mass index and the frequency of peripheral neuropathy, retinopathy and coronary insufficiency were not different between the two groups. Diabetic nephropathy was more frequent (29.8 vs 16.1%, P<0.05) in the group with uncontrolled hypertension. Loss of circadian blood pressure rhythm was noted in 239 patients (79.6%) and it was more frequently observed in patients with uncontrolled hypertension (84 vs 66%, P<0.001).

CONCLUSION

Our type 2 diabetic patients had a poorly controlled hypertension. Close monitoring of blood pressure with adjustment of antihypertensive treatment are necessary to improve cardiovascular prognosis of our patients.

Regulation of circadian blood pressure: from mice to astronauts

PURPOSE OF REVIEW

Circadian variation is commonly seen in healthy people; aberration in these biological rhythms is an early sign of disease. Impaired circadian variation of blood pressure (BP) has been shown to be associated with greater target organ damage and with an elevated risk of cardiovascular events independent of the BP load. The purpose of this review is to examine the physiology of circadian BP variation and propose a tripartite model that explains the regulation of circadian BP.

RECENT FINDINGS

The time-keeper in mammals resides centrally in the suprachiasmatic nucleus. Apart from this central clock, molecular clocks exist in most peripheral tissues including vascular tissue and the kidney. These molecular clocks regulate sodium balance, sympathetic function and vascular tone. A physiological model is proposed that integrates our understanding of molecular clocks in mice with the circadian BP variation among humans. The master regulator in this proposed model is the sleep-activity cycle. The equivalents of peripheral clocks are endothelial and adrenergic functions. Thus, in the proposed model, the variation in circadian BP is dependent upon three major factors: physical activity, autonomic function, and sodium sensitivity.

SUMMARY

The integrated consideration of physical activity, autonomic function, and sodium sensitivity appears to explain the physiology of circadian BP variation and the pathophysiology of disrupted BP rhythms in various conditions and disease states. Our understanding of molecular clocks in mice may help to explain the provenance of blunted circadian BP variation even among astronauts.