Blood pressure variability over 24 h: prognostic implications and treatment perspectives. An assessment using the smoothness index with telmisartan–amlodipine monotherapy and combination

Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden

Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.

Long-term systolic blood pressure variability independent of mean blood pressure is associated with mortality and cardiovascular events: A systematic review and meta-analysis

The association between long-term systolic blood pressure variability (SBPV) and cardiovascular (CV) outcomes after being adjusted with mean blood pressure (BP) is questionable. This systematic review aims to evaluate the associations between mean BP adjusted long-term SBPV and CV outcomes. A systematic search was conducted on PubMed, Scopus, and Science Direct on January 4, 2023. A total of 9,944,254 subjects from 43 studies were included in this meta-analysis. Long-term SBPV increased the risk of all-cause mortality (HR 1.21 [95%CI 1.16-1.25], I2=100%), CV mortality (HR 1.10 [95%CI 1.07-11.4], I2 = 90%), MACE (HR 1.10 [1.07-1.13], I2 = 91%), cerebrovascular stroke (HR 1.22 [1.16-1.29], I2=100%), and myocardial infarction (HR 1.13 [95%CI (1.07-1.19)], I2=91%). European populations generally had higher risk compared to other continents. In conclusion, long-term SBPV is associated with all-cause mortality, CV mortality, MACE, MI, and stroke. Poor outcomes related to long-term SBPV seem more dominated by cerebrovascular than coronary events.

[Sartans in the treatment of arterial hypertension: focus on telmisartan and azilsartan. A review]

The activity of the renin-angiotensin-aldosterone system is one of the main pathogenetic mechanisms underlying cardiovascular diseases at all stages of the cardiovascular continuum. This article discusses the role of telmisartan and azilsartan as the most powerful sartans in modern cardiology. Azilsartan and especially telmisartan have a significant organoprotection and are superior to other antihypertensive drugs in terms of lowering blood pressure. However, the effect of azilsartan on hard endpoints has not been studied while the efficacy of telmisartan on hard endpoints has been evaluated in plenty clinical trials including 3 large randomized clinical trials with several thousand patients. The article also presents calculations showing the better cost-effectiveness of telmisartan compared to azilsartan.

Amlodipine in the current management of hypertension

Hypertension is the leading cause of death worldwide, affecting 1.4 billion people. Treatment options include the widely used calcium channel blockers, among which amlodipine, a dihydropyridine, has unique characteristics that distinguish it from other drugs within this class. This review aims to provide an updated overview of the evidence supporting the use of amlodipine over the past 30 years and highlights its cardiovascular benefits in current hypertension management. Amlodipine has low renal clearance (7 mL/min/mg) and long half-life (35-50 h) and duration of action, which allows it to sustain its anti-hypertensive effect for more than 24 h following a single dose. Additionally, blood pressure (BP) control is maintained even when a dose has been missed, providing continuous protection in case of incidental noncompliance. It has proven to reduce BP variability and successfully lower BP. Amlodipine also controls BP in patients with a systolic/diastolic BP of 130/80 mm Hg or higher, diabetes, or chronic kidney disease without worsening glycemic or kidney function. Additionally, amlodipine is a wise choice for older adults due to its ability to control BP and protect against stroke and myocardial infarction. Side effects of amlodipine include edema, palpitations, dizziness, and flushing, which are more common with the higher dose of 10 mg. Amlodipine is cost effective and predicted to be cost saving when compared with usual care.

Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper ∗

Blood pressure is not a static parameter, but rather undergoes continuous fluctuations over time, as a result of the interaction between environmental and behavioural factors on one side and intrinsic cardiovascular regulatory mechanisms on the other side. Increased blood pressure variability (BPV) may indicate an impaired cardiovascular regulation and may represent a cardiovascular risk factor itself, having been associated with increased all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia incidence. Nonetheless, BPV was considered only a research issue in previous hypertension management guidelines, because the available evidence on its clinical relevance presents several gaps and is based on heterogeneous studies with limited standardization of methods for BPV assessment. The aim of this position paper, with contributions from members of the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and from a number of international experts, is to summarize the available evidence in the field of BPV assessment methodology and clinical applications and to provide practical indications on how to measure and interpret BPV in research and clinical settings based on currently available data. Pending issues and clinical and methodological recommendations supported by available evidence are also reported. The information provided by this paper should contribute to a better standardization of future studies on BPV, but should also provide clinicians with some indications on how BPV can be managed based on currently available data.

Increased variability of mean arterial pressure is associated with increased risk of short-term mortality in intensive care unit: A retrospective study

Background

In intensive care unit (ICU), what thresholds of MAP variability are effective in distinguishing low- and high-risk patients for short-term mortality (in-hospital and 28-day) remains unclear.

Methods

Fifteen thousand five hundred sixty adult subjects admitted to ICU at Beth Israel Deaconess Medical Center (Boston, USA) between 2001 and 2012 were included in this retrospective study from MIMIC-III database. MAP within the first 24 h after admission were collected. Quantiles of MAP variability from 10% to 90% with 10% increasement each were considered to divide study participants into two groups, either having coefficients of variation of MAP greater or less than the given threshold. The threshold of MAP variability was identified by maximizing the odds ratio associated with increased risk of short-term mortality (in-hospital and 28-day). Logistic regression and Cox regression models were further applied to evaluate the association between increased variability of MAP and short-term mortality (in-hospital and 28-day).

Results

90% quantile of MAP variability was determined as the threshold generating the largest odds ratio associated with the increased risk of short-term mortality. Increased MAP variability, especially over 90% of MAP variability, was associated with increased risk of in-hospital mortality (odds ratio: 2.351, 95% CI: 2.064–2.673), and 28-day mortality (hazard ratio: 2.064, 95% CI: 1.820–2.337).

Conclusion

Increased MAP variability, especially over 90% of MAP variability, is associated with short-term mortality. Our proposed threshold of MAP variability may aid in the early identification of critically ill patients with a high risk of mortality.

24-Hour Blood Pressure Control with Amlodipine: A Review of the Current Scenario

Introduction Hypertension is the leading cause of cardiovascular diseases and premature death worldwide. Antihypertensive therapy using calcium channel blockers (CCBs) is one of the preferred choices to treat blood pressure (BP) and control blood pressure variability (BPV). In contrast to clinic BP, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Amlodipine, a longer acting dihydropyridine CCB is effective for 24 hours BP control and also minimizing BPV. The present article is the comprehensive review highlighting the efficacy of amlodipine in controlling 24-hour BP and minimizing BPV from the review of recent studies.

Materials and Methods The literature search was done using PubMed, Google Scholar, and MEDLINE databases. The studies to be included for review, were identified through the keywords: “amlodipine,” “ambulatory BP monitoring (ABPM),”“blood pressure variability (BPV),” “CCBs,” and filtering articles published in English language only.

Results Pharmacological evidence suggests that amlodipine has the ability to block all the subtypes of CCBs such as L-, N-, P-, Q-, R-, and T-type. Various clinical studies reported that amlodipine is a powerful, well-tolerated, and safe antihypertensive agent which is widely used either alone or as a key component of combination therapy for control of 24 hours BP.

Conclusion Overall, amlodipine is a proven and effective antihypertensive drug and helpful in controlling 24-hour BP, minimizing BP variability and hence reducing the risk of cardiovascular complications.

Patient preferences for ambulatory blood pressure monitoring devices: Wrist-type or arm-type?

Background

Ambulatory blood pressure monitoring (ABPM) is important in evaluating average 24-hour blood pressure (BP) levels, circadian rhythm, sleeping BP and BP variability but many patients are reluctant to use standard ABPM devices.

Methods

We compared two validated ABPM devices, the BPro tonometric wrist monitor and the A&D TM-2430 oscillometric upper arm monitor, for agreement of recordings and acceptability in 37 hypertensive patients (aged 55±9 years).

Results

Successful BP measurements were less frequent with the wrist-type than the arm-type device during the sleeping (66.3% vs. 92.9%, P <0.01) and awake periods (56.2% vs. 86.5%, P <0.01). Comparable paired readings showed no significant difference in systolic BP but diastolic BP (DBP) values were higher with the wrist compared to the arm monitor (24-hour 89±13 vs. 85±14 mmHg, P <0.01) with similar differences awake and sleeping. Bland-Altman analysis showed some large discrepancies between individual arm and wrist monitor measurements. More patients found the wrist monitor more comfortable to use than the arm monitor.

Conclusions

Despite the difference in individual BP measurements and the systematic overestimation of DBP values with the BPro device, wrist monitors with good patient acceptability may be useful to facilitate ABPM in some patients to provide additional information about cardiovascular risk and response to antihypertensive therapies.

Accurate Blood Pressure Estimation During Activities of Daily Living: A Wearable Cuffless Solution

The objective is to develop a cuffless method that accurately estimates blood pressure (BP) during activities of daily living. User-specific nonlinear autoregressive models with exogenous inputs (NARX) are implemented using artificial neural networks to estimate the BP waveforms from electrocardiography and photoplethysmography signals. To broaden the range of BP in the training data, subjects followed a short procedure consisting of sitting, standing, walking, Valsalva maneuvers, and static handgrip exercises. The procedure was performed before and after a six-hour testing phase wherein five participants went about their normal daily living activities. Data were further collected at a four-month time point for two participants and again at six months for one of the two. The performance of three different NARX models was compared with three pulse arrival time (PAT) models. The NARX models demonstrate superior accuracy and correlation with "ground truth" systolic and diastolic BP measures compared to the PAT models and a clear advantage in estimating the large range of BP. Preliminary results show that the NARX models can accurately estimate BP even months apart from the training. Preliminary testing suggests that it is robust against variabilities due to sensor placement. This establishes a method for cuffless BP estimation during activities of daily living that can be used for continuous monitoring and acute hypotension and hypertension detection.

Current challenges for hypertension management: From better hypertension diagnosis to improved patients' adherence and blood pressure control

Hypertension control still remains a largely unmet challenge for public health systems. Despite the progress in blood pressure (BP) measurement techniques, and the availability of effective and safe antihypertensive drugs, a large number of hypertensive patients are not properly identified, and a significant proportion of those who receive antihypertensive treatment fail to achieve satisfactory control of their BP levels. It is thus not surprising that hypertension is still a major contributor to disease burden and disability worlwide, even in developed countries. This paper will address current challenges in hypertension management and potential strategies for an improvement in this field. In its first part relevant issues related to hypertension diagnosis will be addressed, in particular how to improve identification of sustained BP elevation and specific BP phenotypes such as white coat and masked hypertension trough the combined use of office and out-of-office BP monitoring techniques. In its second part focus will be on how to improve achievement of hypertension control in treated patients by optimization and simplification of medication regimens, including more efficient selection and titration of antihypertensive drugs and their combinations, aimed at achieving a more consistent 24hBP control; and by favoring a more active patients' and physicians' involvement in hypertension management also through BP telemonitoring and mobile health technologies.

Recent advances in managing primary hypertension

Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.

How to Choose the Optimal Single-Pill Combination of the First-Line Antihypertensive Drugs? The Benefits of Amlodipine and Telmisartan Combination

In patients with arterial hypertension (AH), an extremely important measure of the effectiveness of antihypertensive drugs (AHD) is not only a direct decrease in blood pressure (BP), but also its stable control throughout the 24 hours, preventing excessive morning surge and increased BP variability, which in turn are recognized cardiovascular risk factors. Currently, in the vast majority of hypertensive patients, the main antihypertensive therapy approach is using single-pill combinations (SPC) of AHD. Among the first-line combinations for a wide range of patients with AH and no special clinical conditions is amlodipine/telmisartan SPC. Distinctive features of these drugs, on the one hand, are unique pharmacological properties, consisting in an ultra-long antihypertensive effects, superior to other AHD in their classes; and on the other hand, there is an large body of evidence from numerous clinical trials confirming their high antihypertensive and target-organ protective potential as well as excellent capabilities in cardiovascular risk reduction. To assess the AHD effectiveness extent, several parameters have been proposed, of which the most rational and useful is the smoothness index, calculated using the ambulatory blood pressure monitoring data. Smoothness index describes both the degree of BP reduction and its distribution during the monitoring period. This index inversely associates with the changes in BP variability, and has predictive value in relation to the hypertension-mediated organ damage regression during different antihypertensive regimens. Amlodipine/telmisartan SPC has also been studied in many trials, including comparative ones with other AHD. In these works its direct powerful antihypertensive effect and a pronounced beneficial impact on the smoothness index have been proved, demonstrating stable BP control throughout the 24 hours (especially in the most dangerous morning hours), and also a decrease in BP variability. Therefore, amlodipine/telmisartan SPC can effectively reduce cardiovascular risk and improve prognosis in patients with AH.

Study on the Formation of Antihypertensive Twin Drugs by Caffeic Acid and Ferulic Acid with Telmisartan

PURPOSE

This study aimed to synthesize twin drugs from cinnamic acid compounds, caffeic acid (CFA) and ferulic acid (FLA), which can antagonize endothelin-1 (ET-1) with telmisartan through ester bonds. Moreover, the antihypertensive effect of telmisartan and its influence on blood pressure variability (BPV) were enhanced, and the bioavailability of caffeic acid and ferulic acid was improved.

METHODS

Six twin drugs, which were the target compounds, were synthesized. Hypertensive rats (SHR) and conscious sinoaortic-denervated (SAD) rats were spontaneously used as models for pharmacodynamic research to study the antihypertensive efficacy of these twin drugs. Wistar rats were employed as pharmacokinetic research models to investigate the pharmacokinetics of the target compounds via intragastric administration. Cellular pharmacodynamic research was also conducted on the antagonistic action on Ang II-AT1, ETA and ETB receptor.

RESULTS

Compound 1a was determined as the best antihypertensive twin drug and thus was further studied for its effect on BPV. Compared with that of telmisartan, the antihypertensive effect of compound 1a was improved (p<0.05), and the BPV was reduced (p<0.05). The bioavailability of caffeic acid and ferulic acid after hydrolysis from twin drugs could be increased to varying degrees, and the differences of the main pharmacokinetic parameters among the different forms of caffeic acid and ferulic acid were statistically significant (p<0.05 or p<0.01). Compound 1a had the best antagonistic effect on the Ang II-AT1 receptor. However, the IC50 of Lps-2 was still two orders of magnitude higher than that of the positive drug telmisartan. Hence, the twin drugs worked by metabolizing and regenerating telmisartan and caffeic acid or ferulic acid in the body.

CONCLUSION

The synthesized twin drugs improved telmisartan's antihypertensive effects, significantly decreased BPV in SAD rats and increased the bioavailability of caffeic acid and ferulic acid. This study serves as a basis for the development of new angiotensin receptor blocker (ARB) in the future and a reference for the development of new drugs to antagonize ET-1.

The association of smoothness index of central blood pressure with ambulatory carotid femoral pulse wave velocity after 20-week treatment with losartan in combination with amlodipine versus hydrochlorothiazide

Supplemental Digital Content is available in the text

The aim of this study was to identify associations between the smoothness index of central SBP (CSBP) and changes of ambulatory carotid femoral pulse wave velocity in response to 20-week treatments with losartan and amlodipine vs. losartan and hydrochlorthiazide combinations.

How to reliably diagnose arterial hypertension: lessons from 24 h blood pressure monitoring

BACKGROUND

Hypertension is a common condition in modern society. As blood pressure fluctuates with time, a single blood pressure measurement is useless to diagnose hypertension. Nevertheless, no well-defined number of measurements is often used for this purpose. Diagnosis and therapeutic control of hypertension are therefore suboptimal.

OBJECTIVE

To determine the number and timing of measurements needed to give a trustworthy approximation of an individual's average blood pressure.

METHODS

In this observational study 306 clinically indicated 24h ABPM datasets were analysed. Hypertension was defined as a daytime blood pressure mean exceeding 135/85 mm Hg. Kappa coefficients determined the best time of day for measuring blood pressure. The optimal number of measurements was estimated using canonical correlation.

RESULTS

162 (53%) patients were diagnosed with hypertension. Kappa statistics indicated that measuring during the afternoon gave the best agreement with the 24h blood pressure mean (κ = 0.78). According to canonical correlation, about 8-10 blood pressure readings give enough information for hypertension diagnosis.

CONCLUSIONS

Eight to ten blood pressure measurements between 01:00 and 05:00 p.m. are sufficient to give a clinically useful approximation of the daytime mean blood pressure and therefore for diagnosing hypertension accurately. Future research should determine the ideal dispersion of measurements and include patient characteristics which could influence the required number and timing of measurements. These results may increase the future importance of telemonitoring in diagnosing hypertension.

Daily variability of arterial stiffness of patients with arterial hypertension depending on the category of cardiovascular risk

PURPOSE

The study of the daily variability of arterial stiffness indicators, depending on the category of cardiovascular risk. Materials and methods. The study consistently included patients with essential hypertension who were admitted to the cardiology department of the Volga district medical center from November 1, 2015 to October 1, 2017. The study involved 134 patients with an average age of 52±1 years. Depending on the category of total cardiovascular risk, the patients were divided into 3 groups from I (lowest risk) to III (highest risk). The analysis was carried out on ABPM for 12-14 days (BPLab system of "Peter Telegin" firm). Determined: glomerular filtration rate (GFR), the thickness of the intima-media of the common carotid arteries, analysis of the lipid spectrum. For statistical analysis of clinical and instrumental data, a T-criterion for independent samples was used and an ANOVA analysis was performed. A correlation analysis was performed. Results. Patients of group III had the highest level of av. SBP (рI-III =0.010; pII-III =0.020) and mean pulse BP (PBP) (рI-III =0.002; pII-III =0.002), also more unfavorable the indicators cALALx (pI-II=0.025; рI-III =0.004), varAlx (рI-III =0.004) and av. ASI (рI-III =0.034). When comparing the data of patients of groups II and III, adjusted for gender and age, it was found that statistically significant differences between the groups of varPAD (pII-III =0.008), AASI (рI-III =0.043), varAlx (pII-III=0.049), as well as a pronounced tendency for varASI (pII-III=0.050). Markers of target organ damage (TIM, LVML, GFR) were more pronounced in the high-risk group. As the risk group increased, the level of HDL decreased (рI-III =0.002; pII-III I=0.0001), the level of TG increased (рI-III =0.007; pII-III =0.009) and the CA (рI-III =0.015). The total cholesterol level was lower in patients of group III compared to group II (pII-III=0.004). Statistically signifi nt relationships of arterial wall stiffness indicators with age were found: crAlx (0.467, p&lt;0.001), varAlx (0.272, p&lt;0.01), cpASI (0.227, p&lt;0.01), varASI (0.407, p&lt;0.001). In addition, women showed significant correlations of medium and high strength between age and mean values of mean SPD (r = 0.490, p&lt;0.05), varPAD (r=0.540, p&lt;0.05), avAS (r=0.460, p&lt;0.05) and varASI (r=0.620, p&lt;0.05). VarASI and WedSASI were most closely associated with the level of SRSAD and SRPAD. Only cASI was associated with GFR, and only varASI was associated with the parameters of the lipid spectrum (HSLPVP, TG, KA and LVMI. Conclusion. The most statistically significant dynamics was observed when evaluating varASI, which varied in the sequence I gr. &lt;II gr. &lt; III gr. Corrected by sex and age, the analysis showed a greater variability in arterial stiffness in high-risk patients.

Effect of inter-individual blood pressure variability on the progression of atherosclerosis in carotid and coronary arteries: a post hoc analysis of the NORMALISE and PREVENT studies

Aims

To investigate the relationship between visit-to-visit blood pressure variability (BPV) and the progression of both carotid and coronary artery disease (CAD).

Methods and results

Data from two cardiovascular endpoint studies [Norvasc for Regression of Manifest Atherosclerotic Lesions by Intravascular Sonographic Evaluation (NORMALISE) and Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT)] were analysed separately. Systolic BPV was assessed as within-subject standard deviation of systolic BP across visits from 12-weeks onwards. Follow-up was 24 months (NORMALISE) or 36 months (PREVENT). Any association between BPV and progression of atherosclerosis was assessed using quantitative coronary angiography (QCA), intravascular ultrasound (IVUS), or B-mode ultrasound (depending on study). Patients from NORMALISE (n = 261) and PREVENT (n = 688 for QCA; n = 364 for ultrasound) were stratified within study according to median systolic BPV. No significant difference in change of minimal luminal diameter (by QCA in PREVENT) or change in percent atheroma volume or normalized total atheroma volume (by IVUS in NORMALISE) was detected for subjects with low BPV (BPV < median) compared with high BPV (BPV ≥ median), regardless of treatment. In PREVENT, a significantly greater reduction in maximum carotid intima-media thickness (IMT) (left and right common carotid artery far wall) was observed for patients with BPV < median compared with those with BPV ≥ median [least squares mean difference 0.06 (95% confidence interval 0.01, 0.11); P = 0.0271], after adjusting for treatment, carotid artery segment (left or right), baseline maximum carotid IMT, and other baseline and cardiovascular risk factors/covariates.

Conclusions

In patients with existing CAD and well-controlled BP, visit-to-visit BPV was not associated with progression of coronary atherosclerosis; however, a significantly greater reduction in maximum carotid IMT was observed for patients with low BPV.

Ambulatory blood pressure monitoring and neurocognitive function in children with primary hypertension

BACKGROUND

Children with primary hypertension have been reported to have diminished scores in measures of cognition. However, little is known about the relative correlation between office and ambulatory blood pressure (BP) and neurocognitive test performance, and whether short-term BP variability is associated with decreased neurocognitive function. We sought to determine whether ambulatory BP monitoring (ABPM) was more strongly associated with neurocognitive test performance compared with office BP, and whether increased short-term BP variability was associated with lower neurocognitive scores.

METHODS

Seventy-five subjects ages 10-18 years, with untreated primary hypertension, and 75 matched normotensive controls completed neurocognitive testing. All subjects had office BP and ABPM prior to neurocognitive testing.

RESULTS

On multivariate analyses, there was no significant association between office BP and neurocognitive tests. However, several ABPM parameters were significantly associated with neurocognitive test scores in the lower quartile, in particular 24 h SBP load and wake systolic blood pressure (SBP) index [Rey Auditory Verbal learning Test (RAVLT) List A Trial 1, 24 h SBP load, odds ratio (OR) = 1.02, wake SBP index, OR = 1.06; List A Total, 24 h SBP load, OR = 1.02, wake SBP index, OR = 1.06; Short Delay Recall, wake SBP index, OR = 1.06; CogState Maze delayed recall, 24 h SBP load, OR = 1.03, wake SBP index, OR = 1.08; Grooved Pegboard, 24 h SBP load, OR = 1.02; all p < 0.05]. In contrast, short-term BP variability measures were not associated with neurocognitive test performance.

CONCLUSIONS

ABPM is superior to office BP in distinguishing hypertensive youth with lower neurocognitive test performance.

[Relationship between blood pressure variability and combined cardiovascular events in 5-10 years in hypertensive patients]

OBJECTIVE

To explore the relationship between blood pressure variability (BPV) and combined cardiovascular events in 5-10 years in patients with hypertension.

METHODS

A total of 367 hypertensive patients treated in our hospital from January, 2000 to January, 2005 were analyzed, and their BPV was assessed in comparison with 145 normotensive individuals. The hypertensive patients were classified into high BPV group and low BPV group, and the general clinical data and biochemical profiles were compared. The relationship between BPV and combined cardiovascular events of the patients within 5-10 years were explored.

RESULTS

Compared with the normotensive individuals, the hypertensive patients showed significantly increased standard deviation and coefficient of variation of 24-h systolic blood pressure (SBP), 24-h diastolic blood pressrue (DBP), daytime SBP, daytime DBP, night-time SBP and night-time DBP (P<0.01). The percentages of drinking, smoking, diabetes and coronary heart disease were significantly higher in patients with high BPV than those with lower BPV (P<0.01 or 0.05); uric acid, homocysteine, urinary protein/creatinine ratio and urinary microalbumin increased more significantly in patients with high BPV (P<0.01 or 0.05). In addition, the combined cardiovascular events in 5-10 years were significantly higher in the patients with higher BPV than those with lower BPV (P<0.01 or 0.05). Logistic multivariate logistic regression analysis showed that alcohol, diabetes, coronary heart disease, uric acid and homocysteine were independent risk factors for cardiovascular events in hypertensive patients (P<0.01 or 0.05).

CONCLUSION

In hypertensive patients, BPV is closely correlated with the long-term combined cardiovascular events, and a high BPV is associated with a greater likeliness of combined cardiovascular events.

Effects of NWT-03, an egg-protein hydrolysate, on blood pressure in normotensive, high-normotensive and mild-hypertensive men and women: a dose-finding study

Angiotensin-converting enzyme (ACE) inhibitors are important agents in blood pressure (BP) management. It was recently shown that the egg-protein hydrolysate NWT-03 inhibited ACE in Zucker diabetic fatty rats. We therefore designed a dose-finding study to assess the effects of 1, 2 and 5 g NWT-03 on daytime, 36-h, and night-time systolic and diastolic BP (SBP and DBP) in ninety-two generally healthy subjects with normal BP (n 29), high-normal BP (n 34) or mild hypertension (n 29). The study had a cross-over design with six treatment arms (1 g NWT-03 or placebo in period 1 and placebo or 1 g NWT-03 in period 2, 2 g NTW-03 or placebo in period 1 and placebo or 2 g NWT-03 in period 2, or 5 g NTW-03 or placebo in period 1 and placebo or 5 g NTW-03 in period 2). A comparable number of subjects from each BP class were included in each study arm. Duration of both treatments in each arm was 7 d, separated by 5-d wash-out periods. BP was measured with an ambulatory BP monitor before and after the treatments. In mild-hypertensive subjects, 2 g NWT-03 significantly decreased daytime SBP (7·9 mmHg; P=0·006), daytime DBP (4·2 mmHg; P=0·009), 36-h SBP (6·9 mmHg; P=0·015) and 36-h DBP (3·5 mmHg; P=0·035) compared with placebo subjects. In addition, in mild-hypertensive subjects, 5 g NWT-03 significantly decreased night-time SBP (14·8 mmHg; P=0·008) and night-time DBP (8·4 mmHg; P=0·020) compared with that in placebo subjects. To conclude, we found that 2 g NWT-03 lowered daytime and 36-h BP in subjects with mild hypertension, and 5 g NWT-03 lowered night-time BP in subjects with mild hypertension. As no dose–response relationship was evident, these results should be interpreted with care, and additional studies are needed.

Phase 4 Studies in Heart Failure - What is Done and What is Needed?

Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.

Effect of visit-to-visit blood pressure variability on cardiovascular events in patients with coronary artery disease and well-controlled blood pressure

This post hoc analysis of CAMELOT and PREVENT analyzed the impact of blood pressure variability (BPV, assessed as within-subject standard deviation of SBP from 12 weeks onward) on the incidence of major adverse cardiovascular events (MACE, defined according to original studies). Patients (n = 1677 CAMELOT; n = 776 PREVENT) were stratified by BPV quartile. Regardless of study, BPV was significantly lower for amlodipine versus other treatments. In CAMELOT, a significant association between BPV quartile and MACE was observed with amlodipine treatment. Significant associations between BPV quartile and MACE were observed for both studies, when analyzed overall (adjusting for treatment). In CAMELOT, with amlodipine treatment, an increased risk for MACE was observed with high (BPV ≥ Q3) versus low BPV (< Q1; adjusting for characteristics and risk factors). In both studies, increased risk for MACE was observed for BPV ≥ Q3 versus BPV < Q1 (analyzed overall, adjusting for treatment and covariates). For both studies, BPV, but not mean SBP, was associated with cardiovascular events. BPV was associated with cardiovascular outcomes in patients with CAD and well-controlled BP.

Evening versus morning dosing of antihypertensive drugs in hypertensive patients with sleep apnoea: a cross-over study

OBJECTIVE

Beneficial effects of continuous positive airway pressure (CPAP) on both blood pressure (BP) levels and variability have been documented in patients with obstructive sleep apnoea (OSA). We investigated the relevant impact of different dosing times of antihypertensive drugs beyond CPAP application.

METHODS

In this prospective, cross-over trial, we included 41 patients with newly diagnosed hypertension and never treated OSA (apnoea-hypopnea index ≥15/h), without increased daytime somnolence (Epworth Score ≤10 points). Patients first received treatment with valsartan or with a fixed combination of amlodipine and valsartan in a single morning dose for 8 weeks. In the following 8-week period, patients received the same therapeutic regimen in a single evening dose. Office and ambulatory BP were measured at baseline and after each treatment period.

RESULTS

Compared with morning administration, evening dosing induced a greater decrease in office SBP (by 3.7 ± 6.5 mmHg, P = 0.001). The decrease in 24-h SBP/DBP was significant and similar after morning and evening dosing (-16.4 ± 11/11.0 ± 7.5 and -18.4 ± 11/12.1 ± 7.5 mmHg, respectively, P < 0.001 for both). Evening compared with morning dosing further reduced night-time SBP/DBP by 4.4 ± 8.6/2.9 ± 5.6 mmHg (P = 0.007 and P = 0.006, respectively). Night-time dippers increased from 24% at baseline to 34% with morning dosing and to 61% with evening dosing. There was no significant interaction between concurrent CPAP application and drugs dosing time on BP changes.

CONCLUSION

Evening dosing of antihypertensive drugs improves night-time BP and dipping status in nonsleepy patients with OSA, irrespective of CPAP application.

Blood pressure variability: assessment, predictive value, and potential as a therapeutic target

A large body of evidence has consistently supported the relationship between blood pressure (BP) levels and the risk of cardiovascular complications. In recent years, several independent studies have also indicated that this risk may not only depend on the magnitude of the blood pressure elevation per se but also on the presence of other associated conditions such as increased blood pressure variability. This concept has been supported by a series of reports, most of which post hoc analyses of clinical trials in hypertension, showing that increasing values of BP variability (BPV) (either in the short term, in the midterm, or in the long term) may predict development, progression, and severity of cardiac, vascular, and renal organ damage, as well as cardiovascular events and mortality. Remarkably, studies conducted in populations at high cardiovascular risk have shown increasing values of BPV in the individual subjects (so-called intra- or within-individual BPV) to be strong predictors of cardiovascular morbidity and mortality, even to a larger extent than average BP values. However, in subjects at low to moderate cardiovascular risk, the contribution of BPV to cardiovascular risk prediction over and beyond average BP values has been shown to be only moderate. The aim of this paper is to critically review the evidence addressing the prognostic relevance of different components of BPV addressing a yet open question, i.e., whether routine assessment of BPV in clinical practice should be regarded as an additional target of antihypertensive treatment to improve cardiovascular protection.

Molecular mechanism of aggravation of hypertensive organ damages by short-term blood pressure variability

There is increasing evidence that not only the elevation of systolic and diastolic blood pressure (BP) but also the increase in BP variability (or fluctuation) are associated with hypertensive organ damages and the morbidity and mortality of cerebrovascular and cardiovascular events. However, the molecular mechanism whereby the increase in BP variability aggravates hypertensive organ damages remains unknown. Thus, we created a rat chronic model of a combination of hypertension and large BP variability by performing bilateral sino-aortic denervation in spontaneously hypertensive rat. A series of our studies using this model revealed that large BP variability induces chronic myocardial inflammation by activating local angiotensin II and mineralocorticoid receptor systems and thereby aggravates cardiac hypertrophy and myocardial fibrosis, leading to systolic dysfunction, in hypertensive hearts. In addition, large BP variability induces the aggravation of arteriolosclerotic changes and ischemic cortical fibrosis in hypertensive kidney via local angiotensin II system.

Differences in 24-h blood pressure profile of Japanese hypertensive patients under ARB treatment

Blood pressure (BP) control throughout the entire day is recommended for cardiovascular protection. Angiotensin-II receptor blockers (ARBs) are widely used in hypertensive patients because of beneficial class effects. It is uncertain, however, whether are there any differences in 24-h BP profiles among ARBs. We examined ambulatory blood pressure monitoring (ABPM) among 211 Japanese hypertensive patients (age, 69.4 ± 9.6 years; female, 59.2%) under treatment with five different ARBs. Patients were divided into five groups according to ARBs prescribed. Patient backgrounds were almost identical in all the groups and there were no differences in office, 24-h and daytime BP; however, nighttime BP with olmesartan was significantly lower than with other ARBs. Office BPs with candesartan and telmisartan, but not other ARBs, correlated well with 24-h BP (p < 0.01). Also, there were higher correlations between daytime and nighttime BP with candesartan and telmisartan. In all patients, pulse pressure with office BP was significantly correlated with ambulatory arterial stiffness index (p = 0.001) and fluctuation of systolic BP on ABPM (p = 0.002). In conclusion, different ARB treatments produced meaningful differences in 24-h profiles.

Clinical implications of the 2013 ESH/ESC hypertension guidelines: targets, choice of therapy, and blood pressure monitoring

The European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines for the management of arterial hypertension included simplified blood pressure (BP) targets across patient groups, more balanced discussion on monotherapy vs. combination therapy, as well as reconfirmation of the importance of out-of-office BP measurements. In light of these updates, we wished to review some issues raised and take a fresh look at the role of calcium channel blocker (CCB) therapy; an established antihypertensive class that appears to be a favorable choice in many patients. Relaxed BP targets for high-risk hypertensive patients in the 2013 ESH/ESC guidelines were driven by a lack of commanding evidence for an aggressive approach. However, substantial evidence demonstrates cardiovascular benefits from more intensive BP lowering across patient groups. Individualized treatment of high-risk patients may be prudent until more solid evidence is available. Individual patient profiles and preferences and evidence for preferential therapy benefits should be considered when deciding upon the optimal antihypertensive regimen. CCBs appear to be a positive choice for monotherapy, and in combination with other agent classes, and may provide specific benefits beyond BP lowering. Ambulatory and home BP monitoring have an increasing role in defining the diagnosis and prognosis of hypertension (especially non-sustained); however, their value for comprehensive diagnosis and appropriate treatment selection should be more widely acknowledged. In conclusion, further evidence may be required on BP targets in high-risk patients, and optimal treatment selection based upon individual patient profiles and comprehensive diagnosis using out-of-office BP measurements may improve patient management.