Combined effects of hypertension and heart rate on the risk of stroke and coronary heart disease: a population-based prospective cohort study among Inner Mongolians in China

Increasing burden of stroke in China: A systematic review and meta-analysis of prevalence, incidence, mortality, and case fatality

BACKGROUND

The epidemiology of stroke is evolving in China as the population undergoes demographic, lifestyle, and economic transitions. An updated review is pertinent to providing feedback on current, and in planning future, prevention and management strategies.

AIMS

To identify high-quality epidemiological studies for quantifying the prevalence, incidence, mortality, and case fatality for stroke in China.

METHODS

A search was undertaken across a range of bibliographic databases on 30 November 2021 without time limitation. Assessments were made of the risk of bias of the included studies. The outcomes were synthesized using a random-effects model. Subgroup analysis and meta-regression models were used to define the source of heterogeneity.

RESULTS

Of 9407 identified records, 26 population-based studies were included. Due to significant heterogeneity across the studies, the original range for crude rates of indices was wide. The pooled annual prevalence was 1329.5/100,000 (95% confidence interval (CI) 713.6-2131.9, p < 0.001), incidence 442.1/100,000 (327.6-573.8, p < 0.001), mortality 154.1/100,000 (52.6-308.8, I² = 100%, p < 0.001), and case fatality 35.8% (26.1% to 46.1%, I² = 97%, p < 0.001). The prevalence and incidence of stroke have increased, but stroke-related case fatality has declined in China over recent decades. There are significant regional and rural-urban differences in incidence rates.

CONCLUSION

Despite improved public health policies and healthcare delivery, the burden of stroke remains high in China. Further coordinated efforts are required in prevention and community care to offset the likelihood of further expansion in the absolute number of stroke cases in this large population.

Lower urinary potassium excretion was associated with higher risk of cerebro-cardiovascular- and renal events in patients with hypertension under treatment with anti-hypertensive drugs

BACKGROUND

Hypertension is one of the risk factors for cerebro-cardiovascular and renal (CCR) diseases. High blood pressure is affected by the amount of salt (NaCl) and potassium (K) intake. There are many studies reporting the relationship between urinary sodium or potassium excretion and CCR events or all-cause mortality in general populations. Thus, it is necessary to investigate the relationship between urinary NaCl or K excretion and CCR events or all-cause mortality in hypertensive patients under control with anti-hypertensive drugs.

METHODS

A prospective, multi-center cohort study was performed in 3210 hypertensives under treatment with anti-hypertensive drugs for 5 years. The primary outcome was the CCR events, and the secondary outcome was all-cause mortality. A time-dependent Cox proportional hazards regression analysis was performed to assess the association between outcomes and urinary NaCl and K excretion, blood pressure, or heart rate.

RESULTS

During the follow-up period, 61 CCR events and 110 all-cause deaths occurred. There was no association between urinary NaCl excretion and CCR events or all-cause mortality. Lower urinary K excretion and higher Na/K ratio were associated with higher risk of CCR events or all-cause mortality. The CCR events were not associated with systolic, diastolic blood pressure, or heart rate.

CONCLUSION

Lower urinary K excretion was associated with higher risk of CCR events or all-cause mortality in hypertensive patients under treatment with anti-hypertensive drugs.

Cardiovascular Disease Risk Factors in Hypertensive Patients: A Case Study of Jimma University Medical Center

Background

Cardiovascular diseases are a group of disorders of the heart and blood vessels. Globally an estimated 17.9 million people died from cardiovascular diseases, which covers 31% of all global deaths, and the three quarters taking place in developing countries. Hypertension is the major cause of cardiovascular diseases. Its influence is high with other risk factors. This study aimed to determine the major risk factors of cardiovascular disease among hypertensive patients at Jimma University Medical Center.

Methods

Using December to January 2017 hypertension-related report of Jimma University Medical Center (JUMC), a retrospective cohort study type was conducted on purposively selected 343 patients. Three nurses from JUMC participated in the data collection, and the data were fitted using the Cox-Proportional Hazard (Cox-PH) model.

Results

About 138 (40.23%) patients were experienced cardiovascular disease at 28 months median time. From the Cox-PH model, the hazard ratio and 95% CI of age (HR = 1.0495, 95% CI: 1.0250-1.0747), urban (HR = 2.1225, 95% CI: 1.3813-3.2613), diabetes mellitus (HR = 1.702, 95% CI: 1.0082-2.8731), proteinuria (HR = 1.8749, 95% CI: 1.2675-2.7734), two drug users (HR = 0.2533, 95% CI: 0.1376-0.4662), systolic blood pressure (HR = 1.0343, 95% CI: 1.0147-1.0542) and pulse rate (HR = 1.0111, 95% CI: 0.9933-1.0293).

Conclusion

The presence of proteinuria, diabetes mellitus, and being an urban resident had a great impact on the cardiovascular diseases of hypertensive patients.

Effect of Presence versus Absence of Hypertension on Admission Heart Rate-Associated Cardiovascular Risk in Patients with Acute Coronary Syndrome

Background and Aims

Heart rate (HR) and hypertension are both important risk factors for adverse cardiovascular (CV) events in patients with established coronary artery disease (CAD). We sought to evaluate whether hypertension can modify the effect of admission HR on adverse CV events in patients with acute coronary syndrome (ACS).

Methods

A total of 1056 patients with ACS undergoing percutaneous coronary intervention (PCI) were analyzed. All patients were classified into three groups according to the tertiles of admission HR (T1: ≤66 bpm, n = 369; T2: 67–73 bpm, n = 322; and T3: ≥74 bpm, n = 365). The primary endpoint was defined as major adverse CV events (MACEs), including all-cause death, stroke, myocardial infarction, or unplanned repeat revascularization. The multivariate Cox regression model was performed to evaluate the association of admission HR with MACE stratified by hypertension.

Results

During the median follow-up of 30 months, a total of 232 patients developed at least one event. After adjusting for other covariates, elevated admission HR was significantly associated with an increased risk of MACE only in patients with hypertension (when T1 was taken as a reference, the adjusted HR of T2 was 1.143 [95% CI: 0.700–1.864] and that of T3 was 2.062 [95% CI: 1.300–3.270]); however, in patients without hypertension, admission HR was not associated with the risk of MACE (when T1 was taken as a reference, the adjusted HR of T2 was 0.744 [0.406–1.364] and that of T3 was 0.614 [0.342–1.101]) (P=0.025 for interaction).

Conclusions

In patients with ACS undergoing PCI, the association of elevated admission HR with an increased risk of MACE was present in individuals with hypertension but not in those without hypertension. This finding suggests a potential benefit of HR control for ACS patients when they concomitantly have hypertension.

Resting Heart Rate and Cardiovascular Outcomes during Intensive and Standard Blood Pressure Reduction: An Analysis from SPRINT Trial

The association between elevated resting heart rate (RHR) as a cardiovascular risk factor and lowering of systolic blood pressure (SBP) to currently recommended values remain unknown. Systolic Blood Pressure Intervention Trial (SPRINT) data obtained from the NHLBI were used to describe the relationship between RHR and SBP reduction to <120 mmHg compared to SBP reduction to <140 mmHg. The composite clinical endpoint (CE) was defined as myocardial infarction, acute coronary syndrome, decompensation of heart failure, stroke, or cardiovascular death. Increased RHR was associated with a higher CE risk compared with low RHR in both treatment arms. A more potent increase of risk for CE was observed in subjects who were allocated to the SBP < 120 mmHg treatment goal. A similar effect of intensive and standard blood pressure (BP) reduction (p for interaction, 0.826) was observed in subjects with RHR in the 5th quintile (hazard ratio, 0.78, with 95% confidence interval (CI), 0.55–1.11) and in other quintiles of baseline RHR (hazard ratio, 0.75, with 95% CI, 0.62–0.90). Lower in-trial than baseline RHR was associated with reduced CE risk (hazard ratio, 0.80, with 95% CI, 0.66–0.98). We concluded that elevated RHR remains an essential risk factor independent of SBP reduction.

The distribution and epidemic characteristics of cerebrovascular disease in followed-up hypertension patients

To explore distribution and epidemic characteristics of CVD in followed-up HP patients. Using the Hypertension Follow-up Management System database in Jiading district in Shanghai. We designed a retrospective cohort study that included all followed-up hypertension patients between 2002 and 2020. The endpoint was the occurrence of CVD confirmed by the hospital; otherwise, the patients were tracked until September 30, 2020. Record information of every patient has been collected in the registration card and each followed-up record. Among 223,097 observational followed-up HP patients, the total number of person years of observation was 4,244,421.25 person-year, 11,143 patients had developed CVD from hypertension before the deadline, the total incidence density was 0.00263 per person-year (male 0.00292; female 0.00238) and the complication ratio of CVD in HP patients was 4.99% (male 5.25%; female 4.76%) during follow-up period. The proportion of ischemic cerebrovascular, hemorrhagic cerebrovascular and unclassified stroke was respectively 71.18%, 5.95% and 22.87% in hypertensive CVD. Complication ratio of CVD increased with age, the group under 30 was 0, and the group over 70 was the highest (6.90%). The complication ratio of grad I, grad II and grad III blood pressure were respectively 4.79%, 4.96% and 6.13%. The complication ratio was 4.92% in only high systolic blood pressure patients; 17.23% in only high diastolic blood pressure patients; 4.59% in high systolic and diastolic blood pressure patients. The peak of complication ratio of CVD was 9–10 years after the registered and followed-up. The proportion of CVD cases in HP patients from April to June was the largest in the four seasons; the proportion of patients from October to December was the minimum. HP patient was prone to falling cerebrovascular disease; the main type of disease was cerebral infarction. Complication ratio in male incidence was higher than that in female. The complication ratio of CVD increased with age, blood pressure and duration of HP patients. It had seasonal characteristics, which was relatively high from April to June within year.

Associations Between Hypertension Status and Increased Heart Rate - China, 2015

What is already known on this topic?

Hypertension is a major public health concern in China, and hypertensive patients have elevated heart rates (HR), which can synergize with higher blood pressure to promote adverse health outcomes.

What is added by this report?

The risk of increased HR was statistically significant but relatively lower in subjects with treated and controlled hypertension. This lower impact might be modified by sex, marital status, smoking, and physical activity.

What are the implications for public health practice?

To mitigate the substantial burden of increased HR among hypertensive patients, improving blood pressure control and promoting healthy lifestyles should be prioritized.

Heart rate as a predictor of cardiovascular risk

Heart rate is a parameter that is very easy to measure and is widely used both in clinic and during daily life activities. Its value gained more relevance with the evidence, in prospective studies and meta-analysis, of association between elevated heart rate values and diseases and outcomes.The increased knowledge of physiological mechanisms of heart rate control and the pathophysiological mechanisms responsible for its dysfunction allows to identify the cut-off value of normalcy providing info for non-pharmacological and pharmacological treatments to reduce the cardiovascular risk both in general population and in pathophysiological conditions. This paper overviews the knowledges of the role of resting heart rate as predictor of cardiovascular risk.

Heart rate as cardiovascular risk factor

Heart rate is a parameter that is widely used by the general population as a marker of health. The availability of wearable electronic heart rate monitoring devices and use of specific apps are widely used both at rest and during daily life activities. Resting heart rate values gained more relevance with the evidence of association between elevated heart rate values at rest and diseases and adverse events. Also longitudinal studies demonstrated a clear association between increase in heart rate over time and cardiovascular and all-cause mortality. The increased knowledge of physiological mechanisms of heart rate control and the pathophysiological mechanisms responsible for its dysfunction allows identification of the cutoff value of normalcy. This information can be used to select non-pharmacological and pharmacological interventions to reduce the cardiovascular risk both in the general population and in patients with pathophysiological conditions. This review provides an overview of the current knowledge of resting heart rate as cardiovascular risk factor.

Resting heart rate and the risk of hypertension and heart failure: a dose-response meta-analysis of prospective studies

BACKGROUND

Studies on the relationship of resting heart rate to the risks of hypertension and heart failure have been inconsistent, and the question as to whether there is a linear association between them is unanswered.

OBJECTIVE

To evaluate this possible relationship, we carried out a dose-response meta-analysis of studies that looked at risks associated with resting heart rate and hypertension or heart failure.

METHODS

We searched PubMed, Embase, CNKI and WanFang databases for articles published before 15 June 2017. A random-effect model was used to pool relative risks and 95% confidence intervals. Restricted cubic spline analysis was used to model the resting heart rate-hypertension and heart failure risk association.

RESULTS

We identified 13 and 17 cohort studies for hypertension and heart failure, respectively. The risk for each disease, respectively, increased by 11% relative risk: 1.11 (95% confidence interval: 1.07-1.15) and 19% relative risk: 1.19 (95% confidence interval: 1.13-1.25) for each 10 beats-per-minute increment in resting heart rate. The relationship between resting heart rate and hypertension or heart failure was consistent in most subgroup analyses except for gender subgroups, with no significant association observed in the women subgroup. The results provide no evidence of a nonlinear association of elevated resting heart rate with hypertension and heart failure risk.

CONCLUSION

Resting heart rate shows a linear positive association with the incidence of hypertension and heart failure.

Tachycardia: The hidden cardiovascular risk factor in uncomplicated arterial hypertension

Early detection and management of elevated blood pressure is crucial in reducing the burden of cardiovascular disease (CVD). The importance of an absolute risk assessment and patient risk stratification has been highlighted in the European hypertension guidelines since 2003. Amongst numerous risk factors influencing patient prognosis, elevated heart rate (HR) has been indicated as important predictor of future risk of hypertension, coronary heart disease, sudden cardiac death, heart failure, CVD, stroke, total cancer and mortality. Given that resting HR can be easily determined in clinical practice and modified by lifestyle changes as well as beta-blocker therapy, it seems reasonable that lowering resting HR should be a potential target to reduce disease burden and premature mortality. However, there is a lack of outcome studies of HR lowering in tachycardia-related hypertension. This review outlines the underlying mechanisms of early course hypertension pathophysiology with the critical role of the sympathetic nervous system activation, the prognostic significance of fast HR and the mechanistic rationale for the use of non-pharmacological approaches and/or highly long-acting cardioselective beta-blockers with some consideration given to betaxolol properties.

Prevalence and factors associated with fast resting heart rate in hypertensive and normotensive patients

Background: Fast resting heart rate (RHR) is easily neglected in clinical practice of hypertension treatment.Aims: We aimed to investigate the prevalence of fast RHR and associated factors in hypertensive and normotensive individuals.Methods: We retrospectively analyzed data from two cross-sectional studies conducted in China. A total of 6763 hypertensive patients and 2807 age and sex-matched normotensive subjects with complete data on resting electrocardiogram and medical history were included. Fast RHR was defined as RHR > 85 bpm.Results: The prevalence of fast RHR was higher in hypertensive patients as compared with the normotensives (14.4% vs 7.1%, P < 0.01). In both hypertensive and normotensive subjects, fast RHR appeared as a "U-type" distribution as aging and a "inverted J type" trend as body mass index (BMI) increasing. Multivariate regression analysis showed that fast RHR was associated with age >65 or <25 years old (OR = 1.32, 95% CI 1.08-1.61), BMI <18.5 kg/m² (OR = 2.94, 95%CI 1.47-5.87) and hypercholesterolemia (OR = 1.30, 95%CI 1.10-1.53) in hypertensive patients. Fast RHR in the normotensives was associated with female (OR = 1.78, 95%CI 1.27-2.48), pre-hypertensive state (OR = 2.38, 95%CI 1.61-3.52), and rural area origin (OR = 1.50, 95%CI 1.01-2.42). Stroke and diabetes conferred closer relevance to fast RHR in both hypertensive (OR = 1.31, 95%CI 1.02-1.69 and OR 2.26, 95%CI 1.60-3.21) and normotensive individuals (OR = 2.67, 95%CI 1.36-5.21 and OR = 2.77, 95%CI 1.47-5.23).Conclusion: Fast RHR might be common in patients with hypertension. Prior stroke and diabetes history is common associated with fast RHR. Other factors associated with fast RHR seem to be different between hypertensive patients and normotensive subjects.Abbreviations: BMI: body mass index; CI: Confidence Interval; DBP: diastolic blood pressure; ECG: electrocardiogram; OR: odd ratio; RHR: resting heart rate; SBP: systolic blood pressure.

Interaction of diabetes and smoking on stroke: a population-based cross-sectional survey in China

OBJECTIVES

Diabetes and smoking are known independent risk factors for stroke; however, their interaction concerning stroke is less clear. We aimed to explore such interaction and its influence on stroke in Chinese adults.

DESIGN

Cross-sectional study.

SETTING

Community-based investigation in Xuzhou, China.

PARTICIPANTS

A total of 39 887 Chinese adults who fulfilled the inclusion criteria were included.

METHODS

Participants were selected using a multistage stratified cluster method, and completed self-reported questionnaires on stroke and smoking. Type 2 diabetes mellitus (DM2) was assessed by fasting blood glucose or use of antidiabetic medication. Interaction, relative excess risk owing to interaction (RERI), attributable proportion (AP) and synergy index (S) were evaluated using a logistic regression model.

RESULTS

After adjustment for age, sex, marital status, educational level, occupation, physical activity, body mass index, hypertension, family history of stroke, alcohol use and blood lipids, the relationships between DM2 and stroke, and between smoking and stroke, were still significant: ORs were 2.75 (95% CI 2.03 to 3.73) and 1.70 (95% CI 1.38 to 2.10), respectively. In subjects with DM2 who smoked, the RERI, AP and S values (and 95% CIs) were 1.80 (1.24 to 3.83), 0.52 (0.37 to 0.73) and 1.50 (1.18 to 1.84), respectively.

CONCLUSIONS

The results suggest there are additive interactions between DM2 and smoking and that these affect stroke in Chinese adults.

Heart rate as a predictor of cardiovascular risk

BACKGROUND

Heart rate (HR) is a predictor of cardiovascular, cerebrovascular and all-cause mortality in the general population, as well as in patients with cardio- and cerebrovascular diseases. We aimed to summarize current knowledge regarding the influence of HR on cardio- and cerebrovascular morbidity and mortality.

MATERIALS AND METHODS

PubMed, MEDLINE, Ovid and EMBASE databases were searched for large follow-up studies or meta-analysis published between January 1990 and September 2017 in the English language using the following keyword "heart rate," "resting heart rate," "mortality," "outcome," "hypertension," "heart failure," "ischaemic heart disease," "coronary heart disease" and "stroke."

RESULTS

The relationship between increased HR and cardio- and cerebrovascular morbidity and mortality has been reported in a large number of studies, and the results regarding this association are concurrent. This connection is generally stronger in men than in women. The increase in HR usually occurs in parallel with elevation of blood pressure and metabolic disturbances (insulin resistance, dyslipidaemia). However, even after adjustment for the most important cardiovascular risk factors, HR remained an independent predictor of adverse events in global population or in patients with cardio- and cerebrovascular diseases.

CONCLUSION

HR has an important negative effect on cardio- and cerebrovascular morbidity and mortality. Future longitudinal investigations should clarify HR significance and optimal HR reduction for primary and secondary prevention in cardio- and cerebrovascular events.

Age-dependent sympathetic neural responses to ß1 selective beta-blockade in untreated hypertension-related tachycardia

BACKGROUND

Elevated heart rate (HR) increases cardiovascular morbidity and mortality in hypertension. The impact of beta-blockers on patient prognosis in hypertension is controversial. This study examined the age-related effects of betaxolol on HR, muscle sympathetic nerve activity (MSNA), blood pressure (BP) and sympathovagal balance in untreated males with hypertension and tachycardia.

METHODS

Ten young (age 26 ± 1 years) and seven older (age 50 ± 4 years) males underwent measurement of BP, HR, HR variability (Poincare plot) and MSNA before and after 8 weeks treatment with betaxolol at the initial starting dose of 10 mg/day, which was increased to 20 mg/day once daily after 4 weeks in all subjects.

RESULTS

In younger subjects, betaxolol decreased systolic BP (-13 ± 4 mm Hg, p = .01) and HR (-29 ± 4 bpm, p < .001) but not MSNA (3 ± 3 burst/min., p = 0.47) after 8 weeks. In older subjects a pronounced reduction in BP (-27 ± 7, p = .007) was accompanied by a significant decrease in MSNA (-13 ± 5 burst/min., p < .05) and HR (-17 ± 4 bpm, p = .002). SD1/SD2 ratio of Poincare plot increased in younger (0.36 ± 0.03 vs 0.51 ± 0.05, p = .004), but not in older (0.43 ± 0.08 vs 0.54 ± 0.12, p = .50) subjects.

CONCLUSION

Autonomic neural responses to betaxolol are age-dependent in hypertension-related tachycardia. Betaxolol reduces sympathetic drive to the heart, but not to the peripheral vessels confirming the contribution of augmented cardiac sympathetic activity to disease pathophysiology in younger adults. In older hypertensives, the sympathovagal balance is not influenced by betaxolol. The paradoxical reduction in MSNA despite lowering of BP and HR in older patients may suggest age-related functional decrements in autonomic control and/or inhibitory effects of betaxolol on the central nervous system.

Network pharmacology exploration reveals endothelial inflammation as a common mechanism for stroke and coronary artery disease treatment of Danhong injection

Although Danhong injection (DHI) is the most widely prescribed Chinese medicine for both stroke and coronary artery disease (CAD), its underlying common molecular mechanisms remain unclear. An integrated network pharmacology and experimental verification approach was used to decipher common pharmacological mechanisms of DHI on stroke and CAD treatment. A compound-target-disease & function-pathway network was constructed and analyzed, indicating that 37 ingredients derived from DH (Salvia miltiorrhiza Bge., Flos Carthami tinctorii and DHI) modulated 68 common targets shared by stroke and CAD. In-depth network analysis results of the top diseases, functions, pathways and upstream regulators implied that a common underlying mechanism linking DHI’s role in stroke and CAD treatment was inflammatory response in the process of atherosclerosis. Experimentally, DHI exerted comprehensive anti-inflammatory effects on LPS, ox-LDL or cholesterol crystal-induced NF-κB, c-jun and p38 activation, as well as IL-1β, TNF-α, and IL-10 secretion in vascular endothelial cells. Ten of 14 predicted ingredients were verified to have significant anti-inflammatory activities on LPS-induced endothelial inflammation. DHI exerts pharmacological efficacies on both stroke and CAD through multi-ingredient, multi-target, multi-function and multi-pathway mode. Anti-endothelial inflammation therapy serves as a common underlying mechanism. This study provides a new understanding of DHI in clinical application on cardiovascular and cerebrovascular diseases.

Resting heart rate and the risk of cardiovascular disease, total cancer, and all-cause mortality - A systematic review and dose-response meta-analysis of prospective studies

BACKGROUND AND AIM

Epidemiological studies have reported increased risk of cardiovascular disease, cancer and all-cause mortality with greater resting heart rate, however, the evidence is not consistent. Differences by gender, adjustment for confounding factors, as well as the potential impact of subclinical disease are not clear. A previous meta-analysis missed a large number of studies, and data for atrial fibrillation have not been summarized before. We therefore aimed to clarify these associations in a systematic review and meta-analysis of prospective studies.

METHODS AND RESULTS

PubMed and Embase were searched up to 29 March 2017. Summary RRs and 95% confidence intervals (CIs) were calculated using random effects models. Eighty seven studies were included. The summary RR per 10 beats per minute increase in resting heart rate was 1.07 (95% CI: 1.05-1.10, I² = 61.9%, n = 31) for coronary heart disease, 1.09 (95% CI: 1.00-1.18, I² = 62.3%, n = 5) for sudden cardiac death, 1.18 (95% CI: 1.10-1.27, I² = 74.5%, n = 8) for heart failure, 0.97 (95% CI: 0.92-1.02, I² = 91.4%, n = 9) for atrial fibrillation, 1.06 (95% CI: 1.02-1.10, I² = 59.5%, n = 16) for total stroke, 1.15 (95% CI: 1.11-1.18, I² = 84.3%, n = 35) for cardiovascular disease, 1.14 (95% CI: 1.06-1.23, I² = 90.2%, n = 12) for total cancer, and 1.17 (95% CI: 1.14-1.19, I² = 94.0%, n = 48) for all-cause mortality. There was a positive dose-response relationship for all outcomes except for atrial fibrillation for which there was a J-shaped association.

CONCLUSION

This meta-analysis found an increased risk of coronary heart disease, sudden cardiac death, heart failure, atrial fibrillation, stroke, cardiovascular disease, total cancer and all-cause mortality with greater resting heart rate.

Hypothalamic-pituitary-adrenal-axis dysregulation and double product increases potentiate ischemic heart disease risk in a Black male cohort: the SABPA study

Emotional distress has been associated with a poorer prognosis in myocardial infarction patients. Elevated adrenocorticotrophic hormone (ACTH), lower cortisol, dehydroepiandrosterone sulfate (DHEAS) and cortisol:DHEAS, as measures of emotional distress, might correlate with silent myocardial ischemia (SMI) and workload. Thus, we assessed the relationship between emotional distress, SMI and double product (systolic blood pressure (SBP) × heart rate). Cross-sectional South African biethnic single-set cohorts (N=378), aged 44.7±9.52 years, were investigated. Depressive symptoms (Patient Health Questionnaire-9), anthropometric, fasting blood, 24-h double product and 24-h 2-lead electrocardiogram (ST-segment depression) values were obtained. Blacks, mostly men, had increased depressive symptoms, hyperglycemia, SMI, double product, SBP hypertension and ACTH but lower cortisol, DHEAS and cortisol:DHEAS than their White counterparts. Black men had the highest combined SBP hypertension and below-median cortisol prevalence, 38%, compared with 5.9-13.8% in the other groups. Their SMI was associated with ACTH and cortisol:DHEAS (adj. R² 0.29; β 0.27-0.31 (0.12-0.64); P⩽0.05), double product (adj. R² 0.29; β 0.38 (0.18-0.57); P=0.050) and SBP hypertension (area under the curve: 0.68 (95% CI: 0.56, 0.80); P=0.042; sensitivity/specificity 49/85%). Double product was positively associated with central obesity in all sex groups and with cortisol in the Black men (P<0.05). A dysregulated hypothalamic-pituitary-adrenal-axis (HPAA) showed signs of a hyporesponsive adrenal cortex, suggesting chronic emotional stress in the Black male cohort. In this cohort, HPAA dysregulation and compensatory increases in double product occur as a potential defense mechanism to alleviate perfusion deficits, thereby potentiating ischemic heart disease risk.

Relationship between asymptomatic intra-cranial lesions and brachial-ankle pulse wave velocity in coronary artery disease patients without stroke

Little is known about the significance of asymptomatic intra-cranial lesions (ICL) identified by brain MRI in coronary artery disease (CAD) patients. Silent cerebral lesions are suggested to be associated with arterial stiffness in healthy subjects. We investigated whether subclinical ICL are associated with arterial stiffness and the prognosis in CAD patients without medical history of cerebrovascular diseases. We recruited CAD patients who required percutaneous coronary intervention (PCI), did not meet exclusion criteria, and agreed with MRI before PCI. Subjects were divided into two groups according to the presence of ICL of cerebral microbleeds or lacunar infarction. Arterial stiffness was evaluated by brachial-ankle pulse wave velocity (baPWV). Clinical outcome was defined as a composite of cardiovascular death, non-fatal myocardial infarction, stroke, unstable angina and heart failure. In total, 149 patients underwent brain MRI. Patients with ICL (n=55) had significantly higher baPWV than those without ICL (1591-2204 vs. 1450-1956 cm per sec; P=0.009). A multivariate analysis showed that male sex (odds ratio (OR), 3.15; 95% confidence interval (CI), 1.38-7.20; P=0.006) and baPWV (OR, 1.001; 95% CI, 1.000-1.002; P=0.023) were predictors of ICL. In total, 12 patients experienced a cardiovascular event. The Kaplan-Meier analysis indicated a significantly higher incidence of cardiovascular events in patients with ICL (log-rank test: P=0.018). Multivariate Cox proportional hazards analyses indicated that ICL finding was a significant predictor of clinical outcome (hazard ratio, 3.41; 95% CI, 1.02-11.5; P=0.047). Patients with subclinical ICL had a higher baPWV and worse prognoses than those without ICL.

Comparison of bisoprolol to a metoprolol CR/ZOK tablet for control of heart rate and blood pressure in mild-to-moderate hypertensive patients: the CREATIVE study

This open-label study investigated the long action of bisoprolol compared with metoprolol CR/ZOK for controlling the mean dynamic heart rate (HR) and blood pressure (BP) in patients with mild-to-moderate primary hypertension. Patients from seven centers in China were treated with either bisoprolol 5 mg or metoprolol CR/ZOK 47.5 mg once daily for 12 weeks. The primary end points were the mean dynamic HR reduction and the mean dynamic diastolic BP (DBP) control in the last 4 h of the treatment period. Secondary end points included ambulatory monitoring of the BP and HR, safety and compliance. A total of 186 patients, with 93 patients in each group, were enrolled and analyzed. In the last 4 h of the treatment period, patients receiving bisoprolol demonstrated a significantly greater reduction in the mean dynamic HR compared with patients receiving metoprolol CR/ZOK (least squares means (LSmeans) of difference: -3.79 b.p.m.; 97.5% confidence interval (CI): -7.45, -0.14; P=0.0202). Furthermore, in the last 4 h of the treatment period, bisoprolol demonstrated non-inferiority vs. metoprolol CR/ZOK in lowering the mean dynamic DBP (LSmeans of difference: -1.00; 97.5% CI: -4.79, 2.78; P=0.5495). Bisoprolol further significantly lowered the 24-h mean ambulatory, mean daytime and mean nighttime HR. The overall adverse event rate was similar between the two groups. Noncompliance was reported in 3 (3.53%) and 6 (7.32%) patients in the bisoprolol and metoprolol CR/ZOK groups, respectively. In conclusion, bisoprolol provided superior dynamic HR reduction and non-inferior dynamic BP reduction vs. metoprolol CR/ZOK in patients with mild-to-moderate hypertension. No new safety concerns were found.