Prognostic Value of C-Reactive Protein in Resistant Hypertension

Prognostic impact of fibrinogen in patients with resistant hypertension

In this study, we investigated the long-term prognostic effects of fibrinogen levels in patients with resistant hypertension. A total of 266 patients with resistant hypertension who had serum fibrinogen measurements and 5 years of follow-up information were retrospectively included in the study. The patients were stratified according to their fibrinogen levels, which were then divided into tertiles. Clinical outcomes for major adverse cardiovascular events (MACE) were assessed at 5 years. MACE was defined as all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction (MI), non-fatal stroke, a new diagnosis of heart failure, or hospitalization for heart failure and peripheral arterial disease. The incidence of MACE at 5 years in patients with resistant hypertension was higher in the highest tertile of fibrinogen. Multivariate analysis identified fibrinogen as an independent predictor of MACE in patients with resistant hypertension (odds ratio = 1.002; 95% CI: 1.001-1.004; p = 0.009). Compared to the lowest tertile, MACE was approximately 2.5 times higher in tertile 2 and approximately 6.9 times higher in the highest tertile. Fibrinogen was able to predict MACE in patients with resistant hypertension (AUC for MACE 0.662 (95% CI 0.596-0.727; p < 0.001) based on receiver operating characteristic curve analysis. In the Kaplan-Meier curve showing follow-up without MACE (MACE-free) according to the fibrinogen cut-off value, the 5-year incidence of MACE was significantly higher in the high fibrinogen group (p < 0.001). Fibrinogen is a risk marker for MACE in patients with resistant hypertension. Antihypertensive therapy aimed at lowering fibrinogen levels may improve prognosis.

Low-Grade Inflammation Associated with Major Depression Subtypes: A Cross-Sectional Study

Major depressive disorder (MDD) is associated with inflammation and a high level of comorbidities. Atypical depression (AD) is a MDD subtype based on DSM criteria, that could have specific underlying biological mechanisms. AD is associated with elevated cardiovascular (CVD) comorbidities, higher risk of suicide attempts, hypersomnia, and anxiety disorder. In this study, we aim to investigate if AD and polysomnographic parameters could be associated with low-grade inflammation (LGI). LGI is defined by a range from 3 to 10 mg/L of C-reactive protein levels. We carried out a retrospective cohort study in which 765 individuals with MDD were split into two groups: with and without LGI. Our results exhibit differences between the groups for the polysomnographic parameters, with the LGI group showing parameters already associated with inflammation such as reduced rapid eye movement sleep and elevated hypoxemia markers (identified as CVD risk factor). We found that AD is associated with LGI (OR 1.48; p = 0.047) after adjustment. Likewise, we found an LGI prevalence in AD higher (34.8%) than in MDD without atypical features (26.8%). Overall, these results confirm the low-grade inflammation feature of AD and highlight polysomnographic parameters associated with LGI that could also act as risk factors in this context.

Impact of Intermittent Hypoxia Related to Obstructive Sleep Apnoea Syndrome on Low-Grade Inflammation in Hypertensive Patients: Potential Implications for Cardiovascular Risk

There is evidence for a particular relationship between low-grade inflammation (LGI) and intermittent hypoxia (IH) related to obstructive sleep apnoea syndrome (OSAS). However, despite the potential deleterious cardiovascular consequences associated with this LGI in hypertensive patients, few studies have investigated the impact of IH related to OSAS on CRP levels in this subpopulation. In total, 1404 hypertensive patients were selected retrospectively from the Sleep Laboratory database. CRP levels ≥3 mg/L but <10 mg/L were used as cut-offs to identify hypertensive patients with LGI. Logistic regressions were conducted to examine the risk of LGI associated with IH related to OSAS in hypertensive patients. LGI was frequent (33.8%) in hypertensive patients. After adjustment for confounders, multivariate logistic regressions revealed that only moderate to severe OSAS (apnoea-hypopnoea index ≥ 15/h) with high IH (oxygen desaturation index ≥ 15/h) [OR 1.51 (95% CI 1.06-2.14)] was significantly associated with LGI in hypertensive patients (p-value = 0.045). Consistent with our hypothesis, our results demonstrated the existence of a particular subtype of hypertensive patients at high cardiovascular risk characterised by the presence of LGI induced by IH hypoxia related to moderate to severe OSAS, which justifies the establishment of adequate management of this pathology to allow better cardiovascular prevention in this subpopulation.

Association between Cardiovascular Health, C-Reactive Protein, and Comorbidities in Spanish Urban-Dwelling Overweight/Obese Hypertensive Patients

The relationship between poorer cardiovascular health metrics (CVHM) plus low-grade inflammation (LGI) and hypertension-mediated organ damage (HMOD) and hypertension-related comorbidities (HRC) in hypertensive populations with an overweight/obese (Ow/Ob) hypertension-related phenotype is understudied. We examined the relationship between the CVHM score and the presence of LGI and Ow/Ob hypertension-associated phenotype morbidities and mortality in 243 hypertensive patients from an urban primary care center. We recorded the baseline CVHM score plus clinical data, including hs-C-reactive protein (CRP) and prevalent and incident HMOD-HRC and death. A total of 26 (10.7%) had a body mass index (BMI) < 25 kg/m², 95 (31.1%) were overweight (BMI 25-29.9 kg/m²), and 122 (50.2%) were obese (BMI ≥ 30 kg/m²). There were 264 cases of HMOD-HRC and 9 deaths. Higher hs-CRP levels were observed as BMI increased. Linear regression analysis showed a significant correlation between BMI and hs-CRP, adjusted for confounders. Additionally, individuals with a higher hs-CRP tertile had a significant increase in BMI. Significantly lower log hs-CRP levels were found as the number of ideal CVHM scores rose. Multivariate binary logistic regression found the risk of HMOD-HRC increased significantly as the ideal CVHM scores decreased, and hs-CRP levels also correlated with HMOD-HRC in the whole cohort and in the Ow and Ob subpopulations. These findings highlight the need for early intervention targeting ideal CVHMs among hypertensive individuals with an Ow/Ob phenotype in order to attenuate the inflammatory state and prevent cardiovascular disease.

Relationships between Easily Available Biomarkers and Non-Dipper Blood Pressure Pattern in Patients with Stable Coronary Artery Disease

Introduction. Chronic inflammation plays an essential role in the pathophysiology of both arterial hypertension (HTN) and coronary artery disease (CAD), and is more pronounced in individuals with a non-dipper circadian blood pressure (BP) pattern. A non-dipping BP pattern is in turn is associated with increased cardiovascular morbi-mortality, and a higher risk of atherosclerotic events. Neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR) and platelet to lymphocyte ratio (PLR) are readily available predictors of systemic inflammation and cardiovascular risk. The purpose of our study is to evaluate whether NLR, MLR and PLR can be used as cost-effective predictors of a non-dipping blood pressure pattern in hypertensive patients with stable CAD. Materials and Methods: We performed a cross-sectional retrospective analysis that included 80 patients with hypertension and stable CAD (mean age 55.51 ± 11.83 years, 71.3% male) referred to a cardiovascular rehabilitation center. All patients underwent clinical examination, 24 h ambulatory blood pressure monitoring (ABPM) and standard blood analysis. Results: Baseline demographic characteristics were similar in both groups. Patients with non-dipper pattern had significantly higher NLR (median = 2, IR (2–3), p < 0.001), MLR (median = 0.31, IR (0.23–0.39), p < 0.001) and PLR (median = 175, IR (144–215), p < 0.001) compared to dippers. Conclusion: Our results suggest that MLR and PLR are inexpensive and easily accessible biomarkers that predict a non-dipping pattern in hypertensive patients with stable CAD.

FEATURES OF THE DAILY PROFILE OF ARTERIAL BLOOD PRESSURE IN PATIENTS WITH RHEUMATOID ARTHRITIS IN COMBINATION WITH ARTERIAL HYPERTENSION

OBJECTIVE

The aim: To determine the features of daily shifts in blood pressure (BP), the influence of the presence of rheumatoid arthritis (RA) on BP control and identify factors that affect BP among patients with RA in combination with resistant hypertension (RH).

PATIENTS AND METHODS

Materials and methods: All material for writing this scientific work were the results of a comprehensive survey of 201 people with RH and RA, hypertension (H) and RA, RA without H, H without RA and relatively healthy individuals. A laboratory study was performed: rheumatoid factor, C-reactive protein (CRP), K+ serum, and creatinine levels. All patients underwent office BP measurement and ambulatory BP monitoring for 24 hours. Statistical processing of the study results was carried out using "IBM SPSS Statistics 22".

RESULTS

Results: Among patients with RA in combination with RH non-dippers (38.7%) are the most common type of BP profile. Patients with RH in combination with RA are characterized by an increase in BP more at night (p <0.003), which corresponds to the high frequency of night-peackers (17.7%). The presence of RA determines worse control of diastolic BP (p <0.01) and more vascular overload on organs and systems during the night (p <0.05).

CONCLUSION

Conclusions: An increase in BP in patients with RA in combination with RH is more significant at night, characterized by poorer BP control and greater vascular load at night indicating the need for tighter control of BP during sleep. Non-dippers are most often detected among patients with RA in combination with RH, which is prognostically unfavorable for the development of nocturnal "vascular accidents".

Advanced lung cancer inflammation index is associated with long-term cardiovascular death in hypertensive patients: national health and nutrition examination study, 1999-2018

Background: Hypertension is one of the main causes of cardiovascular death. Inflammation was considered influential factors of cardiovascular (CVD) death in patients with hypertension. Advanced lung cancer inflammation index (ALI) is an index to assess inflammation, few studies have investigated the relationship between advanced lung cancer inflammation index and cardiovascular death in hypertensive patients. Objective: The aim of this study was to investigate the association between advanced lung cancer inflammation index and long-term cardiovascular death in hypertensive patients. Method: Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 with mortality follow-up through 31 December 2019 were analyzed. Advanced lung cancer inflammation index was calculated as BMI (kg/㎡) × serum albumin level (g/dL)/neutrophil to lymphocyte ratio (NLR). A total of 20,517 participants were evaluated. Patients were divided into three groups based on tertiles of advanced lung cancer inflammation index as follows: T1 (n = 6,839), T2 (n = 6,839), and T3 (n = 6,839) groups. The relationship between advanced lung cancer inflammation index and long-term cardiovascular death was assessed by survival curves and Cox regression analysis based on the NHANES recommended weights. Results: The median advanced lung cancer inflammation index value in this study was 61.9 [44.4, 84.6]. After full adjustment, the T2 group (hazard ratio [HR]: 0.59, 95% confidence interval [CI]: 0.50-0.69; p < 0.001) and T3 group (HR: 0.48, 95% CI: 0.39-0.58; p < 0.001) were found to have a significantly lower risk of cardiovascular death compared to the T1 group. Conclusion: High levels of advanced lung cancer inflammation index were associated with reduced risk of cardiovascular death in hypertensive patients.

The relationship between the pan-immune-inflammation value and long-term prognoses in patients with hypertension: National Health and Nutrition Examination Study, 1999-2018

Background

Direct antihypertensive therapy in hypertensive patients with a high CVD risk can reduce the incidence of cardiovascular death but increase adverse cardiovascular events, so additional ways to identify hypertensive patients at high risk may be needed. Studies have shown that immunity and inflammation affect the prognoses of patients with hypertension and that the pan-immune-inflammation value (PIV) is an index to assess immunity and inflammation, but few studies have applied the PIV index to patients with hypertension.

Objective

To explore the relationship between the PIV and long-term all-cause and cardiovascular mortality in patients with hypertension.

Method

Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 with a mortality follow-up through December 31, 2019, were analyzed. A total of 26,781 participants were evaluated. The patients were grouped based on PIV levels as follows: T1 group (n = 8,938), T2 group (n = 8,893), and T3 group (n = 8,950). The relationship between the PIV and long-term all-cause and cardiovascular death was assessed by survival curves and Cox regression analysis based on the NHANES recommended weights.

Result

The PIV was significantly associated with long-term all-cause and cardiovascular mortality in patients with hypertension. After full adjustment, patients with higher PIV have a higher risk of all-cause [Group 3: HR: 1.37, 95% CI: 1.20-1.55, p < 0.001] and cardiovascular [Group 3: HR: 1.62, 95% CI: 1.22-2.15, p < 0.001] mortality.

Conclusion

Elevated PIV was associated with increased all-cause mortality and cardiovascular mortality in hypertensive patients.

Relationship between the prognostic nutritional index and resistant hypertension in patients with essential hypertension

OBJECTIVES

Immune system activation plays a role in resistant hypertension (RHTN) pathogenesis. The clinical effect of the prognostic nutritional index (PNI) on patients with RHTN remains unclear. The aim of this study investigated the possible correlation between PNI and RHTN.

METHODS

In this cross-sectional study, we enrolled 180 adult subjects. In patients were classified into three groups according to their office and ambulatory blood pressure measurements (ABPM): RHTN (n = 60), controlled hypertension (CHTN, n = 60), and normotension-control (NT-C, n = 60). RHTN was defined as BP ≥140/90 mm Hg while taking ≥3 antihypertensive medications or BP <140/90 mm Hg while taking ≥4 medications. The PNI was calculated from the 10 x serum albumin (g/dL) + 0.005 x total lymphocyte count (/μL) formula.

RESULTS

Office and ABPM were significantly higher in patients with RHTN. Patients in the RHTN (46.1 ± 5.3) had significantly lower PNI than that in the CHTN (54.9 ± 6.7) (P = .032), and PNIs of both hypertensive groups were significantly lower than the NT-C group (P = .019, for both). The ROC curve analysis performed to assess the predictive value of PNI for RHTN and using 50.9 optimal cutoff value of PNI for RHTN gave a sensitivity of 77% and a specificity of 68.5% (AUC = 0.73, 95% CI 0.69-0.96).Multivariate analysis indicated diabetes, 24-h ABPM SBP, CRP, pill burden, and PNI (<51.6) as independent predictors of RHTN.

CONCLUSION

This study showed that the level of PNI was significantly lower in patients with RHTN compared to patients with CHTN. PNI is independently related to RHTN.

Impaired l-arginine-nitric oxide pathway contributes to the pathogenesis of resistant hypertension

The precise mechanisms underlying resistant hypertension remain elusive. Reduced nitric oxide (NO) bioavailability is frequently documented in chronic kidney disease, obesity, diabetes and advanced age, all of which are risk factors for resistant hypertension. Sympathetic overactivity and chronic activation of the renin-angiotensin system are salient features of resistant hypertension. Interestingly, recent data indicate that renal sympathetic overactivity can reduce the expression of neuronal nitric oxide synthase in the paraventricular nucleus. Reduced NO levels in the paraventricular nucleus can increase sympathetic outflow and this can create a vicious cycle contributing to resistant hypertension. Angiotensin II can reduce l-arginine transport and hence NO production. Reduced NO levels may reduce the formation of angiotensin 1-7 dampening the cardio-protective effects of the renin-angiotensin system contributing to resistant hypertension. In addition, interleukin-6 (IL-6) is demonstrated to be independently associated with resistant hypertension, and IL-6 can reduce NO synthesis. Despite this, NO levels have not been quantified in resistant hypertension. Findings from a small proof of concept study indicate that NO donors can reduce blood pressure in patients with resistant hypertension but more studies are required to validate these preliminary findings. In the present paper, we put forward the hypothesis that reduced NO bioavailability contributes substantially to the development of resistant hypertension.

Evaluation of Molecularly Imprinted Polymers for Point-of-Care Testing for Cardiovascular Disease

Molecular imprinting is a rapidly growing area of interest involving the synthesis of artificial recognition elements that enable the separation of analyte from a sample matrix and its determination. Traditionally, this approach can be successfully applied to small analyte (<1.5 kDa) separation/ extraction, but, more recently it is finding utility in biomimetic sensors. These sensors consist of a recognition element and a transducer similar to their biosensor counterparts, however, the fundamental distinction is that biomimetic sensors employ an artificial recognition element. Molecularly imprinted polymers (MIPs) employed as the recognition elements in biomimetic sensors contain binding sites complementary in shape and functionality to their target analyte. Despite the growing interest in molecularly imprinting techniques, the commercial adoption of this technology is yet to be widely realised for blood sample analysis. This review aims to assess the applicability of this technology for the point-of-care testing (POCT) of cardiovascular disease-related biomarkers. More specifically, molecular imprinting is critically evaluated with respect to the detection of cardiac biomarkers indicative of acute coronary syndrome (ACS), such as the cardiac troponins (cTns). The challenges associated with the synthesis of MIPs for protein detection are outlined, in addition to enhancement techniques that ultimately improve the analytical performance of biomimetic sensors. The mechanism of detection employed to convert the analyte concentration into a measurable signal in biomimetic sensors will be discussed. Furthermore, the analytical performance of these sensors will be compared with biosensors and their potential implementation within clinical settings will be considered. In addition, the most suitable application of these sensors for cardiovascular assessment will be presented.

A Proposed Inflammatory Score of Circulating Cytokines/Adipokines Associated with Resistant Hypertension, but Dependent on Obesity Parameters

Background

There is evidence that subclinical systemic inflammation is present in resistant hypertension (RHTN).

Objective

The aim of the study was to develop an integrated measure of circulating cytokines/adipokines involved in the pathophysiology of RHTN.

Methods

RHTN (n = 112) and mild to moderate hypertensive (HTN) subjects (n=112) were studied in a cross-sectional design. Plasma cytokines/adipokines (TNF-alpha, interleukins [IL]-6, -8, -10, leptin and adiponectin) values were divided into tertiles, to which a score ranging from 1 (lowest tertile) to 3 (highest tertile) was assigned. The inflammatory score (IS) of each subject was the sum of each pro-inflammatory cytokine scores from which anti-inflammatory cytokines (adiponectin and IL-10) scores were subtracted. The level of significance accepted was alpha = 0.05.

Results

IS was higher in RHTN subjects compared with HTN subjects [4 (2-6) vs. 3 (2-5); p = 0.02, respectively]. IS positively correlated with body fat parameters, such as body mass index (r = 0.40; p < 0.001), waist circumference (r = 0.30; p < 0.001) and fat mass assessed by bioelectrical impedance analysis (r = 0.31; p < 0.001) in all hypertensive subjects. Logistic regression analyses revealed that IS was an independent predictor of RHTN (OR = 1.20; p = 0.02), independent of age, gender and race, although it did not remain significant after adjustment for body fat parameters.

Conclusion

A state of subclinical inflammation defined by an IS including TNF-alpha, IL-6, IL-8, IL-10, leptin and adiponectin is associated with obese RHTN. In addition, this score correlates with obesity parameters, independently of hypertensive status. The IS may be used for the evaluation of conditions involving low-grade inflammation, such as obesity-related RHTN. Indeed, it also highlights the strong relationship between obesity and inflammatory process.

Exposure to Parental Smoking in Childhood is Associated with High C-Reactive Protein in Adulthood: The Cardiovascular Risk in Young Finns Study

Aim: Children exposed to parental smoking are at increased long-term risk of subclinical atherosclerosis in adulthood. However, it has not been quantified if exposure to parental smoking in childhood is associated with adult systemic inflammation. This study aimed to determine if childhood exposure to parental smoking was associated with high-sensitivity C-reactive protein (hsCRP) in adulthood.

Methods: This longitudinal analysis of 2,511 participants used data from the Cardiovascular Risk in Young Finns Study, a prospective cohort of Finnish children. In 1980 or 1983, parents self-reported their smoking status and serum hsCRP was collected up to 31 years later in adulthood.

Results: Compared with children with non-smoking parents, the relative risk of developing high hsCRP (> 3 mg/L) in adulthood increased among those with 1 or both parents who smoked [relative risk (RR), 1.3; 95%confidence interval (CI), 1.0–1.8] after adjustment for socioeconomic status, cardiovascular risk factors, and smoking status in childhood and adulthood. Moreover, children exposed to mother smoking [RR, 2.4; 95% CI, 1.3–4.2] had highest risk of developing high hsCRP in adulthood compared with those exposed to father smoking [RR, 1.6; 95% CI, 1.2–2.3] and both parents smoking [RR, 1.4; 95% CI, 0.9–2.0].

Conclusion: Our findings suggest that children exposed to parental smoking are at increased risk of having high hsCRP in adulthood. Limiting children's exposure to passive smoking may have long-term benefits on general low-grade inflammation.

Prognostic Importance of C-Reactive Protein in High Cardiovascular Risk Patients With Type 2 Diabetes Mellitus: The Rio de Janeiro Type 2 Diabetes Cohort Study

Background

The prognostic value of C‐reactive protein (CRP) is controversial in type 2 diabetes mellitus. We aimed to assess it in a cohort of high cardiovascular risk diabetic patients.

Methods and Results

CRP was measured at baseline and during the second year of follow‐up in 616 patients. The primary end points were a composite of total fatal and nonfatal cardiovascular events (CVEs), major CVEs, and all‐cause and cardiovascular mortalities. Association between baseline and second‐year CRP with end points were evaluated by multivariable Cox survival analyses. Baseline median CRP was 2.8 mg/L (interquartile range: 1.2–6.0 mg/L), and 47.8% of the patients either increased or persisted with high CRP levels during the first 2 years of follow‐up. After a median follow‐up of 8.4 years, 131 total CVEs occurred (89 major CVEs), and 129 patients died (53 of cardiovascular causes). Baseline and second‐year CRP, analyzed as a continuous variable and dichotomized at >3.0 mg/L, were significantly associated with total and major CVEs occurrence (with adjusted hazard ratios between 1.22 and 1.34 for increments of 1‐SD log of continuous CRP, and between 1.47 and 1.89 for dichotomized CRP), but not with mortality. Additionally, increasing CRP levels or persisting with high levels were associated with a 1.84 (95% CI: 1.10–3.06) excess risk of major CVEs, independent of baseline CRP values.

Conclusions

Baseline and serial changes in CRP levels provide cardiovascular risk prediction independent of standard risk factors and glycemic control, and may be useful to refine cardiovascular risk stratification in high‐risk patients with type 2 diabetes mellitus.