Additional impact of morning haemostatic risk factors and morning blood pressure surge on stroke risk in older Japanese hypertensive patients

Impaired endogenous fibrinolysis status: a potential prognostic predictor in ischemic stroke

Stroke confers a severe global healthcare burden, hence exploring risk factors for stroke occurrence and prognosis is important for stroke prevention and post-stroke management strategies. Endogenous fibrinolysis is a spontaneous physiological protective mechanism that dissolves thrombus to maintain vascular patency. Recently, impaired endogenous fibrinolysis has been considered as a potential novel cardiovascular risk factor, but its link with ischaemic stroke in the past has been underappreciated. In this review, we summarize the latest mechanisms of endogenous fibrinolysis, review the current evidence and data on endogenous fibrinolysis in ischemic stroke. It includes the structure of thrombus in ischemic stroke patients, the effect of fibrin structure on the endogenous fibrinolytic efficiency, and the association between intravenous thrombolytic therapy and endogenous fibrinolysis in ischemic stroke. It also includes the single factors (tissue plasminogen activator, urokinase plasminogen activator, plasminogen activator inhibitor-1, thrombin activatable fibrinolysis inhibitor, complement component 3, complement component 5, alpha-2-antiplasmin, plasmin-alpha-2-antiplasmin complex, and lipoprotein[a]), and the global assessments of endogenous fibrinolysis status (thromboelastography, rotational thromboelastometry, and global thrombosis test), and their potential as predictors to identify occurrence or unfavorable functional outcomes of ischemic stroke. All of these assessments present advantages and limitations, and we suggest that the global thrombosis test may be more appropriate for detecting impaired endogenous fibrinolysis status in ischemic stroke patients.

Mediating effect of subclinical inflammation on the process of morning hypertension leading to atrial fibrillation in community-based older adults

BACKGROUND

The impacts and mechanisms of morning hypertension (MHT) on the risk of new-onset atrial fibrillation (AF) in the elderly have not been clarified. We aimed to investigate an association between MHT and new-onset AF and explore a mediating effect of subclinical inflammation on this association.

METHODS

From 2008 to 2010, 1789 older adults aged ≥60 years were recruited in Shandong area, China. Morning blood pressure (BP) was assessed using 24-hour ambulatory BP monitoring. MHT was defined as BP ≥ 135/85 mm Hg during the period from wake time to 0900 a.m. Subclinical inflammation was assessed by hypersensitive C-reactive protein (hsCRP), tumor necrosis factor-alpha (TNF-α), systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and galectin-3. New-onset AF was rated during the follow-up period.

RESULTS

Over an average 129.0 [standard deviation (SD): 21.58] months of follow-up, the hazard ratio of new-onset AF in MHT patients was 1.39 (95% confidence interval: 1.01 to 1.91) compared with non-MHT participants (Padjusted = 0.027). The risk of new-onset AF was 1.17-fold with one-SD increment of morning systolic BP. Subclinical inflammation was significantly associated with new-onset AF. The hazard ratios of new-onset AF were 2.29, 2.04, 2.08, 2.08, 2.03, and 3.25 for one-SD increment in hsCRP, TNF-α, SII, NLR, PLR, and galectin-3, respectively (Padjusted < 0.001). The analysis showed that hsCRP, TNF-α, SII, NLR, PLR, and galectin-3 separately mediated the process of MHT inducing new-onset AF (Padjusted < 0.05).

CONCLUSIONS

MHT is associated with an increased risk of new-onset AF. The subclinical inflammation might play a mediating role in this association.

Different Factors Associated with Morning Blood Pressure Surge in Antihypertensive-Naïve Dipper and Non-Dipper Subjects

The relationship between the morning blood pressure surge (MBPS) and cardiovascular risk is inconclusive. Previous studies have not taken into consideration dipping status in examining the MBPS and its associated factors. The aim was to examine factors associated with the MBPS in dippers and non-dippers. The MBPS was calculated by data obtained from ambulatory blood pressure monitoring, using the definition of sleep-trough morning surge. Dipping systolic blood pressure (DipSBP) was defined as [1 - (SBPsleeping/SBPawake)] × 100%. The value in milliseconds of standard deviation of normal-to-normal RR interval after waking up (SDNNaw) was calculated during the 2 h period after waking up. A total of 140 eligible subjects were divided into dippers (n = 62) and non-dippers (n = 78). Multiple regression analysis on data for all subjects revealed different correlations with the MBPS: positive in age, body mass index (BMI), and DipSBP, and inverse in cholesterol/high density lipoprotein-cholesterol (HDL-C) ratio, fasting blood glucose, and 2 h SDNNaw. When dippers were examined separately, age, female gender, and BMI correlated positively with MBPS, while cholesterol/HDL-C ratio and 2 h SDNNaw correlated negatively. For non-dippers, only age was associated with the MBPS. The factors associated with the MBPS were different for dippers and non-dippers. The MBPS seems to be a physiological response in this dipper group because age and BMI correlated positively with the MBPS, while parasympathetic neural activity after waking up and cholesterol/HDL-C ratio showed inverse correlations.

Epigenetic and integrative cross-omics analyses of cerebral white matter hyperintensities on MRI

Cerebral white matter hyperintensities on MRI are markers of cerebral small vessel disease, a major risk factor for dementia and stroke. Despite the successful identification of multiple genetic variants associated with this highly heritable condition, its genetic architecture remains incompletely understood. More specifically, the role of DNA methylation has received little attention. We investigated the association between white matter hyperintensity burden and DNA methylation in blood at ∼450 000 cytosine-phosphate-guanine (CpG) sites in 9732 middle-aged to older adults from 14 community-based studies. Single CpG and region-based association analyses were carried out. Functional annotation and integrative cross-omics analyses were performed to identify novel genes underlying the relationship between DNA methylation and white matter hyperintensities. We identified 12 single CpG and 46 region-based DNA methylation associations with white matter hyperintensity burden. Our top discovery single CpG, cg24202936 (P = 7.6 × 10-8), was associated with F2 expression in blood (P = 6.4 × 10-5) and co-localized with FOLH1 expression in brain (posterior probability = 0.75). Our top differentially methylated regions were in PRMT1 and in CCDC144NL-AS1, which were also represented in single CpG associations (cg17417856 and cg06809326, respectively). Through Mendelian randomization analyses cg06809326 was putatively associated with white matter hyperintensity burden (P = 0.03) and expression of CCDC144NL-AS1 possibly mediated this association. Differentially methylated region analysis, joint epigenetic association analysis and multi-omics co-localization analysis consistently identified a role of DNA methylation near SH3PXD2A, a locus previously identified in genome-wide association studies of white matter hyperintensities. Gene set enrichment analyses revealed functions of the identified DNA methylation loci in the blood-brain barrier and in the immune response. Integrative cross-omics analysis identified 19 key regulatory genes in two networks related to extracellular matrix organization, and lipid and lipoprotein metabolism. A drug-repositioning analysis indicated antihyperlipidaemic agents, more specifically peroxisome proliferator-activated receptor-alpha, as possible target drugs for white matter hyperintensities. Our epigenome-wide association study and integrative cross-omics analyses implicate novel genes influencing white matter hyperintensity burden, which converged on pathways related to the immune response and to a compromised blood-brain barrier possibly due to disrupted cell-cell and cell-extracellular matrix interactions. The results also suggest that antihyperlipidaemic therapy may contribute to lowering risk for white matter hyperintensities possibly through protection against blood-brain barrier disruption.

The relationship between morning blood pressure surge and asymptomatic episodes of paroxysmal atrial fibrillation in patients with systemic arterial hypertension

BACKGROUND

Hypertension is a known risk factor for developing atrial fibrillation. However, there is limited data to investigate the association between morning blood pressure surge (MBPS) and paroxysmal atrial fibrillation (PAF). We conducted the present study to determine whether there is a relationship between asymptomatic PAF and MBPS and whether MBPS may be a predictor of asymptomatic PAF episodes.

METHODS

This prospective study comprised 264 adult patients who were newly diagnosed with essential hypertension or were previously diagnosed but not receiving regular antihypertensive therapy. We evaluated the patients in 2 groups according to their 24-h electrocardiography monitoring results: group 1 included patients who exhibited PAF (n = 32, 23 females/9 males; mean age 60.2 ± 7.4 years) and group 2 included patients with no signs of PAF as a control group (n = 232, 134 females/98 males; mean age 56.9 ± 9.4 years). We calculated the MBPS as the difference between mean systolic blood pressure (SBP) in the 2 h after getting up and the minimum nocturnal SBP.

RESULTS

: MBPS values were significantly higher in group 1 than in group 2 (35.3 ± 7.0 vs. 22.0 ± 6.7, p < 0.001). MBPS was positively associated with left atrial diameter (LAD) (r = 0.441, p < 0.001), left ventricle mass index (LVMI) (r = 0.235, p < 0.001), the ratio of early (E) peak of mitral inflow velocity to early (Em) diastolic mitral annular velocity (E / Em) (r = 0.239, p < 0.001), 24-h mean (r = 0.270, p < 0.001) and daytime SBP (r = 0.291, p < 0.001). We determined a cut-off value for MBPS as 28.6 for predicting PAF episodes development and identified LAD and MBPS as independent risk factors for PAF.

DISCUSSION

Patients who had larger MBPS were observed to have higher PAF incidence. MBPS values may be sensitive in predicting asymptomatic episodes of paroxysmal atrial fibrillation.

Cerebral Small Vessel Disease: Neuroimaging Features, Biochemical Markers, Influencing Factors, Pathological Mechanism and Treatment

Cerebral small vessel disease (CSVD) is the most common chronic vascular disease involving the whole brain. Great progress has been made in clinical imaging, pathological mechanism, and treatment of CSVD, but many problems remain. Clarifying the current research dilemmas and future development direction of CSVD can provide new ideas for both basic and clinical research. In this review, the risk factors, biological markers, pathological mechanisms, and the treatment of CSVD will be systematically illustrated to provide the current research status of CSVD. The future development direction of CSVD will be elucidated by summarizing the research difficulties.

Comparison of the antihypertensive efficacy of morning and bedtime dosing on reducing morning blood pressure surge: A protocol for systemic review and meta-analysis

BACKGROUND

It is well known that morning blood pressure surge increases the risk of myocardial events in the first several hours post-awakening. This meta-analysis was performed to compare the antihypertensive efficacy of morning and bedtime dosing on decreasing morning blood pressure surge.

METHODS

Articles in 4 databases about clinical trials of ingestion time of antihypertensive drugs were searched and performed a meta-analysis to evaluate the different effects on morning blood pressure and absolute blood pressure (BP) reduction from baseline of between bedtime administration (experimental group) and morning awaking administration (control group).

RESULTS

The aim of this study is to compare the antihypertensive efficacy of morning and bedtime dosing on decreasing morning blood pressure surge.

CONCLUSIONS

The bedtime will provide evidence support for clinicians and patients for reducing morning blood pressure surge.

ETHICS AND DISSEMINATION

This study does not require ethical approval.

Association of Circadian Rhythm of Blood Pressure and Cerebral Small Vessel Disease in Community-Based Elderly Population

BACKGROUND

Although it is accepted that the etiology of cerebral small vessel disease (CSVD) is associated with cardiovascular risk factors, the association between CSVD and the circadian rhythm of blood pressure (BP) is unclear. We aimed to determine if such an association existed in the elderly population.

METHOD

White matter hyperintensities (WMHs), lacunes, microbleeds, nocturnal dipping pattern (NDP), and morning surge in systolic blood pressure (SBP) were assessed in 2,091 participants ≥60 years of age.

RESULTS

During an average of 63 months of follow-up, WMH and the WMH-to-intracranial volume ratio were significantly increased in extreme dippers, nondippers, and reverse dippers than those in dippers (p < .001). For new-incident Fazekas scale ≥2, the hazard ratios were 1.77 (95% confidence interval [CI], 1.09-2.86) for extreme dippers, 2.20 (95% CI, 1.48-3.28) for nondippers, and 2.43 (95% CI, 1.59-3.70) for reverse dippers compared with dippers, and 1.04 (95% CI, 0.81-1.35) for higher morning surge compared with lower morning surge. Nondippers and reverse dippers were associated with higher risks of new-incident lacunes and microbleeds than dippers (p < .05). Higher morning surge was associated with a higher risk of new-incident microbleeds than lower morning surge (p < .05).

CONCLUSION

NDPs in SBP played an important role in CSVD, and the morning surge in SBP was associated with cerebral microbleeds in community-based elderly population beyond the average SBP level.

Combination therapy with an Xa inhibitor and antihypertensive agent improved anticoagulant activity in patients with nonvalvular atrial fibrillation: the hypertension and atrial fibrillation treated by rivaroxaban for the morning and night with sYnergy with calcium antagonists (HARMONY) study

Background: Anticoagulant activity and blood pressure increase in the morning. The aim of this study was to evaluate changes of anticoagulant activity, blood pressure and target organ damage in patients with nonvalvular atrial fibrillation (AF) given combination treatment with Xa inhibitor and antihypertensive agent.Methods: We enrolled 72 patients with nonvalvular AF. Rivaroxaban (10-15 mg) was continuously administered once daily over 8 weeks (study period I). For subjects (n = 50) who exhibited uncontrolled morning hypertension (home systolic blood pressure [SBP]≥125 mmHg) at the end of study period I (at 8 weeks), nifedipine CR (20-40 mg) was added at bedtime, and rivaroxaban administration was continued an additional 8 weeks. We assessed prothrombin fragment 1 + 2 (optimal range: 69-229 pmol/L) and D-dimer (negative D-dimer measurement: <1.0 μg/mL).Results: The percentage of patients with optimal-range prothrombin fragment 1 + 2 was significantly increased at 4 weeks compared to baseline (70.8% vs. 86.1%, p = .033). In period II, office and home morning SBP were reduced at 12 compared to 8 weeks (office SBP: 135.2 ± 15.7 vs. 125.6 ± 18.4mmHg, p < .001; home morning SBP: 133.5 ± 10.5 vs. 119.9 ± 12.1mmHg, p<.001).The percentage of patients with negative D-dimer  was increased at 8 weeks compared to baseline (92% vs. 100%, p = .044), and remained at 100% at 16 weeks.Conclusions: Xa inhibitor therapy improved anticoagulant activity, and additional antihypertensive therapy maintained the anticoagulant activity in patients with nonvalvular AF.

Effect of morning blood pressure peak on early progressive ischemic stroke: a prospective clinical study

OBJECTIVE

To prospectively evaluate the effect of morning blood pressure peak (MBPP) on early progressive ischemic stroke (EPIS).

PATIENTS AND METHODS

A total of 135 patients with acute ischemic stroke were enrolled and completed all assessments. The patients were divided into EPIS group and non-EPIS group, with 22 and 113 cases in each group, respectively, according to the assessment of Scandinavian stroke scale within three days after onset. All cases received conventional treatment for stroke and its risk factors. 24 -h dynamic blood pressure monitoring was performed within 24 h after admission. Based on the 24 -h mean blood pressure, MBPP, morning blood pressure, and other risk factors for EPIS, we conducted a logistic regression analysis to evaluate whether MBPP was an independent risk factor for EPIS.

RESULTS

Mean systolic blood pressure, systolic and diastolic MBPP, morning systolic and diastolic blood pressure were all significantly higher in EPIS group than in non-EPIS group (p = 0.037, p = 0.001, p = 0.035, p = 0.003, p = 0.042, respectively). Logistic regression analysis showed that MBPP was an independent risk factor for EPIS (OR = 1.057, 95% CI 1.014-1.102, p = 0.009). Further stratified analysis showed that incidences of EPIS in patients with elevated MBPP combined with large artery atherosclerosis or small artery occlusion were comparable (41.2% vs. 25.0%, p = 0.367), and the systolic MBPP was significantly higher in morning EPIS group than in non-morning EPIS group (p = 0.041).

CONCLUSION

Elevated systolic MBPP might be an independent risk factor for EPIS, and play a more obvious effect on EPIS manifesting in the morning especially.

Olmesartan with azelnidipine versus with trichlormethiazide on home blood pressure variability in patients with type II diabetes mellitus

The aim of the present study was to compare the effects of olmesartan combined with azelnidipine versus olmesartan combined with trichlormethiazide, on home blood pressure (BP) and pressure variability in type II diabetes mellitus patients using home BP telemonitoring system. We performed an open-label cross-over pilot study of 28 patients with type II diabetes mellitus. Patients received combination treatment with either olmesartan 20 mg plus azelnidipine 16 mg or olmesartan 20 mg plus trichlormethiazide 1 mg for more than 6 weeks each in a cross-over method. The coefficient of morning systolic BP variability in the olmesartan plus azelnidipine group was significantly lower than that in the olmesartan plus trichlormethiazide group (6.4 ± 1.9 vs. 7.5 ± 2.6, P = .004). There were no significant differences in mean morning systolic BP between the two groups. Using home BP telemonitoring for hypertensive patients with type II diabetes, this study revealed for the first time that the olmesartan with azelnidipine combination is superior to the olmesartan with trichlormethiazide combination in reducing home BP variability.

Resveratrol improves delayed r-tPA treatment outcome by reducing MMPs

OBJECTIVES

Although recombinant tissue plasminogen activator (r-tPA) is currently the most effective treatment for brain ischemic stroke, the 3-h narrow therapeutic windows severely limits its clinical efficacy. We aim to investigate the effect of resveratrol on improving treatment outcomes of delayed r-tPA administration.

MATERIALS & METHODS

Patients were randomly divided according to their onset-to-treatment time (OTT), as early OTT or delayed OTT. Then, they were either treated with r-tPA + placebo or with r-tPA + resveratrol. Twenty-four hours after the treatment, outcomes were assessed with NIH stroke scale (NIHSS), and plasma levels of MMP-2 and MMP-9 were also examined with ELISA.

RESULTS

In patients receiving delayed r-tPA treatment, co-administration of resveratrol significantly improves their treatment outcomes compared with those receiving placebo, as indicated by improved NIHSS scores. This improved outcome was be caused by resveratrol-induced reduction in plasma levels of both matrix metalloproteinase (MMP)-2 and MMP-9, as a positive correlation was observed between reductions in both MMPs and patient NIHSS scores.

CONCLUSIONS

Resveratrol could be potentially administered as an adjuvant with r-tPA treatment, which extends the clinical therapeutic window of r-tPA, therefore improving the outcome of patients receiving late stroke treatment.

Morning Blood Pressure Surge, Dipping, and Risk of Coronary Events in Elderly Treated Hypertensive Patients

BACKGROUND

The independent prognostic significance of morning surge (MS) of blood pressure (BP) is not yet clear. We investigated the association between MS of systolic BP and risk of coronary events in elderly treated hypertensive patients.

METHODS

The occurrence of coronary events was evaluated in 1,191 elderly treated hypertensive patients (age range 60-90 years). Subjects were divided according to tertiles of MS of systolic BP of the population as a whole, by dipping status and by group-specific tertiles of MS of systolic BP in dippers and nondippers.

RESULTS

During the follow-up (9.1 ± 4.9 years, range 0.4-20 years), 120 coronary events occurred. In the population as a whole, coronary event risk was not significantly associated with tertiles of MS of systolic BP, whereas nondippers were at higher risk than dippers. When nondippers and dippers were analyzed separately, by group-specific tertiles of MS of systolic BP, coronary event risk was associated with MS of systolic BP in dippers but not in nondippers. After adjustment for various covariates, Cox regression analysis showed that dippers in the third tertile (>23 mm Hg) of MS of systolic BP (hazard ratio 1.912, 95% confidence interval 1.048-3.488, P = 0.03) and nondippers (hazard ratio 1.739, 95% confidence interval 1.074-2.815, P = 0.02) were at higher coronary event risk than dippers with MS of systolic BP <23 mm Hg .

CONCLUSIONS

In elderly treated hypertensive patients, high MS of systolic BP predicts coronary events in dippers but not in nondippers. Nondippers, however, show higher risk of coronary events independently of MS in systolic BP.

Sleep Duration, Kidney Function, and Their Effects on Cerebral Small Vessel Disease in Elderly Hypertensive Patients

BACKGROUND

Short sleep duration has been shown to be associated with cardio/cerebrovascular disease. White matter hyperintensities (WMH) have been associated with an increased risk of stroke. In addition to high ambulatory blood pressure (BP), chronic kidney disease (CKD) is a risk for WMH. In this study, we investigated the relationships among sleep duration, CKD, and WMH in elderly hypertensives.

METHODS

Ambulatory BP monitoring and brain magnetic resonance imaging were performed in 514 Japanese elderly hypertensives (mean age 72.3 years, males 37%). WMH cases were further divided into deep subcortical white matter lesion or periventricular hyperintensity (PVH). CKD (n = 193) was defined as estimated glomerular filtration rate less than 60 ml/min/1.73 m(2).

RESULTS

According to sleep duration (<7.5, ≥7.5 to <9.5, and ≥9.5 hour per night), significant associations of sleep duration were observed with WMH and PVH. In the regression analysis including age, gender, smoking, antiplatelet agents use, 24-hour systolic BP, nondipper, white coat hypertension and CKD, short sleep duration was significantly positively associated with WMH and PVH when subjects with mid-range sleep duration were used as a reference group. A significant interaction was found between short sleep duration and CKD for PVH. In the non-CKD group, short sleep duration had strong significant positive associations with WMH and PVH.

CONCLUSIONS

In the present study, short sleep duration was a positive significant determinant for WMH and PVH in elderly hypertensives. Sleep duration might serve as a strong determinant for white matter lesions especially in those without CKD.

Association of electrocardiographic left ventricular hypertrophy with incident cardiovascular disease in Japanese older hypertensive patients

BACKGROUND

Our aim was to assess whether electrocardiographic left ventricular hypertrophy (ECG-LVH) is associated with a higher risk of cardiovascular disease (CVD) events, independent of 24-hour blood pressure (BP) and circulating levels of norepinephrine and hemostatic factors.

METHODS

In 514 older hypertensive patients (mean age 72.3 years; 37% men), we assessed ambulatory BP values, circulating levels of norepinephrine and hemostatic factors (plasma fibrinogen, prothrombin fragment 1+2 (F1+2), von Willebrand factor (vWF), and plasminogen activator inhibitor-1 (PAI-1)), and the presence or absence of ECG-LVH (Sokolow-Lyon voltage ≥ 3.5 mV). The incidence of CVD events (i.e., myocardial infarction and stroke) was prospectively ascertained.

RESULTS

During an average 41 months of follow-up (1,751 person-years), 43 stroke and 3 myocardial infarction events occurred. At baseline, patients with ECG-LVH had higher mean 24-hour BP (148.8/83.8mm Hg vs. 135.7/77.2mm Hg) and circulating norepinephrine levels (404.6 pg/ml vs. 336.3 pg/ml) compared to those without ECG-LVH; the differences remained unchanged after adjustment for age, gender, smoking status, presence of diabetes, and antihypertensive medication uses at follow-up time (all P < 0.01). Cox proportional hazards models suggested that the hazard ratio (HR; 95% confidence interval (CI)) of CVD events for those with ECG-LVH was 4.4 (2.3-8.2), and the association between ECG-LVH and incident CVD events remained significant after adjustment for high 24-hour BP (≥130/80mm Hg), nocturnal SBP, circulating norepinephrine and fibrinogen levels (HRs, 3.5-4.2, all P < 0.001).

CONCLUSIONS

In older hypertensive patients, ECG-LVH was associated with a higher risk of CVD events, independent of ambulatory BP parameters and circulating norepinephrine and fibrinogen levels.

Relationship between mean platelet volume and morning blood pressure surge in newly diagnosed hypertensive patients

OBJECTIVE

Morning blood pressure surge (MBPS) is an independent predictor of atherothrombotic cardiovascular events in hypertensive patients. There is evidence from studies supporting the validity of mean platelet volume (MPV) as a marker of vascular risk and predictor of thrombotic complications. The aim of this study is to investigate the relationship between MPV and MBPS in hypertensive patients.

METHODS

Measurements were obtained from 298 patients with newly diagnosed essential hypertension (Mean age: 51.9 ± 11.7 years). The patients were divided into two groups (MPV(low) group; <10.8 fL, MPV(high) group; ≥ 10.8 fL). The MBPS was calculated as mean systolic BP during the 2 hours after awaking minus the mean systolic BP during the 1 hour that included the lowest sleep BP.

RESULTS

MPV was independently associated with MBPS (β=0.554, p<0.001) and hs-CRP level (β=0.286, p<0.001).

CONCLUSION

Finally, higher MPV values related to enhanced MBPS which are associated with atherothrombotic cardiovascular events.

Morning blood pressure surge is associated with serum gamma-glutamyltransferase activity in essential hypertensive patients

The phenomenon that blood pressure rises sharply in the morning is called 'Morning Blood Pressure Surge' (MBPS). Serum gamma-glutamyltransferase (GGT) is a proinflammatory marker involved in the pathogenesis of cardiovascular diseases. Although both are novel cardiovascular risk factors associated with inflammation and atherosclerosis, the specific relationship between MBPS and serum GGT is unknown. This study investigates the relationship between MBPS and serum GGT activity in essential hypertensive patients. Totally, 320 hypertensive patients were recruited. Mean MBPS was 17.0 ± 12.9 mm Hg. MBPS was positively correlated with age (r = +0.222, P < 0.0001), body mass index (r = +0.132, P = 0.018), GGT (r = +0.271, P < 0.0001), daytime augmentation index adjusted for heart rate (AIx@75) (r = +0.140, P=0.014), 24-h pulse wave velocity (PWV) (r = +0.143, P = 0.014) and daytime PWV (r = +0.158, P = 0.007). From the 25th to 75th quartile of serum GGT, MBPS increased significantly (Ptrend < 0.0001). In multivariate linear regression analysis, MBPS was independently associated with age (P = 0.002), dipping status (P < 0.0001) and logGGT (P < 0.0001). In conclusion, MBPS is independently associated serum GGT activity in essential hypertensive patients. This is the first study in the literature to demonstrate an independent and a dose-response relationship between the two novel cardiovascular risk factors, MBPS and serum GGT, in this patient population.

Association of lifestyle-related factors with circadian onset patterns of acute myocardial infarction: a prospective observational study in Japan

OBJECTIVE

The onset of acute myocardial infarction (AMI) shows characteristic circadian variations involving a definite morning peak and a less-defined night-time peak. However, the factors influencing the circadian patterns of AMI onset and their influence on morning and night-time peaks have not been fully elucidated.

DESIGN, SETTING AND PARTICIPANTS

An analysis of patients registered between 1998 and 2008 in the Osaka Acute Coronary Insufficiency Study, which is a prospective, multicentre observational study of patients with AMI in the Osaka region of Japan. The present study included 7755 consecutive patients with a known time of AMI onset.

MAIN OUTCOMES AND MEASURES

A mixture of two von Mises distributions was used to examine whether a circadian pattern of AMI had uniform, unimodal or bimodal distribution, and the likelihood ratio test was then used to select the best circadian pattern among them. The hierarchical likelihood ratio test was used to identify factors affecting the circadian patterns of AMI onset. The Kaplan-Meier method was used to estimate survival curves of 1-year mortality according to AMI onset time.

RESULTS

The overall population had a bimodal circadian pattern of AMI onset characterised by a high and sharp morning peak and a lower and less-defined night-time peak (bimodal p<0.001). Although several lifestyle-related factors had a statistically significant association with the circadian patterns of AMI onset, serum triglyceride levels had the most prominent association with the circadian patterns of AMI onset. Patients with triglyceride ≥150 mg/dL on admission had only one morning peak in the circadian pattern of AMI onset during weekdays, with no peaks detected on weekends, whereas all other subgroups had two peaks throughout the week.

CONCLUSIONS

The circadian pattern of AMI onset was characterised by bimodality. Notably, several lifestyle-related factors, particularly serum triglyceride levels, had a strong relation with the circadian pattern of AMI onset.

TRIAL REGISTRATION NUMBER

UMIN000004575.

Orthostatic hypertension-a new haemodynamic cardiovascular risk factor

Orthostatic hypertension-a condition characterized by a hyperactive pressor response to orthostatic stress-is an emerging risk factor for cardiovascular disease and is associated with hypertensive target-organ damage (resulting in silent cerebrovascular disease, left ventricular hypertrophy, carotid atherosclerosis and/or chronic kidney disease) and cardiovascular events (such as coronary artery disease and lacunar stroke). The condition is also considered to be a form of prehypertension as it precedes hypertension in young, normotensive adults. Orthostatic blood pressure changes can be assessed using orthostatic stress tests, including clinic active standing tests, home blood pressure monitoring and the head-up tilting test. Devices for home and for ambulatory blood pressure monitoring that are equipped with position sensors and do not induce a white-coat effect have increased the sensitivity and specificity of diagnosis of out-of-clinic orthostatic hypertension. Potential major mechanisms of orthostatic hypertension are sympathetic hyperactivity (as a result of hypersensitivity of the cardiopulmonary and arterial baroreceptor reflex) and α-adrenergic hyperactivation. Orthostatic hypertension is also associated with morning blood pressure surge and extreme nocturnal blood pressure dipping, both of which increase the pulsatile haemodynamic stress of central arterial pressure and blood flow in patients with systemic haemodynamic atherothrombotic syndrome.

Both chronic kidney disease and nocturnal blood pressure associate with strokes in the elderly

BACKGROUND

Among elderly hypertensive patients, we aimed to assess the association of nocturnal blood pressure (BP) pattern on stroke; interaction of dipping pattern with kidney disease was explored.

METHODS

We retrospectively analyzed the records of 1,276 elderly (≥60 years) hypertensive Japanese patients (mean 74 years; 40% were men) who had measurements of estimated glomerular filtration rate and ambulatory BP.

RESULTS

Stroke events occurred in 73 people over an average of 3.2 years (4,026 person-years). Chronic kidney disease (CKD) at baseline (n = 634, 50%) was more prevalent in people with strokes (71%) than those without strokes (48%; p < 0.01). Both CKD and nocturnal systolic BP (SBP) increase (10 mm Hg) were independently associated with increased risk for stroke [hazard ratio (HR), 1.9; 95% confidence interval (CI), 1.1-3.1 for CKD and HR 1.2; 1.1-1.4 for SBP]. After adjustment for office SBP, a 10-mm Hg increase in nocturnal SBP was similarly associated with strokes in patients with CKD (HR 1.2; 95% CI 1.0-1.3) and those without CKD (HR 1.2; 95% CI 0.97-1.5). Although reverse dipping (nocturnal SBP ≥ daytime SBP) was associated with stroke only in patients with CKD (HR 2.1; 95% CI 1.1-4.1) and not those without CKD (HR 1.1; 95% CI 0.3-3.8), the interaction effect was not significant (p = 0.30).

CONCLUSION

In elderly hypertensive patients, both high nocturnal SBP and CKD are independent risk factors for stroke.

The impact of cigarette smoking on 24-hour blood pressure, inflammatory and hemostatic activity, and cardiovascular risk in Japanese hypertensive patients

The aim of the study was to assess the impact of current smoking on 24-hour blood pressure (BP) and inflammatory and hemostatic activity and thereby the incidence of cardiovascular disease (CVD) in Japanese hypertensive patients. A total of 810 hypertensive patients (mean age 72 years; 38% men) were prospectively followed-up (2799 person-years). During the follow-up, 66 cases of CVD occurred (stroke, 55; myocardial infarction, 7; both, 4). At baseline, the current smokers (n=166) had higher levels of high-sensitivity C-reactive protein (hs-CRP) (0.21 mg/dL vs 0.14 mg/dL) and plasminogen activator inhibitor-1 (PAI-1) (46.1 ng/mL vs 37.8 ng/mL; both P=.001), but not of 24-hour BP, compared with nonsmokers. Using a Cox regression analysis, current smoking was independently associated with an increased risk of CVD (hazard ratio [HR], 2.6; P<.01), and the risk was substantially higher in women (HR, 6.1; P<.001) than in men (HR, 1.4; P=.41). The CVD risk of current smokers was magnified when it was accompanied with high hs-CRP (highest quartile range, ≥0.40 mg/L) or PAI-1 levels (≥58.9 ng/mL) compared with that in smokers with low hs-CRP or PAI-1 levels (both P<.05). Among hypertensive patients, current smokers had increased risk of CVD events, and the increase was more prominent when accompanied by circulatory inflammatory and hemostatic abnormalities.

Optimizing blood pressure control in hypertension: the need to use ABPM

Hypertension is the most prevalent, treatable cause of cardiovascular (CV) disease. Patients with hypertension and one or more comorbidities increasingly form a significant part of the primary care practitioner's caseload. The emphasis on intensive blood pressure (BP) lowering has softened, encouraging any degree of BP lowering, since any fall in BP is beneficial for reducing CV risk. Consistency of BP control during long-term therapy (i.e. low visit-to-visit variability) and decreasing BP variability over 24-h may be as, if not more, important than degree of BP lowering per se. Fluctuations in BP between visits as well as within a 24-h period have been associated with increased CV risk. Ambulatory BP monitoring (ABPM) is a crucial element of the clinician's armamentarium not only for assessing the "true" BP load and fluctuations under real-life conditions but for identification of various abnormal BP patterns that may require attention, including white- coat hypertension, masked hypertension, non-dipping and the morning BP surge. ABPM provides accurate assessment of treatment effectiveness over 24-h and may lead to better tailoring of therapy. This article reviews the benefits of ABPM and discusses the importance of selecting long-acting antihypertensive agents for optimizing BP control.

Association of prothrombotic status with markers of cerebral small vessel disease in elderly hypertensive patients

BACKGROUND

Aging and hypertension are well-known risk factors for cerebral white matter lesions. Prothrombotic status has been shown to be a risk factor for cardiovascular disease. In this study, we investigated the relationships among prothrombotic status, ambulatory blood pressure (ABP), and white matter hyperintensity (WMH) in elderly hypertensives.

METHODS

Measurement of prothrombin fragments 1+2 (F1+2), von Willebrand Factor (vWF) and plasminogen activator inhibitor-1 (PAI-1), ABP monitoring (ABPM), and brain magnetic resonance imaging (MRI) were performed in 514 Japanese elderly hypertensives (72.3 years old, male 37%). WMH cases were further divided into deep subcortical white matter lesion (DWML) or periventricular hyperintensity (PVH).

RESULTS

Deep WMH (DWMH) had significant positive correlations with age, use of antiplatelet agents, log F1+2, log vWF, log PAI-1, and 24-h systolic BP (SBP). PVH had significant positive correlations with age, male gender, smoking, use of antiplatelet agents, white coat hypertension (WCH), log vWF, and 24-h SBP. Severe PVH had significant positive correlations with age, use of antiplatelet agents, WCH, and 24-h SBP, and that was marginally correlated with log F1+2. In the logistic linear regression analysis, log F1+2 was significantly associated with DWMH (P < 0.01) and severe PVH (P < 0.05) adjusted for age and 24-h SBP. Log PAI-1 was significantly associated with DWMH (P < 0.05) adjusted for age and 24-h SBP.

CONCLUSIONS

In the present study, F1+2 and PAI-1 were positively associated with WMH after adjustment for 24-h SBP in elderly hypertensives. In addition to the conventional risk factors, prothrombotic status might serve as a significant determinant for WMH.