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de la Sierra A, Ruilope LM, Martínez-Camblor P, Vinyoles E, Gorostidi M, Segura J, Williams B. Impact of timing of antihypertensive treatment on mortality: an observational study from the Spanish Ambulatory Blood Pressure Monitoring Registry. J Hypertens 2024; 42:260-266. [PMID: 37796235 DOI: 10.1097/hjh.0000000000003581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND AIMS Whether bedtime versus morning administration of antihypertensive therapy is beneficial on outcomes is controversial. We evaluated the risk of total and cardiovascular mortality in a very large observational cohort of treated hypertensive patients, according to the timing of their usual treatment administration (morning versus evening). METHODS Vital status and cause of death were obtained from death certificates of 28 406 treated hypertensive patients (mean age 62 years, 53% male individuals), enrolled in the Spanish Ambulatory Blood Pressure Monitoring (ABPM) Registry between 2004 and 2014. Among the 28 406 patients, most (86%) received their medication exclusively in the morning; whilst 13% were treated exclusively in the evening or at bedtime. Follow-up was for a median of 9.7 years and 4345 deaths occurred, of which 1478 were cardiovascular deaths. RESULTS Using Cox-models adjusted for clinical confounders and 24-h SBP, and compared with patients treated in the morning (reference group), all-cause mortality [hazard ratio 1.01; 95% CI 0.93-1.09) and cardiovascular mortality (hazard ratio 1.04; 95% CI 0.91-1.19) was not significantly different in those receiving evening medication dosing. The results were consistent in all the subgroups of patients analysed. CONCLUSION In this very large observational study, morning versus bedtime dosing of antihypertensive medication made no difference to the subsequent risk of all-cause or cardiovascular mortality. These findings are in accordance with results from a recent randomized controlled trial and do not support the hypothesis of a specific beneficial effect of night-time antihypertensive treatment dosing on risk of all-cause or cardiovascular death.
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Affiliation(s)
| | - Luis M Ruilope
- Hypertension Unit and Cardiorenal Translational Laboratory, Hospital 12 de Octubre, Madrid, Spain
| | - Pablo Martínez-Camblor
- Departments of Anesthesiology and Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Faculty of Health Sciences, Universidad Autónoma de Chile, Chile
| | - Ernest Vinyoles
- Primary Care Centre 'La Mina', IDIAP Jordi Gol, University of Barcelona, Barcelona
| | - Manuel Gorostidi
- Department of Nephrology, Hospital Universitario Central de Asturias, Oviedo
| | - Julián Segura
- Hypertension Unit and Cardiorenal Translational Laboratory, Hospital 12 de Octubre, Madrid, Spain
| | - Bryan Williams
- University College London (UCL) Institute of Cardiovascular Science and National Institute for Health Research (NIHR) UCL Hospitals Biomedical Research Centre, London, UK
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Ahmed M, Nudy M, Bussa R, Hajduczok A, Naccarelli GV, Filippone EJ, Foy AJ. A systematic review, meta-analysis, and meta regression of the sham controlled renal denervation randomized controlled trials. Trends Cardiovasc Med 2023; 33:490-498. [PMID: 35667638 DOI: 10.1016/j.tcm.2022.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 12/13/2022]
Abstract
Renal denervation (RD) has been investigated as a novel blood pressure (BP) lowering treatment for hypertension. The primary objective of this meta-analysis was to assess the efficacy of RD and factors that may associate with treatment effect heterogeneity. The primary outcomes were raw mean differences (RMD) in 24-hour ambulatory, daytime ambulatory, nighttime, and office systolic BP (SBP) and diastolic BP (DBP) between sham control and RD. A prespecified subgroup analysis was performed comparing studies with follow-up less than versus greater than 4 months. If inter-study heterogeneity was found for any of the above outcomes, additional analyses were performed to assess potential moderator variables. Ten sham-controlled randomized trials were identified and included 1,544 participants, followed for a mean of 4.20 months. RD was associated with a statistically significant reduction in all SBP and DBP measures except for nighttime SBP (-2.64 mmHg; 95% confidence interval (CI) -5.84 to 0.56, p = 0.11) and nighttime DBP (- 1.21 mmHg; 95% CI -3.17 to 0.75, p = 0.23). Mild to moderate inter-study heterogeneity was identified for three outcomes (office SBP and nighttime SBP and DBP). Studies that followed patients for longer than 4 months had numerically lower reductions in most BP outcomes; however, there were no statistically significant interactions between subgroups. Compared to a sham procedure, RD was associated with statistically significant reductions in most measures of SBP and DBP that were within bounds of what would be expected from standard blood pressure lowering medications.
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Affiliation(s)
- Mohammad Ahmed
- Penn State Hershey Medical Center, Department of Internal Medicine, United States
| | - Matthew Nudy
- Penn State Hershey Medical Center, Heart and Vascular Institute, Division of Cardiology, United States
| | - Rahul Bussa
- Penn State Hershey Medical Center, Department of Internal Medicine, United States
| | - Alexander Hajduczok
- Penn State Hershey Medical Center, Department of Internal Medicine, United States
| | - Gerald V Naccarelli
- Penn State Hershey Medical Center, Heart and Vascular Institute, Division of Cardiology, United States
| | - Edward J Filippone
- Thomas Jefferson University Hospitals, Division of Nephrology, United States
| | - Andrew J Foy
- Penn State Hershey Medical Center, Heart and Vascular Institute, Division of Cardiology, United States.
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Garrison SR, Youngson E, Perry DA, Campbell FN, Kolber MR, Korownyk C, Allan GM, Green L, Bakal J. Bedtime versus morning use of antihypertensives in frail continuing care residents (BedMed-Frail): protocol for a prospective, randomised, open-label, blinded end-point pragmatic trial. BMJ Open 2023; 13:e074777. [PMID: 37527898 PMCID: PMC10394547 DOI: 10.1136/bmjopen-2023-074777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION BedMed-Frail explores risks and benefits of switching antihypertensives from morning to bedtime in a frail population at greater risk of hypotensive adverse effects. METHODS AND ANALYSIS Design: Prospective parallel randomised, open-label, blinded end-point trial.Participants: Hypertensive continuing care residents, in either long-term care or supportive living, who are free from glaucoma, and using ≥1 once daily antihypertensive.Setting: 16 volunteer continuing care facilities in Alberta, Canada, with eligible residents identified using electronic health claims data.Intervention: All non-opted out eligible residents are randomised centrally by the provincial health data steward to bedtime versus usual care (typically morning) administration of once daily antihypertensives. Timing changes are made (maximum one change per week) by usual care facility pharmacists.Follow-up: Via linked governmental healthcare databases tracking hospital, continuing care and community medical services.Primary outcome: Composite of all-cause death, or hospitalisation for myocardial infarction/acute-coronary syndrome, stroke, or congestive heart failure.Secondary outcomes: Each primary outcome element on its own, all-cause unplanned hospitalisation or emergency department visit, non-vertebral fracture and, as assessed roughly 135 days postrandomisation, fall in the last 30 days, deteriorated cognition, urinary incontinence, decubitus skin ulceration, inappropriate or disruptive behaviour a minimum of 4 days per week, and receipt of antipsychotic medication or physical restraints in the last 7 days.Process outcome: Proportion of blood pressure medication doses taken at bedtime (broken down monthly).Primary outcome analysis: Cox-Proportional Hazards Survival Analysis.Sample size: The trial will continue until a projected 368 primary outcome events have occurred.Current status: Enrolment is ongoing with 642 randomisations to date (75% female, mean age 88 years). ETHICS AND DISSEMINATION BedMed-Frail has ethical approval from the University of Alberta Health Ethics Review Board (Pro00086129) and will publish results in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04054648.
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Affiliation(s)
- Scott R Garrison
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Erik Youngson
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Danielle A Perry
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Programs and Practice Support, College of Family Physicians of Canada, Mississauga, Alberta, Canada
| | - Farah N Campbell
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Michael R Kolber
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Christina Korownyk
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Gary Michael Allan
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Programs and Practice Support, College of Family Physicians of Canada, Mississauga, Alberta, Canada
| | - Lee Green
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jeffrey Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
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Huart J, Persu A, Lengelé JP, Krzesinski JM, Jouret F, Stergiou GS. Pathophysiology of the Nondipping Blood Pressure Pattern. Hypertension 2023; 80:719-729. [PMID: 36606502 DOI: 10.1161/hypertensionaha.122.19996] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The nondipping blood pressure (BP) pattern corresponds to a disruption in the circadian BP rhythm with an insufficient decrease in BP levels during nighttime sleep as observed using 24-hour ambulatory BP monitoring. Patients with nondipping BP pattern have poorer renal and cardiovascular outcomes, independent of their average 24-hour BP levels. The pathophysiology of nondipping BP is complex and involves numerous mechanisms: perturbations of (1) the circadian rhythm, (2) the autonomic nervous system, and (3) water and sodium regulation. This review provides an outline of the pathways potentially involved in the nondipping BP profile in different conditions. A recent hypothesis is also discussed involving the role of gut microbiota in the dipping/nondipping patterns, via the fecal diet-derived short chain fatty acids.
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Affiliation(s)
- Justine Huart
- Division of Nephrology, University of Liège Hospital (ULiège CHU), University of Liège, Belgium (J.H., J.-M.K., F.J.).,Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Belgium (J.H., J.-M.K., F.J.)
| | - Alexandre Persu
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (A.P., J.-P.L.)
| | - Jean-Philippe Lengelé
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (A.P., J.-P.L.).,Department of Nephrology, Grand Hôpital de Charleroi, Gilly, Belgium (J.-P.L.)
| | - Jean-Marie Krzesinski
- Division of Nephrology, University of Liège Hospital (ULiège CHU), University of Liège, Belgium (J.H., J.-M.K., F.J.).,Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Belgium (J.H., J.-M.K., F.J.)
| | - François Jouret
- Division of Nephrology, University of Liège Hospital (ULiège CHU), University of Liège, Belgium (J.H., J.-M.K., F.J.).,Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Belgium (J.H., J.-M.K., F.J.)
| | - George S Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (G.S.S.)
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Gumz ML, Shimbo D, Abdalla M, Balijepalli RC, Benedict C, Chen Y, Earnest DJ, Gamble KL, Garrison SR, Gong MC, Hogenesch JB, Hong Y, Ivy JR, Joe B, Laposky AD, Liang M, MacLaughlin EJ, Martino TA, Pollock DM, Redline S, Rogers A, Dan Rudic R, Schernhammer ES, Stergiou GS, St-Onge MP, Wang X, Wright J, Oh YS. Toward Precision Medicine: Circadian Rhythm of Blood Pressure and Chronotherapy for Hypertension - 2021 NHLBI Workshop Report. Hypertension 2023; 80:503-522. [PMID: 36448463 PMCID: PMC9931676 DOI: 10.1161/hypertensionaha.122.19372] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Healthy individuals exhibit blood pressure variation over a 24-hour period with higher blood pressure during wakefulness and lower blood pressure during sleep. Loss or disruption of the blood pressure circadian rhythm has been linked to adverse health outcomes, for example, cardiovascular disease, dementia, and chronic kidney disease. However, the current diagnostic and therapeutic approaches lack sufficient attention to the circadian rhythmicity of blood pressure. Sleep patterns, hormone release, eating habits, digestion, body temperature, renal and cardiovascular function, and other important host functions as well as gut microbiota exhibit circadian rhythms, and influence circadian rhythms of blood pressure. Potential benefits of nonpharmacologic interventions such as meal timing, and pharmacologic chronotherapeutic interventions, such as the bedtime administration of antihypertensive medications, have recently been suggested in some studies. However, the mechanisms underlying circadian rhythm-mediated blood pressure regulation and the efficacy of chronotherapy in hypertension remain unclear. This review summarizes the results of the National Heart, Lung, and Blood Institute workshop convened on October 27 to 29, 2021 to assess knowledge gaps and research opportunities in the study of circadian rhythm of blood pressure and chronotherapy for hypertension.
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Affiliation(s)
- Michelle L Gumz
- Department of Physiology and Aging; Center for Integrative Cardiovascular and Metabolic Disease, Department of Medicine, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL (M.L.G.)
| | - Daichi Shimbo
- Department of Medicine, The Columbia Hypertension Center, Columbia University Irving Medical Center, New York, NY (D.S.)
| | - Marwah Abdalla
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY (M.A.)
| | - Ravi C Balijepalli
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
| | - Christian Benedict
- Department of Pharmaceutical Biosciences, Molecular Neuropharmacology, Uppsala University, Sweden (C.B.)
| | - Yabing Chen
- Department of Pathology, University of Alabama at Birmingham, and Research Department, Birmingham VA Medical Center, AL (Y.C.)
| | - David J Earnest
- Department of Neuroscience & Experimental Therapeutics, Texas A&M University, Bryan, TX (D.J.E.)
| | - Karen L Gamble
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, AL (K.L.G.)
| | - Scott R Garrison
- Department of Family Medicine, University of Alberta, Canada (S.R.G.)
| | - Ming C Gong
- Department of Physiology, University of Kentucky, Lexington, KY (M.C.G.)
| | | | - Yuling Hong
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
| | - Jessica R Ivy
- University/British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, United Kingdom (J.R.I.)
| | - Bina Joe
- Department of Physiology and Pharmacology and Center for Hypertension and Precision Medicine, University of Toledo College of Medicine and Life Sciences, OH (B.J.)
| | - Aaron D Laposky
- National Center on Sleep Disorders Research, Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (A.D.L.)
| | - Mingyu Liang
- Center of Systems Molecular Medicine, Department of Physiology, Medical College of Wisconsin, Milwaukee, WI (M.L.)
| | - Eric J MacLaughlin
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Amarillo, TX (E.J.M.)
| | - Tami A Martino
- Center for Cardiovascular Investigations, Department of Biomedical Sciences, University of Guelph, Ontario, Canada (T.A.M.)
| | - David M Pollock
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL (D.M.P.)
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.R.)
| | - Amy Rogers
- Division of Molecular and Clinical Medicine, University of Dundee, United Kingdom (A.R.)
| | - R Dan Rudic
- Department of Pharmacology and Toxicology, Augusta University, GA (R.D.R.)
| | - Eva S Schernhammer
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.S.S.)
| | - George S Stergiou
- Hypertension Center, STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (G.S.S.)
| | - Marie-Pierre St-Onge
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center' New York, NY (M.-P.S.-O.)
| | - Xiaoling Wang
- Georgia Prevention Institute, Department of Medicine, Augusta University, GA (X.W.)
| | - Jacqueline Wright
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
| | - Young S Oh
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
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6
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Garrison SR, Kolber MR, Allan GM, Bakal J, Green L, Singer A, Trueman DR, McAlister FA, Padwal RS, Hill MD, Manns B, McGrail K, O'Neill B, Greiver M, Froentjes LS, Manca DP, Mangin D, Wong ST, MacLean C, Kirkwood JE, McCracken R, McCormack JP, Norris C, Korownyk T. Bedtime versus morning use of antihypertensives for cardiovascular risk reduction (BedMed): protocol for a prospective, randomised, open-label, blinded end-point pragmatic trial. BMJ Open 2022; 12:e059711. [PMID: 35210352 PMCID: PMC8883279 DOI: 10.1136/bmjopen-2021-059711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Sleep-time blood pressure correlates more strongly with adverse cardiovascular events than does daytime blood pressure. The BedMed trial evaluates whether bedtime antihypertensive administration, as compared with conventional morning use, reduces major adverse cardiovascular events. METHODS AND ANALYSIS: DesignProspective randomised, open-label, blinded end-point trial.ParticipantsHypertensive primary care patients using blood pressure lowering medication and free from glaucoma.SettingCommunity primary care providers in 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba and Ontario) are mailing invitations to their eligible patients. Social media campaigns (Google, Facebook) are additionally running in the same provinces.InterventionConsenting participants are allocated via central randomisation to bedtime vs morning use of all antihypertensives.Follow-up(1) Telephone or email questionnaire at 1 week, 6 weeks, 6 months and every 6 months thereafter, and (2) accessing linked governmental healthcare databases tracking hospital and community medical services.Primary outcomeComposite of all-cause death, or hospitalisation for myocardial infarction/acute-coronary syndrome, stroke or congestive heart failure.Secondary outcomesEach primary outcome element on its own, all-cause hospitalisation or emergency department visit, long-term care admission, non-vertebral fracture, new glaucoma diagnosis, 18-month cognitive decline from baseline (via Short Blessed Test).Select other outcomesSelf-reported nocturia burden at 6 weeks and 6 months (no, minor or major burden), 1-year self-reported overall health score (EQ-5D-5L), self-reported falls, total cost of care (acute and community over study duration) and mean sleep-time systolic blood pressure after 6 months (via 24-hour monitor in a subset of 302 sequential participants).Primary outcome analysisCox proportional hazards survival analysis.Sample sizeThe trial will continue until a projected 254 primary outcome events have occurred.Current statusEnrolment ongoing (3227 randomised to date). ETHICS AND DISSEMINATION BedMed has ethics approval from six research ethics review boards and will publish results in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02990663.
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Affiliation(s)
- Scott R Garrison
- Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael R Kolber
- Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - G Michael Allan
- Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Lee Green
- Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Singer
- Family Medicine, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
| | | | | | - Raj S Padwal
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden Manns
- Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Braden O'Neill
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Greiver
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Donna P Manca
- Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dee Mangin
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sabrina T Wong
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cathy MacLean
- Academic Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Rita McCracken
- Family Medicine, Providence Health Care, Vancouver, British Columbia, Canada
- Family Practice, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - James P McCormack
- Faculty of Pharmaceutical Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colleen Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Tina Korownyk
- Family Medicine, University of Alberta, Edmonton, Alberta, Canada
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7
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Diagnosis and treatment of arterial hypertension 2021. Kidney Int 2021; 101:36-46. [PMID: 34757122 DOI: 10.1016/j.kint.2021.09.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/10/2021] [Accepted: 09/23/2021] [Indexed: 12/20/2022]
Abstract
In the last 4 years, several evidence-based, national, and international guidelines on the management of arterial hypertension have been published, mostly with concordant recommendations, but in some aspects with discordant opinions. This in-depth review takes these guidelines into account but also addresses several new data of interest. Although being somewhat obvious and simple, accurate blood pressure (BP) measurement with validated devices is the cornerstone of the diagnosis of hypertension, but out-of-office BP measurements are of crucial importance as well. Simplified antihypertensive drug treatment such as single-pill combinations enhances the adherence to medication and speeds up the process of getting into the BP target range, a goal not so far adequately respected. Recommended (single-pill) combination therapy includes diuretics as part of the first step of antihypertensive therapy, and updated analysis does not provide evidence to exclude diuretics from this first step because of the recently discussed potential risk of increasing cancer incidence. Target BP goals need to be individualized, according to comorbidities, hypertension-mediated organ damage, coexistence of cardiovascular risk factors (including age), frailty in the elderly, and individual tolerability. There are also concordant recommendations in the guidelines that an office BP between 120 and 140 mm Hg systolic and between 70 and 80 mm Hg diastolic should be achieved. The BP target of Kidney Disease: Improving Global Outcomes for hypertensive patients with chronic kidney disease are not applicable for clinical practice because they heavily rely on 1 study that used a study-specific, nontransferable BP measurement technique and excluded the most common cause of chronic kidney disease, namely, diabetic nephropathy. Actual data even from a prospective trial on chronotherapy have to be disregarded, and antihypertensive medication should not be routinely dosed at bedtime. Rigorously conducted trials justify the revival of renal denervation for treatment of (at least, but not only) uncontrolled and treatment-resistant hypertension.
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Abstract
Circadian disruption is pervasive and can occur at multiple organizational levels, contributing to poor health outcomes at individual and population levels. Evidence points to a bidirectional relationship, in that circadian disruption increases disease severity and many diseases can disrupt circadian rhythms. Importantly, circadian disruption can increase the risk for the expression and development of neurologic, psychiatric, cardiometabolic, and immune disorders. Thus, harnessing the rich findings from preclinical and translational research in circadian biology to enhance health via circadian-based approaches represents a unique opportunity for personalized/precision medicine and overall societal well-being. In this Review, we discuss the implications of circadian disruption for human health using a bench-to-bedside approach. Evidence from preclinical and translational science is applied to a clinical and population-based approach. Given the broad implications of circadian regulation for human health, this Review focuses its discussion on selected examples in neurologic, psychiatric, metabolic, cardiovascular, allergic, and immunologic disorders that highlight the interrelatedness between circadian disruption and human disease and the potential of circadian-based interventions, such as bright light therapy and exogenous melatonin, as well as chronotherapy to improve and/or modify disease outcomes.
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Affiliation(s)
- Anna B Fishbein
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital, and
| | - Kristen L Knutson
- Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Phyllis C Zee
- Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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9
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Zeng WW, Chan SW, Tomlinson B. Patient preferences for ambulatory blood pressure monitoring devices: Wrist-type or arm-type? PLoS One 2021; 16:e0255871. [PMID: 34370782 PMCID: PMC8352047 DOI: 10.1371/journal.pone.0255871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ambulatory blood pressure monitoring (ABPM) is important in evaluating average 24-hour blood pressure (BP) levels, circadian rhythm, sleeping BP and BP variability but many patients are reluctant to use standard ABPM devices. METHODS We compared two validated ABPM devices, the BPro tonometric wrist monitor and the A&D TM-2430 oscillometric upper arm monitor, for agreement of recordings and acceptability in 37 hypertensive patients (aged 55±9 years). RESULTS Successful BP measurements were less frequent with the wrist-type than the arm-type device during the sleeping (66.3% vs. 92.9%, P <0.01) and awake periods (56.2% vs. 86.5%, P <0.01). Comparable paired readings showed no significant difference in systolic BP but diastolic BP (DBP) values were higher with the wrist compared to the arm monitor (24-hour 89±13 vs. 85±14 mmHg, P <0.01) with similar differences awake and sleeping. Bland-Altman analysis showed some large discrepancies between individual arm and wrist monitor measurements. More patients found the wrist monitor more comfortable to use than the arm monitor. CONCLUSIONS Despite the difference in individual BP measurements and the systematic overestimation of DBP values with the BPro device, wrist monitors with good patient acceptability may be useful to facilitate ABPM in some patients to provide additional information about cardiovascular risk and response to antihypertensive therapies.
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Affiliation(s)
- Wei-wei Zeng
- Shenzhen Baoan Women’s and Children’s Hospital, Jinan University, Shenzhen, Guangdong Province, China
| | - Sze Wa Chan
- School of Health Sciences, Caritas Institute of Higher Education, Tseung Kwan O, Hong Kong
| | - Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Taipa, Macau, China
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Zhang J, Sun R, Jiang T, Yang G, Chen L. Circadian Blood Pressure Rhythm in Cardiovascular and Renal Health and Disease. Biomolecules 2021; 11:biom11060868. [PMID: 34207942 PMCID: PMC8230716 DOI: 10.3390/biom11060868] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 12/21/2022] Open
Abstract
Blood pressure (BP) follows a circadian rhythm, it increases on waking in the morning and decreases during sleeping at night. Disruption of the circadian BP rhythm has been reported to be associated with worsened cardiovascular and renal outcomes, however the underlying molecular mechanisms are still not clear. In this review, we briefly summarized the current understanding of the circadian BP regulation and provided therapeutic overview of the relationship between circadian BP rhythm and cardiovascular and renal health and disease.
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Affiliation(s)
- Jiayang Zhang
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China; (J.Z.); (R.S.); (T.J.)
| | - Ruoyu Sun
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China; (J.Z.); (R.S.); (T.J.)
| | - Tingting Jiang
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China; (J.Z.); (R.S.); (T.J.)
| | - Guangrui Yang
- School of Bioengineering, Dalian University of Technology, Dalian 116024, China;
| | - Lihong Chen
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China; (J.Z.); (R.S.); (T.J.)
- Correspondence: ; Tel.: +86-411-86118984
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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Kario K, Hettrick DA, Prejbisz A, Januszewicz A. Obstructive Sleep Apnea-Induced Neurogenic Nocturnal Hypertension: A Potential Role of Renal Denervation? Hypertension 2021; 77:1047-1060. [PMID: 33641363 DOI: 10.1161/hypertensionaha.120.16378] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There is a bidirectional, causal relationship between obstructive sleep apnea (OSA) and hypertension. OSA-related hypertension is characterized by high rates of masked hypertension, elevated nighttime blood pressure, a nondipper pattern of nocturnal hypertension, and abnormal blood pressure variability. Hypoxia/hypercapnia-related sympathetic activation is a key pathophysiological mechanism linking the 2 conditions. Intermittent hypoxia also stimulates the renin-angiotensin-aldosterone system to promote hypertension development. The negative and additive cardiovascular effects of OSA and hypertension highlight the importance of effectively managing these conditions, especially when they coexist in the same patient. Continuous positive airway pressure is the gold standard therapy for OSA but its effects on blood pressure are relatively modest. Furthermore, this treatment did not reduce the cardiovascular event rate in nonsleepy patients with OSA in randomized controlled trials. Antihypertensive agents targeting sympathetic pathways or the renin-angiotensin-aldosterone system have theoretical potential in comorbid hypertension and OSA, but current evidence is limited and combination strategies are often required in drug resistant or refractory patients. The key role of sympathetic nervous system activation in the development of hypertension in OSA suggests potential for catheter-based renal sympathetic denervation. Although long-term, randomized controlled trials are needed, available data indicate sustained and relevant reductions in blood pressure in patients with hypertension and OSA after renal denervation, with the potential to also improve respiratory parameters. The combination of lifestyle interventions, optimal pharmacological therapy, continuous positive airway pressure therapy, and perhaps also renal denervation might improve cardiovascular risk in patients with OSA.
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Affiliation(s)
- Kazuomi Kario
- From the Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
| | | | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., A.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., A.J.)
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Arterielle Hypertonie – Was war 2020 wichtig? DER KARDIOLOGE 2021. [PMCID: PMC7943936 DOI: 10.1007/s12181-021-00470-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Die arterielle Hypertonie bleibt weltweit der prävalenteste Risikofaktor für kardiovaskuläre Erkrankungen und damit einhergehende Behinderungen. Auch im Bereich der arteriellen Hypertonie bestimmte die COVID-19-Pandemie einen Teil der wissenschaftlichen Debatte. Die arterielle Hypertonie ist mit einem schwereren Krankheitsverlauf von COVID-19 assoziiert, wohingegen das SARS-CoV-2-Infektionsrisiko bei Hypertonikern nicht erhöht zu sein scheint. Nach aktueller Datenlage ist die Therapie mit ACE(Angiotensin-Converting-Enzym)-Hemmer und Angiotensin-Typ-1-Rezeptorblocker weder mit einem erhöhten SARS-CoV-2-Infektionsrisiko noch mit einem schwereren Krankheitsverlauf von COVID-19 verbunden. Eine Studie zur antihypertensiven Chronotherapie bestimmte den wissenschaftlichen Diskurs zur medikamentösen Therapie der Hypertonie. Die HYGIA-Studie kam zu der Schlussfolgerung, dass eine abendliche Medikamenteneinnahme das kardiovaskuläre Risiko von Patienten*innen mit arterieller Hypertonie reduziert. Aufgrund einiger Limitationen ist die Datenlage aktuell unzureichend, um eine routinemäßige nächtliche Gabe von antihypertensiven Medikamenten zu empfehlen. Wir werden einige der Aspekte diskutieren. Ein weiterer wissenschaftlicher Schwerpunkt lag auf den neuen Studien zur renalen Denervation. Hier kann man zusammenfassen, dass nach neuer Studienlage die katheterbasierte renale Denervation ein effektives und sicheres Verfahren zur Behandlung der arteriellen Hypertonie darstellt, das sich als alternatives Verfahren zur medikamentösen Blutdrucksenkung weiter etablieren könnte.
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