Classes of antihypertensive medications and blood pressure control in relation to metabolic risk factors

Renin-angiotensin system inhibitors reduce cardiovascular mortality in hypertensive patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: insights from the EffecTAVI registry

Objectives

Arterial hypertension is associated with the triggering of the renin-angiotensin system, leading to left ventricle fibrosis and worse cardiovascular outcomes. In this study, patients with comorbid arterial hypertension and severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) were selected from the EffecTAVI registry to evaluate the impact of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) on cardiovascular mortality.

Methods

We enrolled 327 patients undergoing TAVI from the EffecTAVI registry. Using Kaplan-Meier event rates and study-stratified multivariable Cox proportional hazards regression models, we evaluated 2-year clinical outcomes according to the ACEI/ARB therapy status at enrollment.

Results

Among the included patients, 222 (67.9%) were on ACEIs/ARBs at baseline, whereas 105 (32.1%) were not. Treatment with ACEIs/ARBs was significantly associated with a 2-year decrease in the rate of cardiovascular mortality (HR = 0.44, 95% CI: 0.23-0.81, p = 0.009). This association remained stable after both multivariable adjustment and propensity score matching.

Conclusion

In a cohort of hypertensive patients with severe AS who were selected from the EffecTAVI registry, ACEI/ARB treatment at baseline was found to be independently associated with a lower risk of 2-year cardiovascular mortality, suggesting a potential benefit of this treatment. More trials are needed to validate this finding and to understand the full benefit of this treatment.

Artificial intelligence in cardiovascular prevention: new ways will open new doors

Prevention and effective treatment of cardiovascular disease are progressive issues that grow in tandem with the average age of the world population. Over recent decades, the potential role of artificial intelligence in cardiovascular medicine has been increasingly recognized because of the incredible amount of real-world data (RWD) regarding patient health status and healthcare delivery that can be collated from a variety of sources wherein patient information is routinely collected, including patient registries, clinical case reports, reimbursement claims and billing reports, medical devices, and electronic health records. Like any other (health) data, RWD can be analysed in accordance with high-quality research methods, and its analysis can deliver valuable patient-centric insights complementing the information obtained from conventional clinical trials. Artificial intelligence application on RWD has the potential to detect a patient's health trajectory leading to personalized medicine and tailored treatment. This article reviews the benefits of artificial intelligence in cardiovascular prevention and management, focusing on diagnostic and therapeutic improvements without neglecting the limitations of this new scientific approach.

Effect of Hypertension, Waist-to-Height Ratio, and Their Transitions on the Risk of Type 2 Diabetes Mellitus: Analysis from the China Health and Retirement Longitudinal Study

BACKGROUND

Diabetes is a major reason of death and disability worldwide and frequently coexists with hypertension and central obesity. This study is aimed at investigating the effects of hypertension, waist-to-height ratio (WHtR), and their dynamic transitions on type 2 diabetes mellitus (T2DM) onset among middle-aged and elderly people in China.

METHODS

We analyzed 9843 participants free of T2DM (average age, 59.04 ± 9.26 years) at baseline from the China Health and Retirement Longitudinal Study. We classified the participants into the following four categories based on hypertension and WHtR statuses: nonhypertensive with a normal WHtR (NHNW); hypertensive with a normal WHtR (HTNW); nonhypertensive with an elevated WHtR (NHEW); and hypertensive with an elevated WHtR (HTEW). By using a Cox proportional hazards regression model, we assessed whether hypertension, WHtR, and their transitions over time correlated with T2DM risk.

RESULTS

During the follow-up of 8 years, 1263 participants developed incident T2DM. The hazard ratio (HR) for T2DM was 1.48 (95% CI: 1.12, 1.97), 1.56 (95% CI: 1.27, 1.92), and 2.15 (95% CI: 1.74, 2.67) in the HTNW, NHEW, and HTEW groups, respectively, compared with the NHNW group after controlling for confounding factors. When stratified by statuses of hypertension and WHtR transitions, the participants who transitioned from HTNW to HTEW (HR = 1.98, 95% CI: 1.24-3.17), or NHEW to NHNW/HTNW (HR = 1.74, 95% CI: 1.14-2.65), or remained NHEW (HR = 1.42, 95% CI: 1.04-1.93), or NHEW to HTEW (HR = 2.40, 95% CI: 1.66-3.49), or remained HTEW (HR = 2.51, 95% CI: 1.87-3.37) during the follow-up period showed a higher T2DM risk than the consistently NHNW participants.

CONCLUSIONS

Being HTNW, NHEW or HTEW or occurring adverse transitions between those states was strongly associated with T2DM onset. Effectively warding off hypertension and central obesity or preventing their further aggravation may substantially decrease the T2DM risk.

The intergated approach to the management of arterial hypertension: The CampaniaSalute Network

The second half of the last century was characterized by intense research in the field of arterial hypertension and related therapies. These studies showed that the management of arterial hypertension requires a robust coordination with close integration of the "health care systems" and "health care professionals". In 1998, the health care organization named "Campania Salute Network" was set up at the University of Naples Federico II. The Campania Salute Network involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Regione Campania's area, 60 randomly selected general practitioners uniformly distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (coordinating centre). Through this network, clinical data collected at each visit are shared (via text messages or emails) with peripheral units (general practitioners and community hospital outpatient hypertensive clinics). The coordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients (i.e. assessing hypertension mediated organ damage and associated diseases). Informations about patients are shared through on-line access to the remote web-based database. The integrated approach to the mamangement of hyperetension determined a better control of blood pressure, that was associated with a reduction of hypertension mediated organ damage and decreased incidence of fatal or non-fatal cardiovascular events. Furthermore, this innovative approach improved the adherence and the persistence to the initial pharmacologic treatment. Campania Salute Network is also a powerful tool for the clinical and translational research with more 15,000 hypertensive patients followed for more than 15 years. This database allowed, in prospetic, large scale studies, to identify the hemodimìnamic and metabolic determinants of hypertension mediated organ damage and major cardiovascular events. The experience of Campania Salute Netwiork indicates that the creation of large databases from real life experiences becomes an indispensable condition also for artificial intelligence which, in the near future, thanks to scientific knowledge, the availability of particularly advanced hardware and software, will also be able to transform the management of arterial hypertension.

Metabolic syndrome is related to vascular structural alterations but not to functional ones both in hypertensives and healthy subjects

BACKGROUND AND AIMS

Metabolic Syndrome (MS) has been related to an impairment in arterial structural and functional properties with heterogeneous results. In this paper we focused on the effects of MS on arterial carotid-femoral PWV and common carotid IMT in two different populations, one of hypertensive patients and one of healthy controls.

METHODS AND RESULTS

We enrolled 816 consecutive HT and 536 healthy controls. Vascular structural (IMT) and functional (PWV) properties were evaluated. NCEP-ATP-III criteria were used for diagnosis of MS. MS was diagnosed in 26.9% and 6.9% in hypertensive and control subjects, respectively. PWV was similar in controls with and without MS (7.7 ± 1.9 vs 7.6 ± 1.1 m/s, p = 0.69), while IMT was higher in controls with than those without MS (0.64 ± 0.18 vs 0.57 ± 0.13 mm, p = 0.02). Hypertensives with MS were older (57.9 ± 12.2 vs 52.7 ± 14.1 years, p < 0.001) and showed higher PWV (9.0 ± 2.3 vs 8.4 ± 2.1 m/s, p = 0.001) and IMT (0.72 ± 0.22 vs 0.65 ± 0.17 mm, p < 0.001) than those without MS, however at the age-adjusted analysis only the difference in IMT was confirmed (p = 0.007). Regression models showed that MS was an independent determinant of IMT in both controls (β = 0.08, p = 0.03) and hypertensives (β = 0.08, p = 0.01), but not of PWV either in controls (β = 0.006, p = 0.886 and β = 0.04, p = 0.19, respectively).

CONCLUSIONS

the main finding of our work is that MS is a significant determinant of IMT while this is not the case for PWV. This result have been confirmed both in hypertensive subjects and in healthy controls.

Metabolic syndrome and cardiovascular risk factors among female employees of a private educational institution in the Federal District, Brazil

BACKGROUND

Metabolic syndrome (MetS) is independently associated with type 2 diabetes and cardiovascular disease.

OBJECTIVE

To establish the frequency of MetS components and cardiovascular risk profile of female employees of a private educational institution in the Federal District, Brazil.

METHODS

Cross-sectional study performed with 120 female workers aged 20 to 59 years old allocated to the administration and outsourced departments. We administered a questionnaire to investigate demographic, socioeconomic and lifestyle characteristics, and performed anthropometric, blood pressure and biochemical measurements.

RESULTS

The sample comprised 120 participants, the largest proportion were aged 31 to 40 years old (47.5%) and 74 (61.7%) participants reported to be brown skinned. About 73.3% of the participants were rated insufficiently active, 81.7% reported not to smoke and 65% to consume alcohol 3 times/week. About 40% of the sample exhibited increased waist circumference and 43.3% excess weight. About 26.7% of the participants exhibited high blood sugar, 56.7% high triglyceride and 61.7% low HDL levels. About 10.1% of the sample exhibited borderline blood pressure levels. We found association between number of MetS components and age range and physical activity (p<0.05).

CONCLUSION

The participants exhibited a large number of MetS components and cardiovascular risk factors, high prevalence of excess weight, sedentary lifestyle and lipid profile abnormalities. Implementing public policies for health promotion, protection and support for workers likely to improve their working and living conditions in the medium and long term is indispensable.

Hypertension Survey in Italy: Novel Findings from the Campania Salute Network

The "Campania Salute" (CS) is a network system aimed at improving the management of essential hypertension by integrating the activity of general practitioners (GPs) with that of the hypertension specialists. It involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Napoli's metropolitan area, 60 randomly selected GPs homogeneously distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (co-ordinating centre). Through the CS system it is possible to share clinical data collected during each visit at peripheral units (general practitioners and community hospitals hypertensive clinics), which manage low-risk hypertensive patients, and the co-ordinating centre, which mainly manages high-risk hypertensive patients. The co-ordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients. Since the first reports on the CS network activity, it has been evident the effectiveness of this network in ameliorating the clinical management of the hypertensive disease. CS network is also a large prospective registry that generated several scientific reports based on the longitudinal assessment of hypertensive patients during their treatment. Nowadays, as observed in the Health Search Database, the rate of BP control in Campania was 69.5%, almost reaching the "Objective 70%", a result that could be in part linked to the activity of the CS network.

Differential effect of obesity on prevalence of cardiac and carotid target organ damage in hypertension (the Campania Salute Network)

BACKGROUND

Whether increasing body mass index (BMI) is independently associated with parallel increased prevalence of hypertensive vascular and cardiac target organ damage (TOD) needs further clarification.

METHODS

We analyzed 8815 hypertensive patients without prevalent cardiovascular disease, participating in the Campania Salute Network, grouped into BMI classes (normal 20-24.9kg/m², overweight 25-29.9kg/m² and obese ≥30kg/m²). Vascular and cardiac TOD was defined as ultrasound plaque (intima-media thickness>1.5mm) in >1 of the common or internal carotid arteries and echocardiographic left ventricular (LV) hypertrophy (LVH) (LV mass/height^2.7>47g/m^2.7 in women and >50g/m^2.7 in men), respectively.

RESULTS

A majority of patients were either overweight (49%) or obese (27%). In spite of more use of combination therapy, the obese group had higher blood pressure (BP) and prevalence of TOD. In multivariate logistic analyses, obesity was associated with a 6.9 times higher prevalence of LVH (95% confidence interval [CI] 5.84-8.17, p=0.0001), independent of significant associations with female sex, age, diabetes mellitus, office systolic BP, antihypertensive and antiplatelet treatment. In contrast, only a 17% increased prevalence of carotid plaques (OR=1.17; 95% CI 1.02-1.33, p=0.02) was found in obese patients independent of significant effect of male sex, older age and higher clinic systolic BP, an association that disappeared once effect of metabolic risk factors and related therapy was also considered.

CONCLUSIONS

In hypertensive patients participating in the Campania Salute Project, concomitant obesity was associated with a modestly increased prevalence of carotid plaques and a pronounced increase in prevalent LVH.

Associations of metabolic disorder factors with the risk of uncontrolled hypertension: a follow-up cohort in rural China

We evaluated how metabolic disorders affected antihypertension therapy. 2,912 rural Chinese patients with hypertension who provided blood samples, demographic and clinical data at baseline and after 1 year of antihypertension therapy were evaluated. At baseline, 1,515 patients (52.0%) were already receiving drug therapy and 11.4% of them had controlled blood pressure (BP). After 1 year, all 2,912 patients were receiving antihypertension therapy that was administered by community physicians, and 59.42% of them had controlled BP. Central obesity and abnormal triglyceride, high-density lipoprotein cholesterol, and glucose were associated with 15-70% higher risks of uncontrolled hypertension. Metabolic syndrome using the JIS criteria was associated with poor BP control (odds ratio: 1.71 and 1.54 for the baseline and follow-up datasets, respectively). The risk of uncontrolled hypertension increased with the number of metabolic disorders (p for trend <0.01). The presence of ≥3 metabolic disorder factors was associated with higher risks of poor BP control. The associations of metabolic factors and uncontrolled hypertension were stronger for the standard and modified ATP III criteria, compared to the IDF and JIS criteria. Metabolic factors were associated with less effective antihypertension therapy, and all definitions of metabolic syndrome helped identify patients with elevated risks of uncontrolled hypertension.

Effect of diabetes and metabolic syndrome on myocardial mechano-energetic efficiency in hypertensive patients. The Campania Salute Network

Reduced myocardial mechano-energetic efficiency (MEE), estimated as stroke volume/heart rate ratio per g of left ventricular (LV) mass (LVM), and expressed in μl s^-1 g^-1 (MEEi), is a strong predictor of cardiovascular (CV) events, independently of LV hypertrophy and other confounders, including type II diabetes (DM). Decreased MEEi is more frequent in patients with diabetes. In the present analysis we evaluated the interrelation among MEEi, DM and metabolic syndrome (MetS) in the setting of arterial hypertension. Hypertensive patients from the Campania Salute Network, free of prevalent CV disease and with ejection fraction >50% (n=12 503), were analysed. Coexistence of MetS and DM was ordinally categorized into 4 groups: 8235 patients with neither MetS nor DM (MetS-/DM-); 502 without MetS and with DM (MetS-/DM+); 3045 with MetS and without DM (MetS+/DM-); and 721 with MetS and DM (MetS+/DM+). After controlling for sex, systolic blood pressure, body mass index, relative wall thickness (RWT), antihypertensive medications and type of antidiabetic therapy, MEEi was 333 μl s^-1 g^-1 in MetS-/DM-, 328 in MetS-/DM+, 326 in MetS+/DM- and 319 in MetS+/DM+ (P for trend <0.0001). In pairwise comparisons (Sidak-adjusted), all conditions, except MetS-/DM+, were significantly different from MetS-/DM- (all P<0.02). No statistical difference was detected between MetS-/DM+ and MetS+/DM-. Both MetS and DM are associated with decreased MEEi in hypertensive patients, independently to each other, but the reduction is statistically less evident for MetS-/DM+. MetS+/DM+ patients have the lowest levels of MEEi, consistent with the alterations of energy supply associated with the combination of insulin resistance with insulin deficiency.

Development of Left Ventricular Hypertrophy in Treated Hypertensive Outpatients: The Campania Salute Network

There is little information on left ventricular (LV) hypertrophy (LVH) development during antihypertensive treatment. We evaluate incident LVH in a treated hypertensive cohort, the Campania Salute Network registry. We analyzed prospectively 4290 hypertensives (aged 50.3±11.1 years, 40% women) with at least 1-year follow-up, without LVH at baseline. Incident LVH was defined as the first detection of echocardiographic LV mass index ≥47 in women or ≥50 g/m^2.7 in men. During a median 48-month follow-up, 915 patients (21.3%) developed LVH. They were older, more frequently women, and obese (P<0.0001), with initial higher fasting glucose, diastolic and systolic blood pressure, LV mass index, lower heart rate and glomerular filtration rate, longer hypertension history and follow-up, and higher average systolic blood pressure during follow-up (all P<0.05), despite a more frequent treatment with Ca⁺⁺-channel blockers and diuretics (both P<0.02). At multivariable Cox regression, incident LVH was independently associated with older age, female sex, obesity, higher average systolic blood pressure during follow-up, and initial greater LV mass index (all P<0.02). By categorizing patients according to obesity and sex, obesity independently increased the risk for incident LVH in both sexes (obese versus nonobese men: hazard ratio, 1.34; confidence interval, 1.05-1.72; P=0.019; and obese versus nonobese women: hazard ratio, 1.34; confidence interval, 1.08-1.66; P=0.007). Despite more aggressive antihypertensive therapy, 21% of hypertensive patients develop clear-cut LVH. After adjusting for confounders, risk of incident LVH is particular relevant among women and is further increased by the presence of obesity.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02211365.

Obesity and hypertensive heart disease: focus on body composition and sex differences

There is evidence that hypertension is frequently associated with overweight/obesity even in kids and adolescents. Either conditions influence development of left ventricular (LV) hypertrophy (LVH), through different biological and hemodynamic mechanisms: obesity is conventionally thought to elicit a coherent growth of LV chamber dimensions and myocardial wall thickness (eccentric LV geometry), whereas a more accentuated increase in wall-thickness (concentric LV geometry) is attributed to hypertension. While during youth these differences are visible, proportion of LV concentric geometry, the most harmful LV geometric pattern, sharply raises in obese individuals during middle age, and becomes the most frequent geometric patterns among obese-hypertensive individuals. Two conditions with elevated hemodynamic impact, severe obstructive sleep apnea and masked hypertension contribute to the development of such a geometric pattern, but non-hemodynamic factors, and specifically body composition, also influence prevalence of concentric LV geometry. Contrasting a general belief, it has been observed that adipose mass strongly influences LV mass, particularly in women, especially when fat-free mass is relatively deficient. Thus, though blood pressure control is mandatory for prevention and reduction of LVH in obese hypertensive patients, without reduction of visceral adiposity regression of LVH is difficult. Future researches should be addressed on (1) assessing whether LVH resulting from alteration of body composition carries the same prognosis as pressure overload LVH; (2) defining tissue characterization of the hypertrophic heart in obese-hypertensive patients; (3) evaluating whether assessment of hemodynamic loading conditions and biological markers can help defining management of the association of obesity with hypertension.

Prevalence of metabolic components in university students

OBJECTIVE:

to identify the frequency of components of Metabolic Syndrome (MetS) among university students.

METHOD:

descriptive study with 550 students, from various courses run by a public university. The socioeconomic data, lifestyle, and components of MetS were filled out using a questionnaire. Blood sample collection was undertaken in the university itself by a contracted clinical analysis laboratory.

RESULTS:

66.2% were female, with a mean age of 22.6±4.41; 71.7% were sedentary; 1.8% stated that they smoke; and 48.5% were classified as at medium risk for alcoholism. 5.8% had raised abdominal circumference and 20.4% had excess weight; 1.3% and 18.9% had raised fasting blood glucose levels and triglycerides, respectively; 64.5% had low HDL cholesterol and 8.7% had blood pressure levels compatible with borderline high blood pressure. Thus, of the sample, 64.4% had at least one component for MetS; 11.6% had two, and 3.5% had three or more.

CONCLUSION:

a significant proportion of the population already has the components for metabolic syndrome, and this profile reinforces the importance of early diagnosis so as to reduce the risk of developing chronic comorbidities.

An update on telmisartan/hydrochlorothiazide combinations for the management of hypertensive patients with additional cardiovascular risk factors

International hypertension guidelines endorse the use of combination therapy to achieve blood pressure control in the majority of patients. Angiotensin AT1 receptor blockers, in combination with diuretics, are among the preferred combinations, with telmisartan plus hydrochlorothiazide (HCTZ) being an effective and well-tolerated combination. This article provides an up-to-date review of the existing data on telmisartan/HCTZ combination for the management of hypertension in patients with additional cardiovascular risk factors, including reports emerging from a number of recent clinical trials and secondary analyses of older trials. The accumulated evidence from clinical trials demonstrates that telmisartan/HCTZ combinations are effective and well tolerated in patients with mild-to-severe hypertension, including subgroups of patients with cardiovascular risk factors such as advanced age, obesity, chronic kidney disease, diabetes mellitus and treatment-resistant hypertension.

Efficacy of Single-Pill Combination of Telmisartan 80 mg and Hydrochlorothiazide 25 mg in Patients with Cardiovascular Disease Risk Factors: A Prospective Subgroup Analysis of a Randomized, Double-Blind, and Controlled Trial

Objective. Report of prespecified and post hoc subgroup analyses of a randomized, controlled trial comparing telmisartan 80 mg/hydrochlorothiazide 25 mg (T80/H25) combination therapy with T80 monotherapy, according to the presence of cardiovascular disease (CVD) risk factors. Methods. Hypertensive patients were randomized (2 : 1) to receive T80/H25 or T80 for 6 weeks, following a 1-week, low-dose, and run-in period. Systolic blood pressure (SBP) and diastolic BP reductions and BP goal achievement were evaluated in patients with CVD risk factors: presence of diabetes mellitus (DM), renal impairment, increased body mass index (BMI), and 10-year estimated risk for coronary heart disease (CHD). Results. In total, 888 patients received treatment. Overall, T80/H25 therapy significantly reduced SBP more than T80 monotherapy, irrespective of patient subgroup. In patients with DM, renal impairment, high BMI, and high CHD risk, BP goal achievement rates (<140/90 mm Hg) at Week 7, among those treated with T80/H25, were 52.8%, 52.8%, 50.6%, and 38.5%, respectively. More patients with DM reached a guideline-based BP goal (<130/80 mm Hg) at 7 weeks with T80/H25 than with T80 monotherapy (16.7% versus 8.8%). Rates of treatment-related adverse events were low and comparable across patient subgroups. Conclusions. Antihypertensive treatment with T80/H25 single-pill combination is effective and generally well tolerated, irrespective of the presence of CVD risk factors.

Comparison of the effect of combination therapy with an angiotensin II receptor blocker and either a low-dose diuretic or calcium channel blocker on cardiac hypertrophy in patients with hypertension

Left ventricular hypertrophy (LVH) regression is an important issue in hypertensive patients. Patients with LVH who had received the angiotensin receptor blocker (ARB) treatment for 8 weeks and had not reached the target blood pressure level were enrolled in the study. Patients were assigned to either losartan (50 mg)/hydrochlorothiazide (HCTZ, 12.5 mg) group or ARB + CCB group (usual dose of ARB and calcium channel blocker, CCB). After 48 weeks, LV mass index was found to be reduced significantly in the losartan/HCTZ group but not in the ARB + CCB group. These results suggest that combination therapy of an ARB and diuretic has greater potential to cause regression compared with an ARB and CCB.