H-Type hypertension, stroke and diabetes in China: Opportunities for primary prevention

Relationship between TyG index and the degree of coronary artery lesions in patients with H-type hypertension

BACKGROUND

The TyG index, a prominent metric for assessing insulin resistance, has gained traction as a prognostic tool for cardiovascular disease. Nevertheless, the understanding of the prognostic significance of the extent of coronary artery stenosis in individuals afflicted with H-type hypertension remains limited.

METHODS

A retrospective study was conducted at Wuhan Third Hospital, including a cohort of 320 inpatients who were diagnosed with hypertension in combination with coronary artery disease. The study period spanned from January 1, 2021, to February 1, 2023. The study cohort was stratified based on the severity of stenosis into three distinct groups: low stenosis, medium stenosis, and high stenosis, as determined by the Gensini score derived from coronary angiography findings. The present study aimed to investigate the association between the severity of coronary stenosis and the number of lesion branches, utilizing the TyG index as a testing indicator. The predictive ability of TyG for coronary lesion severity was assessed using logistic regression analysis.

RESULTS

The results of our study indicate a positive correlation between elevated levels of TyG and an increased susceptibility to severe stenosis in individuals diagnosed with H-type hypertension. Upon careful consideration of potential confounding variables, it has been observed that the TyG index exhibits a robust association with the likelihood of severe stenosis in individuals with H-type hypertension (odds ratio [OR] = 4000, 95% confidence interval CI 2.411-6.635, p = 0.0001), as well as the prevalence of multivessel disease (OR = 1.862, 95% CI 1.036-3.348, p < 0.0001). The TyG index demonstrated superior predictive ability for severe coronary stenosis in patients with H-type hypertension compared to those without H-type hypertension (area under the curve [AUC] = 0.888, 95% confidence interval CI 0.838-0.939, p < 0.0001, versus AUC = 0.615, 95% CI 0.494-0.737, p < 0.05).

CONCLUSION

The TyG index is an independent risk factor for the degree of coronary stenosis and a better predictor in patients with H-type hypertension combined with coronary artery disease.

Association between triglyceride glucose index and H-type hypertension in postmenopausal women

Background

Recent studies have reported better predictive performance of triglyceride glucose (TyG) index for cardiovascular events in women, however, whether this association persists in postmenopausal women is inconclusive. We investigated the association between TyG index and H-type hypertension (HHT) in postmenopausal women.

Methods

1,301 eligible women with hypertension were included in this cross-sectional study. Concomitant homocysteine levels >10 μmol/L were defined as H-type hypertension. The TyG index was calculated as ln [triglycerides (mg/dl) × fasting glucose (mg/dl)/2]. Multivariable logistic regression models and restricted cubic spline models were used to assess the association between TyG index and H-type hypertension in postmenopausal women, and subgroup analyses were performed for potential confounders.

Results

Of the 1,301 hypertensive patients, 634 (48.7%) participants had H-type hypertension. In each adjusted model, TyG index was significantly associated with the risk of H-type hypertension. each 1-unit increase in TyG index was associated with an increased risk of H-type hypertension in all participants (OR = 1.6; 95% CI, 1.3-2.0; P < 0.001), and there was a linear relationship between TyG index and H-type hypertension (P for linear trend < 0.001).

Conclusion

TyG index is positively associated with H-type hypertension in postmenopausal women, suggesting that TyG index may be a promising marker for H-type hypertension. By controlling lipid levels and blood glucose levels, it may help prevent H-type hypertension in postmenopausal women.

Combined use of amlodipine and folic acid are significantly more efficacious than amlodipine alone in lowering plasma homocysteine and blood pressure among hypertensive patients with hyperhomocysteinemia and intolerance to ACEI: A multicenter, randomized, double-blind, parallel-controlled clinical trial

Hyperhomocysteinemia with hypertension can synergistically increase the risk of stroke. The China stroke primary prevention trial showed that combining 0.8 mg folic acid (FA) with angiotensin-converting enzyme inhibitor (ACEI) can effectively lower plasma total homocysteine (tHcy) and blood pressure (BP); and reduce first stroke risk by additional 21% compared to ACEI alone. However, intolerance to ACEI is common in Asians and amlodipine can be alternative. This is a multicenter, randomized, double-blind, parallel-controlled clinical trial (RCT) which evaluated whether amlodipine combined with FA is more efficacious than amlodipine alone in lowering tHcy and BP among Chinese hypertensive with hyperhomocysteinemia and intolerance to ACEI. 351 Eligible patients were randomly assigned by 1:1:1 ratio to receive amlodipine-FA tablet daily (amlodipine 5 mg/FA 0.4 mg, A group); amlodipine 5 mg/FA 0.8 mg tablet daily (B group); amlodipine 5 mg daily (C group, control group). Follow-up was conducted at 2, 4, 6, and 8 weeks. The primary outcome was efficacy of lowering both tHcy and BP at the end of 8-week treatment. Compared with C group, A group had a significantly higher rate of lowering both tHcy and BP (23.3% vs. 6.0%; Odds Ratio [OR], 8.68; 95% CI, 3.04-24.78, P < .001); B group also had a higher rate of lowering both tHcy and BP (20.3% vs. 6.0%; OR: 5.90; 95% CI, 2.11-16.47, P < .001). This RCT showed amlodipine combined with FA compared with amlodipine alone, each had significantly higher efficacy of lowering both tHcy and BP. No difference was found in BP-lowering and occurrence of adverse events between the three groups.

H-type hypertension is a risk factor for chronic total coronary artery occlusion: a cross-sectional study from southwest China

BACKGROUND

Chronic total coronary occlusion (CTO) is serious and the "last bastion" of percutaneous coronary intervention. Hypertension and hyperhomocysteinemia (HHCY) are synergistic and significantly increase cardiovascular event risk. The relationship between H-type hypertension and CTO remains unclear; thus, this cross-sectional study investigated this potential association.

METHODS

Between January 2018 and June 2022, 1446 individuals from southwest China were recruited to participate in this study. CTO was defined as complete coronary artery occlusion persisting for over three months. H-type hypertension was defined as hypertension with plasma homocysteine levels ≥ 15 µmol/L. Multivariate logistic regression models were applied to assess the association between H-type hypertension and CTO. Receiver operating characteristic (ROC) curves were generated to determine the accuracy of H-type hypertension in predicting CTO.

RESULTS

Of the 1446 individuals, 397 had CTO, and 545 had H-type hypertension. After multivariate adjustment, the odds ratio (OR) for CTO in individuals with H-type hypertension was 2.3-fold higher (95% CI 1.01-5.26) than that in healthy controls. The risk of CTO is higher in individuals with H-type hypertension than in those with isolated HHCY and hypertension. The area under the ROC curve for CTO was 0.685 (95% CI, 0.653-0.717) for H-type hypertension.

CONCLUSIONS

In southwest China, H-type hypertension is significantly related to the occurrence of CTO.

TRIAL REGISTRATION

This retrospective study was registered with the Chinese Clinical Trials Registry ( http://www.chictr.org.cn , ChiCTR2100050519.2.2).

A U-shaped association between dietary phosphorus intake and new-onset hypertension: a nationwide cohort study in China

BACKGROUND

The association between dietary phosphorus intake and the risk of hypertension remains uncertain. We aimed to investigate the relation of dietary phosphorus intake with new-onset hypertension among Chinese adults.

METHODS

A total of 12,177 participants who were free of hypertension at baseline from the China Health and Nutrition Survey (CHNS) were included. Dietary intake was measured by 3 consecutive 24-hour dietary recalls combined with a household food inventory. New-onset hypertension was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or diagnosed by a physician or under antihypertensive treatment during the follow-up.

RESULTS

During a median follow-up of 6.1 years, 4,269 participants developed new-onset hypertension. Overall, the association between dietary phosphorus intake and new-onset hypertension followed a U-shape (P for nonlinearity<.001). Consistently, when dietary phosphorus intake was assessed as quintiles, compared with those in the 3rd to 4th quintiles (912.0-<1089.5 mg/d), a significantly higher risk of new-onset hypertension was found in participants in the 1st to 2nd quintiles (<912.0 mg/d: HR, 1.23; 95% CI, 1.14-1.33), and the fifth quintile (≥1089.5 mg/d: HR, 1.21; 95% CI, 1.10-1.33).

CONCLUSION

There was a U-shaped association between dietary phosphorus intake and new-onset hypertension in general Chinese adults.

Circulating level of homocysteine contributes to diabetic retinopathy associated with dysregulated lipid profile and impaired kidney function in patients with type 2 diabetes mellitus

BACKGROUND

To test the hypothesis that elevated plasma levels of homocysteine (Hcy) and lipoprotein (a) (LPA) contribute to diabetic retinopathy (DR) associated with dysregulated lipid profile, dyslipidaemia, and kidney function.

METHODS

A total of 83 patients with type 2 diabetes mellitus (T2DM) were enrolled in this prospective case-control study. Patients were categorized into those with no DR (DM), non-proliferative DR (NPDR), and proliferative DR (PDR). Age and sex-matched individuals with no diabetes were included in the control group. Biochemical tests, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), Hcy, LPA, lipid profile, and urine microalbumin (UMA), were evaluated.

RESULTS

Hcy was negatively correlated with high-density lipoprotein-cholesterol (HDL-C) (p < 0.05), but positively correlated with [total cholesterol (TC)-HDL-C)/HDL-C] (p < 0.05), low-density lipoprotein cholesterol (LDL-C)/HDL-C (p < 0.05), and UMA (p < 0.05). Traditional risk factors, Hcy, arteriosclerosis-associated plasma indices, and UMA, resulted as the independent risk factors for the occurrence of DM and DR. After controlling for age, sex, duration of DM, and FBG, a multiple ordinal logistic regression model showed that LPA [OR = 2.90, 95% confidence interval (95% CI) 1.16-7.23, p = 0.023)], LDL-C (OR = 4.28, 95% CI 1.24-14.79, p = 0.021), and (TC-HDL-C)/HDL-C (OR = 1.92, 95% CI 1.05-3.53, p = 0.035) were risk factors for DM and DR.

CONCLUSIONS

Hcy and LPA contributed to DM and DR. Hcy was positively correlated with kidney dysfunction and the ratios of lipid profiles, and negatively with HDL-C, LPA, LDL-C, and (TC-HDL-C)/HDL-C resulted as predictors of the occurrence of DM and severity of DR.

Serum homocysteine level is an independent risk factor for 1-year stroke recurrence in patients with acute ischemic stroke and H-type hypertension: results from the Xi'an stroke registry study of China

Background

H-type hypertension has a high prevalence in China. However, the association of serum homocysteine levels with 1-year stroke recurrence in patients with acute ischemic stroke (AIS) and H-type hypertension has not been studied.

Methods

A prospective cohort study of patients with AIS admitted to hospitals between January and December 2015 in Xi'an, China, was conducted. Serum homocysteine levels, demographic data, and other relevant information were collected from all patients upon admission. Stroke recurrences were routinely tracked at 1, 3, 6, and 12 months after discharge. The blood homocysteine level was studied as a continuous variable and tertiles (T1-T3). A multivariable Cox proportional hazard model and a two-piecewise linear regression model were utilized to evaluate the association and ascertain the threshold effect regarding the serum homocysteine level and 1-year stroke recurrence in patients with AIS and H-type hypertension.

Results

Overall, 951 patients with AIS and H-type hypertension were enrolled, of whom 61.1% were male. After adjusting for confounders, patients in T3 had a significantly increased risk of recurrent stroke within 1 year, compared with those in T1 as the reference (hazard ratio = 2.24, 95% confidence interval: 1.01-4.97, p = 0.047). Curve fitting showed that serum homocysteine levels were positively curvilinearly correlated with 1-year stroke recurrence. Threshold effect analysis showed that an optimal threshold of serum homocysteine level <25 μmol/L was effective in reducing the risk of 1-year stroke recurrence in patients with AIS and H-type hypertension. Elevated homocysteine levels in patients with severe neurological deficits on admission significantly increased the risk of 1-year stroke recurrence (p for interaction = 0.041).

Conclusions

In patients with AIS and H-type hypertension, the serum homocysteine level was an independent risk factor for 1-year stroke recurrence. A serum homocysteine level of ≥25 μmol/L significantly increased the risk of 1-year stroke recurrence. These findings can inform the creation of a more precise homocysteine reference range for the prevention and treatment of 1-year stroke recurrence in patients with AIS and H-type hypertension and provide a theoretical foundation for the individualized prevention and treatment of stroke recurrence.

Exploring the association of dietary patterns with the risk of hypertension using principal balances analysis and principal component analysis

OBJECTIVE

In the field of nutritional epidemiology, principal component analysis (PCA) has been used extensively in identifying dietary patterns. Recently, compositional data analysis (CoDA) has emerged as an alternative approach for obtaining dietary patterns. We aimed to directly compare and evaluate the ability of PCA and principal balances analysis (PBA), a data-driven method in CoDA, in identifying dietary patterns and their associations with the risk of hypertension.

DESIGN

Cohort study. A 24-h dietary recall questionnaire was used to collect dietary data. Multivariate logistic regression analysis was used to analyse the association between dietary patterns and hypertension.

SETTING

2004 and 2009 China Health and Nutrition Survey.

PARTICIPANTS

A total of 3892 study participants aged 18-60 years were included as the subjects.

RESULTS

PCA and PBA identified five patterns each. PCA patterns comprised a linear combination of all food groups, whereas PBA patterns included several food groups with zero loadings. The coarse cereals pattern identified by PBA was inversely associated with hypertension risk (highest quintile: OR = 0·74 (95 % CI 0·57, 0·95); Pfor trend = 0·037). None of the five PCA patterns was associated with hypertension. Compared with the PCA patterns, the PBA patterns were clearly interpretable and accounted for a higher percentage of variance in food intake.

CONCLUSIONS

Findings showed that PBA might be an appropriate and promising approach in dietary pattern analysis. Higher adherence to the coarse cereals dietary pattern was associated with a lower risk of hypertension. Nevertheless, the advantages of PBA over PCA should be confirmed in future studies.

J-shaped association between dietary zinc intake and new-onset hypertension: a nationwide cohort study in China

We aimed to investigate the relationship of dietary zinc intake with new-onset hypertension among Chinese adults. A total of 12,177 participants who were free of hypertension at baseline from the China Health and Nutrition Survey were included. Dietary intake was assessed by three consecutive 24-h dietary recalls combined with a household food inventory. Participants with systolic blood pressure ≽ 140 mmHg or diastolic blood pressure ≽ 90 mmHg or diagnosed by a physician or under antihypertensive treatment during the follow-up were defined as having new-onset hypertension. During a median follow-up duration of 6.1 years, 4269 participants developed new-onset hypertension. Overall, the association between dietary zinc intake and new-onset hypertension followed a J-shape (P for non-linearity < 0.001). The risk of new-onset hypertension significantly decreased with the increment of dietary zinc intake (per mg/day: hazard ratio (HR) 0.93; 95% confidence interval (CI) 0.88-0.98) in participants with zinc intake < 10.9 mg/day, and increased with the increment of zinc intake (per mg/day: HR 1.14; 95% CI 1.11-1.16) in participants with zinc intake ≽ 10.9 mg/day. In conclusion, there was a J-shaped association between dietary zinc intake and new-onset hypertension in general Chinese adults, with an inflection point at about 10.9 mg/day.

Lowering serum homocysteine in H-type hypertensive patients with atrial fibrillation after radiofrequency catheter ablation to prevent atrial fibrillation recurrence

Background

Prior investigation revealed that elevated serum total homocysteine (tHcy) are strongly correlated with atrial fibrillation (AF) recurrence. Herein, the goal of this study was to elucidate whether folic acid (FA) treatment reduced AF recurrence following radiofrequency catheter ablation (RFCA).

Methods

To conduct this retrospective research, we included consecutive H-type hypertensive AF patients, who were treated with first RFCA, between January 2010 and January 2022. We assessed the AF recurrence risk between patients who were taking 10 mg enalapril and 0.8 mg FA in a single-pill combination (enalapril–FA) daily and those who were taking a pill of 10 mg enalapril only. Outcomes were compared using the propensity-score matched analysis. Cox regression model was employed for the evaluation of AF recurrence events.

Results

Out of 2,714 patients, 645 patients receiving enalapril and 282 patients receiving enalapril-FA were included for analysis. Following propensity score matching, 239 patients remained in each group. These patients were followed-up for a median of 379 (137–596) days, and revealed that the enalapril-FA patients had drastically reduced AF recurrence, compared to the enalapril patients [adjusted hazard ratio (HR), 0.68; 95% confidence interval (CI), 0.48–0.97; P = 0.029]. Apart from this, no interactions were detected in the subgroup analysis.

Conclusion

In H-type hypertensive AF patients who were treated with first RFCA, FA supplementation was correlated with a reduced AF recurrence risk.

Association between serum 5-methyltetrahydrofolate and homocysteine in Chinese hypertensive participants with different MTHFR C677T polymorphisms: a cross-sectional study

Background and aims

Clarifying the association between 5-methyltetrahydrofolate and homocysteine and the effect pattern of methylene tetrahydrofolate reductase (MTHFR C677T) may contribute to the management of homocysteine and may serve as a significant reference for a randomized controlled trial of 5-methyltetrahydrofolate intervention. This study aimed to reveal the association between these two biochemical indices.

Methods

Study population was drawn from the baseline data of the China Stroke Primary Prevention Trial (CSPPT), including 2328 hypertensive participants. 5-methyltetrahydrofolate and homocysteine were determined by stable-isotope dilution liquid chromatography-tandem mass spectrometry and automatic clinical analyzers, respectively. MTHFR C677T polymorphisms were detected using TaqMan assay. Multiple linear regression was performed to evaluate the association between serum 5-methyltetrahydrofolate and homocysteine.

Results

There was a significant inverse association between 5-methyltetrahydrofolate and homocysteine when 5-methyltetrahydrofolate was ≤ 10 ng/mL, and this association was modified by MTHFR C677T (per 1-ng/mL increment; All: β = − 0.50, P <  0.001; CC: β = − 0.14, P = 0.087; CT: β = − 0.20, P = 0.011; TT: β = − 1.19, P <  0.001). Moreover, the decline in trend in genotype TT participants was stronger than in genotype CC participants (P for difference <  0.001) and genotype CT participants (P for difference <  0.001), while there was no significant difference between genotype CC and genotype CT participants (P for difference = 0.757).

Conclusions

Our data showed a non-linear association between serum homocysteine and 5-methyltetrahydrofolate among Chinese hypertensive adults, however, it could be inversely linearly fitted when serum 5-methyltetrahydrofolate was ≤ 10 ng/mL, and this association was modified by MTHFR C677T.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-022-00786-w.

Association of Plasma Bilirubin Levels With Peripheral Arterial Disease in Chinese Hypertensive Patients: New Insight on Sex Differences

Background and aims: Previous studies have indicated that Plasma total bilirubin (TBiL) might play an essential role in peripheral arterial disease (PAD). However, the effects of different levels of TBiL on PAD development remain uncertain. We aimed to examine the TBiL and the prevalence of PAD among Chinese adults with hypertension, with particular attention paid to sex differences.

Methods: A total of 10,900 hypertensive subjects were included in the current study. The mean age of our study participants was 63.86 ± 9.25 years, and there were 5,129 males and 5,771 females. The outcome was peripheral arterial disease (PAD), defined as present when the ankle-brachial index (ABI) of either side was ≤0.90. The association between TBiL and PAD was examined using multivariate logistic regression analysis and the restricted cubic spline.

Results: Of 10,900 hypertensive participants, 350 (3.21%) had PAD, and the mean plasma total bilirubin was 14.66 (6.86) μmol/L. The mean TBiL was 15.67 μmol/L in men and 13.76 μmol/L in women. The smoothing curve showed that a U-shaped curve association existed between TBiL and the prevalence of PAD in Chinese adults with hypertension. When stratified by sex, TBiL was significantly U-shaped associated with PAD among men but not women. Among males, the inflection point was 11.48 μmol/L; to the left inflection point, the effect size and 95% CI were 0.08, 0.01, 0.66, respectively; to the right inflection point, OR, 5.16; 95% CI,1.64, 16.25.

Conclusions: We found an independent U-shaped association between TBiL and the prevalence of PAD among hypertensive subjects and a differential association between men and women. We further revealed a turning point by threshold effect analysis.

Association of MTHFR Polymorphisms with H-Type Hypertension: A Systemic Review and Network Meta-Analysis of Diagnostic Test Accuracy

Purpose

An association between MTHFR polymorphisms and H-type hypertension (H-HTN) has been investigated by epidemiological studies, but results have been inconsistent. Thus, a systematic assessment of the association was performed based on a literature review and pooled analysis, to provide stronger evidence on the effects of single nucleotide polymorphisms on H-HTN risk.

Methods

Three investigators independently retrieved relevant studies in PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Database, and China Biomedical Literature Database (CBM). A fixed or random effects model was selected to calculate pooled odds ratio (OR) and 95% confidence intervals (CIs). A network meta-analysis of diagnostic test and Thakkinstian's algorithm were used to select the most appropriate genetic model, along with false-positive report probability (FPRP) for noteworthy associations. All data were processed using Stata 15.0 and Meta-Disc.

Results

A total of 14 studies involving 1759 cases and 1581 controls for MTHFR were included in our meta-analysis. In a direct meta-analysis, we found that MTHFR C667T rs1801133 significantly increased the risk of H-HTN susceptibility except for an overdominant model. However, MTHFR A1298C rs1801131 polymorphism had no significant correlation with H-HTN risk. Besides, MTHFR C667T rs1801133 is a potential diagnostic biomarker for estimating H-HTN risk. The results indicated that the dominant model was an optimal diagnosis model for excluding diseases, which could reduce a missed diagnosis rate and further improve the accuracy of disease diagnosis.

Conclusion

The present result suggests that MTHFR C667T rs1801133 polymorphism is associated with H-HTN risk and may act as a promising predictive biomarker for H-HTN risk. However, further well-designed studies are warranted to confirm these results.

Explore the Role of the rs1801133-PPARG Pathway in the H-type Hypertension

Both rs1801133 mutation on Methylenetetrahydrofolate reductase (MTHFR) gene and transcription factor peroxisome proliferator-activated gamma (PPARG) have been associated with plasma homocysteine (Hcy) levels and hypertension. However, their role in H-type hypertension remains unclear. In this study, we first tested the association between rs1801133 genotypes and Hcy level in H-type hypertension using clinical profiles collected from 203 patients before and after the treatment using enalapril maleate and folic acid tablets (EMFAT). Then, we constructed a literature-based pathway analysis to explore the role of the rs1801133-PPARG signaling pathway in H-type hypertension and its treatment. Although presented similar blood pressure, the patients with TT genotype of rs1801133 were much younger ( $p$ value <0.05) and significantly higher in Hcy levels ( $x^2=6.11$ and $p<0.005$ ) than that in the CC and CT genotype groups. Pathway analysis showed that T-allele of rs1801133 could inhibit the expression of PPARG through the downregulation of folate levels and upregulation of Hcy levels, which increased the risk of hypertension and hyperhomocysteinemia. Treatment using EMFAT led to similarly decreased Hcy levels for all patients with different genotypes ( $x^2=86.00$ ; $p<0.36$ ), which may occur partially through the activation of PPARG. Moreover, even after treatment, the patients with TT genotype still presented significantly higher Hcy levels ( $x^2=7.87$ and $p<0.001$ ). Our results supported that rs1801133 mutation could play a role in H-type hypertension, which might be partially through the downregulation of PPARG. Moreover, PPARG might also be involved in treating H-type hypertension using EMFAT.

Associations of Serum and Red Blood Cell Folate With All-Cause and Cardiovascular Mortality Among Hypertensive Patients With Elevated Homocysteine

Objectives

This study aims to explore the associations between serum and red blood cell (RBC) folate as indicators of short- and long-term folate status, respectively, and all-cause as well as CVD mortality among hypertensive patients with elevated homocysteine.

Methods

A prospective cohort study of the National Health and Nutrition Examination Survey (1999–2006) and 2015 Linked Mortality File was performed. All-cause and CVD mortality risk estimated using Cox proportional hazards models with adjusting for multiple potential covariates.

Results

A total of 1,753 hypertensive patients with elevated homocysteine [mean (SD) age, 68.5 (13.1)] were included in the analysis. During a median follow-up of 10.0 years, a total of 899 all-cause and 257 CVD deaths occurred. Compared the highest with the lowest quartile of RBC folate, the multivariable adjusted hazard ratios and 95% confidence intervals for all-cause and CVD death were 1.13 (0.92–1.39) and 1.47 (1.01–2.16) respectively. There was a significant and positive trend between RBC folate and the risk of CVD death (p for trend = 0.0196). No significant association was found between serum folate and mortality risk among the study sample.

Conclusions

High level of RBC folate is associated with an increased risk of cardiovascular mortality among hypertensive patients with elevated homocysteine while serum folate has no such effects.

The Relative Contribution of Plasma Homocysteine Levels vs. Traditional Risk Factors to the First Stroke: A Nested Case-Control Study in Rural China

Background

Approximately 75% of Chinese hypertensive patients have elevated homocysteine (Hcy). Its implication in risk assessment and prevention of the first stroke remains an important clinical and public health question.

Methods

This study was based on a community cohort recruited from 2016 to 2018 in the rural China. To maximize cost efficiency, we used a nested case-control design, including 3,533 first stroke cases and 3,533 controls matched for age ±1 years, sex, and village. Individual associations of tHcy and traditional risk factors with the first stroke were examined, and their population-attributable risks (PARs) were estimated.

Results

There was a significant dose-response association between first stroke and total Hcy (tHcy) levels, with adjusted odds ratios of 1.11 (95% CI: 0.97, 1.26) for tHcy 10–15 μmol/L and 1.44 (1.22, 1.69) for tHcy ≥ 15 μmol/L, all compared to tHcy &lt; 10 μmol/L. A similar trend was found for ischemic and hemorrhagic stroke. tHcy and systolic blood pressure (SBP) were independently and additively associated with the risk of first stroke (tHcy: 1.06 [1.02, 1.1]; SBP: 1.13 [1.1, 1.16]; P-interaction, 0.889). Among the ten main risk factors examined, the top two contributors to the first stroke were SBP and tHcy, with PARs of 25.73 and 11.24%, respectively.

Conclusions

Elevated tHcy is the second most important contributor and acts additively with SBP to increase the risk of the first stroke. This finding underscores the importance of screening and treating elevated tHcy along with traditional risk factors to further reduce the burden of the first stroke in the high-risk populations.

Association Between Hyperhomocysteinemia Combined with Metabolic Syndrome and Higher Prevalence of Stroke in Chinese Adults Who Have Elevated Blood Pressure

Background

Hyperhomocysteinemia (HHcy) and metabolic syndrome (MS) are established cardiovascular risk factors of stroke and are frequently associated with hypertension. However, studies on the association between HHcy combined with MS and stroke risk in hypertensive patients were absent.

Material/Methods

In 14 059 selected participants with elevated blood pressure, we assessed the prevalence of the MS and stroke. We defined HHcy as plasma total homocysteine >15 μmol/L. MS was defined according to the Chinese Diabetes Society (CDS) criterion. Multivariable analysis was used to examine the association of HHcy or (and) MS with stroke risk in different models.

Results

The prevalence rates of HHcy and MS were 49.96% and 42.21%, respectively. Patients with stroke had higher plasma total homocysteine levels and a higher prevalence of MS (P<0.001). Multivariable analyses indicated that HHcy and MS are independently associated with higher prevalence of stroke (adjusted-odds ratio (OR): 1.36, 95% CI 1.17 to 1.58, P<0.001; adjusted-OR: 1.68, 95% CI 1.44 to 1.96, P<0.001, respectively). Those with combined HHcy and MS had higher odds of stroke than those with isolated HHcy or MS (adjusted-OR: 1.78, 95% CI 1.47 to 2.15, P<0.001; adjusted-OR: 1.39, 95% CI 1.13 to 1.70, P=0.002, respectively).

Conclusions

HHcy combined with MS was associated with higher prevalence of stroke in Chinese adults with elevated blood pressure.

Urinary albumin-to-creatinine ratio and the risk of first stroke in Chinese hypertensive patients treated with angiotensin-converting enzyme inhibitors

We aimed to evaluate the relationship of the albumin-to-creatinine ratio (ACR) with the risk of first stroke and examine possible effect modifiers in hypertensive patients. A total of 11,632 hypertensive participants with urinary ACR measurements and without a history of stroke from the China Stroke Primary Prevention Trial (CSPPT) were included in this analysis. The primary outcome was first stroke. Over a median follow-up of 4.4 years, 728 first strokes were identified, of which 633 were ischemic, 89 were hemorrhagic, and 6 were uncertain types. Overall, there was a significant positive association between natural log-transformed ACR and the risk of first stroke (HR, 1.11; 95% CI: 1.03-1.20) and first ischemic stroke (HR, 1.12; 95% CI: 1.03-1.22). Consistently, participants with ACR ≥ 10 mg/g had a significantly higher risk of first stroke (HR, 1.26; 95% CI: 1.06-1.50) and first ischemic stroke (HR, 1.33; 95% CI: 1.10-1.59) than those with ACR < 10 mg/g. Moreover, the association of ACR with first stroke was significantly stronger in participants with higher total homocysteine (tHcy) levels (<10 versus ≥ 10 μmol/L; P for interaction = 0.044). However, there was no significant association between ACR and first hemorrhagic stroke (per natural log [ACR] increment: HR, 1.02; 95% CI: 0.82-1.27). In summary, hypertensive patients with ACR ≥ 10 mg/g had a significantly increased risk of first stroke or first ischemic stroke. This positive association was more pronounced among participants with higher tHcy levels.

Exploration of the risk factors of essential hypertension with hyperhomocysteinemia: A hospital-based study and nomogram analysis

OBJECTIVES

To explore the risk factors of essential hypertension with hyperhomocysteinemia (H-type hypertension) and design a nomogram to predict this risk.

METHODS

A hospital-based study was conducted on 1,712 individuals, including 282 patients with H-type hypertension, 105 patients with simple hypertension, 645 individuals with hyperhomocysteinemia, and 680 healthy controls. Logistic regression and nomogram models were applied to evaluate the risk factors.

RESULTS

Logistic regression showed that advanced age, male sex, high body mass index (BMI), high total cholesterol levels, high glucose levels, and high creatinine levels were risk factors of H-type hypertension in the healthy population and were integrated into the nomogram model. Advanced age, male sex, high BMI, high total cholesterol levels, and high glucose levels were shown to be risk factors of H-type hypertension in the hyperhomocysteinemia population. Male sex and high creatinine levels were shown to be risk factors of H-type hypertension in the hypertension population. Nomogram analysis showed that the total factor score ranged from 106 to 206, and the corresponding risk rate ranged from 0.05 to 0.95.

CONCLUSIONS

Men are more likely to have H-type hypertension, and advanced age, high BMI, high total cholesterol levels, and high glucose levels are risk factors of H-type hypertension in healthy and hyperhomocysteinemia populations. Furthermore, high creatinine level is a risk factor of H-type hypertension in healthy and hypertension populations. Nomogram models may be used to intuitively evaluate H-type hypertension risk and provide a basis for personalized interventions.

Evaluation of Dietary Niacin and New-Onset Hypertension Among Chinese Adults

IMPORTANCE

The relationship of dietary niacin intake with the risk of hypertension remains unknown.

OBJECTIVE

To determine the prospective association between dietary niacin intake and new-onset hypertension, and examine factors that may modify the association among Chinese adults.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cohort study of 12 243 Chinese adults used dietary intake data from 7 rounds of the China Health and Nutrition Survey. Dietary intake was measured by 3 consecutive 24-hour dietary recalls from participants in combination with a weighing inventory taken over the same 3 days at the household level. Statistical analysis was conducted from May 2020 to August 2020.

EXPOSURES

Dietary intake.

MAIN OUTCOMES AND MEASURES

The study outcome was new-onset hypertension, defined as systolic blood pressure 140 mm Hg or greater and/or diastolic blood pressure 90 mm Hg or greater, diagnosis by physician, or current antihypertensive treatment during the follow-up.

RESULTS

The mean (SD) age of the study population was 41.2 (14.2) years, and 5728 (46.8%) of participants were men. The mean (SD) dietary niacin intake level was 14.8 (4.1) mg/d. A total of 4306 participants developed new-onset hypertension during a median (interquartile range) follow-up duration of 6.1 (3.6-11.3) years. When dietary niacin was assessed in quartiles, the lowest risk of new-onset hypertension was found in participants in quartile 3 (14.3 to <16.7 mg/d; adjusted hazard ratio, 0.83; 95% CI, 0.75-0.90) compared with those in quartile 1 (<12.4 mg/d). Consistently in the threshold analysis, for every 1 mg/d increase in dietary niacin, there was a 2% decrease in new-onset hypertension (adjusted HR, 0.98; 95% CI, 0.96-1.00) in those with dietary niacin intake less than 15.6 mg/d, and a 3% increase in new-onset hypertension (adjusted HR, 1.03; 95% CI, 1.02-1.04) in participants with dietary niacin 15.6 mg/d or greater. Based on these results, there was a J-shaped association between dietary niacin intake and new-onset hypertension in the general population of Chinese adults, with an inflection point at 15.6 mg/d and a minimal risk at 14.3 to 16.7 mg/d (quartile 3) of dietary niacin intake.

CONCLUSIONS AND RELEVANCE

The results of this study provide some evidence for maintaining the optimal dietary niacin intake levels for the primary prevention of hypertension.

Association of serum VLDL level with hyperhomocysteinemia in hypertensive patients: A cross-sectional study

BACKGROUND

Increasing evidence suggests that hyperhomocysteinemia (HHcy) and hyperlipidemia have been recognized as two independent risks for cardiovascular disease. However, the association between hyperlipidemia and HHcy in hypertensive patients has not been systemically elucidated. The aim of this study was to investigate the relation between very low-density lipoprotein (VLDL) and HHcy in hypertensive patients.

METHODS

From July 2013 to March 2014, a large cross-sectional study was performed using 4012 participants from urban and rural communities in Hunan province, China. Participants underwent accurate assessment of lipid profiles, homocysteine (Hcy), anthropometric, blood pressure, and other biochemical indicators.

RESULTS

Among 1257 participants with hypertension, 626 (49.80%) were men and 631 (50.20%) were women. In total, 1081 (86.00%) of the participants were found to have HHcy, of which 559 (44.47%) were men and 522 (41.53%) were women. In the univariate analysis, the OR for patients with hypertension associated with hyperhomocysteinemia was significantly enhanced as the quartiles of the Log VLDL were increased. OR for quartile 4 was significantly higher than that for quartile 1 (OR = 3.7, 95% CI: 2.6-5.1; P< .001). Additional adjustment for the confounding variables did not reduce the ORs for the association between the Log VLDL and hypertension associated with hyperhomocysteinemia (OR = 3.8, 95% CI: 2.7-5.5; P< .001; OR = 4.3, 95% CI: 1.6-11.8; P= .004, respectively). We also conducted analyses with Log VLDL as a continuous variable. Each unit increase in the Log VLDL was associated with the 1.3-fold increased risk of hypertension associated with hyperhomocysteinemia (95% CI: 1.9-2.9; P< .001). Adjusting for Cr, TG, TC, and HDL did not affect the relationship.

CONCLUSIONS

Our data indicate that the Log VLDL concentrations appear to be an independent contributor to hypertension associated with hyperhomocysteinemia, even after adjusting for age and other covariables. The utility of the Log VLDL as a diagnostic, prognostic, and therapeutic indicator for the disease warrants further investigation.

ABBREVIATIONS

HHcy: hyperhomocysteinemia; Hcy: homocysteine; VLDL: very low-density lipoprotein; CVD: cardiovascular disease; SBP: systolic blood pressure; DBP: diastolic blood pressure; BMI: body mass index; ALT: alanine aminotransferase; Cr: creatinine; UA: uric acid; TG: triglycerides; TC: total cholesterol; HDL: high-density lipoprotein; LDL: low-density lipoprotein; FBG: fasting blood glucose; CRP: C-reactive protein; MTHFR: methylene tetrahydrofolate reductase; NO: nitric oxide; HDL-C: high-density lipoprotein cholesterol.

Serum alkaline phosphatase levels and the risk of new-onset diabetes in hypertensive adults

BACKGROUND

The association between alkaline phosphatase (ALP) and incident diabetes remains uncertain. Our study aimed to investigate the prospective relation of serum ALP with the risk of new-onset diabetes, and explore possible effect modifiers, in hypertensive adults.

METHODS

A total 14,393 hypertensive patients with available ALP measurements and without diabetes and liver disease at baseline were included from the China Stroke Primary Prevention Trial (CSPPT). The primary outcome was new-onset diabetes, defined as physician-diagnosed diabetes or use of glucose-lowering drugs during follow-up, or fasting glucose ≥ 7.0 mmol/L at the exit visit. The secondary study outcome was new-onset impaired fasting glucose (IFG), defined as FG < 6.1 mmol/L at baseline and ≥ 6.1 but < 7.0 mmol/L at the exit visit.

RESULTS

Over a median of 4.5 years follow-up, 1549 (10.8%) participants developed diabetes. Overall, there was a positive relation of serum ALP and the risk of new-onset diabetes (per SD increment, adjusted OR, 1.07; 95% CI: 1.01, 1.14) and new-onset IFG (per SD increment, adjusted OR, 1.07; 95% CI: 1.02, 1.14). Moreover, a stronger positive association between baseline ALP (per SD increment) with new-onset diabetes was found in participants with total homocysteine (tHcy) < 10 μmol/L (adjusted OR, 1.24; 95% CI: 1.10, 1.40 vs. ≥ 10 μmol/L: adjusted OR, 1.03; 95% CI: 0.96, 1.10; P-interaction = 0.007) or FG ≥ 5.9 mmol/L (adjusted OR, 1.16; 95% CI: 1.07, 1.27 vs. < 5.9 mmol/L: adjusted OR, 1.00; 95% CI: 0.93, 1.08; P-interaction = 0.009) CONCLUSIONS: In this non-diabetic, hypertensive population, higher serum ALP was significantly associated with the increased risk of new-onset diabetes, especially in those with lower tHcy or higher FG levels. Clinical Trial Registration-URL Trial registration: NCT00794885 (clinicaltrials.gov). Retrospectively registered November 20, 2008.

Evaluation of H-type hypertension prevalence and its influence on the risk of increased carotid intima-media thickness among a high-risk stroke population in Hainan Province, China

H-type hypertension, defined as a combination of hypertension and hyperhomocysteinemia (Hhcy), is associated with atherosclerosis and, therefore, increased stroke risk. However, the role of hypertension and Hhcy in high-risk stroke populations has not been studied. The present study investigated the prevalence of H-type hypertension in a high-risk stroke population of Hainan Province, China and to assess possible joint effects between hypertension and Hhcy for increased carotid intima-media thickness (CIMT). In this community-based cross-sectional study, 959 high-risk stroke subjects (age, 65.8 ± 10.8 years; 46.6% men) were recruited from Hainan Province, China. The demographic and clinical characteristics were collected, and blood samples were obtained. Analysis of variance or chi-square tests were performed to compare variates among groups based on both homocysteine levels and blood pressure status. The associations of hypertension and Hhcy with increased CIMT were evaluated through logistic regression. The prevalence of H-type hypertension was 34.8% in this population, with a higher ratio of H-type hypertension in men than in women. Compared with the normotension and normal homocysteine subgroup, the risk of increased CIMT was significantly higher in the subgroup with hypertension and Hhcy (odds ratio [OR] = 2.639; 95% confidence interval [CI], 1.690-4.091) after adjusting for age and sex. Increased CIMT was affected by an additive synergetic interaction between Hhcy and hypertension (synergy index = 1.105). It emphasized the clinical importance of anti-hypertension and lowering Hhcy in the high-risk stroke population.

Clinical characteristics of H-type hypertension and its relationship with the MTHFR C677T polymorphism in a Zhuang population from Guangxi, China

Objective

This study was designed to assess the clinical presentation of patients with H‐type hypertension who were of Zhuang nationality in Guangxi, China. The relationship between the C677T polymorphism in the MTHFR gene and H‐type hypertension was also assessed.

Methods

This was a case‐control study in which 185 Zhuang nationality patients with hypertension that had been hospitalized at the Wuming Hospital of Guangxi Medical University between February 2018 and December 2018 were assessed for plasma homocysteine (Hcy) levels. These levels were used to divide patients into H‐type (>15 μmol/L) and non‐H‐type (≤15 μmol/L) hypertension groups. Patient clinical data were then analyzed, and PCR was used to analyze samples from all patients for the presence of the C677T polymorphism in the MTHFR gene. Differences between these two groups of hypertension patients were then compared using appropriate statistical methods.

Results

We found that relative to patients in the non‐H‐type hypertension group, patients in the H‐type hypertension group exhibited significant differences in sex, age, urea nitrogen levels, creatinine levels, and uric acid levels. There were, however, no significant differences between these two groups with respect to interventricular septum thickness, left ventricular posterior wall thickness, or ejection fraction. We did not detect any association between the MTHFR gene C677T polymorphism and H‐type hypertension in Zhuang nationality individuals in Guangxi.

Conclusion

Risk of H‐type hypertension is not associated with the MTHFR C677T polymorphism in hypertensive individuals of Guangxi Zhuang nationality in China.

Degree of Blood Pressure Control and Incident Diabetes Mellitus in Chinese Adults With Hypertension

Background

The association between blood pressure (BP) control and incident diabetes mellitus remains unknown. We aim to investigate the association between degree of time‐averaged on‐treatment systolic blood pressure (SBP) control and incident diabetes mellitus in hypertensive adults.

Methods and Results

A total of 14 978 adults with hypertension without diabetes mellitus at baseline were included from the CSPPT (China Stroke Primary Prevention Trial). Participants were randomized double‐masked to daily enalapril 10 mg and folic acid 0.8 mg or enalapril 10 mg alone. BP measurements were taken every 3 months after randomization. The primary outcome was incident diabetes mellitus, defined as physician‐diagnosed diabetes mellitus, or use of glucose‐lowering drugs during follow‐up, or fasting glucose ≥126 mg/dL at the exit visit. Over a median of 4.5 years, a significantly higher risk of incident diabetes mellitus was found in participants with time‐averaged on‐treatment SBP 130 to <140 mm Hg (10.3% versus 7.4%; odds ratio [OR], 1.37; 95% CI, 1.15‒1.64), compared with those with SBP 120 to <130 mm Hg. Moreover, the risk of incident diabetes mellitus increased by 24% (OR, 1.24; 95% CI, 1.00‒1.53) and the incidence of regression to normal fasting glucose (<100 mg/dL) decreased by 29% (OR, 0.71; 95% CI, 0.57‒0.89) in participants with intermediate BP control (SBP/diastolic blood pressure, 130 to <140 and/or 80 to <90 mm Hg), compared with those with a tight BP control of <130/<80 mm Hg. Similar results were found when the time‐averaged BP were calculated using the BP measurements during the first 6‐ or 24‐month treatment period, or in the analysis using propensity scores.

Conclusions

In this non‐diabetic, hypertensive population, SBP control in the range of 120 to <130 mm Hg, compared with the 130 to <140 mm Hg, was associated with a lower risk of incident diabetes mellitus.

Distribution characteristics of circulating homocysteine and folate and related factors in agriculture, stock-raising and urban populations: a cross-sectional survey

OBJECTIVE

To investigate homocysteine (Hcy) and folate levels, prevalence of hyperhomocysteinaemia (HHcy) and folate deficiency, which are affected by lifestyles in urban, agricultural and stock-raising populations.

DESIGN

This is a cross-sectional study.

SETTING

Urban, agricultural and stock-raising regions in Emin, China.

PARTICIPANTS

Totally 1926 subjects - 885 (45·9 %) from urban, 861 (44·7 %) from agricultural and 180 (9·4 %) from stock-raising regions - were obtained using multistage stratified random sampling. Inclusion criteria encompassed inhabitants aged ≥15 years who resided at the current address for ≥6 months and agreed to participate in the study. Surveys on health behaviour questionnaires and physical examinations were conducted and blood samples collected.

RESULTS

The folate level of subjects from the stock-raising region was the lowest, followed by those from the agricultural region, and the highest in those from the urban region (3·48 v. 6·50 v. 7·12 ng/ml, P < 0·001), whereas mean Hcy showed no significant difference across regions. The OR for HHcy in stock-raising regions was 1·90 (95 % CI 1·11, 3·27) compared with the urban region after adjusting for all possible covariates. The OR for folate deficiency in stock-raising and agriculture regions was 11·51 (95 % CI 7·09, 18·67) and 1·91 (95 % CI 1·30, 2·82), respectively, compared with the urban region after adjusting for all possible covariates.

CONCLUSIONS

HHcy and folate deficiency are highly prevalent in stock-raisers, which is of important reference for HHcy control in Xinjiang, with a possibility of extension to others with approximate lifestyles.

Effects of Probiotics on Patients with Hypertension: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

This meta-analysis and systematic review was conducted to evaluate the effect of probiotics on blood pressure, body mass index (BMI), and blood glucose changes in patients with hypertension.

RECENT FINDINGS

We searched the PubMed, Cochrane, Embase, and ProQuest databases using a combination of MeSH and free text, from the inception of these databases to 20 January 2020, with no language restrictions. The quantitative PEDro scale method was used to assess the quality of the included studies. We used the random effects models to estimate the outcomes, with heterogeneity among the studies assessed using Cochran's Q statistic. Fourteen included studies published between 2002 and 2019 were included in the meta-analysis, reporting results of 846 hypertension participants. A significant reduction in SBP by - 2.05 mmHg (95% CI - 3.87, -0.24, P = 0.03), DBP by - 1.26 mmHg (95% CI - 2.51, - 0.004, P = 0.047), BMI by - 1.03 (95% CI - 1.28, - 0.97, P < 0.01), and blood glucose by - 0.18 mmol/L (95% CI - 0.30 - 0.05, P = 0.007) was observed following probiotics intervention. Our meta-analysis showed a modest but a significant reduction in SBP and DBP in patients with hypertension, particularly in those with diabetes mellitus, following probiotic supplementation. This effect was associated with treatment duration, dosage, and the age of subject but was not associated with single or multiple strains usage. Additionally, probiotic supplement had a beneficial effect in reducing BMI and blood glucose.

Effect of Banxia Baizhu Tianma Tang for H-type hypertension: A protocol for a systematic review

BACKGROUND

H-type hypertension is a kind of cardiovascular disease that threatens human life and health seriously. Banxia Baizhu Tianma Tang (BBTT) has been used widely for H-type hypertension while its effective evidence is not clear. Hence, we provide a systematic review protocol to evaluate the efficacy and safety of BBTT in the treatment of H-type hypertension.

METHODS

Nine databases including Cochrane Library, PubMed, EMBASE, WOS, Medline, CNKI, WangFang, CBM, and VIP will be searched from their inception to October 2019. All randomized controlled trials (RCTs) of BBTT for H-type hypertension will be included. The language is limited to Chinese and English. The primary outcome measure will be the major adverse cardiac and cerebral events (MACCE). The entire process will include study selection, data extraction, assessment of bias risk, data synthesis. Data analysis will be performed using RevMan V.5.3.5 (The Cochrane Collaboration, Oxford, UK).

RESULTS

This study will evaluate the efficacy and safety of BBTT in the treatment of H-type hypertension from several aspects, including MACCE, blood pressure (BP), blood lipids, inflammation indicators and homocysteine (Hcy).

CONCLUSION

This systematic review will provide evidence for determining whether or not BBTT is an effective and safe intervention for H-type hypertension.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42019131491.

Interaction of serum vitamin B12 and folate with MTHFR genotypes on risk of ischemic stroke

OBJECTIVE

We evaluated the interaction of serum folate and vitamin B₁₂ with methylenetetrahydrofolate reductase (MTHFR) C677T genotypes on the risk of first ischemic stroke and on the efficacy of folic acid treatment in prevention of first ischemic stroke.

METHODS

A total of 20,702 hypertensive adults were randomized to a double-blind treatment of daily enalapril 10 mg and folic acid 0.8 mg or enalapril 10 mg alone. Participants were followed up every 3 months.

RESULTS

Median values of folate and B₁₂ concentrations at baseline were 8.1 ng/mL and 280.2 pmol/L, respectively. Over a median of 4.5 years, among those not receiving folic acid, participants with baseline serum B₁₂ or serum folate above the median had a significantly lower risk of first ischemic stroke (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.96), especially in those with MTHFR 677 CC genotype (wild-type) (HR, 0.49; 95% CI, 0.31-0.78). Folic acid treatment significantly reduced the risk of first ischemic stroke in participants with both folate and B₁₂ below the median (2.3% in enalapril-folic acid group vs 3.6% in enalapril-only group; HR, 0.62; 95% CI, 0.46-0.86), particularly in MTHFR 677 CC carriers (1.6% vs 4.9%; HR, 0.24; 95% CI, 0.11-0.55). However, TT homozygotes responded better with both folate and B₁₂ levels above the median (HR, 0.28; 95% CI, 0.10-0.75).

CONCLUSIONS

The risk of first ischemic stroke was significantly higher in hypertensive patients with low levels of both folate and B₁₂. Effect of folic acid treatment was greatest in patients with low folate and B₁₂ with the CC genotype, and with high folate and B₁₂ with the TT genotype.

Joint Effects of Plasma Homocysteine Concentration and Traditional Cardiovascular Risk Factors on the Risk of New-Onset Peripheral Arterial Disease

PURPOSE

Hyperhomocysteinemia is an independent risk factor for cardio- and cerebrovascular diseases. However, the relationship between plasma homocysteine (Hcy) concentration and peripheral arterial disease (PAD) has not been completely characterized. The aim of the present study was to determine the relationship between plasma Hcy concentration and new-onset PAD and to assess the effects of combinations of Hcy and traditional cardiovascular risk factors.

PATIENTS AND METHODS

We conducted a prospective community-based cohort study of 3119 Chinese participants who did not have PAD at baseline, with a median follow-up period of 2.30 years. We used multivariate logistic regression models to evaluate the relationship between high Hcy (≥10µmol/L) and new-onset PAD. The effects of combinations of high Hcy and traditional cardiovascular risk factors were assessed using logistic regression analysis.

RESULTS

After adjustment for 14 covariates, high Hcy concentration was significantly associated with new-onset PAD (odds ratio [OR]=2.08, 95% confidence interval [CI]: 1.08-4.03, P=0.030). Smokers with high Hcy concentration were substantially more likely to have new-onset PAD than non-smokers with normal Hcy concentration (OR=4.44, 95% CI: 1.77-11.12, P=0.001). The effect of diabetes on PAD became significant when present in combination with high Hcy concentration (OR=3.67, 95% CI: 1.25-10.80, P=0.018). Participants with both elevated Hcy levels and older age had the highest risk of new-onset PAD (OR=4.28, 95% CI: 1.83-10.01, P<0.001). With regard to the joint effect of Hcy and hypertension, dyslipidemia or sex, there was also a trend towards increased risk across four different groups (P for trend=0.026, 0.035, 0.016, respectively).

CONCLUSION

High plasma Hcy concentration independently predicts the incidence of PAD. Furthermore, there is a joint effect of high Hcy concentration and traditional cardiovascular risk factors such as smoking, diabetes and aging on the incidence of PAD.

Periodontal Disease Is Associated With Increased Risk of Hypertension: A Cross-Sectional Study

Objective: Published evidence showed that periodontal disease is associated with hypertension. However, relevant findings remain controversial, with few evidences focusing on Chinese population. Therefore, the aim of this study was to investigate the association between periodontal disease and hypertension in Chinese population.

Methods: A total of 4,930 participants from an available health examination that was carried out in 2017 were selected for this retrospective study. The correlations between periodontal disease and hypertension were investigated using univariate and multiple logistic regression analyses and propensity score adjusted analysis. Interaction and subgroup analyses were also used to detect variable factors.

Results: Finally, a total of 3,952 participants aged 30–68 years were eligible for this study. The results showed that hypertension risk was statistically significant associated with periodontal disease either in unadjusted (OR = 1.28, 95%CI = 1.14–1.47) or in adjusted (OR = 1.34, 95%CI = 1.14–1.58) model. Result from propensity score adjusted analysis also demonstrated a similar association (OR = 1.23, 95%CI = 1.06–1.42).

Conclusion: Periodontal disease is significantly and positively correlated with increased risk of hypertension in Chinese population, and exact mechanisms of this association should be explored in future.

The Association Between Tea Consumption and Hyperhomocysteine in Chinese Hypertensive Patients

BACKGROUND

There is no consistent evidence for the relationship between tea-drinking and hyperhomocysteine (hHcy). Because tea-drinking habit and hHcy have prevailed in Chinese hypertensive patients, this study aimed to investigate the association between hHcy and tea consumption in patients with hypertension.

METHODS

A total of 335 hypertensive participants were recruited from 7 communities. Demographic characteristics of participants were collected through face-to-face interviews using a standard questionnaire, whereas laboratory data were obtained within 1 week after patient recruitment. Multiple logistic regression analysis was performed to examine the association between tea consumption and hHcy in hypertensive patients.

RESULTS

Of the 335 patients, 245 had a tea-drinking habit, and 252 of them were detected with hHcy. A significant association was found between tea consumption and hHcy in hypertensive patients (adjusted odds ratio [OR] = 1.84, 95% confidence interval [CI] = 1.01-3.36, P = 0.048). Subgroup analyses showed that black tea drinking group (adjusted OR = 8.81, 95% CI = 2.74-28.33, P < 0.001) was significantly associated with the risk of hHcy, but not oolong and green tea drinking groups (P > 0.05). Furthermore, consuming a small amount (≤1 cup per day) of green tea was negatively associated with hHcy (adjusted OR = 0.19, 95% CI = 0.07-0.51, P = 0.001), whereas a large intake (>3 cups per day) of green tea was associated with high odds of hHcy (adjusted OR = 5.00, 95% CI = 1.33-18.79, P = 0.02).

CONCLUSIONS

These data suggest a hypothesis that selecting green tea or limiting tea consumption might reduce risk of hHcy in hypertensive patients and that warrants further study.

Blood homocysteine levels could predict major adverse cardiac events in patients with acute coronary syndrome: A STROBE-compliant observational study

The Global Registry of Acute Coronary Events (GRACE) risk score independently predicts major adverse cardiac events (MACEs) in patients with acute coronary syndrome (ACS). This study aims to evaluate whether the level of plasma homocysteine in addition to the GRACE score enhances the predictive value for MACEs in patients with acute coronary syndrome.A total of 361 patients with ACS evaluated at our hospital were included in the study and tested for blood homocysteine levels. We recorded 40 (11.1%) instances of MACE during a median follow-up of 43.3 months (quartile 40.6-44.4 months), including 29 cases (8.0%) of all-cause death and 11 cases (3.1%) of nonfatal myocardial infarction.The GRACE score was significantly associated with homocysteine levels, and multivariate Cox regression analysis showed that both the GRACE risk score and homocysteine content were independent predictors of MACEs (HR 2.63; 95% confidence interval (CI) 1.54 to 4.49; P < .001 and 2.27; 1.06 to 4.86; P = .035, respectively). Moreover, meta-analysis showed that as the homocysteine level increased, the incidence of MACEs also increased (log-rank 8.41; P = .015). GRACE scores adjusted by homocysteine level increased the area under the curve (AUC) from 0.78 to 0.83 (P = 0.006).Blood homocysteine levels are significantly associated with the GRACE risk score, and using both parameters can further improve risk stratification in patients with acute coronary syndrome.

Association of H-Type Hypertension with Stroke Severity and Prognosis

Background. The correlation between H-type hypertension and acute ischemic stroke remains uncertain. Objective. The present study was designed to explore the possible relationship between H-type hypertension and severity and prognosis of acute ischemic stroke. Method. We included 372 patients with acute ischemic stroke and divided them into four groups: H-type hypertension group, simple hypertension group, simple hyperhomocysteinemia (HHcy) group, and the control group. NIHSS score was measured at both admission and two weeks later. mRS score, stroke recurrence, cardiovascular event, or all-cause mortality was recorded at 3-month and 1-year follow-up. Result. The results showed that the NIHSS score on admission in the H-type hypertension group (6.32 ± 5.91) was significantly higher than that in the control group (3.97 ± 3.59) (P < 0.05), while there was no obvious association between H-type hypertension and NIHSS score after 2-week treatment (P = 0.106). Endpoint events incidence in H-type hypertension group was the highest; however, in the cox regression model of multiple factor analysis, H-type hypertension was not an independent risk factor. Conclusion. H-type hypertension may result in early functional deterioration and higher incidence rate of endpoint events but not act as an independent risk factor.

Contribution of non-traditional lipid profiles to reduced glomerular filtration rate in H-type hypertension population of rural China

BACKGROUND

Despite current interest in the unfavourable impact of non-traditional lipid profiles on cardiovascular disease, information regarding its relations to reduced glomerular filtration rate (GFR) in H-type hypertension population has not been systemically elucidated.

METHODS

Analyses were based upon a cross-sectional study of 3259 participants with H-type hypertension who underwent assessment of biochemical, anthropometric and blood pressure values. Reduced GFR was considered if meeting estimated GFR <60 ml/min/1.73 m².

RESULTS

A stepwise multivariate regression analysis indicated that non-traditional lipid parameters remained as independent determinants of estimated GFR (all p < .001). In multivariable models, we observed a 50%, 51%, 31%, and 24% higher risk for decreased GFR with each SD increment in TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C levels, respectively. The highest quartile of TC/HDL-C, TG/HDL-C and LDL-C/HDL-C ratios carried reduced GFR odds (confidence intervals) of 5.50 (2.50 to 12.09), 6.63 (2.58 to 17.05) and 2.22 (1.15 to 4.29), respectively.

CONCLUSIONS

The relative independent contribution of non-traditional lipid profiles, as indexed by TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C, towards reduced GFR putting research evidence at the very heart of lipoprotein-mediated renal injury set a vital example for applying a clinical and public health recommendation for reducing the burden of chronic kidney disease. KEY MESSAGES Non-traditional lipid profiles has been linked with the occurrence of cardiovascular disease, but none of the studies that address the effect of non-traditional lipid profiles on reduced GFR risk in H-type hypertension population has been specifically established. A greater emphasis of this study resided in the intrinsic value of TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C that integrate atherogenic and anti-atherogenic lipid molecules to predict the risk of reduced GFR among H-type hypertension population and provide insight into the pathophysiology of subsequent cardio-cerebrovascular outcomes. In a large Chinese H-type hypertension adults, the relative independent contribution of non-traditional lipid profiles, as indexed by TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C, towards reduced GFR putting research evidence at the very heart of lipoprotein-mediated renal injury set a vital example for applying a clinical and public health recommendation for reducing the burden of CKD.

Association between H-type Hypertension and Asymptomatic Extracranial Artery Stenosis

Asymptomatic extracranial artery stenosis (ECAS) is a well-known risk factor for stroke and H-type hypertension, which is defined as hypertension with hyperhomocysteinemia, is associated with cardio-cerebrovascular diseases. However, the impact of H-type hypertension on ECAS is mostly unknown. We designed this study to investigate the association between H-type hypertension and prevalence of ECAS. We included 2330 participants in this study and classified them into four groups: the control group without hypertension or hyperhomocysteinemia, isolated hypertension group, isolated hyperhomocysteinemia group and H-type hypertension group. We measured the baseline plasma total homocysteine levels and assessed ECAS by carotid duplex sonography twice at baseline and during follow up. We used a Cox regression model to analyse the association between H-type hypertension and ECAS. At baseline, 608 subjects suffered from H-type hypertension. Within two years of follow-up, asymptomatic ECAS occurred in 250 (10.73%) participants. After adjusting for relevant risk factors, we found H-type hypertension to be an independent risk factor for asymptomatic ECAS (relative risk (RR) 3.16, 95% confidence interval (95% CI) 2.00-5.00). Our findings provide direct evidence for the importance of H-type hypertension in the occurrence of ECAS and as a potential therapeutic target for carotid atherosclerosis.

Impact of hyperhomocysteinemia on insulin resistance in patients with H-type hypertension

BACKGROUND

Hypertension (HT) and hyperhomocysteinemia (HHcy) had been considered influential factors of insulin resistance. H-type HT occurred as HHcy associated with HT. The impact of HHcy on insulin resistance in H-type HT patients remains to be estimated. The interacted effects of HHcy and HT on insulin resistance are still unclear.

METHODS

A total of 790 patients were recruited and classified into four groups according to their blood pressure and plasma Hcy level, i.e., control group (C group), HHcy group (HHcy subjects without HT), HT group (HT subjects without HHcy), and H group (subjects with H-type HT). The relationship between HHcy and insulin resistance, as estimated using the HOMA-IR, was analyzed and related to blood pressure.

RESULTS

HOMA-IR values were significantly higher in the HHcy group than the C group (2.97 (2.23-4.01) versus 2.54 (1.87-3.58), P ＜ 0.01). H-type HT patients showed more severe insulin resistance than those who only got HT (3.58 (2.59-4.85) versus 2.96 (1.90-3.49)，P ＜ 0.01). Moreover, HOMA-IR values were positively correlated with Hcy levels (r = 0.26, P ＜ 0.01). After correcting for possible risking factors, a linear regression relationship between insulin resistance and HHcy was found (β = 0.158, P ＜ 0.01). HHcy was interacted with HT on the exacerbation of insulin resistance in H-type HT patients (β = 0.501, P ＜ 0.01).

CONCLUSIONS

HHcy obviously exacerbate insulin resistance, especially in H-type HT patients. HHcy and HT have a multiplicative effect on metabolic dysfunction, which may help to interpret why these patients are suffering a high risk of cardiovascular disease and stroke.

Relation of four nontraditional lipid profiles to diabetes in rural Chinese H-type hypertension population

Background

Mounting evidence suggested that nontraditional lipid profiles have been recognized as a reliable indicator for unfavorable cardiovascular events. The purpose of this study was to explore the role of nontraditional lipid profiles as potential clinical indices for the assessment of prevalent diabetes in rural Chinese H-type hypertension population.

Methods

During 2012 to 2013, we conducted a large cross-sectional study of 2944 H-type hypertension participants (≥35 years of age) from rural areas in northeast China. Subjects underwent accurate assessment of lipid profiles, fasting plasma glucose (FPG), homocysteine (Hcy) according to standard protocols.

Results

The proportion of diabetes showed a graded and linear increase across the quartiles for all four nontraditional lipid parameters. Nontraditional lipid variables were independent determinants of FPG, and its correlation for TG/HDL-C was strongest, whether potential confounders were adjusted or not. Multivariable logistic regression analysis established that the highest triglycerides (TG)/ high-density lipoprotein cholesterol (HDL-C) quartile manifested the largest ORs of prevalent diabetes (OR: 3.275, 95%CI: 2.109–5.087) compared with the lowest quartile. The fully adjusted ORs (95%CI) were 2.753 (1.783–4.252), 2.178 (1.415–2.351), 1.648 (1.097–2.478) for the top quartile of total cholesterol (TC)/HDL-C, low-density lipoprotein cholesterol (LDL-C)/HDL-C, and non-high-density lipoprotein cholesterol (non-HDL-C), respectively. On the basis of the area under receiver-operating characteristic curve (AUC), TG/HDL-C showed the optimal discriminating power for diabetes (AUC: 0.684, 95% CI: 0.650–0.718).

Conclusions

Nontraditional lipid profiles (TG/HDL-C, TC/HDL-C, LDL-C/HDL-C and non-HDL-C) were all consistently and independently correlated with prevalent diabetes among the H-type hypertension population in rural China. TG/HDL-C was prone to be more profitable in assessing the risk of prevalent diabetes and should be encouraged as an effective clinical tool for monitoring and targeted intervention of diabetes in H-type hypertension adults.

The Prevalence of Hypertension Accompanied by High Homocysteine and its Risk Factors in a Rural Population: A Cross-Sectional Study from Northeast China

Previous studies found that hypertension and high homocysteine (HHcy) exhibited a synergistic effect on the risk of cardiovascular diseases. This study aimed to investigate the prevalence of hypertension accompanied by HHcy and its risk factors in the rural areas of northeast China. This study was conducted using a stratified cluster random sampling method, and included 6529 subjects with complete data. Demographic characteristics were obtained from a questionnaire. Blood pressure and anthropometric indices were measured, and serum indices were analyzed. Hypertension accompanied by HHcy was defined as hypertension plus HHcy [homocysteine (Hcy) > 10 µmol/L]. The mean concentration of Hcy was 17.29 μmol/L in the general population. The prevalence of hypertension accompanied by HHcy was so high that it reached 45.1% of our study population and accounted for 86.8% of the total participants with hypertension. Multiple logistic regression analysis indicated that the modifiable risk factors of hypertension accompanied by HHcy included obesity, diabetes, dyslipidemia, and inactive physical activities. We found that the mean level of Hcy, and the prevalences of HHcy and hypertension accompanied by HHcy were very high among the rural population of northeast China. Obesity, diabetes, dyslipidemia, and inactive physical activities were modifiable risk factors of hypertension accompanied by HHcy.

H-Type Hypertension and C Reactive Protein in Recurrence of Ischemic Stroke

Hypertension with high homocysteine (HHcy) (H-type hypertension) and C reactive protein (CRP) can increase the incidence of ischemic stroke. However, it is not clear whether recurrent ischemic stroke (RIS) is related to H-type hypertension and CRP. The present study investigated the correlation of H-type hypertension and CRP level with RIS. Totally, 987 consecutive patients with acute ischemic stroke were recruited in a teaching hospital in Henan province, China during March 2014 to March 2015. The demographic and clinical characteristics and blood biochemical parameters of patients were analyzed. Elevated levels of CRP and homocysteine (Hcy) were defined as >8.2 mg/L and 10 μmol/L, respectively. Among the 987 patients, 234 were RIS. Thirty-eight percent of RIS patients had elevated CRP level and 91.5% of RIS patients had HHcy. In multivariate analysis, adjusted odds ratio (OR) of RIS in patients aged ≥60 years was 1.576 (95% CI: 1.125–2.207), in male patients 1.935 (95% CI: 1.385–2.704), in patients with diabetes 1.463 (95% CI: 1.037–2.064), CRP levels 1.013 (95% CI: 1.006–1.019), simple hypertension 3.370 (95% CI: 1.15–10.183), and H-type hypertension 2.990 (95% CI: 1.176–7.600). RIS was associated with older age, male, diabetes, H-type hypertension and CRP. Controlling H-type hypertension and CRP level may reduce the risk of RIS.

H-type hypertension and risk of stroke in chinese adults: A prospective, nested case-control study

Objectives

To investigate the independent and joint associations of hyperhomocysteinemia and hypertension with incident stroke and stroke death in Chinese adults.

Methods

About 39,165 rural Chinese adults aged 35 years or older who had no history of stroke at the baseline study were prospectively followed to determine major cardiovascular events, with an average follow-up of 6.2 years. Using a nested case–control design, this report includes 179 incident stroke cases (121 stroke deaths) and 179 controls without vascular events from the original cohort matched by age, sex, community, and length of plasma storage. Baseline plasma total homocysteine (tHcy) measurements were obtained for all subjects. Logistic regression analysis was performed to investigate the independent and joint associations between H-type hypertension, defined as subjects with concomitant hypertension and elevated homocysteine (≥10 μmol/L), and risk of incident stroke and stroke death, after adjusting for important covariates.

Results

We analyzed each risk factor independently and jointly. For analysis, homocysteine was divided into three groups: low (tHcy <10 μmol/L), moderate (≥10 μmol/L tHcy <20 μmol/L), and high (tHcy≥20μmol/L). Compared to subjects in the low group, the odds ratios (95% CI) of incident stroke for those in the moderate group and the high group were 1.7 (0.8–3.7) and 3.1 (1.2–8.6), respectively. The odds ratios (95% CI) of stroke death for the moderate and high groups were 2.8 (1.1–7.4) and 5.1 (1.6–16.4), respectively. Hypertension was also independently associated with a higher risk of incident stroke and stroke death: 3.8 (2.3–6.4) and 3.2 (1.8–6.0), respectively, compared to those without hypertension. When analyzed jointly, the highest risk was found among patients with H-type hypertensive with both hyperhomocysteinemia and hypertension: 12.7 (2.8–58.0) for incident stroke and 11.7 (2.5–54.7) for stroke death.

Conclusions

This study provides strong evidence that hyperhomocysteinemia and hypertension are two independent, modifiable risk factors, which act additively to increase the risk of incident stroke and stroke death. The results strongly suggest that H-type hypertension is a major risk factor for vascular disease and mortality, and those with H-type hypertension may particularly benefit from homocysteine-lowering therapy along with anti-hypertension therapy in Chinese populations.