Different definitions of prevalent hypertension impact: the clinical epidemiology of hypertension and attainment of Healthy People goals

Higher serum ferritins are associated with higher blood pressure: A cross-sectional study

The aim of the study was to investigate the association between serum ferritin and hypertension among American adults from National Health and Nutrition Examination Survey (NHANES) 1999 to 2018. A total of 16,125 participants were included. Weighted logistic regression and subgroup analyses were performed to explore the association. We found that serum ferritin was closely correlated to hypertension. Individuals with high serum ferritin were more likely to have higher systolic or diastolic blood pressure (SBP, DBP) than those with lower serum ferritin. Restricted cubic spline showed a significant non-linear association between serum ferritin and SBP/DBP. Higher level of serum ferritin (Q3 74.1-147 μg/L and Q4 > 147 μg/L) was found to have positive association with high SBP [Q3 (OR: 1.246, 95% CI:1.020-1.523), Q4 (OR: 1.354, 95% CI:1.096-1.674)], and hypertension [Q3 (OR: 1.283, 95% CI:1.099-1.499), Q4 (OR: 1.424, 95% CI:1.197-1.63)] in the whole population. In people aged between 20 and 60, subjects with high serum ferritin were significantly associated with a higher risk of hypertension, but in those over 60, the relationship between serum ferritin level and hypertension is negative. A non-linear association between serum ferritin and SBP, as well as DBP, was discovered. There was age difference in association between serum ferritin and hypertension in American adults, and further researches were needed to understand the mechanisms behind the difference.

Screening, Characterization, and Mechanistic Evaluation of Angiotensin Converting Enzyme Inhibitory Peptides Derived from Milk Fermented with Lactobacillus delbrueckii QS306 with and without Ultrahigh-Pressure Treatment

In this study, the peptides in milk fermented with Lactobacillus delbrueckii QS306 with and without ultrahigh-pressure treatment were identified using UPLC-Q-exactive-HF-X-MS/MS. In total, 27 novel pentapeptides with potential angiotensin converting enzyme inhibitory (ACEI) activity were screened via bioinformatic analysis, and the activities of seven novel pentapeptides were assessed. Among them, HLPLP, PYPQR, and VAPFP exhibited better IC50 values. Stability assessment via in vitro simulation revealed that the three pentapeptides were significantly reduced (P < 0.05) during digestion but exhibited 85% activity after digestion. HLPLP was a competitive inhibitor, while PYPQR and VAPFP were noncompetitive inhibitors of ACE. Molecular docking indicated that the three peptides could stably bind to ACE. Molecular dynamics (MD) simulation and activity verification indicated that PYPQR and VAPFP had better stability and activity. This study demonstrated that novel ACEI pentapeptides in milk fermented with L. delbrueckii QS306 with and without ultrahigh-pressure treatment could be considered promising candidates for controlling hypertension.

Edible mushrooms as potential functional foods in amelioration of hypertension

Edible mushrooms are popular functional foods attributed to their rich nutritional bioactive constituent profile influencing cardiovascular function. Edible mushrooms are omnipresent in various prescribed Dietary Approaches to Stop Hypertension, Mediterranean diet, and fortified meal plans as they are rich in amino acids, dietary fiber, proteins, sterols, vitamins, and minerals. However, without an understanding of the influence of mushroom bioactive constituents, mechanism of action on heart and allergenicity, it is difficult to fully comprehend the role of mushrooms as dietary interventions in alleviating hypertension and other cardiovascular malfunctions. To accomplish this endeavor, we chose to review edible mushrooms and their bioactive constituents in ameliorating hypertension. Hypertension and cardiovascular diseases are interrelated and if the former is managed by dietary changes, it is postulated that overall heart health could also be improved. With a concise note on different edible varieties of mushrooms, a particular focus is presented on the antihypertensive potential of mushroom bioactive constituents, mode of action, absorption kinetics and bioavailability. Ergosterol, lovastatin, cordycepin, tocopherols, chitosan, ergothioneine, γ-aminobutyric acid, quercetin, and eritadenine are described as essential bioactives with hypotensive effects. Finally, safety concerns on allergens and limitations of consuming edible mushrooms with special reference to chemical toxins and their postulated metabolites are highlighted. It is opined that the present review will redirect toxicologists to further investigate mushroom bioactives and allergens, thereby influencing dietary interventions for heart health.

Higher Levels of Urinary Thiocyanate, a Biomarker of Cruciferous Vegetable Intake, Were Associated With Lower Risks of Cardiovascular Disease and All-Cause Mortality Among Non-smoking Subjects

Background

Epidemiologic studies on cruciferous vegetable (CV) intake and cardiovascular disease (CVD) were inconclusive.

Objective

To investigate the associations of urinary thiocyanate, a biomarker of CV intake, with CVD and all-cause mortality among non-smoking adults.

Methods

This prospective cohort study comprised 10,489 non-smoking adults (weighted mean age, 46.8 years; 43.4% male) from the National Health and Nutrition Examination Survey 2001–2014. Non-smokers were defined as subjects with serum cotinine < 3 ng/mL. Urinary thiocyanate was measured with ion chromatography tandem mass spectrometry at baseline, and CVD and all-cause mortality were identified through linkage to National Death Index until December 31, 2015. Cox proportional hazards model was applied to estimate the hazard ratios (HRs) with 95% confidence intervals (CIs) for CVD and all-cause mortality.

Results

A total of 800 deaths, of which 136 died of CVD, were ascertained within a median 7.8 years of follow-up. Urinary thiocyanate was positively correlated with total CV intake among non-smoking adults (r_s = 0.088, P < 0.001). Comparing extreme quartiles, the multivariate-adjusted HRs for CVD and all-cause mortality were 0.50 (95% CI: 0.29–0.85) and 0.75 (95% CI: 0.60–0.92), respectively. Each 1 μg/g creatinine increment of log-transformed urinary thiocyanate was associated with a 25% (HR: 0.75; 95% CI: 0.62–0.91) reduced CVD mortality risk and 12% (HR: 0.88; 95% CI: 0.81–0.96) reduced all-cause mortality risk. The documented inverse associations persisted in sensitivity analyses.

Conclusion

Increased levels of urinary thiocyanate, a candidate biomarker of CV intake, were associated with low risks of CVD and total mortality among non-smoking adults. This prospective biomarker-based study provided further evidence to support the cardiovascular benefits of CVs.

The association between serum ferritin and blood pressure in adult women: a large cross-sectional study

BACKGROUND

Studies on the relationships between ferritin and blood pressure remain limited, especially in adult women. The aim of the present study was to investigate the associations between serum ferritin and blood pressure among adult women.

METHODS

Using the National Health and Nutrition Examination Survey, a cross-sectional study, including 5521 adult women, was performed. Weighted multivariate regressions, subgroup analyses, threshold effect analyses, and sensitivity analysis were used.

RESULTS

The authors found that serum ferritin was independently and positively correlated to diastolic blood pressure (DBP), and this positive correlation kept present among women who are 26-30 years old, non-pregnant women, Mexican American women, and women of other races in the subgroup analyses. Additionally, no significant association was found between serum ferritin and systolic blood pressure (SBP), except in women aged 26-30, Mexican American women, and women of other races. In pregnant women, the association between serum ferritin and SBP was an inverted U-shaped curve with an inflection point at 39.5 ng/mL.

CONCLUSIONS

The authors demonstrated that serum ferritin was positively correlated to DBP in adult women, which may provide a novel reference for clinical management.

Mobile Health Applications and Medication Adherence of Patients With Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Current evidence has revealed the beneficial effects of mobile health applications on systolic and diastolic blood pressure. However, there is still no solid evidence of the underlying factors for these outcomes, and hypertension treatment is performed mainly by medication intake. This study aims to analyze the impacts of health applications on medication adherence of patients with hypertension and understand the underlying factors.

METHODS

A systematic review and meta-analysis were conducted considering controlled clinical trials published, without year filter, through July 2020. The searches were performed in the electronic databases of Scopus, MEDLINE, and BVSalud. Study characteristics were extracted for qualitative synthesis. The meta-analysis examined medication-taking behavior outcomes using the generic inverse-variance method to combine multiple variables.

RESULTS

A total of 1,199 records were identified, of which 10 studies met the inclusion criteria for qualitative synthesis, and 9 met the criteria for meta-analysis with 1,495 participants. The analysis of mean changes revealed significant improvements in medication adherence (standardized mean difference=0.41, 95% CI=0.02, 0.79, I²=82%, p=0.04) as well as the analysis of the values measured after follow-up (standardized mean difference=0.60, 95% CI=0.30, 0.90, I²=77%, p<0.0001). Ancillary improvements were also identified, such as patients' perceived confidence, treatment self-efficacy and self-monitoring, acceptance of technology, and knowledge about the condition and how to deal with health issues.

DISCUSSION

There is evidence that mobile health applications can improve medication adherence in patients with hypertension, with broad heterogeneity between studies on the topic. The use of mobile health applications conceivably leads to ancillary improvements inherent to better medication adherence.

Using a mobile health app to improve patients' adherence to hypertension treatment: a non-randomized clinical trial

Poor adherence to hypertension treatment increases complications of the disease and is characterized by a lack of awareness and acceptance of ongoing treatment. Mobile health (mHealth) apps can optimize processes and facilitate access to health information by combining treatment methods with attractive solutions. In this study, we aimed at verifying the influence of using an mHealth app on patients' adherence to hypertension treatment, also examining how user experience toward the app influenced the outcomes. A total of 49 participants completed the study, men and women, diagnosed with hypertension and ongoing medical treatment. For 12 weeks, the control group continued with conventional monitoring, while the experimental group used an mHealth app. From the experimental group, at baseline, 8% were non-adherent, 64% were partial adherents and 28% were adherent to the treatment. Baseline in the control group indicated 4.2% non-adherents, 58.3% partial adherents, and 37.5% adherents. After follow-up, the experimental group had an increase to 92% adherent, 8% partially adherent, and 0% non-adherent (P < 0.001). In the control group, adherence after follow-up remained virtually the same (P ≥ 0.999). Results of user experience were substantially positive and indicate that the participants in the experimental group had a satisfactory perception of the app. In conclusion, this study suggests that using an mHealth app can empower patients to manage their own health and increase adherence to hypertension treatment, especially when the app provides a positive user experience.

Mobile phones and applications in the management of patients with arterial hypertension

The use of mobile health (mHealth) in the field of medicine is constantly evolving and advancing. Arterial hypertension, a major modifiable cardiovascular risk factor with a high prevalence in the general population, frequently remains underdiagnosed and thus untreated. Furthermore, the majority of hypertensive patients fail to achieve blood pressure target levels. The purpose of this review is to identify and evaluate current use of mHealth strategies, with focus on mobile phones, smartphones and applications, in the management of patients with arterial hypertension. Current mobile technology has the capacity to inform and motivate the general public for timely diagnosis of hypertension, to facilitate communication between physicians and patients, to aid in the monitoring of blood pressure levels and the optimization of treatment and to promote, in general, a healthy lifestyle and assist in the management of other cardiovascular risk factors. There is potential for positive impact of mHealth technology in the management of arterial hypertension, as well as probable detrimental effects that warrant caution. The research in this field is ongoing and future well-conducted studies are needed in order to establish the use of mobile technology in arterial hypertension management.

Influenza vaccine and cardiac protection: a study from a tertiary care center

Patients with heart disease (HD) are at increased risk of developing cardiac complications if they acquire the influenza virus. The objective of this study was to determine whether the influenza vaccine has a primary role in preventing newly diagnosed HD in patients who have no history of HD and who were being followed up at the American University of Beirut Medical Center (AUBMC). The study is a retrospective cohort, with 2-years follow up, which was conducted using electronic medical records between the years of 2011-2013 in a tertiary care center. All patients 60 years and older (n = 698) who have taken the flu vaccine were randomly selected from the University Health Service records (UHS) and compared to a group who has not taken the flu vaccine during the same period. The odds of developing HD among vaccinated people with cofactors are 0.97 times the odds of that among non-vaccinated. This odds ratio is not significantly different than that of people vaccinated without cofactors (OR = 1.74). The occurrence of HD in the presence of vaccination revealed a non-significant decrease trend with the increase in a number of risk factors (OR = 1.61 vs 0.97). Our results suggest that there was a non-significant difference between the effect of the vaccine for influenza on patients who had cofactors for HD and those who had not. Similarly, the effect of vaccine showed a non-significant increase in protective effect as the number of comorbidities increase. The potential effects of the vaccine may be related to the protection against flu.

The Relationship Between Interocular Asymmetry of Visual Field Defects and Optic Nerve Head Blood Flow in Patients With Glaucoma

PURPOSE

To investigate the association between asymmetry of visual field (VF) defects and optic nerve head (ONH) blood flow in patients with glaucoma using laser speckle flowgraphy.

METHODS

In total, 170 eyes of 85 patients with primary open-angle glaucoma were included. Intraocular pressure, VF (Humphrey 24-2, SITA program), mean blur rate in the tissue area (MBR-T) of the ONH measured by laser speckle flowgraphy, axial length, circumpapillary retinal nerve fiber layer thickness (cpRNFLT), disc area, cup/disc area ratio, and parapapillary atrophy (PPA) area was measured in each eye. The paired eyes were divided into better and worse eyes according to the mean deviation (MD) of VF, and intereye differences of various parameters (better MD eye minus worse MD eye) were examined. Factors associated with MD difference, MBR-T difference, or cpRNFLT difference were investigated.

RESULTS

MD of the VF in better and worse eyes were -10.2±7.3 dB and -16.8±7.4 dB, respectively. In stepwise multiple regression analysis, MBR-T differences, cpRNFLT differences and sex (male) were significantly correlated with MD differences (β, 0.26, 0.21, 0.20; P=0.01, 0.04, 0.047, respectively). MD differences were significantly associated with MBR-T differences (β, 0.28; P=0.01). For cpRNFLT differences, differences in β-PPA area and MD differences were identified as significant factors (β, -0.26, 0.22; P=0.02, 0.04, respectively).

CONCLUSIONS

Asymmetry of ONH blood flow is significantly associated with asymmetry of visual field defects in patients with glaucoma independently of cpRNFLT.

Risk of Cardiovascular Disease Related to Smoking Is Greater Among Women With Sleep-Disordered Breathing

STUDY OBJECTIVES

Although both sleep-disordered breathing (SDB) and smoking are associated with cardiovascular disease (CVD), the potential for an interactive effect on CVD risk has not been explored. Our objective was to determine if smoking-related risk for CVD rises with greater SDB severity.

METHODS

Polysomnography and smoking history were obtained in 3,852 men and women in the Sleep Heart Health Study without baseline CVD. Fine-Gray proportional hazard models accounting for competing risk were used to calculate risk of incident CVD associated with SDB severity (defined by clinical cutoffs of the apnea-hypopnea index), smoking status (never, former, and current) and their interaction adjusting for potential confounders.

RESULTS

Over a mean (standard deviation) follow-up period of 10.3 (3.4) years, there were 694 incident CVD events. We found a significant three-way interaction of sex, current smoking, and moderate to severe SDB (P = .039) in the adjusted proportional hazards model. In adjusted analyses, women who were current smokers with moderate to severe SDB had a hazard ratio for incident CVD of 3.5 (95% confidence interval 1.6-8.0) relative to women who were nonsmokers without SDB. No such difference in CVD risk was observed in men or women of other strata of smoking and SDB.

CONCLUSIONS

In women, smoking-related risk for CVD is significantly higher among individuals with moderate to severe SDB.

Cross-sectional and longitudinal associations between serum 25-hydroxyvitamin D and cognitive functioning

BACKGROUND

Vitamin D deficiency is common in older persons. The objectives of this study were: To examine the cross-sectional and longitudinal association between serum 25-hydroxyvitamin D (25(OH)D) and cognitive functioning in older persons; and to explore the optimal cut-off for serum 25(OH)D.

METHODS

Data of the Longitudinal Aging Study Amsterdam (LASA) were used. Serum 25(OH)D was determined using a competitive protein binding assay in 1995/6 (n = 1,320). Cognitive functioning was assessed in 1995/6 and 1998/9 using the Mini-Mental State Examination (MMSE, general cognitive functioning), Raven's Colored Progressive Matrices (RCPM, ability of nonverbal and abstract reasoning), the Coding Task (CT, information processing speed), and the 15 Words Test (15WT, immediate memory and delayed recall). The data were analyzed using linear regression analyses and restricted cubic spline functions. The MMSE was normalized using ln(31-MMSE).

RESULTS

Mean serum 25(OH)D was 53.7 nmol/L. After adjustment for confounding, patients with serum 25(OH)D levels below 30 nmol/L had significantly lower general cognitive functioning (beta of ln(31-MMSE) = 0.122; p = 0.046) and slower information processing speed (beta = -2.177, p = 0.001) as compared with patients having serum 25(OH)D levels ≥ 75 nmol/L in the cross-sectional analyses. For both outcomes, the optimal cut-off was about 60 nmol/L. No other significant associations were observed.

CONCLUSIONS

A lower serum 25(OH)D was significantly associated with lower general cognitive functioning and slower information processing speed, but not with a faster rate of cognitive decline.

Blood Pressure Control Provides Less Cardiovascular Protection in Adults With Than Without Apparent Treatment-Resistant Hypertension

Hypertension control may offer less protection from incident cardiovascular disease (CVDi ) in adults with than without apparent treatment-resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to <140/<90 mm Hg while taking four or more antihypertensive medications. Electronic health data were matched to health claims for 2006-2012. Patients with CVDi in 2006-2007 or with untreated hypertension were excluded, leaving 118,356 treated hypertensives, including 40,690 with aTRH, and 460,599 observation years. Blood pressure and medication number were determined by all clinic visit means from 2008 to CVDi or end of study. Primary outcome was first CVDi (stroke, coronary heart disease, heart failure) from hospital and emergency department claims. Controlling for age, race, sex, diabetes, chronic kidney disease, and statin use, hypertension control afforded less CVDi protection in patients with aTRH (hazard ratio, 0.87; 95% confidence interval, 0.82-0.93) than without aTRH (hazard ratio, 0.69; 95% confidence interval, 0.65-0.74; P<.001). Strategies beyond hypertension control may prevent more CVDi in patients with aTRH.

Nephrotoxicity caused by oral antiviral agents in patients with chronic hepatitis B treated in a hospital for tropical diseases in Thailand

BACKGROUND

There is increasing concern about the potential for nephrotoxicity in patients with chronic hepatitis B (CHB) treated long-term with nucleotide analogs.

METHODS

We examined renal dysfunction and its associated risk factors in patients with CHB treated with antiviral regimens containing either nucleosides or nucleotide analogs. We undertook a retrospective cohort study from 2006 to 2014 at the Hospital for Tropical Diseases, Bangkok, Thailand, and analyzed the data of 102 patients with a median follow-up time of 44.5 months (range 4-101 months).

RESULTS

Seventy-three patients were treated with an antiviral regime containing a nucleoside analog, and 29 with a regime containing a nucleotide analog. Abnormally elevated serum creatinine concentration was observed in 12 patients (11.8 %) after 8 years of treatment. Thirty one percent of patients treated with nucleotide analogs had elevated serum creatinine levels and three of these patients (10.3 %) developed nephrotoxicity. In contrast, serum creatinine concentrations were elevated in three of the 73 patients treated with a nucleoside analog (4.1 %), and none developed nephrotoxicity. The incidence of renal dysfunction by the nucleotide analog regimen was cumulative, with 11.1, 21.0, 26.5 and 47.6 % of patients affected after 2, 4, 6 and 8 years, respectively. Univariate and multivariate analysis indicated that a nucleotide analog-based regimen significantly predicted renal dysfunction (odds ratio 10.5, 95 % confidence intervals 2.6-42.4, P <0.001).

CONCLUSION

The long-term use of nucleotide analogs increased the risk of nephrotoxicity in patients with CHB. Thus, the regular assessment of renal function is recommended for all patients with CHB, particularly those treated with a nucleotide analog.

Null mutation of the nicotinamide adenine dinucleotide phosphate-oxidase subunit p67phox protects the Dahl-S rat from salt-induced reductions in medullary blood flow and glomerular filtration rate

Null mutations in the p67(phox) subunit of nicotinamide adenine dinucleotide phosphate-oxidase confer protection from salt sensitivity on Dahl salt-sensitive rats. Here, we track the sequential changes in medullary blood flow (MBF), glomerular filtration rate (GFR), urinary protein, and mean arterial pressure in SSp67(phox) null rats and wild-type littermates during 21 days of 4.0% NaCl high-salt (HS) diet. Optical fibers were implanted in the renal medulla and MBF was measured in conscious rats by laser Doppler flowmetry. Separate groups of rats were prepared with femoral venous catheters and GFR was measured by the transcutaneous assessment of fluorescein isothiocyanate-sinistrin disappearance curves. Mean arterial blood pressure was measured by telemetry. In wild-type rats, HS caused a rapid reduction in MBF, which was significantly lower than control values by HS day-6. Reduced MBF was associated with a progressive increase in mean arterial pressure, averaging 170±5 mm Hg by HS salt day-21. A significant reduction in GFR was evident on day-14 HS, after the onset of hypertension and reduced MBF. In contrast, HS had no significant effect on MBF in SSp67(phox) null rats and the pressor response to sodium was blunted, averaging 150±3 mm Hg on day-21 HS. GFR was maintained throughout the study and proteinuria was reduced. In summary, when p67(phox) is not functional in the salt-sensitive rats, HS does not cause reduced MBF and salt-sensitive hypertension is attenuated, and consequently renal injury is reduced and GFR is maintained.

Differences and similarities in explanatory models of hypertension in the United States of america, Tanzania and Jamaica

BACKGROUND

Misperceptions detract from effective disease management in a number of conditions but the nature of underlying illness beliefs and their relative consistency in patients with chronic hypertension (cHTN) who present to the Emergency Department (ED) with poor blood pressure control is not known.

OBJECTIVES

1) To explore disease knowledge in ED patients with cHTN using explanatory modelling; and 2) to compare gaps in cHTN knowledge across racially similar but geographically divergent ED patients.

METHODS

Emergency department patients of African origin with cHTN were recruited from three sites: Detroit Receiving Hospital (DRH - Detroit, MI), the Tanzanian Training Center for International Health (TTCIH - Ifakara, TZ) and the University Hospital of the West Indies (UHWI - Kingston, JA). Demographic and baseline data were collected along with open-ended responses to a series of questions related to cHTN. Qualitative responses were coded into predefined, disease-relevant quantitative domains by two separate, blinded reviewers and multilevel comparisons were performed using Kruskal-Wallis or analysis of variance (ANOVA) tests, where appropriate.

RESULTS

One hundred and ninety-seven patients were enrolled; mean age (50.5 years vs 51.6 years vs 50.8 years; p = 0.86) and gender distribution (% male: 49.5 vs 44 vs 40; p = 0.53) were similar across sites but patients at DRH (vs TTCIH vs UHWI) were more hypertensive at presentation (mean systolic BP in mmHg: 166.8 vs 153 vs 152.7; p = 0.003), had a longer mean duration of cHTN (12.1 years vs 4.6 years vs 9.1; p < 0.0001), and were less likely to be on antihypertensive therapy (84.5% vs 92% vs 100%, p = 0.001). Explanatory models revealed limited recognition of cHTN as a "disease" (19.6% vs 28% vs 16%; p = 0.31) and consistency in the belief that cHTN was curable (44.3% vs 36% vs 42%; p = 0.62). Stress (48.4% vs 60% vs 50%; p = 0.31) and, especially at DRH, diet (62.2% vs 22% vs 36%; p < 0.0001) were identified most frequently as causes of cHTN and an association with symptoms was common (83.5% vs 98% vs 78%; p = 0.15). Clear differences existed for perceived benefits of treatment and consequences of poor control by site, but in general, both were under-appreciated.

CONCLUSIONS

Misperceptions related to cHTN are common in ED patients. While specific areas of disconnect exist by geographic region, failure to recognize cHTN as a dire and fixed disease state is consistent, suggesting that a uniform educational intervention may be of benefit in this setting.

Closing the gap in hypertension control between younger and older adults: National Health and Nutrition Examination Survey (NHANES) 1988 to 2010

BACKGROUND

Joint National Committee goal blood pressure for all adults was <140/<90 mm Hg or lower from 1984 to 2013. Adults aged ≥60 years (older) have mainly isolated systolic hypertension, with major trials attaining systolic blood pressure <150 but not <140 mm Hg. The main objective was to assess changes in hypertension control to <140/<90 mm Hg in younger (aged <60 years) and older adults and <150/<90 mm Hg in the latter.

METHODS AND RESULTS

National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to <140/<90 mm Hg improved in older (31.6% to 53.1%; P<0.001) and younger (45.7% to 55.9%; P<0.001) patients. The age gap in control declined from 14.1% (P<0.01) in 1988 to 1994 to 2.8% (P=0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P<0.001). Control to <150/<90 mm Hg rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but increased more in older patients (P<0.01). Blood pressure control was higher in both age groups with ≥2 healthcare visits per year and on statin therapy.

CONCLUSIONS

The age gap in hypertension control to <140/<90 mm Hg was virtually eliminated in 2005 to 2010 as clinicians intensified therapy, especially in older patients in whom isolated systolic hypertension predominates, controlling 70% to <150/<90 mm Hg. More frequent healthcare visits and the use of statin therapy may improve hypertension control in all adults.

Role of aldosterone blockade in resistant hypertension

Apparent treatment-resistant hypertension (aTRH), defined as uncontrolled blood pressure using 3 or more antihypertensive medications or controlled using 4 or more antihypertensive medications, affects approximately 30% of uncontrolled and 12% of controlled blood pressure (BP) patients. aTRH is used when pseudoresistance cannot be excluded (eg, BP measurement artifacts, mainly office resistance, suboptimal adherence, suboptimal treatment regimens, and true TRH). True TRH comprises approximately 30% to 50% of TRH. Patients with TRH have a high prevalence of obesity, insulin resistance, sleep apnea, and volume expansion. Aldosterone, a mineralocorticoid, is an important contributor to TRH, with primary aldosteronism present in approximately 20% of patients. Spironolactone, a mineralocorticoid-receptor antagonist, as a fourth-line agent, decreases BP 20 to 25/10 to 12 mm Hg in TRH patients with and without primary aldosteronism. The BP response to spironolactone is roughly double that of other classes of antihypertensive medications in TRH. Although approximately 70% of patients with uncontrolled TRH have estimated glomerular filtration rate of 50 or greater and a serum potassium level of 4.5 or less, which are associated with a low risk for hyperkalemia, only a small percentage receive a mineralocorticoid-receptor antagonist. This review examines the clinical epidemiology and pharmacotherapy of controlled and uncontrolled hypertension with an emphasis on aTRH, the role of aldosterone in blood pressure regulation, and the potential benefits of mineralocorticoid-receptor antagonist in uncontrolled TRH.

Prevalence of optimal treatment regimens in patients with apparent treatment-resistant hypertension based on office blood pressure in a community-based practice network

Hypertensive patients with clinical blood pressure (BP) uncontrolled on ≥3 antihypertensive medications (ie, apparent treatment-resistant hypertension [aTRH]) comprise ≈28% to 30% of all uncontrolled patients in the United States. However, the proportion receiving these medications in optimal doses is unknown; aTRH is used because treatment adherence and measurement artifacts were not available in electronic record data from our >200 community-based clinics Outpatient Quality Improvement Network. This study sought to define the proportion of uncontrolled hypertensives with aTRH on optimal regimens and clinical factors associated with optimal therapy. During 2007-2010, 468 877 hypertensive patients met inclusion criteria. BP <140/<90 mm Hg defined control. Multivariable logistic regression was used to assess variables independently associated with optimal therapy (prescription of diuretic and ≥2 other BP medications at ≥50% of maximum recommended hypertension doses). Among 468 877 hypertensives, 147 635 (31.5%) were uncontrolled; among uncontrolled hypertensives, 44 684 were prescribed ≥3 BP medications (30.3%), of whom 22 189 (15.0%) were prescribed optimal therapy. Clinical factors independently associated with optimal BP therapy included black race (odds ratio, 1.40 [95% confidence interval, 1.32-1.49]), chronic kidney disease (1.31 [1.25-1.38]), diabetes mellitus (1.30 [1.24-1.37]), and coronary heart disease risk equivalent status (1.29 [1.14-1.46]). Clinicians more often prescribe optimal therapy for aTRH when cardiovascular risk is greater and treatment goals lower. Approximately 1 in 7 of all uncontrolled hypertensives and 1 in 2 with uncontrolled aTRH are prescribed ≥3 BP medications in optimal regimens. Prescribing more optimal pharmacotherapy for uncontrolled hypertensives including aTRH, confirmed with out-of-office BP, could improve hypertension control.