Masked hypertension defined by home blood pressure monitoring is associated with impaired flow-mediated vasodilatation in patients with cardiovascular risk factors

Cardiovascular risk in patients receiving antihypertensive drug treatment from the perspective of endothelial function

Blood-pressure-lowering therapy with antihypertensive drugs can reduce the risk of cardiovascular morbidity and mortality in patients with hypertension. However, patients treated with antihypertensive drugs generally have a worse prognosis than untreated individuals. Consistent with the results obtained from epidemiological studies, a clinical study showed that endothelial function was impaired more in treated patients with hypertension than in untreated individuals with the same blood pressure level, suggesting that blood-pressure-lowering therapy with currently available antihypertensive drugs cannot restore endothelial function to the level of that in untreated individuals. Several mechanisms of endothelial dysfunction in treated patients are postulated: irreversible damage to the endothelium caused by higher cumulative elevated blood pressure exposure over time; the persistence of the primary causes of hypertension even after the initiation of antihypertensive drug treatment, including an activated renin-angiotensin-aldosterone system, oxidative stress, and inflammation; and higher global cardiovascular risk related not only to conventional cardiovascular risk factors but also to undetectable nonconventional risk factors. Lifestyle modifications/nonpharmacological interventions should be strongly recommended for both untreated and treated individuals with hypertension. Lifestyle modifications/nonpharmacological interventions may directly correct the primary causes of hypertension, which can improve endothelial function and consequently reduce cardiovascular risk regardless of the use or nonuse of antihypertensive drugs.

Correlation between masked hypertension and endothelial dysfunction measured by flow-mediated dilation: a protocol of systematic review and meta-analysis

INTRODUCTION

A surrogate marker to evaluate artery endothelial response when stimulated by reactive hyperaemia, known as brachial flow-mediated dilation (FMD), has prognostic value in predicting hypertensive organ damage and cardiovascular disease events. However, the degree of correlation between brachial FMD and masked hypertension (MH) outcomes is still unclear. Therefore, the purpose of this study is to pool data regarding FMD with respect to MH.

METHODS AND ANALYSIS

Electronic databases MEDLINE, EMBASE, China National Knowledge Infrastructure and Cochrane Library will be searched for the following keywords: endothelial dysfunction, flow-mediated dilation, and masked hypertension, masked uncontrolled hypertension (MUCH) and prehypertension. The following are the eligibility criteria: population-adults (18 years old or older) without hypertension at baseline, with suspected endothelial dysfunction, or from MH/MUCH populations (office blood pressure <140/90 mm Hg and home blood pressure ≥135 mm Hg and/or 85 mm Hg) and from controlled clinical trials, cohort studies, or randomised and controlled trials; exposures-any metrics for FMD; comparisons-participants without MH or MUCH; and outcome-change in FMD between the case group and the control group. Two authors will be engaged in screening and collecting data independently; disagreements will be resolved through discussion. Data extraction will include primary data designated as HR, OR, correlations and regression coefficients. Comprehensive Meta-Analysis V.2.0 will be used to conduct related subgroup and sensitivity analyses and publication bias.

ETHICS AND DISSEMINATION

This study does not require ethics approval. It will be submitted to a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020208362.

Diversity of and initiatives for hypertension management in Asia-Why we need the HOPE Asia Network

The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30 years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices.

Blood Pressure Measurement and Treatment Decisions

White-coat and masked hypertension are important hypertension phenotypes. Out-of-office blood pressure measurement is essential for the accurate diagnosis and monitoring of these conditions. This review summarizes literature related to the detection and diagnosis, prevalence, epidemiology, prognosis, and treatment of white-coat and masked hypertension. Cardiovascular risk in white-coat hypertension appears to be dependent on the presence of coexisting risk factors, whereas patients with masked hypertension are at increased risk of target organ damage and cardiovascular events. There is an unmet need for robust data to support recommendations around the use of antihypertensive treatment for the management of white-coat and masked hypertension.

The effects of topiroxostat on vascular function in patients with hyperuricemia

Xanthine oxidoreductase (XOR) inhibitors, such as allopurinol and febuxostat, inhibit the catalysis of serum uric acid (SUA) synthesis. In doing so, they are thought to improve vascular endothelial function in patients with hyperuricemia and cardiovascular risk by reducing increases in SUA and reactive oxygen species levels. We performed a retrospective cohort study to evaluate the effects of topiroxostat, a novel XOR inhibitor, on vascular function measured by flow-mediated dilation (FMD) on ultrasonography. In total, 23 patients with hyperuricemia were enrolled. After approximately 8 weeks, topiroxostat was associated with a significant increase in the peak percentage change in diameter (∆FMD) from 4.53% ± 2.09% to 5.54% ± 3.08% (P = .045). It also significantly reduced the SUA levels from 7.31 ± 1.43 to 5.44 ± 1.11 mg/dL (P < .001). Although further studies are needed to validate these results, it appears that topiroxostat improves vascular endothelial function in patients with hyperuricemia.

Associations between parameters of flow-mediated vasodilatation obtained by continuous measurement approaches and the presence of coronary artery disease and the severity of coronary atherosclerosis

We investigated the associations between the parameters of flow-mediated vasodilatation (FMD) obtained by continuous measurement approaches and the presence of coronary artery disease (CAD) and the severity of coronary atherosclerosis. The subjects consisted of 282 consecutive patients who underwent coronary angiography (CAG) and in whom we could measure FMD. Using continuous measurement approaches, we measured FMD as the magnitude of the percentage change from brachial artery diameter from baseline to peak (bFMD), the maximum FMD rate calculated as the maximal slope of dilation (FMD-MDR), and the integrated FMD response calculated as the area under the dilation curve during the 60- and 120 s dilation periods (FMD-AUC60 and FMD-AUC120). We divided the patients into two groups, the CAD group and the non-CAD group, and defined the severity of coronary atherosclerosis according to the Gensini score. The CAD group showed significantly lower %FMD, FMD-MDR, FMD-AUC60, and FMD-AUC120. Gender, smoking, dyslipidemia (DL), and diabetes mellitus (DM), in addition to FMD-AUC120, were identified as significant independent variables that predicted the presence of CAD by a multivariate logistic regression. In addition, a multiple regression analysis indicated that gender, DL, and hypertension, in addition to FMD-AUC120, were predictors of the Gensini score. Finally, we defined the cutoff value of FMD-AUC120 for the prediction of CAD in all patients as 11.1 (sensitivity 0.582, specificity 0.652) by a receiver-operating characteristic (ROC) curve analysis. In conclusion, FMD-AUC120 as assessed by continuous measurement approaches may be a superior marker for evaluating the presence of CAD and the severity of coronary atherosclerosis.

Endothelial function in postmenopausal women with nighttime systolic hypertension

OBJECTIVE

Hypertension becomes more prevalent in women during their postmenopausal years. Nighttime systolic blood pressure (SBP) is especially predictive of adverse cardiac events, and the relationship between rising nighttime SBP and cardiovascular risk increases more rapidly in women compared with men. The reasons for the prognostic significance of nighttime SBP are not completely known but may involve vascular endothelial dysfunction. The purposes of this study were to examine the relationship between nighttime SBP and endothelial function, as assessed by brachial artery flow-mediated dilation (FMD), and to determine whether postmenopausal women with nighttime hypertension (SBP ≥120 mm Hg) evidenced greater endothelial dysfunction compared with women with normal nighttime SBP.

METHODS

One hundred postmenopausal women (mean [SD] age, 65.8 [7.5] y; mean [SD] body mass index, 28.3 [4.7] kg/m; hypertension, 47%; coronary artery disease, 51%; mean [SD] clinic SBP, 137 [17] mm Hg; mean [SD] clinic diastolic blood pressure, 67 [11] mm Hg; nighttime hypertension, 34 women) underwent 24-hour ambulatory blood pressure monitoring, actigraphy, and brachial artery FMD assessment.

RESULTS

Multivariate regression models showed that higher nighttime SBP and larger baseline artery diameter were inversely related to FMD. Nighttime SBP and baseline artery diameter accounted for 23% of the variance in FMD. After adjustment for baseline artery diameter, women with nighttime hypertension had lower mean (SD) FMD than women with normal nighttime SBP (2.95% [0.65%] vs 5.52% [0.46%], P = 0.002).

CONCLUSIONS

Nighttime hypertension is associated with reduced endothelial function in postmenopausal women. Research examining the therapeutic benefits of nighttime hypertension treatment on endothelial function and future cardiovascular risk in postmenopausal women is warranted.