Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment-Resistant Hypertension

The association between fluoride in water and blood pressure in children and adolescents

BACKGROUND

The objective of this study was to determine the association between water and plasma fluoride and blood pressure (BP) among children and adolescents.

METHODS

Our study population was individuals of 8-18 years in the 2013-2016 National Health and Nutrition Examination Survey. We performed a multivariable linear and logistic regression analysis to examine the relationship between fluoride and BP.

RESULTS

In a linear regression analysis for systolic BP (SBP) (mm Hg) adjusting for age, sex, race, and poverty, fluoride in water (mg/L) was significant with a coefficient of -0.44 (p = 0.046) among adolescents (12-18 years). Additional adjustments for race, poverty, serum levels of cotinine, and BMI remained significant. While an inverse relationship was found in children (8-11 years), none were significant. Fluoride in plasma was not significant across all ages. The odds ratio of high BP for an increase in water fluoride also was not significant.

CONCLUSIONS

Higher concentrations of fluoride in water were associated with low SBP only among adolescents. Fluoride alone cannot be responsible for BP as several biological metabolic processes may influence its physiological effects. Fluoride consumption should be considered in conjunction with these processes.

IMPACT

The high fluoride in drinking water was statistically significantly associated with low systolic BP in children and adolescents. The odds ratio of high BP for an increase in fluoride in drinking water was not significant. Our study contributes to the existing literature by providing individualized data and results on an individual level.

The adverse health effects of waterpipe smoking in adolescents and young adults: A narrative review

Waterpipe (WP) smoking has rapidly grown in popularity in the United States and other Western countries with the fastest uptake among younger individuals. This growth has been encouraged by the misperception that WP smoke is harmless or less harmful than cigarette smoke. To better understand how WP affects the health of young people, we conducted a narrative review of the literature focusing on the adverse health effects of WP smoking in adolescents and younger adults. We searched scientific literature databases including PubMed, MEDLINE, EMBASE, and ISI Web and selected papers that met the inclusion criteria. Sixty-three papers met the inclusion criteria and were selected for review. Data were abstracted from the selected papers into a standardized table. The evidence demonstrates that WP smoking can cause acute lung infection and injury, and carbon monoxide (CO) poisoning, in adolescents and young adults. It is also associated with adverse subclinical effects in this sub-population, including oral and systemic genotoxicity, lung function decline, and the alteration of vascular and hemodynamic functions. Limited evidence that is available indicates associations with psychological and neurological effects and asthma. No identified publications examined the association between WP use and type 2 diabetes, a condition that is associated with cigarette smoking among young people. WP smoking by younger individuals can result in their hospitalization due to systemic CO poisoning and acute lung disease, and induce subclinical adverse effects in the oral cavity, pulmonary system, and in circulation, that are involved in the pathogenesis of local and systemic chronic diseases.

Patients with adrenal insufficiency have cardiovascular features associated with hypovolemia

CONTEXT

Patients with adrenal insufficiency (AI) have excess mortality and morbidity, mainly due to cardiovascular (CV) diseases. The mechanisms for this is unclear.

OBJECTIVE

To assess CV structure and function in AI patients on conventional replacement therapy and after switching to once-daily, modified-release hydrocortisone (OD-HC) in comparison with healthy matched controls.

METHODS

This was a retrospective analysis of 17 adult AI patients (11 with primary AI, 6 with secondary AI) on stable replacement with cortisone acetate [median (minimum, maximum) 33.5 (12.5-50) mg] and, if needed, fludrocortisone [0.1 (0.05-0.2) mg], and 17 healthy matched controls. Ten patients were switched to an equivalent dose of OD-HC. Data from echocardiography, 24 h Holter-ECG and 24 h blood pressure monitoring were collected at baseline and 6 months after the switch to OD-HC.

RESULTS

At baseline, AI patients had smaller left ventricular diastolic diameter (47.1 ± 4.2 vs. 51.6 ± 2.3 mm; P = 0.001) and left atrial diameter (34.9 ± 4.7 vs. 38.2 ± 2.6 cm; P = 0.018), and a higher ejection fraction (62.5 ± 6.9% vs. 56.0 ± 4.7%; P = 0.003) than controls. AI patients had lower nocturnal systolic and diastolic blood pressure than controls (108 ± 15 mmHg vs. 117 ± 8 mmHg; P = 0.038 and 65 ± 9 mmHg vs. 73 ± 7 mmHg; P = 0.008, respectively). After the switch to OD-HC, nocturnal diastolic blood pressure normalised. No significant changes were observed in echocardiographic and Holter-ECG parameters following the switch.

CONCLUSIONS

AI patients on conventional treatment display cardiovascular abnormalities that could be related to hypovolemia. Switch to OD-HC seems to have beneficial effect on blood pressure profile, but no effect on cardiovascular structure and function.

Resistant Hypertension: Novel Insights

Hypertension is the most common chronic disease and the leading risk factor for disability and premature deaths in the world, accounting for more than 9 million deaths annually. Resistant hypertension is a particularly severe form of hypertension. It was described 50 years ago and since then has been a very active field of research. This review aims at summarizing the most recent findings on resistant hypertension. The recent concepts of apparent- and true-resistant hypertension have stimulated a more precise definition of resistant hypertension taking into account not only the accuracy of blood pressure measurement and pharmacological class of prescribed drugs but also patient adherence to drugs and life-style recommendations. Recent epidemiological studies have reported a 10% prevalence of resistant hypertension among hypertensive subjects and demonstrated the high cardiovascular risk of these patients. In addition, these studies identified subgroups of patients with even higher morbidity and mortality risk, probably requiring a more aggressive medical management. In the meantime, guidelines provided more standardized clinical work-up to identify potentially reversible causes for resistant hypertension such as secondary hypertension. The debate is however still ongoing on which would be the optimal method(s) to screen for non-adherence to hypertension therapy, recognized as the major cause for (pseudo)-resistance to treatment. Recent randomized clinical trials have demonstrated the strong benefit of anti-aldosterone drugs (mostly spironolocatone) as fourth-line therapies in resistant hypertension whereas clinical trials with device-based therapies displayed contrasting results. New trials with improved devices and more carefully selected patients with resistant hypertension are ongoing.

The relationship between pulse pressure, insulin resistance, and beta cell function in non-diabetic Korean adults

AIMS

The present study was conducted to assess the association of pulse pressure (PP) with insulin resistance and beta cell function in Korean non-diabetic populations.

METHODS

This study used the data from the 2015 Korean National Health and Nutrition Examination Survey including 4380 adults, aged 20 or older.

RESULTS

A multivariate analysis revealed that systolic blood pressure (SBP) (β=0.089, 95% confidence interval [CI], 0.004-0.011; p<0.001), diastolic blood pressure (DBP) (β=-0.057, 95% CI -0.014 to -0.003; p=0.002), and PP (β=0.069, 95% CI 0.004-0.011; p<0.001) were significant factors determining the homeostasis model assessment of insulin resistance (HOMA-IR). SBP (β=0.070, 95% CI, 0.113-0.420; p=0.001), DBP (β=-0.068, 95% CI -0.676 to -0.203; p<0.001), and PP (β=0.050, 95% CI 0.115-0.422; p=0.001) were significant factors determining the homeostasis model assessment of beta cell function (HOMA-B). In the analysis of covariance test, after adjusting for related variables (except age), the quartiles of PP were not associated with HOMA-IR (p=0.191) and were inversely associated with HOMA-B (p<0.001). However, when further adjusting for age, the quartiles of PP were positively associated with both HOMA-IR (p<0.001) and HOMA-B (p=0.027).

CONCLUSION

PP was positively associated with insulin resistance and beta cell function in non-diabetic Korean adults.

Low Systolic Blood Pressure From Treatment and Association With Serious Falls/Syncope

INTRODUCTION

With the growing emphasis on intensive blood pressure control, the potential for overtreatment and treatment-related adverse outcomes has become an area of interest. A large representative population within a real-world clinical environment with successful hypertension control rates was used to evaluate serious falls and syncope in people with low-treated systolic blood pressure (SBP).

METHODS

A cross-sectional study among medically treated hypertensive individuals within the Kaiser Permanente Southern California health system (2014-2015) was performed. Serious fall injuries and syncope were identified using ICD codes based on emergency department and hospitalization diagnoses. SBPs in a 1-year window were used to compare serious falls and syncope among individuals with SBP <110 mmHg vs ≥110 mmHg. Logistic regression was used to evaluate the association between low minimum and mean SBP and serious falls/syncope after adjustment for demographics, comorbidities, and medications.

RESULTS

In 477,516 treated hypertensive individuals, the mean age was 65 (SD=13) years and the mean SBP was 129 (SD=10) mmHg, with 27% having a minimum SBP <110 mmHg and 3% having mean SBP <110 mmHg. A total of 15,419 (3.2%) individuals experienced a serious fall or syncope or both during the observation window (5.7% among minimum SBP <110 mmHg and 5.4% among mean SBP <110 mmHg). The multivariable ORs for serious falls/syncope were 2.18 (95% CI=2.11, 2.25) for minimum SBP <110 mmHg and 1.54 (95%CI=1.43, 1.66) for mean SBP <110 mmHg compared with SBP ≥110 mmHg.

CONCLUSIONS

Among treated hypertensive patients, both minimum and mean SBP less than 110 mmHg were associated with serious falls and syncope. Low treatment-related blood pressures deserve consideration given the emphasis on intensive blood pressure control.

Gender difference in the relationship between uric acid and pulse pressure among Korean adults

Hyperuricemia is associated with cardiovascular disease, but the relationship between uric acid (UA) and pulse pressure (PP) is unclear. Therefore, the present study assesses the relationship between UA and PP among Korean adults. Data from 6,310 subjects (2,800 men and 3,510 women) in the seventh Korean National Health and Nutrition Examination Survey (2016) were analyzed. After adjusting for related variables, the odds ratios (ORs) of hyperuricemia (UA ≥ 7.0 mg/dL in men or ≥ 6.0 mg/dL in women) in the high PP group (PP > 65.0 mmHg) in overall populations (OR, 1.563; 95% confidence interval [CI], 1.144-2.136) and women (OR, 1.631; 95% CI, 1.046-2.544) were significantly higher than those in normal PP, but not in men (OR, 1.309; 95% CI, 0.840-2.040). In conclusion, uric acid was positively associated with pulse pressure in women, but not in men.

The J-curve between Diastolic Blood Pressure and Risk of All-cause and Cardiovascular Death

BACKGROUND AND OBJECTIVES

The J-curve phenomenon between diastolic blood pressure (DBP) and mortality has been reported repeatedly in treated patients. However, the baseline risk of low DBP has not been fully explored. This study was to examine the relationship between DBP and risk of mortality from all-cause, atherosclerotic vascular diseases (ASCVD), and ischemic heart disease (IHD) using a prospective cohort of general population.

METHODS

We analyzed 1,234,435 participants of the Korean Cancer Prevention Study cohort (789,255 men, 30-95 years of age) who had a medical evaluation from 1992 to 1995 using Cox proportional hazards models.

RESULTS

A total of 22.5 million person-years were followed up (mean age 46.6 years, deaths 193,903 cases). The hazard ratios of mortality from all-cause and ASCVD, among those with DBP <60 mmHg compared to 70-79 mmHg were 1.23 (95% confidence interval [CI], 1.16-1.30) and 1.37 (95% CI, 1.20-1.57), respectively, after adjustment for multivariable including systolic blood pressure. Increased risks of all-cause death in the lowest DBP category group were maintained in men or women, 30-59 or ≥60 years of age, smoker or non-smoker and diabetes mellitus (DM) or non-DM subgroups. The risk in DBP 60-69 mmHg groups increased in several subgroups. However, the risk for ASCVD death in 30-59 years and DM group, and risk for IHD death in most subgroups except for elderly (≥60 years) decreased.

CONCLUSION

A J-curve relationship between low DBP and all-cause death was found consistently. The baseline risk in the general population may be considered for risk assessment, particularly in case of interventions that lower DBP below 60 mmHg.

Resistant Hypertension, Time-Updated Blood Pressure Values and Renal Outcome in Type 2 Diabetes Mellitus

Background

Apparent treatment resistant hypertension (aTRH) is highly prevalent in patients with type 2 diabetes mellitus (T2D) and entails worse cardiovascular prognosis. The impact of aTRH and long‐term achievement of recommended blood pressure (BP) values on renal outcome remains largely unknown. We assessed the role of aTRH and BP on the development of chronic kidney disease in patients with T2D and hypertension in real‐life clinical practice.

Methods and Results

Clinical records from a total of 29 923 patients with T2D and hypertension, with normal baseline estimated glomerular filtration rate and regular visits during a 4‐year follow‐up, were retrieved and analyzed. The association between time‐updated BP control (ie, 75% of visits with BP <140/90 mm Hg) and the occurrence of estimated glomerular filtration rate <60 and/or a reduction ≥30% from baseline was assessed. At baseline, 17% of patients had aTRH. Over the 4‐year follow‐up, 19% developed low estimated glomerular filtration rate and 12% an estimated glomerular filtration rate reduction ≥30% from baseline. Patients with aTRH showed an increased risk of developing both renal outcomes (adjusted odds ratio, 1.31 and 1.43; P<0.001 respectively), as compared with those with non‐aTRH. No association was found between BP control and renal outcomes in non‐aTRH, whereas in aTRH, BP control was associated with a 30% (P=0.036) greater risk of developing the renal end points.

Conclusions

ATRH entails a worse renal prognosis in T2D with hypertension. BP control is not associated with a more‐favorable renal outcome in aTRH. The relationship between time‐updated BP and renal function seems to be J‐shaped, with optimal systolic BP values between 120 and 140 mm Hg.