COVID-19 and hypertension-evidence and practical management: Guidance from the HOPE Asia Network

Home blood pressure-centered approach - from digital health to medical practice: HOPE Asia Network consensus statement 2023

Recent innovations in digital technology have enabled the simultaneous accumulation, and the linking and analysis of time-series big data relating to several factors that influence blood pressure (BP), including biological indicators, physical activity, and environmental information. Various approaches can be used to monitor BP: in the office/clinic; at home; 24-h ambulatory recording; or with wearable and cuffless devices. Of these, home BP monitoring is a reliable and convenient method, and is recommended for hypertension management by current national and international guidelines. This recommendation is based on evidence showing that home BP is an important predictor of cardiovascular, cerebrovascular and kidney disease in patients with hypertension. In addition, lifetime personalized health record (PHR)-based home BP with telemonitoring combined with co-interventions has been shown to lower BP more effectively than the traditional approach based on office BP. Thus, home BP represents a key metric for personalized anticipation medicine, from digital healthcare to digital medicine. This paper summarizes the latest evidence on home BP monitoring and proposes a Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network consensus on a home BP-centered approach to the management of hypertension.

Phenome-wide association study and precision medicine of cardiovascular diseases in the post-COVID-19 era

SARS-CoV-2 infection causes injuries of not only the lungs but also the heart and endothelial cells in vasculature of multiple organs, and induces systemic inflammation and immune over-reactions, which makes COVID-19 a disease phenome that simultaneously affects multiple systems. Cardiovascular diseases (CVD) are intrinsic risk and causative factors for severe COVID-19 comorbidities and death. The wide-spread infection and reinfection of SARS-CoV-2 variants and the long-COVID may become a new common threat to human health and propose unprecedented impact on the risk factors, pathophysiology, and pharmacology of many diseases including CVD for a long time. COVID-19 has highlighted the urgent demand for precision medicine which needs new knowledge network to innovate disease taxonomy for more precise diagnosis, therapy, and prevention of disease. A deeper understanding of CVD in the setting of COVID-19 phenome requires a paradigm shift from the current phenotypic study that focuses on the virus or individual symptoms to phenomics of COVID-19 that addresses the inter-connectedness of clinical phenotypes, i.e., clinical phenome. Here, we summarize the CVD manifestations in the full clinical spectrum of COVID-19, and the phenome-wide association study of CVD interrelated to COVID-19. We discuss the underlying biology for CVD in the COVID-19 phenome and the concept of precision medicine with new phenomic taxonomy that addresses the overall pathophysiological responses of the body to the SARS-CoV-2 infection. We also briefly discuss the unique taxonomy of disease as Zheng-hou patterns in traditional Chinese medicine, and their potential implications in precision medicine of CVD in the post-COVID-19 era.

Peak home blood pressure as an earlier and strong novel risk factor for stroke: the practitioner-based nationwide J-HOP study extended

While home blood pressure (BP) measurement is recommended for hypertension management, the clinical implications of peak home BP values have not been well studied. This study investigated the association between pathological threshold or frequency of peak home BP and cardiovascular events in patients with ≥1 cardiovascular risk factor. The Japan Morning Surge-Home Blood Pressure (J-HOP) study enrolled participants from 2005-2012 with extended follow-up from December 2017 to May 2018, which generated the dataset for this analysis. Average peak home systolic BP (SBP) was defined as average of the highest three BP values on 14-day measurement period. Patients were divided into quintiles of peak home BP, and the risk of stroke, coronary artery disease (CAD) and atherosclerotic cardiovascular disease (ASCVD; stroke+CAD) was determined. In 4231 patients (mean 65 years) followed for 6.2 years there were 94 strokes and 124 CAD events. The adjusted hazard ratio (HR) (95% CI) for the risk of stroke and ASCVD in patients with average peak home SBP in the highest versus lowest quintile was 4.39 (1.85-10.43) and 2.04 (1.24-3.36), respectively. Risk was greatest for stroke in the first 5 years: HR 22.66 (2.98-172.1). The pathological threshold of average peak home SBP for 5-year stroke risk was 176 mmHg. There was a linear association between the number of times peak home SBP > 175 mmHg and stroke risk. Peak home BP was a strong risk factor for stroke, especially within the first 5 years. We propose exaggerated peak home SBP > 175 mmHg as an early and strong novel risk factor for stroke.

Hypertension management before and under the COVID-19 pandemic: lessons and future directions

Hypertension is a significant risk factor for cardiovascular diseases. The prevalence of hypertension and its complications is increasing yearly, yet it remains inadequately controlled worldwide. It has already been recognized that self-management, including self-measured blood pressure monitoring at home, is more important than office blood pressure monitoring. The practical application of telemedicine using digital technology was already underway. COVID-19 has promoted the popularization of these management systems in primary care, although the COVID-19 pandemic disrupted lifestyle and healthcare access. At the beginning of the pandemic, we were at the mercy of information on whether certain antihypertensive drugs, for example, might pose a risk of infection in the face of unknown infectious diseases. Over the past three years, however, much knowledge has been accumulated. It has been scientifically proven that there is no serious problem in managing hypertension in the same way as before the pandemic. That is to control blood pressure mainly through home blood pressure monitoring and continuing conventional drug therapy while modifying lifestyle. On the other hand, in the New Normal era, it is necessary to accelerate digital hypertension management and the establishment of new social networks and medical systems to prepare for the re-emergence of future pandemics while continuing to protect against infection. This review will summarize the lessons and future directions we learned from the impact of the COVID-19 pandemic on hypertension management. The COVID-19 pandemic has disrupted our daily life, restricted access to healthcare, and altered some of the conventional management of hypertension.

Arterial Hypertension and Severe COVID-19 in Hospitalized Patients: Data from a Cohort Study

Aim. To assess the association  of hypertension  with the severe forms and fatal outcomes of Coronavirus disease 2019 (COVID-19).

Material and Methods. This retrospective  cohort study involved adult patients (≥18 years old),  admitted to the University  hospital №4 of Sechenov University (Moscow, Russia) between 08 April 2020 and 19 November 2020 with clinically diagnosed or laboratory-confirmed COVID-19. The cohort included 1637 patients. The primary outcome was all-cause in-hospital mortality. The secondary outcomes included intensive care unit admission (ICU) and invasive ventilation. Multiple logistic regression was performed to assess the independent association  between risk factors and endpoints.

Results. A total of 1637 patients were included in the study. 51.80% (n=848) of the subjects were males. The median age was 59.0 (48.0; 70.0) years and 55.90% (n=915) had pre-existing diagnosis of hypertension. Patients with hypertension  had significantly more severe lung injury based on chest CT scan findings  as well as lower oxygen saturation  (SрO2). More of them were admitted to ICU  and  placed  on invasive  ventilation.  The hypertension  group  also  had  higher  mortality.  Age,  hypertension, glucose, C-reactive protein and decreased platelet count were independently associated with mortality, hypertension  having the strongest association (OR 1.827, 95% CI 1.174-2.846, p=0.008). Age,  hypertension, neutrophil count, platelet count, glucose, and CRP were independently associated  with ICU  admission, with hypertension  having  the strongest  association  (OR  1.595, 95% CI 1.178-2.158, p=0.002). Age, hypertension, glucose, CRP and decreased platelet count were independently associated with invasive ventilation, with hypertension having the strongest association  (OR  1.703, 95% CI 1.151-2.519, p=0.008).Based on the multiple logistic regression models, odds of death, ICU admission, and invasive ventilation were higher in the hypertension  group as compared  to the group without hypertension.

Conclusion. Hypertension can be an independent predictor of severe COVID-19 and adverse outcomes, namely death, ICU admission, and invasive ventilation in hospitalized  patients.

Inflammaging and body composition: New insights in diabetic and hypertensive elderly men

Age-related changes in the body's physiological responses play a critical role in systemic arterial hypertension (SAH) and type 2 Diabetes mellitus (T2DM). SAH and T2DM have clinically silent low-grade inflammation as a common risk factor. This inflammation has a relevant element, the excess of fatty tissue. In this scenario, little is known about how inflammatory markers interact with each other. Therefore, this work evaluated the interplay among anthropometric, biochemical, and inflammatory markers in the elderly with SAH and T2DM. Men aged 60-80 years old with SAH and T2DM were classified by body mass index (BMI) as eutrophic elderly (EE, 24 individuals) or overweight elderly (OE, 25 individuals). Body composition analysis was performed using bioimpedance. Blood samples were collected to perform inflammatory and biochemical evaluations. The cytokines IL-17A, IL-1β, IFN-y, TNF-α, and IL-10, were evaluated by ELISA. Triglycerides, total and fractions of cholesterol, and glucose were measured by spectrophotometry. Overweight elderly men had a higher glycemic index and an increase in most anthropometric markers, as well as higher means for all pro-inflammatory cytokines analyzed (IL-17A, IL-1β, IFN-y, and TNF-α) in comparison to their eutrophic elderly counterparts. However, there was a decrease in IL-10 anti-inflammatory cytokine and IL-10/IL-17A ratio compared to their eutrophic elderly counterparts. Although overweight elderly men have worsening inflammatory parameters, the magnitude of their correlations with anthropometric and biochemical parameters becomes less evident. The Bayesian networks highlight that in the eutrophic elderly, IL-17A and TNF-α are the cytokines most associated with interactions, and most of these interactions occur with biochemical parameters. It is worth highlighting the role of IFN-y in overweight elderly men. This cytokine influences IL-10 and TNF-α production, contributing to the inflammatory profile exacerbated in this group.

Effect of Hypertension Comorbidity on Clinical Characteristics of COVID-19 Patients Infected by the Wild-Type, the Delta or Omicron Variant SARS-CoV-2

Background

Hypertension was the most common comorbidity in patients with the coronavirus disease 2019 (COVID-19). We aim to study the effect of comorbid hypertension on the clinical characteristics of COVID-19 patients with the underlying mechanism.

Methods

We retrospectively analyzed 459, 336 and 659 COVID-19 patients who were infected by the wild-type, the delta and omicron variant, respectively, including their demographic information, medical history, immunization record (if available), and laboratory parameters, to investigate the clinical differences between COVID-19 patients with and without hypertension.

Results

In this study 26.1%, 26.8%, and 12.9% of COVID-19 patients had pre-existing hypertension in the cohort of wild-type, delta, and omicron variant, respectively. Compared to non-hypertensive peers, hypertension patients demonstrated older age, higher occurrence of other major comorbidities, and poorer blood or coagulation parameters, showing worse prognosis. In case of the delta or omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hypertension patients produced robust antibody responses, although indistinguishable whether it was due to vaccination or natural infection and resembled those of non-hypertensive peers in blood cell and coagulation profiles with still varying viremic damages to major organs.

Conclusions

Resultantly, COVID-19 infection promoted pro-inflammatory and pro-thrombotic states in hypertension patients, whereas vaccinated individuals would exhibit favorable prognoses.

[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Video or text? Education through a social media website in hypertension

Background

Currently, several studies are available on the effective use of the Instagram social media platform to conduct training projects for CVD patients. The aim of this study was to determine the most effective methods (text or video) of informing people about the primary prevention of hypertension using a social media website.

Materials and methods

A total of 125 participants were randomly selected and assigned to one of the four training groups depending on the training mode, i.e. text posts (4000 characters) - Group 1, video clips (5 min) - Group 2, text followed by video - Group 3 and video followed by text - Group 4. Before and after training, respondents in all four groups completed the Heart Disease Knowledge Questionnaire (HDKQ).

Results

The total number of people who listened to and read the materials of the online school was 2108 people. Before training, the number of correct responses for 29 HDKQ statements was 18.4 ± 5.1, after training it increased to 21.9 ± 3.9 (CI, 21; 22.7) (p < 0.0001). The post-hoc analysis showed that after training the participants in Group 4 had more correct responses than the respondents in Group 3, 2, 1 i.e. Δ = 5.2, Δ = 1.5, Δ = 0.3, respectively. The respondents from Group 3 gave the lowest number of correct responses in other groups.

Conclusions

The most effective method of informing people about the primary prevention of hypertension using a social media website corresponded to the following sequence: a video clip followed by a text post.

Results and effects of patients who have recovered from COVID-19: identifying the relationship with risk factors and comorbidities

The number of deaths from COVID-19 is closely associated with multimorbidities. This study aimed to review the clinical and functional conditions of patients who recovered from COVID-19. Additionally, identify the relationship with risk factors and comorbidities. Systemic arterial hypertension (SAH) was more frequently observed in patients with severe COVID-19. Diabetes mellitus (DM) is one of the comorbidities that has contributed the most to the increase in the number of hospitalizations due to complications and the number of deaths due to infection by COVID-19. Obesity has been shown to be a risk factor for hospitalization in patients with COVID-19 under 60 years of age. Most survivors of COVID-19 suffer primarily from muscle fatigue or weakness. In addition, patients who were more seriously ill during their hospital stay have greater impairment of functional capacity, pulmonary diffusion and fatigue symptoms, and are the main target population for long-term recovery interventions. To optimize the post-hospitalization rehabilitation of patients after discharge from COVID-19, the need for multidisciplinary work in rehabilitation, the reinforcement of public policies to ensure equity in access to the public health system and training should be considered of the health team in view of the new demands and realities generated by COVID-19.

Hypertension as an independent risk factor for severity and mortality in patients with COVID-19: a retrospective study

PURPOSE OF THE STUDY

Hypertension is one of the most common comorbidities in COVID-19 pneumonia. However, whether it is an independent factor on the severity and mortality of COVID-19 has not been studied.

STUDY DESIGN

In this study, 736 patients with a PCR-confirmed diagnosis of COVID-19 were included from 12 January 2020 to 25 March 2020. All patients were divided into two groups according to whether or not they were hypertensive. After propensity score matching (PSM) to remove the interference of mismatches in the baseline data, the clinical characteristics and outcomes of angiotensin II receptor blocker (ARB)/ACE inhibitors application were analysed.

RESULTS

A total of 220 (29.9%) patients were hypertensive, and 516 (70.1%) patients were not hypertensive. PSM eliminated demographic and comorbidity differences between the two groups. Of all participants, 32 patients died (4.3% mortality), including 17 out of 220 in the hypertension group (7.7%) and 15 out of 516 in the non-hypertension group (2.9%). The incidence of intensive care unit (ICU) stay in the hypertension group (12.8%) was higher than in the non-hypertension group (5.3%) (p<0.05). Logistic regression analysis showed that hypertension was an independent risk factor for death, not other comorbidities. Kaplan-Meier analysis showed that mortality was higher in the hypertension group than in the non-hypertension group before and after PSM (p<0.05). There was no statistically significant difference in ICU therapy, mortality and hospitalisation time between hypertensive patients with or without ARBs/ACE inhibitors (p>0.05).

CONCLUSION

Hypertension was an independent risk factor for the severity and mortality of patients with COVID-19. ARBs/ACE inhibitors should not be discontinued in hypertensive patients with COVID-19.

The impact of pre-existing hypertension and its treatment on outcomes in patients admitted to hospital with COVID-19

The impact of pre-existing hypertension on outcomes in patients with the novel corona virus (SARS-CoV-2) remains controversial. To address this, we examined the impact of pre-existing hypertension and its treatment on in-hospital mortality in patients admitted to hospital with Covid-19. Using the CAPACITY-COVID patient registry we examined the impact of pre-existing hypertension and guideline-recommended treatments for hypertension on in-hospital mortality in unadjusted and multi-variate-adjusted analyses using logistic regression. Data from 9197 hospitalised patients with Covid-19 (median age 69 [IQR 57–78] years, 60.6% male, n = 5573) was analysed. Of these, 48.3% (n = 4443) had documented pre-existing hypertension. Patients with pre-existing hypertension were older (73 vs. 62 years, p < 0.001) and had twice the occurrence of any cardiac disease (49.3 vs. 21.8%; p < 0.001) when compared to patients without hypertension. The most documented class of anti-hypertensive drugs were angiotensin receptor blockers (ARB) or angiotensin converting enzyme inhibitors (ACEi) (n = 2499, 27.2%). In-hospital mortality occurred in (n = 2020, 22.0%), with more deaths occurring in those with pre-existing hypertension (26.0 vs. 18.2%, p < 0.001). Pre-existing hypertension was associated with in-hospital mortality in unadjusted analyses (OR 1.57, 95% CI 1.42,1.74), no significant association was found following multivariable adjustment for age and other hypertension-related covariates (OR 0.97, 95% CI 0.87,1.10). Use of ACEi or ARB tended to have a protective effect for in-hospital mortality in fully adjusted models (OR 0.88, 95% CI 0.78,0.99). After appropriate adjustment for confounding, pre-existing hypertension, or treatment for hypertension, does not independently confer an increased risk of in-hospital mortality patients hospitalized with Covid-19.

Seven-action approaches for the management of hypertension in Asia - The HOPE Asia network

Asia is a large continent and there is significant diversity between countries and regions. Over the last 30 years, absolute blood pressure (BP) levels in Asia have increased to a greater extent than those in other regions. In diverse Asia‐Pacific populations, for choosing an Asia‐specific approach to hypertension management is important to prevent target organ damage and cardiovascular diseases. In this consensus document of HOPE Asia Network, we introduce seven action approaches for management of hypertension in Asia.

Should we continue to use renin-angiotensin-aldosterone system blockers in patients with COVID-19?

Patients with chronic kidney disease, chronic heart failure and hypertension have an increased risk of coronavirus disease 2019 (COVID-19)-related death. Renin–angiotensin–aldosterone system (RAS) blockers are commonly prescribed to decrease morbidity and mortality in these conditions. Following the pre-clinical demonstration of COVID-19 viral entry into cells via angiotensin-converting enzyme-2, the use of RAS blockers was questioned in infected individuals. Theodorakopoulou et al. extensively review the pathophysiology behind that hypothesis and observational or clinical trials on RAS blockers and COVID-19. Despite being a scientific hot spot of an ongoing debate, discontinuation of RAS blockers is not associated with improved clinical outcomes in COVID-19 and may have potential harmful effects, including exacerbation of the underlying disease.

Home Blood Pressure and Telemedicine: A Modern Approach for Managing Hypertension During and After COVID-19 Pandemic

Hypertension is the most common cardiovascular risk factor for acute cardiovascular outcomes, including acute coronary disease, stroke, chronic kidney disease and congestive heart failure. Despite the fact that it represents the most prevalent risk factor in the general population, mostly in elderly individuals, its awareness is still relatively low, being about one third of patients living with undiagnosed hypertension and high risk of experiencing acute cardiovascular events. In addition, though recent improvement in pharmacological and non-pharmacological therapeutic options, hypertension is largely uncontrolled, with about 35-40% of treated hypertensive patients achieving the recommended therapeutic targets. Among different modern interventions proposed for improving blood pressure control in treated hypertensive patients, a systematic adoption of home BP monitoring has demonstrated to be one of the most effective. Indeed, it improves patients' awareness of the disease and adherence to prescribed medications and allows tailoring and personalizing BP lowering therapies. Home BP monitoring is particularly suitable for telemedicine and mobile-health solutions. Indeed, in specific conditions, when face-to-face interactions between patients and physicians are not allowed or even suspended, as in case of COVID-19 pandemic, telemedicine may ensure effective management of hypertension, as well as other cardiovascular and non-cardiovascular comorbidities. This review will summarize strengths and limitations of telemedicine in the clinical management of hypertension with a particular focus on the lessons learned during the COVID-19 pandemic.

Renin-angiotensin system blockers during the COVID-19 pandemic: an update for patients with hypertension and chronic kidney disease

Hypertension and chronic kidney disease (CKD) are among the most common comorbidities associated with coronavirus disease 2019 (COVID-19) severity and mortality risk. Renin–angiotensin system (RAS) blockers are cornerstones in the treatment of both hypertension and proteinuric CKD. In the early months of the COVID-19 pandemic, a hypothesis emerged suggesting that the use of RAS blockers may increase susceptibility for COVID-19 infection and disease severity in these populations. This hypothesis was based on the fact that angiotensin-converting enzyme 2 (ACE2), a counter regulatory component of the RAS, acts as the receptor for severe acute respiratory syndrome coronavirus 2 cell entry. Extrapolations from preliminary animal studies led to speculation that upregulation of ACE2 by RAS blockers may increase the risk of COVID-19-related adverse outcomes. However, these hypotheses were not supported by emerging evidence from observational and randomized clinical trials in humans, suggesting no such association. Herein we describe the physiological role of ACE2 as part of the RAS, discuss its central role in COVID-19 infection and present original and updated evidence from human studies on the association between RAS blockade and COVID-19 infection or related outcomes, with a particular focus on hypertension and CKD.

Prognostic value of masked uncontrolled apparent resistant hypertension detected through home blood pressure monitoring

OBJECTIVE

Resistant hypertension carries a poor prognosis and current guidelines recommend the exclusion of the white-coat phenomenon for proper diagnosis. However, guidelines do not focus on patients treated with at least three drugs whose blood pressure (BP) is controlled at the office but elevated out of it. We aimed at determining whether this masked uncontrolled apparent resistant hypertension (MUCRH) detected through home blood pressure monitoring (HBPM) has prognostic value for fatal and nonfatal events in these hypertensive patients.

METHODS

Hypertensive patients treated with at least three drugs who performed a baseline HBPM between 2008 and 2015 were followed to register the occurrence of total mortality, cardiovascular mortality, and fatal and nonfatal cardiac and cerebrovascular events. MUCRH was defined as office blood pressure less than 140/90 mmHg and home BP at least 135 and/or 85 mmHg. Multivariable Cox proportional hazard models were adjusted to determine the independent prognostic value of MUCRH for the events of interest.

RESULTS

We included 470 patients, 35.5% male, mean age 71.9 years, and treated with 3.3 antihypertensive drugs on average. Among study population, 15.5% had MUCRH (33.3% when considering only patients with adequate BP control at the office). Median follow-up was 6.7 years. In multivariable models, MUCRH was an independent predictor for cardiovascular mortality and cerebrovascular events: hazard ratio 4.9 (95% CI 1.2-19.9, P = 0.03) and 5.1 (95% CI 1.5-16.9, P = 0.01), respectively.

CONCLUSION

MUCRH is not rare and is independently associated with cardiovascular morbidity and mortality. The systematic monitoring of intensively treated individuals through HBPM would be useful for the detection of patients at increased risk of events.

Associations between Socio-Demographic Factors and Hypertension Management during the COVID-19 Pandemic: Preliminary Findings from Malaysia

The perspectives of hypertensive patients on the state of hypertension control during the ongoing pandemic restrictions have not been extensively studied in Malaysia. Therefore, this study aimed to assess the impact of socio-demographic factors, health literacy, and adherence on the overall hypertension management in a group of Malaysian hypertensive patients during the COVID-19 pandemic. An anonymous, online cross-sectional study was conducted over three months that involved a group of Malaysian adults with hypertension. A validated, self-administered 30-item questionnaire was prepared in Malay and English languages on Google Forms. The link was then distributed to participants on social media (Facebook and WhatsApp). Following survey validation, a pilot study with 30 participants who met the inclusion criteria was carried out. The total scores for health literacy, adherence, and pandemic impact on hypertension control were calculated and compared across all independent variables. In a total of 144 study participants, controlled blood pressure was reported in 77% (N = 111). There were good levels of adherence and health literacy scores but moderate levels of pandemic impact scores. The total adherence scores showed a statistically significant difference between age groups (χ² = 6.48, p = 0.039) and those who reported having controlled and uncontrolled blood pressure (U = 1116, p = 0.001). Moreover, the analysis revealed statistically significant differences in total pandemic impact scores based on the age group (χ² = 15.008, p = 0.001), household income (χ² = 6.887, p = 0.032), employment (U = 1712, p = 0.006), and marital status (U = 520.5, p < 0.001). The youngest age group (18-39) years, the lowest income group, unemployed and unmarried individuals, had significantly higher pandemic impact scores. This denotes that those individuals were more prone to be negatively affected by the pandemic regarding their hypertension management. Most participants reported relatively controlled blood pressure and good levels of health literacy as well as adherence amidst the pandemic. To a moderate extent, study participants perceived that the pandemic had a negative effect on hypertension management. The perceived negative impact of the pandemic was attributed to several socio-demographic factors, such as age, household income, employment, and marital status.

Predictive Factors for the Care and Control of Hypertension based on the Health Belief Model among hypertensive patients during the COVID-19 epidemic in Sirjan, Iran

BACKGROUND

Hypertension is a leading risk factor for morbidity and mortality around the world. Preventing this health problem is considered an important priority. The aim of this study was to investigate the predictive factors for care and control of hypertension (CCH) according to the health belief model (HBM) in patients with hypertension during the COVID-19 epidemic in Sirjan, Iran.

METHODS

In this cross-sectional study, participants were chosen by simple random sampling. Data were collected by a valid and reliable researcher-made questionnaire from 200 patients with high blood pressure aged 30-60 years. Data were analyzed by SPSS21 and analysis based on descriptive statistics, Pearson correlation coefficients and linear regression were conducted.

RESULTS

The results of Pearson correlation coefficients showed that there was a significant correlation between almost all constructs of Health Belief Model (HBM), but the strongest correlations were between self-efficacy and perceived susceptibility (r = 0.940, P ≤ 0.001), and between perceived barriers with perceived benefits (r = -0.615, P ≤ 0.001). According to linear regression, perceived barriers (β = -0.291), cues to action (β = -0.590), and knowledge (β = 0.973) predicted more than 26% of CCH variability. Knowledge had a stronger role than other variables.

CONCLUSIONS

The results of this study show that the constructs of the Health Belief Model can predict CCH in hypertensive patients. This model can be used as a tool for designing and implementing educational interventions to increase CCH among hypertensive patients.

Digital therapeutics for essential hypertension using a smartphone application: A randomized, open-label, multicenter pilot study

Hypertension is the most considerable but treatable risk factor for cardiovascular disease. Although physicians prescribe multiple antihypertensive drugs and promote lifestyle modifications, the real-world blood pressure (BP) control rate remains poor. To improve BP target achievement, we developed a novel digital therapeutic-the HERB software system -to manage hypertension. Here, we performed a randomized pilot study to assess the safety and efficacy of the HERB system for hypertension. We recruited 146 patients with essential hypertension from March 2018 to March 2019. We allocated eligible patients to the intervention group (HERB system + standard lifestyle modification) or control group (standard lifestyle modification alone). The primary outcome was the mean change from baseline to 24 weeks in 24-hour systolic BP (SBP) measured by ambulatory blood pressure monitoring (ABPM). The baseline characteristics in each group were well balanced; the mean age was approx. 57 years, and 67% were male. In the primary end point at 24 weeks, HERB intervention did not lower the mean change of 24-hour SBP by ABPM compared with the controls (adjusted difference: -0.66 mmHg; p = .78). In an exploratory analysis focusing on antihypertensive drug-naïve patients aged <65, the effects of the HERB intervention were significantly greater than the control for reducing 24-hour SBP by ABPM at 16 weeks (adjusted difference: -7.6 mmHg; p = .013; and morning home SBP at 24 weeks (adjusted difference - 6.0 mmHg; p = .012). Thus, the HERB intervention did not achieve a primary efficacy end point. However, we observed that antihypertensive drug-naïve adult hypertensive patients aged <65 years could be a potential HERB system-effective target for further investigations of the efficacy of the system.

Novel Indices of Home Blood Pressure Variability and Hypertension-Mediated Organ Damage in Treated Hypertensive Patients

INTRODUCTION

Although multiple home blood pressure variability (HBPV) indices have been proposed, the superiority of one over another is not clear in treated hypertensives.

AIM

We evaluated the correlation between different indices of HBPV and hypertension-mediated organ damage (HMOD) in this population and determined predictors of greater HBPV.

METHODS

We included adult treated hypertensives who performed an HBP monitoring (duplicate sitting BP readings in the morning, afternoon, and evening for 4 days, Omron HEM-705CP-II), laboratory measurements, transthoracic echocardiogram and carotid-femoral pulse wave velocity. We selected HBPV indices from three different calculation approaches: coefficient of variation (CoV), difference between maximum and minimum BP (MMD), and morning BP increase (MI), and evaluated their correlation with left ventricular mass index, relative wall thickness (RWT), ejection fraction, arterial stiffness and estimated glomerular filtration rate through a correlation matrix. For those variability indices significantly associated with HMOD, we constructed multiple linear regression models to determine independent predictors of HBPV.

RESULTS

We included 204 patients, mean age 67.2 (± 13.8) years, 64% female. CoV and MMD for systolic BP showed the greatest correlation with HMOD. Factors independently associated both with CoV and MMD were: older age (b = 0.07; 95% CI 0.04-0.07; p < 0.001 and b = 0.4; 95% CI 0.2-0.5; p < 0.001, respectively), history of stroke (b = 3.6; 95% CI 0.9-6.4; p = 0.01 and b = 25.7; 95% CI 10.1-41.2; p = 0.001, respectively), and body mass index [b = - 0.1; 95% CI - 0.2 to (- 0.02); p = 0.01 and b = - 0.5; 95% CI - 0.9 to (- 0.1); p = 0.01, respectively].

CONCLUSION

CoV and MMD showed the greatest association with HMOD in treated hypertensives. Older age, history of stroke and lower body mass index were easy-to-detect predictors.

COVID-19: Are Non-Communicable Diseases Risk Factors for Its Severity?

OBJECTIVE

To identify and describe the mechanisms of lifestyle characteristics-obesity, DM, hypertension and physical inactivity-that may lead to the severity of illness among individuals with COVID-19.

DATA SOURCE

A scoping review was conducted by searching electronic databases of PubMed and Scopus from December 2019 to August 2020.

INCLUSION/EXCLUSION CRITERIA

inclusion criteria were studies that explicitly describe the mechanism of COVID-19 in relationship with either hypertension, type 2 diabetes mellitus type 2 (DM), obesity and/or physical inactivity. Studies of epidemiological background, descriptive surveys and interventional studies were excluded.

DATA EXTRACTION

study characteristics were tabulated according to purpose, type of non-communicable diseases (NCDs), the hypothesis on the mechanism of infestation (MOI) and conclusion.

DATA SYNTHESIS

NCDs were categorized according to type and hypothesis on mechanisms of infestation. The interplay between COVID-19, type of NCDs and MOI leading to the severity of the disease was appraised.

RESULTS

Twenty-four (24) studies were identified from 357 unique records. Eight studies postulated the mechanism of infestation and interaction between COVID 19 illness severity and Obesity, while 7 studies described COVID-19 and DM. Five studies highlighted the interaction between COVID-19 and hypertension with 4 studies showing how physical activity restriction suppresses immunity.

CONCLUSION

The current review, identified and explicitly described the mechanisms of the lifestyle characteristics that may increase the severity of illness among people with COVID-19.

Disaster hypertension and cardiovascular events in disaster and COVID-19 pandemic

The incidence of large disasters has been increasing worldwide. This has led to a growing interest in disaster medicine. In this review, we report current evidence related to disasters and coronavirus disease‐2019 (COVID‐19) pandemic, such as cardiovascular diseases during disasters, management of disaster hypertension, and cardiovascular diseases associated with COVID‐19. This review summarizes the time course and mechanisms of disaster‐related diseases. It also discusses the use of information and communication technology (ICT) as a cardiovascular risk management strategy to prevent cardiovascular events. During the 2011 Great East Japan Earthquake, we used the “Disaster Cardiovascular Prevention” system that was employed for blood pressure (BP) monitoring and risk management using ICT. We introduced an ICT‐based BP monitoring device at evacuation centers and shared patients’ BP values in the database to support BP management by remote monitoring, which led to improved BP control. Effective use of telemedicine using ICT is important for risk management of cardiovascular diseases during disasters and pandemics in the future.

COVID-19, Angiotensin-Converting Enzyme 2 and Renin-Angiotensin System Inhibition: Implications for Practice

BACKGROUND

Recent studies suggested that patients with coronavirus disease 2019 (COVID-19) who use renin-angiotensin system (RAS) inhibitors have an increased risk of respiratory failure and death. The hypothesis was that angiotensin-converting enzyme inhibitor (ACEIs) or angiotensin receptor blocker (ARBs) may up-regulate ACE2 expression that is used as receptor for viral entry into cells.

OBJECTIVE

The purpose of this review is to discuss the existing evidence on the interaction between COVID-19 infection, ACE2 and ACEIs or ARBs and to examine the main implications for clinical practice. In addition, novel therapeutic strategies for blocking ACE2-mediated COVID-19 infection will be displayed.

METHODS

We performed a comprehensive review of the literature to identify data from clinical and experimental studies for the association between COVID-19 infection, ACE2 and RAS inhibition.

RESULTS

The current clinical and experimental evidence for ACEIs or ARBs to facilitate severe acute respiratory distress syndrome-coronavirus-2 (SARS-CoV-2) is insufficient to suggest discontinuing these drugs. Several observational studies arrive at the conclusion that the continued use of RAS inhibitors is unlike to be harmful in COVID-19-positive patients.

CONCLUSIONS

Further randomized trials are needed to answer definitely the question of whether RAS inhibitors are harmful or beneficial to patients with COVID-19.

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Anti-Hypertensive Potential and Epigenetics of Angiotensin II type 2 Receptor (AT2R)

BACKGROUND

Renin angiotensin system (RAS) is a critical pathway involved in blood pressure regulation. Octapeptide, angiotensin II (Ang II), is a biologically active compound of RAS pathway which mediates its action by binding to either angiotensin II type 1 receptor (AT1R) or angiotensin II type 2 receptor (AT2R). Binding of Ang II to AT1R facilitates blood pressure regulation, whereas AT2R is primarily involved in wound healing and tissue remodeling.

OBJECTIVES

Recent studies have highlighted the additional role of AT2R to counterbalance the detrimental effects of AT1R. Activation of angiotensin II type 2 receptor using AT2R agonist has shown the effect on natriuresis and release of nitric oxide. Additionally, AT2R activation has been found to inhibit angiotensin converting enzyme (ACE) and enhance angiotensin receptor blocker (ARB) activity. These findings highlight the potential of AT2R as a novel therapeutic target against hypertension.

CONCLUSION

The potential role of AT2R highlights the importance of exploring additional mechanisms that might be crucial for AT2R expression. Epigenetic mechanisms, including DNA methylation and histone modification, have been explored vastly with relation to cancer, but the role of such mechanisms in the expression of AT2R has recently gained interest.

Clinical Characteristics and Risk Factors for Fatality and Severity in Patients with Coronavirus Disease in Korea: A Nationwide Population-Based Retrospective Study Using the Korean Health Insurance Review and Assessment Service (HIRA) Database

BACKGROUND

We aimed to investigate the clinical characteristics and risk factors for fatality and severity in these patients.

METHODS

In this nationwide population-based retrospective study, we investigated the data of 7339 laboratory-confirmed COVID-19 patients, aged ≥ 18 years, using the Korean Health Insurance Review and Assessment Service (HIRA) database. Comorbidities and medications used were identified using HIRA codes, and severe COVID-19 was defined as that requiring oxygen therapy, mechanical ventilator, cardiopulmonary resuscitation, or extracorporeal membrane oxygenation. The outcomes were death due to COVID-19 and COVID-19 severity.

RESULTS

Mean patient age was 47.1 years; 2970 (40.1%) patients were male. Lopinavir/ritonavir, hydroxychloroquine, antibiotics, ribavirin, oseltamivir, and interferon were administered to 35.8%, 28.4%, 38.1%, 0.1%, 0.3%, and 0.9% of patients, respectively. After adjusting for confounding factors, diabetes mellitus, chronic kidney disease, previous history of pneumonia, aging, and male were significantly associated with increased risk of death and severe disease. No medication was associated with a reduced risk of fatality and disease severity.

CONCLUSIONS

We found several risk factors for fatality and severity in COVID-19 patients. As the drugs currently used for COVID-19 treatment have not shown significant efficacy, all efforts should be made to develop effective therapeutic modalities for COVID-19.

[Cardiovascular preventive recommendations. PAPPS 2020 update]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: Epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; Cardiovascular (CV) risk tables and recommendations for the calculation of CV risk; Main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; Indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation. The quality of testing and the strength of the recommendation are included in the main recommendations.

COVID-19 and hypertension-evidence and practical management: Guidance from the HOPE Asia Network

There are several risk factors for worse outcomes in patients with coronavirus 2019 disease (COVID-19). Patients with hypertension appear to have a poor prognosis, but there is no direct evidence that hypertension increases the risk of new infection or adverse outcomes independent of age and other risk factors. There is also concern about use of renin-angiotensin system (RAS) inhibitors due to a key role of angiotensin-converting enzyme 2 receptors in the entry of the SARS-CoV-2 virus into cells. However, there is little evidence that use of RAS inhibitors increases the risk of SARS-CoV-2 virus infection or worsens the course of COVID-19. Therefore, antihypertensive therapy with these agents should be continued. In addition to acute respiratory distress syndrome, patients with severe COVID-19 can develop myocardial injury and cytokine storm, resulting in heart failure, arteriovenous thrombosis, and kidney injury. Troponin, N-terminal pro-B-type natriuretic peptide, D-dimer, and serum creatinine are biomarkers for these complications and can be used to monitor patients with COVID-19 and for risk stratification. Other factors that need to be incorporated into patient management strategies during the pandemic include regular exercise to maintain good health status and monitoring of psychological well-being. For the ongoing management of patients with hypertension, telemedicine-based home blood pressure monitoring strategies can facilitate maintenance of good blood pressure control while social distancing is maintained. Overall, multidisciplinary management of COVID-19 based on a rapidly growing body of evidence will help ensure the best possible outcomes for patients, including those with risk factors such as hypertension.