Prognostic value of ambulatory blood pressure : current evidence and clinical implications

Publication guidelines for human heart rate and heart rate variability studies in psychophysiology-Part 1: Physiological underpinnings and foundations of measurement

This Committee Report provides methodological, interpretive, and reporting guidance for researchers who use measures of heart rate (HR) and heart rate variability (HRV) in psychophysiological research. We provide brief summaries of best practices in measuring HR and HRV via electrocardiographic and photoplethysmographic signals in laboratory, field (ambulatory), and brain-imaging contexts to address research questions incorporating measures of HR and HRV. The Report emphasizes evidence for the strengths and weaknesses of different recording and derivation methods for measures of HR and HRV. Along with this guidance, the Report reviews what is known about the origin of the heartbeat and its neural control, including factors that produce and influence HRV metrics. The Report concludes with checklists to guide authors in study design and analysis considerations, as well as guidance on the reporting of key methodological details and characteristics of the samples under study. It is expected that rigorous and transparent recording and reporting of HR and HRV measures will strengthen inferences across the many applications of these metrics in psychophysiology. The prior Committee Reports on HR and HRV are several decades old. Since their appearance, technologies for human cardiac and vascular monitoring in laboratory and daily life (i.e., ambulatory) contexts have greatly expanded. This Committee Report was prepared for the Society for Psychophysiological Research to provide updated methodological and interpretive guidance, as well as to summarize best practices for reporting HR and HRV studies in humans.

Validation of the Raycome model M2 ambulatory blood pressure monitor in the general population according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization Universal Standard (ISO 81060-2:2018)

OBJECTIVE

The aim of this study was to evaluate the accuracy of the Raycome model M2 oscillometric upper-arm blood pressure (BP) monitor developed for ambulatory BP measurement in the general population according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard (ISO 81060-2:2018) at rest and during dynamic exercise.

METHOD

Subjects were recruited to fulfill the age, gender, BP and cuff distribution criteria of the AAMI/ESH/ISO Universal Standard in the general population using the same arm sequential BP measurement method. Three cuffs of the test device were used for arm circumference 18-22 cm (small), 22-32 cm (medium) and 32-42 cm (large).

RESULTS

For the general validation study, 106 subjects were recruited and 85 were analyzed. For validation criterion 1, the mean ± SD of the differences between the test device and reference BP readings was 0.5 ± 6.2/-0.2 ± 5.1 mmHg (systolic/diastolic). For criterion 2, the SD of the mean BP differences between the test device and reference BP per subject was 5.23/4.50 mmHg (systolic/diastolic). In the ambulatory validation study ( N  = 35), the mean difference was 0.4 ± 5.9/-1.1 ± 5.8 mmHg. The Raycome model M2 performed well against the standard in both the general and ambulatory validations and the Bland-Altman plots did not show any systematic variation in the error.

CONCLUSION

These data show that the Raycome model M2 monitor meets the requirements of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) and in the ambulatory setting, indicating its suitability for measuring BP in the general population.

Age-dependent implications of left ventricular hypertrophy regression in patients with hypertension

Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular mortality and morbidity in patients with hypertension. However, the effect of age on LVH regression or persistence and its differential prognostic value remain unclear. Therefore, we investigated the clinical implications of LVH regression in 1847 patients with hypertension and echocardiography data (at baseline and during antihypertensive treatment at an interval of 6-18 months) according to age. LVH was defined as a left ventricular mass index (LVMI) > 115 g/m2 and >95 g/m2 in men and women, respectively. LVH prevalence at baseline was not different according to age (age < 65 years: 42.6%; age ≥65 years: 45.7%; p = 0.187), but LVH regression was more frequently observed in the younger group (36.4% vs. 27.5%; p = 0.008). Spline curves and multiple linear regression analysis showed a significant relationship between reductions in systolic blood pressure and LVMI in the younger group (β = 0.425; p < 0.001), but not the elderly group (β = 0.044; p = 0.308). LVH regression was associated with a lower risk of the study outcome (composite of cardiovascular death and hospitalization for heart failure) regardless of age. In conclusion, the association between the reduction in blood pressure and LVH regression was prominent in patients with age < 65 years, but not in those with age ≥65 years. However, an association between LVH regression and lower risk of cardiovascular death and hospitalization for heart failure was observed regardless of patient age, suggesting the prognostic value of the LVH regression not only in the younger patients but also in elderly patients.

Assessment of Nocturnal Blood Pressure: Importance of Determining the Time in Bed-A Pilot Study

Objectives: Nocturnal blood pressure (BP) monitoring is essential for evaluating cardiovascular risk and guiding treatment decisions. However, the standardized narrow-fixed nighttime period between 10 p.m. and 6 a.m. may not accurately reflect individual sleep schedules. This pilot study aimed to investigate the comparability between the standardized nighttime period and actual time in bed (TIB) regarding BP assessment. Further, our goal was to evaluate the clinical relevance of the observed BP differences. Methods: A total of 30 participants underwent 24 h ambulatory blood pressure monitoring (ABPM). Patient-specific TIB was precisely assessed through an accelerometer and a position sensor from the SOMNOtouch NIBP™ (SOMNOmedics GmbH, Randersacker, Germany). We analysed the effect of considering individual TIB as nighttime instead of the conventional narrow-fixed interval on the resulting nocturnal BP levels and dipping patterns. Results: We observed differences in both systolic and diastolic BP between the standardized nighttime period and the TIB. Furthermore, a notable percentage of patients (27%) changed their dipping pattern classification as a function of the nighttime definition adopted. We found strong correlations between the start (r = 0.75, p < 0.01), as well as the duration (r = -0.42, p = 0.02) of TIB and the changes in dipping pattern classification. Conclusions: Definition of nocturnal period based on the individual TIB leads to clinically relevant changes of nocturnal BP and dipping pattern classifications. TIB is easily detected using a body position sensor and accelerometer. This approach may thus improve the accuracy of cardiovascular risk evaluation and enhance treatment strategies.

Circadian blood pressure dysregulation in children with obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) adversely affects normal blood pressure (BP) and may disrupt circadian BP patterns. We sought to examine 24-hour circadian BP rhythms in children with OSA and healthy controls.

METHODS

Children 5-14 years with OSA and healthy controls underwent 24-hour BP monitoring and actigraphy to quantify sleep. Shape invariant statistical models compared circadian BP patterns (e.g. times of BP peaks, time arrived at peak BP velocity [TAPV]) in the OSA and control groups.

RESULTS

The analytic sample included 219 children (mild OSA: n = 52; moderate-to-severe OSA (MS-OSA): n = 50; controls: n = 117). In the morning, the MS-OSA group had earlier TAPV for DBP than controls (51 minutes, p < 0.001). TAPV in the evening was earlier for the MS-OSA group than controls (SBP: 95 minutes, p < 0.001; DBP: 28 minutes, p = 0.028). At mid-day, SBP and DBP velocity nadirs were earlier for the MS-OSA group than controls (SBP: 57 minutes, p < 0.001; DBP: 38 minutes, p < 0.01). The MS-OSA group reached most BP values significantly earlier than controls; the largest differences were 118 minutes (SBP) and 43 minutes (DBP) (p < 0.001). SBP and DBP were elevated in the MS-OSA group (hours 18-21 and 7--12, respectively, p < 0.01) compared to controls. The MS-OSA group was prone to "non-dipping" compared to controls (SBP: odds ratio [OR] = 2.16, 95% CI: 1.09, 4.29; DBP: OR = 3.45, 95% CI: 1.21, 10.23).

CONCLUSIONS

Children with MS-OSA had changes in circadian BP patterns, namely earlier TAPV and BP peaks and nadirs than controls. Circadian disturbances in BP rhythms may be key to mapping the natural history of BP dysregulation in children with OSA.

Hypertension Management in Peripheral Artery Disease: A Mini Review

Lower extremity peripheral artery disease (PAD) affects over 230 million adults globally, with hypertension being one of the major risk factors for the development of PAD. Despite the high prevalence, patients with hypertension who have concomitant PAD are less likely to receive adequate therapy. Through this review, we present the current evidence underlying hypertension management in PAD, guideline-directed therapies, and areas pending further investigation. Multiple studies have shown that both high and relatively lower blood pressure levels are associated with worse health outcomes, including increased morbidity and mortality. Hence, guideline-directed recommendation involves cautious management of hypertensive patients with PAD while ensuring hypotension does not occur. Although any antihypertensive medication can be used to treat these patients, the 2017 American Heart Association/American College of Cardiology (AHA/ACC), 2017 European Society of Cardiology (ESC), and 2022 Canadian guidelines favor the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) as the initial choice. Importantly, data on blood pressure targets and treatment of hypertension in PAD are limited and largely stem from sub-group studies and post-hoc analysis. Large randomized trials in patients with PAD are required in the future to delineate hypertension management in this complex patient population.

Blood pressure responses are dependent on call type and related to hypertension status in firefighters

BACKGROUND

Impaired cardiovascular health is a concern for firefighters, with over 50% of line-of-duty deaths having cardiac causes. Many firefighters have hypertension and <25% have their blood pressure (BP) controlled. The alarm response could be an unidentified cardiac risk, but interestingly, the BP response to different calls and on-the-job activity is unknown.

PURPOSE

We aimed to measure the physiological stress resulting from different call types (fire, medical) and job activity (riding apparatus, pre-alert alarms) through ambulatory BP (ABP) monitoring in a population of firefighters.

MATERIALS AND METHODS

During 111 12-h work shifts firefighters wore an ABP monitor. BP was measured at 30-min intervals and manual measurements were prompted when the pager went off or whenever they felt stress.

RESULTS

Firefighters were hypertensive (124.3 ± 9.9/78.1 ± 6.7 mmHg), overweight (30.2 ± 4.6 kg/m2), middle-aged (40.5 ± 12.6 years) and experienced (17.3 ± 11.7 years). We calculated an average 11% increase in systolic and 10.5% increase in diastolic BP with alarm. Systolic BP (141.9 ± 13.2 mmHg) and diastolic BP (84.9 ± 11.1 mmHg) and the BP surges were higher while firefighters were responding to medical calls compared to fire calls. Between BP groups we found that medical call systolic BP (p = .001, d = 1.2), diastolic BP (p = .017, d = 0.87), and fire call systolic BP (p = .03, d = 0.51) levels were higher in the hypertensive firefighters.

CONCLUSION

This is the first report of BP surge responses to alarms and to occupational activities in firefighters, and medical calls elicited the largest overall responses.PLAIN LANGUAGE SUMMARYCardiovascular disease and impaired cardiovascular health are substantially more prevalent in firefighters, with over 50% of line-of-duty deaths being cardiac related.Many firefighters are diagnosed with high blood pressure (hypertension), which is known to increase the risk of heart attacks, strokes, heart disease, and other serious health complications.Upon stress, our body enacts the 'fight or flight' response where sympathetic nervous system activity triggers an immediate increase in heart rate and blood pressure. This response can be dangerous when surges reach extreme levels due to underlying impaired cardiovascular function. It is known that alarm sounds trigger a stress response.Firefighters respond to different alarms while on the job, each indicating different call types, such as a house fire or a medical emergency. Due to the prevalence of impaired cardiovascular health in firefighters, the physical stress resulting from these alerts is cause for concern.The blood pressure surge response to different call types and job activities in healthy and hypertensive firefighters had not been measured before this study.Through the ambulatory blood pressure monitoring of 111 on-duty firefighters, this study discovered that medical calls caused the greatest blood pressure and heart rate surge.Also, firefighters with hypertension experienced a greater blood pressure surge in response to alarms than their non-hypertensive co-workers.

Cardiopulmonary baroreceptors modify pain intensity in patients with chronic back pain

Objective

Baroreceptors play a significant role in nociceptive pain. However, the extent to which baroreceptors modulate nociception in patients with chronic pain is unclear. We tested the hypothesis that cardiopulmonary baroreceptor unloading via LBNP would significantly increase pressure pain threshold and habituation to heat pain among patients with chronic back pain.

Methods

Mechanical pressure pain threshold at the upper trapezius (hand-held algometer) and habituation to heat pain at the forearm were performed during sitting and supine position, and during baroreceptor unloading via lower body negative pressure (LBNP) of -10 mmHg in 12 patients with chronic back pain (54 ± 11 years of age). To determine whether pain reduction is normal during LBNP, studies were repeated in 7 young, healthy participants (23 ± 7).

Results

Mechanical pressure pain threshold (P < 0.01) and habituation to heat pain (P = 0.04) were significantly reduced during supine compared with sitting. Conversely, baroreceptor unloading via LBNP significantly increased pressure pain threshold (P = 0.03) and heat pain habituation (P < 0.01) compared with supine. In young healthy controls, pressure pain threshold was similarly affected when comparing sitting and supine (P = 0.01) and during LBNP (P < 0.01), whereas habituation to heat pain was unaltered when comparing sitting and supine (P = 0.93) and during LBNP (P = 0.90). Total peripheral resistance was increased during LBNP (P = 0.01) but not among young, healthy controls (P = 0.71).

Conclusions

The findings demonstrate cardiopulmonary baroreceptor modulation of nociceptive pain in patients with chronic pain. Interestingly, habituation to heat pain appears more readily modified by cardiopulmonary baroreceptors in patients with chronic back pain compared with young, healthy individuals.

Different Factors Associated with Morning Blood Pressure Surge in Antihypertensive-Naïve Dipper and Non-Dipper Subjects

The relationship between the morning blood pressure surge (MBPS) and cardiovascular risk is inconclusive. Previous studies have not taken into consideration dipping status in examining the MBPS and its associated factors. The aim was to examine factors associated with the MBPS in dippers and non-dippers. The MBPS was calculated by data obtained from ambulatory blood pressure monitoring, using the definition of sleep-trough morning surge. Dipping systolic blood pressure (DipSBP) was defined as [1 - (SBPsleeping/SBPawake)] × 100%. The value in milliseconds of standard deviation of normal-to-normal RR interval after waking up (SDNNaw) was calculated during the 2 h period after waking up. A total of 140 eligible subjects were divided into dippers (n = 62) and non-dippers (n = 78). Multiple regression analysis on data for all subjects revealed different correlations with the MBPS: positive in age, body mass index (BMI), and DipSBP, and inverse in cholesterol/high density lipoprotein-cholesterol (HDL-C) ratio, fasting blood glucose, and 2 h SDNNaw. When dippers were examined separately, age, female gender, and BMI correlated positively with MBPS, while cholesterol/HDL-C ratio and 2 h SDNNaw correlated negatively. For non-dippers, only age was associated with the MBPS. The factors associated with the MBPS were different for dippers and non-dippers. The MBPS seems to be a physiological response in this dipper group because age and BMI correlated positively with the MBPS, while parasympathetic neural activity after waking up and cholesterol/HDL-C ratio showed inverse correlations.

Concomitantly higher resting arterial blood pressure and transduction of sympathetic neural activity in human obesity without hypertension

OBJECTIVE

Central (abdominal) obesity is associated with elevated adrenergic activity and arterial blood pressure (BP). Therefore, we tested the hypothesis that transduction of spontaneous muscle sympathetic nerve activity (MSNA) to BP, that is, sympathetic transduction, is augmented in abdominal obesity (increased waist circumference) and positively related to prevailing BP.

METHODS

Young/middle-aged obese (32 ± 7 years; BMI: 36 ± 5 kg/m2, n = 14) and nonobese (29 ± 10 years; BMI: 23 ± 4 kg/m2, n = 14) without hypertension (24-h ambulatory average BP < 130/80 mmHg) were included. MSNA (microneurography) and beat-to-beat BP (finger cuff) were measured continuously and the increase in mean arterial pressure (MAP) during 15 cardiac cycles following MSNA bursts of different patterns (single, multiples) and amplitude (quartiles) was signal-averaged over a 10 min baseline period.

RESULTS

MSNA burst frequency was not significantly higher in obese vs. nonobese (21 ± 3 vs. 17 ± 3 bursts/min, P = 0.34). However, resting supine BP was significantly higher in obese compared with nonobese (systolic: 127 ± 3 vs. 114 ± 3; diastolic: 76 ± 2 vs. 64 ± 1 mmHg, both P < 0.01). Importantly, obese showed greater increases in MAP following multiple MSNA bursts (P = 0.02) and MSNA bursts of higher amplitude (P = 0.02), but not single MSNA bursts (P = 0.24), compared with nonobese when adjusting for MSNA burst frequency. The increase in MAP following higher amplitude bursts among all participants was associated with higher resting supine systolic (R = 0.48; P = 0.01) and diastolic (R = 0.48; P = 0.01) BP when controlling for MSNA burst frequency, but not when also controlling for waist circumference (P > 0.05). In contrast, sympathetic transduction was not correlated with 24-h ambulatory average BP.

CONCLUSION

Sympathetic transduction to BP is augmented in abdominal obesity and positively related to higher resting supine BP but not 24-h ambulatory average BP.

Masked Hypertension in Pediatric Heart Transplant Recipients

BACKGROUND

Masked hypertension (HTN), especially, isolated nocturnal HTN (INH) has been shown to be a risk factor for cardiovascular disease (CVD) but is not studied well in pediatric heart transplant (PHT) patients. Ambulatory blood pressure monitoring (ABPM) is known to identify patients with HTN but is not used routinely in PHT.

METHODS

A single-center, prospective, cross-sectional study of PHT recipients was performed to observe the incidence of masked HTN using 24-h ABPM. The relationship between ABPM parameters and clinical variables was assessed using Spearman correlation coefficient. p value < 0.05 was considered significant.

RESULTS

ABPM was performed in 34 patients, mean age 14 ± 5 years, median 5.5 years post-PHT. All patients had normal cardiac function, left ventricular mass index and blood pressure measurements in the clinic. Four patients had known prior HTN and on medications, one of them was uncontrolled. Of the remaining 30 patients, 18 new patients were diagnosed with masked HTN, of which 14 had INH. Diurnal variation was abnormal in 82% (28/34) patients. 24-h diastolic blood pressure (DBP) index correlated with glomerular filtration rate (GFR) (r = - 0.44, p = 0.01). There was no correlation between other ABPM parameters with tacrolimus trough levels.

CONCLUSIONS

ABPM identified masked HTN in 60% of patients, with majority being INH. Abnormal circadian BP patterns were present in 82% and an association was found between GFR and DBP parameters. HTN, especially INH, is under-recognized in PHT recipients and ABPM has a role in their long-term care.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease

Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.

Frontal QRS-T angle may predict reverse dipping pattern in masked hypertensives

AIMS

The frontal QRS-T (fQRST) angle is associated with worse cardiovascular outcome. The study aimed to assess the effect of reverse dipping pattern on f(QRST) angle in newly diagnosed masked hypertensive (MH) patients.

MATERIALS AND METHODS

Newly diagnosed 244 consecutive MH patients were included. According to dipping pattern, patients were grouped into three: dipper (n = 114), non-dipper (n = 106), and reverse dipper (n = 24) patterns. The f(QRST) angle, QT and corrected QT interval, and QT dispersion were measured from the 12-lead surface electrocardiogram and compared between groups.

RESULTS

Of all, 51.2% (n = 125) were male. No gender difference was observed. Reverse dipper MH group had a significantly higher f(QRST) angle than the non-dipper and dipper MH groups (77.9 ± 8.6 vs. 32.4 ± 18.8 and 26.0 ± 18.5, respectively, p < .001). The cutoff value for f(QRST) angle of 51 predicts reverse dipping pattern (AUC: 0.84; 95% CI: 0.77-0.90; p < .001), with a sensitivity of 83% and a specificity of 78%.

CONCLUSION

This study revealed that f(QRST) angle is gradually increased starting from the dipper, non-dipper to reverse dipper masked hypertensives. The f(QRST) angle appears as an easy marker for the detection and risk stratification of hypertensive patients.

Predictors of Hypertension Development 1 Y After Heart Transplantation

BACKGROUND

Hypertension after heart transplantation (HTx) is common. We investigated predictors of and mechanisms for hypertension development during the first year after HTx, with particular attention toward immunosuppressive agents, reinnervation processes, and donor/recipient sex.

METHODS

Heart transplant recipients (HTxRs) were consecutively enrolled 7 to 12 wk after surgery and followed prospectively for 12 mo. Ambulatory blood pressure recordings and autonomic cardiovascular control assessments were performed at baseline and follow-up. Possible predictors of posttransplant hypertension development were investigated in bivariate linear regression analyses followed by multiple regression modeling.

RESULTS

A total of 50 HTxRs were included; 47 attended the follow-up appointment at 12 mo. Mean systolic and diastolic blood pressure increased significantly during the observational period (systolic blood pressure from 133 to 139 mm Hg, P = 0.007; diastolic blood pressure from 81 to 84 mm Hg, P = 0.005). The blood pressure increment was almost exclusively confined to HTxRs with a female donor heart, doubling the cases of systolic hypertension (from 6 to 13/14; 46% to 93%, P = 0.031) and diastolic hypertension (from 7 to 14/14; 54% to 100%, P = 0.031) in this subgroup. Autonomic cardiovascular control assessments suggested tonically constricted resistance and capacitance vessels in recipients with female donor hearts. Immunosuppressive agents and reinnervation markers were not associated with hypertension development.

CONCLUSIONS

Blood pressures increase during the first year after HTx, with female donor sex as a strong predictor of recipient hypertension development. The underlying mechanism seems to be enhanced peripheral vasoconstriction caused by attenuated cardiovascular homeostasis capabilities. Further studies are needed to confirm the results.

Is there any true distinction in extreme dipping versus nondipping or dipping phenotype regarding hypertension-mediated organ damage in newly diagnosed and never-treated hypertensive patients?

Dipping phenomena is defined as nocturnal BP fall >10% during 24-h ambulatory blood pressure (BP) monitoring (ABPM) which carries a favorable cardiovascular risk (CVR) prognosis due to reduced 24-h hypertension burden. To date, extreme dipping phenotype (defined as BP decrease ≥20%) has led to controversial prognostic results regarding CVR. We aimed to explore hypertension-mediated organ damage (HMOD) in extreme dippers compared to the other dipping phenotypes (nondipping, dipping). From 490 consecutive patients with newly diagnosed never-treated arterial hypertension (mean age 51 ± 11 years, 294 males) subjected to 24-h ABPM, we studied 52 extreme dippers, 52 age- and gender-matched nondippers, and 52 age- and gender-matched dippers. All patients were subjected to arterial stiffness (PWV), 24-h microalbumin levels, carotid intima-media thickness (cIMT), diastolic dysfunction (E/Ea), and left ventricular mass index (LVMI) evaluation. ANOVA analysis found no differences regarding HMOD between groups. Multiple regression analysis revealed the following independent direct relationships between: (i) office SBP and PWV in nondippers (β = 0.35, p = 0.01) and extreme dippers (β = 0.49, p < 0.001), (ii) office SBP and E/Ea in extreme dippers (β = 0.39, p = 0.007), (iii) 24-h diurnal and nocturnal SBP and E/Ea in dippers (β = 0.40, p = 0.004, β = 0.39, p = 0.005, and β = 0.40, p = 0.004, respectively), and (iv) 24-h and nocturnal SBP and LVMI in nondippers (β = 0.29, p = 0.04 and β = 0.36, p = 0.009, respectively). In the early phases of untreated-arterial hypertension disease, extreme dipping phenotype in middle-aged hypertensives does not imply an adverse or favorable prognosis regarding the incidence of HMOD either as continuous variables or as abnormal HMOD compared to other dipping phenotypes.

Higher hemoglobin levels are an independent risk factor for adverse metabolism and higher mortality in a 20-year follow-up

The aim of this study was to cross-sectionally and longitudinally examine whether higher hemoglobin (Hb) levels within the normal variation associate with key components of metabolic syndrome and total and cardiovascular mortality. The study included 967 Finnish subjects (age 40-59 years) followed for ≥ 20 years. The focus was on Hb levels, cardiovascular diseases (CVDs) and mortality rates. Higher Hb levels associated positively with key anthropometric and metabolic parameters at baseline. At the follow-up similar associations were seen in men. The highest Hb quartile showed higher leptin levels and lower adiponectin levels at baseline and follow-up (p < 0.05) and lower plasma ghrelin levels at baseline (p < 0.05). Higher baseline Hb levels associated independently with prevalence of type 2 diabetes at follow-up (p < 0.01). The highest Hb quartile associated with higher serum alanine aminotransferase levels (p < 0.001) and independently with increased risk for liver fat accumulation (OR 1.63 [1.03; 2.57]) at baseline. The highest Hb quartile showed increased risk for total (HR = 1.48 [1.01; 2.16]) and CVD-related mortality (HR = 2.08 [1.01; 4.29]). Higher Hb levels associated with an adverse metabolic profile, increased prevalence of key components of metabolic syndrome and higher risk for CVD-related and total mortality.

Association Between Nocturnal Blood Pressure Dipping and Chronic Kidney Disease Among Patients With Controlled Office Blood Pressure

BACKGROUND

Although abnormal blood pressure (BP) patterns are associated with adverse cardiorenal outcomes, their associations are yet unquantified by nocturnal dipping status. We examined the association of nocturnal BP dipping pattern with albuminuria and kidney function among participants with controlled hypertension without prior advanced kidney disease.

METHODS

Ambulatory BP (ABP) measurements were collected from 995 middle-aged, cardiology clinic patients with controlled office BP (OBP) (<140/90 mm Hg). The magnitude of dipping was calculated as the difference between daytime and nighttime systolic BP (SBP) divided by daytime SBP. Accordingly, the participants were categorized as extreme-dipper (≥20%), dipper (10% to <20%), non-dipper (0% to <10%), or reverse-dipper (<0%). We analyzed the cross-sectional associations of dipping with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) and decreased estimated glomerular filtration rate (<60 ml/min/1.73 m2), adjusting for OBP/ABP, antihypertensive class, body mass index, total cholesterol, fasting glucose, socioeconomic status, and health behavior.

RESULTS

The participants (mean age 60.2 years; 52.9% male) consisted of 13.5% extreme-dippers, 43.1% dippers, 34.7% non-dippers, and 8.7% reverse-dippers. In reference to dippers, odds ratios [95% confidence interval] for albuminuria were 1.73 [1.04-2.60] in reverse-dippers, 1.67 [1.20-2.32] in non-dippers, and 0.62 [0.38-1.04] in extreme-dippers. Likewise, abnormal dipping profile was associated with decreased kidney function: reverse-dipping, 2.02 [1.06-3.84]; non-dipping, 1.98 [1.07-3.08]; extreme-dipping, 0.69 [0.20-1.17]. The associations persisted among participants with more conservatively controlled OBP (<130/80 mm Hg).

CONCLUSIONS

Monitoring diurnal and nocturnal BP may identify chronic kidney disease otherwise overlooked based on OBP.

Effects of Cranberry Juice Supplementation on Cardiovascular Disease Risk Factors in Adults with Elevated Blood Pressure: A Randomized Controlled Trial

Emerging cardiovascular disease (CVD) risk factors, including central vascular function and HDL efflux, may be modifiable with food-based interventions such as cranberry juice. A randomized, placebo-controlled, crossover trial was conducted in middle-aged adults with overweight/obesity (n = 40; mean BMI: 28.7 ± 0.8 kg/m²; mean age: 47 ± 2 years) and elevated brachial blood pressure (mean systolic/diastolic BP: 124 ± 2/81 ± 1 mm Hg). Study participants consumed 500 mL/d of cranberry juice (~16 fl oz; 27% cranberry juice) or a matched placebo juice in a randomized order (8-week supplementation periods; 8-week compliance break), with blood samples and vascular measurements obtained at study entry and following each supplementation period. There was no significant treatment effect of cranberry juice supplementation on the primary endpoint of central systolic blood pressure or central or brachial diastolic pressure. Cranberry juice significantly reduced 24-h diastolic ambulatory BP by ~2 mm Hg compared to the placebo (p = 0.05) during daytime hours. Cranberry juice supplementation did not alter LDL-C but significantly changed the composition of the lipoprotein profile compared to the placebo, increasing the concentration of large LDL-C particles (+29.5 vs. −6.7 nmol/L; p = 0.02) and LDL size (+0.073 vs. −0.068 nm; p = 0.001). There was no effect of treatment on ex vivo HDL efflux in the total population, but exploratory subgroup analyses identified an interaction between BMI and global HDL efflux (p = 0.02), with greater effect of cranberry juice in participants who were overweight. Exploratory analyses indicate that baseline C-reactive protein (CRP) values may moderate treatment effects. In this population of adults with elevated blood pressure, cranberry juice supplementation had no significant effect on central systolic blood pressure but did have modest effects on 24-h diastolic ambulatory BP and the lipoprotein profile. Future studies are needed to verify these findings and the results of our exploratory analyses related to baseline health moderators.

High prevalence of non-dipping patterns among Black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

BACKGROUND

Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction.

OBJECTIVES

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients.

METHODS

This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.

RESULTS

The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17-2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01-1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95-0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar's Chi2 0.71, p-value 0.40).

CONCLUSION

There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes. Trial registration ClinicalTrials.gov (NCT02742467).

The role of baseline and post-treatment frontal QRS-T angle for detecting arterial blood pressure control

Objectives: In this study, we aimed to investigate the value of the frontal QRS-T angle (f(QRS-T)) in determining blood pressure control among newly diagnosed hypertensive patients with no left ventricular hypertrophy.Methods: Fifty patients with newly diagnosed hypertension were included in this single-center study. The patients were examined with 12-lead ECGs and 24-hour ambulatory blood pressure monitoring (24 h-ABPM) before and 1 month after antihypertensive treatment.Results: Baseline and post-treatment f(QRS-T) angle values were observed to be similar (38.0 [0.0-174.0] and 37.0 [1.0-139.0], respectively; p = .827). The values of QT minimum (p = .006), QTc mean (p = .030), Tp-e (p = .027), and JTc (p = .010) significantly decreased after control of blood pressure.Conclusions: The f(QRS-T) angle, which can be easily calculated on the ECG, is not a useful tool to determine hypertension control at early stage in newly diagnosed hypertensive patients.

Influence of hypertension and other risk factors on the onset of sublingual varices

Background

Sublingual varices (SV) are dilatations of tortuous veins that increased with age. Previous studies showed that this pathology could be correlated to some risk factors such as hypertension, age, gender and diabetes mellitus. In this study we evaluated, on a large number of subjects, the relationship between SV and different grades of hypertension as well as some risk factors extending the analysis to new risk factors such as dyslipidemia, obesity and antihypertensive therapy, modelling a possible dependence of SV on all these factors.

Methods

In the study 1008 subjects, 284 with and 724 without SV, were examined. The blood pressure was measured in office condition and, to exclude subjects with white coat syndrome or masked hypertension, also using a 24 h Holter pressure monitor. Hypertensive subjects were divided in resistant, drugs controlled (compensated) and patients with prior unknown hypertension (new diagnosed) groups. The presence or absence of SV as well as of the risk factors was assessed clinically. We tested the influence of age on the presence of SV by using the chi-square test and the relation between each risk factor and SV by the Cochran–Mantel–Haenszel test. Finally, we carried out a multivariate regression tree analysis in order to predict the presence of SV.

Results

We confirmed the influence of age on SV and found a significant relationship between SV and both the compensated and resistant hypertension grades. We highlighted a relationship between SV and dyslipidemia in subjects with new diagnosed hypertension, and between SV and smoking in subjects with compensated hypertension grade. The regression tree showed a classification accuracy of about 75% using as variables hypertension grades, age and antihypertensive treatment.

Conclusions

We confirmed the SV dependence on age, resistant hypertension and smoking, highlighting a new association with dyslipidemia in new diagnosed hypertensive subjects and new relations depending on the hypertension grades. Thus, the SV inspection could be used to suggest a lipidologist as well as a hypertension specialist visit for a pharmacological and pressure check particularly in subjects presenting SV and dyslipidemia. However, further parameters are to be considered to improve the sensitivity of the prognostic tree model.

Which is responsible for target organ damage in masked hypertension? Is it an increase in blood pressure or a disruption of the circadian rhythm?

OBJECTIVE

Masked hypertension (MH) and non-dipping pattern are conditions associated with target organ damage and cardiovascular risk, which are frequently observed together. We aimed to show the relationship between the target organ damage observed in MH and the deterioration in the dipping pattern.

METHODS

Patients who underwent ambulatory blood pressure monitoring (ABPM) and office blood pressure (BP) <140/90 mmHg were retrospectively screened. In ABPM data, those with daytime BP ≥135/85 mmHg and night BP ≥120/70 mmHg were included in the MH group, while the others were included in the normotensive group. The patients were grouped as dipper, non-dipper and reverse-dipper according to ABPM results. Left ventricular mass index (LVMI), glomerular filtration rate (GFR) and serum creatinine levels were used to determine target organ damage.

RESULTS

289 patients [mean age 46.6 ± 12.4 years, 136 (47.1%) males], 154 (53.3%) of whom had MH were included in our study. GFR value was found to be significantly lower, serum creatinine levels and LVMI were significantly higher in patients with MH compared to normotensives (p < .05, for all). When the subgroups were examined, it was found that this difference was associated with the disruption in the dipping pattern. In patients with MH, dipping pattern disruption without change in systolic BP was independently associated with an increase in LVMI (p < .05, for both).

CONCLUSION

Target organ damage seen in MH may be due to the deterioration of the dipping pattern.

Acute and chronic effects of combined exercise on ambulatory blood pressure and its variability in hypertensive postmenopausal women

The aim of this study was to investigate the acute and chronic effects, and their correlation, after combined aerobic and resistance exercises in blood pressure (BP) and its variability (BPV) in hypertensive postmenopausal women. Fourteen hypertensive postmenopausal women monitored BP at rest and during 24 h by ambulatory BP monitoring in a control day without exercise performance a pretraining (baseline), after an acute exercise session (acute), and after a chronic exercise training for 10 weeks (chronic). After exercise training, systolic BP (SBP, Δ = -150 mmHg.24 h), diastolic BP (DBP, Δ = -96 mmHg.24 h), and mean BP (MBP, Δ = -95 mmHg.24 h) area under the curve were smaller than baseline measurements (P < 0.05) with no difference between acute and baseline measurements. The SBP (ΔSD₂₄ = -2, ΔSD_dn = -1.7, and ΔARV₂₄ = -1.9 mmHg), DBP (ΔSD₂₄ = -0.9, ΔSD_dn = -0.8, and ΔARV₂₄ = -0.9 mmHg), and MBP (ΔSD₂₄ = -1.5, ΔSD_dn = -1.3, and ΔARV₂₄ = -1.2 mmHg) variability reduced in acute session in relation to baseline, with no chronic effects. There are moderate correlations between acute and chronic responses in wake SBP, sleep DBP, and SD₂₄. In conclusion, combined exercise reduces ambulatory BP chronically but not acutely. In contrast, BPV decreases after an acute session but not chronically. Awake SBP, sleep DBP, and SD₂₄indices are promising candidates to predict individual cardiovascular responses to exercise.

AHA/ACC-defined stage 1 hypertensive adults do not display cutaneous microvascular endothelial dysfunction

In 2017, the American Heart Association (AHA) and American College of Cardiology (ACC) redefined stage 1 hypertension to systolic blood pressure (BP) 130-139 mmHg or diastolic BP 80-89 mmHg; however, the degree to which microvascular endothelial dysfunction is evident in adults with stage 1 hypertension remains equivocal. We tested the hypotheses that cutaneous microvascular endothelial dysfunction would be present in adults with stage 1 hypertension (HTN1) compared with normotensive adults (NTN; BP <120/<80 mmHg) but would be less severe compared with adults with stage 2 hypertension (HTN2; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) and that this graded impairment would be mediated by reductions in nitric oxide (NO)-dependent dilation. This retrospective analysis included 20 NTN (5 men; 45-64 yr; BP 94-114/60-70 mmHg), 22 HTN1 (11 men; 40-74 yr; BP 110-134/70-88 mmHg), and 44 HTN2 (27 men; 40-74 yr; BP 128-180/80-110 mmHg). BP and nocturnal dipping status were also assessed using 24-h ambulatory BP monitoring. Red cell flux (laser Doppler flowmetry) was measured during intradermal microdialysis perfusion of acetylcholine (ACh; 10^-10 to 10^-1M) alone and concurrently with the nonspecific nitric oxide (NO) synthase inhibitor N^G-nitro-l-arginine methyl ester (l-NAME; 15 mM). ACh-induced dilation was impaired in HTN2 (P < 0.01), but not in HTN1 (P = 0.85), compared with NTN. Furthermore, reductions in NO-dependent dilation were evident in HTN2 (P < 0.01) but not in HTN1 (P = 0.76). Regardless of BP, endothelium-dependent dilation was impaired in nondippers (nighttime drop in systolic BP <10%) compared with dippers (nighttime drop in systolic BP ≥10%, P < 0.05). In conclusion, functional impairments in NO-mediated endothelium-dependent dilation were not evident in HTN1. However, regardless of BP classification, the lack of a nocturnal dip in BP was associated with blunted endothelium-dependent dilation.NEW & NOTEWORTHY This is the first study to pharmacologically assess the mechanistic regulation of endothelial function in adults with hypertension, classified according to the 2017 clinical guidelines set for by the American Heart Association (AHA) and American College of Cardiology (ACC). Compared with that in normotensive adults, nitric oxide-mediated endothelium-dependent dilation is impaired in adults with stage 2, but not stage 1, hypertension. Adults lacking a nighttime dip in blood pressure demonstrated reductions in endothelium-dependent dilation.

Adult outcomes after preterm birth

Extremely preterm birth reflects global disruption of the third trimester environment. Young adults born preterm have an adverse cardiovascular and metabolic health profile, together with molecular evidence of accelerated ageing and a reduced life expectancy. The underlying mechanism for these observations is unknown. This review summarises recent evidence of the lifetime effects of preterm birth and highlights the risks survivors face.

Nighttime blood pressure decline as a predictor of renal injury in patients with hypertension: a population-based cohort study

We explored whether the nighttime blood pressure (BP) decline predicts renal function decline in a population-based cohort with primary hypertension. We measured the baseline ambulatory BP and glomerular filtration rate (GFR) in a cohort of 1,042 primary hypertensive patients. We repeated the GFR measurements and calculated the rate of GFR decline after a median follow-up of 5.8 years. The estimated GFR (eGFR) declined by -0.23 to -0.20 mL/min per year as the nighttime systolic BP (SBP), diastolic BP (DBP), and mean BP decline rates increased by 1% (P < 0.001). In the fully adjusted model, the nighttime SBP, DBP, and mean BP were all related to a steeper rate of eGFR decline by -0.25 to -0.22 mL/min per 1% increase. The adjusted multivariable results indicated that the odds of an eGFR decline were reduced by 46% when the nighttime SBP decline rate increased by 1% (OR= 0.54, 95% CI: 0.46-0.62). The restricted cubic spline model indicated a non-linear dose-response relationship with the nighttime SBP, DBP, and mean BP. Nighttime BP may be an important biomarker of renal function injury in hypertensive patients.

Molecular Mechanisms Underlying the Circadian Rhythm of Blood Pressure in Normotensive Subjects

PURPOSE OF REVIEW

Blood pressure (BP) follows a circadian rhythm (CR) in normotensive subjects. BP increases in the morning and decreases at night. This review aims at providing an up-to-date overview regarding the molecular mechanisms underlying the circadian regulation of BP.

RECENT FINDINGS

The suprachiasmatic nucleus (SCN) is the regulatory center for CRs. In SCN astrocytes, the phosphorylated glycogen synthase kinase-3β (pGSK-3β) also follows a CR and its expression reaches a maximum in the morning and decreases at night. pGSK-3β induces the β-catenin migration to the nucleus. During the daytime, the nuclear β-catenin increases the expression of the glutamate excitatory amino acid transporter 2 (EAAT2) and glutamine synthetase (GS). In SCN, EAAT2 removes glutamate from the synaptic cleft of glutamatergic neurons and transfers it to the astrocyte cytoplasm where GS converts glutamate into glutamine. Thus, glutamate decreases in the synaptic cleft. This decreases the stimulation of the glutamate receptors AMPA-R and NMDA-R located on glutamatergic post-synaptic neurons. Consequently, activation of NTS is decreased and BP increases. The opposite occurs at night. Despite several studies resulting from animal studies, the circadian regulation of BP appears largely controlled in normotensive subjects by the canonical WNT/β-catenin pathway involving the SCN, astrocytes, and glutamatergic neurons.

Activated double-negative T cells (CD3+CD4-CD8-HLA-DR+) define response to renal denervation for resistant hypertension

PURPOSE

To explore the cellular immune response of patients with resistant hypertension treated with renal denervation (RDN).

METHODS AND RESULTS

Twenty-three patients were included and blood samples were obtained in six timings, pre and post procedure. Response was evaluated at six-months and one year and was observed in 69.6% and 82.6% of patients, respectively. Absolute values of HLA-DR+ double negative (DN) T cells were significantly lower in the group of 'responders' at one year, and interaction between the timings were found in three T cell subsets (T CD4, T CD8 and naïve T CD8 cells), with the 'responders' tending to present with lower absolute values and little inter-timing variation.

CONCLUSIONS

'Responders' significantly present with lower absolute values of activated DN T cells and have lower and more stable values of total T CD8+, CD4+, and naïve T CD8+ cells. These cell types may be able to predict response to RDN.

Peptide hormones and risk for future cardiovascular events among prediabetics: a 20-year follow-up in the OPERA study

Background: Prediabetes has proven to have many unfavourable impacts on the cardiovascular system.Methods: The OPERA (Oulu Project Elucidating Risk of Atherosclerosis) study included 1045 middle-aged subjects followed from the years 1990-1993 to 2014. The focus was on peptide hormones.Results: Plasma resistin levels were higher among prediabetics (p = .001), particularly impaired glucose tolerance (IGT) (p < .001), but not impaired fasting glucose (IFG) patients than among normal glucose tolerance (NGT) or diabetes groups. Diabetics showed lower resistin levels than IGT subjects (p < .001). IGT or diabetes groups showed lower adiponectin and higher leptin levels compared to the NGT group (p < .001). The IFG group had the highest blood pressure and left ventricular mass index, even higher than the diabetic group. Diabetics had the highest, prediabetics (IFG + IGT) intermediate and NGT the lowest risk for CVD events during follow-up (p < .001). Among prediabetics, high plasma ghrelin was an independent predictor of CVD events (p < .05) in the Cox regression analysis although it did not significantly improve either classification or discrimination of the patients.Conclusions: Among glucose tolerance groups, patients with IGT had the highest resistin, but equally high leptin and low adiponectin levels as diabetics. Among prediabetics, ghrelin seems to predict independently cardiovascular events in the long term.KEY MESSAGEAmong glucose tolerance groups, patients with IGT had the highest resistin, but equally high leptin and low adiponectin levels as diabetics.Among prediabetics, ghrelin seems to predict independently cardiovascular events in the long term.

Diabetes mellitus is associated with high sleep-time systolic blood pressure and non-dipping pattern

INTRODUCTION

Compared to clinic blood pressure (BP), sleep-time BP and non-dipping BP pattern are better predictors of target organ damage and cardiovascular sequalae.

AIM

In a retrospective study, we determined whether diabetes mellitus (DM) status is associated with high sleep-time BP and non-dipping pattern.

METHODS

We analyzed 1092 patients who underwent ambulatory BP monitoring between 2015 and 2017 in a tertiary cardiology institution. During a 24-hour period, BP was automatically measured every 15 minutes between 7:00 AM and 11:59 PM and every 30 minutes thereafter.

RESULTS

Compared with the non-DM group (n = 910), the DM group (n = 182) had a higher 24-hour systolic BP (137 ± 17 vs. non-DM, 132 ± 14 mmHg, p < 0.001) and sleep-time systolic BP (132 ± 20 vs. 123 ± 16 mmHg, p < 0.001), and was more likely to exhibit non-dipping (63% vs 42%, p˂0.001). The DM group was also less likely to meet the guideline-recommended target of 120/70 mmHg for the sleep-time BP measured via ambulatory monitoring (22% vs. 34%, p = 0.002). After adjusting for the effects of age, sex, body mass index, smoking, urea, eGFR, previous myocardial infarction, previous percutaneous coronary intervention, previous coronary artery bypass surgery, and previous stroke, DM remained a significant independent predictor of a higher 24-hour systolic BP (coefficient: 2.8, 95% confidence interval: 0.1-5.5, p = 0.042) and higher sleep-time systolic BP (coefficient: 4.2, 95% confidence interval: 1.1-7.3, p = 0.008). There was a trend toward more sleep-time non-dipping BP pattern (odds ratio: 1.4, 95% confidence interval: 1.0-2.0, p = 0.087) in the DM group.

CONCLUSION

DM is independently associated with suboptimal 24-hour BP control. This association is mainly attributed to a high sleep-time systolic BP.

[Office and 44-hour ambulatory blood pressure and central haemodynamic parameters in the patients with end-stage renal diseases undergoing haemodialysis]

AIM

To assess the incidence of blood pressure (BP) control and various phenotypes of BP by comparing the results of office and 44-hour ambulatory brachial and central BP measurement in patients with end-stage renal disease (ESRD) on program hemodialysis (HD).

MATERIALS AND METHODS

In 68 patients ESRD receiving renal replacement therapy we evaluated office peridialysis BP and performed 44-hour ambu latory monitoring (ABPM) of brachial and central BP during peridialysis period using a validated oscillometric device BPLabVasotens (OOO "Petr Telegin"). Results were considered statistically significant with p&lt;0.05.

RESULTS

The frequency of control of peripheral office BP before the HD session was 25%, after - 23.5%; control of central BP - 48.6% and 49%, respectively. According to office measurement the frequency of systolic-diastolic hypertension was 44.1%, isolated systolic hypertension - 25%, isolated diastolic hypertension - 5.9%. The values of peripheral and central office systolic BP (SBP) before and after HD were not consistent with the corresponding mean and daily SBP levels for 44 hours and for the first and second days of the interdialysis period. The frequency of true uncontrolled arterial hypertension (AH) according to peripheral ABPM was 66.5%, masked uncontrolled AH - 9%. Circadian rhythm abnormalities for 44-h peripheral BP were detected in 77%, for central - in 76%. In 97% of patients agreement between phenotypes of the daily profile of peripheral and central BP was observed. 73% of patients had a significant increase in peripheral and central SBP and pulse pressure (PP) and an increase in the proportion of non-dippers from the 1st to the 2nd day.

CONCLUSION

Patients with ESRD on HD were characterized by poor control of BP control and predominance of unfavourable peripheral and central ambulatory BP phenotypes. A single measurement of clinical peripheral and central BP in the peridialysis period was not sufficient to assess the control of hypertension in this population. The 24-h BP profiles in the 1st and 2nd days of interdialysis period had significant differences.

Sex and age differences in the association between sympathetic outflow and central elastic artery wall thickness in humans

Aging is characterized by increased wall thickness of the central elastic arteries (i.e., aorta and carotid arteries), although the mechanisms involved are unclear. Evidence suggests that age-related increases in muscle sympathetic nerve activity (MSNA) may be a contributing factor. However, studies in humans have been lacking. Therefore, we tested the hypothesis that age-related increases in MSNA would be independently associated with carotid artery intima-media thickness (IMT) but not in young women given the reduced influence of MSNA on the vasculature in this group. In 93 young and middle-age/older (MA/O) adults (19-73 yr, 41 women), we performed assessments of MSNA (microneurography) and common carotid IMT and lumen diameter (ultrasonography). Multiple regression that included MSNA and other cardiovascular disease risk factors indicated that MSNA (P = 0.002) and 24-h systolic blood pressure (BP) (P = 0.024) were independent determinants of carotid IMT-to-lumen ratio (model R² = 0.38, P < 0.001). However, when examining only young women (<45 yr), no correlation was observed between MSNA and carotid IMT-to-lumen ratio (R = -0.01, P = 0.963). MSNA was significantly correlated with IMT-to-lumen ratio while controlling for 24-h systolic BP among young men (R = 0.49, P < 0.001) and MA/O women (R = 0.59, P = 0.022). However, among MA/O men, controlling for 24-h systolic BP attenuated the association between MSNA and carotid IMT-to-lumen ratio (R = 0.50, P = 0.115). Significant age differences in IMT-to-lumen ratio between young and MA/O men (P = 0.047) and young and MA/O women (P = 0.023) were removed when adjusting for MSNA (men: P = 0.970; women: P = 0.152). These findings demonstrate an association between higher sympathetic outflow and carotid artery wall thickness with a particular exception to young women.NEW & NOTEWORTHY Increased wall thickness of the large elastic arteries serves as a graded marker for cardiovascular disease risk and progression of atherosclerosis. Findings from the present study establish an independent association between higher sympathetic outflow and carotid artery wall thickness in adults with an exception to young women and extend findings from animal models that demonstrate hypertrophy of vascular smooth muscle following chronic sympathetic-adrenergic stimulation.

Blood Pressure in De Novo Heart Transplant Recipients Treated With Everolimus Compared With a Cyclosporine-based Regimen: Results From the Randomized SCHEDULE Trial

BACKGROUND

Systemic hypertension is prevalent in heart transplant recipients and has been partially attributed to treatment with calcineurin inhibitors (CNIs). SCandinavian HEart transplant De-novo stUdy with earLy calcineurin inhibitors avoidancE trial was the first randomized trial to study early withdrawal of CNIs in de novo heart transplant recipients, comparing an everolimus-based immunosuppressive regimen with conventional CNI-based treatment. As a prespecified secondary endpoint, blood pressure was repeatedly compared across treatment arms.

METHODS

The The SCandinavian HEart transplant De-novo stUdy with earLy calcineurin inhibitors avoidancE trial was a prospective, multicenter, randomized, controlled, parallel-group, open-label trial in de novo adult heart transplant recipients, undertaken at transplant centers in Scandinavia. Blood pressure was assessed with 24-hour ambulatory blood pressure monitoring up to 3 years after heart transplantation (HTx) in 83 patients.

RESULTS

Overall, systolic blood pressure fell with time, from 138 ± 15 mm Hg 2 weeks after HTx to 134 ± 11 mm Hg after 12 months and 132 ± 14 mm Hg after 36 months (P = 0.003). Diastolic blood pressure did not change over time. After 12 months, there was a numerically larger fall in systolic blood pressure in the everolimus arm (between-group difference 8 mm Hg; P = 0.053), and after 36 months, there was a significant between group difference of 13 mm Hg (P = 0.02) in favor of everolimus.

CONCLUSIONS

In this first, randomized trial with early CNI avoidance in de novo HTx recipients, we observed a modest fall in systolic blood pressure over the first 1 to 3 years after transplantation. The fall in systolic blood pressure was more pronounced in patients allocated to everolimus.

Fragmented QRS as a Marker of Myocardial Fibrosis in Hypertension: a Systematic Review

PURPOSE OF REVIEW

Hypertension cause damage in cardiac structure and induce pathological myocardial fibrosis that leads to hypertensive cardiomyopathy. A narrow fragmented QRS complex (fQRS) is associated with myocardial fibrosis and scar tissue in various cardiovascular diseases. It is also associated with myocardial fibrosis in hypertensive patients even in the absence of any structural heart diseases. This article aimed to demonstrate importance and usefulness of fQRS in hypertensive patients.

RECENT FINDINGS

Current evidence suggest that the frequency of fQRS is significantly higher in hypertensive patients compared to normotensives. Also, fQRS seems to be a predictor of left ventricular hypertrophy, increased systolic blood pressure, non-dipping, deterioration of the left ventricular geometry, and worse systolic and diastolic functions in hypertensive patients. As a simple and easy detectable electrocardiographic finding, fQRS may indicate myocardial fibrosis, uncontrolled blood pressure, and deteriorated cardiac structure in hypertensive patients even in the absence of other structural heart diseases, and may also be useful to predict high-risk hypertensives.

Association Between Non-Dipping and Fragmented QRS Complexes in Prehypertensive Patients

Background

Fragmented QRS (fQRS) is a sign of adverse cardiovascular events in various cardiovascular diseases. It is also associated with increased blood pressure and non-dipping in hypertensive patients. However, no study has investigated the importance of fQRS in prehypertensive patients.

Objectives

The aim of our study is to investigate the relationship between fQRS and non-dipper status in prehypertensive patients.

Methods

Two hundred and sixteen eligible, newly diagnosed prehypertensive patients who underwent 24-hour ambulatory blood pressure monitoring (ABPM) for further evaluation of blood pressure between June 2015 and July 2016 were included into the study. Patients were divided into three groups according to ABPM results: normotensives, dipper prehypertensives, and non-dipper prehypertensives. Groups were compared regarding presence of fQRS on electrocardiography. Additionally, multinomial logistic regression analysis was used to determine the relationship between fQRS and blood pressure pattern in prehypertensive patients.

Results

According to ABPM recordings, 61 patients had normotensive blood pressure pattern (systolic blood pressure < 120 mmHg and diastolic blood pressure < 80 mmHg). Of the remaining 155 prehypertensive patients, 83 were dippers and 72 were non-dippers. Non-dipper prehypertensives had a significantly higher frequency of fQRS compared to normotensives (p = 0.048). Furthermore, multinomial logistic regression analysis revealed that fQRS is an independent predictor of non-dipping blood pressure pattern in prehypertensive patients (p = 0.017, OR: 4.071, 95% CI: 1.281-12.936).

Conclusions

We found that fQRS is a predictor of non-dipping in prehypertensives. As a marker of fibrosis and higher fibrotic burden within myocardium, fQRS may be useful in identifying high-risk prehypertensive patients before the development of hypertension.

Strategies for the Prevention of Coronary Artery Disease Complications: Can We Do Better?

Billions of dollars have been spent over the past 25 years on developing new therapies for the prevention/treatment of adverse cardiac events related to atherosclerotic cardiovascular disease. Although some therapies have been lifesaving, several mega-randomized studies have shown only a <2% absolute reduction in adverse events with a large residual event rate. Is all this money well spent? Atherosclerosis develops decades before an adverse event, and the trials previously alluded to have nearly always been applied to secondary prevention, decades after disease initiation. Will earlier intervention result in a lower incidence of events? Individuals with an absence of the usual cardiac risk factors have a lifelong low incidence of events. Early initiation of strategies against the common cardiovascular risk factors in primary or primordial prevention will lower the incidence of adverse events, although many groups have not been well studied, including individuals younger than 40 years of age. New strategies are required to realize a radical reduction in events, and this article proposes new methods of prevention/treatment for coronary artery disease complications.

High Blood Pressure at Early School Age Among Extreme Preterms

BACKGROUND AND OBJECTIVES

Former preterm infants are at increased risk of hypertension with increasing age. Our objective was to identify rates of high blood pressure (BP) (≥90th percentile) and hypertension (BP ≥95th percentile) and associated risk factors among extreme preterm (EPT) infants at 6 to 7 years of age.

METHODS

Assessment included BP and anthropometrics. Comparisons were made by BP ≥90th versus <90th percentile. Regressions were run to identify relative risk (RR) of factors associated with BP ≥90th percentile.

RESULTS

Among 379 EPT infants, 20.6% had systolic high BP, 10.8% systolic hypertension, 21.4% diastolic high BP, and 11.4% diastolic hypertension. Children with systolic high BP had higher rates of BMI, triceps skinfolds >85th percentile, and waist circumference >90th percentile. In regression analyses, weight gain velocity from 18 months to school age (RR = 1.36), and maternal gestational diabetes (MGD) (RR = 2.04) predicted systolic and either systolic and/or diastolic high BP (RR = 1.27 and RR = 1.67). Among children with BMI <85th percentile, 17% had systolic and 19% had diastolic high BP. Regression analysis for normal weight children indicated public insurance (RR = 2.46) and MGD (RR = 2.16) predicted systolic high BP, and MGD (RR = 2.08) predicted either systolic or diastolic high BP.

CONCLUSIONS

Both overweight and normal weight EPT children are at risk for high BP and hypertension. Public insurance, MGD, and weight gain velocity are risk factors. Findings of high BP among EPT children at early school age are worrisome and indicate a need for close follow-up.

Dynamic coupling between the central and autonomic nervous systems during sleep: A review

Sleep is characterized by coordinated cortical and cardiac oscillations reflecting communication between the central (CNS) and autonomic (ANS) nervous systems. Here, we review fluctuations in ANS activity in association with CNS-defined sleep stages and cycles, and with phasic cortical events during sleep (e.g., arousals, K-complexes). Recent novel analytic methods reveal a dynamic organization of integrated physiological networks during sleep and indicate how multiple factors (e.g., sleep structure, age, sleep disorders) affect "CNS-ANS coupling". However, these data are mostly correlational and there is a lack of clarity of the underlying physiology, making it challenging to interpret causality and direction of coupling. Experimental manipulations (e.g., evoking K-complexes or arousals) provide information on the precise temporal sequence of cortical-cardiac activity, and are useful for investigating physiological pathways underlying CNS-ANS coupling. With the emergence of new analytical approaches and a renewed interest in ANS and CNS communication during sleep, future work may reveal novel insights into sleep and cardiovascular interactions during health and disease, in which coupling could be adversely impacted.

Understanding short-term blood-pressure-variability phenotypes: from concept to clinical practice

Clinic blood pressure (BP) is recognized as the gold standard for the screening, diagnosis, and management of hypertension. However, optimal diagnosis and successful management of hypertension cannot be achieved exclusively by a handful of conventionally acquired BP readings. It is critical to estimate the magnitude of BP variability by estimating and quantifying each individual patient's specific BP variations. Short-term BP variability or exaggerated circadian BP variations that occur within a day are associated with increased cardiovascular events, mortality and target-organ damage. Popular concepts of BP variability, including "white-coat hypertension" and "masked hypertension", are well recognized in clinical practice. However, nocturnal hypertension, morning surge, and morning hypertension are also important phenotypes of short-term BP variability that warrant attention, especially in the primary-care setting. In this review, we try to theorize and explain these phenotypes to ensure they are better understood and recognized in day-to-day clinical practice.

Validation of the Beneware model ABP-021 ambulatory blood pressure monitor according to the revised 2010 European Society of hypertension international protocol

OBJECTIVES

This study aimed to evaluate the accuracy of the Beneware model ABP-021 oscillometric blood pressure monitor in the general population according to the European Society of Hypertension International Protocol (ESH-IP). The accuracy of the device was assessed in relation to various clinical variables, including age, sex, BMI, and arm circumference.

METHODS

Thirty-three individuals (18 men and 15 women), with a mean age of 36±14 years (age range: 20-68 years), were studied according to the recommendations of the ESH-IP. Sequential same-arm blood pressure measurements were performed, alternating between a mercury standard and the automatic device. The differences among the test-control measurements were assessed and divided into categorization zones of 5, 10, and 15 mmHg discrepancy.

RESULTS

The device complied with the quality requirements of the ESH-IP. The device-observer disagreement was -1.2±4.7 mmHg for systolic blood pressure (SBP) and -1.7±4.3 mmHg for diastolic blood pressure (DBP). The device produced 77, 93, and 98 measurements, respectively, within the 5, 10, and 15 mmHg discrepancy limits for SBP. For DBP, 80, 97, and 99 measurements were observed within the 5, 10, and 15 mmHg discrepancy limits. The number of participants with two or three of the device-observer differences within 5 mmHg was 26 for SBP and 29 for DBP, whereas there were only two participants with no device-observer differences within 5 mmHg for DBP.

CONCLUSION

These data show that the Beneware model ABP-021 monitor meets the requirements of the ESH-IP, in static conditions, indicating its suitability for measuring blood pressure in the general adult population.

Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomised trial

BACKGROUND

Previous catheter-based renal denervation studies have reported variable efficacy results. We aimed to evaluate safety and blood pressure response after renal denervation or sham control in patients with uncontrolled hypertension on antihypertensive medications with drug adherence testing.

METHODS

In this international, randomised, single-blind, sham-control, proof-of-concept trial, patients with uncontrolled hypertension (aged 20-80 years) were enrolled at 25 centres in the USA, Germany, Japan, UK, Australia, Austria, and Greece. Eligible patients had an office systolic blood pressure of between 150 mm Hg and 180 mm Hg and a diastolic blood pressure of 90 mm Hg or higher; a 24 h ambulatory systolic blood pressure of between 140 mm Hg and 170 mm Hg at second screening; and were on one to three antihypertensive drugs with stable doses for at least 6 weeks. Patients underwent renal angiography and were randomly assigned to undergo renal denervation or sham control. Patients, caregivers, and those assessing blood pressure were masked to randomisation assignments. The primary efficacy endpoint was blood pressure change from baseline (measured at screening visit two), based on ambulatory blood pressure measurements assessed at 6 months, as compared between treatment groups. Drug surveillance was used to assess medication adherence. The primary analysis was done in the intention-to-treat population. Safety events were assessed through 6 months as per major adverse events. This trial is registered with ClinicalTrials.gov, number NCT02439775, and follow-up is ongoing.

FINDINGS

Between July 22, 2015, and June 14, 2017, 467 patients were screened and enrolled. This analysis presents results for the first 80 patients randomly assigned to renal denervation (n=38) and sham control (n=42). Office and 24 h ambulatory blood pressure decreased significantly from baseline to 6 months in the renal denervation group (mean baseline-adjusted treatment differences in 24 h systolic blood pressure -7·0 mm Hg, 95% CI -12·0 to -2·1; p=0·0059, 24 h diastolic blood pressure -4·3 mm Hg, -7·8 to -0·8; p=0.0174, office systolic blood pressure -6·6 mm Hg, -12·4 to -0·9; p=0·0250, and office diastolic blood pressure -4·2 mm Hg, -7·7 to -0·7; p=0·0190). The change in blood pressure was significantly greater at 6 months in the renal denervation group than the sham-control group for office systolic blood pressure (difference -6·8 mm Hg, 95% CI -12·5 to -1·1; p=0·0205), 24 h systolic blood pressure (difference -7·4 mm Hg, -12·5 to -2·3; p=0·0051), office diastolic blood pressure (difference -3·5 mm Hg, -7·0 to -0·0; p=0·0478), and 24 h diastolic blood pressure (difference -4·1 mm Hg, -7·8 to -0·4; p=0·0292). Evaluation of hourly changes in 24 h systolic blood pressure and diastolic blood pressure showed blood pressure reduction throughout 24 h for the renal denervation group. 3 month blood pressure reductions were not significantly different between groups. Medication adherence was about 60% and varied for individual patients throughout the study. No major adverse events were recorded in either group.

INTERPRETATION

Renal denervation in the main renal arteries and branches significantly reduced blood pressure compared with sham control with no major safety events. Incomplete medication adherence was common.

FUNDING

Medtronic.

The Impact of Blood Pressure Dipping Status on Cognition, Mobility, and Cardiovascular Health in Older Adults Following an Exercise Program

Objectives: To determine whether a dual-task gait and aerobic exercise intervention differentially impacted older adults with normal blood pressure (BP) dipping status (dippers) compared to those with nondipping status (nondippers). Methods: This study was a secondary analysis involving participants (mean age = 70.3 years, 61% women) who attended a laboratory-based exercise intervention over a 6-month period (40 min/day and 3 days/week). Participants were assessed in measures of cognition, mobility, and cardiovascular health at baseline, 3, 6, and 12 months (after a 6-month no-contact follow-up). Results: We observed improvements in cognition in both groups at 6 and 12 months, although no between-group differences were seen. Nondippers demonstrated superior improvements in usual gait velocity and step length after the exercise intervention compared to dippers. Dippers reduced daytime systolic BP at 6 and 12 months to a greater extent than nondippers. Discussion: BP dipping status at baseline did not influence exercise benefits to cognition but did mediate changes in mobility and cardiovascular health.

Circadian Blood Pressure Variations in Postmenopausal Females with Hypertension

The abnormalities of blood pressure (BP) nocturnal decline have been found to be predictive for carotid plaque and lacunar infarction in patients with hypertension. In this study, BP dipping patterns in postmenopausal females with hypertension were investigated. The nocturnal decline of systolic BP (SBP) was evaluated using 24-hour ambulatory BP monitoring (ABPM). A total of 163 postmenopausal females were eventually included in our study. The prevalence of reverse-dipper BP pattern was 32.3% in females with menopause age in their 40s and 40% in their 50s. However, after multivariate logistic regression analysis, menopause age was shown to be an independent risk factor for BP reverse dipping (Odds ratio [OR] 1.148; 95%CI 1.020 - 1.292; P = 0.020). Moreover, menopause age was negatively correlated with the decline rate of nocturnal SBP (r = -0.159; P < 0.05) and diastolic BP (r = -0.161; P < 0.05). Our study suggested that the menopause age might serve as a risk factor for reverse-dipper BP pattern in postmenopausal females with hypertension.