Isolated Systolic Hypertension in Young People Is Not Spurious and Should Be Treated

Differences between brachial and aortic blood pressure in adolescence and their implications for diagnosis of hypertension

OBJECTIVES

Blood pressure (BP) is the leading global cause of mortality, and its prevalence is increasing in children and adolescents. Aortic BP is lower than brachial BP in adults. We aimed to assess the extent of this difference and its impact on the diagnosis of hypertension among adolescents.

METHODS

We used data from 3850 participants from a UK cohort of births in the early 1990s in the Southwest of England, who attended their ∼17-year follow-up and had valid measures of brachial and aortic BP at that clinic [mean (SD) age 17.8 (0.4) years, 66% female individuals]. Data are presented as mean differences [95% prediction intervals] for both sexes.

RESULTS

Aortic systolic BP (SBP) was lower than brachial SBP [male, -22.3 (-31.2, -13.3) mmHg; female, -17.8 (-25.5, -10.0) mmHg]. Differences between aortic and brachial diastolic BP (DBP) were minimal. Based on brachial BP measurements, 101 male individuals (6%) and 22 female individuals (1%) were classified as hypertensive. In contrast, only nine male individuals (<1%) and 14 female individuals (<1%) met the criteria for hypertension based on aortic BP, and the predictive value of brachial BP for aortic hypertension was poor (positive-predictive value = 13.8%). Participants with aortic hypertension had a higher left ventricular mass index than those with brachial hypertension.

CONCLUSION

Brachial BP substantially overestimates aortic BP in adolescents because of marked aortic-to-brachial pulse pressure amplification. The use of brachial BP measurement may result in an overdiagnosis of hypertension during screening in adolescence.

Sex differences in blood pressure phenotypes over time - the HELIUS study

BACKGROUND

Hypertension can be classified into different phenotypes according to systolic and diastolic blood pressure (BP). In younger adults, these phenotypical differences have different prognostic value for men and women. However, little is known about sex differences in the natural course of different BP phenotypes over time.

METHODS

We used baseline and follow-up data from the multiethnic, population-based HELIUS study to assess differences in BP phenotypes over time in men and women aged < 45 years stratified according to baseline office BP into normotension (<140/<90 mmHg), isolated systolic hypertension (ISH, ≥140/<90 mmHg), isolated diastolic hypertension (IDH, <140/≥90 mmHg) or systolic diastolic hypertension (SDH, ≥140/≥90 mmHg). Logistic regression adjusted for age, ethnicity, and follow-up time was used to assess the risk of hypertension at follow-up (BP ≥140/90 mmHg or use of antihypertensive medication), stratified by sex.

RESULTS

We included 4103 participants [mean age 33.5 years (SD 7.4), 43.4% men] with a median follow-up time of 6.2 years. Compared to normotensive individuals, the age-adjusted odds ratios (OR) for having hypertension at follow-up were 4.78 (95% CI 2.90; 7.76) for ISH, 6.02 (95% CI 3.70; 9.74) for IDH and 33.73 (95% CI 20.35; 58.38) for SDH in men, while in women, OR were 10.08 (95% CI 4.09; 25.56) for ISH, 27.59 (95% CI 14.68; 53.82) for IDH and 50.58 (95% CI 24.78; 114.84) for SDH.

CONCLUSIONS

The risk of hypertension at follow-up was higher among women for all phenotypes compared to men, particularly in those with IDH. Findings of this study emphasize the importance of close BP monitoring in the young, especially in women.

Effectiveness of the knowledge, attitude, practice intervention model in the management of hypertension in the elderly

This study illustrated the effectiveness of the knowledge, attitude, practice (KAP) intervention model for community hypertension in the elderly by the community physician-led, describing the study design and baseline data. The aim of the study was to compare the changes in the elderly hypertensive population before and after the KAP intervention model by managing the elderly hypertensive patients for a period of 1 year. Basic information and risk factors affecting blood pressure control based on baseline data of recruited elderly hypertensive patients. The management approach consists of two parts: (1) the unified management of the community physician to whom the patient belongs; and (2) the management of the contracted patient by the community physician. The aim was to demonstrate the anti-hypertensive effectiveness (control rate, blood pressure reduction, and pulse pressure), the distribution of blood pressure types, and the change of the KAP in elderly hypertensive patients before and after the intervention. The KAP intervention model was administered to 2660 elderly hypertensive patients in a 1-year period. The blood pressure control rate improved by 54.03%. Mean values of overall systolic and diastolic blood pressure decreased by 16.00 and 5.31 mmHg, respectively. The proportion of isolated systolic hypertension (ISH) and systolic-diastolic hypertension (SDH) decreased by 29.14% and 24.81%, respectively. The KAP compliance improved significantly. These results suggest that the community physician-led KAP intervention model is effective in the management of hypertension in the elderly.

Central-to-peripheral blood pressure amplification: role of the recording site, technology, analysis approach, and calibration scheme in invasive and non-invasive data agreement

Background

Systolic blood pressure amplification (SBPA) and pulse pressure amplification (PPA) can independently predict cardiovascular damage and mortality. A wide range of methods are used for the non-invasive estimation of SBPA and PPA. The most accurate non-invasive method for obtaining SBPA and/or PPA remains unknown.

Aim

This study aims to evaluate the agreement between the SBPA and PPA values that are invasively and non-invasively obtained using different (1) measurement sites (radial, brachial, carotid), (2) measuring techniques (tonometry, oscillometry/plethysmography, ultrasound), (3) pulse waveform analysis approaches, and (4) calibration methods [systo-diastolic vs. approaches using brachial diastolic and mean blood pressure (BP)], with the latter calculated using different equations or measured by oscillometry.

Methods

Invasive aortic and brachial pressure (catheterism) and non-invasive aortic and peripheral (brachial, radial) BP were simultaneously obtained from 34 subjects using different methodologies, analysis methods, measuring sites, and calibration methods. SBPA and PPA were quantified. Concordance correlation and the Bland-Altman analysis were performed.

Results

(1) In general, SBPA and PPA levels obtained with non-invasive approaches were not associated with those recorded invasively. (2) The different non-invasive approaches led to (extremely) dissimilar results. In general, non-invasive measurements underestimated SBPA and PPA; the higher the invasive SBPA (or PPA), the greater the underestimation. (3) None of the calibration schemes, which considered non-invasive brachial BP to estimate SBPA or PPA, were better than the others. (4) SBPA and PPA levels obtained from radial artery waveform analysis (tonometry) (5) and common carotid artery ultrasound recordings and brachial artery waveform analysis, respectively, minimized the mean errors.

Conclusions

Overall, the findings showed that (i) SBPA and PPA indices are not "synonymous" and (ii) non-invasive approaches would fail to accurately determine invasive SBPA or PPA levels, regardless of the recording site, analysis, and calibration methods. Non-invasive measurements generally underestimated SBPA and PPA, and the higher the invasive SBPA or PPA, the higher the underestimation. There was not a calibration scheme better than the others. Consequently, our study emphasizes the strong need to be critical of measurement techniques, to have methodological transparency, and to have expert consensus for non-invasive assessment of SBPA and PPA.

Blood Pressure Level in Late Adolescence and Risk for Cardiovascular Events : A Cohort Study

BACKGROUND

Not enough is known about the association between blood pressure (BP) in adolescence and future cardiovascular events.

OBJECTIVE

To measure this association using the 2017 American College of Cardiology/American Heart Association guidelines for classifying BP elevation.

DESIGN

Cohort study.

SETTING

Sweden.

PARTICIPANTS

Males in late adolescence who were conscripted into the military from 1969 to 1997.

MEASUREMENTS

Baseline BP was measured at conscription. The primary outcome was a composite of cardiovascular death or first hospitalization for myocardial infarction, heart failure, ischemic stroke, or intracerebral hemorrhage.

RESULTS

The study included 1 366 519 males with a mean age of 18.3 years. The baseline BP was classified as elevated (120 to 129/<80 mm Hg) for 28.8% of participants and hypertensive (≥130/80 mm Hg) for 53.7%. During a median follow-up of 35.9 years, 79 644 had a primary outcome. The adjusted hazard ratio was 1.10 for elevated BP (95% CI, 1.07 to 1.13), 1.15 for stage 1 isolated systolic hypertension (ISH) (CI, 1.11 to 1.18), 1.23 for stage 1 isolated diastolic hypertension (IDH) (CI, 1.18 to 1.28), 1.32 for stage 1 systolic-diastolic hypertension (SDH) (CI, 1.27 to 1.37), 1.31 for stage 2 ISH (CI, 1.28 to 1.35), 1.55 for stage 2 IDH (CI, 1.42 to 1.69), and 1.71 for stage 2 SDH (CI, 1.58 to 1.84). The cumulative risk for cardiovascular events also increased gradually across BP stages, ranging from 14.7% for normal BP to 24.3% for stage 2 SDH at age 68 years.

LIMITATION

This was an observational study of Swedish men.

CONCLUSION

Increasing BP levels in late adolescence are associated with gradually increasing risks for major cardiovascular events, beginning at a BP level of 120/80 mm Hg.

PRIMARY FUNDING SOURCE

Västerbotten County Council, Swedish Society for Medical Research, and Heart Foundation of Northern Sweden.

Assessing the Impact of Intensified Hypertension (HTN) Treatment Guidelines: A Single Center Experience

INTRODUCTION

 Hypertension (HTN) is an independent risk factor for heart disease, stroke, and premature death. In 2017 there was a shift in the definition of HTN by the American College of Cardiology (ACC), as well as the American Heart Association (ACC/AHA), resulting in lower blood pressure (BP) readings meeting criteria for diagnosis. Our study aimed to explore the impact the change had on a single cardiology practice's management of patients with HTN.

METHODS

We performed a retrospective chart review of a single cardiology practice. We separated the time into two categories: 12 months before and 12 months after the reclassification of HTN categories in November 2017. A paired t-test analysis was done comparing averaged blood pressures (BPs) in each of the two time periods, as well as the number of medications in each time period and several subgroup analyses.

RESULTS

A total of 441 patients were included in the final analysis. Patients were prescribed an average of 2.61 ± 1.20 medications at baseline, and 2.74 ± 1.22 medications post-reclassification (p < 0.0001). There was an average of 0.82 ± 1.28 medication changes per patient. The overall average BP was 133.7 ± 14.1/76.4 ± 9.5 at baseline, and 131.3 ± 13.1/76.7 ± 7.7 after the recategorization [Δ -2.41 (95% CI 1.18-3.63)/0.269 (95% CI -0.29 to 0.459); p<0.0001 for systolic blood pressure (SBP), p=0.467 for diastolic blood pressure (DBP)].

CONCLUSION

The change in definition of HTN significantly impacted this single cardiology practice. There was a statistically significant increase in antihypertensive medications prescribed with an expected decrease in BP observed in this study.

Isolated systolic hypertension in the young: a heterogeneous condition

Isolated systolic hypertension in the youth, is still a challenging problem. The prevalence of this hypertensive subtype may vary according to the different population study and is peculiar of male subjects among the youngest age classes. Several are the mechanisms reported as possible underlying causes of isolated systolic blood pressure elevation and again these differ according to the different study cohort and may vary from overweight and obesity status, linked to sympathetic overactivity, to increased and earlier arterial stiffness, hyperkinetic state, or exaggerated pulse pressure amplification form central to peripheral sites, due to enhanced arterial elasticity. Evidence is lacking regarding whether this condition is benign or associated to unfavorable cardiovascular events. The few long-term studies that followed isolated systolic hypertensives in the long-term, again reported conflicting results. Waiting for future studies, some clinical and hemodynamic characteristics of young isolated systolic hypertensives may help clinicians to better characterized patient's risk profile and decide whether to perform a strict follow-up with non-pharmacological measurements or to start drug treatment.

Importance of central BP assessment in ISH of the young. Which devices are best suited for practical use?

Isolated systolic hypertension (ISH), defined as brachial systolic blood pressure (bSBP) ≥140 mmHg and diastolic blood pressure (DBP) <90 mmHg, is highly prevalent among young subjects and in the elderly. The prognostic significance of ISH in young individuals remains the object of large debate which might be solved, at least in part, if considering the prognostic role of central BP. For any given value of pBP, the cardiovascular (CV) risk is better defined by central BP (cBP). Young individuals with ISH have long been considered at low CV risk, given the assumption that a "spurious hypertension" phenotype characterized by elevated peripheral (brachial) BP (pBP), normal cBP, and elevated BP amplification was often found in this population. However, this remains to be proven, because many other studies found no differences in BP amplification between ISH and sisto-diastolic hypertension. Despite numerous attempts, methodologies for cBP assessment by non-invasive devices are currently not standardized. As a result, different devices could provide different cBP values despite using the same biological signals. Devices providing accurate estimates of BP amplification as a dimensionless ratio between amplitudes of central and peripheral arterial waveforms might be well suited for clinical purposes in young individuals with ISH. There is urgent need of well-designed prospective studies aiming at longitudinally evaluating the amount of CV risk associated with elevated cBP in young subjects with ISH and their related incremental prognostic value.

Relationship between heart rate and central aortic blood pressure: implications for assessment and treatment of isolated systolic hypertension in the young

Isolated systolic hypertension in the young (ISHY) remains a challenging problem, partly due to the differences in central aortic pressure observed in studies investigating ISHY. The fundamental relationship between heart rate and central aortic pressure, and more precisely, the relationship between heart rate and amplification of central aortic pressure in the periphery, underpins the assessment and, as a consequence, the treatment of ISHY. Physiology warrants that an increase in heart rate would lead to increased amplification of the pressure pulse between the aorta and the brachial artery. Heart rate generally decreases with age, in particular over the first two decades of life. Thus, a higher heart rate in the young would result in higher pulse pressure amplification, and therefore an elevated brachial systolic pressure would not necessarily translate to elevated aortic systolic pressure. However, elevated heart rate is not a consistent feature in ISHY, and studies have shown that ISHY can present with either high or low central aortic systolic pressure. In this brief review, we summarize the physiological aspects underlying the relationship between heart rate and central aortic blood pressure and its amplification in the brachial artery, how this relationship changes with age, and examine the implications of these effects on the assessment and treatment of ISHY.

Isolated systolic hypertension and its associated risk factors in Iranian middle age and older population: a population-based study

Background

Isolated systolic hypertension (ISH), is the most common form of hypertension in older adults. However, the ISH prevalence is not well known in many developing countries such as Iran. This study was conducted to determine the ISH prevalence and its related risk factors in an Iranian population.

Methods

Data were obtained from the second phase of the Shahroud eye cohort study (ShECS) in 2014. ShECS is a longitudinal population-based study which the first phase had been conducted in 2009 using the stratified multistage cluster sampling design on 5190 people aged 40 to 70 years. The ISH prevalence was determined based on the eighth Joint National Commission guidelines for different demographic variables. The associated risk factors were estimated by multiple logistic regression and a two-tailed p-value less than 0.05 was considered significant.

Results

The ISH prevalence was 15.89% (95% CI: 14.88–16.96). It was 15.68% (14.12–17.39) and 15.87% (14.54–17.29) for men and women, respectively. The prevalence of ISH increased significantly with increasing age. The 65–70 compared to 45–69 year age group (OR = 4.21), body mass index (OR = 1.03), diabetes (OR = 1.64), retirement, compared to practitioner job (OR = 1.53), and waist to hip ratio (WHR) (OR = 9.81) were significantly associated with ISH prevalence.

Conclusions

ISH is highly prevalent among the older adult population in Iran. Given the risk of cardiovascular disease associated with ISH, it is recommended to conduct education and public health interventions to improve the detection, prevention, and treatment of ISH.

Prevalence, time-trends and clinical characteristics of hypertension in young adults: nationwide cross-sectional study of 1.7 million Swedish 18-year-olds, 1969-2010

OBJECTIVE

The prevalence of hypertension in young adulthood, as well as the clinical characteristics associated with different hypertension subtypes, have been inconsistently described. Our aim was to assess the prevalence, time-trends and characteristics associated with isolated systolic hypertension (ISH), isolated diastolic hypertension and combined systodiastolic hypertension.

METHODS

Serial cross-sectional analysis, using data from the Swedish conscription registry, including 1701 314 (99.2% male) individuals from 1969 to 2010. Risk factor associations were assessed through multivariable logistic regression.

RESULTS

The prevalence of hypertension increased progressively during the study period, from 20.4% in 1969 to 29.3% in 2010, with ISH being the most common subtype (94.3%). ISH was associated with elevated resting heart rate (odds ratio 1.85, 95% confidence interval 1.84-1.86, per SD), increased exercise capacity (1.37, 1.36-1.39) and increased BMI (1.30, 1.29-1.31). Isolated diastolic hypertension and combined hypertension were also associated with elevated resting heart rate (1.37, 1.32-1.41 and 2.05, 1.99-2.11, respectively) and more strongly associated with increased BMI (1.36, 1.33-1.40 and 1.54, 1.51 - 1.58), but inversely associated with exercise capacity (0.79, 0.75-0.83 and 0.90, 0.86-0.95).

CONCLUSION

The prevalence of hypertension in young adulthood has increased substantially over time, predominantly due to an increase in ISH. Risk factor patterns differed between ISH and other forms of hypertension, suggesting potentially different underlying mechanisms.

Stressful life events, neighbourhood characteristics, and systolic blood pressure in South Africa

The relationship between negative events, neighbourhood characteristics, and systolic blood pressure in developing countries is not well-documented, particularly using longitudinal data. To explore this relationship, we analysed panel data from the first three waves of the South African National Income Dynamics Study using a correlated random effects model adjusted for confounding risk factors. Our sample comprised of 15,631 respondents in 2008, 14,443 respondents in 2010/2011, and 14,418 respondents in 2012, all aged above 15 years. The prevalence of at least one negative household event across the three waves was approximately 30%. In any of the three waves, the adjusted prevalence of hypertension was 23.84%. This share was 21.75% in 2008 (95% CI 18.06-25.44), 23.16% in 2010/11 (95% CI 19.18-27.14), and 18.39% in 2012 (95% CI 16.03-20.75). In our adjusted correlated random effects model, we found that systolic blood pressure was significantly higher among respondents from households that reported death of a household member (0.85 mmHg; p =  0.02) and a reduction in grant income and remittances (2.14 mm Hg; p = 0.01). We also found no significant association between systolic blood pressure and neighbourhood income level. In a country with social and economic challenges, our results indicate that grief and negative financial events are adversely associated with blood pressure, which may explain in part the significant burden of hypertension in low- and middle-income countries.

Isolated systolic hypertension and insulin resistance assessment tools in young and middle-aged Chinese men with normal fasting glucose: a cross-sectional study

The vital role of insulin resistance (IR) in the pathogenesis of isolated systolic hypertension (ISH) has been expounded at the theoretical level. However, research on the correlation between some specific IR indicators and ISH is still rare, especially at different glycemic statuses. We conducted this study to explore the association between three IR indicators and ISH among young and middle-aged adults with normal fasting plasma glucose (NFG). This large cross-sectional study included 8246 young and middle-aged men with NFG and diastolic blood pressure < 90 mmHg. The homeostasis model assessment for IR (HOMA-IR) index, triglyceride glucose (TyG) index, and the metabolic score for IR (METS-IR) were calculated with the corresponding formula. The proportions of ISH among young and middle-aged men were 6.7% and 4.4%, respectively. After fully adjusting, only HOMA-IR rather than TyG and METS-IR was significantly associated with ISH. Moreover, fully adjusted smooth curve fitting showed that the association between HOMA-IR and ISH were approximately linear in both two age groups (P for non-linearity were 0.047 and 0.430 in young and middle-aged men, respectively). Among young and middle-aged men with NFG, using HOMA-IR instead of noninsulin-dependent IR indicators may have advantages in the hierarchical management of ISH. Further longitudinal research may be needed to determine their potential causal relationship.

Cardiovascular mortality risk in young adults with isolated systolic hypertension: findings from population-based MONICA/KORA cohort study

The clinical significance of isolated systolic hypertension in young adults (ISHY) remains a topic of debate due to evidence ISHY could be a spurious condition resulting from exageratted pulse pressure amplification in "young tall men with elastic arteries". Hence, we aimed to investigate whether ISHY is associated with an increased risk of cardivascular (CVD) mortality in a sample of 5597 young adults (49.8% men, 50.2% women) between 25 and 45 years old from the prospective population-based MONICA/KORA cohort. ISHY was prevalent in 5.2% of the population, affecting mostly men (73.1%), and associated with increased smoking, obesity, and hypercholesterolemia in comparison to participants with normal blood pressure (BP). Within a follow-up period of 25.3 years (SD ± 5.2; 141,768 person-years), 133(2.4%) CVD mortality cases were observed. Participants with ISHY had a hazard ratio (HR) of 1.89(1.01-3.53, p < 0.05) times higher risk of CVD mortality than participants with normal BP, even following adjustment for CVD risk factors. However, adjustment for antihypertensive medication (HR 0.46; 0.26-0.81, p < 0.001) and increasing height (HR 0.96; 0.93-0.99, p < 0.05) revealed independently protective effects against CVD mortality, suggesting that although ISHY is associated with an increased risk of CVD mortality, the protective effects of increasing height or antihypertensive medication should be considered in treatment rationale.

Prevalence and clinical characteristics of isolated systolic hypertension in young: analysis of 24 h ambulatory blood pressure monitoring database

Isolated systolic hypertension (ISHT) is common in elderly patients, whilst its prevalence and clinical impact in young adults are still debated. We aimed to estimate prevalence and clinical characteristics of ISHT and to evaluate out-of-office BP levels and their correlations with office BP in young adults. A single-center, cross-sectional study was conducted at our Hypertension Unit, by including treated and untreated individuals aged 18-50 years, who consecutively underwent home, clinic and 24 h ambulatory BP assessment. All BP measurements were performed and BP thresholds were set according to European guidelines: normotension (NT), clinic BP <140/<90 mmHg; ISHT, BP ≥140/<90 mmHg; isolated diastolic hypertension (IDHT), BP <140/≥90 mmHg; systolic-diastolic hypertension (SDHT), BP ≥140/≥90 mmHg. European SCORE, vascular and cardiac HMOD were also assessed. From an overall sample of 13,053 records, we selected 2127 young outpatients (44.2% female, age 40.5 ± 7.4 years, BMI 26.7 ± 5.0 kg/m², clinic BP 141.1 ± 16.1/94.1 ± 11.8 mmHg, 24 h BP 129.0 ± 12.8/82.4 ± 9.8 mmHg), among whom 587 (27.6%) had NT, 391 (18.4%) IDHT, 144 (6.8%) ISHT, and 1005 (47.2%) SDHT. Patients with ISHT were predominantly male (61.1%), younger and with higher BMI compared to other groups. They also showed higher home and 24 h ambulatory SBP levels than those with NT or IDHT (P < 0.001), though similar to those with SDHT. ISHT patients showed significantly higher pulse pressure (PP) levels than other groups, at all BP measurements (P < 0.001 for all comparisons), and significantly higher proportion (65.3%) of patients with ISHT had PP >60 mmHg. European SCORE resulted significantly higher in patients with ISHT (1.6 ± 2.9%) and SDHT (1.5 ± 2.7%) compared to those with IDHT (0.9 ± 1.5%) or NT (0.8 ± 1.9%) (P = 0.017). Though relatively rare, ISHT should be not viewed as a benign condition, being associated with sustained SBP elevation, high European SCORE risk, and vascular HMOD.

Early-childhood BMI trajectories in relation to preclinical cardiovascular measurements in adolescence

Cardiovascular diseases are the leading causes of morbidity and mortality. Overweight, obesity, and accelerated growth during early childhood have been associated with adverse cardiovascular outcomes in later life. Few studies have assessed whether trajectories of accelerated growth in early childhood are associated with preclinical cardiovascular measurements. We aimed to evaluate the associations between childhood body mass index (BMI) growth trajectories and measures of macro- and microvascular function in early adolescence. Measurements of macrovascular function (systolic and diastolic blood pressure (SBP and DBP), pulse wave velocity (PWV), and microvascular function (central retinal arteriolar/veinular equivalent) were assessed at 11 years old in a Spanish birth cohort study (n = 489). BMI trajectories from birth to 9 years were identified using latent class growth analysis. Multiple linear regression assessed the associations between the BMI trajectories and macro- and microvascular function. Compared to children with average birth size and slower BMI gain (reference), children with a lower birth size and accelerated BMI gain had increased SBP [β = 6.57; (95% CI 4.00, 9.15)], DBP [β = 3.65; (95% CI 1.45, 5.86)], and PWV [β = 0.14; (95% CI 0.01, 0.27)]. Children with higher birth size and accelerated BMI gain had increased SBP [β = 4.75; (95% CI 1.79, 7.71) compared to the reference. No significant associations between BMI trajectories and the microvascular measurements were observed. In conclusion, we found that childhood BMI trajectories characterized by accelerated growth are associated with preclinical macrovascular measurements in young adolescents.

A Community-Based Study on Waist-to-Height Ratio: An Indicator for Systolic Hypertension in a Rural Community of Hilly Region

The prevalence of hypertension gradually becomes a serious public health threat as it is a very pertinent risk factor for cardiovascular and cerebrovascular diseases. This study aims to estimate the prevalence of isolated systolic hypertension (ISH) among the hilly region's rural community and identify the indicators of ISH among study participants. A community-based cross-sectional study was conducted among 1220 participants in the rural community of the hilly region. A multistage random sampling technique was applied to recruit the participants. Demographic and anthropometric dimensions were measured to analyze the outcome of the study. The participants' mean age was 44.42 ± 15.54 years, with a majority of 822 female participants (67.40%). The prevalence of ISH was found as 27.45%. A statistically significant positive correlation (p < 0.05) of the waist-to-height ratio (WHtR) and body mass index (BMI) were observed with systolic blood pressure (SBP) in male as well as female participants, whereas BMI and WHtR had no correlation with diastolic blood pressure (DBP). Among female participants, the area under the curve (AUC) for BMI and WHtR was 0.604 (95% confidence interval 0.565-0.643, p-value = 0.020*) and 0.622 (95% confidence interval 0.584-0.660, p-value = 0.020*), respectively. Among male participants, the AUC for BMI and WHtR was 0.574 and 0.592, respectively. Hence, it cannot be considered very satisfactory. The increasing prevalence of ISH in a rural community is also a public health concern. At the preliminary stage, anthropocentric measurements are the primary tool for a family physician while treating the patients. This study concluded that WHtR is a better indicator than BMI for systolic hypertension. Although we have not observed a strong correlation of WHtR with systolic hypertension, it is required to perform future research to support this study's evidence.

Isolated systolic hypertension in young males: a scoping review

Isolated systolic hypertension typically occurs in young males; however, its clinical significance is unknown. Given the prevalence of the hypertension and its contribution to global morbidity and mortality, a synthesis of the most recent available evidence around isolated systolic hypertension is warranted. This review aims firstly to review the haemodynamic and physical characteristics indicative of cardiovascular risk in young males (aged 18 to 30 years) with isolated systolic hypertension, and secondly to synthesize the associated clinical management recommendations reported in the literature. Six databases were systematically searched for all relevant peer-reviewed literature examining isolated systolic hypertension in young males. Search results were screened and examined for validity, those that did not meet the inclusion criteria were removed. A total of 20 articles were appropriate for inclusion. Key factors indicative of cardiovascular risk in isolated systolic hypertension were characterized by several distinctive haemodynamic parameters and physical characteristics. After the literature was synthesized based around these key factors, two distinct cohorts (healthy and unhealthy) were highlighted. The healthy cohort of younger males with isolated systolic hypertension was associated with a decreased cardiovascular risk and therefore no medical interventions were recommended. The second (unhealthy) cohort was, however, associated with an increased cardiovascular risk and may therefore, benefit from antihypertensive therapy.

Blood Pressure in Young Adults and Cardiovascular Disease Later in Life

Cardiovascular disease (CVD) mortality has declined markedly over the past several decades among middle-age and older adults in the United States. However, young adults (18-39 years of age) have had a lower rate of decline in CVD mortality. This trend may be related to the prevalence of high blood pressure (BP) having increased among young US adults. Additionally, awareness, treatment, and control of hypertension are low among US adults between 20 and 39 years of age. Many young adults and healthcare providers may not be aware of the impact of high BP during young adulthood on their later life, the associations of BP patterns with adverse outcomes later in life, and benefit-to-harm ratios of pharmacological treatment. This review provides a synthesis of the related resources available in the literature to better understand BP-related CVD risk among young adults and better identify BP patterns and levels during young adulthood that are associated with CVD events later in life, and lastly, to clarify future challenges in BP management for young adults.

Association Between Central-Peripheral Blood Pressure Amplification and Structural and Functional Cardiac Properties in Children, Adolescents, and Adults: Impact of the Amplification Parameter, Recording System and Calibration Scheme

INTRODUCTION

Systolic blood pressure (SBPA) and pulse pressure amplification (PPA) were quantified using different methodological and calibration approaches to analyze (1) the association and agreement between different SBPA and PPA parameters and (2) the association between these SBPA and PPA parameters and left ventricle (LV) and atrium (LA) structural and functional characteristics.

METHODS

In 269 healthy subjects, LV and LA parameters were echocardiography-derived. SBPA and PPA parameters were quantified using: (1) different equations (n = 9), (2) methodological approaches (n = 3): brachial sub-diastolic (Mobil-O-Graph®) and supra-systolic oscillometry (Arteriograph®) and aortic diameter waveform re-calibration (RCD; ultrasonography), and (3) using three different calibration schemes: systo-diastolic (SD), calculated mean (CM) and oscillometric mean (OscM).

RESULTS

SBPA and PPA parameters obtained with different equations, techniques, and calibration schemes show a highly variable association level (negative, non-significant, and/or positive) among them. The association between SBPA and PPA with cardiac parameters were highly variable (negative, non-significant, or positive associations). Differences in BPA parameter data between approaches were more sensitive to the calibration method than to the device used. Both, SBPA and PPA obtained with brachial sub-diastolic technique and calibrated to CM or OscM showed higher levels of association with LV and LA structural characteristics.

CONCLUSIONS

Our data show that many of the parameters that assume to quantify the same phenomenon of BPA are not related to each other in the different age groups. Both, SBPA and PPA obtained with brachial sub-diastolic technique and calibrated to CM or OscM showed higher levels of association with LV and LA structural characteristics.

Isolated systolic hypertension and central blood pressure: Implications from the national nutrition and health survey in Taiwan

We aimed to investigate the association between isolated systolic hypertension (ISH) and central blood pressure (BP) in a nationally representative population, with a focus on the young and middle‐aged adults (<50 years old). A total of 2029 adults without taking antihypertensive medications, aged ≥ 19 years old, participated in the 2013–2016 National Nutrition and Health Survey in Taiwan. Central and brachial BP were simultaneously measured using a cuff‐based stand‐alone central blood pressure monitor purporting to measure invasive central BP (type II device). Central hypertension was defined by central systolic (SBP)/diastolic BP (DBP) ≥130 or 90 mm Hg, and ISH was defined by brachial SBP ≥ 140 and DBP < 90 mm Hg. Overall, the prevalence rates of ISH, isolated diastolic hypertension (IDH, brachial SBP < 140 and DBP ≥ 90 mmHg), and systolic/diastolic hypertension (SDH, brachial SBP ≥ 140 and DBP ≥ 90 mmHg) were 6.51%, 1.92%, and 4.34%, respectively. ISH subjects had significantly higher central pulse pressure (PP) (62.8 ± 9.7 mm Hg for age < 50 years and 72.4 ± 13.5 mmHg for age ≥ 50 years) than those subjects with either IDH (44.7 ± 10.7 and 44.9 ± 10.6 mmHg) or SDH (55.2 ± 14.0 and 62.6 ± 17.1 mmHg). All ISH adults had central hypertension, and a higher prevalence of central obesity than the normotensives (80.95% vs. 26.15%, for age < 50 years; and 63.96% vs. 43.37% for age ≥ 50 years). All untreated subjects with ISH, whether younger or older, had central hypertension and had significantly higher central PP than those with IDH or SDH. Central obesity was one of the major characteristics of ISH, especially in the young‐ and middle‐aged adults.

Assessment of Prevalence, Awareness, and Characteristics of Isolated Systolic Hypertension Among Younger and Middle-Aged Adults in China

IMPORTANCE

Isolated systolic hypertension (ISH) is increasing in prevalence among young and middle-aged adults. However, most studies of ISH are limited to older individuals, and a substantial knowledge gap exists regarding younger adults with ISH.

OBJECTIVE

To assess the prevalence, awareness, and characteristics of ISH among younger and middle-aged adults in China.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was performed as part of the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project, which enrolled 3.1 million community residents aged 35 to 75 years from all of the 31 provinces in China between December 15, 2014, and May 15, 2019. The present analysis included only participants younger than 50 years. Data were analyzed from May to November 2019.

MAIN OUTCOMES AND MEASURES

Prevalence and awareness of ISH (defined as systolic blood pressure of 140 mm Hg or higher and diastolic blood pressure of less than 90 mm Hg) and individual characteristics of participants with ISH.

RESULTS

Among 898 929 participants aged 35 to 49 years, the mean (SD) age was 43.8 (3.9) years; 548 657 participants (61.0%) were women, and 235 138 participants (26.2%) had hypertension. Of those with hypertension, 62 819 participants (26.7%; 95% CI, 26.5%-26.9%) had ISH (mean [SD] age, 45.0 [3.5] years; 41 417 women [65.9%]), and 54 463 of those with ISH (86.7%; 95% CI, 86.4%-87.0%) had not received treatment. The prevalence of ISH was higher among individuals who were older, were female, were farmers, resided in the eastern region of China, and had an educational level of primary school or lower. Women and older individuals were more likely to have ISH than to be normotensive or to have other hypertension subtypes. Participants who were obese, currently used alcohol, had diabetes, and experienced previous cardiovascular events were more likely to have other types of hypertension and less likely to have normotension than to have ISH. Among the 54 463 participants with ISH who had not received treatment, only 3682 individuals (6.8%; 95% CI, 6.6%-7.0%) were aware of having hypertension, and awareness rates remained low even among those with systolic blood pressure of 160 mm Hg or higher (7135 individuals [13.1%; 95% CI, 12.4%-13.9%]).

CONCLUSIONS AND RELEVANCE

In this study, ISH was identified in 1 of 4 young and middle-aged adults with hypertension in China, most of whom remained unaware of having hypertension. These results highlight the increasing need for better guidance regarding the management of ISH in this population.

Isolated systolic hypertension in Asia

Isolated systolic hypertension (ISH) is the most common type of essential hypertension in the elderly and young adults. With rapid industrialization and population aging, the prevalence of ISH in Asia will rise substantially. Asian populations have distinct epidemiological features, risk factors and are especially vulnerable to ISH. There is a pressing need for Asian countries to formulate their unique strategies for control of ISH. In this review, we focus on the (1) epidemiology and pathophysiology, (2) risk factors and impact on outcomes, and (3) treatment goal and strategy for ISH in Asia.

Ambulatory blood pressure phenotypes and isolated elevation of office central or brachial blood pressure

Disagreements in office brachial and central blood pressure (BP) have resulted in the identification of novel hypertension phenotypes, namely isolated central hypertension (ICH) and isolated brachial hypertension (IBH). This study investigated the relationship of ICH and IBH with ambulatory BP phenotypes among 753 individuals (mean age = 47.6 ± 15.2 years, 48% males) who underwent office and 24-hours brachial and central BP measures using a Mobil-O-Graph PWA monitor. Thresholds for elevated office central and brachial BP were 130/90 and 140/90 mm Hg. Results of multivariable analysis adjusted for potential confounders showed that ICH (n = 25) had 3.71-fold (95% CI 1.48-9.32; P = .005) greater risk of masked hypertension than normal brachial/central BP (n = 362), while IBH (n = 20) had 4.65-fold (95% CI 1.76-12.25; P = .002) greater risk of white coat hypertension compared with combined brachial/central hypertension (n = 346). These findings suggest that the diagnosis of ICH and IBH might be useful in identifying individuals at higher risk of presenting discordant office and ambulatory BP phenotypes.

Cardiovascular Risk of Isolated Systolic or Diastolic Hypertension in Young Adults

BACKGROUND

Little is known regarding health outcomes associated with isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), or systolic and diastolic hypertension (SDH) among young adults with stage 1 hypertension, defined using the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline.

METHODS

From a nationwide health screening database, we included 6 424 090 participants, aged 20 to 39 years, who were not taking antihypertensive medication at the baseline examination in 2003 to 2007. Participants were categorized as having normal BP (untreated systolic BP [SBP] <120/diastolic BP [DBP] <80 mm Hg; n=2 665 310); elevated BP (SBP 120-129/DBP <80 mm Hg; n=705 344); stage 1 IDH (SBP <130/DBP 80-89 mm Hg; n=1 271 505); stage 1 ISH (SBP 130-139/DBP <80 mm Hg; n=255 588); stage 1 SDH (SBP 130-139/DBP 80-89 mm Hg; n=711 503); and stage 2 hypertension (SBP ≥140, DBP ≥90 mm Hg; n=814 840). The primary outcome was composite cardiovascular disease (CVD) events, including myocardial infarction, stroke, heart failure, and CVD-related death.

RESULTS

The median age of the participants was 30 years and 60.9% were male. Over a median follow-up of 13.2 years, 44 070 new CVD events occurred. With normal BP as the reference, multivariable-adjusted hazard ratios (95% CIs) for CVD events were 1.14 (1.09-1.18) for elevated BP, 1.32 (1.28-1.36) for stage 1 IDH, 1.36 (1.29-1.43) for stage 1 ISH, 1.67 (1.61-1.72) for stage 1 SDH, and 2.40 (2.33-2.47) for stage 2 hypertension.

CONCLUSIONS

Among young adults, stage 1 ISH, IDH, and SDH were all associated with higher CVD risks than normal BP. The CVD risks of stage 1 ISH and IDH were similar to each other but lower than the risk of stage 1 SDH. Categorizing young adults with stage 1 hypertension further into stage 1 ISH, IDH, and SDH may improve risk stratification for identifying high-risk individuals.

The Effect of Blood Pressure on Cognitive Performance. An 8-Year Follow-Up of the Tromsø Study, Comprising People Aged 45-74 Years

Background

The relationship between blood pressure (BP) and cognition is complex were age appears to be an intervening variable. High and low BP have been associated with cognitive deficits as part of the aging process, but more studies are needed, especially in more recent birth cohorts.

Methods

The study sample comprised 4,465 participants, with BP measured at baseline in the Tromsø Study, Wave 6 in 2007–2008 (T0), and cognition assessed at follow-up 8 years later, in 2015–2016 in Tromsø Study 7 (T1). Age at T0 was 45–74 years, and at T1 it was 53–82 years. Cognition was assessed with three tests: The Mini Mental State Examination (MMSE), the Digit Symbol Test, and the Twelve-word Test. The associations between BP and cognition were examined specifically for age and sex using linear regression analysis adjusted for baseline BP medication use, education and body mass index (kg/m²).

Results

BP was associated with cognition at the 8-year follow-up, but the association differed according to age and sex. In men, higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) at a young age (45–55 years of age) was associated with poorer cognition; the association was reversed at older ages, especially for those above 65 years of age. In women, the associations were generally weaker than for men, and sometimes in the opposite direction: For women, a higher SBP was associated with better cognition at a younger age and higher SBP poorer cognition at older ages – perhaps due to an age delay in women compared to men. Digit Symbol Test results correlated best with BP in a three-way interaction: BP by age by sex was significant for both SBP (p = 0.005) and DBP (p = 0.005).

Conclusion

Increased SBP and DBP at the younger age was clearly associated with poorer cognitive function in men 8 years later; in women the associations were weaker and sometimes in the opposite direction. Our findings clearly indicate that interactions between age and sex related to BP can predict cognitive performance over time. Men and women have different age trajectories regarding the influence of BP on cognition.

Pressure and Flow Relations in the Systemic Arterial Tree Throughout Development From Newborn to Adult

Objective: Distributed models of the arterial tree allow studying the effect of physiological and pathophysiological changes in the vasculature on hemodynamics. For the adult, several models exist; however, a model encompassing the full age range from newborn to adult was until now lacking. Our goal is to describe a complete distributed hemodynamic model for normal development from newborn to adult. Methods: The arterial system was modeled by 121 segments characterized by length, radius, wall thickness, wall stiffness, and wall viscosity. The final segments ended in three-element Windkessels. All parameters were adapted based on body height and weight as a function of age as described in the literature. Results: Pressures and flows are calculated as a function of age at sites along the arterial tree. Central to peripheral transfer functions are given. Our results indicate that peripheral pressure in younger children resembles central pressure. Furthermore, total arterial compliance, inertance and impedance are calculated. Findings indicate that the arterial tree can be simulated by using a three-element Windkessel system. Pulse wave velocity in the aorta was found to increase during development. Conclusions: The arterial system, modeled from newborn to adult bears clinical significance, both for the interpretation of peripheral measured pressure in younger and older children, and for using a Windkessel model to determine flow from pressure measurements.

Central hemodynamic characteristics of young adults with isolated systolic hypertension: an ambulatory blood pressure monitoring-based study of real-world clinical patients

The central hemodynamic characteristics of young adults with isolated systolic hypertension (ISH) remain controversial, particularly regarding the extent of pulse pressure amplification (PPamp) compared with that of normotensives (NTs). Given the lack of ambulatory blood pressure monitoring (ABPM)-based data, this study evaluated 509 untreated young adults (18-35 years) who had undergone ABPM during the last decade, 109 who had undergone both ABPM and SphygmoCor analysis, and 26 newly recruited NTs. The agreement rate between office BP- and ABPM-based subtype classification was alarmingly low (50.7%). ISH was distinguishable from systolic-diastolic hypertension, the predominant subtype characterized by increased central BPs and stiffened arteries. The central hemodynamic parameters were all similar between patients with ISH and white-coat hypertension (WC). ISH patients had central BPs that were, albeit higher than those of NTs, at an upper-normal level that was comparable to those of WC patients. ISH patients had similar cfPWV but significantly higher PPamp than NTs (p = 0.032). The central hemodynamic parameters of the participants were further analyzed according to central pressure waveform types (A vs. B vs. C). Type C waves were associated with the highest PPamp and lowest cfPWV, whereas type A waves were associated with the lowest PPamp and highest cfPWV. Subjects with type B waves, an intermediate form, also had considerably high PPamps. Waveform composition differed significantly across hypertension subtypes (p < 0.001). ISH patients mostly had type B or C waves (96.7%), with only 3.3% having type A waves. This study based on a refined diagnosis showed that the ambulatory ISH of young adults arises from highly elastic arteries and related robustness of PPamp and shares similar central hemodynamic characteristics with WC patients.

Central blood pressure and pulse wave velocity in young and middle-aged Japanese adults with isolated systolic hypertension

Isolated systolic hypertension (ISH), defined as systolic blood pressure (SBP) ≥140 mmHg and diastolic BP (DBP) <90 mmHg, is a common type of hypertension among young men. This study aimed to investigate the clinical characteristics, central blood pressure, and arterial stiffness of young and middle-aged Japanese individuals with ISH. A total of 432 male participants, aged 18-49 years, were classified into six subgroups: optimal BP (SBP <120 mmHg and DBP <80 mmHg), high-normal BP (SBP 120-129 mmHg and DBP <80 mmHg), high-BP (SBP 130-139 mmHg and/or DBP 80-89 mmHg), ISH (SBP ≥140 mmHg and DBP <90 mmHg), isolated diastolic hypertension (IDH) (SBP <140 mmHg and DBP ≥90 mmHg), and systolic and diastolic hypertension (SDH) (SBP ≥140 mmHg and DBP ≥90 mmHg). Participants with ISH had a greater body mass index (BMI) and waist circumference than the optimal BP participants but were more likely to be physically active than the IDH and SDH participants. The central SBP of the ISH subgroup was higher than that of the optimal/high-normal/high-BP subgroups and lower than that of the SDH subgroup. The carotid-femoral pulse wave velocity (cfPWV) of the ISH subgroup was higher than that of the optimal and high-normal BP subgroups and lower than that of the SDH subgroup after adjusting for age, heart rate, BMI, and physical activity. These differences disappeared after further adjustment for central mean arterial pressure. In conclusion, the central SBP of Japanese men with ISH was greater than that of Japanese men with optimal/high-normal/high-BP, but the progression of arterial stiffness was unclear.

Isolated systolic hypertension in the young: a position paper endorsed by the European Society of Hypertension

: Whether isolated systolic hypertension in the young (ISHY) implies a worse outcome and needs antihypertensive treatment is still a matter for dispute. ISHY is thought to have different mechanisms than systolic hypertension in the elderly. However, findings from previous studies have provided inconsistent results. From the analysis of the literature, two main lines of research and conceptualization have emerged. Simultaneous assessment of peripheral and central blood pressure led to the identification of a condition called pseudo or spurious hypertension, which was considered an innocent condition. However, an increase in pulse wave velocity has been found by some authors in about 20% of the individuals with ISHY. In addition, obesity and metabolic disturbances have often been documented to be associated with ISHY both in children and young adults. The first aspect to consider whenever evaluating a person with ISHY is the possible presence of white-coat hypertension, which has been frequently found in this condition. In addition, assessment of central blood pressure is useful for identifying ISHY patients whose central blood pressure is normal. ISHY is infrequently mentioned in the guidelines on diagnosis and treatment of hypertension. According to the 2013 European Guidelines on the management of hypertension, people with ISHY should be followed carefully, modifying risk factors by lifestyle changes and avoiding antihypertensive drugs. Only future clinical trials will elucidate if a benefit can be achieved with pharmacological treatment in some subgroups of ISHY patients with associated risk factors and/or high central blood pressure.

Evaluation of inert gas rebreathing for determination of cardiac output: influence of age, gender and body size

The aim of this study was to evaluate an inert gas rebreathing method (Innocor) for measurement of cardiac output and related haemodynamic variables and to provide robust normative data describing the influence of age, gender and body size on these variables. Four separate studies were conducted: measurement repeatability (study 1, n = 45); postural change (study 2, n = 40); response to submaximal cycling exercise (study 3, n = 20); and the influence of age, gender and body size (study 4, n = 1400). Repeated measurements of cardiac output, stroke volume and heart rate were similar, with low mean (±SD) differences (0.26 ± 0.53 L/min, 0 ± 11 mL and 2 ± 6beats/min, respectively). In addition, cardiac output and stroke volume both declined progressively from supine to seated and standing positions (P < 0.001 for both) and there was a stepwise increase in both parameters moving from rest to submaximal exercise (P < 0.001 for both). In study 4, there was a significant age-related decline in cardiac output and stroke volume in males and females, which remained significant after adjusting for body surface area (BSA, P < 0.001 for all comparisons). Both parameters were also significantly higher in those with high body mass index (BMI; P < 0.01 versus those with normal BMI for all comparisons), although indexing cardiac output and stroke volume to BSA reversed these trends. Inert gas rebreathing using the Innocor device provides repeatable measurements of cardiac output and related indices, which are sensitive to the effects of acute physiological manoeuvres. Moreover, inert gas rebreathing is a suitable technique for examining chronic influences such as age, gender and body size on key haemodynamic components of the arterial blood pressure.

2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension

: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.

Isolated systolic hypertension of the young and its association with central blood pressure in a large multi-ethnic population. The HELIUS study

Background

Isolated systolic hypertension (ISH) of the young has been associated with both normal and increased cardiovascular risk, which has been attributed to differences in central systolic blood pressure and arterial stiffness.

Methods

We assessed the prevalence of ISH of the young and compared differences in central systolic blood pressure and arterial stiffness between ISH and other hypertensive phenotypes in a multi-ethnic population of 3744 subjects (44% men), aged <40 years, participating in the HELIUS study.

Results

The overall prevalence of ISH was 2.7% (5.2% in men and 1.0% in women) with the highest prevalence in individuals of African descent. Subjects with ISH had lower central systolic blood pressure and pulse wave velocity compared with those with isolated diastolic or systolic-diastolic hypertension, resembling central systolic blood pressure and pulse wave velocity values observed in subjects with high-normal blood pressure. In addition, they had a lower augmentation index and larger stroke volume compared with all other hypertensive phenotypes. In subjects with ISH, increased systolic blood pressure amplification was associated with male gender, Dutch origin, lower age, taller stature, lower augmentation index and larger stroke volume.

Conclusion

ISH of the young is a heterogeneous condition with average central systolic blood pressure values comparable to individuals with high-normal blood pressure. On an individual level ISH was associated with both normal and raised central systolic blood pressure. In subjects with ISH of the young, measurement of central systolic blood pressure may aid in discriminating high from low cardiovascular risk.

Isolated Systolic Hypertension in Young and Middle-Aged Adults

Young and middle-aged adults (ages ≤50 years) are increasingly prone to stroke, kidney disease, and worsening cardiovascular disease (CVD) mortality. An alarming increase in the prevalence of high blood pressure (BP) may underlie the adverse trend. However, there is often uncertainty in BP management for young and middle-aged adults. Isolated systolic hypertension (ISH) is one such example. Whether ISH in young and middle-aged adults represents "pseudo" or "spurious" hypertension is still being debated. ISH in young and middle-aged adults is a heterogeneous entity; some individuals appear to have increased stroke volume, whereas others have stiffened aortae, or both. One size does not seem to fit all in the clinical management of ISH in young and middle-aged adults. Rather than treating ISH as a monolithic condition, detailed phenotyping of ISH based on (patho)physiology and in the context of individual global cardiovascular risks would seem to be most useful to assess an individual expected net benefit from therapy. This review provides an overview of the current understanding of ISH in young and middle-aged adults, including the prevalence, pathophysiology, and treatment.

Prevalence of Hypertension Defined by Central Blood Pressure Measured Using a Type II Device in a Nationally Representative Cohort

OBJECTIVES

Central blood pressure (BP) can be used to define hypertension. A central BP approach may be more sensitive than a conventional brachial BP approach in detecting hypertension. We aimed to compare the 2 approaches in estimating the prevalence hypertension in a nationally representative population.

METHODS

A total of 2,742 adults older than 19 years participated in the 2013-2016 National Nutrition and Health Survey in Taiwan. Central and brachial BP were simultaneously measured using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device). Central hypertension was defined by central systolic (SBP)/diastolic BP (DBP) ≥130 or 90 mm Hg or using antihypertensive medications, and brachial hypertension was defined by brachial SBP/DBP ≥140 or 90 mm Hg or using antihypertensive medications.

RESULTS

The World Health Organization-standardized and national weighted prevalence rates of central hypertension were 27.95% and 32.48%, respectively, and both were significantly higher than those of brachial hypertension (20.80% and 25.43%, both P < 0.001). The national weighted prevalence rates of concordant central and brachial hypertension, concordant central and brachial nonhypertension, isolated central hypertension, and isolated brachial hypertension were 25.13%, 67.22%, 7.35%, and 0.30%, respectively. Most subjects with the isolated central hypertension (97%) were within the range of brachial prehypertension, but only 38.0% of subject with brachial prehypertension had central hypertension.

CONCLUSION

Almost one-third of a nationally representative population had hypertension detected by a central BP approach. Hypertension detection using a conventional brachial BP approach may underestimate the prevalence of hypertension and result in a less effective hypertension control.

Hemodynamic and Mechanical Properties of the Proximal Aorta in Young and Middle-Aged Adults With Isolated Systolic Hypertension: The Dallas Heart Study

The aim of this study was to assess characteristic impedance (Z_c) of the proximal aorta in young and middle-aged individuals with isolated systolic hypertension (ISH). Z_c is an index of aortic stiffness relative to aortic size. In the Dallas Heart Study, 2001 untreated participants 18 to 64 years of age (mean age: 42.3 years; 44% black race) were divided into the following groups based on office blood pressure (BP) measurements: (1) optimal BP (systolic BP [SBP] <120 mm Hg and diastolic BP [DBP] <80 mm Hg; n=837); (2) prehypertension (SBP 120-139 mm Hg and DBP 80-89 mm Hg; n=821); (3) ISH (SBP ≥140 mm Hg and DBP <90 mm Hg; n=121); (4) isolated diastolic hypertension (SBP <140 mm Hg and DBP ≥90 mm Hg; n=44); and (5) systolic-diastolic hypertension (SBP ≥140 mm Hg and DBP ≥90 mm Hg; n=178). Z_c, aortic arch pulse wave velocity, and minimum ascending aortic size were quantified using cardiovascular magnetic resonance. In multivariable-adjusted linear models, Z_c was highest in the ISH group compared with the optimal BP, isolated diastolic hypertension, or systolic-diastolic hypertension groups (103.2±4.0 versus 68.3±2.1, 75.4±6.0, and 88.9±4.8 dyne*seconds/cm⁵, respectively; all P<0.05). The Z_c-ISH association did not differ by race. Aortic pulse wave velocity was highest in the ISH group compared with the optimal BP, isolated diastolic hypertension, or systolic-diastolic hypertension groups (6.3±0.3 versus 4.3±0.1, 4.4±0.4 and 5.5±0.3 m/s, respectively; all P<0.05), whereas aortic size was similar across groups (all P>0.2). Results were similar in a subgroup of 1551 participants 18 to 49 years of age. In a multiracial population-based sample, we found evidence of a mismatch between proximal aortic stiffness and diameter in young and middle-aged adults with ISH.

Isolated Systolic Hypertension in Young Individuals: Pathophysiological Mechanisms, Prognostic Significance, and Clinical Implications

Isolated systolic hypertension (ISH) is the most common form of hypertension in older persons and its predictive value for adverse outcome is well known. However, ISH can be frequently found also in young individuals, especially among males, but its prognostic significance in this setting is still controversial. Increased large artery stiffness is the main determinant of ISH in elderly patients whereas the mechanisms that lead to ISH in the young are still debated. According to some authors ISH in youth is a totally benign condition that can be called "spurious hypertension" a phenomenon due to enhanced pulse pressure amplification of the pulse wave from central to peripheral sites. According to others the main determinant of ISH in young individuals is increased sympathetic activity and the consequent hyperkinetic state characterized by elevated heart rate and stroke volume. This phenomenon is often amplified by a powerful alarm reaction to the medical visit. However, recent research has shown that ISH in the young is a heterogeneous condition and that in some individuals also increased arterial stiffness can play a role. Although ISH seems to be a benign condition chiefly in young men, only few longitudinal data assessing the association with adverse outcomes are available. Future studies with long term follow-up are needed to better understand the clinical significance of this condition.