Distinctive Risk Factors and Phenotype of Younger Patients With Resistant Hypertension: Age Is Relevant

Associations and attributable burden between risk factors and all-cause and cause-specific mortality at different ages in patients with hypertension

It remains unclear the age-specific associations of risk factors with deaths and mortality burden attributable across age. In a territory-wide retrospective cohort, 1,012,228 adults with hypertension were identified. Comorbidities including diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), heart failure, and cancer, and risk factors including current smoking and suboptimal control of blood pressure (BP), glucose and low-density lipoprotein cholesterol were defined. Associations of comorbidities/risk factors with all-cause and cause-specific mortality across age groups (18-54, 55-64, 65-74, and ≥75 years) were assessed. Population attributable fractions were also quantified. During a median follow-up of 10.7 years, 244,268 (24.1%) patients died, with pneumonia (7.2%), cancer (5.1%), and CVD (4.2%) being the leading causes. Despite increasing deaths with age, relative risk of mortality related to comorbidities/risk factors decreased with age; similar patterns were found for cause-specific mortality. The assessed risk factors accounted for 24.0% (95% CI 22.5%, 25.4%) deaths, with highest proportion in the youngest group (33.5% [28.1%, 38.5%] in 18-54 years vs 19.4% [17.0%, 21.6%] in ≥75 years). For mortality burden, CKD was the overall leading risk factor (12.7% [12.4%, 12.9%]) with higher proportions in older patients (11.1-13.1% in ≥65 years), while diabetes was the leading risk factor in younger patients (15.9-13.5% in 18-54 years). The association of comorbidities or risk factors with mortality is stronger in younger patients with hypertension, despite lower absolute mortality in young patients than in the elderly. Leading risk factors differed across age, highlighting the importance of targeted and precise risk management.

Concurrent dietary intake to nitrate, thiocyanate, and perchlorate is negatively associated with hypertension in adults in the USA

We aimed to comprehensively evaluate the association of urinary nitrate, thiocyanate, and perchlorate metabolites with hypertension among a nationally representative sample of the US adult population. This cross-sectional study investigated data from 15,717 adults aged more than 20 years obtained from the National Health and Nutritional Examination Survey (NHANES) for the years 2005-2016. In the survey, urinary levels of nitrate, thiocyanate, and perchlorate were measured using ion chromatography combined with electrospray tandem mass spectrometry. Blood pressure was calculated as the mean of three measurements. Hypertension was defined as (a) systolic BP ≥130 and/or diastolic BP ≥80 mmHg and/or (b) self-report. Multivariate logistic regression and weighted quantile sum (WQS) regression models were applied to estimate the association between exposure to multiple inorganic anions and hypertension. Restricted cubic spline (RCS) regressions were fitted to discern the potential relationship between the anion exposure and hypertension. These innovation methods used to support our results. Overall, 7533 (49.95%) people with and 7638 (50.35%) without hypertension were included in this study. In the multivariable-adjusted logistic regression models, urinary nitrate (P < 0.001) and perchlorate (P < 0.001) were independently negatively associated with increased occurrence of hypertension, while urinary thiocyanate was insignificantly associated with hypertension (P = 0.664). The WQS regression index showed that, in combination, the three inorganic anions mixture were negatively correlated with hypertension (adjusted OR 0.89; 95% CI 0.83-0.95, P < 0.001). Urinary nitrate was the most heavily weighted component in the hypertension model (weight = 0.784). RCS regression demonstrated that nitrate (nonlinearity P = 0.205) and perchlorate (nonlinearity P = 0.701) were linearly associated with decreased occurrence of hypertension. Concurrent exposure to nitrate, thiocyanate, and perchlorate is associated with a decreased risk of hypertension, with the greatest influence coming from nitrate probably; urinary specific thiocyanate alone had an insignificant association with hypertension.

Identifying drug-related attributes to personalise antihypertensive agents: the outcome report of patients receiving metoprolol therapy

Background

Currently, numerous antihypertensive drugs from different pharmacological classes are available; however, blood pressure control is achieved in only less than a third of patients treated for hypertension. Moreover, providing optimal and personalised treatment for hypertension is challenging. Therefore, in this study, we propose a ‘drug-related attributes’ sensitive spectrum. This novel concept can assist clinicians in selecting an optimal antihypertensive drug and improve blood pressure control after examining the attributes of a patient.

Methods

We collected clinical data on attributes related to hypertension and its therapy of inpatients from West China Hospital who received metoprolol therapy and constructed the sensitive spectrum using data-visualisation tools.

Results

Our analysis revealed that haematocrit, haemoglobin, serum creatinine, serum cystatin C, serum urea, age, sex, systolic pressure, diastolic pressure, pulse pressure, and heart rate are metoprolol-related attributes.

Conclusion

Our study showed that all metoprolol-related attributes identified are reasonable and helpful in improving the personalisation of metoprolol therapy. The proposed drug-related attributes spectrum can help personalise antihypertensive medication. Moreover, data-visualisation tools can be effectively used to mine the drug-related attributes sensitive spectrum.

Conicity index in people with hypertension followed in the Brazil's Family Health Strategy

OBJECTIVES

to analyze the conicity index in people with hypertension followed in the Brazil's Family Health Strategy.

METHODS

cross-sectional study conducted in a medium-sized municipality located in the state of Paraná. Data collection took place in the first semester of 2016. using an adapted and validated instrument. which addresses attributes of Primary Health Care. Sociodemographic and anthropometric variables and blood pressure were used in the study. The analysis of variance and linear regression was used to analyze the variables.

RESULTS

a total of 417 people participated in the study. most were women. elderly. married. with less than eight years of education and retired. Conicity index was prevalent in most of the study population. being significantly associated with the group of people with inadequate blood pressure control and high anthropometric parameters.

CONCLUSIONS

most of the study participants had altered conicity index. especially those with inadequate blood pressure control.

Characterizing the critical features when personalizing antihypertensive drugs using spectrum analysis and machine learning methods

Globally, methods of controlling blood pressure in hypertension patients remain inefficient. The difficulty of prescribing appropriate drugs specific to a patient's clinical features serves as one of the most important factors. Characterizing the critical drug-related features, just like that of the antibacterial spectrum (where each item is sensitive to the targeted drug's effectiveness or a specified indication), may help a doctor easily prescribe appropriate drugs by matching a patient's attributes with drug-related features, and effectiveness of the selected drugs would also be ascertained. In this study, we aimed to apply data mining methods to obtain the clinical characteristics spectrum or important clinical features of five frequently used drugs (Irbesartan, Metoprolol, Felodipine, Amlodipine, and Levamlodipine) for hypertension control by comparing successful and unsuccessful cases. Spectrum analysis based on a statistical method and five algorithms based on machine learning were used to extract the critical clinical features. A visualized relative weight matrix was then achieved by combining the results from the characteristic spectrum and machine learning-based methods. Our results indicated that the five targeted antihypertension agents had different importance orders of the 15 relative clinical features. Clinical analysis showed that the extracted important clinical attributes of the five drugs were both reasonable and meaningful in the selection of hypertension treatment. Therefore, our study provided a data-driven reference for the personalization of clinical antihypertensive drugs.

Apparent treatment-resistant hypertension: characteristics and prevalence in a real-world environment of an integrated health system

OBJECTIVES

We compared the prevalence of apparent treatment-resistant hypertension (aTRH) according to the seventh report of the Joint National Committee (JNC 7) and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline in an integrated healthcare delivery system.

METHODS

We identified individuals aged at least 18 years with hypertension from Kaiser Permanente Southern California between 1 July 2014 and 30 June 2015. aTRH was defined as either blood pressure (BP) above goal (≥140/90 mmHg per JNC7, and ≥130/80 mmHg per 2017 ACC/AHA for most adults with hypertension) while taking at least 3 classes of antihypertensive medication or taking at least four classes regardless of BP level. A secondary analysis was conducted requiring use of a diuretic for the definition of aTRH. Patient clinical characteristics and antihypertensive medication use were described using electronic health records.

RESULTS

We included 469 509 patients with treated hypertension [mean (SD) age 65 years (12), 46% white, 26% Hispanic, 13% black, and 12% Asian]. The prevalence of aTRH was 16.9 and 21.8% according to the JNC 7 and the 2017 ACC/AHA guidelines, respectively [Δ = 4.9% (95% CI: 4.7--5.1%)]. By requiring a diuretic to be considered as aTRH, the prevalence of aTRH decreased to 13.4 and 17.2% according to the JNC 7 and the 2017 ACC/AHA guidelines, respectively. Among patients with aTRH, 1.9% received a long-acting thiazide-like diuretic, and 5.6% received a mineralocorticoid receptor blocker.

CONCLUSION

The prevalence of aTRH increased using the more stringent BP goals of the 2017 ACC/AHA guideline. The use of recommended therapy for aTRH was suboptimal suggesting a potential area for improvement.

Natural selection and local adaptation of blood pressure regulation and their perspectives on precision medicine in hypertension

Prevalence of hypertension (HTN) varies substantially across different populations. HTN is not only common - affecting at least one third of the world's adult population - but is also the most important driver for cardiovascular diseases. Yet up to a third of hypertensive patients are resistant to therapy, contributed by secondary hypertension but more commonly the hitherto inability to precisely predict response to specific antihypertensive agents. Population and individual genomics information could be useful in guiding the selection and predicting the response to treatment - an approach known as precision medicine. However this cannot be achieved without the knowledge of genetic variations that influence blood pressure (BP). A number of evolutionary factors including population demographics and forces of natural selection may be involved. This article explores some ideas on how natural selection influences BP regulation in ethnically and geographically diverse populations that could lead to them being susceptible to HTN. We explore how such evolutionary factors could impact the implementation of precision medicine in HTN. Finally, in order to ensure the success of precision medicine in HTN, we call for more initiatives to understand the genetic architecture within and between diverse populations with ancestry from different parts of the world, and to precisely classify the intermediate phenotypes of HTN.

Resistant hypertension: Renal denervation or intensified medical treatment?

Resistant hypertension (RH) can be diagnosed if blood pressure (BP) is not controlled with the combination of three antihypertensive drugs, including a diuretic, all at effective doses. Patients affected by this condition exhibit a marked increase in the risk of cardiovascular and renal morbid and fatal events. They also exhibit an increased activity of the sympathetic nervous system which is likely to importantly contribute at the renal and other vascular levels to the hypertensive state. Almost 10years ago renal denervation (RDN) by radiofrequency thermal energy delivery to the walls of the renal arteries was proposed for the treatment of RH. Several uncontrolled studies initially reported that this procedure substantially reduced the elevated BP values but this conclusion has not been supported by a recent randomized control trial, which has almost marginalized this therapeutic approach. A revival, however, is under way because of recent positive findings and technical improvement that hold promise to make renal denervation more complete. The antihypertensive efficacy and overall validity of RDN will have to be tested against drug treatment of RH. Several studies indicate that an excess of aldosterone production contributes to RH and recent evidence documents indisputably that anti-aldosterone agents such as spironolactone can effectively control BP in many RH patients, although with some side effects that require close patients' monitoring. At present, it is advisable to treat RH with the addition of an anti-aldosterone agent. If BP control is not achieved or serious side effects become manifest RDN may then be considered.