Race and Sex Differences of Long-Term Blood Pressure Profiles From Childhood and Adult Hypertension: The Bogalusa Heart Study

Sex-Dependent Effects of CYP2D6 on the Pharmacokinetics of Berberine in Humans

An over-the-counter product berberine (a major alkaloid in goldenseal) is a substrate of the uptake transporter OCT1 and the metabolizing enzyme CYP2D6. The two genes exhibit common functional polymorphisms. Approximately 9% of Europeans and white Americans are either poor CYP2D6 metabolizers or poor OCT1 transporters. In this study, we investigated the effects of OCT1 and CYP2D6 polymorphisms on berberine pharmacokinetics in humans. We confirmed in vitro that berberine is an OCT1 substrate (KM of 7.0 μM, CLint of 306 ± 29 μL/min/mg). Common OCT1 alleles *3 to *6 showed uptake reduced by at least 65% and Oct1/2 knockout mice showed 3.2-fold higher AUCs in liver perfusion experiments. However, in humans, poor OCT1 transporters did not show any differences in berberine pharmacokinetics compared with reference participants. In contrast, CYP2D6 polymorphisms significantly affected berberine metabolism, but exclusively in females. Females who were poor CYP2D6 metabolizers had an 80% lower M1-to-berberine ratio. General linear model analyses suggest strong synergistic, rather than additive, effects between female sex and CYP2D6 genotype. Overall, berberine displayed low oral bioavailability, yet females had a 2.8-fold higher AUC and a 3.6-fold higher Cmax than males (P < 0.001). These effects were only partially attributable to the sex-CYP2D6 genotype interaction. In conclusion, despite berberine being an OCT1 substrate, OCT1 deficiency did not affect berberine pharmacokinetics in humans. In contrast, CYP2D6 emerges as a critical enzyme for berberine metabolism in females, but not in males, highlighting sex-specific differences. We suggest that factors beyond CYP2D6 metabolism are determining berberine's systemic exposure, especially in males (NCT05463003).

Blood Pressure Trajectories During Young Adulthood and Cardiovascular Events in Later Life

BACKGROUND

Studying the association between blood pressure (BP) trajectories during young adulthood and subsequent cardiovascular disease (CVD) risk can provide insights into how long-term BP patterns in early-life influence the development of CVD later in life.

METHODS

We pooled data from 2 US cohorts (Coronary Artery Risk Development in Young Adults, Framingham Heart Study). We used latent growth curve models to identify distinct BP trajectory groups between ages 18 and 39 years. We then used Cox proportional hazards models to assess the associations between BP trajectories and CVD events (composite of coronary heart disease [CHD], stroke, and heart failure [HF]) after age 40 years.

RESULTS

We included 6,579 participants and identified 4 distinct systolic BP (SBP) trajectory groups during young adulthood. During a median follow-up of 18.2 years after age 40 years, 213 CHD, 139 stroke, 120 HF, and 400 composite CVD events occurred. Individuals in an elevated-increasing vs. low-stable SBP trajectory during young adulthood were associated with a higher risk of CVD after adjusting for traditional CVD risk factors, with hazard ratios (95% confidence interval) of 3.25 (1.63, 6.46) for CHD, 3.92 (1.63, 9.43) for stroke, 8.30 (2.97, 23.17) for HF, and 3.91 (2.38, 6.41) for composite CVD outcomes. Adding BP trajectory to BP at baseline improved model discrimination for all outcomes (changes in Harrell's C-index 0.0084-0.0192).

CONCLUSIONS

An elevated-increasing BP trajectory during young adulthood is associated with a higher risk of CVD later in life, highlighting the importance of maintaining a low-stable BP trajectory throughout the young adulthood period for prevention of CVD in later life.

Hypertension in children and adolescents: perspectives in Japan

Hypertension in children and adolescents is associated with increased risk of hypertension and cardiovascular disease (CVD) in adulthood. Therefore, preventing hypertension among children and adolescents is an important public health objective worldwide. Although the importance of hypertension in children and adolescents has increasingly been recognized, the field of research is relatively new and evidence for etiologies, prevention and treatment is sparse. This review mainly summarizes the content regarding hypertension in children and adolescents published in Hypertension Research in 2023/24. Highlights include the following: The prevalence of hypertension was higher in female than male Japanese junior high school students (13.7% vs. 4.7%), but there was no significant gender difference among Japanese senior high school students (7.4% vs. 5.4%). Hematological parameters, including red blood cell counts, hemoglobin counts, hematocrit and iron levels, were positively associated with blood pressure (BP) levels in healthy children and adolescents. Higher-risk longitudinal BP trajectories in early life were associated with increased risk of target organ damage (TOD) and higher combined TOD load in midlife. BP phenotypes (e.g., masked hypertension, white-coat hypertension) assessed using office and 24-h ambulatory BP monitoring were not highly reproducible in children. The salt check sheet was a useful tool for evaluating the approximate dietary salt intake in Japanese children and adolescents. It is recommended that healthcare providers screen for hypertension in children and adolescents and recognize the importance of early intervention for those with elevated BP levels. Beginning in childhood, continuous education on hypertension and proper dietary salt intake are key to reducing the risk of hypertension and decreasing the burden of CVD in adulthood.

Sex disparities in hypertension prevalence, blood pressure trajectories and the effects of anti-hypertensive treatment

INTRODUCTION

Sex differences in blood pressure (BP), hypertension and hypertension mediated cardiovascular complications have become an increasingly important focus of attention. This narrative review gives an overview of current studies on this topic, with the aim to provide a deeper understanding of the sex-based disparities in hypertension with essential insights for refining prevention and management strategies for both men and women.

METHODS AND RESULTS

We searched Medline, Embase and the Cochrane libray on sex differences in BP-trajectories and hypertension prevalence. In the past decade various population-based studies have revealed substantial sex-disparities in BP-trajectories throughout life with women having a larger increase in hypertension prevalence after 30 years of age and a stronger association between BP and cardiovascular disease (CVD). In general, the effects of antihypertensive treatment appear to be consistent across sexes in different populations, although there remains uncertainty about differences in the efficacy of BP lowering drugs below 55 years of age.

CONCLUSION

The current uniform approach to the diagnosis and management of hypertension in both sexes neglects the distinctions in hypertension, while the differences underscore the need for sex-specific recommendations, particularly for younger individuals. A major limitation hampering insights into sex differences in BP-related outcomes is the lack of sex-stratified analyses or an adequate representation of women. Additional large-scale, longitudinal studies are imperative.

High-intensity interval training for improving cardiometabolic health in children and adolescents: An umbrella review of systematic reviews

High-intensity interval training (HIIT) is an emerging exercise strategy to improve health and fitness, but previous studies have evaluated HIIT interventions across different populations and outcomes. This review aimed to comprehensively synthesize published evidence on the effects of HIIT on key cardiometabolic health parameters in children and adolescents. We searched seven databases until February 2024. Systematic reviews were eligible if they 1) compared HIIT and active/non-active control conditions with meta-analysis, 2) examined cardiorespiratory fitness, body composition and cardiometabolic risk biomarkers, and 3) examined children and adolescents. We included 18 systematic reviews with meta-analysis, including 223 original studies and 13,900 unique participants. HIIT is effective for cardiorespiratory fitness in children and adolescents with diverse health and weight status (median standardized mean difference [SMD] = 0.75). Improvements in body composition and several cardiometabolic risk biomarkers, including systolic blood pressure (median SMD = -0.40), diastolic blood pressure (median SMD = -0.22), triglyceride (median SMD = -0.30), low-density lipoprotein cholesterol (median SMD = -0.90), and high-density lipoprotein cholesterol (median SMD = 0.34), have also been observed following HIIT, with a notably more pronounced effect in youth with overweight/obesity or metabolic disorders. Our umbrella review supports the effectiveness of HIIT in enhancing cardiometabolic health, suggesting its integration into physical activity promotion programmes in schools and communities.

Sex Differences in Hypertension and Its Management Throughout Life

BACKGROUND

The prevalence of hypertension and uncontrolled hypertension may differ by age and sex.

METHODS

We included participants in the Atherosclerosis Risk in Communities study at seven study visits over 33 years (visit 1: 15 636 participants; mean age, 54 years; 55% women), estimating sex differences in prevalence of hypertension (systolic blood pressure ≥130 mm Hg; diastolic blood pressure ≥80 mm Hg; or self-reported antihypertension medication use) and uncontrolled hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) using unadjusted and comorbidity-adjusted models.

RESULTS

The prevalence of hypertension increased with age from 40% (ages, 43-46 years) to 93% (ages, 91-94 years). Within hypertensive individuals, the prevalence of uncontrolled hypertension was higher in men (33%) than women (23%) at ages 43 to 46 years but became higher in women than men starting at ages 61 to 64, with 56% of women and 40% men having uncontrolled hypertension at ages 91 to 94. This sex difference was not explained by differences in coronary heart disease, diabetes, body mass index, estimated glomerular filtration rate, number of antihypertension medications, classes of medications, or adherence to medications. In both sexes, uncontrolled hypertension was associated with a higher risk for chronic kidney disease progression (hazard ratio, 1.5 [1.2-1.9]; P=4.5×10-4), heart failure (hazard ratio, 1.6 [1.4-2.0]; P=8.1×10-7), stroke (hazard ratio, 2.1 [1.6-2.8]; P=1.8×10-8), and mortality (hazard ratio, 1.5 [1.3-1.6]; P=6.2×10-19).

CONCLUSIONS

Sex differences in the prevalence of hypertension and uncontrolled hypertension vary by age, with the latter having implications for health throughout the life course.

Pediatric Blood Pressure and Cardiovascular Health in Adulthood

PURPOSE OF REVIEW

This review summarizes current knowledge on blood pressure in children and adolescents (youth), with a focus on primary hypertension-the most common form of elevated blood pressure in this demographic. We examine its etiology, progression, and long-term cardiovascular implications. The review covers definitions and recommendations of blood pressure classifications, recent developments in measurement, epidemiological trends, findings from observational and clinical studies, and prevention and treatment, while identifying gaps in understanding and suggesting future research directions.

RECENT FINDINGS

Youth hypertension is an escalating global issue, with regional and national variations in prevalence. While the principles of blood pressure measurement have remained largely consistent, challenges in this age group include a scarcity of automated devices that have passed independent validation for accuracy and a generally limited tolerance for ambulatory blood pressure monitoring. A multifaceted interplay of factors contributes to youth hypertension, impacting long-term cardiovascular health. Recent studies, including meta-analysis and sophisticated life-course modelling, reveal an adverse link between youth and life-course blood pressure and subclinical cardiovascular outcomes later in life. New evidence now provides the strongest evidence yet linking youth blood pressure with clinical cardiovascular events in adulthood. Some clinical trials have expanded our understanding of the safety and efficacy of antihypertensive medications in youth, but this remains an area that requires additional attention, particularly regarding varied screening approaches. This review outlines the potential role of preventing and managing blood pressure in youth to reduce future cardiovascular risk. A global perspective is necessary in formulating blood pressure definitions and strategies, considering the specific needs and circumstances in low- and middle-income countries compared to high-income countries.

Achieving Equity in Hypertension: A Review of Current Efforts by the American Heart Association

The purpose of this article is to summarize disparities in blood pressure (BP) by race in the United States, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association BP equity initiatives, and highlight missed opportunities for achieving equity in hypertension. Over 122 million American adults have hypertension, with the highest prevalence among Black Americans. Racial disparities in hypertension and BP control in the United States are estimated to be the single largest contributor to the excess risk for cardiovascular disease among Black versus White adults. Worsening disparities in cardiovascular disease and life expectancy during the COVID-19 pandemic warrant an evaluation of the strategies and opportunities to increase equity in BP in the United States. Racial disparities in hypertension are largely driven by systemic inequities that limit access to quality education, economic opportunities, neighborhoods, and health care. To address these root causes, recent studies have evaluated evidence-based strategies, including community health workers, digital health interventions, team-based care, and mobile health care to enhance access to health education, screenings, and BP care in Black communities. In 2021, the American Heart Association made a $100 million pledge and 10 commitments to support health equity. This commitment included implementing multifaceted interventions with a focus on hypertension as a seminal risk factor contributing to disparities in cardiovascular disease mortality and morbidity. The American Heart Association is one organizational example of advocacy for equity in BP. Achieving equity nationwide will require sustained collaboration among individual stakeholders and public, private, and community organizations to address barriers across multiple socioecological levels.

Defining childhood hypertension: is it too complicated? An evaluation of the potential impact of different approaches in an Australian paediatric population

OBJECTIVES

Current American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) thresholds defining hypertension in children use blood pressure (BP) normalised to age, sex and height. However, scare data exists regarding the relative importance of these variables to accurately model the 95th quantile of BP. We hypothesised that height alone may fit the population data equally well compared to more complex definitions. We also compare the potential impact of various thresholds for defining hypertension in an Australian population.

METHODS

Longitudinal data from the Raine Study were used, with 2248 participants contributing 7479 valid BP values across the 3/5/10/14/17-year study visits. BP was measured after 5 min rest, ≥3 times at each visit, using a Dinamap device. Quantile regression was used to predict the 95th percentile of BP, with nonlinear modelling of covariates through restricted cubic spline terms.

RESULTS

At a single visit, 6-16% of young children exceeded the ESH threshold and 12-23% the AAP threshold. The transition to fixed thresholds (≥13 years AAP, ≥16 years ESH), increased the number of males (AAP only) and reduced the number of females considered hypertensive. A quantile regression model constructed with Raine Study data using height-only as the explanatory variable better predicted BP than the respective model using age-only (or a combination of the two).

CONCLUSIONS

There may be large differences in the prevalence of hypertension according to AAP and ESH criteria, with a marked sex-discrepancy emerging from the point of fixed threshold application in adolescence. It may not be necessary to normalise BP by both age and height, the latter being a better predictor of childhood BP. Simpler methods may be preferable in clinical practice but require validation against clinical outcomes.

Secular trends in blood pressure among university students in Japan over the last two decades

High blood pressure (BP) increases the risk of cardiovascular disease, not only among middle-aged and older adults, but also in young adults. Early interventions for high BP may prevent future organ damage. Therefore, it is essential to monitor BP trends in young adults to support this approach. During the COVID-19 pandemic, a trend of increasing BP was observed worldwide. However, young adults have not been fully evaluated. Therefore, this study examined BP trends among university students (n = 106,691) over two decades, every 5 years from 2003 to 2023, including the period before and after the COVID-19 pandemic. From 2003 to 2018, there were no notable changes in BP. However, following the COVID-19 pandemic, increased BP was observed in both men and women, with systolic BP increasing from 118.1 (SD, 14.2) mmHg in 2018 to 120.6 (SD, 12.5) mmHg in 2023 among men, and from 104.6 (SD, 11.8) mmHg to 105.1 (SD, 11.7) mmHg among women. These trends were particularly pronounced among students with normal and underweight somatotypes and among first- and second-year students. The results of the lifestyle survey showed a decrease in smoking and drinking habits, insufficient sleep, mental stress, consumption of fast food and snacks, and an increase in exercise habits. Although contributing factors to the recent increase in BP were not identified, there was an upward trend in BP among Japanese university students. It is important to carefully observe how BP trends change over the long term following the end of the COVID-19 pandemic.

Improving Cardiovascular Disease Primary Prevention Treatment Thresholds in a New England Health Care System

Background

Atherosclerotic cardiovascular disease (ASCVD) risk estimation based on the pooled cohort equation (PCE) overestimates in population-based cohorts. Whether it performs equally across disaggregated demographics in health care populations is less known.

Objectives

The purpose of the study was to recalibrate PCE and rederive prevention thresholds in a contemporary health care system and evaluate its performance across sociodemographics.

Methods

We retrospectively inspected electronic health records between 2010 to 2012 and 2020 to 2022 within Mass General Brigham health care in New England region. We compared performance of the original vs recalibrated PCE measured by calibration, discrimination, reclassification rate, and net benefit among 160,926 patients aged 40 to 79 years and without prior ASCVD or lipid-lowering medication.

Results

Of the 160,926 patients (mean age: 54.6 ± 8.6 years; 61.4% female), 20,373 (12.7%) developed ASCVD over 10 years. The original PCE globally underestimated ASCVD risk (observed vs predicted incidence rate: 0.13 vs 0.05). Recalibration upclassified risk primarily among individuals with low-to-borderline risk by the original PCE and additionally identified 40% of patients who had undergone ASCVD events yet deemed statin-ineligible based on the original PCE. Treatment thresholds yielding the greatest net benefit were ≥24.0% for women (+23.3%) vs ≥26.0% for men (+18.7%), whereas ≥26.0% for White or other race (+24.7%) vs ≥14.0% Black or African American (+12.5%), respectively. Specifically, Hispanic or Latino and non-Hispanic Black patients conferred the greatest sensitivity improvement at ≥12.3% threshold compared to higher ≥23.6% among non-Hispanic Asian or Pacific Islanders. Generally, lower thresholds earlier in life were optimal.

Conclusions

Recalibration and personalized treatment thresholds derived within a health system may improve prevention treatment allocation efficiency.

Association of body composition with ambulatory blood pressure among Chinese youths

BACKGROUND

For youths, abnormalities in ambulatory blood pressure (ABP) patterns are known to be associated with increased cardiovascular disease risk and potential target organ damage. Body composition, including indicators such as lean mass index (LMI), fat mass index (FMI), and visceral fat level (VFL), plays a significant role in blood pressure (BP) regulation. However, little is known about the association between these body composition indicators and ABP. Therefore, the present study examined the association between these body composition indicators and BP among Chinese youths.

METHODS

A total of 477 college students aged 17 to 28 years old (mean ± Standard deviation = 18.96 ± 1.21) from a university in Changsha, Hunan Province, China, were included in this study. Body composition indicators were measured with a bioelectrical impedance body composition analyzer, and 24-hour ambulatory blood pressure monitoring (ABPM) was conducted. Multivariable logistic regression was performed to assess the relationship between body composition indicators and abnormal ABP.

RESULTS

The prevalence of abnormal BP, including 24-hour BP, daytime BP, nighttime BP, and clinic BP, were 4.8%, 4.2%, 8.6%, and 10.9%, respectively. After adjusting for potential covariates, LMI [abnormal 24-hour BP (OR = 1.85, 95%CI:1.31, 2.62), abnormal daytime BP (OR = 1.76, 95%CI:1.21, 2.58), abnormal nighttime BP (OR = 1.64, 95%CI:1.25, 2.14), abnormal clinic BP (OR = 1.84, 95%CI:1.38, 2.45)], FMI [abnormal 24-hour BP (OR = 1.20, 95%CI:1.02, 1.41), abnormal daytime BP (OR = 1.30, 95%CI:1.07, 1.57), abnormal nighttime BP (OR = 1.24, 95%CI:1.10, 1.39), abnormal clinic BP (OR = 1.42, 95%CI:1.22, 1.65)], and VFL [abnormal 24-hour BP (OR = 1.22, 95%CI:1.06, 1.39), abnormal daytime BP (OR = 1.29, 95%CI:1.10, 1.51), abnormal nighttime BP (OR = 1.24, 95%CI:1.12, 1.39), abnormal clinic BP (OR = 1.38, 95%CI:1.21, 1.57)] are positively linked to abnormal BP. Additionally, there were significant sex differences in the association between body composition and abnormal BP.

CONCLUSIONS

Our findings suggested maintaining an individual's appropriate muscle mass and fat mass and focusing on the different relations of males' and females' body composition is crucial for the achievement of appropriate BP profiles.

The Pathophysiology, Prognosis and Treatment of Hypertension in Females from Pregnancy to Post-menopause: A Review

PURPOSE OF REVIEW

We summarise the physiological changes and risk factors for hypertension in females, potential sex-specific management approaches, and long-term prognosis.

KEY FINDINGS

Pregnancy and menopause are two key phases of the life cycle where females undergo significant biological and physical changes, making them more prone to developing hypertension. Gestational hypertension occurs from changes in maternal cardiac output, kidney function, metabolism, or placental vasculature, with one in ten experiencing pregnancy complications such as intrauterine growth restriction and delivery complications such as premature birth. Post-menopausal hypertension occurs as the protective effects of oestrogen are reduced and the sympathetic nervous system becomes over-activated with ageing. Increasing evidence suggests that post-menopausal females with high blood pressure (BP) experience greater risk of cardiovascular events at lower BP thresholds, and greater vulnerability to treatment-related adverse effects. Hypertension is a key risk factor for cardiovascular disease in females. Current BP treatment guidelines and recommendations are similar for both sexes, without addressing sex-specific factors. Future investigations into ideal diagnostic thresholds, BP control targets and treatment regimens in females are needed.

Metabolomic signatures for blood pressure from early to late adolescence: findings from a U.S. cohort

INTRODUCTION

Metabolite signatures for blood pressure (BP) may reveal biomarkers, elucidate pathogenesis, and provide prevention targets for high BP. Knowledge regarding metabolites associated with BP in adolescence remains limited.

OBJECTIVES

Investigate the associations between metabolites and adolescent BP, both cross-sectionally (in early and late adolescence) and prospectively (from early to late adolescence).

METHODS

Participants are from the Project Viva prospective cohort. During the early (median: 12.8 years; N = 556) and late (median: 17.4 years; N = 501) adolescence visits, we conducted untargeted plasma metabolomic profiling and measured systolic (SBP) and diastolic BP (DBP). We used linear regression to identify metabolites cross-sectionally associated with BP at each time point, and to assess prospective associations of changes in metabolite levels from early to late adolescence with late adolescence BP. We used Weighted Gene Correlation Network Analysis and Spearman's partial correlation to identify metabolite clusters associated with BP at each time point.

RESULTS

In the linear models, higher androgenic steroid levels were consistently associated with higher SBP and DBP in early and late adolescence. A cluster of 59 metabolites, mainly composed of androgenic steroids, correlated with higher SBP and DBP in early adolescence. A cluster primarily composed of fatty acid lipids was marginally associated with higher SBP in females in late adolescence. Multiple metabolites, including those in the creatine and purine metabolism sub-pathways, were associated with higher SBP and DBP both cross-sectionally and prospectively.

CONCLUSION

Our results shed light on the potential metabolic processes and pathophysiology underlying high BP in adolescents.

Polygenic risk scores associate with blood pressure traits across the lifespan

AIMS

Hypertension is a major modifiable cause of morbidity and mortality that affects over 1 billion people worldwide. Blood pressure (BP) traits have a strong genetic component that can be quantified with polygenic risk scores (PRSs). To date, the performance of BP PRSs has mainly been assessed in adults, and less is known about polygenic hypertension risk in childhood.

METHODS AND RESULTS

Multiple PRSs for systolic BP (SBP), diastolic BP (DBP), and pulse pressure were developed using either genome-wide significant weights, pruning and thresholding, or Bayesian regression. Among 87 total PRSs, the top performer for each trait was applied in independent cohorts of children and adult to assess genotype-phenotype associations and disease risk across the lifespan. Differences between those with low (1st decile), average (2nd-9th decile), and high (10th decile) PRS emerge in the first years of life and are maintained throughout adulthood. These diverging BP trajectories also seem to affect cardiovascular and renal disease risk, with increased risk observed among those in the top decile and reduced risk among those in the bottom decile of the polygenic risk distribution compared with the rest of the population.

CONCLUSION

Genetic risk factors are associated with BP traits across the lifespan, beginning in the first years of life. Given the importance of exposure time in disease pathogenesis and the early rise in BP levels among those genetically susceptible, PRSs may help identify high-risk individuals prior to hypertension onset, facilitate primordial prevention, and reduce the burden of this public health challenge.

Financial responsibility, financial context, and ambulatory blood pressure in early middle-aged African-American women

BACKGROUND

African-American women have excess rates of elevated blood pressure (BP) and hypertension compared to women of all other racial/ethnic backgrounds. Several researchers have speculated that race and gender-related socioeconomic status (SES) stressors might play a role.

OBJECTIVE

To examine the association between a novel SES-related stressor highly salient among African-American women, financial responsibility for one's household, and 48-h ambulatory BP. We further examined whether aspects related to African-American women's financial context (e.g., single parenthood, household income, marital status) played a role.

METHODS

Participants were N = 345 employed, healthy African-American women aged 30-46 from diverse SES backgrounds who underwent 48-h ambulatory BP monitoring. Linear regression analyses were conducted to examine associations between self-reported financial responsibility and daytime and nighttime BP, adjusting for age, SES and other sociodemographics, cardiovascular risk factors, financial strain and depressive symptoms. Interactions between financial responsibility and single parenthood, household income, and marital/partnered status were tested.

RESULTS

In age-adjusted analyses, reporting financial responsibility was associated with higher daytime systolic (β = 4.42, S.E. = 1.36, p = 0.0013), and diastolic (β = 2.82, S.E. = 0.98, p = 0.004) BP. Associations persisted in fully adjusted models. Significant associations were also observed for nighttime systolic and diastolic BP. There were no significant interactions with single parenthood, household income, nor marital/partnered status.

CONCLUSION

Having primary responsibility for one's household may be an important driver of BP in early middle-aged African-American women, independent of SES, financial strain, and across a range of financial contexts. Future studies examining prospective associations are needed, and policy interventions targeting structural factors contributing to financial responsibility in African-American women may be warranted.

Associations of central precocious puberty with blood pressure trajectories: prospective cohort study

BACKGROUND

Sex differences in blood pressure (BP) appear during childhood and adolescence, but the role of central precocious puberty (CPP) remains unclear. In this study, we aimed to examine the association of CPP with the risk of early hypertension and BP trajectories in girls and boys.

METHODS

We analyzed trajectories of BP before and after puberty in girls aged 6-13 years (n = 305) and boys aged 10-15 years (n = 153) in the Taiwan Pubertal Longitudinal Study. The timing of puberty onset was defined as the month at which the children reached Tanner stage 2. We examined the association of CPP with the risk of early hypertension and BP trajectories before and after puberty onset.

RESULTS

Among boys, CPP was found to be associated with early hypertension (odds ratio, 7.45 [95% CI, 1.15-48.06]), whereas no such association was observed among girls. Boys with CPP had higher systolic BP than did those with normal puberty onset before puberty onset (mean difference, 6.51 [95% CI, 0.58-12.43]) and after puberty onset (mean difference, 8.92 [95% CI, 8.58-15.26]).

CONCLUSION

A large proportion of the higher systolic BP observed in boys with CPP compared with in those with normal puberty onset is accrued after puberty.

IMPACT

We examined the sex-specific association of central precocious puberty with blood pressure trajectories to better understand whether central precocious puberty was associated with early hypertension. Central precocious puberty was associated with differences in systolic blood pressure trajectories, especially after puberty onset in boys. For boys only, central precocious puberty was associated with early hypertension. A large proportion of the higher systolic blood pressure observed in boys with central precocious puberty compared with in those with normal puberty onset was accrued after puberty. Interventions targeting central precocious puberty are likely to influence systolic blood pressure in early adulthood.

Sex-related association of modifiable risk factors with hypertension: A national cross-sectional study of NHANES 2007-2018

OBJECTIVE

Sex difference is commonly observed in hypertension. We aimed to assess sex differences in the associations of modifiable lifestyle and metabolic risk factors with risk of hypertension.

DESIGN

National cross-sectional population study.

SETTING

Data from the 2007 to 2018 National Health and Nutrition Examination Survey.

PARTICIPANTS

7087 adults aged ≥30 years without a prior history of hypertension.

PRIMARY AND SECONDARY OUTCOME MEASURES

Odds ratios and population attributable fraction (PAF) of hypertension associated with 10 modifiable risk factors: five lifestyle risk factors (current smoking, excess alcohol intake, poor diet, physical inactivity, and unhealthy sleep), and five metabolic risk factors (obesity, diabetes, dyslipidaemia, hyperuricemia, and chronic kidney disease) in women versus men.

RESULTS

Compared with women, men had 84% increased risk of prevalence of hypertension. The sex difference in risk for hypertension is more evident in those aged <60 years (p for interaction <.001). For those aged <60 years the combination of lifestyle risk factors accounted for a PAF of 27.2% in men and 48.8% in women, and the combination of metabolic risk factors accounted for a PAF similarly in men (37.4%) and women (38.2%). For those aged ≥60 years, the PAF of lifestyle risk factors was similar between men and women and the metabolic risk factors accounted for a greater proportion in women (33.0% vs. 14.5% in men).

CONCLUSIONS

Sex differences may exist in the relation and attribution of lifestyle and metabolic risk factors to hypertension, which may have implications for implementing sex-specific strategies to prevent hypertension.

Secular trends and age-specific distribution of blood pressure in Japanese adolescents aged 12-18 years in 2000-2019

Adolescent blood pressure is a predictor of future risk for hypertension and cardiovascular diseases, and therefore its status needs to be accurately determined. However, limited evidence is available regarding the secular trends and distribution of adolescent blood pressure. In the present study, we assessed the secular trends and age-specific distributions of blood pressure in Japanese adolescents aged 12-18 years by using data drawn from 20 years of annual health checkups conducted between 2000 and 2019. Participants underwent health checkups every year for three years at the same school and the data were divided into four 5-year cycles: 2000-2004, 2005-2009, 2010-2014, and 2015-2019. From a total of 124,460 records (33,496 individuals) retrieved, 3000 records (3000 individuals) from each year-cycle were randomly selected to avoid duplicating data from the same individuals. In the study period, in males systolic blood pressure showed a decreasing trend over time, whereas in females diastolic blood pressure showed an increasing trend. Subgroup analyses by school category (junior/senior high school) and by obesity category showed similar blood pressure trends as in the overall analysis. Age-specific blood pressure values in Japanese adolescents increased with age in males but not in females. Thus, different patterns of change in blood pressure values over the past 20 years were observed between males and females. Age-specific blood pressure distributions are also presented. Together, these findings will be useful for understanding blood pressure trends among adolescents.

Cumulative burden and trajectories of body mass index and blood pressure from childhood and carotid intima-media thickness in young adulthood

There are significant gaps in understanding of the association between levels and rate of change of body mass index (BMI) and blood pressure (BP) at different ages during childhood and carotid intima-media thickness (CIMT) in adulthood. We investigated the association between trajectories of BMI and BP from childhood to adulthood and adult CIMT among Iranian participants in the Tehran Lipid and Glucose Study (TLGS) cohort. A total of 1334 participants (692 men), from the TLGS cohort (1999-2018) with repeated measurements of BMI and BP (2-6 times) from childhood (3-18 years) to young adulthood (20-40 years) were selected. Trajectory parameters included levels and linear slopes of BMI and BP growth curve models, and cumulative burden defined as the area under those curves (AUC). After adjusting for confounders, AUC of BMI and diastolic blood pressure (DBP) were significantly associated with high CIMT in adulthood, with the standardized odds ratios (OR) and 95% confidence interval (95% CI) of 1.35 (1.12-1.62) and 1.27 (1.01-1.60), respectively. Associations between level-independent slopes of BMI and adult CIMT were significantly positive (ORs: 1.27 to 1.26) during childhood ages (3-18 years). Further, levels of BMI (ORs: 1.23 to 1.29) and DBP (ORs: 1.25 to 1.33) during the ages of 13-18 and 11-17 years, respectively, were significantly associated with CIMT in adulthood (all P < 0.05). The cumulative burden of BMI and DBP was associated with CIMT in adulthood. Adolescence is a crucial period for high CIMT, which has implications for early prevention of atherosclerosis.

The association between leisure-time physical activity and blood pressure changes from adolescence to young adulthood: Tehran Lipid and Glucose Study

The effectiveness of long-term leisure time physical activity (LTPA) on blood pressure (BP) changes is still under debate. Since adolescence lifestyle behaviors shape the adulthood health profile, this study aimed to investigate the sex-specific impact of LTPA on BP changes from adolescence to young adulthood. This longitudinal study uses the data of 1412 adolescents (52% females) aged 12-18 years through a median follow-up of 12.2 years in the Tehran Lipid and Glucose Study (TLGS) framework. LTPA was calculated using the reliable and valid Iranian version of the modified activity scale (MAQ), and BP was measured at least twice by trained physicians. The linear mixed model was used to examine the study variables, considering individual and intrapersonal differences during the study. The majority of participants consistently demonstrated insufficient LTPA throughout the follow-up assessments, ranging from 54.7 to 67.1% for males and 77.7-83.4% for females. Despite a declining trend in LTPA (β = - 2.77 for males and β = - 1.43 for females), an increasing trend was noticeable in SBP, DBP, and BMI (β = 1.38, β = 1.81, β = 0.97 for males, and β = 0.10, β = 0.20, β = 0.97 for females, respectively). The unadjusted model revealed a significant trend in all variables for both sexes, except for female BP (P = 0.45 for SBP and P = 0.83 for DBP). Using the adjusted model, no significant association was observed between LTPA and changes in BP over time in both sexes. Our study indicates no association between LTPA and BP changes from adolescence to young adulthood. Insufficient LTPA levels, particularly among Iranian females, are likely the primary factor. Further research is crucial to identify appropriate LTPA levels to promote cardiovascular health and implement targeted interventions to achieve optimal LTPA levels in the Iranian population.

Blood Pressure in Children in the 21st Century: What Do We Know and Where Do We Go From Here?

The association between hypertension in adulthood and cardiovascular morbidity and death is well known. Based on that association, a diagnosis of elevated blood pressure in children has been clinically interpreted as early cardiovascular disease. The objective of this review is to discuss historical data and new research on the relationship between elevated blood pressure and early preclinical and later adult cardiovascular disease. After summarizing the evidence, we will address the gaps in knowledge around Pediatric hypertension in an effort to stimulate research into the important role that control of blood pressure in youth may play in preventing adult cardiovascular disease.

Impact of puberty, sex determinants and chronic inflammation on cardiovascular risk in young people

Worrying trends of increased cardiovascular disease (CVD) risk in children, adolescents and young people in the Modern Era have channelled research and public health strategies to tackle this growing epidemic. However, there are still controversies related to the dynamic of the impact of sex, age and puberty on this risk and on cardiovascular health outcomes later in life. In this comprehensive review of current literature, we examine the relationship between puberty, sex determinants and various traditional CVD-risk factors, as well as subclinical atherosclerosis in young people in general population. In addition, we evaluate the role of chronic inflammation, sex hormone therapy and health-risk behaviours on augmenting traditional CVD-risk factors and health outcomes, ultimately aiming to determine whether tailored management strategies for this age group are justified.

Development of a genetic risk score to predict the risk of hypertension in European adolescents from the HELENA study

Introduction

From genome wide association study (GWAS) a large number of single nucleotide polymorphisms (SNPs) have previously been associated with blood pressure (BP) levels. A combination of SNPs, forming a genetic risk score (GRS) could be considered as a useful genetic tool to identify individuals at risk of developing hypertension from early stages in life. Therefore, the aim of our study was to build a GRS being able to predict the genetic predisposition to hypertension (HTN) in European adolescents.

Methods

Data were extracted from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) cross-sectional study. A total of 869 adolescents (53% female), aged 12.5-17.5, with complete genetic and BP information were included. The sample was divided into altered (≥130 mmHg for systolic and/or ≥80 mmHg for diastolic) or normal BP. Based on the literature, a total of 1.534 SNPs from 57 candidate genes related with BP were selected from the HELENA GWAS database.

Results

From 1,534 SNPs available, An initial screening of SNPs univariately associated with HTN (p < 0.10) was established, to finally obtain a number of 16 SNPs significantly associated with HTN (p < 0.05) in the multivariate model. The unweighted GRS (uGRS) and weighted GRS (wGRS) were estimated. To validate the GRSs, the area under the curve (AUC) was explored using ten-fold internal cross-validation for uGRS (0.802) and wGRS (0.777). Further covariates of interest were added to the analyses, obtaining a higher predictive ability (AUC values of uGRS: 0.879; wGRS: 0.881 for BMI z-score). Furthermore, the differences between AUCs obtained with and without the addition of covariates were statistically significant (p < 0.05).

Conclusions

Both GRSs, the uGRS and wGRS, could be useful to evaluate the predisposition to hypertension in European adolescents.

Association between fluoride exposure and blood pressure in children and adolescents aged 6 to19 years in the United States: NHANES, 2013-2016

To examine the association between fluoride exposure and childhood blood pressure (BP), we used data involving 3260 subjects participating in the National Health and Nutrition Examination Survey (NHANES) from 2013 to 2016. Both plasma and water fluoride concentrations were measured using the ion-specific electrode. Outcome variables were systolic blood pressure (SBP) and diastolic blood pressure (DBP). For a 1-mg/L increase in water fluoride concentration, the participants' SBP decreased by 0.473 mm Hg (95% CI: -0.860, -0.087). Specifically, inverse associations were found between water fluoride and SBP in girls (β= -0.423, 95% CI: -0.886, -0.021), adolescents (β= -0.623, 95% CI: -0.975, -0.272), and non-Hispanic whites (β= -0.694, 95% CI: -1.237, -0.151). Also, every 1-μmol/L increase in plasma fluoride concentration was associated with a 1.183 mm Hg decrease in SBP among other races (95% CI: -2.258, -0.108). This study suggested that fluoride exposure may affect childhood blood pressure.

Analysis of salivary flow rate, biochemical composition, and redox status in orchiectomized spontaneously hypertensive rats

OBJECTIVE

This study aimed to analyze the salivary flow rate, biochemical composition, and redox status in orchiectomized spontaneously hypertensive rats (SHR) compared to normotensive Wistar rats.

DESIGN

Thirty-two young adult male SHR and Wistar (3-months-old) rats were randomly distributed into four groups; either castrated bilaterally (ORX) or underwent fictitious surgery (SHAM) as Wistar-SHAM, Wistar-ORX, SHR-SHAM, and SHR-ORX. Two months beyond castration, pilocarpine-induced salivary secretion was collected from 5-month-old rats to analyze salivary flow rate, pH, buffer capacity, total protein, amylase, calcium, phosphate, sodium, potassium, chloride, thiobarbituric acid reactive substances (TBARs), carbonyl protein, nitrite, and total antioxidant capacity.

RESULTS

The salivary flow rate was higher in the Wistar-ORX compared to the Wistar-SHAM group, while remaining similar between the SHR-SHAM and SHR-ORX groups. ORX did not affect pH and salivary buffer capacity in both strains. However, salivary total protein and amylase were significantly reduced in the Wistar-ORX and SHR-ORX compared to the respective SHAM groups. In both ORX groups, salivary total antioxidant capacity and carbonylated protein were increased, while lipid oxidative damage (TBARs) and nitrite concentration were higher only in the Wistar-ORX than in the Wistar-SHAM group. In the Wistar-ORX and SHR-ORX, the salivary calcium, phosphate, and chloride were increased while no change was detected in the SHAM groups. Only salivary buffering capacity, calcium, and chloride in the SHR-ORX adjusted to values similar to Wistar-SHAM group.

CONCLUSION

Hypertensive phenotype mitigated the orchiectomy-induced salivary dysfunction, since the disturbances were restricted to alterations in the salivary biochemical composition and redox state.

Sex differences in impact of cumulative systolic blood pressure from childhood to adulthood on albuminuria in midlife: a 30-year prospective cohort study

BACKGROUND AND OBJECTIVES

Albuminuria is recognized as being a predictor of cardiovascular and renal disease. We aimed to identify the impact of the long-term burden and trends of systolic blood pressure on albuminuria in midlife, as well as to explore sex differences concerning this relationship.

METHODS

This longitudinal study consisted of 1,683 adults who had been examined 4 or more times for blood pressure starting in childhood, with a follow-up time period of 30 years. The cumulative effect and longitudinal trend of blood pressure were identified by using the area under the curve (AUC) of individual systolic blood pressure measurement with a growth curve random effects model.

RESULTS

Over 30 years of follow-up, 190 people developed albuminuria, including 53.2% males and 46.8% females (aged 43.39 ± 3.13 years in the latest follow-up). The urine albumin-to-creatinine ratio (uACR) values increased as the total and incremental AUC values increased. Additionally, women had a higher albuminuria incidence in the higher SBP AUC groups than men do (13.3% for men vs. 33.7% for women). Logistic regression showed that the ORs of albuminuria for males and females in the high total AUC group were 1.34 (0.70-2.60) and 2.94 (1.50-5.74), respectively. Similar associations were found in the incremental AUC groups.

CONCLUSIONS

Higher cumulative SBP was correlated with higher uACR levels and a risk of albuminuria in middle age, especially in women. The identification and control of cumulative SBP levels from an early age may assist in reducing the incidences of renal and cardiovascular disease for individuals in later life.

Weight status change from birth to childhood and the odds of high blood pressure among Chinese children

Background

It is well documented that birth weight and childhood weight are associated with the blood pressure (BP) levels in childhood. However, the impact of weight status change from birth to childhood on BP among children is less well described. We aimed to assess the association between changes in weight status from birth to childhood and high BP in childhood.

Methods and results

Data were obtained from a cross-sectional survey conducted in Jinan, China, and a total of 5,546 children aged 6–17 years were included in this study. Based on the birth weight status [high weight (&gt; 4,000 g) vs. normal weight (2,500–4,000 g)] and childhood weight status during the survey period [high weight (overweight and obesity) vs. normal weight], children were assigned into four groups: persistently normal weight (normal birth weight and normal childhood weight), resolved high weight (high birth weight but normal childhood weight), incident high weight (normal birth weight but high childhood weight), and persistently high weight (high birth weight and high childhood weight). After adjustment for sex and age, BP in childhood was more responsive to current body mass index (BMI) than birth weight. After adjustment for the potential covariates, compared with children who had persistently normal weight from birth to childhood, those with incident high weight (odds ratio [OR] = 3.88, 95% confidence interval [CI] = 3.29–4.57) and persistently high weight (OR = 3.52, 95% CI = 2.71–4.57) were associated with the increased odds of childhood high BP. However, children who had resolved high weight did not have significantly increased odds of high BP in childhood (OR = 0.86, 95% CI = 0.59–1.25).

Conclusion

The association of BP with recent BMI was stronger than with birth weight. Children who had incident or persistently high weight from birth to childhood had increased odds of high BP in childhood, whereas the odds was not significantly increased among those with high birth weight but changed to normal weight in childhood. Our findings highlight the importance of maintaining an appropriate weight in the early lifetime for the prevention of high BP and other related diseases, especially for those with high birth weight.

Sex and gender differences in the treatment of arterial hypertension

INTRODUCTION

Arterial hypertension represents the leading modifiable risk factor for all-cause death and early development of cardiovascular disease in women. Current clinical guidelines for the treatment of hypertension noted that women respond to antihypertensive drugs similarly to men and, therefore, treatment recommendations remain the same for both sexes. However, clinical evidence suggests the existence of sex- and gender-related differences (SGRD) in the prevalence, pathophysiology, pharmacodynamics (efficacy and safety) and pharmacokinetics of antihypertensive drugs.

AREAS COVERED

This review summarizes SGRD in the prevalence of hypertension, hypertension-mediated organ damage and blood pressure control, prescription patterns, and pharmacokinetics/ pharmacodynamics and doses of antihypertensive drugs.

EXPERT OPINION

There is limited information on SGRD in antihypertensive drug efficacy because of the underrepresentation of women in randomized clinical trials and, more important, because few trials reported results stratified by sex or performed sex-specific analyses. However, there are SGRD in hypertension-mediated organ damage, drug pharmacokinetics and, particularly, in drug safety. Prospective trials specifically designed to better understand the basis for SGRD in the pathophysiology of hypertension and in the efficacy and safety of antihypertensive drugs are needed to achieve a more personalized treatment of hypertension and hypertension-mediated organ damage in women.

Decrease in the prevalence of hypertension in Spanish schoolchildren from 2010 to 2017: Cuenca Study

AIMS

To examine the secular trends in blood pressure measurements and normal or high blood pressure classification among Spanish schoolchildren from 2010 to 2017, to analyze the persistence in the blood pressure category reported in 2017 compared with 2013 in those children born in 2007-08 and to compare in this cohort the prevalence of high blood pressure using both definitions, the 2004 and 2017 guidelines.

METHODS AND RESULTS

The data for the prevalence/trend analysis were obtained from cross-sectional analyses conducted in 2010, 2013, and 2017 of 2709 schoolchildren aged 4-6 and 8-11 years from 22 schools in the province of Cuenca, Spain. The data for the longitudinal analysis were obtained from cross-sectional analyses of measurements gathered in 2013 and 2017 in the same cohort of children (n = 275). The prevalence of normal blood pressure increased by 5.4% in children aged 4-6 years from 2013 to 2017 and by 2.2% in children aged 8-11 from 2010 to 2017. This increase was mainly driven by a decrease in the children classified in any stage of hypertension by 4.2% and 2.3% in each age range, respectively. In the same birth cohort, there was an increase of 7.6% in normal blood pressure prevalence.

CONCLUSION

The high blood pressure prevalence in Spanish children has clearly decreased over the last decade, but is still important to detect this condition to design specific school-based interventions and the evaluation of children classified as hypertensive who might need medical supervision and treatment.

Arterial stiffness and blood pressure increase in pediatric kidney transplant recipients

BACKGROUND

Pulse wave velocity (PWV) is a measure of arterial stiffness. We investigated PWV and blood pressure (BP) to determine to what extent BP changes contribute to arterial stiffness, and secondly, to identify influencing factors on BP in children after kidney transplantation.

METHODS

Seventy children ≥ 2.5 years post-transplantation with at least two PWV measurements were included. Changes of systolic (Δ SBP) and diastolic BP (Δ DBP) were classified into "stable/decreasing," "1-10 mmHg increase," and " > 10 mmHg increase." Linear mixed modeling for PWV z-score (PWVz) adjusted either for Δ SBP or Δ DBP was performed. An extended dataset with monthly entries of BP, immunosuppression, and creatinine was obtained in 35 participants over a median of 74 months to perform linear mixed modeling for SBP and DBP.

RESULTS

PWVz increased with a rate of 0.11/year (95% CI 0.054 to 0.16). Compared to participants with stable BP, those with 1-10-mmHg SBP and DBP increase showed a higher PWVz of 0.59 (95% CI 0.046 to 1.13) and 0.86 (95% CI 0.43 to 1.30), respectively. A > 10-mmHg BP increase was associated with an even higher PWVz (SBP β = 0.78, 95% CI 0.22 to 1.34; DBP β = 1.37, 95% CI 0.80 to 1.94). Female sex and participants with lower eGFR showed higher PWVz. In the extended analysis, DBP was positively associated with cyclosporin A and everolimus trough levels.

CONCLUSIONS

A higher increase of PWV is seen in patients with greater BP increase, with higher cyclosporin A and everolimus trough levels associated with higher BP. This emphasizes the role of BP as a modifiable risk factor for the improvement of cardiovascular outcome after transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Maximum home blood pressure and cardiovascular outcomes in patients with type 2 diabetes: KAMOGAWA-HBP study

OBJECTIVE

The maximum blood pressure was reported as a possible marker of organ damage. We previously showed that maximum home blood pressure was significantly associated with development of diabetic nephropathy. In the same cohort of patients with diabetes as in the previous study, this study aimed to evaluate the prognostic blood pressure values for the onset of first cardiovascular events.

METHODS

This retrospective cohort study included 1082 patients with type 2 diabetes (47.0% female, median age 65.0) without a history of macrovascular complications. Blood pressure measurements were performed in triplicates every morning and evening for 14 consecutive days from the start of the study. Cox hazards model was used to evaluate the risk of primary endpoint, which was defined as the onset of first major cardiovascular event.

RESULTS

The primary endpoint occurred in 119 patients (incidence rate, 15.7/1000 person-years) during an average of 7.0-year follow-up. The adjusted hazard ratios (95% confidence interval [CI]) of maximum morning systolic blood pressure (SBP) and maximum evening SBP for cardiovascular events were 1.12 (1.01-1.24) and 1.19 (1.07-1.31), respectively, adjusted by sex, duration of diabetes, body mass index, hemoglobin A1c, low density lipoprotein cholesterol, smoking status, and use of antihypertensive medications. The cutoff values of maximum blood pressure for the events were 150 mmHg in the morning (hazard ratio, 1.73; 95% CI, 1.07-2.81) and 157 mmHg in the evening (hazard ratio, 2.30; 95% CI, 1.46-3.61), using the Youden's index.

CONCLUSION

Maximum home blood pressure is a predictor of subsequent cardiovascular events in patients with type 2 diabetes.

Neighborhood Socioeconomic Deprivation in Early Childhood Mediates Racial Disparities in Blood Pressure in a College Student Sample

The influence of childhood contexts on adult blood pressure is an important yet understudied topic. Using a developmental perspective, this study examines the association between neighborhood socioeconomic disadvantage in early childhood (0-5 yrs), middle childhood (6-12 yrs) and adolescence (13-18 yrs) on subsequent blood pressure in young adulthood. Data were from 263 college students (52% Black; M_age = 19.21 years) and neighborhood socioeconomic disadvantage was measured using a tract-level Area Deprivation Index. Neighborhood disadvantage in early childhood was significantly associated with diastolic blood pressure and explained 22% of the race difference between Black and White adults. The findings are consistent with the notion that early childhood may be a sensitive period for the effects of neighborhood disadvantage on blood pressure.

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.

Sex differences in arterial hypertension

There is strong evidence that sex chromosomes and sex hormones influence blood pressure (BP) regulation, distribution of cardiovascular (CV) risk factors and co-morbidities differentially in females and males with essential arterial hypertension. The risk for CV disease increases at a lower BP level in females than in males, suggesting that sex-specific thresholds for diagnosis of hypertension may be reasonable. However, due to paucity of data, in particularly from specifically designed clinical trials, it is not yet known whether hypertension should be differently managed in females and males, including treatment goals and choice and dosages of antihypertensive drugs. Accordingly, this consensus document was conceived to provide a comprehensive overview of current knowledge on sex differences in essential hypertension including BP development over the life course, development of hypertension, pathophysiologic mechanisms regulating BP, interaction of BP with CV risk factors and co-morbidities, hypertension-mediated organ damage in the heart and the arteries, impact on incident CV disease, and differences in the effect of antihypertensive treatment. The consensus document also highlights areas where focused research is needed to advance sex-specific prevention and management of hypertension.

Puberty Timing and Sex-Specific Trajectories of Systolic Blood Pressure: a Prospective Cohort Study

BACKGROUND

Sex differences in systolic blood pressure (SBP) emerge during adolescence but the role of puberty is not well understood. We examined sex-specific changes in SBP preceding and following puberty and examined the impact of puberty timing on SBP trajectories in females and males.

METHODS

Trajectories of SBP before and after puberty and by timing of puberty in females and males in a contemporary birth cohort study were analyzed. Repeated measures of height from age 5 to 20 years were used to identify puberty timing (age at peak height velocity). SBP was measured on ten occasions from 3 to 24 years (N participants, 4062; repeated SBP measures, 29 172). Analyses were performed using linear spline multilevel models based on time before and after puberty and were adjusted for parental factors and early childhood factors.

RESULTS

Mean age at peak height velocity was 11.7 years (SD, 0.8) for females and 13.6 years (SD, 0.9) for males. Males had faster rates of increase in SBP before puberty leading to 10.19 mm Hg (95% CI, 6.80-13.57) higher mean SBP at puberty which remained similar at 24 years (mean difference, 11.43 mm Hg [95% CI, 7.22-15.63]). Puberty timing was associated with small transient differences in SBP trajectories postpuberty in both sexes and small differences at 24 years in females only.

CONCLUSIONS

A large proportion of the higher SBP observed in males compared with females in early adulthood is accrued before puberty. Interventions targeting puberty timing are unlikely to influence SBP in early adulthood.

Height-based equations as screening tools for high blood pressure in pediatric practice, the GENOBOX study

Due to the absence of easily applicable cut‐off points to determine high blood pressure or hypertension in children, as in the adult population, blood pressure is rarely measured in the pediatrician's clinical routine. This has led to an underdiagnosis of high blood pressure or hypertension in children. For this reason, the present study evaluate the utility of five equations for the screening of high blood pressure in children: blood pressure to height ratio, modified blood pressure to height ratio, new modified blood pressure to height ratio, new simple formula and height‐based equations. The authors evaluated 1599 children between 5 and 18 years. The performance of the five equations was analyzed using the receiver‐operating characteristics curves for identifying blood pressure above P90th according to the American Academy of Pediatrics Clinical Practice Guideline 2017. All equations showed an area under the curve above 0.882. The new modified blood pressure to height ratio revealed a high sensitivity whereas the height‐based equations showed the best performance, with a positive predictive value above 88.2%. Finally, all equations showed higher positive predictive values in children with overweight or obesity. The height‐based equation obtained the highest PPV values above 71.1% in children with normal weight and above 90.2% in children with overweight or obesity. In conclusions, the authors recommend the use of the height‐based equations equation because it showed the best positive predictive values to identify children with elevated blood pressure, independently of their sex, pubertal and weight status.

School-based high-intensity interval training programs in children and adolescents: A systematic review and meta-analysis

PURPOSE

1) To investigate the effectiveness of school-based high-intensity interval training (HIIT) interventions in promoting health outcomes of children and adolescents compared with either a control group or other exercise modality; and 2) to explore the intervention characteristics and process outcomes of published school-based HIIT interventions.

METHODS

We searched Medline, Embase, CINAHL, SPORTDiscus, and Web of Science from inception until 31 March 2021. Studies were eligible if 1) participants aged 5-17 years old; 2) a HIIT intervention within a school setting ≥ 2 weeks duration; 3) a control or comparative exercise group; 4) health-related, cognitive, physical activity, nutrition, or program evaluation outcomes; and 5) original research published in English. We conducted meta-analyses between HIIT and control groups for all outcomes with ≥ 4 studies and meta-regressions for all outcomes with ≥ 10 studies. We narratively synthesised results between HIIT and comparative exercise groups.

RESULTS

Fifty-four papers met eligibility criteria, encompassing 42 unique studies (35 randomised controlled trials; 36 with a high risk of bias). Meta-analyses indicated significant improvements in waist circumference (mean difference (MD) = -2.5cm), body fat percentage (MD = -1.7%), body mass index (standardised mean difference (SMD) = -1.0), cardiorespiratory fitness (SMD = +1.0), resting heart rate (MD = -5bpm), homeostatic model assessment-insulin resistance (MD = -0.7), and low-density lipoprotein cholesterol (SMD = -0.9) for HIIT compared to the control group. Our narrative synthesis indicated mixed findings between HIIT and other comparative exercise groups.

CONCLUSION

School-based HIIT is effective for improving several health outcomes. Future research should address the paucity of information on physical activity and nutrition outcomes and focus on the integration and long-term effectiveness of HIIT interventions within school settings.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018117567.

Effect of blood pressure trajectory and variability on new-onset chronic kidney disease in patients with type 2 diabetes

This study aimed to evaluate the effects of BP trajectory and variability on chronic kidney disease (CKD) incidence in patients with type 2 diabetes. This retrospective longitudinal study included 4,560 participants with type 2 diabetes, aged ≥30 years, free of CKD, with ≥3 years of follow-up, and who attended the Diabetes Care Management Program in 2001-2013. The follow-up period ended in 2016. The adverse outcome was a new-onset CKD event, which was determined using eGFR and albuminuria. Cox proportional hazards models were used to assess the associations. At the end of the follow-up, 1255 participants had developed CKD, with a mean follow-up of 4.3 ± 3.2 years. Three trajectory subgroups of BP, i.e., Cluster 1: "moderate-stable" for SBP and "moderate-downward" for DBP, Cluster 2: "low-upward-downward" for both SBP and DBP, and Cluster 3: "high-downward-upward" for both SBP and DBP, were generated. The BP variability was grouped into three classes on the basis of tertiles. For the BP trajectory, patients in Cluster 3 of DBP had a higher CKD risk than those in Cluster 1 (HR = 1.24, 95% CI = 1.03-1.50). For the BP variability, patients in Tertile 3 had a significantly higher CKD risk than those in Tertile 1 (SBP: 1.28, 1.11-1.47; DBP: 1.17, 1.02-1.34). Persons with type 2 diabetes who achieved a small reduction in DBP after participating in the education program but rebounded and those who had the highest variation in both SBP and DBP faced the highest increase in CKD risk.

Sex Differences in Myocardial and Vascular Aging

It is well known that cardiovascular disease manifests differently in women and men. The underlying causes of these differences during the aging lifespan are less well understood. Sex differences in cardiac and vascular phenotypes are seen in childhood and tend to track along distinct trajectories related to dimorphism in genetic factors as well as response to risk exposures and hormonal changes during the life course. These differences underlie sex-specific variation in cardiovascular events later in life, including myocardial infarction, heart failure, ischemic stroke, and peripheral vascular disease. With respect to cardiac phenotypes, females have intrinsically smaller body size-adjusted cardiac volumes and they tend to experience greater age-related wall thickening and myocardial stiffening with aging. With respect to vascular phenotypes, sexual dimorphism in both physiology and pathophysiology are also seen, including overt differences in blood pressure trajectories. The majority of sex differences in myocardial and vascular alterations that manifest with aging seem to follow relatively consistent trajectories from the very early to the very later stages of life. This review aims to synthesize recent cardiovascular aging-related research to highlight clinically relevant studies in diverse female and male populations that can inform approaches to improving the diagnosis, management, and prognosis of cardiovascular disease risks in the aging population at large.

Association of Net Worth and Ambulatory Blood Pressure in Early Middle-aged African American Women

Importance

Low socioeconomic status (SES) in the form of educational level and income has been linked to greater cardiovascular risk across cohorts; however, associations have been inconsistent for African American individuals. Net worth, a measure of overall assets, may be a more relevant metric, especially for African American women, because it captures longer-term financial stability and economic reserve.

Objective

To examine whether net worth is associated with increased ambulatory blood pressure (ABP), a marker of cardiovascular disease (CVD) risk, independent of educational level and income, in young to middle-aged African American women.

Design, Setting, and Participants

A cross-sectional, community-based study conducted in the southeastern US was performed using 48-hour ambulatory BP monitoring. Participants included 384 African American women aged 30 to 46 years without clinical CVD recruited between December 16, 2016, and March 21, 2019; data analysis was performed from September 2020 to December 2021.

Exposures

Self-reported net worth (total financial assets minus debts), self-reported educational level, and self-reported income.

Main Outcomes and Measures

Mean daytime and nighttime BP levels, assessed via 48-hour ABP monitoring and sustained hypertension (ABP daytime and clinic BP ≥130/80 mm Hg).

Results

The 384 African American women in this study represented a range of SES backgrounds; mean (SD) age was 38.0 (4.3) years. Excluding 66 women who were not receiving antihypertensive medications, in linear regression models adjusted for age, marital status, educational level, family income, and family size, women reporting a negative net worth (debt) had higher levels of daytime (β = 6.7; SE = 1.5; P < .001) and nighttime (β = 6.4; SE = 1.4; P < .001) systolic BP, compared with women reporting a positive net worth. Similar associations were observed with sustained hypertension: women reporting a negative net worth had 150% higher odds (odds ratio, 2.5; 95% CI, 1.3-4.7) of sustained hypertension than those reporting a positive net worth. Associations remained significant after additional adjustments for smoking, body mass index, psychosocial stress due to debt, and depressive symptoms and were similar, although attenuated, when women receiving antihypertensive medications were included and treatment was controlled for in all analyses.

Conclusions and Relevance

In this cross-sectional study, having a negative net worth (ie, debt) was associated with elevated BP in African American women, independent of traditional indicators of SES. This finding suggests that limited assets or a lack of economic reserve may be associated with poor CVD outcomes in this at-risk group.

Association between pubertal development and elevated blood pressure in children

Blood pressure (BP) increased with age and height development, but little was known about the effect of pubertal development on blood pressure in children. A cross‐sectional study was performed among 4146 children aged 7–12 years old in China. Pubertal development was assessed based on breast stages and testicular volume. The associations of pubertal development with BP levels and the rate of elevated blood pressure (EBP) were quantified using multiple linear and logistic regressions. We found that pubertal developmental level was positively correlated with BP, and children who experienced puberty onset and early pubertal timing had higher BP levels and prevalence of EBP. After adjusting for covariates, children experienced puberty onset had 3.84 and 2.24 mmHg increase in systolic blood pressure and diastolic blood pressure, and 70%, 53%, and 62% increased odds of EBP, ESBP, and EDBP, respectively, compared with those without puberty onset. Similar results were observed for children who had early pubertal timing. The change of BP in puberty is greater and the association between pubertal development and BP is stronger in girls than boys. These findings suggested that pubertal development could be an important independent factor and one critical period for the EBP progress. Monitoring and management of pubertal development are necessary particularly among girls.

Blood Pressure Trajectories Across the Life Course

High blood pressure (BP) is a strong modifiable risk factor for cardiovascular disease (CVD). Longitudinal BP patterns themselves may reflect the burden of risk and vascular damage due to prolonged cumulative exposure to high BP levels. Current studies have begun to characterize BP patterns as a trajectory over an individual's lifetime. These BP trajectories take into account the absolute BP levels as well as the slope of BP changes throughout the lifetime thus incorporating longitudinal BP patterns into a single metric. Methodologic issues that need to be considered when examining BP trajectories include individual-level vs. population-level group-based modeling, use of distinct but complementary BP metrics (systolic, diastolic, mean arterial, mid, and pulse pressure), and potential for measurement errors related to varied settings, devices, and number of readings utilized. There appear to be very specific developmental periods during which divergent BP trajectories may emerge, specifically adolescence, the pregnancy period, and older adulthood. Lifetime BP trajectories are impacted by both individual-level and community-level factors and have been associated with incident hypertension, multimorbidity (CVD, renal disease, cognitive impairment), and overall life expectancy. Key unanswered questions remain around the additive predictive value of BP trajectories, intergenerational contributions to BP patterns (in utero BP exposure), and potential genetic drivers of BP patterns. The next phase in understanding BP trajectories needs to focus on how best to incorporate this knowledge into clinical care to reduce the burden of hypertensive-related outcomes and improve health equity.

Blood Pressure in Childhood and Adolescence

Elevated blood pressure (BP) and hypertension commonly occur in children and adolescents and increase the risk of cardiovascular disease in adulthood. The purpose of this review is to summarize recent research in pediatric hypertension including changes in defining hypertension, BP measurement techniques, hypertension epidemiology, risk factors, treatment, and BP-related target organ damage. Defining pediatric hypertension using the 2017 American Academy of Pediatrics' updated Clinical Practice Guideline resulted in a larger proportion of children being classified as having elevated BP or hypertension compared with prior guidelines. Trends in the distribution of BP among US children and adolescents suggest that BP levels and the prevalence of hypertension may have increased from 2011-2014 to 2015-2018. Factors including a family history of hypertension, obesity, minority race/ethnicity, physical inactivity, high dietary intake of sodium, and poor sleep quality are associated with an increased prevalence of elevated BP and hypertension. Evidence of a linear relationship between systolic BP and target organ damage indicates that BP levels currently considered normal could increase the risk of target organ damage in childhood. Lifestyle changes, such as adhering to the Dietary Approaches to Stop Hypertension diet, are a central component of effectively reducing BP and have been shown to reduce target organ damage. Pharmacologic treatment using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers is an effective and safe method for reducing BP among children with uncontrolled BP after implementing lifestyle changes. Research gaps in the prevention, detection, classification, and treatment of hypertension in children demonstrate opportunities for future study.

A reappraisal of the prevalence of pediatric hypertension through a nationwide database in Taiwan

Hypertension in childhood and adolescence is associated with adult cardiovascular morbidity and mortality. However, the reported prevalence of pediatric hypertension varies considerably. We conducted a pioneer nationwide population-based study to investigate the prevalence of hypertension among children and adolescents. Pediatric patients who had been diagnosed with hypertension between 2000 and 2013 were selected from the National Health Insurance Research Database in Taiwan. Other metabolic syndrome-related diseases that would increase cardiovascular risk, including diabetes mellitus (DM), hyperlipidemia, and obesity, were also retrieved for further evaluation. In total, 10,364 children and adolescents diagnosed with hypertension were identified. The prevalence of pediatric hypertension in Taiwan ranged from 0.19 to 0.38 per 1000 children and adolescents between 2000 and 2013. Essential hypertension was most commonly coded (90.6%), which was much more than secondary hypertension (14.3%). Children and adolescents with hypertension were often associated with DM, hyperlipidemia, and obesity, with the odds ratios as 14.05 (95% confidence interval (CI) 11.74-16.81, p < 0.001), 10.65 (95% CI 9.48-11.97, p < 0.001), and 19.08 (95% CI 15.65-23.26, p < 0.001), respectively. To improve lifelong cardiovascular health, our results emphasize the importance of early proper recognition and suitable management of hypertension, as well as metabolic syndrome-related diseases, among children and adolescents.

Blood Pressure Tracking From Childhood to Adulthood

Hypertension is the most common non-communicable disease among adults and is the most important modifiable risk factor for premature cardiovascular disease. The increasing worldwide burden of hypertension is a major global health issue. Early prevention with lifestyle modification or pharmaceutical treatment reduces the incidence of hypertension and the risk of subsequent cardiovascular disease. Therefore, identification of young persons at risk for hypertension has the obvious benefit of providing a chance for early intervention. Previous studies have demonstrated the positive association of elevated childhood blood pressure with hypertension in adulthood. Accumulated evidence also indicates the possibility that elevated pediatric blood pressure is associated with increased risk of future cardiovascular disease. In this article, we review the tracking of blood pressure from childhood to adulthood and emphasize the importance of pediatric blood pressure monitoring and control for predicting and preventing adult hypertension and cardiovascular disease.

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.

Airborne metals exposure and risk of hypertension in the Sister Study

BACKGROUND

Hypertension-related disease burden is a major challenge globally, with an estimated 1.56 billion adults expected to be affected by hypertension by 2025. Environmental factors, such as metals, could be risk factors for hypertension, but the relationship between airborne metals and hypertension is rarely studied.

METHODS

Census-tract airborne metal concentrations (arsenic, cadmium, chromium, cobalt, lead, manganese, mercury, nickel, selenium, and antimony) from the U.S. Environmental Protection Agency 2005 National Air Toxics Assessment database were linked to enrollment residential addresses of 47,595 women in the Sister Study cohort. Hypertension was defined as high systolic (≥140 mm Hg) or diastolic (≥90 mm Hg) blood pressure measured by trained examiners at enrollment or taking anti-hypertensive medications. Multivariable log binomial regression was used to estimate adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association between individual metals and hypertension, with and without co-adjustment for other metals. Quantile-based g-computation was used to estimate the joint effect of the overall metal mixture.

RESULTS

Comparing the highest to lowest quartiles, risk of hypertension was higher among women with higher residential exposure to arsenic (PR = 1.05, 95%CI = 1.02,1.09), lead (PR = 1.04, 95%CI = 1.01,1.08), chromium (PR = 1.03, 95%CI = 1.00,1.06), cobalt (PR = 1.03, 95%CI = 1.00,1.07), and manganese (PR = 1.03, 95%CI = 1.00,1.06). Selenium was associated with lower risk of hypertension (PR = 0.96, 95%CI = 0.93,0.99). Results were similar with mutual adjustment for all other metals. The associations varied by race/ethnicity, with greater PRs in other races/ethnicities (Hispanic, black, and other participants) compared to non-Hispanic white participants. The joint effect of a quartile increase in exposure to all the metals was 1.02 (95%CI = 0.99,1.04).

CONCLUSION

We found that living in areas of higher exposure to arsenic, lead, chromium, cobalt, and manganese was related to higher risk of hypertension, whereas living in areas with higher selenium was inversely related to the risk of hypertension.

Update on Preventive Cardiology

Although progress had been made in reducing cardiovascular disease (CVD) mortality, the positive trend has reversed in recent years, and CVD remains the most common cause of mortality in US women and men. Youth represent the future of CVD prevention; emerging evidence suggests exposure to risk factors in children contributes to atherosclerosis and results in vascular changes and increased CVD events. The contributors to CVD include those commonly seen in adults. This article reviews hypercholesterolemia, hypertension, obesity, diabetes, and smoking. It discusses the prevalence of each disease, diagnosis, treatment, and cardiovascular complications.