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

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.

Sex Differences in Blood Pressure Trajectories Over the Life Course

Importance

If we assume that women and men exhibit variations of the same fundamental vascular physiology, then conventional analyses of subclinical measures would suggest that women catch up to men by midlife in the extent of potentially important vascular disease. Alternatively, under the assumption that vascular physiology may fundamentally differ between women and men, a sex-specific analysis of existing data could offer new insights and augment our understanding of sex differences in cardiovascular diseases.

Objective

To evaluate whether longitudinal patterns of blood pressure (BP) elevation differ between women and men during the life course when considering baseline BP levels as the reference.

Design, Setting, and Participants

We conducted sex-specific analyses of longitudinal BP measures (144 599 observations) collected for a period of 43 years (1971 to 2014) in 4 community-based US cohort studies. The combined total included 32 833 participants (54% female) spanning ages 5 to 98 years. Data were analyzed between May 4, 2019, and August 5, 2019.

Exposures

Age and serially assessed longitudinal BP measures: systolic BP, diastolic BP, mean arterial pressure (MAP), and pulse pressure (PP).

Main Outcomes and Measures

Sex-specific change in each primary BP measure compared with baseline BP levels, derived from multilevel longitudinal models fitted over the age span, and new-onset cardiovascular disease events.

Results

Of the 32 833 participants, 17 733 were women (54%). Women compared with men exhibited a steeper increase in BP that began as early as in the third decade and continued through the life course (likelihood ratio test χ2 = 531 for systolic BP; χ2 = 123 for diastolic BP; χ2 = 325 for MAP; and χ2 = 572 for PP; P for all <.001). After adjustment for multiple cardiovascular disease risk factors, these between-sex differences in all BP trajectories persisted (likelihood ratio test χ2 = 314 for systolic BP; χ2 = 31 for diastolic BP; χ2 = 129 for MAP; and χ2 = 485 for PP; P for all <.001).

Conclusions and Relevance

In contrast with the notion that important vascular disease processes in women lag behind men by 10 to 20 years, sex-specific analyses indicate that BP measures actually progress more rapidly in women than in men, beginning early in life. This early-onset sexual dimorphism may set the stage for later-life cardiovascular diseases that tend to present differently, not simply later, in women compared with men.

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.

Sex differences in the human reward system: convergent behavioral, autonomic and neural evidence

Several studies have suggested that females and males differ in reward behaviors and their underlying neural circuitry. Whether human sex differences extend across neural and behavioral levels for both rewards and punishments remains unclear. We studied a community sample of 221 young women and men who performed a monetary incentive task known to engage the mesoaccumbal pathway and salience network. Both stimulus salience (behavioral relevance) and valence (win vs loss) varied during the task. In response to high- vs low-salience stimuli presented during the monetary incentive task, men showed greater subjective arousal ratings, behavioral accuracy and skin conductance responses (P < 0.006, Hedges' effect size g = 0.38 to 0.46). In a subsample studied with functional magnetic resonance imaging (n = 44), men exhibited greater responsiveness to stimulus salience in the nucleus accumbens, midbrain, anterior insula and dorsal anterior cingulate cortex (P < 0.02, g = 0.86 to 1.7). Behavioral, autonomic and neural sensitivity to the valence of stimuli did not differ by sex, indicating that responses to rewards vs punishments were similar in women and men. These results reveal novel and robust sex differences in reward- and punishment-related traits, behavior, autonomic activity and neural responses. These convergent results suggest a neurobehavioral basis for sexual dimorphism observed in the reward system, including reward-related disorders.

[Awareness, treatment and control of blood pressure according to place of recruitment and sex in the May Measure Month 2018 survey in Spain]

OBJECTIVE

To analyse the data, according to recruiting place and sex, of the survey May Measure Month in 2018 (MMM18) in Spain, promoted by the International Society of Hypertension.

METHODS

Subjects more than 18 years old were studied. MMM18 protocol was performed. Volunteers were recruited through the Spanish Society of Community Pharmacy (SEFAC) and the Spanish Society of Hypertension (SEH-LELHA). General linear models of blood pressure (BP) were carried out in subjects with and without treatment, and adjusted by age, sex, tobacco use, obesity and recruitment site.

RESULTS

7 511 individuals (mean age 51.7 ± 19.6 years, 36.8% males) were screened. Systolic and diastolic BP was higher in males (129.0-16.7/119.6-18.2 mmHg) (78.3-11.1/74.8-10.7 mmHg) (p < 0.001). There was a linear relationship between systolic BP, age and sex, with higher values in males (11.2 mmHg in untreated and 4.5 mmHg in treated) (p < 0.001). Diastolic BP was inverted U-shaped, with highest level in males and between 50-55 years. The proportion of individuals with hypertension (pharmacies; public and clinical area) was 47.2% (54.2; 34.1 and 34.8%). Seventy-five percent were aware of their diagnosis (77.5; 61.5 and 69.2%), with 22% of them without pharmacological treatment (20.7; 26.0 and 27.9%). Sixty-four point five percent of those under antihypertensive treatment met targets (62.9; 65.6 and 69.1%) (p < 0.001).

CONCLUSIONS

There is big room for improvement in MMM indicators in Spain. Nearly half of subjects are hypertensive. Of those aware of their condition, 1 in 5 did not follow pharmacological treatment and of those treated, 1 in 3 did not meet targets. BP levels were significantly higher in males. Our study suggests that gender differences described should be considered in the BP thresholds established.

Association of Resting Heart Rate With Blood Pressure and Incident Hypertension Over 30 Years in Black and White Adults: The CARDIA Study

Few studies have assessed the association of resting heart rate (RHR) through young adulthood with incident hypertension by middle age. We investigated the association between RHR measured over 30 years with incident hypertension in a cohort of young Black and White men and women. A joint longitudinal time-to-event model consisting of a mixed random effects submodel, quadratic in follow-up time, and a survival submodel adjusted for confounders, was used to determine hazard ratios for a 10 bpm higher RHR. Race-sex specific effects were examined in a single joint model that included interactions of race-sex groups with longitudinal RHR. Out of 5115 participants enrolled in year 0 (1985-1986), after excluding prevalent cases of hypertension at baseline, 1615 men and 2273 women were included in the analytic cohort. Hypertension event rates per 1000 person-years were 42.5 and 25.7 in Black and White men, respectively, and 36.2 and 15.3 in Black and White women, respectively. The hazard ratios for a 10 bpm higher RHR were 1.47 (95% CI, 1.23-1.75), 1.51 (95% CI, 1.28-1.78), 1.48 (95% CI, 1.26-1.73), and 1.02, (95% CI, 0.89-1.17) for Black men, White men, White women, and Black women, respectively. Higher RHR during young adulthood is associated with a greater risk of incident hypertension by middle age. The association is similarly strong in Black men, White men, and White women, but absent in Black women, which may suggest racial differences in the effect of sympathetic nervous activity on hypertension among women.

Hypertension and selected indicators of health assessment in a population of 19-year-old men subject to military qualifications

Assessment the prevalence of hypertension and its relation to selected indicators of health status and performance, including classification of BMI, obesity classifications, and body structure in a large test group of 19-year-old men.The study was observational-retrospective, and included a group of 17,282 men, aged 19, from the Małopolska region. All subjects met the qualifications for compulsory military service in 2017. We analyzed selected data obtained from the records of the Ministry of National Defense-spiral-ZINT. Data collection and analysis were carried out from April 1, 2018 to August 31, 2018.Hypertension was found at 0.6%, weak body structure at 0.8% and obesityco-existing with cardiorespiratory insufficiency has been reported 2.6% of respondents and it was more frequent in the recruiters from HT II than I. The underweight concerned almost 7%, and the overweight and obesity of 1/4 of conscripts. The vast majority of people with hypertension were characterized by excessive body weight (74.8%), mainly overweight.Hypertension was seen in a negligible percentage of males studied and was significantly associated with an increase in BMI, particularly with regards to being overweight.

Sex differences in cardio-metabolic and cognitive parameters in rats with high-fat diet-induced metabolic dysfunction

IMPACT STATEMENT

Excessive dietary fat intake plays important roles in the process of metabolic dysfunction and increases susceptibilities to chronic diseases such as hypertension. Few previous studies, however, have accurately reflected real-world medical conditions. In addition, studies performed to date have not examined detailed sex-differences in cardio-metabolic and cognitive parameters, precluding the development of sex-tailored interventions for patients with metabolic dysfunction who are susceptible to hypertension and cognitive impairment. In this study, using rats with HFD-induced metabolic dysfunction that made them susceptible to hypertension and cognitive impairment, we demonstrate that male rats show greater impairment of acetylcholine-induced vasorelaxation of the carotid artery and systolic blood pressure compared to female rats. These findings may provide a basis for the early detection of carotid artery dysfunction and systolic blood pressure increase, especially in males.

Critical review of nutrition, blood pressure and risk of hypertension through the lifecycle: do B vitamins play a role?

Hypertension is the leading cause of preventable mortality worldwide, contributing to over 9 million deaths per annum, predominantly owing to cardiovascular disease. The association of obesity, physical inactivity and alcohol with elevated blood pressure (BP) is firmly established. Weight loss or other dietary strategies, such as the Dietary Approaches to Stop Hypertension (DASH) diet, have been shown to be effective in lowering BP. Additionally, specific nutrients are recognised to contribute to BP, with higher sodium intake linked with an increased risk of hypertension, while potassium is associated with a reduced risk of hypertension. Of note, emerging evidence has identified a novel role for one-carbon metabolism and the related B vitamins, particularly riboflavin, in BP. Specifically in adults genetically at risk of developing hypertension, owing to the common C677T polymorphism in MTHFR, supplemental riboflavin (co-factor for MTHFR) was shown in randomised trials to lower systolic BP by up to 13 mmHg. A BP response to intervention of this magnitude could have important clinical impacts, given that a reduction in systolic BP of 10 mmHg is estimated to decrease stroke risk by 40%. This review aims to explore the factors contributing to hypertension across the lifecycle and to critically evaluate the evidence supporting a role for nutrition, particularly folate-related B vitamins, in BP and risk of hypertension. In addition, gaps in our current knowledge that warrant future research in this area, will be identified.

Association between antecedent blood pressure, hypertension-mediated organ damage and cardiovascular outcome

Purpose: The objective of this study was to test if combining antecedent systolic blood pressure (SBP) with traditional risk factors and hypertension-mediated organ damage (HMOD) improves risk stratification for subsequent cardiovascular disease.Materials and methods: 1910 subjects participated in this study. Antecedent SBP was defined as the average of measurements obtained in 1982 and in 1987. Current SBP was obtained in 1993. HMOD were examined in 1993. HMOD was defined as either atherosclerotic plaque(s), increased pulse wave velocity, increased urine albumin creatinine ratio (above the 90th percentile) or left ventricular hypertrophy. Major adverse cardiovascular events (MACE) including myocardial infarction, cerebrovascular disease, heart failure and arrhythmia were obtained from national registries.Results: Subjects were divided into two age categories: a middle-aged group (aged 41 or 51) and an older group (aged 61 or 71). From 1993 to 2010, 425 events were observed. In multivariable analysis with both current and antecedent SBP adjusted for traditional risk factors, current SBP was associated with each measure of HMOD whilst antecedent SBP was not significantly associated with urine albumin creatinine ratio in the older group, LVMI in the middle-aged group, or the presence of plaque in any of the age groups (all p > 0.15). When current and antecedent SBP were evaluated together, current SBP was not associated with MACE in the middle-aged subgroup [HR = 1.09 (0.96-1.22), p = 0.18] but remained associated with MACE in the older subgroup [HR = 1.21 (1.10-1.34), p < 0.01]. Contrariwise, antecedent SBP was only associated with MACE in the middle-aged subgroup [HR = 1.24 (1.04-1.48), p = 0.02]. Adding antecedent SBP to traditional risk factors did not improve the predictive accuracy of the survival model.Conclusion: In healthy non-medicated middle-aged subjects, antecedent SBP is associated with cardiovascular outcome independently of current BP, traditional risk factors and HMOD. However, improvement in risk stratification seems to be limited.

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

BACKGROUND

Primary aldosteronism (PA) is the most common cause of secondary hypertension; early diagnosis and intervention correlate with outcomes. We hypothesized that race may influence clinical presentation and outcomes.

METHODS

We conducted a retrospective analysis of patients with PA (1997-2017) who underwent adrenal vein sampling (AVS). Patients were classified by self-reported race as black or non-black. Improvement was defined as postoperative decrease in mean arterial pressure (MAP), antihypertensive medications (AHM), or both.

RESULTS

Among patients undergoing AVS (n = 443), 287 underwent adrenalectomy. Black patients (28.2%) had higher body mass index (33.9 vs 31.8 kg/m² ; P = .01), longer median duration of hypertension (12 vs 10 years; P = .003), higher modified Elixhauser comorbidity index (2 vs 1; P = .004), and lower median income ($47 134 vs $78 280; P < .001). Black patients had similar aldosterone:renin ratios (150 vs 135.6 [ng/dL]/[ng·mL·^-1 hr^-1 ]; P = .23) compared to non-blacks. At long-term follow-up, black patients had a similar requirement for AHM (1 vs 0; P = .13) but higher MAP (100.6 vs 95.3 mm Hg; P = .004).

CONCLUSION

Black patients present with longer duration of hypertension and more comorbidities. They are equally likely to lateralize on AVS, suggesting similar disease phenotype. However, black patients demonstrate less improvement with adrenalectomy; this may reflect a delay in diagnosis or concomitant essential hypertension.

Sex and age as determinants for high blood pressure in pediatric renal transplant recipients: a longitudinal analysis of the CERTAIN Registry

BACKGROUND

High prevalence of arterial hypertension is known in pediatric renal transplant patients, but how blood pressure (BP) distribution and control differ between age groups and whether sex and age interact and potentially impact BP after transplantation have not been investigated.

METHODS

This retrospective analysis included 336 pediatric renal transplant recipients (62% males) from the Cooperative European Pediatric Renal Transplant Initiative Registry (CERTAIN) with complete BP measurement at discharge and 1, 2 and 3 years post-transplant.

RESULTS

At discharge and 3 years post-transplant, arterial hypertension was highly prevalent (84% and 77%); antihypertensive drugs were used in 73% and 68% of the patients. 27% suffered from uncontrolled and 9% from untreated hypertension at 3 years post-transplant. Children transplanted at age < 5 years showed sustained high systolic BP z-score and received consistently less antihypertensive treatment over time. Younger age, shorter time since transplantation, male sex, higher body mass index (BMI), high cyclosporine A (CSA) trough levels, and a primary renal disease other than congenital anomalies of the kidney and urinary tract (CAKUT) were significantly associated with higher systolic BP z-score. Sex-stratified analysis revealed a significant association between high CSA and higher systolic BP in older girls that likely had started puberty already. An association between BP and estimated glomerular filtration rate was not detected.

CONCLUSIONS

BP control during the first 3 years was poor in this large European cohort. The description of age- and sex-specific risk profiles identified certain recipient groups that may benefit from more frequent BP monitoring (i.e. young children) or different choices of immunosuppression (i.e. older girls).