Could 130/80 mm Hg Be Adopted as the Diagnostic Threshold and Management Goal of Hypertension in Consideration of the Characteristics of Asian Populations?

Ethnic differences in knowledge, attitudes, and practices related to dietary salt intake and association with hypertension in Malaysia: a multi-centre cross-sectional study

The association between high salt intake and elevated blood pressure levels has been well-documented. However, studies on how effectively this knowledge translates into actionable practices, particularly across different ethnic groups, remain limited. This study aimed to evaluate the knowledge, attitudes, and practices (KAP) towards dietary salt intake across ethnicities and determine its association with hypertension. 5128 Malaysian adults recruited from a national blood pressure screening study completed questionnaires on demographics, and KAP related to dietary salt intake. There were 57.4% Malay, 23.5% Chinese, 10.4% Indian, and 8.7% individuals of other ethnic groups. Overall, more than 90% of the participants knew that a high salt intake causes serious health problems, but only around one-third knew the relationship between high salt intake and strokes and heart failure. Participants of different ethnic groups displayed significant differences in the KAP domains, where Indians generally exhibited better knowledge, attitudes, and reported better practices such as reading salt labels and using spices. Those who were unaware of the difference between salt and sodium and who reported not reading salt labels had higher odds of having elevated blood pressure. These findings demonstrate that while there is a suboptimal translation of salt knowledge into practice in Malaysia, with significant differences in KAP observed between ethnic groups, the potential of improving health outcomes by improving the clarity and awareness of salt labels is substantial. Tailored education promoting salt-label reading, minimizing processed foods intake and discretionary salt use should be ethnic-specific to better curb this escalating hypertension epidemic.

Home blood pressure-lowering effect of a non-steroidal mineralocorticoid receptor blocker, esaxerenone, versus trichlormethiazide for uncontrolled hypertension: the EXCITE-HT randomized controlled study

The EXCITE-HT study aimed to evaluate the efficacy and safety of esaxerenone versus thiazide diuretics (trichlormethiazide) as second-line treatment for Japanese patients with uncontrolled essential hypertension. This was a 12-week, multicenter, randomized, open-label, parallel-group study. The non-inferiority of esaxerenone to trichlormethiazide was confirmed if the upper limit of the two-sided 95% confidence interval (CI) for the difference in systolic blood pressure (SBP)/diastolic blood pressure (DBP) change between groups was below 3.9/2.1 mmHg. A total of 295 and 290 patients were included in the esaxerenone and trichlormethiazide groups, respectively. The non-inferiority of esaxerenone to trichlormethiazide was demonstrated: least squares mean change differences in morning home SBP/DBP at end of treatment (EOT) were -2.2 (95% CI, -3.6, -0.8) mmHg for SBP/-0.6 (-1.4, 0.2) mmHg for DBP. Morning home, bedtime home, and office BP significantly decreased (all p < 0.001) from baseline to EOT in both groups. The urinary albumin-to-creatinine ratio and N-terminal pro-brain natriuretic peptide level decreased from baseline to Week 12 in both groups, with no notable intergroup difference. Serum potassium elevations occurred more frequently with esaxerenone, while serum potassium reductions occurred more with trichlormethiazide. Uric acid elevations were observed in both groups, but more frequently with trichlormethiazide than esaxerenone. No cases of gout occurred in this study. Reductions in estimated glomerular filtration rate were similarly observed in both groups. EXCITE-HT is the first randomized controlled study to demonstrate evidence that esaxerenone is non-inferior to trichlormethiazide as second-line treatment for Japanese patients with uncontrolled essential hypertension, with no new safety concerns. The EXCITE-HT study demonstrated the non-inferiority of esaxerenone to trichlormethiazide in its morning home blood pressure lowering effect and safety profile in Japanese patients with uncontrolled essential hypertension who were previously treated with an angiotensin II receptor blocker or calcium channel blocker.

Strategies for improving the treatment and control of hypertension in Japan

Despite the significant advancements in the diagnosis and treatment of hypertension, the burden of hypertension remains a major global health care concern. In Japan, estimates show that more than two-thirds of the population have uncontrolled hypertension, regardless of whether they were taking antihypertensive medication. To improve hypertension management, hypertension guidelines have been developed and updated regularly by hypertension societies across various countries and regions. The Japanese Society of Hypertension (JSH) updated the Guidelines for the Management of Hypertension in 2019 (JSH 2019). The JSH 2019 aims to establish a standard management strategy for hypertension and provide evidence to all health care providers. One of its updated main features is its proposal for multidisciplinary team-based care (TBC) involving physicians, pharmacists, nurses, dietitians, and other health care providers. The TBC will help initiate and intensify the management of hypertension, as well as combat clinical inertia, which is expected to contribute to uncontrolled blood pressure and subsequent development of cardiovascular diseases. This is consistent with the recommendations from recent major guidelines on hypertension management. Moreover, to reduce the evidence-practice gap in hypertension management, it is essential to disseminate the essence of the guidelines and provide hypertension education programs for all health care providers and patients. This review summarizes the points of the JSH 2019-based strategy for improving hypertension management and discusses guidelines for its implementation into actual clinical practice.

Elevated level of urinary tellurium is a potential risk for increase of blood pressure in humans and mice

BACKGROUND

People worldwide are routinely exposed to tellurium mainly via dietary ingestion. There has been no study to clarify the contribution of tellurium to blood pressure in humans or animals.

METHODS

In this cross-sectional study conducted in a general population of 2592 residents in Japan, the associations of urinary tellurium levels with blood pressure and prevalence of hypertension were investigated. The potential sources of tellurium were also investigated. An interventional study in mice confirmed the effect of tellurium exposure on blood pressure.

RESULTS

Linear and logistic regression analyses with consideration of confounders including urinary sodium-potassium ratio showed significant positive associations of urinary tellurium level with prevalence of hypertension and blood pressure. Cereals/beans and vegetables/fruits were determined to be potential dietary sources of tellurium exposure. Intermediary analysis suggested that increased intake of cereals/beans, but not that of vegetables/fruits, is positively associated with the tellurium-mediated risk of hypertension. Correspondingly, the mouse study showed that exposure to a putative human-equivalent dose of tellurium via drinking water increased blood pressure with an elevated level of urinary tellurium. The temporally increased blood pressure was decreased to the normal level by a break of tellurium exposure with a reduced level of urinary tellurium.

CONCLUSIONS

The interdisciplinary approach provided the first evidence that tellurium exposure is a potential risk for increase of blood pressure. Since the human urinary tellurium level in this study is comparable with the levels in general populations in other Asian and European countries in previous studies, exposure to tellurium may be a latent universal risk for hypertension.

A controlled trial of percutaneous adrenal arterial embolization for hypertension in patients with idiopathic hyperaldosteronism

Our prior study has suggested that percutaneous superselective adrenal arterial embolization (SAAE) with ethanol reduces blood pressure in patients with primary aldosteronism. This study aimed to compare the efficacy of SAAE with mineralocorticoid receptor antagonists (MRA) in treating patients with idiopathic hyperaldosteronism. In this prospective, randomized, controlled trial, we randomly assigned patients with idiopathic hyperaldosteronism in a 1:1 ratio to undergo SAAE (n = 29) or receive MRA (n = 30) treatment. The primary endpoint was the change in mean 24-hour ambulatory systolic blood pressure at 6 months. The secondary endpoints included changes in office blood pressure, home blood pressure, correction of aldosterone-to-renin ratio, and adverse events at 6 months. The mean change in 24-h ambulatory systolic blood pressure from baseline to 6-month follow-up was significantly different between the two groups (-8.4 mmHg; 95% confidence interval, -15.2 to -2.1 mmHg; P < 0.01). Office, home, and ambulatory blood pressure reduction at 6 months was more pronounced in the SAAE group than the MRA group (all P < 0.05). Aldosterone-to-renin ratio was lower in the SAAE group than the MRA group at 1 and 3 months (both P < 0.01), while it had no difference between the two groups at 6 months. None of the patients experienced serious adverse events in the perioperative and 6-month follow-up periods. SAAE, as a hormonal debulking procedure, is superior to MRA in blood pressure control and correction of biochemical abnormalities in patients with idiopathic hyperaldosteronism.

Agreement Between Guideline Thresholds Using an "All-in-One" Device to Measure Office, Home, and Ambulatory Blood Pressures

BACKGROUND

Blood pressure (BP) thresholds for diagnosing and managing hypertension vary for office, home, and ambulatory readings, and between guideline documents. This analysis determined corresponding office, home, and ambulatory BP thresholds using baseline data from the HI-JAMP (Home-Activity Information and Communication Technology-Based Japan Ambulatory Blood Pressure Monitoring Prospective) study, which used a validated "all-in-one" BP monitoring device.

METHODS AND RESULTS

Data from 2322 treated patients with hypertension who underwent office BP measurement, then 24-hour ambulatory BP monitoring, then home BP monitoring for 5 days were analyzed. Corresponding BP thresholds for office, home, and ambulatory measurements were determined using Deming regression. Values equivalent to office systolic BP (SBP) of 120 and 140 mm Hg were as follows: 115.9 and 127.7 mm Hg for 24-hour ambulatory SBP; 120.8 and 134.0 mm Hg for daytime ambulatory SBP; 104.9 and 117.9 mm Hg for nighttime ambulatory SBP; and 122.0 and 134.2 mm Hg for morning-evening average home SBP. Deming regression showed that morning-evening average home SBP and daytime ambulatory SBP were almost the same (home SBP=0.99×daytime ambulatory SBP+0.27 mm Hg; r=0.627). Morning-evening average home SBP values of 120 and 135 mm Hg were equivalent to daytime ambulatory SBP values of 119.1 and 133.9 mm Hg, respectively. A home SBP threshold of 130 mm Hg corresponded to 24-hour and nighttime ambulatory SBP values of 123.5 and 113.6 mm Hg, whereas a home SBP threshold of 135 mm Hg corresponded to 24-hour and nighttime ambulatory SBP values of 128.0 and 119.2 mm Hg.

CONCLUSIONS

Ambulatory and home BP thresholds in this analysis were similar to those proposed by existing guidelines. The similarity between the home BP and daytime ambulatory BP thresholds was a clinically relevant finding.

Achievement rate of target blood pressure in patients with hypertension treated by hypertension specialists and non-specialists in a real-world setting

Hypertension remains a major global healthcare issue. Considering that most Japanese patients with hypertension are managed by general practitioners, hypertension specialists should be involved in actual clinical practice. We investigated the blood pressure (BP), guidelines recommended for achievement rate of the target BP, and clinical variables of patients with hypertension treated by hypertension specialists and those treated by non-specialists in a real-world setting. Factors associated with the target BP achievement in this population were also investigated. Outpatients with hypertension from 12 medical facilities in Okinawa Prefecture were enrolled (n = 1469 [specialist group, 794; non-specialist group, 675]; mean age, 64.2 years; females, 45.8%). For all patients, BP and rate of the target BP achievement were 129.0 ± 15.5/74.6 ± 10.6 mmHg, and 51.8%, respectively. BP and the rate of target of BP achievement were 128.0 ± 15.1/73.4 ± 10.4 mmHg and 56.7% in the specialist group, and they were 130.1 ± 15.9/76.0 ± 10.8 mmHg and 46.1% in the non-specialist group. The urinary salt excretion and obesity rates were comparable between the specialist and non-specialist groups. Multivariable logistic analyses indicated that hypertension specialists and good medication adherence were positive factors, whereas obesity, chronic kidney disease, diabetes mellitus, and urinary salt excretion were inverse factors associated with target BP achievement in this population. Initiatives for salt reduction, medication adherence, and proper obesity management are crucial to improving BP management in patients with hypertension. Hypertension specialists are expected to play an essential role in them. For all patients, the target blood pressure (BP) achievement rate were 51.8%. Hypertension specialists and good medication adherence were positive factors in achieving target BP; conversely, obesity, diabetes mellitus, chronic kidney disease, and high urinary salt excretion were inverse factors in achieving target BP among patients with hypertension.

The impact of blood pressure variability on cognition: current limitations and new advances

Dementia is the most common neurodegenerative disease in the aging population. Emerging evidence indicates that blood pressure (BP) variability is correlated with cognitive impairment and dementia independent of mean BP levels. The state-of-the-art review summarizes the latest evidence regarding the impact of BP variability on cognition in cognitively intact populations, patients with mild cognitive impairment, and different dementia types, focusing on the important confounding factors and new advances. This review also summarizes the potential mechanisms underlying the relationship between BP variability and cognitive impairment, and dementia, briefly discussing sex differences in the relationship. At last, current limitations and future perspectives are discussed to optimize BP management in preventing cognitive impairment and dementia.

Clinical characteristics and outcomes of Chinese patients with coronary heart disease and resistant hypertension

There is currently few research on clinical characteristics and outcomes of coronary heart disease (CHD) with resistant hypertension in central region of China. This study aimed to assess the risk factors and outcomes of CHD and resistant hypertension in population of central region of China. A total of 1467 CHD patients with hypertension were included and considered to three groups according to blood pressure control: controlled group (blood pressure < 140/90 mmHg on three or less antihypertensive drugs); uncontrolled group (blood pressure ≥ 140/90 mmHg on two or less antihypertensive drugs); or resistant group (blood pressure ≥ 140/90 mmHg on three antihypertensive drugs or < 140/90 mmHg on at least four antihypertensive drugs including diuretic). The authors evaluated the clinical outcomes of three groups at 1-year follow-up. The prevalence of resistant hypertension was 21.8%. Significant adjusted associated factors of resistant hypertension included per unit changes body mass index (BMI, OR 1.12), and four categorical variable diagnosis by yes or no: heart failure (HF, OR 2.62), left ventricular hypertrophy (LVH, OR 2.83), diabetes (OR 1.55), and chronic kidney disease (CKD, OR 1.63). In multiple adjusted Cox regression analysis, patients in resistant group had a higher risk of the primary outcome (HR, 2.14 [95% CI, 1.47-3.11]; p < .001). Moreover, the risk of atherosclerotic cardiovascular disease (ASCVD) in patients with resistant hypertension is also significantly increased (HR, 2.11 [95% CI, 1.39-3.20]; p < .001). In conclusion, resistant hypertension was a quite common and high proportion finding in patients with CHD and hypertension in central region of China, and these patients have a worse clinical prognosis.

Prevalence and predictors of hypertension among adults in Mbarara City, Western Uganda

OBJECTIVE

The study aim was to evaluate the prevalence and predictors of hypertension among an urban adult population in Mbarara city, Western Uganda.

METHODS

We evaluated blood pressure measurements, social demographic and clinical parameters of adults living in Mbarara city, Uganda. These parameters were extracted from medical records of adults who participated in the Uganda World Kidney Day 2020 health screening activities. A total of 302 adults were evaluated for hypertension using the American College of Cardiology/American Heart Association 2017 (blood pressure threshold 130/80 mmHg) and International Society of Hypertension 2020 guidelines (threshold 140/90 mmHg).

RESULTS

The mean age of the participants was 42.5 years (standard deviation: 15.1) and majority were male 195/302 (64.6%). Using American College of Cardiology/American Heart Association 2017 guidelines, 156/302 (51.7%) adults were newly diagnosed with hypertension compared to 68/302 (22.5%) newly diagnosed with hypertension using International Society of Hypertension 2020 guidelines. Only 23/302 (7.6%) were on treatment. Based on American College of Cardiology/American Heart Association 2017 guidelines, age ≥40 years and overweight/obesity were statistically significant predictors of hypertension (p < 0.05 for all) at multivariate analysis. Using the International Society of Hypertension 2020 guidelines, age ≥40 years predicted hypertension.

DISCUSSION

The prevalence of hypertension is high among this urban adult population irrespective of the guidelines used, highlighting the need for hypertension prevention interventions.

The role of blood pressure management in stroke prevention: current status and future prospects

INTRODUCTION

Stroke is the second-leading cause of death worldwide and the second-leading cause of disability-adjusted life-years. It is well known that hypertension is a significant risk factor for cardiovascular events, including stroke.

AREAS COVERED

Recent interventional trials have demonstrated the superiority of intensive blood pressure (BP) control for prevention of cardiovascular events compared to standard BP control. Notably, in the Strategy of Blood Pressure Intervention in Elderly Hypertensive Patients (STEP) trial, intensive BP control showed superiority in the prevention of stroke events in elderly hypertensive patients. Novel medications such as angiotensin receptor-neprilysin inhibitors and sodium glucose cotransporter 2 inhibitors have the potential to suppress various CVD events including stroke. Non-pharmacological antihypertensive therapies such as renal denervation have demonstrated BP-lowering effects and may be useful for stroke prevention. Additionally, new methods and systems of BP monitoring including various kinds of nighttime BP measurement devices, wearable devices, and methods using information and communication technology can be used to assess the pathophysiology of BP variability as a risk factor and an event trigger of stroke incidence.

EXPERT OPINION

Novel therapies and new technologies for BP evaluation strongly support the development of individualized anticipatory medicine, which should be useful for the prevention of stroke.

Food Choices and Hypertension Among Rural Thais: Evidence From a Discrete Choice Experiment

Objective: The rural northern region of Thailand exhibits the highest rate of hypertension. This study explored hypertensive-related food choices between normotensive and hypertensive people residing in rural northern Thailand to determine which food attributes influence their choices. Methods: The study conducted a discrete choice experiment (DCE) survey among Thai adults residing in rural northern Thailand (n = 403) to estimate the relative importance of four food attributes, including food preparation, price, taste, and amount of salt. A mixed logit model was used to analyze the data from the DCE. Results: The first and second most important attributes in both hypertensive and normotensive groups were the amount of salt and food preparation at home, respectively, followed by price and taste. Specifically, the normotensive group was more attentive to the amount of salt in their food than their hypertensive counterparts. Conclusion: Intervention programs in rural communities may benefit from focusing their attention on embracing low-salt cultural foods and providing guidance on how to add flavor without additional salt or reduce high sodium seasonings without losing flavor when cooking.

Day to Day Blood Pressure Variability Associated With Cerebral Arterial Dilation and White Matter Hyperintensity

Previous studies suggested blood pressure variability (BPV) might help reveal interactions between blood pressure fluctuation and white matter lesions, and the impact of elevated BPV on white matter hyperintensity (WMH) or cerebral arterial dilation is unclear.

Relationship of resting heart rate and blood pressure with all-cause and cardiovascular disease mortality

OBJECTIVES

This study aimed to investigate associations of resting heart rate (RHR) and blood pressure (BP) with all-cause and cardiovascular disease (CVD) mortality.

STUDY DESIGN

A retrospective cohort study.

METHODS

A total of 67,028 Chinese participants aged ≥60 years were included in the analysis. RHR, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were evaluated according to quartiles ([41-69, 70-74, 75-79, 80-127 beats/min], [80-119, 120-129, 130-139, 140-238 mm Hg], and [40-70, 71-79, 80-84, 85-133 mm Hg]). Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause and CVD mortality with RHR, SBP, and DBP. Restricted cubic splines were used to evaluate the dose-response association.

RESULTS

During the 361,975 person-year follow-up, 9326 deaths were recorded, of which 5039 deaths were due to CVD. The risk of all-cause mortality was increased by 25% with the quartiles four vs quartile one of RHR (HR [95% CI]:1.25 [1.17-1.33]), and CVD mortality was increased by 32% (HR [95% CI]: 1.32 [1.22-1.44]). Similar results were observed when comparing the quartiles four vs quartile one of SBP with the risk of all-cause and CVD mortality (HRs [95% CIs]: 1.14 [1.07, 1.22] and 1.23 [1.12. 1.34]) and DBP with the risk of all-cause and CVD mortality (HRs [95% CIs]: 1.17 [1.11. 1.24] and 1.36 [1.26. 1.47]). We found linear associations of RHR, SBP, and DBP with all-cause and CVD mortality (P_{non-linearity} >0.05), except for the approximately J-shaped association between DBP and all-cause mortality (P_{non-linearity} = 0.008). There was a significant interaction of RHR and SBP with all-cause and CVD mortality (P_interaction <0.05).

CONCLUSIONS

RHR and BP increased the risk of all-cause and CVD mortality, especially fast RHR combined with high SBP.

Association between social participation and hypertension control among older people with self-reported hypertension in Japanese communities

Hypertension control remains poor worldwide despite well-established strategies for lowering blood pressure. Social participation has been associated with a lower prevalence of hypertension, but evidence is scarce regarding hypertension control. The aim of this study was to examine the relationship between social participation and hypertension control among older people. We used cross-sectional data from participants of the 2019 wave of the Japan Gerontological Evaluation Study (JAGES; n = 13,629). Social participation was defined as no participation, participation in one group, or participation in two or more groups. After adjusting for covariates, modified Poisson regression analysis showed that participation in two or more groups (prevalence ratio [95% confidence interval]: 1.08 [1.03-1.13]) was associated with better control of hypertension than no participation, but participation in one group (1.02 [0.96-1.08]) was not. Social participation in multiple groups was associated with better control of hypertension among older people in Japan.

2022 Malaysian Working Group Consensus Statement on Renal Denervation for management of arterial hypertension

Hypertension is highly prevalent and a major contributor to cardiovascular mortality and morbidity. In spite of the availability of efficacious, safe and affordable anti-hypertensive drugs, hypertension remains poorly controlled in the majority of hypertensive patients. Various reasons including non-adherence to the anti-hypertensive drugs, account for the poor control. Resistant hypertension is also one of the reasons for poor control of blood pressure (BP). The sympathetic nervous system (SNS) has long been recognized as one of the determinants in the pathophysiology of a raised BP. Overactivity of the SNS is a contributor to sustained arterial hypertension. Renal denervation (RDN) is increasingly recognized as a safe and effective adjunctive therapy to control BP with or without pharmacotherapy. Hence for patients who remain uncontrolled despite all efforts, renal denervation (RDN) is a novel treatment that can potentially improve BP control, hence reducing the major adverse cardiovascular events (MACE). More recent randomized, sham control trials of RDN have shown that RDN produces a sustained lowering of BP. To date, this lowering of BP through RDN is maintained for at least 3 years. Furthermore, this procedure has been found to be safe. Hence this consensus summarises the science behind RDN and the available clinical data to support the use of this therapy. It is hoped that this consensus will offer guidance on the importance of identifying patients who will benefit most from this therapy. A multidisciplinary team approach in the management of the patient undergoing RDN is recommended.

Seven-action approaches for the management of hypertension in Asia - The HOPE Asia network

Asia is a large continent and there is significant diversity between countries and regions. Over the last 30 years, absolute blood pressure (BP) levels in Asia have increased to a greater extent than those in other regions. In diverse Asia‐Pacific populations, for choosing an Asia‐specific approach to hypertension management is important to prevent target organ damage and cardiovascular diseases. In this consensus document of HOPE Asia Network, we introduce seven action approaches for management of hypertension in Asia.

Changes in prevalence and risk factors of hypertension among adults in Bangladesh: An analysis of two waves of nationally representative surveys

Introduction

Bangladesh is one of the countries where the prevalence of non-communicable diseases (NCDs) such as hypertension is rising due to rising living standards, sedentary lifestyles, and epidemiological transition. Among the NCDs, hypertension is a major risk factor for CVD, accounting for half of all coronary heart disease worldwide. However, detailed research in this area has been limited in Bangladesh. The objective of the study was to estimate changes in the prevalence and risk factors of hypertension among Bangladeshi adult population. The study also sought to identify socioeconomic status-related inequality of hypertension prevalence in Bangladesh.

Methods

Cross-sectional analysis was conducted using nationally representative two waves of the Bangladesh Demographic and Health Survey (BDHS) in 2011 and 2017–18. Survey participants were adults 18 years or older- which included detailed biomarker and anthropometric measurements of 23539 participants. The change in prevalence of hypertension was estimated, and adjusted odds ratios were obtained using multivariable survey logistic regression models. Further, Wagstaff decomposition method was also used to analyze the relative contributions of factors to hypertension.

Results

From 2011 to 2018, the hypertension prevalence among adults aged ≥35 years increased from 25.84% to 39.40% (p<0.001), with the largest relative increase (97%) among obese individuals. The prevalence among women remained higher than men whereas the relative increase among men and women were 75% and 39%, respectively. Regression analysis identified age and BMI as the independent risk factors of hypertension. Other risk factors of hypertension were sex, marital status, education, geographic region, wealth index, and diabetes status in both survey years. Female adults had significantly higher hypertension risk in both survey years in the overall analysis in, however, in the subgroup analysis, the gender difference in hypertension risk was not significant in rural 2011 and urban 2018 samples. Decomposition analysis revealed that the contributions of socio-economic status related inequality of hypertension in 2011 were46.58% and 20.85% for wealth index and BMI, respectively. However, the contributions of wealth index and BMI have shifted to 12.60% and 55.29%, respectively in 2018.

Conclusion

The prevalence of hypertension among Bangladeshi adults has increased significantly, and there is no subgroup where it is decreasing. Population-level approaches directed at high-risk groups (overweight, obese) should be implemented thoroughly. We underscore prevention strategies by following strong collaboration with stakeholders in the health system of the country to adopt healthy lifestyle choices.

Association of blood pressure and long-term change with chronic kidney disease risk among Chinese adults with different glucose metabolism according to the 2017 ACC/AHA guidelines

Whether the definition of hypertension according to 2017 AHA/ACC guidelines and blood pressure (BP) changes was related to the increased risk of chronic kidney disease (CKD) remained debated. This prospective cohort study aimed to investigate the association of BP and long‐term BP change with CKD risk with different glucose metabolism according to the new hypertension guidelines. This study examined 12 951 participants and 11 183 participants derived from the older people cohort study, respectively. Participants were divided into three groups based on blood glucose and the risks were assessmented by the logistic regression model. During a 10 years of follow‐up period, 2727 individuals developed CKD (21.1%). Compared with those with BP < 130/80 mmHg, individuals with increased BP levels had significantly increased risk of incident CKD. Participants with BP of 130–139/80–89 or ≥140/90 mmHg had 1.51‐ and 1.89‐fold incident risk of CKD in patients with diabetes mellitus (DM). Compared with individuals with stable BP (−5 to 5 mmHg), the risk of CKD was reduced when BP decreased by 5 mmHg or more and increased when BP increased ≥5 mmHg among normoglycemia and prediabetes participants. Similar results were observed for rapid estimated glomerular filtration rate (eGFR) decline. In conclusion, the BP of 130–139/80–89 mmHg combined with prediabetes or DM had an increased risk of incident CKD and rapid eGFR decline in older people. Long‐term changes of BP by more than 5 mmHg among normoglycemia or prediabetes were associated with the risk of incident CKD and rapid eGFR decline.

Efficacy of Cilnidipine (L/N-type Calcium Channel Blocker) in Treatment of Hypertension: A Meta-Analysis of Randomized and Non-randomized Controlled Trials

INTRODUCTION

 Hypertension is one of the most common cardiovascular diseases, and the prevalence of hypertension continues to rise across the globe. National and international guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), diuretics, and beta-blockers for the management of hypertension. CCBs are among the most used antihypertensive medications and Cilnidipine is a newer dihydropyridine CCB shown to have a prolonged antihypertensive property.

OBJECTIVE

 This meta-analysis of comparative randomized and non-randomized clinical trials evaluated the effect of Cilnidipine monotherapy or combination therapy on systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate (PR) over 48 weeks of therapy.

STUDY DESIGN

 PubMed (MEDLINE) and Google scholar databases were searched to identify studies designed to evaluate the effects of Cilnidipine in the treatment of hypertensive patients. The study criteria for inclusion into the meta-analysis were all prospective, randomized, and non-randomized clinical studies published till March 2021, studies published in a peer-reviewed journal, the inclusion of patients with hypertension, assessment of blood pressure and heart rate, and a follow-up of four weeks or longer. The initial search identified 82 potential articles; of these, 24 met the inclusion criteria. Studies with <4 weeks treatment period and those not having a CCB were excluded.

OUTCOMES

 Change in SBP, DBP, and PR from baseline at the end of therapy compared between the Cilnidipine and other CCB's.

RESULTS

Cilnidipine caused a significant reduction (p<0.05) in SBP, DBP, and PR at end of therapy, whereas the reduction in SBP, DBP, and PR with Cilnidipine was similar to other CCB's (p>0.05). The results of this meta-analysis revealed that there were no significant differences in the efficacy in the treatment of hypertensive patients with Cilnidipine and the other therapies.

CONCLUSION

 Cilnidipine has similar anti-hypertensive effects compared with other first-line antihypertensive drugs commonly used in practice. We recommend Cilnidipine as a novel first-line CCB for the management of hypertension either as a monotherapy or as a combination therapy.

Efficacy of a digital therapeutics system in the management of essential hypertension: the HERB-DH1 pivotal trial

AIMS

Digital therapeutics is a new approach to facilitate the non-pharmacological treatment of hypertension using software programmes such as smartphone applications and/or device algorithms. Based on promising findings from a small pilot trial, the HERB Digital Hypertension 1 (HERB-DH1) pivotal trial investigated the efficacy of digital therapeutics in patients with hypertension not receiving antihypertensive medication.

METHODS AND RESULTS

This prospective, open-label, randomized controlled study was performed at 12 sites in Japan. Patients with hypertension [office systolic blood pressure (SBP) 140 to <180 mmHg and 24 h SBP ≥130 mmHg] were randomly assigned 1:1 to the digital therapeutics group (HERB system + standard lifestyle modification) or control group (standard lifestyle modification alone). The primary efficacy endpoint was the mean change in 24 h ambulatory SBP from baseline to 12 weeks; key secondary efficacy endpoints were mean changes in office and home blood pressure (BP) from baseline to 12 weeks. All analyses were conducted in the full analysis set population. Between December 2019 and June 2020, 390 patients were randomly assigned to the digital therapeutics group (n = 199) or control (n = 191) group. Between-group differences in 24-h ambulatory, home, and office SBPs at 12 weeks were -2.4 (95% confidence interval -4.5 to -0.3), -4.3 (-6.7 to -1.9), and -3.6 (-6.2 to -1.0) mmHg, respectively. No major programme-related safety events occurred up to 24 weeks.

CONCLUSION

The HERB-DH1 pivotal study showed the superiority of digital therapeutics compared with standard lifestyle modification alone to reduce 24-h ambulatory, home, and office BPs in the absence of antihypertensive medications.

The blood pressure control and arteriosclerotic cardiovascular risk among Chinese community hypertensive patients

The present study aimed to describe the blood pressure (BP) control rate and 10-years arteriosclerotic cardiovascular disease (ASCVD) risk estimation among community hypertensive patients. A total of 196,803 subjects were enrolled. The control rates calculated as the intensive (SBP < 130 mmHg and DBP < 80 mmHg) and standard (SBP < 140 mmHg and DBP < 90 mmHg) threshold. Multivariable logistic analysis was employed to assess the associations between cardiovascular factors and BP control. Sensitivity, specificity and Youden’s index were used to identify the ability of high risk of ASCVD estimation by different thresholds. The control rate was 16.34% and 50.25% by the intensive and standard threshold, respectively. Besides regular medication, the risk factors for BP control included older age, male, unhealthy lifestyle, obesity, dyslipidemia and abnormal FPG. 25.08% of subjects had high risk of 10-years ASCVD estimation. The sensitivity, specificity and Youden’s index of intensive threshold was 84.37%, 16.15% and 0.51%, and were significantly different from 50.55%, 50.42% and 0.98% of the standard threshold, respectively. Half of community hypertensive patients did not control BP, and nearly a quarter have high risk of 10-years ASCVD risk estimation. The intensive threshold resulted in a one-third reduction in the control rate compared to the standard threshold. No matter which threshold was used, a single BP control status seemed not a suitable indicator for identification of high risk of 10-years ASCVD risk estimation.

Trajectories of Systolic Blood Pressure in Children: Risk Factors and Cardiometabolic Correlates

OBJECTIVE

To identify systolic blood pressure (SBP) percentile trajectories in children and to describe the early-life risk factors and cardiometabolic correlates of those trajectories.

STUDY DESIGN

Using age-, sex-, and height-specific SBP percentiles based on the American Academy of Pediatrics reference, we examined SBP trajectories using latent class mixed models from ages 3 to 8 years (n = 844) from the Growing Up in Singapore Towards healthy Outcomes-study, a Singaporean mother-offspring cohort study. We analyzed associations between SBP trajectories and early-life risk factors using multinomial logistic regression and differences across trajectories in cardiometabolic outcomes using multiple linear regression.

RESULTS

Children were classified into 1 of 4 SBP percentile trajectories: "low increasing" (15%), "high stable" (47%), "high decreasing" (20%), and "low stable" (18%). Maternal hypertension during early pregnancy was a predictor of the "high stable" and "low increasing" SBP trajectories. Rapid child weight gain in the first 2 years of life was only associated with the "high stable" trajectory. Compared with children in the "low stable" trajectory, children in the "high stable" SBP trajectory had greater body mass index z scores, sum of skinfold thicknesses, waist circumference from ages 3 to 8 years, and abdominal adipose tissue (milliliters) at 4.5 years (adjusted mean difference [95% CI]: superficial and deep subcutaneous abdominal adipose tissue: 115.2 [48.1-182.3] and 85.5 [35.2-135.8]). Their fat mass (kilograms) (1.3 [0.6-2.0]), triglyceride levels (mmol/L) (0.10 [0.02-0.18]), and homeostasis model assessment of insulin resistance (0.28 [0.11 0.46]) at age 6 years were also greater but not their arterial thickness and stiffness.

CONCLUSIONS

Reducing maternal blood pressure during pregnancy and infant weight gain in the first 2 years of life might help to prevent the development of high SBP.

Faculty Service-Learning Students as Home-Visitors: Outcomes of a Lifestyle Modification Program for Vulnerable Families With Residents in Rural Indonesian Communities

Background: Risks attributed to chronic diseases, cancer, musculoskeletal discomfort, and infectious diseases among Indonesians were found to be associated with lifestyle behaviors, particularly in rural areas. The aim of this study was to examine the outcomes of a home-visiting lifestyle modification program on improving health risk behaviors among Indonesians living in rural areas. Methods: A total of 160 Indonesians living in rural hamlets in the Yogyakarta Region of Indonesia participated in the program in the period of June 21 to July 21, 2019. In the pre-intervention home interview, learning needs of diet, exercise, hand hygiene, and substance use were identified by using structured assessment tools. In the next home visit, the visitors provided health education and facilitated lifestyle planning based on the related affective and cognitive domains of learning. Subsequent follow-up interviews were conducted 3 weeks after intervention. Results: The results showed that the self-reported intake of vegetables, fruits, meat and salt, cooking with less oil, hand hygiene before eating, number of cigarettes smoked, and symptoms of muscle stiffness significantly improved after the intervention. The lifestyle modification program consisted of the affective and cognitive domains of learning, and could lead to the target behavioral changes in self-reported and observable measures over 1 month. Conclusions: The findings contributed to the framework of community-based health education for health risk reduction and behavioral modification in developing rural communities where health care resources were limited. Further studies with control groups and vigorous objective measures were recommended to elucidate its long-term impacts. The factors leading to its sustainability concerning collaborative care partnerships between community residents and faculty resources are worthy of continued exploration.

Digital therapeutics for essential hypertension using a smartphone application: A randomized, open-label, multicenter pilot study

Hypertension is the most considerable but treatable risk factor for cardiovascular disease. Although physicians prescribe multiple antihypertensive drugs and promote lifestyle modifications, the real-world blood pressure (BP) control rate remains poor. To improve BP target achievement, we developed a novel digital therapeutic-the HERB software system -to manage hypertension. Here, we performed a randomized pilot study to assess the safety and efficacy of the HERB system for hypertension. We recruited 146 patients with essential hypertension from March 2018 to March 2019. We allocated eligible patients to the intervention group (HERB system + standard lifestyle modification) or control group (standard lifestyle modification alone). The primary outcome was the mean change from baseline to 24 weeks in 24-hour systolic BP (SBP) measured by ambulatory blood pressure monitoring (ABPM). The baseline characteristics in each group were well balanced; the mean age was approx. 57 years, and 67% were male. In the primary end point at 24 weeks, HERB intervention did not lower the mean change of 24-hour SBP by ABPM compared with the controls (adjusted difference: -0.66 mmHg; p = .78). In an exploratory analysis focusing on antihypertensive drug-naïve patients aged <65, the effects of the HERB intervention were significantly greater than the control for reducing 24-hour SBP by ABPM at 16 weeks (adjusted difference: -7.6 mmHg; p = .013; and morning home SBP at 24 weeks (adjusted difference - 6.0 mmHg; p = .012). Thus, the HERB intervention did not achieve a primary efficacy end point. However, we observed that antihypertensive drug-naïve adult hypertensive patients aged <65 years could be a potential HERB system-effective target for further investigations of the efficacy of the system.

Stage 1 hypertension by the 2017 American College of Cardiology/American Heart Association hypertension guidelines and risk of cardiovascular disease events: systematic review, meta-analysis, and estimation of population etiologic fraction of prospective cohort studies

BACKGROUND

Epidemiological studies reported an inconsistent association between stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg) defined by the 2017 American College of Cardiology/American Heart Association hypertension guidelines and cardiovascular disease (CVD) events. In addition, the proportion of CVD events that could be prevented with effective control of stage 1 hypertension is unknown.

OBJECTIVES

To assess the association between stage 1 hypertension and CVD events and estimate the population etiologic fraction.

METHODS

PubMed, Embase, and Web of Science databases were searched from 1 January 2017 to 22 September 2019. Normal BP was considered SBP less than 120 mmHg and DBP less than 80 mmHg. Hazard ratios and 95% confidence intervals (95% CIs) were pooled by using a random-effects model.

RESULTS

We included 11 articles (16 studies including 3 212 447 participants and 65 945 events) in the analysis. Risk of CVD events was increased with stage 1 hypertension versus normal BP (hazard ratio 1.38, 95% CI 1.28-1.49). On subgroup analyses, stage 1 hypertension was associated with coronary heart disease (CHD) (hazard ratio 1.30, 95% CI 1.20-1.41), stroke (1.39, 1.27-1.52), CVD morbidity (1.42, 1.32-1.53), and CVD mortality (1.34, 1.05-1.71). The population etiologic fraction for the association of CVD events, CHD, stroke, CVD morbidity, and CVD mortality with stage 1 hypertension was 12.90, 10.48, 12.71, 14.03, and 11.69%, respectively.

CONCLUSION

Stage 1 hypertension is associated with CVD events, CVD morbidity, CVD mortality, CHD, and stroke. Effective control of stage 1 hypertension could prevent more than 10% of CVD events.

Regional differences in office and self-measured home heart rates in Asian hypertensive patients: AsiaBP@Home study

Increased heart rate is a predictor of cardiovascular disease, heart failure, and all‐cause mortality. In those with high heart rates, interventions for heart rate reduction have been associated with reductions in coronary events. Asia is a diverse continent, and the prevalences of hypertension and cardiovascular disease differ among its countries. The present analysis of AsiaBP@Home study data investigated differences among resting heart rates (RHRs) in 1443 hypertensive patients from three Asian regions: East Asia (N = 595), Southeast Asia (N = 680), and South Asia (N = 168). This is the first study to investigate self‐measured RHR values in different Asian countries/regions using the same validated home BP monitoring device (Omron HEM‐7130‐AP/HEM‐7131‐E). Subjects in South Asia had higher RHR values compared with the other two regions, and the regional tendency found in RHR values was different from that found in BP values. Even after adjusting for age, sex, BMI, habitual alcohol consumption, current smoking habit, shift worker, hyperlipidemia, diabetes, chronic kidney disease, history of heart failure, and beta‐blocker use, both office and home RHR values in South Asia were the highest among Asia (mean values ± SE of office: East Asia [E] 75.2 ± 1.5 bpm, Southeast Asia [Se] 76.7 ± 1.5 bpm, South Asia [S] 81.9 ± 1.4 bpm; home morning: [E] 69.0 ± 1.2 bpm, [Se] 72.9 ± 1.2 bpm, [S] 74.9 ± 1.1 bpm; home evening: [E] 74.6 ± 1.2 bpm, [Se] 78.3 ± 1.2 bpm, [S] 83.8 ± 1.1 bpm). Given what is known about the impact of RHR on heart disease, our findings suggest the possible benefit of regionally tailored clinical strategies for cardiovascular disease prevention.

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Dietary Salt-Related Determinants of Hypertension in Rural Northern Thailand

Hypertension and its connection to high salt consumption have been observed in the Thai population. This study mainly contributed to the literature to examine the dietary-salt-related determinants associated with the risk of hypertension in rural northern Thailand, which exhibited the highest prevalence of hypertension. A total of 376 adults residing in San Pa Tong District, Chiang Mai province, were face-to-face interviewed using a structured questionnaire assessing dietary-salt-related knowledge, attitudes, consumption, sources, and habits. The subject’s blood pressure (BP) was measured twice before and after the interview. Hypertension was defined as a systolic BP ≥ 130 mmHg or a diastolic BP ≥ 80 mmHg. The dietary-salt-related knowledge, attitude, and habits toward salt reduction were positively correlated; however, knowledge and attitudes were not significantly correlated with consumption. Multivariate logistic regression results indicated subjects who frequently bought ready-to-eat food, ate out, or used bouillon cube/monosodium glutamate (MSG) during food preparation were likely to have hypertension (OR = 2.24, 95% CI: 1.36–3.69, p = 0.002). MSG was heavily consumed and used as a flavor enhancer in northern Thai cuisine; however, a few subjects realized it contains sodium due to no salty taste. The deficiency of specific dietary-salt-related knowledge illustrated the need for tailored educational intervention strategies.

High prevalence of masked uncontrolled morning hypertension in elderly non-valvular atrial fibrillation patients: Home blood pressure substudy of the ANAFIE Registry

In the ANAFIE Registry home blood pressure subcohort, we evaluated 5204 patients aged ≥75 years with non-valvular atrial fibrillation (NVAF) to assess blood pressure (BP) control, prevalence of masked hypertension, and anticoagulant use. Mean clinic (C) and home (H) systolic/diastolic BP(SBP/DBP) was 128.5/71.3 and 127.7/72.6 mm Hg, respectively. Overall, 77.5% of patients had hypertension; of these, 27.7%, 13.4%, 23.4%, and 35.6% had well-controlled, white coat, masked, and sustained hypertension, respectively. Masked hypertension prevalence increased with diabetes, decreased renal function, age ≥80 years, current smoker status, and chronic obstructive pulmonary disease. By morning/evening average, 59.0% of patients had mean H-SBP ≥ 125 mm Hg; 48.9% had mean C-SBP ≥ 130 mm Hg. Early morning hypertension (morning H-SBP ≥ 125 mm Hg) was found in 65.9% of patients. Although 51.1% of patients had well-controlled C-SBP, 52.5% of these had uncontrolled morning H-SBP. In elderly NVAF patients, morning H-BP was poorly controlled, and masked uncontrolled morning hypertension remains significant.

Prevalence and prognosis of the 2018 vs 2008 AHA definitions of apparent treatment-resistant hypertension in high-risk hypertension patients

Resistant hypertension was defined according to the 2008 scientific statement as office blood pressure ≥ 140/90 mm Hg and the 2018 scientific statement as office blood pressure ≥ 130/80 mm Hg. We investigated the prognostic significance of lowered blood pressure threshold for defining resistant hypertension in the 2018 American Heart Association scientific statement compared with that in the 2008 scientific statement. The participants of this prospective cohort were enrolled from December 2013 to November 2018. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and heart failure hospitalization. Renal event was defined as a ≥ 50% decline in estimated glomerular filtration rate or progression to end-stage renal disease. A total of 206 patients among 2018 (10.2%) were diagnosed with resistant hypertension by the previous definition (≥140/90 mm Hg), and 276 patients among 2011 (13.7%) were diagnosed with resistant hypertension by the updated definition (≥130/80 mm Hg). During a median follow-up of 4.5 years, 33 MACEs (3.7 per 1000 patient-years) and 164 renal events (19.9 per 1000 patient-years) occurred in the study population. Treatment-resistant hypertension groups had a higher incidence rate of MACEs and renal events than the control groups. In multivariate Cox proportional hazards regression analysis, resistant hypertension by both definitions was significantly associated with increased risk of MACE and renal event. Both the previous and updated definitions of resistant hypertension were significant predictors of MACEs and renal events. This finding supports the adoption of the updated criteria for resistant hypertension in clinical practice.

A multicenter clinical trial to assess the efficacy of the digital therapeutics for essential hypertension: Rationale and design of the HERB-DH1 trial

Digital therapeutics is a new approach to treat hypertension via using software programs such as smartphone apps and/or device algorithms. We develop a HERB system-new interactive smartphone app (HERB Mobile) with web-based patient management console (HERB Console)-to lower blood pressure (BP) based on an algorithm that helps users to promote lifestyle modifications in conjunction with medically validated non-pharmacological interventions. The app can assess the personalities, behavior characteristics, and hypertension determinants of each patient with hypertension to provide adequate guidance. To demonstrate the efficacy of the system, we designed a randomized, controlled, multicenter, open-label trial "HERB-DH1 (HERB digital hypertension 1)" to assess the efficacy of HERB system in patients with essential hypertension. The authors allocate patients to the intervention group (HERB system + standard lifestyle modification) or to the control group (standard lifestyle modification alone). In the intervention group, we provide the HERB Mobile for patients and the HERB Console for their primary physicians for 24 weeks. Both groups are instructed for standard lifestyle modifications based on the current recommendations in the Japanese Society of Hypertension 2019 guideline. The primary outcome is the mean change from baseline to 12 weeks in 24-hour systolic BP measured by ambulatory BP monitoring. We started this study in December of 2019, and the trial results will be expected in early 2021. We believe that this trial enables us to verify the efficacy of the HERB system in patients with essential hypertension.

Single-pill combination of cilnidipine, an L-/N-type calcium channel blocker, and valsartan effectively reduces home pulse pressure in patients with uncontrolled hypertension and sympathetic hyperactivity: The HOPE-Combi survey

The home blood pressure (BP) control by a single-pill combination of cilnidipine (an L-/N-type calcium channel blocker; CCB) and valsartan (HOPE-Combi) survey is a multicenter, post-marketing, prospective observational study of a single-pill combination of cilnidipine 10 mg and valsartan 80 mg (SPC of Cil/Val) in patients with uncontrolled hypertension. We examined the effects of the SPC of Cil/Val on morning home systolic BP (MHSBP) and morning home pulse pressure (MHPP) of 1036 patients with hypertension over 12 months. MHSBP decreased by 14.0 mm Hg (P < .01), and MHPP decreased by 6.6 mm Hg (P < .01). Moreover, morning home pulse rate (MHPR) decreased by 2.1 bpm (P < .01). A more progressive and greater decrease in MHSBP (-17.2 vs -10.3 mm Hg, P < .01) and MHPP (-7.6 vs -4.9 mm Hg, P < .01) was observed in patients with higher MHPR (≥70 bpm) than in those with lower MHPR (<70 bpm) over the treatment period. In particular, in patients with a wide MHPP (≥70 mm Hg), the difference in the MHPP reduction was greater in patients with higher MHPR than in those with lower MHPR (-17.9 vs -13.6 mm Hg, P < .01). These results suggested that the SPC of Cil/Val, which possesses the unique sympatholytic characteristics of an L-/N-type CCB, was particularly effective in patients with uncontrolled hypertension and sympathetic hyperactivity.

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.

Renal Denervation in Asia: Consensus Statement of the Asia Renal Denervation Consortium

The Asia Renal Denervation Consortium consensus conference of Asian physicians actively performing renal denervation (RDN) was recently convened to share up-to-date information and regional perspectives, with the goal of consensus on RDN in Asia. First- and second-generation trials of RDN have demonstrated the efficacy and safety of this treatment modality for lowering blood pressure in patients with resistant hypertension. Considering the ethnic differences of the hypertension profile and demographics of cardiovascular disease demonstrated in the SYMPLICITY HTN (Renal Denervation in Patients With Uncontrolled Hypertension)-Japan study and Global SYMPLICITY registry data from Korea and Taiwan, RDN might be an effective hypertension management strategy in Asia. Patient preference for device-based therapy should be considered as part of a shared patient-physician decision process. A practical population for RDN treatment could consist of Asian patients with uncontrolled essential hypertension, including resistant hypertension. Opportunities to refine the procedure, expand the therapy to other sympathetically mediated diseases, and explore the specific effects on nocturnal and morning hypertension offer a promising future for RDN. Based on available evidence, RDN should not be considered a therapy of last resort but as an initial therapy option that may be applied alone or as a complementary therapy to antihypertensive medication.

Perspectives of patients and physicians regarding hypertensive management from an online survey for excellence: a subanalysis of the PARADOX study by physician categories

An existing clinical problem in Japan is the high prevalence of uncontrolled hypertension despite the availability of various effective therapies. Here, we analyzed survey data to gain insight into this paradox from physicians’ perspectives, with results categorized according to specialty (i.e., with or without certification by the Japanese Society of Hypertension [JSH]), institution type, gender, and age. A web-based survey of typical educational activities for patients regarding hypertension management was conducted in Japan between October 19 and 31, 2017. Differences between physician groups were investigated per category. Survey results from 541 physicians were analyzed: 59 JSH certified (i.e., ‘specialist’) vs 482 non-JSH certified (i.e., ‘nonspecialist’) physicians; 192 general practitioners vs 349 hospital physicians; 500 males vs 41 females; and 178 younger (mean age: 40.7 years), 174 middle-aged (52.0 years) or 189 older (61.3 years) physicians. The most statistically significant differences between groups were observed in the category of physician specialty. Compared with nonspecialists, specialist physicians were more conscious of providing education on patient lifestyle modifications, more aware of patient- and physician-derived issues, and understood and followed the treatment guidelines. General practitioners cared more about the patient’s burden than did hospital physicians. Younger physicians identified the need to incorporate the patient’s perspective into their treatment. This analysis shows that the provision and perceptions of education differ between physician categories. Compared with specialist physicians, nonspecialists were less likely to provide adequate guidance on lifestyle modifications, possibly due to their uncertainty in understanding treatment guideline recommendations. Further education of nonspecialists on hypertension management may be warranted.

Sex-Specific Association of Blood Pressure Categories With All-Cause Mortality: The Rural Chinese Cohort Study

Introduction

The relationship between blood pressure categories and all-cause mortality has not been fully addressed in cohort studies, especially in the general Chinese population. Our study aimed to assess the sex-specific association of systolic blood pressure (SBP), diastolic blood pressure (DBP), and 2017 United States hypertension guidelines with all-cause mortality in China.

Methods

We conducted a prospective study of 13,760 rural Chinese adults aged 18 or older (41.1% men). Mean age overall was 49.4, 51.0 for men, and 48.3 for women. We analyzed the blood pressure–mortality relationship by using restricted cubic splines and Cox proportional-hazards regression analysis, estimating hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

During a mean follow-up of 5.95 years, 710 people died (60.3% men) from any cause. We found a U-shaped SBP–mortality or DBP–mortality relationship for both sexes. Mortality risk was increased for men with SBP 120–139 mm Hg (adjusted HR [aHR], 1.42; 95% CI, 1.10–1.82) or ≥140 mm Hg (aHR, 2.05; 95% CI, 1.54–2.72), and for DBP ≥90 mm Hg (aHR, 1.53; 95% CI, 1.10–2.13) as compared with SBP 100–119 mm Hg or DBP 70–79 mm Hg. Mortality risk also was increased for men with blood pressure status defined according to 2017 US hypertension guidelines as elevated, SBP 120–129 and DBP >80 mm Hg (aHR 1.48; 95% CI,1.11–1.98); stage 1 hypertension, SBP/DBP 130–139/80–89 mm Hg (aHR 1.53; CI, 1.19–1.97); and stage 2 hypertension, SBP/DBP ≥140/90 mm Hg (aHR 1.83; CI, 1.33–2.51). No significant relationship was observed for women.

Conclusion

Elevated blood pressure and stages 1 and 2 hypertension were positively associated with all-cause mortality for men but not women in rural China.

Association Between Blood Pressure Variability and Cerebral Small-Vessel Disease: A Systematic Review and Meta-Analysis

Background

Research links blood pressure variability (BPV) with stroke; however, the association with cerebral small‐vessel disease (CSVD) remains unclear. As BPV and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding cerebrovascular morphological characteristics.

Methods and Results

A systematic review was performed from inception until March 3, 2019. Eligibility criteria included population, adults without stroke (<4 weeks); exposure, BPV quantified by any metric over any duration; comparison, (1) low versus high or mean BPV and (2) people with versus without CSVD; and outcomes, (1) CSVD as subcortical infarct, lacunae, white matter hyperintensities, cerebral microbleeds, or enlarged perivascular spaces; and (2) standardized mean difference in BPV. A total of 27 articles were meta‐analyzed, comprising 12 309 unique brain scans. A total of 31 odds ratios (ORs) were pooled, indicating that higher systolic BPV was associated with higher odds for CSVD (OR, 1.27; 95% CI, 1.14–1.42; I²=85%) independent of mean systolic pressure. Likewise, higher diastolic BPV was associated with higher odds for CSVD (OR, 1.30; 95% CI, 1.14–1.48; I²=53%) independent of mean diastolic pressure. There was no evidence of a pairwise interaction between systolic/diastolic and BPV/mean ORs (P=0.47), nor a difference between BPV versus mean pressure ORs (P=0.58). Fifty‐four standardized mean differences were pooled and provided similar results for pairwise interaction (P=0.38) and difference between standardized mean differences (P=0.70).

Conclusions

On the basis of the available studies, BPV was associated with CSVD independent of mean blood pressure. However, more high‐quality longitudinal data are required to elucidate whether BPV contributes unique variance to CSVD morphological characteristics.