US Hypertension Management Guidelines: A Review of the Recent Past and Recommendations for the Future

The usage of anticholinergic medications in a low- and middle-income country: a longitudinal comparison of 2013-15 and 2020-22 datasets

BACKGROUND

While the effects of anticholinergic drug use have been increasingly highlighted, trends in anticholinergic use remain poorly understood.

AIM

To determine the changes in frequency and pattern of anticholinergic drug use within a low- and middle-income country.

METHOD

Comparisons were made between population-based datasets collected from Malaysian residents aged 55 years and older in 2013-15 and 2020-22. Anticholinergic exposure was determined using the anticholinergic cognitive burden (ACB) tool. Drugs with ACB were categorised according to the Anatomical Therapeutic Chemical (ATC) classification.

RESULTS

A total number of 5707 medications were recorded from the 1616 participants included in the 2013-15 dataset. A total number of 6175 medications were recorded from 2733 participants in 2020-22. Two hundred and ninety-three (18.1%) and 280 (10.2%) participants consumed ≥ 1 medication with ACB ≥ 1 in 2013-15 and 2020-22 respectively. The use of nervous system drugs with ACB had increased (27 (0.47%) versus 39 (0.63%). The use of ACB drugs in the cardiovascular (224 (3.9%) versus 215 (3.4%)) and alimentary tract and metabolism (30 (0.52%) versus 4 (0.06%)) classes had reduced over time. Participants in 2020-22 were significantly less likely than those in 2013-15 to have total ACB = 1 - 2 (odds ratio [95% confidence interval] = 0.473[0.385-0.581]) and ACB ≥ 3 (0.251[0.137 - 0.460]) compared to ACB = 0 after adjustment for potential confounders (p < 0.001).

CONCLUSION

Although anticholinergic exposure has decreased over time, the use of medications with anticholinergic effects in the nervous system class has risen. This increase is attributable to antipsychotic use, which is of concern due to potential cardiovascular complications, and deserves further evaluation.

The Effectiveness of Collaborative Advanced Practice Nursing in Primary Hypertension Management: A Randomized Controlled Trial

BACKGROUND

Hypertension is a global health concern that is best managed at the primary care level. In low- and middle-income countries (LMICs) facing resource constraints, collaboration between well-prepared entry-level advanced practice nurses (APNs) and physicians (medical doctors [MDs]) can enhance the care of patients with primary hypertension.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of collaborative entry-level APNs in primary hypertension management, including patient knowledge, physiological and behavioral outcomes, consultation length, and patient satisfaction.

METHODS

Sixty-three eligible patients were randomly assigned to either an entry-level APN intervention group or a control group with MDs. Three master's-prepared nurses, trained in hypertension management, acted as entry-level APNs, following the Joint National Committee guidelines in collaboration with a physician. The control group underwent standard clinic consultations. After 1 month, a mixed analysis of variance was used to assess intervention effectiveness, examining both between-groups and within-groups outcomes.

RESULTS

Both groups shared similar sociodemographic and baseline characteristics. Significant improvements in blood pressure, body mass index, knowledge, self-management, and medication adherence were found at the 1-month follow-up, with no significant differences in outcomes or patient satisfaction between the entry-level APN and MD groups. However, clinical consultation time was significantly longer for entry-level APNs than for MDs.

CONCLUSIONS

Collaborative entry-level APNs managing primary hypertension are comparable with MD care; however, larger, longer trials are essential for a thorough assessment. Strengthening the development of entry-level advanced practice nursing roles in low- and middle-income countries is crucial for addressing service gaps in primary hypertension and other chronic diseases.

Investigating the effect of hypertension on vascular cognitive impairment by using the resting-state functional connectome

Hypertension (HTN) affects over 1.2 billion individuals worldwide and is defined as systolic blood pressure (BP) ≥ 140 mmHg and diastolic BP ≥ 90 mmHg. Hypertension is also considered a high risk factor for cerebrovascular diseases, which may lead to vascular cognitive impairment (VCI). VCI is associated with executive dysfunction and is also a transitional stage between hypertension and vascular dementia. Hence, it is essential to establish a reliable approach to diagnosing the severity of VCI. In 28 HTN (51-83 yrs; 18 males, 10 females) and 28 healthy controls (HC) (51-75 yrs; 7 males, 21 females), we investigated which regions demonstrate alterations in the resting-state functional connectome due to vascular cognitive impairment in HTN by using the amplitude of the low-frequency fluctuations (ALFF), regional homogeneity (ReHo), graph theoretical analysis (GTA), and network-based statistic (NBS) methods. In the group comparison between ALFF/ReHo, HTN showed reduced spontaneous activity in the regions corresponding to vascular or metabolic dysfunction and enhanced brain activity, mainly in the primary somatosensory cortex and prefrontal areas. We also observed cognitive dysfunction in HTN, such as executive function, processing speed, and memory. Both the GTA and NBS analyses indicated that the HTN demonstrated complex local segregation, worse global integration, and weak functional connectivity. Our findings show that resting-state functional connectivity was altered, particularly in the frontal and parietal regions, by hypertensive individuals with potential vascular cognitive impairment.

Traditional Therapeutics and Potential Epidrugs for CVD: Why Not Both?

Cardiovascular disease (CVD) is the leading cause of death worldwide. In addition to the high mortality rate, people suffering from CVD often endure difficulties with physical activities and productivity that significantly affect their quality of life. The high prevalence of debilitating risk factors such as obesity, type 2 diabetes mellitus, smoking, hypertension, and hyperlipidemia only predicts a bleak future. Current traditional CVD interventions offer temporary respite; however, they compound the severe economic strain of health-related expenditures. Furthermore, these therapeutics can be prescribed indefinitely. Recent advances in the field of epigenetics have generated new treatment options by confronting CVD at an epigenetic level. This involves modulating gene expression by altering the organization of our genome rather than altering the DNA sequence itself. Epigenetic changes are heritable, reversible, and influenced by environmental factors such as medications. As CVD is physiologically and pathologically diverse in nature, epigenetic interventions can offer a ray of hope to replace or be combined with traditional therapeutics to provide the prospect of addressing more than just the symptoms of CVD. This review discusses various risk factors contributing to CVD, perspectives of current traditional medications in practice, and a focus on potential epigenetic therapeutics to be used as alternatives.

Long-term oral ACEI/ARB therapy is associated with disease severity in elderly COVID-19 omicron BA.2 patients with hypertension

OBJECTIVE

To explore the effects of long-term oral ACEIs/ARBs on the incidence of exacerbation and in-hospital mortality in elderly COVID-19 Omicron BA.2 patients with hypertension, especially patients aged 80 years or older.

MATERIALS AND METHODS

In this retrospective study, patients suffering mild and rcommon COVID-19 with hypertension who were hospitalized in the Shanghai Fourth People's Hospital between April 2022 and June 2022 were enrolled. Primary outcomes included the incidence of exacerbation and in-hospital mortality. Secondary outcomes included the incidence of respiratory failure of patients, use of mechanical ventilation, nucleic acid conversion time (NCT), hospitalization costs, and the temporal trend of the incidence of exacerbations and in-hospital mortality in different age groups. The data were analysed using propensity score weighting (PSW).

RESULTS

In the entire cohort, there were 298 ACEI/ARB users and 465 non-ACEI/ARB users. The ACEI/ARB group showed a lower incidence of exacerbation (OR = 0.64, 95% CI for OR: 0.46-0.89, P = 0.0082) and lower in-hospital mortality (OR = 0.49, 95% CI for OR: 0.27-0.89, P = 0.0201) after PSW. Sensitivity analysis obtained the same results. The results of the subgroup of patients aged 80 years and older obtained a similar conclusion as the whole cohort. Most of the study indicators did not differ statistically significantly in the subgroup of patients aged 60 to 79 years except for rates of mechanical ventilation and respiratory failure.

CONCLUSION

Antihypertensive therapy with ACEIs/ARBs might reduce the incidence of exacerbation and in-hospital mortality. The findings of this study support the use of ACEIs/ARBs in COVID-19 patients infected by Omicron BA.2, especially in patients aged 80 years or older with hypertension.

[Relationship between the systolic-diastolic shock index and mortality in myocardial infarction]

Background

In the emergency room, the shock index was applied to determine the prognosis in various pathologies, such as acute infarction. The shock index is the re-sult of dividing heart rate by the systolic blood pressure.

Objective

To determine the relationship between the systolic shock index and the di-astolic shock index as prognostic factors for mortality in acute myocardial infarction with ST segment elevation prior to admission to the Hemodynamics Room.

Material and methods

A prolective analytical cross-sectional study was carried out in patients who were admitted to the Hemodynamics Room for cardiac catheterization within a period of 5 months in 2022. The systolic shock index and diastolic shock index were included as independent variables and mortality was the dependent variable. SPSS, version 25, was used and Pearson's chi-square test was used as statistical test, with a p value < 0.05 being significant.

Results

162 patients were analyzed and showed a diastolic shock index > 1.2143 with a sensitivity of 62.5% and a specificity of 77.4% with a p < 0.05. Their systolic shock in-dex was > 0.8908 with a sensitivity of 45.8% and specificity of 91.2%, with a p < 0.05.

Conclusion

It was determined that both shock indices are related as mortality prognos-tic factors in acute myocardial infarction with ST elevation prior to admission to the He-modynamic Room.

Impact assessment of e-trainings in occupational safety and health: a literature review

BACKGROUND

Implementing workplace preventive interventions reduces occupational accidents and injuries, as well as the negative consequences of those accidents and injuries. Online occupational safety and health training is one of the most effective preventive interventions. This study aims to present current knowledge on e-training interventions, make recommendations on the flexibility, accessibility, and cost-effectiveness of online training, and identify research gaps and obstacles.

METHOD

All studies that addressed occupational safety and health e-training interventions designed to address worker injuries, accidents, and diseases were chosen from PubMed and Scopus until 2021. Two independent reviewers conducted the screening process for titles, abstracts, and full texts, and disagreements on the inclusion or exclusion of an article were resolved by consensus and, if necessary, by a third reviewer. The included articles were analyzed and synthesized using the constant comparative analysis method.

RESULT

The search identified 7,497 articles and 7,325 unique records. Following the title, abstract, and full-text screening, 25 studies met the review criteria. Of the 25 studies, 23 were conducted in developed and two in developing countries. The interventions were carried out on either the mobile platform, the website platform, or both. The study designs and the number of outcomes of the interventions varied significantly (multi-outcomes vs. single-outcome). Obesity, hypertension, neck/shoulder pain, office ergonomics issues, sedentary behaviors, heart disease, physical inactivity, dairy farm injuries, nutrition, respiratory problems, and diabetes were all addressed in the articles.

CONCLUSION

According to the findings of this literature study, e-trainings can significantly improve occupational safety and health. E-training is adaptable, affordable, and can increase workers' knowledge and abilities, resulting in fewer workplace injuries and accidents. Furthermore, e-training platforms can assist businesses in tracking employee development and ensuring that training needs are completed. Overall, this analysis reveals that e-training has enormous promise in the field of occupational safety and health for both businesses and employees.

Estimation of the Risk of Postoperative Hypertension Following Minor to Moderate Surgery Using an Echocardiogram and Biomarkers

This study aimed to determine independent factors for developing postoperative hypertension using 4 biomarkers in patients receiving oral and maxillofacial surgery under general anesthesia. Brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity myocardial troponin T (hs-TnT), and high-sensitivity myocardial troponin I (hs-TnI) were measured and preoperative echocardiograms were examined. Episodes of systolic blood pressure (SBP) ≥ 170 mmHg or diastolic blood pressure ≥ 100 mmHg within 1 week after surgery were considered postoperative hypertension. We analyzed 213 (130 men; 83 women) patients, who were divided into a postoperative hypertension group (HT group, n = 32) and a normal group (N group, n = 181). The HT group showed a higher LVMI (113.5 versus 100.1), higher E/e' of the lateral wall (9.1 versus 7.7), and higher BNP (39.2 versus 22.9 pg/mL), NT-proBNP (400.1 versus 143.9 pg/mL), and hs-TnT (15.6 versus 10.3 ng/L) concentrations compared to the N group. NT-proBNP and hs-TnT concentrations positively associated with E/e', but BNP and hs-TnI did not. NT-proBNP (AUC = 0.64, cutoff value: 117.0 pg/mL) and hs-TnT (AUC = 0.61, cutoff value: 11.0 ng/L) concentrations were effective for discriminating E/e' ≥ 12. Multivariate logistic regression analyses showed that risk factors responsible for developing postoperative hypertension were NT-proBNP and hs-TnT using biomarkers and E/e' as independent variables, and NT-proBNP and SBP at admission using biomarkers and SBP at admission as independent variables. These findings suggest that NT-proBNP and hs-TnT concentrations, and SBP at admission, are useful to predict postoperative hypertension after minor to moderate surgery, and that left ventricular filling pressure is a primary factor associated with postoperative hypertension.

From COVID-19 to Sarcoidosis: How Similar Are These Two Diseases?

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leads to the dysregulation of the immune system, exacerbates inflammatory responses, and even causes multiple organ dysfunction syndrome in patients with severe disease. Sarcoidosis is an idiopathic granulomatous multisystem disease characterized by dense epithelioid non-necrotizing lesions with varying degrees of lymphocytic inflammation. These two diseases have similar clinical manifestations and may also influence each other and affect their clinical courses. In this study, we analyzed some possible connections between sarcoidosis and COVID-19, including the role of the renin–angiotensin system in the respiratory system, immune response, and cell death pathways, to understand the underlying mechanisms of SARS-CoV-2 infection, predisposing patients to severe forms of COVID-19. This review will provide a new prospect for the treatment of COVID-19 and an opportunity to explore the pathogenesis and development of sarcoidosis.

Factors responsible for Uncontrolled Hypertension in the Adults over 50 years of age: A pilot study from Northern India

Hypertension is the most common chronic disease of older adults and an important modifiable cause of mortality and morbidity. In this cross-sectional study, we gathered information about the demographic profile and biochemical parameters associated with hypertension in 897 study subjects above 50 years by structured questionnaires and various laboratory investigations. Higher body mass index, sedentary lifestyle, male sex, living alone, diabetes mellitus, alcohol consumption, medication non-compliance, and a higher serum cholesterol level were associated significantly with uncontrolled hypertension in our study. Hence, weight reduction, adopting an active lifestyle, improving social support, and strict compliance with anti-hypertensives are the cornerstones of blood pressure control.

Racial Disparity in Postpartum Readmission due to Hypertension among Women with Pregnancy-Associated Hypertension

OBJECTIVE

Postpartum hypertension is a leading cause of readmission in the postpartum period. We aimed to examine the prevalence of racial/ethnic differences in postpartum readmission due to hypertension in women with antepartum pregnancy-associated hypertension.

STUDY DESIGN

This was a multi-institutional retrospective cohort study of all women with antepartum pregnancy-associated hypertension diagnosed prior to initial discharge from January 2009 to December 2016. Antepartum pregnancy-associated hypertension, such as gestational hypertension, preeclampsia (with or without severe features), hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome, and eclampsia was diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions. Women with chronic hypertension and superimposed preeclampsia were excluded. Our primary outcome was postpartum readmission defined as a readmission due to severe hypertension within 6 weeks of postpartum. Risk factors including maternal age, gestational age at admission, insurance, race/ethnicity (self-reported), type of antepartum pregnancy-associated hypertension, marital status, body mass index (kg/m²), diabetes (gestational or pregestational), use of antihypertensive medications, mode of delivery, and postpartum day 1 systolic blood pressure levels were examined. Multivariable logistic regression models were performed to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

Of 4,317 women with pregnancy-associated hypertension before initial discharge, 66 (1.5%) had postpartum readmission due to hypertension. Risk factors associated with postpartum readmission due to hypertension included older maternal age (aOR = 1.44; 95% CI: 1.20-1.73 for every 5 year increase) and non-Hispanic black race (aOR = 2.12; 95% CI: 1.16-3.87).

CONCLUSION

In women with pregnancy-associated hypertension before initial discharge, non-Hispanic black women were at increased odds of postpartum readmission due to hypertension compared with non-Hispanic white women.

Dairy-originated digestion-resistant and bioactive peptides increase the risk of hypertension: Tehran Lipid and Glucose Study

Milk-protein-derived bioactive peptides (BPs) have been proposed as modulators of different regulatory processes involved in blood pressure regulation. Studies on the long-term effects of BPs on blood pressure have not yet been conducted. We aimed to investigate the association of dairy-originated BPs with the risk of hypertension (HTN) in the Tehran Lipid and Glucose Cohort Study (TLGS). In this cohort study, 4378 subjects with a mean follow-up period of 3.1 years were included in the final analysis. Dietary intake, physical activity, demographic, and anthropometric data and blood pressure measurements were obtained for all participants. Various types of dairy-originated BPs were determined by an in silico method. High intake of total digestion-resistant and bioactive peptides (OR: 1.31, CI 95%: 1.01-1.70), dipeptides (OR: 1.33, CI 95%: 1.03-1.73), peptides with more than seven residues (OR: 1.32, CI 95%: 1.01-1.71), glycosylated residues (OR: 1.39, CI 95%: 1.07-1.80), highly hydrophilic peptides (OR: 1.32, CI 95%: 1.01-1.71), and low hydrophobic peptides (OR: 1.32, CI 95%: 1.01-1.71) was associated with an increased risk of HTN in the adjusted model. In addition, subjects in the higher tertile of anti-HTN peptide (OR: 1.33, CI 95%: 1.02-1.72) and antidiabetic peptide (OR: 1.35, CI 95%: 1.04-1.76) intake had a higher risk of HTN than those in the lower tertile. No significant association emerged between calcium intake from dairy and incident risk of HTN. Our results showed that the intake of some forms of digestion-resistant and BPs, such as anti-HTN peptides, dipeptides, and peptides with more than seven residues, can increase the risk of HTN in the TLGS population.

Comparison of losartan and amlodipine effects on the outcomes of patient with COVID-19 and primary hypertension: A randomised clinical trial

BACKGROUND

Controversy exists regarding the drug selection in hypertension (HTN) management in patients with COVID-19. This study aimed to compare the effects of losartan and amlodipine in patients with primary HTN and COVID-19.

METHODS

In this randomised clinical trial, hospitalised patients with COVID-19 and primary HTN were enrolled in the study. One arm received losartan, 25 mg, twice a day and the other arm received amlodipine, 5 mg per day for 2 weeks. The main outcomes were compare 30-day mortality rate and length of hospital stay.

RESULTS

The mean age of patients treated with losartan (N = 41) and amlodipine (N = 39) was 67.3 ± 14.8 and 60.1 ± 17.3 years, respectively (P value = .068). The length of hospital stay in losartan and amlodipine groups was 4.57 ± 2.59 and 7.30 ± 8.70 days, respectively (P value = .085). Also, the length of ICU admission in losartan and amlodipine group was 7.13 ± 5.99 and 7.15 ± 9.95 days, respectively (P value = .994). The 30-day mortality was two and five patients in losartan and amlodipine groups, respectively (P value = .241).

CONCLUSIONS

There was no priority in losartan or amlodipine administration in COVID-19 patients with primary HTN in decreasing mortality rate, hospital and ICU length stay. Further studies need to clarify the first-line anti-HTN medications in COVID-19.

Dietary Amino Acid Patterns Are Associated With Incidence of Chronic Kidney Disease

OBJECTIVES

No findings are available regarding the association of the dietary amino acid (AA) intakes with the risk of chronic kidney disease (CKD) in adults. We aimed to assess the association between dietary AA patterns and incidence of CKD in adults.

DESIGN AND METHODS

This study was conducted within the framework of Tehran Lipid and Glucose Study on 4,233 adults, who were free of CKD at baseline (2009-2011) and were followed for 3.1 years (2011-2014). The principal component analysis was used based on 8 AA groups to characterize major AA patterns. Multivariable logistic regression models were used to estimate the risk of CKD across quartiles of dietary AA pattern scores.

RESULTS

Three major AA patterns were extracted: (1) higher loads of branched-chain, alcoholic, and aromatic AAs; (2) higher loads of acidic AAs, proline, and lower load of alkaline AAs and small AAs; and (3) higher loads of sulfuric AAs and small AAs. The mean ± standard deviation age of participants (45.9% male) was 39.4 ± 11.7 at baseline and the incidence of CKD was 12.1% (513 cases) after 3.1 years of follow-up. The highest score of first dietary AA pattern tended to be associated with an increased risk of CKD (odds ratio = 1.43, 95% confidence interval1.06-1.93); however, the second pattern was related to a decreased risk of CKD (odds ratio = 0.71, 95% confidence interval: 0.52-0.97) in the multivariable model.

CONCLUSION

These novel findings suggest that the dietary AA patterns may modify risk of CKD.

Comparison Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Incidence of Lung Cancer: A Retrospective Study

INTRODUCTION

Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blockers (ARBs) are taken as the first treatment option for hypertensive patients. The various global trials have suggested that ACEIs and ARBs may increase risk of lung cancer; however, the results are contradictory and there is no local study available. This study is conducted to compare the incidence of lung cancers in patients on ACEIs and ARBs.

METHODS

This retrospective study, conducted in a major cardiology unit of a tertiary care hospital in Pakistan, included patients diagnosed with hypertension, between 2005 and 2010, who were prescribed either ACEIs or ARBs. During the period of 2005 to 2010, 47,823 naïve hypertensive patients were reported in the outpatient department of the cardiology unit. Of which, 22,241 were prescribed ACEI and 25,582 were prescribed ARBs. After sorting patient data based on our inclusion criteria, n = 14,891 participants were included in the ACEI group and n = 19,112 participants were included in the ARB group.

RESULTS

The incidence of lung cancer in the ACEI and ARB group was n = 165 and n = 160, respectively. In this study, the overall incidence rates of lung cancer in the ACEI and ARB cohorts were 12.2 and 16.6 per 10,000 person-years, respectively. The hazard ratio was 1.32 (95% confidence interval: 1.06-1.64; p-value: 0.01).

CONCLUSION

In this study, the incidence of lung cancer was relatively more among people using ACEIs than ARBs. Hence, patients undergoing long-term treatment with ACEIs need regular follow-up and proper scanning to avoid grave complications.

Usage of Angiotensin-Converting Enzyme Inhibitor or Angiotensin II Receptor Blocker in Hypertension Intracerebral Hemorrhage

BACKGROUND

Inflammation plays an essential role in secondary brain injury after intracerebral hemorrhage (ICH). Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) have been suggested to suppress neuroinflammation after central nervous system (CNS) damage in animal models. However, the role of ACEIs and ARBs in ICH patients with hypertension remains unresolved in clinic. The aim of the present study is to evaluate the effect of ACEIs/ARBs on ICH patients with hypertension using a retrospective, single-center data analysis.

METHODS

ICH patients diagnosed by computerized tomographic (CT) at Southwest Hospital, Third Military Medical University were included in the present research from January 2015 to December 2019. According to the medical history for the usage of antihypertensive drugs, patients were assigned into either ACEIs/ARBs group or non-ACEIs/ARBs group. Demographics, clinical baseline, radiological documents and treatments were collected and these data were statistically analyzed between the two groups.

RESULTS

A total of 635 ICH patients with hypertension were included and allocated into 2 groups according to the usage of antihypertensive drugs: 281 in the ACEIs/ARBs group and 354 in the non-ACEIs/ARBs group. The results presented that the 3-months mortality and prevalence of ICH-associated pneumonia were lower in ACEIs/ARBs group than that in non-ACEIs/ARBs group (5.0% vs 11.9%, p=0.002; 58.4% vs 66.7%, p=0.031). While, there was no significant difference in favorable outcome (40.2% vs 33.9%, p=0.101) between the two groups. Furthermore, patients in ACEIs/ARBs group exhibited significantly less perihematomal edema volume on days 3 (23.5 ± 14.4 versus 28.7 ± 20.1 mL, p=0.045) and 7 (21.0 ± 13.7 versus 25.7 ± 17.6 mL, p=0.044), compared to that in non- ACEIs/ARBs group.

CONCLUSION

The usage of ACEIs/ARBs helps decrease mortality, perihematomal edema volume, and prevalence of ICH-associated pneumonia in ICH patients with hypertension.

Renal-Cerebral Pathophysiology: The Interplay Between Chronic Kidney Disease and Cerebrovascular Disease

OBJECTIVES

Cerebrovascular disease has increasingly been linked to overall vascular health. Pathologic conditions like diabetes, hypertension, and kidney disease have been shown to affect brain health and cerebrovascular and nervous systems. Acute kidney injury (AKI) and chronic Kidney Disease (CKD) represent a variety of vascular insults that can adversely affect cerebral health. Hypertension, fluctuations in blood pressure, and diabetic vasculopathy are known risk factors for cerebrovascular disease associated with CKD. Other emerging areas of interest include endothelial dysfunction, vascular calcification due to calcium and phosphorus metabolism dysregulation, and uremic neuropathy present the next frontier of investigation in CKD and cerebrovascular health.

METHODS

It has become apparent that the interrelation of AKI and CKD with vascular health, chemical homeostasis, and hormonal regulation upset many aspects of cerebral health and functioning. Stroke is an obvious connection, with CKD patients demonstrating a higher proclivity for cerebrovascular accidents. Cerebral bleeding risk, uremic neuropathies, sodium dysregulation with impacts on nervous system, vascular calcification, and endothelial dysfunction are the next salient areas of research that are likely to reveal key breakthroughs in renal-cerebral pathophysiology.

RESULTS

In this review nephrological definition are discussed in a neuro-centric manner, and the areas of key overlap between CKD and cerebrovascular pathology are discussed. The multifaceted effects of renal function on the health of the brain are also examined.

CONCLUSION

This review article aims to create the background for ongoing and future neurological-nephrological collaboration on understanding the special challenges in caring for patients with cerebrovascular disease who also have CKD.

The association between dietary glycemic and insulin indices with incidence of cardiovascular disease: Tehran lipid and glucose study

Background

The present study was conducted to investigate the association of dietary insulin index(II), insulin load(IL), glycemic index(GI), and glycemic load(GL) with the risk of cardiovascular disease(CVD).

Methods

This cohort study was conducted within the framework of the Tehran Lipid and Glucose Study on 2198 subjects, aged≥19 years old, who were followed-up for a median (IQR) 6.7 (6.1–7.1) years. Dietary GI, GL, II, and IL were calculated using a food frequency questionnaire at the baseline. Multivariate Cox proportional hazard regression models were used to estimate the risk of CVD across quartiles of dietary insulin and glycemic indices.

Results

Mean ± SD age of the subjects(44.9% men) was 38.3 ± 13.4 years. During a mean of 2406 ± 417 person-years of follow-up, 76(3.5%) new cases of the CVD were ascertained. The mean ± SD of II, IL, GI, and GL of participants were 51.7 ± 6.5, 235.8 ± 90.2, 61.9 ± 7.8, and 202.2 ± 78.1, respectively. After adjusting for the variables of age, sex, smoking, physical activity, daily energy intake, body mass index, diabetes, and hypertension, the hazard ratio (HR) of the highest quartile of dietary GL was 2.77(95%CI:1.00–7.69,P for trend:0.033) compared to the lowest one. Also, each one SD increase in the GL score was associated with a higher risk of CVD[(RR:1.46;CI:1.00–2.16),P-value = 0.047]. However, there was no significant association between the dietary GI, II, and IL and risk for CVD incidence.

Conclusions

Our results suggested that a high GL diet can increase the incidence of CVD, whereas high dietary II and IL were not associated with the risk of CVD among adults.

Association of Inpatient Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers With Mortality Among Patients With Hypertension Hospitalized With COVID-19

Supplemental Digital Content is available in the text.

Use of ACEIs (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin II receptor blockers) is a major concern for clinicians treating coronavirus disease 2019 (COVID-19) in patients with hypertension.

Angioedemas associated with renin-angiotensin system blocking drugs: Comparative analysis of spontaneous adverse drug reaction reports

INTRODUCTION

Angioedema is a subcutaneous swelling typically affecting the face, larynx or pharynx. It is a known adverse drug reaction (ADR) of ACE inhibitors (ACEi), angiotensin-II-receptor blockers (ARBs) and aliskiren (renin inhibitor). Several studies have reported pathophysiological mechanisms and risk factors of ACEi-associated angioedemas, whereas little is known for ARBs and aliskiren. The aim of the study was to analyze comparatively ACEi versus ARBs and aliskiren angioedema reports contained in the European ADR database EudraVigilance with regard to reported risk factors and clinical phenotypes.

METHODS

All spontaneous angioedema reports received between 01/2010-06/2017 reporting either an ACEi, ARB, or aliskiren as "suspected/interacting" drug were identified using the Standardized MedDRA Query "angioedema (narrow)". In order to perform a comparative analysis, odds ratios (ORs) were calculated for angioedema reports of ACEi (n = 3.194) versus ARBs (n = 687) and aliskiren (n = 162).

RESULTS

More patients with a history of allergy were included in angioedema reports of ARBs (6.8%) and aliskiren (13.6%) versus ACEi (4.3%). "Urticaria" as an ADR was reported more frequently in angioedema reports of ARBs (18.5%) and aliskiren (9.0%) versus ACEi (5.0%). ACEi-associated angioedemas were more often designated as "life-threatening" compared to ARBs (OR 2.2 [1.6-2.9]) and aliskiren-associated angioedemas (OR 14.2 (3.5-57.4). Concomitant therapy with mTOR inhibitors (OR 4.3 [1.0-17.9]) and fibrinolytics (OR 7.8 [1.1-57.2]) was reported more often in ACEi versus ARBs angioedema reports.

CONCLUSION

The reported clinical phenotypes differed between ACEi versus ARBs and aliskiren angioedema reports. Differences between the patient populations as observed in our study or differences with regard to underlying pathomechanisms could account for this finding. Due to the methodological limitations of spontaneous reporting systems, we cannot draw a firm conclusion in this regard. Hence, further research is necessary to confirm our observation and elucidate the underyling causes.

White-coat hypertension: management and adherence to guidelines by European and Canadian GPs. A cross-sectional clinical vignette study

BACKGROUND

White-coat hypertension (WCH) is also referred to as 'isolated clinic hypertension'. While it is a frequently encountered phenomenon, WCH is not systematically evoked, and its management remains unclear due to the contradictory guidelines provided by professional societies.

AIM

To examine WCH management by GPs in Europe and Canada.

DESIGN & SETTING

A clinical vignette of a possible case of WCH was created from the literature, and the responses of GPs to WCH-specific questions in a cross-sectional electronic questionnaire were compared.

METHOD

Complete electronic questionnaire responses from Europe and Canada were systematically analysed.

RESULTS

Among 770 eligible questionnaires (useful response rate: 10.6%), 43.5% were from France, 19.2% from Belgium, 7.8% from England, 19.5% from Switzerland, and 10.0% from Canada. Based on the clinical information provided in the vignette, GPs overall diagnosed hypertension and WCH equally (50.7% versus 49.3%, respectively). Canadian GPs suggested hypertension more frequently than European GPs in general (64.2% versus 46.1%, P<10-4), and more frequently used ambulatory blood pressure monitoring ([ABPM] 42.3% versus 26.1%, P = 0.01). In both groups of GPs, WCH was managed similarly (no treatment, 100% versus 97.3%, P = 0.39). Generally, the GPs all followed WCH patients for 3-6 months (51.3% versus 66.2%, P = 0.1), and they were not aware of the WCH guidelines (47.3% versus 52.1%, P = 0.54).

CONCLUSION

Although WCH guidelines are different, WCH management by GPs is very similar except for diagnosis. Homogeneity in WCH guidelines is required and should be systematically implemented in hypertension guidelines to avoid inappropriate management of the condition.

Wave reflections and systemic vascular resistance are stronger determinants of pulse pressure amplification than aortic stiffness in drug-naïve hypertensives

Background: Aortic-to-brachial pulse pressure (PP) amplification is a novel biomarker that prognosticates the cardiovascular risk above and beyond central aortic and brachial blood pressure. This phenomenon is modulated by left ventricular contractility and chronotrophy, large-artery stiffness and reflecting properties of microcirculation. However, the relative importance of these parameters as hemodynamic determinant of PP amplification remains elusive.Methods: A total of 88 consecutive drug-naïve hypertensives underwent a non-invasive assessment of central and peripheral hemodynamics via impedance cardiography and pulse wave analysis. Participants were classified into tertiles according to the magnitude of PP amplification. Hemodynamic determinants of low PP amplification were explored in univariate and multivariate regression analysis.Results: Compared with the high tertile, patients within the low PP amplification tertile were older and more commonly female and had lower height, weight and heart rate. Augmentation index (AIx) and systemic vascular resistance index (SVRI) were higher among patients within the low PP amplification tertile, whereas aortic pulse wave velocity (PWV) did not differ among groups. In multivariate analysis, higher AIx (OR: 1.27; 95% CI: 1.09-1.48) and higher SVRI were independently associated with higher odds for low PP amplification, whereas higher heart rate was the only parameter related to lower odds for low PP amplification (OR: 0.84; 95% CI: 0.71-0.99).Conclusion: This study shows that among newly-diagnosed drug-naïve hypertensives, elevated wave reflections and systemic vascular resistance are stronger determinants of PP amplification than aortic stiffness.

Gender-specific therapeutic approach in arterial hypertension - Challenges ahead

Hypertension was thought to be more important cardiovascular risk factor in men than in women. However, studies showed that overall incidence of hypertension-related cardiovascular diseases is higher in women comparing with men and this is particularly valid in menopause when prevalence of hypertension and its complications sharply and suddenly rises. It was also noticed that the effect of various antihypertensive groups was different in women and men. Some medications are prescribed more often in women, but it does not necessary mean that these drugs are more effective in this gender. There are several important reasons that could explain gender-induced differences in blood pressure levels, blood pressure control and antihypertensive treatment. They involve sex hormones, the renin-angiotensin-aldosterone and sympathetic nervous system, and arterial stiffness. However, taking into account many observational studies and trials, there are no consistent data regarding the impact of gender on effect of antihypertensive medications. Longitudinal study focused on gender and current antihypertensive groups would significantly help to understand the impact of gender. This might change therapeutic approach and improve cost-effectiveness in antihypertensive therapy in both genders. A full understanding of the pathophysiological characteristics of variations between genders demands additional research. This review article summarized the current knowledge regarding differences in the prevalence and awareness of arterial hypertension in women and men; alterations in pathophysiological mechanisms of hypertension between sexes; as well as the impact of sex on the effects of main antihypertensive groups of medications.

Relationship Between Patterns in Antihypertensive Drugs Medication and Mortality in Incident Dialysis Patients: A Multicenter Prospective Cohort Study

Hypertension is common in patients with chronic kidney disease. Whether blood pressure management before dialysis initiation influences prognosis during maintenance dialysis remains unclear. Hence, we surveyed the status of antihypertensive drug use in incident dialysis patients. Moreover, we examined the association between antihypertensive drug use patterns at the time of dialysis initiation and mortality. We used a database derived from the multicenter prospective Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis, which included 1520 incident dialysis patients in Aichi prefecture, Japan. The baseline in the present study was set as the time of dialysis initiation. We examined antihypertensive drug prescription patterns at baseline, as well as the association between use of antihypertensive drugs and mortality after dialysis initiation. Among all participants, 1440 were taking at least one antihypertensive drug. The rate of calcium channel blocker (CCB) use was highest, accounting for 74.3%. CCB use was significantly associated with lower all-cause and cardiovascular-related mortality (hazard ratio [HR]: 0.62 and 0.57, 95% confidence interval [CI]: 0.46-0.85 and [0.35-0.91], respectively). Compared with no use of either drug, combination therapy with a renin angiotensin system blocker (RASB) and CCB was significantly associated with lower mortality (HR: 0.51, 95% CI: 0.34-0.76). The present study demonstrated that antihypertensive drugs were used in 95% of incident dialysis patients. In addition, use of a CCB and combination therapy with a CCB and RASB at the time of dialysis initiation was associated with lower mortality during maintenance dialysis.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Objective

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

Methods

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

Results

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Service design oriented multidisciplinary collaborative team care service model development for resolving drug related problems

Our goal was to help prevent drug-related morbidity and mortality by developing a collaborative multidisciplinary team care (MTC) service model using a service design framework that addressed the unmet needs and perspectives of diverse stakeholders. Our service model was based on a “4D” framework that included Discover, Define, Design, and Develop phases. In the “discover” phase, we conducted desk research and field research of stakeholders to identify the unmet needs in existing patient care services. We used service design tools, including service safaris, user shadowing, and customer journey maps to identify pain and opportunity points in the current services. We also performed focus group discussions and in-depth interviews with stakeholders to explore the needs for improved services. In the “define” phase, we generated the service concept by mind mapping and brainstorming about the needs of stakeholders. The service concept was defined to be a Patient-oriented, Collaborative, Advanced, Renovated, and Excellent (P-CARE) service. We named the service “DrugTEAM” (Drug Therapy Evaluation And Management). In the “design” phase, we designed and refined four prototypes based on results from validation tests for their application towards following services: 1) medication reconciliation, 2) medication evaluation and management, 3) evidence-based drug information, and 4) pharmaceutical care transition services. During the “develop” phase, we implemented four services in a longitudinal chronic care model, considering the time spent by patients for each inpatient and outpatient setting. In conclusion, this is a study to develop a collaborative MTC service model using service design framework, focused on managing the unmet needs of patients and healthcare providers. As a result of implementing this service model, we expect to strengthen the professional relationship between pharmacists and stakeholders to ultimately create better patient outcomes.

The effects of provider-prescribed obesogenic drugs on post-laparoscopic sleeve gastrectomy outcomes: a retrospective cohort study

Background:

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures and has proven effective in providing weight loss. However, considerable variance has been noted in the degree of weight loss. Physician prescription practices may be negatively affecting weight loss post-LSG and, thus, contributing to the broad range of weight loss outcomes. The aim of our study was to determine whether commonly prescribed obesogenic medications negatively affect weight loss outcomes post-LSG.

Subjects/Methods:

This single center retrospective cohort study performed at a University hospital included 323 patients (≥18 years) within University California, San Diego Healthcare System who underwent LSG between 2007 and 2016. We identified a list of 32 commonly prescribed medications that have weight gain as a side effect. We compared the percent excess weight loss (%EWL) of patients divided into two groups based on post-LSG exposure to obesogenic medications. A linear regression model was used to analyze %EWL at 12 months post-LSG while controlling for age, initial body mass index (BMI), and use of leptogenic medications.

Results:

150 patients (Meds group) were prescribed obesogenic medications within the one-year post-LSG follow up period, whereas 173 patients (Control group) were not prescribed obesogenic medications. The Meds group lost significantly less weight compared to the Control group (%EWL ± SEM at 12 months 53.8 ± 2.4 n=78, 65.0 ± 2.6, n=84 respectively, P = 0.002). This difference could not be attributed to differences in age, gender, initial BMI, co-morbidities, or prescription of leptogenic medications between the two groups.

Conclusions:

The use of provider-prescribed obesogenic medications was associated with worse weight loss outcomes post-LSG. Closer scrutiny of patient medications may be necessary to help improve outcomes of weight loss treatments.

PAAP: a web server for predicting antihypertensive activity of peptides

AIM

Hypertension is associated with development of cardiovascular disease and has become a significant health problem worldwide. Naturally-derived antihypertensive peptides have emerged as promising alternatives to synthetic drugs.

MATERIALS & METHODS

This study introduces predictor of antihypertensive activity of peptides constructed using random forest classifier as a function of various combinations of amino acid, dipeptide and pseudoamino acid composition descriptors.

RESULTS

Classification models were assessed via independent test set that demonstrated accuracy of 84.73%. Feature importance analysis revealed the preference of proline and hydrophobic amino acids at the C-terminal as well as the preference of short peptides for robust activity.

CONCLUSION

Model presented herein serves as a useful tool for predicting and analysis of antihypertensive activity of peptides.

Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk

Aims

Optimal blood pressure for prevention of cardiovascular (CV) events in patients with Type 2 diabetes mellitus (T2DM) remains uncertain and there is concern for increased risk with low diastolic blood pressure (DBP). This study analysed the association between blood pressure and CV outcomes in high-risk patients with T2DM.

Methods and results

Patients with T2DM and elevated CV risk were enrolled in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus-Thrombolysis in Myocardial Infarction 53 trial. Cardiovascular outcomes were compared in the biomarker subgroup (n = 12 175) after stratification by baseline systolic blood pressure (SBP) and DBP. Adjusted risk was calculated by blood pressure stratum using clinical covariates plus N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin-T (hsTnT). Trends were tested using linear and quadratic models. Adjusted risk of the composite endpoint of CV death, myocardial infarction (MI), or ischaemic stroke showed U-shaped relationships with baseline SBP and DBP (Pquadratic ≤ 0.01) with nadirs at SBP 130-140 or DBP 80-90 mmHg. Diastolic blood pressure <60 mmHg was associated with increased risk of MI (adjusted hazard ratio 2.30; 95% confidence interval 1.50-3.53) relative to DBP 80-90 mmHg. Adjusted odds of hsTnT concentration ≥14 ng/L showed U-shaped relationships with SBP and DBP (Pquadratic ≤ 0.01). The relationships between low DBP, elevated hsTnT, and increased MI remained after exclusion of patients with prior heart failure or NT-proBNP >median, suggesting that the relationship was not due to confounding from diagnosed or undiagnosed heart failure.

Conclusions

In patients with diabetes and elevated CV risk, even after extensive adjustment for underlying disease burden, there was a persistent association for low DBP with subclinical myocardial injury and risk of MI.

Prevalence and Predictors of Silent Gastroesophageal Reflux Disease in Patients with Hypertension

BACKGROUND

Gastroesophageal reflux disease (GERD) without symptoms or silent GERD can be easily missed in patients with hypertension. We aimed to investigate the prevalence of GERD, specifically the prevalence of silent GERD in hypertensive patients, and to explore its possible predictors.

METHODS

Consecutive patients with hypertension referred to the cardiovascular clinic of Suining Central Hospital in 2016 were screened for this study. A Reflux Disease Questionnaire (RDQ) and an esophagogastroduodenoscopy (EGD) were employed for the evaluation of silent GERD. Included patients were divided into silent-GERD group and non-GERD control group. The demographic characteristics and antihypertensive agent prescriptions were collected and compared between the two groups.

RESULTS

The prevalence of silent GERD and GERD in patients with hypertension was 15.1% and 31.4%, respectively. 66 patients were included in the silent-GERD group, and 298 patients were included in the non-GERD control group. Abdominal obesity and untreated hypertension were positive predictors, while controlled hypertension was a negative predictor for silent GERD. The prescription of calcium channel blockers was not a predictor for it.

CONCLUSIONS

High prevalence of GERD, specifically silent GERD, could be found in patients with hypertension. Abdominal obesity and untreated hypertension were positive predictors for silent GERD, while controlled hypertension was a negative predictor for it.

Effects of Intensive Blood Pressure Control in Patients with Evident Cardiovascular Disease: An Investigation Using the SPRINT Study Data

BACKGROUND

Recent data advocate adoption of a more intensive treatment strategy for management of blood pressure (BP).

OBJECTIVE

We investigated whether the overall effects of the Systolic Blood Pressure Intervention Trial (SPRINT) are applicable to cardiovascular disease (CVD) patients.

METHODS

In a post hoc analysis we analyzed data from SPRINT that randomly assigned 9361 individuals to a systolic BP (SBP) target of <120 mmHg (intensive treatment) or <140 mmHg (standard treatment). 1562 patients had clinically evident CVD (age=70.3±9.3 years, 24% females) at study entry and were followed for 3.1 years. Further, we assessed the effect of low (<150 mmHg) baseline SBP on outcome.

RESULTS

In CVD patients, there was no benefit from the intensive treatment regarding all endpoints, except for a marginally significant benefit on all-cause mortality (hazard ratio [HR]: 0.67; 95% confidence interval [CI], 0.45 to 1.00; p=0.0509). Further, while there was no increase in serious adverse events (SAE) in the intensive group, there was increased risk for study-related SAE, acute renal failure and electrolyte abnormalities. In patients with low baseline SBP there was a beneficial effect on allcause mortality (HR: 0.56; 95% CI: 0.33 to 0.96; p=0.033), but with greater stroke incidence (HR: 2.94; 95% CI: 1.04 to 8.29; p=0.042).

CONCLUSION

We confirm the beneficial effect of the intensive strategy in SPRINT study on all-cause mortality and the harmful effect on specific adverse outcomes in patients with CVD. However, in patients with low baseline SBP stroke may increase.

Expression of Proinflammatory Cytokines Is Upregulated in the Hypothalamic Paraventricular Nucleus of Dahl Salt-Sensitive Hypertensive Rats

Accumulating evidence indicates that inflammation is implicated in hypertension. However, the role of brain proinflammatory cytokines (PICs) in salt sensitive hypertension remains to be determined. Thus, the objective of this study was to test the hypothesis that high salt (HS) diet increases PICs expression in the paraventricular nucleus (PVN) and leads to PVN neuronal activation. Eight-week-old male Dahl salt sensitive (Dahl S) rats, and age and sex matched normal Sprague Dawley (SD) rats were divided into two groups and fed with either a HS (4% NaCl) or normal salt (NS, 0.4% NaCl) diet for 5 consecutive weeks. HS diet induced hypertension and significantly increased cerebrospinal fluid (CSF) sodium concentration ([Na⁺]) in Dahl S rats, but not in normal SD rats. In addition, HS diet intake triggered increases in mRNA levels and immunoreactivities of PVN PICs including TNF-α, IL-6, and IL-1β, as well as Fra1, a chronic marker of neuronal activation, in Dahl S rats, but not in SD rats. Next, we investigated whether this increase in the expression of PVN PICs and Fra1 was induced by increased CSF [Na⁺]. Adult male SD rats were intracerebroventricular (ICV) infused with 8 μl of either hypertonic salt (4 μmol NaCl), mannitol (8 μmol, as osmolarity control), or isotonic salt (0.9% NaCl as vehicle control). Three hours following the ICV infusion, rats were euthanized and their PVN PICs expression was measured. The results showed that central administration of hypertonic saline in SD rats significantly increased the expression of PICs including TNF-α, IL-6, and IL-1β, as well as neuronal activation marker Fra1, compared to isotonic NaCl controls and osmolarity controls. Finally, we tested whether the increase in PICs expression occurred in neurons. Incubation of hypothalamic neurons with 10 mM NaCl in a culture medium for 6 h elicited significant increases in TNF-α, IL-6, and Fra1 mRNA levels. These observations, coupled with the important role of PICs in modulating neuronal activity and stimulating vasopressin release, suggest that HS intake induces an inflammatory state in the PVN, which, may in turn, augments sympathetic nerve activity and vasopressin secretion, contributing to the development of salt sensitive hypertension.

The J-shaped Curve for Blood Pressure and Cardiovascular Disease Risk: Historical Context and Recent Updates

PURPOSE OF REVIEW

The definition and treatment of hypertension have both changed dramatically over the last century, with recent trials suggesting benefit for lower blood pressure (BP) targets than ever before considered. However, tempering the enthusiasm for more intensive BP targets are long-held concerns that BP reduction below a certain threshold may pose dangers, the so-called "J-curve." In this review, we summarize the evidence for a J-curve in the treatment of hypertension.

RECENT FINDINGS

The Systolic Blood Pressure Intervention Trial (SPRINT) reported that achieving a systolic BP target of 120 mmHg reduces cardiovascular disease in high-risk individuals, supporting more intensive BP reduction. However, contemporary observational studies consistently demonstrate a BP J-curve, the threshold of which is often close to the SPRINT target. Studies also suggest that the BP level of this J-curve may vary based on patient characteristics, including age and comorbidities. There is also more compelling evidence for the specific presence of a J-curve between diastolic BP and coronary events, in contrast to conflicting evidence of a J-curve with systolic BP and cardiovascular disease more generally. There is increased risk of coronary events below a diastolic BP of 60-70 mmHg. In comparison, the presence of a systolic J-curve is less clear and some persons at high risk may actually benefit from systolic levels down to 120 mmHg. Therefore, we suggest a personalized approach to BP management considering individual risks, benefits, and preferences when choosing therapeutic targets. Further, well-designed studies are required to support our suggestions and to define J-curve thresholds more clearly.

Dietary amino acids and incidence of hypertension: A principle component analysis approach

The current study aimed to investigate the association between dietary amino acid patterns and incidence of hypertension, using principal components factor analyses. This study was conducted within the framework of Tehran Lipid and Glucose Study on 4288 adults, who were free of hypertension at baseline (2008–2011) and were followed for three years (2011–2014). Principal component factor analyses were conducted based on eight amino acid groups and three amino acid patterns were extracted. The first pattern was characterized by branched chain, aromatic, and alcoholic amino acids, and proline. Acidic amino acids and proline were highly loaded in the second pattern and the third was characterized by sulphuric and small amino acids. Adjusted odds ratio of the highest quartile of the first pattern was 1.83 (95%CI: 1.21–2.77, P for trend = 0.002) compared to the lowest one. The first pattern had high positive correlation with dietary intakes of animal protein and dairy, but was negatively correlated with plant protein, fruit, and vegetable. There was no significant association for the second and third patterns. Findings indicate that the dietary amino acid pattern, rich in branched chain, aromatic, and alcoholic amino acids, and proline could increase the risk of hypertension.

High dietary intake of aromatic amino acids increases risk of hypertension

Recent studies investigated the relation between amino acids and blood pressure. Our aim was to examine the association between intake of aromatic amino acids (AAAs) and risk of hypertension. A total of 4288 individuals, aged 20-70 years, participants of the Tehran Lipid and Glucose Study, who were free of hypertension at baseline (2008-2011), were followed for 3 years (2011-2014). Average intakes of AAAs including phenylalanine, tyrosine, and tryptophan were collected using a valid and reliable food frequency questionnaire at baseline. Adjusted logistic regression models were used to report odds ratio (OR) of hypertension across quartiles of AAAs. At the end of follow-up, 429 (10%) hypertension cases were ascertained. The adjusted OR of hypertension for percentage of AAAs from total protein intakes was 1.63 (95% confidence interval, 1.06-2.50; P for trend: .03) when comparing the highest quartile to the lowest. Furthermore, in the adjusted analyses, a statistically significant positive relationship was observed between the highest versus the lowest quartile intake of phenylalanine (OR = 1.66; 95% confidence interval, 1.14-2.47; P for trend: .03). However, there was no significant association of tyrosine and tryptophan intakes with hypertension risk. Our data suggest that AAAs may increase the risk of incident hypertension.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

The mechanism of action and role of hydrogen sulfide in the control of vascular tone

Our knowledge about hydrogen sulfide (H₂S) significantly changed over the last two decades. Today it is considered as not only a toxic gas but also as a gasotransmitter with diverse roles in different physiological and pathophysiological processes. H₂S has pleiotropic effects and its possible mechanisms of action involve (1) a reversible protein sulfhydration which can alter the function of the modified proteins similar to nitrosylation or phosphorylation; (2) direct antioxidant effects and (3) interaction with metalloproteins. Its effects on the human cardiovascular system are especially important due to the high prevalence of hypertension and myocardial infarction. The exact molecular targets that affect the vascular tone include the K_ATP channel, the endothelial nitric oxide synthase, the phosphodiesterase of the vascular smooth muscle cell and the cytochrome c oxidase among others and the combination of all these effects lead to the final result on the vascular tone. The relative role of each effect depends immensely on the used concentration and also on the used donor molecules but several other factors and experimental conditions could alter the final effect. The aim of the current review is to give a comprehensive summary of the current understanding on the mechanism of action and role of H₂S in the regulation of vascular tone and to outline the obstacles that hinder the better understanding of its effects.

In vivo quantification of aortic stiffness using MR elastography in hypertensive porcine model

PURPOSE

Aortic stiffness plays an important role in evaluating and predicting the progression of systemic arterial hypertension (SAH). The aim of this study is to determine the stiffness of aortic wall using MR elastography (MRE) in a hypertensive porcine model and compare it against invasive aortic pressure measurements.

METHODS

Renal wrapping surgery was performed on eight pigs to induce SAH. Aortic MRE was performed at baseline and 2 months postsurgery using a retrospectively pulse-gated gradient-echo MRE sequence on a 1.5 tesla scanner. Mechanical waves of 70 Hz were introduced into the aorta. Invasive central aortic pressure measurements were obtained prior to each scan to calculate mean arterial pressure (MAP). MRE data were analyzed to obtain effective aortic stiffness. Spearman's rank correlation analysis was performed to assess the relationship between MAP and MRE-derived aortic stiffness.

RESULTS

Significant increase in effective aortic stiffness was observed between baseline and 2 months postsurgery measurements (paired t test; P = 0.004). The average MAP, determined by pooling all animals, was 65.24 ± 9.42 mm Hg at baseline and 92.57 ± 11.80 mm Hg 2 months postsurgery with P < 0.0001. Moderate linear correlation was observed between MAP and effective aortic stiffness (ρ = 0.52; P = 0.046).

CONCLUSION

This study demonstrated that, in a SAH porcine model, MRE-derived aortic stiffness increased with increase in MAP. Magn Reson Med 78:2315-2321, 2017. © 2017 International Society for Magnetic Resonance in Medicine.

Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of Antihypertensive Therapy

BACKGROUND

The use of atherosclerotic cardiovascular disease (ASCVD) risk to personalize systolic blood pressure (SBP) treatment goals is a topic of increasing interest. Therefore, we studied whether coronary artery calcium (CAC) can further guide the allocation of anti-hypertensive treatment intensity.

METHODS

We included 3733 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with SBP between 120 and 179 mm Hg. Within subgroups categorized by both SBP (120-139 mm Hg, 140-159 mm Hg, and 160-179 mm Hg) and estimated 10-year ASCVD risk (using the American College of Cardiology/American Heart Assocation pooled-cohort equations), we compared multivariable-adjusted hazard ratios for the composite outcome of incident ASCVD or heart failure after further stratifying by CAC (0, 1-100, or >100). We estimated 10-year number-needed-to-treat for an intensive SBP goal of 120 mm Hg by applying the treatment benefit recorded in meta-analyses to event rates within CAC strata.

RESULTS

The mean age was 65 years, and 642 composite events took place over a median of 10.2 years. In persons with SBP <160 mm Hg, CAC stratified risk for events. For example, among those with an ASCVD risk of <15% and who had an SBP of either 120 to 139 mm Hg or 140 to 159 mm Hg, respectively, we found increasing hazard ratios for events with CAC 1 to 100 (1.7 [95% confidence interval, 1.0-2.6] or 2.0 [1.1-3.8]) and CAC >100 (3.0 [1.8-5.0] or 5.7 [2.9-11.0]), all relative to CAC=0. There appeared to be no statistical association between CAC and events when SBP was 160 to 179 mm Hg, irrespective of ASCVD risk level. Estimated 10-year number-needed-to-treat for a SBP goal of 120mmHg varied substantially according to CAC levels when predicted ASCVD risk <15% and SBP <160mmHg (eg, 10-year number-needed-to-treat of 99 for CAC=0 and 24 for CAC>100, when SBP 120-139mm Hg). However, few participants with ASCVD risk <5% had elevated CAC. Furthermore, 10-year number-needed-to-treat estimates were consistently low and varied less among CAC strata when SBP was 160 to 179 mm Hg or when ASCVD risk was ≥15% at any SBP level.

CONCLUSIONS

Combined CAC imaging and assessment of global ASCVD risk has the potential to guide personalized SBP goals (eg, choosing a traditional goal of 140 or a more intensive goal of 120 mm Hg), particularly among adults with an estimated ASCVD risk of 5% to 15% and prehypertension or mild hypertension.

Impact of Transcatheter Intervention on Myocardial Deformation in Patients with Coarctation of the Aorta

Myocardial deformation measured by speckle tracking echocardiography can detect subtle abnormalities of left ventricular function before an obvious abnormality in traditional echocardiographic parameters such as ejection fraction is seen. We hypothesized that patients with coarctation of the aorta (CoA) may have impaired myocardial deformation that may persist even after successful transcatheter intervention. This is a retrospective study to assess the myocardial deformation in patients undergoing transcatheter intervention of CoA. The data were compared with age-matched normal controls. Echocardiographic parameters were obtained before, immediately and at median 6 months (range 3-8 months) after transcatheter intervention. Myocardial deformation indices were obtained off-line using Tomtec 2D Cardiac Performance Analysis Software. Repeated measure ANOVA was used to compare the indices between three time points. Independent sample t test or Chi-square test was used to compare data between groups. Twenty-four patients (age 13.5 ± 7.7 years) underwent successful transcatheter CoA intervention (stent 19, balloon angioplasty five) improving CoA peak gradient in the catheterization laboratory from 27.1 ± 11.3 to 4.5 ± 3.0 mmHg (p < 0.001). To compare with normal controls (n = 25, age 14.5 ± 1.9 years), fraction shortening was significantly higher in pre-intervention CoA patients (40.4 ± 7.1 vs. 33.8 ± 2.4 %, p < 0.001). In contrast, CoA patients had significantly abnormal left ventricular longitudinal strain compared to normal controls (-14.9 ± 2.6 vs. -20.5 ± 1.8 %, p < 0.001). In CoA patients, left ventricular longitudinal strain improved immediately and 3-8 months after intervention (-18.0 ± 2.9 and -17.6 ± 2.9 %, p < 0.007) but continued to be abnormal compared to normal controls. Patients with CoA had impaired myocardial deformation compared to normal controls. Myocardial mechanics improved but did not normalize even after successful transcatheter intervention on CoA in the short term.

Oscillating blood pressure therapeutic target in type 2 diabetes patients with hypertension

There is controversy regarding the J-shaped curve associating low blood pressure (BP) with increased cardiovascular events and mortality in hypertensive treated patients. This has partially motivated the revision of several hypertension treatment guidelines to raise the threshold for the definition and initiation of pharmacological treatment of hypertension in diabetes patients from 130/80 to 140/90 mmHg. However, there are increasing evidence that the increase cardiovascular risk caused by lower BP is not due to hypertensive treatment itself, rather to co-morbidities, especially in patients with diabetes. Much more, lower BP than currently recommended might be associated with significantly lower risk of cardiovascular events in diabetes patients. In this paper, we revisit the issue of ideal therapeutic BP target in diabetes patients with hypertension.

Diastolic Blood Pressure, Subclinical Myocardial Damage, and Cardiac Events: Implications for Blood Pressure Control

BACKGROUND

The optimal systolic blood pressure (SBP) treatment goal is in question, with SPRINT (Systolic Blood Pressure Intervention Trial) suggesting benefit for 120 mm Hg. However, achieving an SBP this low may reduce diastolic blood pressure (DBP) to levels that could compromise myocardial perfusion.

OBJECTIVES

This study sought to examine the independent association of DBP with myocardial damage (using high-sensitivity cardiac troponin-T [hs-cTnT]) and with coronary heart disease (CHD), stroke, or death over 21 years.

METHODS

The authors studied 11,565 adults from the ARIC (Atherosclerosis Risk In Communities) cohort, analyzing DBP and hs-cTnT associations as well as prospective associations between DBP and events.

RESULTS

Mean baseline age was 57 years, 57% of patients were female, and 25% were black. Compared with persons who had DBP between 80 to 89 mm Hg at baseline (ARIC visit 2), the adjusted odds ratio of having hs-cTnT ≥14 ng/l at that visit was 2.2 and 1.5 in those with DBP <60 mm Hg and 60 to 69 mm Hg, respectively. Low DBP at baseline was also independently associated with progressive myocardial damage on the basis of estimated annual change in hs-cTnT over the 6 years between ARIC visits 2 and 4. In addition, compared with a DBP of 80 to 89 mm Hg, a DBP <60 mm Hg was associated with incident CHD and mortality, but not with stroke. The DBP and incident CHD association was strongest with baseline hs-cTnT ≥14 ng/l (p value for interaction <0.001). Associations of low DBP with prevalent hs-cTnT and incident CHD were most pronounced among patients with baseline SBP ≥120 mm Hg.

CONCLUSIONS

Particularly among adults with an SBP ≥120 mm Hg, and thus elevated pulse pressure, low DBP was associated with subclinical myocardial damage and CHD events. When titrating treatment to SBP <140 mm Hg, it may be prudent to ensure that DBP levels do not fall below 70 mm Hg, and particularly not below 60 mm Hg.