2018 Korean Society of Hypertension guidelines for the management of hypertension: part I-epidemiology of hypertension

The Role of Vascular Aging in the Development of Hypertension

Vascular stiffness is an age-related pathophysiological process that represents a significant risk of cardiovascular morbidity and mortality in the older adult.

Serum Homocysteine Levels and All-Cause and Cause-Specific Mortality in Korean Adult Men: A Cohort Study

BACKGROUND

Hyperhomocysteinemia can increase the risk of cardiovascular disease (CVD), cancer, and neurological disorders; however, hypohomocysteinemia is generally not considered harmful. This study aimed to evaluate the relationship between all levels of homocysteine, both low and high homocysteine levels, and the risk of all-cause and cause-specific mortality in adult Korean men.

METHODS

Adult Korean men (n = 221,356) were categorized into quintiles based on their homocysteine levels. The primary endpoints were all-cause, CVD, cancer, and dementia mortality. Hazard ratios were calculated using Cox proportional hazards models, and the dose-response relationship between homocysteine levels and mortality risk was further explored using restricted cubic spline models.

RESULTS

Compared with the reference category (Q2, 8.8-9.9 µmol/L), there was a significant increase in all-cause mortality associated with both low and high levels after multivariable adjustment (Pinteraction = 0.002). Additionally, in spline regression, a U-shaped association between homocysteine levels and all-cause and CVD mortality was observed (inflection point = 9.1 µmol/L). This association was not observed in the vitamin supplementation subgroup.

CONCLUSION

Among Korean adult men, both low and high homocysteine levels increased the risk of all-cause and CVD mortality, indicating a U-shaped relationship. However, this relationship was not statistically significant with vitamin supplementation, suggesting a potential protective role for vitamins.

Association between gingivitis, tooth loss and cardiovascular risk: Insights from a 10-year nationwide cohort study of 3.7 million Koreans

BACKGROUND

While studies have suggested an association between periodontal disease and an increased risk of cardiovascular disease, the strength of this association and its specific links to various types of cardiovascular disease have not been thoroughly investigated. This study aimed to examine how gingivitis and tooth loss affect cardiovascular diseases, probing their individual impacts.

METHODS

A retrospective cohort study was conducted, encompassing 3,779,490 individuals with no history of cardiovascular disease, utilizing data from the National Health Examination and the Korean National Health Insurance database from 2006 to 2019. Cox proportional hazards models were applied to estimate the association between tooth loss, gingivitis, and cardiovascular disease.

RESULTS

Following a median follow-up of 10.38 years, 17,942 new cardiovascular disease cases were identified, comprising 10,224 cases of angina pectoris, 6,182 cases of acute myocardial infarction, and 9,536 cases of stroke. It was observed that the risk of stroke was significantly higher in the tooth loss group compared to the control group (adjusted hazard ratio [aHR]: 1.09, 95% confidence interval [CI]: 1.04-1.15). In the group with gingivitis and tooth loss, the risk of stroke and cardiovascular disease was significantly higher than in the control group (aHR: 1.12, 95% CI: 1.04-1.20; aHR: 1.08, 95% CI: 1.03-1.14). The gingivitis group exhibited a higher risk associated with stroke (aHR: 1.05, 95% CI: 1.01-1.10) among individuals aged 50 and above. However, statistically significant associations between periodontal disease and angina pectoris were not observed, nor between periodontal disease and acute myocardial infarction except among those aged above 50. Furthermore, the association between periodontal disease and cardiovascular disease was found to be stronger among individuals over the age of 50, males, those with obesity, and smokers compared to the control group.

CONCLUSIONS

Our results emphasize the association of tooth loss and gingivitis with cardiovascular disease, specifically stroke, underlining the critical need for preventive oral healthcare. Tailored interventions are necessary to reduce the heightened risk of cardiovascular disease events, especially stroke, among older, obese individuals and smokers.

Hypertension in an ageing population: Diagnosis, mechanisms, collateral health risks, treatments, and clinical challenges

Ageing population is considerably increasing worldwide, which is considered to reflect an improved quality of life. However, longevity in the human lifespan has increased the burden of late-life illnesses including cancer, neurodegeneration, and cardiovascular dysfunction. Of these, hypertension is the most common condition with huge health risks, with an increased prevalence among the elderly. In this review, we outline the current guidelines for defining hypertension and examine the detailed mechanisms underlying the relationship between hypertension and ageing-related outcomes, including sodium sensitivity, arterial stiffness, endothelial dysfunction, isolated systolic hypertension, white coat effect, and orthostatic hypertension. As hypertension-related collateral health risk increases among the elderly, the available management strategies are necessary to overcome the clinical treatment challenges faced among elderly population. To improve longevity and reduce adverse health effects, potential approaches producing crucial information into new era of medicine should be considered in the prevention and treatment of hypertension among elderly population. This review provides an overview of mechanisms underlying hypertension and its related collateral health risk in elderly population, along with multiple approaches and management strategies to improve the clinical challenges among elderly population.

Association between Weight Change and Incidence of Dyslipidemia in Young Adults: A Retrospective Cohort Study of Korean Male Soldiers

Background

Recent lifestyle changes have increased the prevalence of dyslipidemia in Korea. Young men are known to have a low awareness of dyslipidemia and a lack of motivation to maintain their weight. However, the association between weight change and dyslipidemia in young adults has not been thoroughly examined.

Methods

Data from the Armed Forces Medical Command Defense Medical Information System database were used. In this study, 15,068 soldiers who underwent private and corporal health examinations between May 2020 and April 2022 were included. The difference in weights between the two different health examinations was used to quantify weight change. Four components of the lipid profile were used to assess dyslipidemia during the corporal health examination.

Results

After adjusting for relevant covariates, weight gain was associated with increased risk of dyslipidemia (adjusted odds ratio [OR], 1.38 [95% confidence interval, CI, 1.15 to 1.64] for the 5% to 10% weight gain group; and OR, 2.02 [95% CI, 1.59 to 2.55] for the ≥10% weight gain group), whereas weight loss was associated with decreased risk (adjusted OR, 0.82 [95% CI, 0.68 to 0.98] for the 5% to 10% weight loss group; and OR, 0.38 [95% CI, 0.27 to 0.53] for the ≥10% weight loss group). In subgroup analysis based on the participants' baseline body mass index, smoking status, regular exercise habits, and hypertension status, there were no significant differences between the subgroups.

Conclusion

Weight change was associated with dyslipidemia in Korean male soldiers. The findings suggest that limiting weight gain in young adults by encouraging a healthy lifestyle may help prevent dyslipidemia.

Potassium-Enriched Salt Substitutes: A Review of Recommendations in Clinical Management Guidelines

Excess dietary sodium intake and insufficient dietary potassium intake are both well-established risk factors for hypertension. Despite some successful initiatives, efforts to control hypertension by improving dietary intake have largely failed because the changes required are mostly too hard to implement. Consistent recent data from randomized controlled trials show that potassium-enriched, sodium-reduced salt substitutes are an effective option for improving consumption levels and reducing blood pressure and the rates of cardiovascular events and deaths. Yet, salt substitutes are inconsistently recommended and rarely used. We sought to define the extent to which evidence about the likely benefits and harms of potassium-enriched salt substitutes has been incorporated into clinical management by systematically searching guidelines for the management of hypertension or chronic kidney disease. We found incomplete and inconsistent recommendations about the use of potassium-enriched salt substitutes in the 32 hypertension and 14 kidney guidelines that we reviewed. Discussion among the authors identified the possibility of updating clinical guidelines to provide consistent advice about the use of potassium-enriched salt for hypertension control. Draft wording was chosen to commence debate and progress consensus building: strong recommendation for patients with hypertension-potassium-enriched salt with a composition of 75% sodium chloride and 25% potassium chloride should be recommended to all patients with hypertension, unless they have advanced kidney disease, are using a potassium supplement, are using a potassium-sparing diuretic, or have another contraindication. We strongly encourage clinical guideline bodies to review their recommendations about the use of potassium-enriched salt substitutes at the earliest opportunity.

Sex differences in the applicability of Western cardiovascular disease risk prediction equations in the Asian population

AIMS

Cardiovascular diseases (CVDs) are the most common cause of death, but they can be effectively managed through appropriate prevention and treatment. An important aspect in preventing CVDs is assessing each individual's comprehensive risk profile, for which various risk engines have been developed. The important keys to CVD risk engines are high reliability and accuracy, which show differences in predictability depending on disease status or race. Framingham risk score (FRS) and the atherosclerotic cardiovascular disease risk equations (ASCVD) were applied to the Korean population to assess their suitability.

METHODS

A retrospective cohort study was conducted using National Health Insurance Corporation sample cohort from 2003 to 2015. The enrolled participants over 30 years of age and without CVD followed-up for 10 years. We compared the prediction performance of FRS and ASCVD and calculated the relative importance of each covariate.

RESULTS

The AUCs of FRS (men: 0.750; women: 0.748) were higher than those of ASCVD (men: 0.718; women: 0.727) for both sexes (Delong test P <0.01). Goodness of fits (GOF) were poor for all models (Chi-square P < 0.001), especially, underestimation of the risk was pronounced in women. When the men's coefficients were applied to women's data, AUC (0.748; Delong test P<0.01) and the GOF (chi-square P = 0.746) were notably improved in FRS. Hypertension was found to be the most influential variable for CVD, and this is one of the reasons why FRS, having the highest relative weight to blood pressure, showed better performance.

CONCLUSION

When applying existing tools to Korean women, there was a noticeable underestimation. To accurately predict the risk of CVD, it was more appropriate to use FRS with men's coefficient in women. Moreover, hypertension was found to be a main risk factor for CVD.

Real-World Effectiveness and Safety of a Single-Pill Combination of Olmesartan/Amlodipine/Hydrochlorothiazide in Korean Patients with Hypertension and Cardiovascular Risk Factors

INTRODUCTION

Patients with hypertension and additional cardiovascular risk factors pose a challenge by requiring more intensive blood pressure (BP) control. Single-pill combination (SPC) therapy can benefit these patients by improving medication adherence.

METHODS

This prospective, multicenter observational study assessed the real-world safety and effectiveness of an SPC containing olmesartan, amlodipine, and hydrochlorothiazide (O/A/H) in South Korean patients with hypertension and cardiovascular risk factors. BP control rates, defined as the percentage of patients achieving systolic BP (SBP) < 130 mmHg and diastolic BP (DBP) < 80 mmHg for intensive BP control, and < 140 mmHg and < 90 mmHg, respectively, for standard BP control, were investigated across various cardiovascular risk groups, along with changes in SBP and DBP from baseline to week 24.

RESULTS

The most prevalent cardiovascular risk factor was age (≥ 45 years in men, ≥ 55 years in women, 86.1%), followed by cardiovascular diseases (64.4%), dyslipidemia (53.7%), body mass index ≥ 25 kg/m2 (53.5%), and diabetes mellitus (DM) (46.3%). Switching to O/A/H showed significant BP reduction, with a mean change of - 17.8 mmHg/- 9.3 mmHg in SBP/DBP within 4 weeks. The intensive BP control rate was 41.4% (95% confidence interval [CI] 39.5, 43.4), and the standard BP control rate was 73.3% (95% CI 71.5, 75.1), with better control rates in the risk age group (43.1% and 74.1%, respectively) and cardiovascular disease group (42.0% and 73.8%, respectively). The DM group had relatively lower control rates (37.5% for intensive control and 69.4% for standard control). Common adverse drug reactions included dizziness (2.91%), hypotension (1.51%), and headaches (0.70%).

CONCLUSION

The SPC therapy of O/A/H caused a rapid and sustained reduction in SBP/DBP in patients' hypertension and additional cardiovascular risk factors. The therapy was safe and well tolerated.

STUDY REGISTRATION NUMBER

KCT0003401 ( https://cris.nih.go.kr/cris/search/detailSearch.do/20795 ).

Resistant hypertension: consensus document from the Korean society of hypertension

Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.

Korea hypertension fact sheet 2022: analysis of nationwide population-based data with a special focus on hypertension in the elderly

BACKGROUND

The Korean Society of Hypertension has published the Korea Hypertension Fact Sheet 2022 to provide an overview of the magnitude and management status of hypertension and their recent trends.

METHODS

The Fact Sheets were based on the analyses of Korean adults aged 20 years or older of the 1998-2020 Korea National Health and Nutrition Examination Survey and the 2002-2020 National Health Insurance Big Data.

RESULTS

As of 2020, 29.4% of the adult population aged 20 or older in Korea, about 12.6 million people, have high blood pressure, of which 5.0 million (40%) are 65 years of age or older and 1.2 million (10%) are 80 years of age or older. Among those with hypertension, the awareness rate is 69%, the treatment rate is 65%, and the control rate is 47%. The number of people diagnosed with hypertension increased from 3.0 million in 2002 to 10.5 million in 2020. During the same period, the number of people using antihypertensive medication increased from 2.5 million to 9.9 million, and the number of people adherent to treatment increased from 0.6 million to 7.4 million. Among those treated for hypertension in 2020, 74% used angiotensin blockers, 61% used calcium channel blockers, 24% used diuretics, and 15% used beta blockers. Combination therapy with at least two classes of antihypertensive medication consisted of 60% of all antihypertensive prescriptions. The number of people with hypertension aged 65 or older is increasing very rapidly compared to those aged 20-64. Awareness and treatment rates of hypertension improved rapidly, especially in those aged 65 or older, but the rate of improvement slowed since 2012.

CONCLUSIONS

In Korea, the level of hypertension management is improving, but the absolute number of people with hypertension, especially elderly hypertension, is increasing due to the rapid aging of the population. It is necessary to develop more efficient and target-specific policies to control blood pressure and prevent cardiovascular disease.

Association between environmental chemical exposure and albumin-to-creatinine ratio is modified by hypertension status in women of reproductive age

Chemicals have been identified as a potential risk factor of renal dysfunction. However, studies that consider both multiple chemicals and non-chemical risk factors, such as hypertension, are rare. In this study, we assessed the associations between exposure to several chemicals, including major metals, phthalates, and phenolic compounds, and the albumin-to-creatinine ratio (ACR). A group of Korean adult women in reproductive age (n = 438, aged between 20 and 49 years), who had previously been studied for association of several organic chemicals, was chosen for this purpose. We constructed multivariable linear regression models for individual chemicals and weighted-quantile sum (WQS) mixtures, by hypertension status. Among the study population, approximately 8.5% of the participants exhibited micro/macro-albuminuria (ACR ≥30 mg/g), and 18.5% and 3.9% exhibited prehypertension and hypertension, respectively. Blood cadmium and lead levels showed a stronger association with ACR only among women with prehypertension or hypertension. Among organic chemicals, depending on the statistial model, benzophenone-1 (BP-1) and mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) showed a significant association regardless of hypertension status, but most associations disappeared in the (pre)hypertensive group. These findings clearly indicate that hypertension status can modify and may potentiate the association of environmental chemicals with ACR. Our observations suggest that low-level environmental pollutant exposure may have potential adverse effects on kidney function among general adult women. Considering the prevalence of prehypertension in the general population, efforts to reduce exposure to cadmium and lead are necessary among adult women to minimize the risk of adverse kidney function.

Sex and gender in hypertension guidelines

This paper reviews 11 current and previous international and some selected national hypertension guidelines regarding sex and gender-related differences. Those differences can be attributed to biological sex and to gender differences that are determined by socially constructed norms. All reviewed guidelines agree on a higher hypertension prevalence in men than in women. They also concur that evidence does not support different blood pressure thresholds and targets for treatment between men and women. Differences refer in addition to the differences in epidemiological aspects to differences in some morphometric diagnostic indices, e.g., left ventricular mass or the limits for daily alcohol intake. Concerning practical management, there are hardly any clear statements on different procedures that go beyond the consensus that blockers of the renin-angiotensin system should not be used in women of childbearing age wishing to become pregnant. Some further sex-specific aspects are related to differences in tolerability or drug-specific side effects of BP-lowering drugs. There is also a consensus about the need for blood pressure monitoring before and during the use of contraceptive pills. For management of pregnancy, several guidelines still recommend no active treatment in pregnant women without severe forms of hypertension, despite a wide consensus about the definition of hypertension in pregnancy. A disparity in treatment targets when treating severe and non-severe hypertension in pregnancy is also observed. Overall, sex-specific aspects are only very sparsely considered or documented in the evaluated guidelines highlighting an unmet need for future clinical research on this topic.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE)

BACKGROUND

Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women.

METHODS

Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD.

RESULTS

Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m²) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each).

CONCLUSIONS

In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Feasibility, credence, and usefulness of out-of-office cuffless blood pressure monitoring using smartwatch: a population survey

BACKGROUND

Cuffless blood pressure (BP) measurement, enabled by recent advances in wearable devices, allows for BP monitoring in daily life. This study aims to evaluate the feasibility, cresdence, and usefulness of cuffless BP monitoring through a population survey.

METHODS

During the "Daily BP Measurement with Your Galaxy Watch" campaign held by the Korean Society of Hypertension, participants were asked to share their experiences with cuffless BP measurement using a smartwatch application through an online survey. The questionnaire included questions about age, underlying medical conditions, smartwatch utilization, experience with BP calibration, the reliability of BP values measured by a smartwatch, and willingness to use the BP monitoring function in the future.

RESULTS

A total of 1071 participants responded to the survey. The largest age group (decile) was 50-59 years old (33.3%), followed by 40-49 years old (29.9%). Although nearly half of the participants (47.5%) had no chronic diseases, 40.1% reported having hypertension. BP monitoring was the most frequently utilized smartwatch function (95.8%), followed by heart rate measurement (87.1%). 31.8% of participants reported that BP values measured by the smartphone application were "very accurate and helpful," while 63.5% rated them as "slightly lower (44.4%)" or "higher (19.1%)" compared to the standard home BP monitoring device. 93% of the participants reported utilizing the BP monitoring function at least once a week. Regarding the BP calibration process, most participants (93.9%) calibrated the BP measurement application themselves, and 50.8% rated the difficulty level as "very easy."

CONCLUSION

Cuffless BP measurement using a smartwatch application was feasible in the general population, including the self-calibration process. However, the satisfaction level in terms of accuracy is still modest, indicating a need for further development.

Computational clustering reveals differentiated coronary artery calcium progression at prevalent levels of pulse wave velocity by classifying high-risk patients

Many studies found that increased arterial stiffness is significantly associated with the presence and progression of Coronary Calcium Score (CCS). However, none so far have used machine learning algorithms to improve their value. Therefore, this study aims to evaluate the association between carotid-femoral Pulse Wave Velocity (cfPWV) and CCS score through computational clustering. We conducted a retrospective cross-sectional study using data from a cardiovascular risk screening program that included 377 participants. We used an unsupervised clustering algorithm using age, weight, height, blood pressure, heart rate, and cfPWV as input variables. Differences between cluster groups were analyzed through Chi-square and T-student tests. The association between (i) cfPWV and age groups, (ii) log (CCS) and age groups, and (iii) cfPWV and log(CCS) were addressed through linear regression analysis. Clusters were labeled post hoc based on cardiovascular risk. A "higher-risk group" had significantly higher left (0.76 vs. 0.70 mm, P < 0.001) and right (0.71 vs. 0.66 mm, P = 0.003) intima-media thickness, CCS (42 vs. 4 Agatston units, P = 0.012), and ascending (3.40 vs. 3.20 cm, P < 0.001) and descending (2.60 vs. 2.37 cm, P < 0.001) aorta diameters. Association with age appeared linear for cfPWV and exponential for log (CCS). The progression of the log (CCS) and cfPWV through age groups was steeper in the "higher-risk group" than in the "lower-risk group". cfPWV strongly correlated with CCS, and CCS progression over cfPWV differed among clusters. This finding could improve PWV as a "gate-keeper" of CCS testing and potentially enhance cardiovascular risk stratification.

Suboptimal control status of young hypertensive population

The prevalence of hypertension (HT) among young adults aged 18 to 39 years is estimated to be 3.7% to 8.6% worldwide. Although the prevalence of HT in young adults is lower than that of the overall population, those with HT are at substantially increased risk of cardiovascular events compared to those without HT. HT in young adults should be taken with even more caution as longer exposure to higher blood pressure leads to a higher lifetime risk of HT-mediated organ damage. However, young patients with HT show low awareness of HT compared to older patients. Also, they are more prone to show low treatment adherence despite the good efficacy of the treatment. Other risk factors that hinder HT control among young adults include alcohol intake, smoking, low physical activity, emotional stress, job stress, metabolic syndrome, and obesity. This review aimed to illustrate the suboptimal control status of the young hypertensive population and to propose strategies for improvement.

Genetic Risk Score for Prediction of Coronary Heart Disease in the Korean Genome and Epidemiology Study

Background

Using a genetic risk score (GRS) to predict coronary heart disease (CHD) may detect disease earlier. The current study aims to assess whether GRS is associated with CHD incidence and whether it is clinically useful for improving prediction using traditional risk factors (TRFs) as well as family history.

Methods

Data from a total of 48,941 participants in the Korean Genome and Epidemiology Study were analyzed in the current study. The weighted GRS was constructed using 55 single-nucleotide polymorphisms based on published genome-wide association studies. The association of GRS with incident CHD was analyzed using Cox proportional hazard model. Discrimination and reclassification were assessed to demonstrate the clinical utility of GRS. The analyses were performed separately by sex.

Results

After adjusting for family history and TRFs, GRS was significantly associated with CHD incidence in men; compared to the low GRS group, men in the high GRS group had a 2.07-fold increased risk of CHD (95% confidence interval [CI]: 1.51-2.85). In men, the combination of TRFs, family history, and GRS had better performance than TRFs alone (C statistics for TRF-only model, 0.66, 95% CI, 0.64-0.69; C statistics for combination model, 0.68, 95% CI, 0.65-0.71; category-free reclassification index, 15%). In women, however, there was no significant association between GRS and CHD and no improvement between models.

Conclusions

GRS was associated with CHD incidence and contributed to a small improvement of CHD prediction in men. The potential clinical use of GRS may not outweigh the value of family history.

Feasibility and measurement stability of smartwatch-based cuffless blood pressure monitoring: A real-world prospective observational study

Cuffless wearable devices are currently being developed for long-term monitoring of blood pressure (BP) in patients with hypertension and in apparently healthy people. This study evaluated the feasibility and measurement stability of smartwatch-based cuffless BP monitoring in real-world conditions. Users of the first smartwatch-based cuffless BP monitor approved in Korea (Samsung Galaxy Watch) were invited to upload their data from using the device for 4 weeks post calibration. A total of 760 participants (mean age 43.7 ± 11.9, 80.3% men) provided 35,797 BP readings (average monitoring 22 ± 4 days [SD]; average readings 47 ± 42 per participant [median 36]). Each participant obtained 1.5 ± 1.3 readings/day and 19.7% of the participants obtained measurements every day. BP showed considerable variability, mainly depending on the day and time of the measurement. There was a trend towards higher BP levels on Mondays than on other days of the week and on workdays than in weekends. BP readings taken between 00:00 and 04:00 tended to be the lowest, whereas those between 12:00 and 16:00 the highest. The average pre-post calibration error for systolic BP (difference in 7-day BP before and after calibration), was 6.8 ± 5.6 mmHg, and was increased with higher systolic BP levels before calibration. Smartwatch-based cuffless BP monitoring is feasible for out-of-office monitoring in the real-world setting. The stability of BP measurement post calibration and the standardization and optimal time interval for recalibration need further investigation.

The association between carbon and nitrogen stable isotope ratios of human hair and hypertension

BACKGROUND

The relationship between stable isotope ratios and dietary protein sources has been reported. However, few studies have examined the effect of stable isotope ratios on metabolic risk in humans. We investigated whether the stable isotope ratios of carbon and nitrogen in human hair are associated with blood pressure and hypertension.

METHODS

We conducted a cross-sectional study of 392 subjects (228 men and 164 women). Hair samples of the subjects were used for the measurement of stable isotope ratios of carbon (δ¹³C) and nitrogen (δ¹⁵N).

RESULTS

The δ¹³C and δ¹⁵N values showed positive correlations with diastolic blood pressure in the subjects without antihypertensive medication. In the subjects without antihypertensive medication, the multivariable-adjusted odds ratio (95% confidence interval) for hypertension was 1.55 (1.04-2.30) per 1‰ increase in δ¹⁵N and 1.22 (0.86-1.73) per 1‰ increase in δ¹³C, respectively. However, in the subjects with antihypertensive medication, neither δ¹³C nor δ¹⁵N values showed a significant association with hypertension.

CONCLUSIONS

The stable isotopic ratio of nitrogen in scalp hair is independently associated with hypertension in subjects without antihypertensive medication. The hair δ¹⁵N value might be used as a surrogate marker to screen a high-risk population for hypertension.

Current Status of Cardiovascular Disease According to the Duration of Hypertension in Korean Adults

Background

Today, medical technology and healthcare advances have led to an increased life expectancy; however, the prevalence of chronic diseases such as hypertension, diabetes mellitus, stroke, and cardiovascular events is continuously rising. In particular, hypertension is a crucial factor in cardiovascular and cerebrovascular diseases, and it is known that prevention and management are essential.

Objectives

This study investigates the prevalence and management of hypertension in Korean adults and evaluates its correlation with the risk of cardiovascular disease (CVD) and stroke.

Method

The Korean National Health and Nutritional Examination Survey (KNHANES) database was utilized for this study (https://knhanes.cdc.go.kr). The subjects of this survey were sampled to represent the entire population of Korea. The study aims to assess the risk of CVD and stroke according to the duration of hypertension. We also examined the impact of hypertension control on the risk of CVD and stroke. This study is a retrospective cross-sectional study, so future risks cannot be assessed, but only the disease status at the same time point.

Results

A total of 61,379 subjects were enrolled in the KNHANES database, representing Korea's population of 49,068,178 subjects. The prevalence of hypertension was 25.7% (9,965,618 subjects) of the total population. The prevalence of hypertension increased rapidly with the age of the population. As the duration of hypertension increased, the risks of CVD and stroke also increased. When hypertension lasts longer than 20 years, ischemic heart disease, myocardial infarction, and stroke prevalence were 14.6%, 5.0%, and 12.2%, respectively. However, achieving a target blood pressure (BP) goal below 140/90 mmHg reduced the risk of all CVD and stroke by nearly half. Nevertheless, fewer than two-thirds of patients in Korea with hypertension achieved this targeted blood pressure goal.

Conclusions

Our study confirmed that the prevalence of hypertension in Korean adults was higher than a quarter but also showed that the risk of CVD and stroke was significantly reduced by achieving optimal blood pressure control. Based on these results, policy efforts are needed to reach the target BP and improve the treatment rates for hypertension in Korea.

Association of the magnitude of the difference in blood pressure between office and ambulatory measurements with blood pressure variability in untreated individuals

OBJECTIVES

We evaluated the association between cardiovascular risk factors and the magnitude of the difference in systolic blood pressure (SBP) between office and ambulatory measurements (masked effect) in untreated individuals without apparent hypertension-mediated organ damage (HMOD).

METHODS

The inclusion criteria were 1) age ≥ 20 years, 2) blood pressure ≥ 140/90 mmHg at the outpatient clinic, and 3) not receiving antihypertensive medications. The difference between office and ambulatory SBP was calculated by subtracting the ambulatory daytime SBP from the office SBP. The association between the masked effect and SBP variability was analyzed in individuals without HMOD (no electrocardiographic left ventricular hypertrophy, spot urine albumin-to-creatinine ratio < 30 mg/g, and estimated glomerular filtration rate ≥ 60 mL/min/1.73 m², n = 296).

RESULTS

Among the cardiovascular risk factors, ambulatory BP variability was significantly correlated with the SBP difference. The standard deviation (SD) and coefficient of variation (cv) of 24-h SBP exhibited a significant negative linear association with the SBP difference in univariate and multivariate analyses adjusted for age, sex, presence of diabetes, and 24-h ambulatory SBP. A significant association was observed in patients with ambulatory daytime hypertension. In the multivariate analysis, individuals with a negative SBP difference > -5 mmHg exhibited a higher SD and cv of 24-h SBP than those with a negative SBP difference ≤ -5 mmHg or a positive SBP difference.

CONCLUSIONS

The results of our study suggest that the magnitude of the negative difference in office and ambulatory SBP may be a potential risk factor, even in individuals without apparent HMOD.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov ( NCT03855605 ).

Association between the triglyceride-glucose (TyG) index and increased blood pressure in normotensive subjects: a population-based study

BACKGROUND

Insulin resistance (IR) is an important contributor to the development of hypertension (HTN), and the triglyceride-glucose (TyG) index has been proposed as a simple, reliable marker of IR. This study investigated the association between the TyG index and blood pressure (BP) elevation in a large general population.

METHODS

The study enrolled 15,721 adults with no history of cardiometabolic diseases from the 2016-2019 Korea National Health and Nutrition Examination Survey. Participants were classified into quartiles based on the TyG index and BP was categorized as normal BP, elevated BP, pre-HTN, and HTN. The associations of the TyG index with BP categories were assessed using multivariate multinomial logistic regression models with normal BP as the reference group.

RESULTS

The mean systolic/diastolic BP and prevalence of HTN increased with the TyG index (P for trend < 0.001). The continuous TyG index had a strong dose-response relationship with increased odds of elevated BP, pre-HTN, and HTN. Compared with the lowest TyG index quartile, the highest TyG index quartile was significantly associated with higher odds of having elevated BP (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.24-1.87; P for trend < 0.001), pre-HTN (OR, 2.22; 95% CI, 1.95-2.53; P for trend < 0.001), and HTN (OR, 4.24; 95% CI, 3.49-5.16; P for trend < 0.001).

CONCLUSION

We found that a higher TyG index was positively associated with the risk of increased BP in normal healthy individuals. This study suggests that the TyG index might serve as a potential predictor of HTN. However, further studies with larger sample sizes and various target populations in longitudinal designs are needed.

Home blood pressure monitoring: a position statement from the Korean Society of Hypertension Home Blood Pressure Forum

Home blood pressure measurement (HBPM) has the advantage of measuring blood pressure (BP) multiple times over a long period. HBPM effectively diagnoses stress-induced transient BP elevations (i.e., white coat hypertension), insufficient BP control throughout the day (i.e., masked hypertension), and even BP variability. In most cases, HBPM may increase self-awareness of BP, increasing the compliance of treatment. Cumulative evidence has reported better improved predictive values of HBPM in cardiovascular morbidity and mortality than office BP monitoring. In this position paper, the Korean Society of Hypertension Home Blood Pressure Forum provides comprehensive information and clinical importance on HBPM.

Prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea

Approximately 29% of Korean adults have hypertension; however, the prevalence of primary aldosteronism among the hypertensive population is largely unknown. The aim of our study was to evaluate the prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea. We retrospectively analyzed 1173 patients with newly diagnosed or preexisting hypertension who were referred to our tertiary-care hospital between January 2013 and December 2018. Patients were screened for primary aldosteronism with the aldosterone-renin ratio and underwent a saline infusion test for diagnostic confirmation. Adrenal computed tomography and adrenal venous sampling were performed for subtype classification for primary aldosteronism. Among the 1173 patients (mean age, 51.8 years; women, 53.2%), 360 (30.7%) had positive screening-test results, of whom 71 (6.1%) were finally diagnosed with primary aldosteronism. Conclusive subtype differentiation was made in 55 patients, of whom 15 (27%) had an aldosterone-producing adenoma, 4 (7%) had unilateral adrenal hyperplasia, and 36 (66%) had bilateral adrenal hyperplasia. Patients with primary aldosteronism had a higher ambulatory blood pressure, left ventricular mass index, and urinary albumin-to-creatinine ratio than those without. Moreover, the primary aldosteronism group had a higher prevalence of left ventricular hypertrophy and albuminuria than the non-primary aldosteronism group. Primary aldosteronism may be more common (6.1%) among Korean patients with hypertension than generally recognized. Primary aldosteronism was associated with a higher degree and prevalence of target organ damage and a higher blood pressure level. Wide application of screening tests for primary aldosteronism may be beneficial in detecting this potentially curable cause of hypertension.

Effect of low sodium and high potassium diet on lowering blood pressure

Background: Hypertension is the leading factor of cardiovascular mortality and morbidity. Although antihypertensive medical treatment is the cornerstone of blood pressure control, lifestyle modification, including optimal diet therapy, such as dietary approaches to stop hypertension (DASH), cannot be overemphasized.Current Concepts: Due to the mismatch between sodium intake and excretion process being the key mechanisms according to physiologic principles, low sodium and high potassium intakes are the critical components of DASH. If the patient has a sensitive elevation of blood pressure following increased sodium intake, a low sodium diet could be essential for optimal blood pressure control. Salt sensitivity is increased by the activated reninangiotensin system, sympathetic nervous activity, sodium channels disorder, and endothelial dysfunction and frequently observed in the elderly and patients with obesity and chronic kidney disease. Increased potassium intake could attenuate sodium absorption by affecting the intracellular chloride and WNK4 activity, especially in patients with salt sensitivity or high salt intake.Discussion and Conclusion: For low sodium and high potassium intakes, the Na/K diet ratio could be a good target for intervention, and this approach is a critical component of DASH.

Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure

Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

Atherogenic Index of Plasma and Its Association with Risk Factors of Coronary Artery Disease and Nutrient Intake in Korean Adult Men: The 2013-2014 KNHANES

Coronary artery disease (CAD) has been linked to one of the highest death rates globally. The atherogenic index of plasma (AIP) may be an important predictor of atherosclerosis and cardiovascular disease, superior to the standard atherosclerotic lipid profile. This study investigated the relationship between AIP and obesity indices, blood glucose, lipid profile, and nutrient intake status in Korean adult men. The study included 1292 males aged ≥19 years old who participated in the Korea National Health and Nutrition Examination Survey, 2013-2014. Participants were divided into four groups according to AIP quartiles, calculated as log (triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C)). Body mass index, waist circumference, fasting blood glucose, hemoglobin A1c, total cholesterol, TG, and low-density lipoprotein cholesterol levels increased as AIP levels increased, whereas HDL-C level declined. As the level of AIP increased, intake of saturated fatty acid, calcium, phosphorus, riboflavin, milk, and dairy product decreased significantly, and the contribution rate of milk and dairy products to fat intake decreased. AIP was linked to obesity indices, blood glucose, and blood lipid profile in Korean men, suggesting that it could predict CAD.

Prevalence and prognosis of refractory hypertension diagnosed using ambulatory blood pressure measurements

The prognosis of refractory hypertension is largely unknown due to its low prevalence. This study aimed to investigate the prognosis of refractory hypertension and compare it with those of resistant and nonresistant hypertension. We retrospectively analyzed the data of 16,284 participants with hypertension who underwent ambulatory blood pressure (BP) monitoring between 2012 and 2019 at a tertiary center. Uncontrolled BP was defined as a 24-h BP ≥ 130/80 mmHg as assessed by ambulatory BP monitoring. Resistant hypertension was defined as uncontrolled BP despite the use of three antihypertensive medications, including a diuretic or the use of ≥4 drugs regardless of BP control. Refractory hypertension was defined as uncontrolled BP despite the use of ≥5 antihypertensive medications. Among 16,284 patients with hypertension (mean age 59.2 ± 15.5 years, 52.7% men), 1501 (9.2%) and 150 (0.9%) patients had resistant and refractory hypertension, respectively. The prevalence of chronic kidney disease, end-stage renal disease, heart failure, previous stroke, left ventricular hypertrophy, and the riser/nondipper patterns of circadian BP rhythm progressively increased from patients with nonresistant hypertension to patients with resistant hypertension to patients with refractory hypertension. During a median follow-up of 3.9 years, the risk of cardiovascular mortality progressively increased from patients with nonresistant hypertension to patients with resistant hypertension (hazard ratio 1.62, 95% confidence interval 1.16-2.26) to patients with refractory hypertension (hazard ratio 5.22, 95% confidence interval 3.04-8.96). In conclusion, refractory hypertension, defined as uncontrolled ambulatory BP levels, was associated with a higher risk of all-cause and cardiovascular mortality than nonresistant or resistant hypertension.

Prevalence trends of non-alcoholic fatty liver disease among young men in Korea: A Korean military population-based cross-sectional study

Background/Aims

Non-alcoholic fatty liver disease (NAFLD) has become a major concern in Korea since its emergence as a dominant cause of chronic liver disease. However, no study has explored its prevalence in adults under 30 years of age. Therefore, we performed a cross-sectional study to investigate the prevalence of NAFLD in Korean men in their early 20s.

Methods

We collected data of 596,359 Korean soldiers who participated in a health examination between January 2015 and July 2021. A total of 571,872 individuals were analyzed after excluding those with missing data and hepatitis B antigen positivity. Hepatic steatosis was determined using the hepatic steatosis index (HSI). Participants with HSI >36 were considered to have NAFLD.

Results

All participants were men, and the mean age was 20.9±1.3 years. Of the 571,872 participants screened, 77,020 (13.47%) were classified as having NAFLD. The prevalence of NAFLD consistently increased from 2015 to 2021 (10.66% vs. 16.44%, P<0.001). Increases from 2015 to 2021 were also noted in the prevalence of hypercholesterolemia, hyperglycemia, and hypertension (P<0.001 for all). The mean body mass index also increased from 23.3±3.0 kg/m² to 23.9±3.1 kg/m² between 2015 and 2021 (P<0.001).

Conclusions

The prevalence of NAFLD and of other metabolic dysfunctions in Korean men in their early 20s increased from 2015 to 2021.

Korea hypertension fact sheet 2021: analysis of nationwide population-based data with special focus on hypertension in women

BACKGROUND

The Korean Society of Hypertension has published the Korea Hypertension Fact Sheet 2021 to provide an overview of the magnitude and management status of hypertension and their recent trends.

METHODS

The Fact Sheets were based on the analyses of Korean adults aged 20 years or older of the 1998-2019 Korea National Health and Nutrition Examination Survey and the 2002-2019 National Health Insurance Big Data.

RESULTS

Currently, the population average of systolic/diastolic blood pressure was 119/76 mmHg in Korean adults aged 20 years or older showing little change in the recent decade. It is estimated that 28% of the adult population aged 20 or older (33% of adults aged 30 or older) have hypertension. The estimated number of people with hypertension was 6.30 million for men and 5.77 million for women, and 1.96 million for men and 2.99 million for women among the population aged 65 or older. The number of people diagnosed with hypertension increased from 3.0 million in 2002 to 10.1 million in 2019. During the same period, the number of people using antihypertensive medication increased from 2.5 million to 9.5 million, and the number of people adherent to treatment increased from 0.6 million to 6.9 million. Among antihypertensive prescriptions, 40.6% of the patients received monotherapy, 43.4% received dual therapy, and 16.0% received triple or more therapy. The most commonly prescribed antihypertensive medication was angiotensin receptor blockers (ARB), followed by calcium channel blockers (CCB) and diuretics. In young women, angiotensin-converting enzyme inhibitors (ACEi), ARB and CCB are less frequently prescribed than in men, but 59.5% of hypertensive women aged 20-39 are prescribed ACEi or ARBs. Hypertensive disorders during pregnancy have been increasing over the past 10 years. In 2019, 5.4% of women who gave birth were diagnosed with chronic hypertension and 3.1% with pregnancy-induced hypertension.

CONCLUSIONS

To achieve further improvement in management of hypertension, we need to encourage awareness and treatment in young adults. It is required to develop tailored prevention and management strategies that are appropriate for and inclusive of various demographics.

Lifestyle Modification in the Management of Metabolic Syndrome: Statement From Korean Society of CardioMetabolic Syndrome (KSCMS)

Metabolic syndrome (MetS) is highly prevalent and is associated with worse cardiovascular outcome. Lifestyle modification is the most effective way to reduce the incidence of cardiovascular complications caused by MetS. Here, we would like to review the effects and specific methods of the 6 lifestyle modifications (weight control, smoking cessation, alcohol drinking in moderation, diet control, exercise and physical activity, and cognitive behavioral therapy) and control of blood pressure, dyslipidemia, and blood sugar based on evidence in the management of MetS.

With the recent rapid increase in obesity worldwide, metabolic syndrome (MetS) has gained significant importance. MetS is a cluster of obesity-related cardiovascular risk factors including abdominal obesity, atherogenic dyslipidemia, high blood pressure and impaired glucose tolerance. MetS is highly prevalent and strongly associated with an increased risk of developing diabetes and cardiovascular disease, putting a great burden on human society. Therefore, it is very important to reduce MetS risk, which can improve patients’ cardiovascular prognosis. The primary and most effective strategy to control each component of MetS is lifestyle change such as losing body weight, keeping regular exercise, adopting a healthy diet, quitting smoking and alcohol drinking in moderation. Many studies have shown that lifestyle modification has improved all components of MetS, and reduces the incidence of diabetes and cardiovascular disease. Here, the Korean Society of CardioMetabolic Syndrome has summarized specific and practical methods of lifestyle modification in the management of MetS in the healthcare field.

Cost-effectiveness analysis of intensive blood pressure control in Korea

This study was a cost-effectiveness analysis of intensive blood pressure (BP) control among hypertensive patients in Korea. We constructed a Markov model comparing intensive versus standard BP control treatment and calculated the incremental cost-effectiveness ratio. The study population consisted of hypertensive patients over 50 years old with systolic blood pressures (SBPs) exceeding 140 mmHg and at high risk of cardiovascular disease. Treatment alternatives included lowering the SBP below 120 mmHg (intensive) and 140 mmHg (standard) for target BP. We assumed five scenarios with different medication adherence. The effectiveness variable was quality-adjusted life years (QALYs), and costs included medical costs related to hypertension (HT), complications, and nonmedical costs. In addition, we performed a sensitivity analysis to confirm the robustness of the results of this study. Scenario 5, with 100% medication adherence, showed the lowest incremental cost-effectiveness ratio (ICER) of $1,373 USD, followed by scenario 1 (first 15 years: 62.5%, 16-30 years: 65.2%, after 30 years: 59.5%), scenario 2 (first five years: 62.5% decrease by 5% every five years), and scenario 3 (first 10 years: 62.5% decrease by 10% every 10 years). The ICERs in all scenarios were lower than the willingness to pay (WTP) threshold of $9,492-$32,907 USD in Korea. Tornado analysis showed that the ICERs were changed greatly according to stroke incidence. Intensive treatment of HT prevents cardiovascular disease (CVD); therefore, intensive treatment is more cost-effective than standard treatment despite the consumption of more health resources. ICERs are considerably changed according to medication adherence, confirming the importance of patient adherence to treatment.

Large Artery Stiffness: A Companion to the 2015 AHA Science Statement on Arterial Stiffness

Large artery stiffness (LAS) has proven to be an independent risk factor for cardiovascular disease and mortality. Nevertheless, the position of current hypertension guidelines regarding the usefulness of assessing LAS differs across different continents. In general, European Guidelines recognize pulse wave velocity (PWV) as a marker of target organ damage but do not recommend its systematic use in general population. Asian guidelines consider PWV as a recommended test at diagnosis of hypertension, in contrast to North American guidelines that do not state any position about its usefulness. However, PWV predicts cardiovascular events, and several studies have shown that it improves risk classification adjusting for established risk factors especially for intermediate-risk patients. Finally, some advances have been made related to treatments affecting LAS. Dietary interventions such as sodium restriction and exercise-based interventions have a modest effect in reducing LAS. Pharmacological interventions, such as statins, or more recent advances with mineralocorticoid blocker seem to have a beneficial effect. Last, controversial effects of renal denervation on LAS have been found. Our goal here is to update the reader on LAS on these areas since the 2015 American Heart Association Scientific Statement.

Real-world evidence on the strategy of olmesartan-based triple single-pill combination in Korean hypertensive patients: a prospective, multicenter, observational study (RESOLVE-PRO)

Background

In this prospective, multicenter, non-comparative observational study, the effectiveness and safety of the triple single-pill combination (SPC) of olmesartan/amlodipine/hydrochlorothiazide (OM/AML/HCTZ) were evaluated in a real clinical practice setting in Korean patients with essential hypertension.

Methods

A total of 3752 patients were enrolled and followed for 12 months after administration of OM/AML/HCTZ. Primary endpoint was change from baseline to month 6 in the mean systolic blood pressure (SBP). Secondary endpoints included changes from baseline in the mean SBP at month 3, 9, 12 and the mean diastolic blood pressure (DBP) at month 3, 6, 9, 12; changes in the mean SBP/DBP according to age and underlying risk factors; and blood pressure control rate (%) at different time points. Adherence to and satisfaction with OM/AML/HCTZ treatment among patients and physicians were assessed by medication possession ratio (MPR) and numeric rating scale, respectively, as exploratory endpoints. Safety was evaluated by the incidence and severity of adverse events (AEs) as well as the discontinuation rate due to AEs.

Results

OM/AML/HCTZ administration led to significant reductions in the mean SBP/DBP by 11.5/6.6, 12.3/7.0, 12.3/7.2, and 12.8/7.4 mmHg from baseline to month 3, 6, 9 and 12, respectively (P < 0.0001). The BP reductions were maintained throughout the 1-year observation period in all patients with different age groups and risk factors (diabetes mellitus, cardiovascular disease, and renal disease). The BP control rate (%) of < 140/90 mmHg was 65.9, 67.9, 68.9, and 70.6% at month 3, 6, 9, and 12, respectively. The mean MPR during the observation period was 0.96. The safety results were consistent with the previously reported safety profile of OM/AML/HCTZ.

Conclusions

Treatment with the triple SPC of OM/AML/HCTZ demonstrated significant effectiveness in reducing SBP/DBP and achieving target BP control with high adherence over the 1-year observation period in Korean hypertensive patients and was well-tolerated.

Trial registration

CRIS, KCT0002196, Registered 3 May 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-021-00177-z.

A nationwide study of patients with monoclonal gammopathy of undetermined significance with a 10-year follow-up in South Korea

In clinical practice, most patients with monoclonal gammopathy of undetermined significance (MGUS) undergo long-term follow-up without disease progression. There is insufficient real-world data about how closely and whether anything other than disease progression should be monitored. Herein, we performed a nationwide study of 470 patients with MGUS with a 10-year follow-up to determine the patterns of disease progression and other comorbidities. During the follow-up period, 158 of 470 patients with MGUS (33.62%) progressed to symptomatic monoclonal gammopathies. Most of these were multiple myeloma (134/470 patients, 28.51%), and those diagnosed within 2 years after diagnosis of MGUS was high. Approximately 30-50% of patients with MGUS had hypertension, diabetes, hyperlipidemia, and osteoarthritis at the time of diagnosis, and these comorbidities were newly developed during the follow-up period in approximately 50% of the remaining patients with MGUS. Approximately 20-40% of patients with MGUS have acute or chronic kidney failure, thyroid disorders, disc disorders, peripheral neuropathy, myocardial infarction, stroke, and heart failure during the follow-up period. Altogether, when MGUS is diagnosed, close follow-up of the possibility of progression to multiple myeloma is required, especially within 2 years after diagnosis; simultaneously, various comorbidities should be considered and monitored during the follow-up of patients with MGUS. Continuous research is needed to establish appropriate follow-up guidelines.

The Korean Hypertension Cohort study: design and baseline characteristics

BACKGROUND/AIMS

Hypertension (HT) has a significant impact on public health and medical expenses. However, HT is a chronic disease that requires the long-term follow-up of a large number of patients.

METHODS

The Korean Hypertension Cohort (KHC) study aimed to develop a model for calculating cardiovascular risk in HT patients by linking and utilizing the detailed clinical and longitudinal data from hospitals and the national health insurance claim database, respectively. This cohort had a planned sample size of over 11,000 HT patients and 100,000 non-HT controls. Eligible patients were hypertensive patients, who were presenting for the first time and were diagnosed with HT as a main disease from 2006 to 2011. Long-term survival data over a period of approximately 9 years were obtained from the national health insurance claim and national health examination data.

RESULTS

This cohort enrolled 11,083 patients with HT. The mean age was 58.87 ± 11.5 years, 50.5% were male, and 31.4% were never-treated HT. Of the enrolled patients, 32.9% and 37.7% belonged to the high and moderate cardiovascular risk groups, respectively. Initial blood pressures were 149.4 ± 18.5/88.5 ± 12.5 mmHg. During the 2 years hospital data follow-up period, blood pressures lowered to 130.8 ± 14.1/78.0 ± 9.7 mmHg with 1.9 ± 1.0 tablet doses of antihypertensive medication. Cardiovascular events occurred in 7.5% of the overall patients; 8.5%, 8.8%, and 4.7% in the high, moderate, and low risk patients, respectively.

CONCLUSION

The KHC study has provided important information on the long-term outcomes of HT patients according to the blood pressure, comorbid diseases, medication, and adherence, as well as health behaviors and health resource use.

Incidence and Risk Factors of Cardio-Cerebrovascular Disease in Korean Menopausal Women: A Retrospective Observational Study using the Korean Genome and Epidemiology Study data

PURPOSE

Cardio-cerebrovascular diseases constitute the most common and fatal disease among menopausal women. However, the risk of cardio-cerebrovascular diseases in menopausal women compared to men has been underestimated, with insufficient related studies. Therefore, we examined the incidence and risk factors of cardio-cerebrovascular diseases among Korean menopausal women.

METHODS

A retrospective observational study design with secondary analysis was conducted using data from the Korean Genome and Epidemiology Study survey. We used the study's data of 1,197 menopausal women, aged 40-64 years, who did not have cardio-cerebrovascular diseases at baseline and their related data from the biennial follow-ups over 14 years. Cardio-cerebrovascular diseases were defined as hypertension, coronary artery disease, or stroke. The incidence of cardio-cerebrovascular diseases was calculated per person-years, and multivariate Cox proportional hazards models were used to determine the predictors of cardio-cerebrovascular diseases during the follow-up period.

RESULTS

Of the 1,197 cases, 264 were early or surgical menopausal women. The overall incidence of cardio-cerebrovascular diseases was 18.75 per 1,000 person-years. Early or surgical menopause (HR = 4.32, p < .001), along with family history of cardiovascular disease (HR = 1.87, p = .024), elevated blood pressure (HR = 1.79, p < .001), abdominal obesity (HR = 1.37, p = .046), or duration of menopause at the same age (HR = 1.01, p = .001), were strong predictors of cardio-cerebrovascular diseases.

CONCLUSION

Based on the results of this study, it is necessary to identify and closely monitor women with early or surgical menopause for cardiovascular and cerebrovascular diseases prevention. Also, prevention of cardio-cerebrovascular diseases through blood pressure and abdominal obesity management is vital for menopausal women.

A soft voting ensemble classifier for early prediction and diagnosis of occurrences of major adverse cardiovascular events for STEMI and NSTEMI during 2-year follow-up in patients with acute coronary syndrome

OBJECTIVE

Some researchers have studied about early prediction and diagnosis of major adverse cardiovascular events (MACE), but their accuracies were not high. Therefore, this paper proposes a soft voting ensemble classifier (SVE) using machine learning (ML) algorithms.

METHODS

We used the Korea Acute Myocardial Infarction Registry dataset and selected 11,189 subjects among 13,104 with the 2-year follow-up. It was subdivided into two groups (ST-segment elevation myocardial infarction (STEMI), non ST-segment elevation myocardial infarction NSTEMI), and then subdivided into training (70%) and test dataset (30%). Third, we selected the ranges of hyper-parameters to find the best prediction model from random forest (RF), extra tree (ET), gradient boosting machine (GBM), and SVE. We generated each ML-based model with the best hyper-parameters, evaluated by 5-fold stratified cross-validation, and then verified by test dataset. Lastly, we compared the performance in the area under the ROC curve (AUC), accuracy, precision, recall, and F-score.

RESULTS

The accuracies for RF, ET, GBM, and SVE were (88.85%, 88.94%, 87.84%, 90.93%) for complete dataset, (84.81%, 85.00%, 83.70%, 89.07%) STEMI, (88.81%, 88.05%, 91.23%, 91.38%) NSTEMI. The AUC values in RF were (98.96%, 98.15%, 98.81%), ET (99.54%, 99.02%, 99.00%), GBM (98.92%, 99.33%, 99.41%), and SVE (99.61%, 99.49%, 99.42%) for complete dataset, STEMI, and NSTEMI, respectively. Consequently, the accuracy and AUC in SVE outperformed other ML models.

CONCLUSIONS

The performance of our SVE was significantly higher than other machine learning models (RF, ET, GBM) and its major prognostic factors were different. This paper will lead to the development of early risk prediction and diagnosis tool of MACE in ACS patients.

May Measurement Month 2019: an analysis of blood pressure screening results from Korea

Hypertension is the biggest contributing risk factor to cerebrovascular disease and is associated with increased risk of coronary artery disease. The May Measurement Month (MMM) campaign is a global initiative aimed at raising awareness of hypertension and acting as a temporary solution to the lack of screening programs worldwide. An opportunistic cross-sectional survey of participants aged ≥18 was carried out during May 2019 in Korea. Over 10 000 participants were recruited in the MMM campaign in Korea, with a slogan of ‘A simple measure to save lives—#checkyourpressure’. A total of 9975 participants with valid clinical and blood pressure (BP) data were used for analysis. All participants were Korean in ethnicity, mean age was 57.2 (SD ± 21.2) years, 57.7% were females, and the mean body mass index was 23.4 kg/m² (SD ± 3.3). In total, 37.7% of the participants reported a previous diagnosis of hypertension, and 91.3% of those diagnosed were on antihypertensive medications. For other comorbidities, 11.6% reported having diabetes mellitus, 2.0% had previous stroke, and 1.0% had previous myocardial infarction. Mean BP was 130.0/81.0 mmHg in the overall population. After multiple imputation, 47.6% of participants were classified as hypertensive (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or on treatment for raised BP). Among all hypertensive participants, the awareness rate, the treatment rate, and the control rate (systolic BP <140 mmHg and diastolic BP <90 mmHg) were 76.2%, 74.0%, and 50.5%, respectively. Of those on antihypertensive medication, the control rate was 68.2%. While awareness and treatment rates were relatively high in the MMM19 campaign, the BP control rate of the total hypertensive population was still only ∼50%, which demands more emphasis on strict BP control.

Development of the prediction model for hypertension in patients with idiopathic inflammatory myopathies

Cardiac involvement is an important cause of morbidity and mortality in patients with idiopathic inflammatory myopathies (IIMs). Hypertension, an important cardiovascular risk factor for the general population, has a crucial role in heart involvement. However, few studies have focused on the hypertension associated with IIMs. This study aimed to develop and assess the prediction model for incident hypertension in patients with IIMs. A retrospective cohort study was performed on 362 patients with IIMs, of whom 54 (14.9%) were given a diagnosis of new-onset hypertension from January 2008 to December 2018. The predictors of hypertension in IIMs were selected by least absolute shrinkage and selection operator (LASSO) regression, multivariable logistic regression, and clinically relevance, and then these predictors were used to draw the nomogram. Discrimination, calibration and clinical usefulness of the model were evaluated using the C-index, calibration plot, and decision curve analysis, respectively. The predicting model was validated by the bootstrapping validation. The nomogram mainly included predictors such as age, diabetes mellitus, triglyceride, low-density lipoprotein-cholesterol (LDL-C), antinuclear antibodies (ANA), and smoking. This prediction model demonstrated good discrimination with a C-index of 0.754 (95%CI, 0.684 to 0.824) and good calibration. The C-index of internal validation was 0.728, and decision curve analysis demonstrated that this nomogram was clinically useful. Clinicians can use this prediction model to assess the risk of hypertension in IIMs patients, and early preventive measures should be taken to reduce the incidence of hypertension in high-risk patients.

Suboptimal Management Status of Younger Hypertensive Population in Korea

BACKGROUND AND OBJECTIVES

Hypertension (HTN) is the most contributable risk factor for cardiovascular disease. May Measurement Month (MMM) is a global initiative to raise awareness of HTN and act as a temporary solution to the lack of screening programs worldwide.

METHODS

An opportunistic cross-sectional survey of participants aged ≥18 was carried out in May 2019. Over 10,000 participants were recruited in the MMM 2019 Korea, with a slogan of "A simple measure to save lives - #checkyourpressure."

RESULTS

A total of 9,950 participants with valid clinical blood pressure (BP) data were used for analysis. All participants were Korean in ethnicity. The mean age was 57.2±21.2 years, 57.8% were females, and the mean body mass index was 23.4±3.3 kg/m². Among the enrolled population, 20.1% were less than 30 years old, and 5.0% were 30-39 years old. 37.0% of the participants reported a previous diagnosis of HTN, and 91.3% of those diagnosed were on antihypertensive medications. Notably, more than 20% of the participants had not measured their BP during the last 12 months, and the awareness rate in the young hypertensive participants (aged <40) was less than 10%. Among hypertensive participants, the treatment rate was 69.3%, and the control rate among those taking medications was 61.2%.

CONCLUSION

MMM 2019 Korea campaign reported high BP control rates in individuals with HTN, reaching 60%. However, the awareness rate in young hypertensive participants was less than 10% along with suboptimal management status. The MMM 2019 Korea again raised the importance of regular BP measurement in the younger population.

Inverse association between serum bilirubin level and testosterone deficiency in middle-aged and older men

Low serum bilirubin levels have been associated with increased risk of cardiovascular disease (CVD) and metabolic syndrome. Testosterone deficiency could also contribute to increased risk of CVD and metabolic syndrome. Therefore, this study aimed to examine the relationship between serum bilirubin level and testosterone deficiency in 1284 Korean men aged 45 to 70 years. Serum bilirubin level was categorized into quartiles: Q1 ≤ 0.7, Q2 0.8-0.9, Q3 1.0-1.1, and Q4 ≥ 1.2 mg/dL. Testosterone deficiency was defined as level less than 8.0 nmol/L, as suggested by the position statement of International Society of Andrology. The overall prevalence of testosterone deficiency was 5.8% and significantly decreased with the quartiles from Q1 to Q4. Compared with the referent fourth quartile (serum bilirubin ≥ 1.2 mg/dL), the ORs (95% CIs) for testosterone deficiency was 2.29 (1.04-4.94) for the first quartile after adjusting for age, fasting glucose, triglyceride, HDL-cholesterol, leukocyte count, hemoglobin, smoking status, and alcohol intake. We found inversely graded associations of serum bilirubin level with testosterone deficiency. These findings suggest that low bilirubin level may be interpreted as a state of testosterone deficiency in middle-aged and older men.

Efficacy and safety of nebivolol in Korean patients with hypertension by age and sex: a subanalysis from the BENEFIT-KOREA study

BACKGROUND

BENEFIT-KOREA (BEnefits after 24 weeks of NEbivolol administration For essential hypertensIon patients wiTh various comorbidities and treatment environments in Korea) study, an observational study in South Korea, demonstrated the efficacy and safety of nebivolol in Asian patients with essential hypertension with and without comorbidities in real-world settings. We present a subanalysis of the efficacy and safety of nebivolol across age and sex in the BENEFIT-KOREA cohort.

METHODS

Adult South Korean patients with essential hypertension participated in the prospective, single-arm, open, observational BENEFIT-KOREA study; 3011 patients received nebivolol as monotherapy or add-on therapy. Changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP), and pulse rate at 12 and 24 weeks were evaluated. Participants were divided into three age groups-young males and females: < 50 years; middle-aged males and females: ≥50 years to < 70 years; and older males and females: ≥70 years.

RESULTS

The mean age of study participants was 63.5 ± 12.9 years; majority were between 50 and 69 years of age and 40.4% were females. A significant decrease was observed in mean SBP, DBP, and pulse rate from baseline at 12 and 24 weeks in males and females across all age groups analyzed (all P < 0.001 vs. baseline), with no significant difference in mean reduction in SBP and DBP from baseline between sex within the age groups. Majority of reported adverse events were mild. The incidence of adverse events was lower in young participants versus middle-aged and older participants.

CONCLUSIONS

Our subanalysis from the real-world BENEFIT-KOREA study in Asian patients with essential hypertension demonstrated the efficacy and safety of once-daily nebivolol across age groups with no between-sex differences.

TRIAL REGISTRATION

Name of the registry: clinicaltrials.gov.

TRIAL REGISTRATION NUMBER

NCT03847350 . Date of registration: February 20, 2019 retrospectively registered.

Risk of Incident Hypertension According to Physical Activity and Temporal Changes in Weight

BACKGROUND

Physical activity (PA) and maintenance of a normal weight contribute to the prevention of hypertension but not always concurrently. Our aim was to investigate whether maintaining PA, regardless of weight change, is associated with a reduced risk of developing hypertension.

METHODS

We conducted a cohort study of 195,045 Koreans (mean age, 37.7 years; standard deviation, 7.1 years) who participated in an occupational health screening program from January 2011 to December 2016. PA levels were measured using the validated Korean version of the International Physical Activity Questionnaire Short Form, and participants were classified into 3 categories as inactive, active, and health-enhancing physically active (HEPA). Weight was tracked, and participants were divided into 2 categories: those whose weight change >0 and those whose weight change ≤0.

RESULTS

During 616,326.5 person-years, 12,206 participants developed hypertension (19.8 per 1,000 person-years). A higher PA level and greater reduction in body mass index were associated with lower risk for incident hypertension. Hazard ratio (HR) for incident hypertension was lower (0.83; 95% confidence interval, 0.79-0.88) in subjects with active/HEPA at baseline and decreased weight than in those in the inactive and increased weight groups after adjustment for confounding factors. Even in the increased weight group, HR for incident hypertension was 0.85 (0.81-0.90) in subjects whose PA was consistently maintained at active or HEPA levels during follow-up.

CONCLUSIONS

In this large cohort of young and middle-aged Koreans, maintaining active or HEPA PA levels was associated with reduced risk of developing hypertension regardless of weight change.

Comorbidity network analysis related to obesity in middle-aged and older adults: findings from Korean population-based survey data

OBJECTIVES

We conducted a comorbidity network analysis using data from the seventh Korea National Health and Nutrition Examination Survey to systematically quantify obesity-related comorbidities.

METHODS

The study included 11,712 subjects aged 45 to 80 (5,075 male and 6,637 female). A prevalent disease was defined as a specific disease for which a subject had been diagnosed by a doctor and was being treated. Comorbidity network analysis was performed for diseases with a prevalence of 1% or more, including overweight and obesity. We estimated the observed-to-expected ratio of all possible disease pairs with comorbidity strength and visualized the network of obesity-related comorbidities.

RESULTS

In subjects over 45 years old, 37.3% of people had a body mass index over 25.0 kg/m2. The most common prevalent disease was hypertension (42.3%), followed by dyslipidemia (17.4%) and diabetes (17.0%). Overweight and obese subjects were 2.1 times (95% confidence interval, 1.9 to 2.3) more likely to have a comorbidity (i.e., 2 or more diseases) than normal-weight subjects. Metabolic diseases such as hypertension, dyslipidemia, diabetes, and osteoarthritis were directly associated with overweight and obesity. The probability of coexistence for each of those 4 diseases was 1.3 times higher than expected. In addition, hypertension and dyslipidemia frequently coexisted in overweight and obese female along with other diseases. In obese male, dyslipidemia and diabetes were the major diseases in the comorbidity network.

CONCLUSIONS

Our results provide evidence justifying the management of metabolic components in obese individuals. In addition, our results will help prioritize interventions for comorbidity reduction as a public health goal.

Smartphone / smartwatch-based cuffless blood pressure measurement : a position paper from the Korean Society of Hypertension

Smartphone technology has spread rapidly around the globe. According to a report released by the Korea Information Society Development Institute, about 95% of Koreans aged more than 30 years old owned smartphones. Recently, blood pressure (BP) measurement using a photoplethysmography-based smartphone algorithm paired with the smartwatch is continuously evolving. In this document, the Korean Society of Hypertension intends to remark the current results of smartphone / smartwatch-based BP measurement and recommend optimal BP measurement methods using a smartphone device. We aim to increase the likelihood of success in implementing these new technologies into improved hypertension awareness, diagnosis, and control.

Long-Term Safety of a Novel Angiotensin Receptor Blocker, Fimasartan, According to the Absence or Presence of Underlying Liver Disease in Korean Hypertensive Patients: A Prospective, 12-Month, Observational Study

Purpose

Fimasartan, the ninth and most recent angiotensin receptor blocker (ARB) approved by the Korea Food and Drug Administration, has shown similar efficacy and safety profiles compared to other ARBs. However, due to being predominantly excreted by the hepatobiliary system, concerns on safety have been raised regarding its use in patients with underlying liver disease.

Patients and Methods

This prospective, 12-month, observational study evaluated patients with essential hypertension (HTN) receiving ≥1 dose of fimasartan. Self-reported and physician-reported events were recorded and classified according to organ class and severity. Outcomes were compared according to the absence and presence of underlying liver disease.

Results

A total of 601 patients were screened, and 566 patients who met predefined inclusion criteria were grouped according to the presence of underlying liver disease. Adverse events (AE) were reported in 28.7% (128/446) of patients without prior liver disease, while 42.5% (51/120) experienced events in the group with chronic liver disease. There was no difference in discontinuations due to liver function between patients with and without baseline liver disease (1.1% [5] vs 2.5% [3], p=0.376), and only a non-significant increase was observed in events associated to the hepatobiliary system in patients with chronic liver disease (9.7% [7] vs 2.7% [9], p=0.061). There were no deaths or serious adverse drug reactions (SADR) during the study period. In multivariate regression analysis, the presence of chronic liver disease (OR 2.01), female sex (OR 1.49) and old age (OR 1.12 for every 5-year increase) were independent predictors for the development of AE. Finally, no significant difference was observed in the reduction of systolic blood pressure after 12 months of treatment (least square mean change −6.57 ± 0.80 mmHg for normal liver function group; −7.65 ± 1.59 mmHg for chronic liver disease group; p=0.546).

Conclusion

Long-term use of fimasartan for treatment of HTN was associated with a low rate of adverse events overall, especially in the absence of underlying liver disease. Even for patients with chronic liver disease, fimasartan treatment was well tolerated. Fimasartan could be a safe option for long-term treatment of essential HTN. ClinicalTrials.gov identifier: NCT02385721.

Dietary Fiber and Its Source Are Associated with Cardiovascular Risk Factors in Korean Adults

We examined the associations of dietary fiber and its source with cardiovascular risk factors in Korean adults. This cross-sectional study involved 16,792 adults from the 2013–2018 Korea National Health and Nutrition Examination Survey data. Dietary data were obtained using a 24 h recall method and used to evaluate intakes of total dietary fiber and its source and fruit consumption. Cardiovascular risk factors included obesity, abdominal obesity, metabolic syndrome, hypercholesterolemia, hypertension, and type 2 diabetes. Multiple logistic regression was used to examine the associations of dietary fiber and its source with cardiovascular risk factors by sex. Total fiber and fruit fiber intake in men were inversely associated with metabolic syndrome (Q5 vs. Q1: odds ratios (OR) = 0.69, 95% confidence intervals (CI) = 0.53–0.92 for total fiber; Q4 vs. Q1: OR = 0.76, 95% CI = 0.61–0.93 for fruit fiber). Among women, a higher intake of fruit fiber was related to a reduced prevalence of obesity (Q4 vs. Q1: OR = 0.85, p trend = 0.029) and abdominal obesity (Q4 vs. Q1: OR = 0.82, p trend = 0.026). Total fruit and whole fruit consumption was inversely associated with obesity, abdominal obesity, and metabolic syndrome in men and hypertension in women. The amount and sources of fiber are associated with metabolic diseases in Korean adults and should be considered in the context of overall dietary quality.

Cardiovascular or mortality risk of controlled hypertension and importance of physical activity

OBJECTIVE

To investigate the risk of major adverse cardiac and cerebrovascular events (MACCEs) and all-cause death of patients with controlled hypertension and suggest the benefits of physical activity in their prognosis.

METHODS

People aged 40-69 years from the prospective UK Biobank cohort (UKB, n=220 026) and the retrospective Korean National Health Insurance Service cohort (KNHIS, n=3 593 202) were included in this observational cohort study, excluding those with previous cerebrocardiovascular diseases or hypertension without treatment. The study groups were stratified into normotension, controlled hypertension (patients with hypertension with systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) and uncontrolled hypertension groups. The outcomes were MACCEs and all-cause mortality, analysed by Cox regression analysis.

RESULTS

We included 161 405/18 844/39 777 and 3 122 890/383 828/86 484 individuals with normotension/controlled hypertension/uncontrolled hypertension state from the UKB and KNHIS cohorts, respectively. The controlled hypertension group showed significantly higher risk of MACCEs (UKB: adjusted HR 1.73 (95% CI 1.55 to 1.92); KNHIS: 1.46 (95% CI 1.43 to 1.49)) and all-cause mortality (UKB: adjusted HR 1.28 (95% CI 1.18 to 1.39); KNHIS: 1.29 (95% CI 1.26 to 1.32)) than individuals with normotension. The controlled hypertension group not involved in any moderate or moderate-to-vigorous physical activity showed high risk of adverse outcomes, which was comparable with or even higher than the risk of patients with uncontrolled hypertension who were engaged in physical activity.

CONCLUSIONS

Controlled hypertension is associated with residual risks of adverse outcomes. Clinicians may encourage physical activity for patients with controlled hypertension, not being reassured by their achieved target blood pressure values.