Epidemiology of masked and white-coat hypertension: the family-based SKIPOGH study

Self-reported caffeine consumption miss-matched consumption measured by plasma levels of caffeine and its metabolites: results from two population-based studies

IMPORTANCE AND OBJECTIVE

Self-reported caffeine consumption has been widely used in research while it may be subject to bias. We sought to investigate the associations between self-reported caffeine consumption and plasma levels of caffeine and its two main metabolites (paraxanthine and theophylline) in the community.

METHODS

Data from two population-based studies (SKIPOGH1 and 2 (N = 1246) and CoLaus|PsyCoLaus (N = 4461)) conducted in Switzerland were used. Self-reported caffeine consumption was assessed using questionnaires. Plasma levels of caffeine and its metabolites were quantified by ultra-high performance liquid chromatography coupled to a tandem quadrupole mass spectrometer.

RESULTS

In both studies, mean log plasma levels of caffeine and its two metabolites were over 6.48 (plasma levels = 652 ng/ml) when no caffeine consumption was reported. Subsequently, nonlinear associations between log plasma levels and self-reported caffeine consumption were observed in SKIPOGH, with a change of the slope at 3-5 cups of espresso per day in SKIPOGH1 but not SKIPOGH2. In CoLaus|PsyCoLaus, increased daily consumption of caffeinated beverages was associated with increased log plasma levels with a change of the slope at 3 cups. In both studies, declared caffeine consumption higher than 3-5 cups per day was not associated with higher plasma levels of caffeine and its metabolites.

CONCLUSION

Self-reports of no or low caffeine consumption and consumption of more than 3-5 cups of coffee should be interpreted with caution, with possible under- or over-estimation. Quantifying plasma levels of caffeine and its metabolites may contribute to a better estimation of caffeine intake.

Serum sclerostin is associated with recurrent kidney stone formation independent of hypercalciuria

Background

Kidney stones are frequent in industrialized countries with a lifetime risk of 10 to 15%. A high percentage of individuals experience recurrence. Calcium-containing stones account for more than 80% of kidney stones. Diet, environmental factors, behavior, and genetic variants contribute to the development of kidney stones. Osteocytes excrete the 21 kDa glycoprotein sclerostin, which inhibits bone formation by osteoblasts. Animal data suggests that sclerostin might directly or indirectly regulate calcium excretion via the kidney. As hypercalciuria is one of the most relevant risk factors for kidney stones, sclerostin might possess pathogenic relevance in nephrolithiasis.

Methods

We performed a prospective cross-sectional observational controlled study in 150 recurrent kidney stone formers (rKSF) to analyse the association of sclerostin with known stone risk factors and important modulators of calcium-phosphate metabolism. Serum sclerostin levels were determined at the first visit. As controls, we used 388 non-stone formers from a large Swiss epidemiological cohort.

Results

Sclerostin was mildly increased in rKSF in comparison to controls. This finding was more pronounced in women compared to men. Logistic regression indicated an association of serum sclerostin with rKSF status. In hypercalciuric individuals, sclerostin levels were not different from normocalciuric patients. In Spearman correlation analysis we found a positive correlation between sclerostin, age, and BMI and a negative correlation with eGFR. There was a weak correlation with iPTH and intact FGF 23. In contrast, serum sclerostin levels were not associated with 25-OH Vitamin D3, 1,25-dihydroxy-Vitamin D3, urinary calcium and phosphate or other urinary lithogenic risk factors.

Conclusion

This is the first prospective controlled study investigating serum sclerostin in rKSF. Sclerostin levels were increased in rKSF independent of hypercalciuria and significantly associated with the status as rKSF. It appears that mechanisms other than hypercalciuria may be involved and thus further studies are required to elucidate underlying pathways.

The urine-to-plasma urea concentration ratio is associated with eGFR and eGFR decline over time in a population cohort

BACKGROUND

Evaluation of renal function and of factors associated with its decline are important public health issues. Besides markers of glomerular function [e.g. glomerular filtration rate (GFR)], those of tubular functions are rarely evaluated. Urea, the most abundant urinary solute, is markedly concentrated in urine when compared with plasma. We explored the urine-to-plasma ratio of urea concentrations (U/P urea ratio) as a marker of tubular functions.

METHODS

We evaluated the relationship of the U/P urea ratio with eGFR at baseline in 1043 participants (48 ± 17 years) from the Swiss Kidney Project on Genes in Hypertension (SKIPOGH) population-based cohort, using mixed regression. In 898 participants, we assessed the relation between U/P urea ratio and renal function decline between two study waves 3 years apart. We studied U/P ratios for osmolarity, Na, K and uric acid for comparison.

RESULTS

In a transversal study at baseline, estimated GFR (eGFR) was positively associated with U/P-urea ratio [βscaled = 0.08, 95% CI (0.04; 0.13)] but not with the U/P ratio of osmolarity. Considering separately participants with renal function >90 or ≤90 mL/min × 1.73 m2, this association was observed only in those with reduced renal function. In the longitudinal study, eGFR declined at a mean rate of 1.2 mL/min per year. A significant association was observed between baseline U/P urea ratio and eGFR decline [βscaled = 0.08, 95% CI (0.01; 0.15)]. A lower baseline U/P urea ratio was associated with a greater eGFR decline.

CONCLUSION

This study provides evidence that the U/P urea ratio is an early marker of kidney function decline in the general adult population. Urea is easy to measure with well-standardized techniques and at low cost. Thus, the U/P urea ratio could become an easily available tubular marker for evaluating renal function decline.

Blood pressure and renal function responses in workers exposed to lead for up to six years

The Study for Promotion of Health in Recycling Lead (SPHERL) assessed the blood pressure (BP) and renal function (RF) responses for up to 6 years in the workers without previous occupational lead exposure. BP was the average of five consecutive readings and the estimated glomerular filtration rate was derived from serum creatinine (eGFRcrt) and cystatin C (eGFRcys). Blood lead (BL) was measured by inductively coupled plasma mass spectrometry (detection limit 0.5 μg/dL). The statistical methods included multivariable-adjusted mixed models and interval-censored Cox regression analysis. The 234 workers analyzed were on average 28.5 years old and included 91.9% men. The baseline BL concentration was 4.35 μg/dL and increased 3.17-fold over follow-up (median: 2.03 years; range: 0.92-6.45 years). The changes in BP and RF were not significantly correlated with the follow-up-to-baseline BL ratio (p ≥ .51 and p ≥ .18, respectively). The fully-adjusted changes in systolic/diastolic BP associated with a doubling of BL were -0.25/-0.12 mm Hg (CI: -0.94 to 0.44/-0.66 to 0.42 mm Hg). Accordingly, the incidence of stage-1 or -2 hypertension was not associated with the BL change (p ≥ .063). Similarly, the changes in eGFRcrt and eGFRcys associated with a 3-fold BL increment were not significant, amounting to -0.70 mL/min/1.73 m2 (CI: -1.70 to 0.30 mL/min/1.73 m2 ) and -1.06 mL/min/1.73 m2 (-2.16 to 0.03 mL/min/1.73 m2 ). In conclusion, the BP and RF responses to an over 3-fold BL increment were small and not significant confirming the safety of modern lead-handing facilities operating under current safety rules.

Investigating the association of measures of epigenetic age with COVID-19 severity: evidence from secondary analyses of open access data

BACKGROUND

Epigenetic modifications may contribute to inter-individual variation that is unexplainable by presently known risk factors for COVID-19 severity (e.g., age, excess weight, or other health conditions). Estimates of youth capital (YC) reflect the difference between an individual's epigenetic - or biological - age and chronological age, and may quantify abnormal aging due to lifestyle or other environmental exposures, providing insights that could inform risk-stratification for severe COVID-19 outcomes. This study aims to thereby a) assess the association between YC and epigenetic signatures of lifestyle exposures with COVID-19 severity, and b) to assess whether the inclusion of these signatures in addition to a signature of COVID-19 severity (EPICOVID) improved the prediction of COVID-19 severity.

METHODS

This study uses data from two publicly-available studies accessed via the Gene Expression Omnibus (GEO) platform (accession references: GSE168739 and GSE174818). The GSE168739 is a retrospective, cross-sectional study of 407 individuals with confirmed COVID-19 across 14 hospitals in Spain, while the GSE174818 sample is a single-center observational study of individuals admitted to the hospital for COVID-19 symptoms (n = 102). YC was estimated using the (a) Gonseth-Nusslé, (b) Horvath, (c) Hannum, and (d) PhenoAge estimates of epigenetic age. Study-specific definitions of COVID-19 severity were used, including hospitalization status (yes/no) (GSE168739) or vital status at the end of follow-up (alive/dead) (GSE174818). Logistic regression models were used to assess the association between YC, lifestyle exposures, and COVID-19 severity.

RESULTS

Higher YC as estimated using the Gonseth-Nusslé, Hannum and PhenoAge measures was associated with reduced odds of severe symptoms (OR = 0.95, 95% CI = 0.91-1.00; OR = 0.81, 95% CI = 0.75 - 0.86; and OR = 0.85, 95% CI = 0.81-0.88, respectively) (adjusting for chronological age and sex). In contrast, a one-unit increase in the epigenetic signature for alcohol consumption was associated with 13% increased odds of severe symptoms (OR = 1.13, 95% CI = 1.05-1.23). Compared to the model including only age, sex and the EPICOVID signature, the additional inclusion of PhenoAge and the epigenetic signature for alcohol consumption improved the prediction of COVID-19 severity (AUC = 0.94, 95% CI = 0.91-0.96 versus AUC = 0.95, 95% CI = 0.93-0.97; p = 0.01). In the GSE174818 sample, only PhenoAge was associated with COVID-related mortality (OR = 0.93, 95% CI = 0.87-1.00) (adjusting for age, sex, BMI and Charlson comorbidity index).

CONCLUSIONS

Epigenetic age is a potentially useful tool in primary prevention, particularly as an incentive towards lifestyle changes that target reducing the risk of severe COVID-19 symptoms. However, additional research is needed to establish potential causal pathways and the directionality of this effect.

Association of plasma zinc levels with anti-SARS-CoV-2 IgG and IgA seropositivity in the general population: A case-control study

INTRODUCTION

Some micronutrients have key roles in immune defence, including mucosal defence mechanisms and immunoglobulin production. Altered micronutrient status has been linked with COVID-19 infection and disease severity. We assessed the associations of selected circulating micronutrients with anti-SARS-CoV-2 IgG and IgA seropositivity in the Swiss community using early pandemic data.

METHODS

Case-control study comparing the first PCR-confirmed COVID-19 symptomatic cases in the Vaud Canton (May to June 2020, n = 199) and controls (random population sample, n = 447), seronegative for IgG and IgA. The replication analysis included seropositive (n = 134) and seronegative (n = 152) close contacts from confirmed COVID-19 cases. Anti-SARS-CoV-2 IgG and IgA levels against the native trimeric spike protein were measured using the Luminex immunoassay. We measured plasma Zn, Se and Cu concentrations by ICP-MS, and 25-hydroxy-vitamin D₃ (25(OH)D₃) with LC-MS/MS and explored associations using multiple logistic regression.

RESULTS

The 932 participants (54.1% women) were aged 48.6 ± 20.2 years (±SD), BMI 25.0 ± 4.7 kg/m² with median C-Reactive Protein 1 mg/l. In logistic regressions, log₂(Zn) plasma levels were negatively associated with IgG seropositivity (OR [95% CI]: 0.196 [0.0831; 0.465], P < 0.001; replication analyses: 0.294 [0.0893; 0.968], P < 0.05). Results were similar for IgA. We found no association of Cu, Se, and 25(OH)D₃ with anti-SARS-CoV-2 IgG or IgA seropositivity.

CONCLUSION

Low plasma Zn levels were associated with higher anti-SARS-CoV-2 IgG and IgA seropositivity in a Swiss population when the initial viral variant was circulating, and no vaccination available. These results suggest that adequate Zn status may play an important role in protecting the general population against SARS-CoV-2 infection.

REGISTRY

CORONA IMMUNITAS:: ISRCTN18181860.

Accuracy of screening strategies for masked hypertension: a large-scale nationwide study based on home blood pressure monitoring

This study compared the ability of guideline-proposed office blood pressure (OBP) screening thresholds [European Society of Hypertension (ESH) guidelines: 130/85 mmHg for individuals with an OBP < 140/90 mmHg; American College of Cardiology/American Heart Association (ACC/AHA) guidelines: 120/75 mmHg for individuals with an OBP < 130/80 mmHg] and novel screening scores to identify normotensive individuals at high risk of having masked hypertension (MH) in an office setting. We cross-sectionally evaluated untreated participants with an OBP < 140/90 mmHg (n = 22,266) and an OBP < 130/80 mmHg (n = 10,005) who underwent home blood pressure monitoring (HBPM) (derivation cohort) from 686 Brazilian sites. MH was defined according to criteria suggested by the ESH (OBP < 140/90 mmHg; HBPM ≥ 135/85 mmHg), Brazilian Society of Cardiology (BSC) (OBP < 140/90 mmHg; HBPM ≥ 130/80 mmHg) and ACC/AHA (OBP < 130/80 mmHg; HBPM ≥ 130/80 mmHg). Scores were generated from multivariable logistic regression coefficients between MH and clinical variables (OBP, age, sex, and BMI). Considering the ESH, BSC, and ACC/AHA criteria, 17.2%, 38.5%, and 21.2% of the participants had MH, respectively. Guideline-proposed OBP screening thresholds yielded area under curve (AUC) values of 0.640 (for ESH criteria), 0.641 (for BSC criteria), and 0.619 (for ACC/AHA criteria) for predicting MH, while scores presented as continuous variables or quartiles yielded AUC values of 0.700 and 0.688 (for ESH criteria), 0.720 and 0.709 (for BSC criteria), and 0.671 and 0.661 (for ACC/AHA criteria), respectively. Further analyses performed with alternative untreated participants (validation cohort; n = 2807 with an OBP < 140/90 mmHg; n = 1269 with an OBP < 130/80 mmHg) yielded similar AUC values. In conclusion, the accuracy of guideline-proposed OBP screening thresholds in identifying individuals at high risk of having MH in an office setting is limited and is inferior to that yielded by scores derived from simple clinical variables.

The Swiss Kidney Stone Cohort: A Longitudinal, Multicentric, Observational Cohort to Study Course and Causes of Kidney Stone Disease in Switzerland

BACKGROUND

Kidney stone disease has a high prevalence worldwide of approximately 10% of the population and is characterized by a high recurrence rate. Kidney stone disease results from a combination of genetic, environmental, and lifestyle risk factors, and the dissection of these factors is complex.

METHODS

The Swiss Kidney Stone Cohort (SKSC) is an investigator-initiated prospective, multicentric longitudinal, observational study in patients with kidney stones followed with regular visits over a period of 3 years after inclusion. Ongoing follow-ups by biannual telephone interviews will provide long-term outcome data. SKSC comprises 782 adult patients (age >18 years) with either recurrent stones or a single stone event with at least one risk factor for recurrence. In addition, a control cohort of 207 individuals without kidney stone history and absence of kidney stones on a low-dose CT scan at enrolment has also been recruited. SKSC includes extensive collections of clinical data, biochemical data in blood and 24-h urine samples, and genetic data. Biosamples are stored at a dedicated biobank. Information on diet and dietary habits was collected through food frequency questionnaires and standardized recall interviews by trained dieticians with the Globodiet software.

CONCLUSION

SKSC provides a unique opportunity and resource to further study cause and course of kidney disease in a large population with data and samples collected of a homogeneous collective of patients throughout the whole Swiss population.

What did we learn from the International Databases on Ambulatory and Home Blood Pressure in Relation to Cardiovascular Outcome?

To assess in individual-person meta-analyses how out-of-office blood pressure (BP) contributes to risk stratification and the management of hypertension, an international consortium set up the International Databases on Ambulatory (IDACO) and Home (IDHOCO) Blood Pressure in Relation to Cardiovascular Outcome. This review summarizes key findings of recent IDACO/IDHOCO articles. Among various BP indexes derived from office and ambulatory BP recordings, the 24-h and nighttime BP level were the best predictors of adverse health outcomes. Second, using the 10-year cardiovascular risk associated with guideline-endorsed office BP thresholds as reference, corresponding thresholds were derived for home and ambulatory BP. Stratified by the underlying cardiovascular risk, the rate of cardiovascular events in white-coat hypertensive patients and matched normotensive controls were not substantially different. The observation that masked hypertension carries a high cardiovascular risk was replicated in Nigerian Blacks, using home BP monitoring. The thresholds for 24-h mean arterial pressure, i.e., the BP component measured by oscillometric devices, delineating normotension, elevated BP and hypertension were <90, 90 to 92 and ≥92 mmHg. At young age, the absolute risk associated with out-of-office BP was low, but the relative risk was high, whereas with advancing age, the relative risk decreased and the absolute risk increased. Using pulse pressure as an exemplary case, the relative risks of death, cardiovascular endpoints and stroke decreased over 3-fold from 55 to 75 years of age, whereas in contrast absolute risk rose 3-fold. In conclusion, IDACO/IDHOCO forcefully support the notion that the pressing need to curb the hypertension pandemic cannot be met without out-of-the-office BP monitoring.

Blood DNA methylation signatures of lifestyle exposures: tobacco and alcohol consumption

BACKGROUND

Smoking and alcohol consumption may compromise health by way of epigenetic modifications. Epigenetic signatures of alcohol and tobacco consumption could provide insights into the reversibility of phenotypic changes incurred with differing levels of lifestyle exposures. This study describes and validates two novel epigenetic signatures of tobacco (EpiTob) and alcohol (EpiAlc) consumption and investigates their association with disease outcomes.

METHODS

The epigenetic signatures, EpiTob and EpiAlc, were developed using data from the Swiss Kidney Project on Genes in Hypertension (SKIPOGH) (N = 689). Epigenetic and phenotypic data available from the 1921 (N = 550) and 1936 (N = 1091) Lothian Birth Cohort (LBC) studies, and two publicly available datasets on GEO Accession (GSE50660, N = 464; and GSE110043, N = 94) were used to validate the signatures. A multivariable logistic regression model, adjusting for age and sex, was used to assess the association between self-reported tobacco or alcohol consumption and the respective epigenetic signature, as well as to estimate the association between CVD and epigenetic signatures. A Cox proportional hazard model was used to estimate the risk of mortality in association with the EpiTob and EpiAlc signatures.

RESULTS

The EpiTob signature was positively associated with self-reported tobacco consumption for current or never smokers with explained variance ranging from 0.49 (LBC1921) to 0.72 (LBC1936) (pseudo-R2). In the SKIPOGH, LBC1921 and LBC1936 cohorts, the epigenetic signature for alcohol consumption explained limited variance in association with self-reported alcohol status [i.e., non-drinker, moderate drinker, and heavy drinker] (pseudo-R2 = 0.05, 0.03 and 0.03, respectively), although this improved considerably when measuring self-reported alcohol consumption with standardized units consumed per week (SKIPOGH R2 = 0.21; LBC1921 R2 = 0.31; LBC1936 R2 = 0.41). Both signatures were associated with history of CVD in SKIPOGH and LBC1936, but not in LBC1921. The EpiTob signature was associated with increased risk of all-cause and lung-cancer specific mortality in the 1936 and 1921 LBC cohorts.

CONCLUSIONS

This study found the EpiTob and EpiAlc signatures to be well-correlated with self-reported exposure status and associated with long-term health outcomes. Epigenetic signatures of lifestyle exposures may reduce measurement issues and biases and could aid in risk stratification for informing early-stage targeted interventions.

Oxidative Potential in Exhaled Air (OPEA) as a Tool for Predicting Certain Respiratory Disorders in the General Adult Population: Cross-Sectional Analysis Nested in the Swiss Health Study

In a pilot clinical study, OPEA allowed for distinguishing participants with and without chronic obstructive pulmonary disease. This study aimed to assess whether abnormal spirometry parameters and immunity against SARS-CoV-2 are associated with increased OPEA and estimating the OPEA reference interval. Swiss adult residents of the Vaud Canton aged 20–69 years randomly selected from the Federal Statistical Office’s registries, speaking French or German, were included and examined between 1 October 2020 and 31 December 2021. General health status and presence of respiratory diseases were assessed by questionnaire and spirometry. Spirometric results were compared with the predicted values and their lower limits of norms of the Global Lung Function Initiative. SARS-CoV-2-seroprevalence was assessed using the Luminex-based test of IgG. Statistical analysis consisted of unilateral t-tests and ANOVA. Lower and upper limit of OPEA reference interval with associated 90%-confidence interval (90%CI) were estimated for the sub-sample of healthy adults by bootstrap, after excluding outliers. The study sample included 247 participants. SARS-CoV-2-seropositive participants and those with an obstructive syndrome had a significantly higher OPEA than seronegative and healthy participants. The estimated reference interval was: −0.0516 (90%CI = −0.0735; −0.0316); −0.0044 (90%CI = −0.0224; 0.0153). OPEA could predict inflammatory-based respiratory disorders, but needs further validation in different settings and for other pathologies.

Omics-informed CNV calls reduce false-positive rates and improve power for CNV-trait associations

Copy-number variations (CNV) are believed to play an important role in a wide range of complex traits, but discovering such associations remains challenging. While whole-genome sequencing (WGS) is the gold-standard approach for CNV detection, there are several orders of magnitude more samples with available genotyping microarray data. Such array data can be exploited for CNV detection using dedicated software (e.g., PennCNV); however, these calls suffer from elevated false-positive and -negative rates. In this study, we developed a CNV quality score that weights PennCNV calls (pCNVs) based on their likelihood of being true positive. First, we established a measure of pCNV reliability by leveraging evidence from multiple omics data (WGS, transcriptomics, and methylomics) obtained from the same samples. Next, we built a predictor of omics-confirmed pCNVs, termed omics-informed quality score (OQS), using only PennCNV software output parameters. Promisingly, OQS assigned to pCNVs detected in close family members was up to 35% higher than the OQS of pCNVs not carried by other relatives (p < 3.0 × 10⁻⁹⁰), outperforming other scores. Finally, in an association study of four anthropometric traits in 89,516 Estonian Biobank samples, the use of OQS led to a relative increase in the trait variance explained by CNVs of up to 56% compared with published quality filtering methods or scores. Overall, we put forward a flexible framework to improve any CNV detection method leveraging multi-omics evidence, applied it to improve PennCNV calls, and demonstrated its utility by improving the statistical power for downstream association analyses.

Is there a relationship between heart rate recovery and blood pressure in white coat hypertension?

Aim    Increasing evidence suggests that autonomic dysfunction may be involved in the etiology of white coat hypertension (WCH). The aim of this study was to evaluate cardiac autonomic function by using heart rate recovery (HRR) indices in patients with WCH classified according to their circadian rhythm type of blood pressure (BP).Material and methods    This cross-sectional study included 120 participants over the age of 18 yrs, including 50 patients diagnosed with WCH and 70 healthy controls with normal in- and out-of-office BP and without any known disease. Circadian rhythm types, i.e., dippers and non-dippers, were identified using ambulatory BP monitoring. The HRR indices were calculated by subtracting the 1st-minute (HRR1), 2nd-minute (HRR2), and 3rd-minute (HRR3) heart rates from the maximal heart rate recorded during stress testing.Results    The lesser decline in nighttime BP (6.4±2.14 and 13.3±2.2 mmHg, respectively; p&lt;0.001) and the smaller mean HRR1 (25.5±3.0 and 30.3±3.1 beats / min, respectively; p&lt;0.001) were evident in WCH non-dippers compared to WCH dippers. Linear regression analysis showed that HRR1 (β±SE=0.43±0.11; p&lt;0.001) and diastolic BP at maximum exercise (β±SE=0.14±0.07; p=0.040) are independent risk factors for the blunted decline in nighttime BP.Conclusion    Delayed recovery of heart rate after an exercise stress test is associated with non-dipper type of circadian rhythm of BP. This was more pronounced in WCH patients, and these patients are at risk of autonomic dysfunction.

Changes of lipoprotein(a) levels with endogenous steroid hormones

BACKGROUND

Lipoprotein(a) [Lp(a)] is an LDL-like molecule that is likely causal for cardiovascular events and Lp(a) variability has been shown to be mostly of genetic origin. Exogenous hormones (hormone replacement therapy) seem to influence Lp(a) levels, but the impact of endogenous hormone levels on Lp(a) is still unknown. The aim of the study was to assess the effect of endogenous steroid hormone metabolites on Lp(a).

METHODS

Lipoprotein(a) levels were measured in 1,021 participants from the Swiss Kidney Project on Genes in Hypertension, a family-based, multicentre, population-based prospective cohort study. Endogenous levels of 28 steroid hormone precursors were measured in 24-h urine collections from 883 individuals. Of the participants with Lp(a) data, 1,011 participants had also genotypes available.

RESULTS

The participants had an average age of 51 years and 53% were female. Median Lp(a) levels were 62 mg/L, and the 90^th percentile was 616 mg/L. The prevalence of a Lp(a) elevation ≥700 mg/L was 3.2%. Forty-three per cent of Lp(a) variability was explained respectively by: age (2%, p < .001), LDL-C (1%, p = .001), and two SNPs (39%, p value<2⋅10^-16 ). Of the 28 endogenous steroid hormones assessed, androstenetriol, androsterone, 16α-OH-DHEA and estriol were nominatively associated with serum Lp(a) levels in univariable analyses and explained 0.4%-1% of Lp(a) variability, but none of them reached significance in multivariable models.

CONCLUSIONS

In this contemporary population-based study, the prevalence of a Lp(a) elevation ≥700 mg/L was 3.2%. The effect of endogenous steroid hormone levels of Lp(a) variability was small at best, suggesting a negligible impact on the wide range of Lp(a) variability.

Gene regulation contributes to explain the impact of early life socioeconomic disadvantage on adult inflammatory levels in two cohort studies

Individuals experiencing socioeconomic disadvantage in childhood have a higher rate of inflammation-related diseases decades later. Little is known about the mechanisms linking early life experiences to the functioning of the immune system in adulthood. To address this, we explore the relationship across social-to-biological layers of early life social exposures on levels of adulthood inflammation and the mediating role of gene regulatory mechanisms, epigenetic and transcriptomic profiling from blood, in 2,329 individuals from two European cohort studies. Consistently across both studies, we find transcriptional activity explains a substantive proportion (78% and 26%) of the estimated effect of early life disadvantaged social exposures on levels of adulthood inflammation. Furthermore, we show that mechanisms other than cis DNA methylation may regulate those transcriptional fingerprints. These results further our understanding of social-to-biological transitions by pinpointing the role of gene regulation that cannot fully be explained by differential cis DNA methylation.

Masked Uncontrolled Hypertension Is Accompanied by Increased Out-of-Clinic Aldosterone Secretion

Masked uncontrolled hypertension (MUCH) in treated patients is defined as controlled office blood pressure (BP) but uncontrolled out-of-clinic ambulatory BP. Previously, we have shown that patients with MUCH have evidence of heightened out-of-clinic sympathetic nervous system activity. The aim is to test the hypothesis that MUCH patients have higher aldosterone secretion compared with patients with true controlled hypertension. Two hundred twenty-two patients were recruited after having controlled office BP readings at ≥3 clinic visits. Patients taking MR (mineralocorticoid receptor) antagonists and epithelial sodium channel blockers were excluded. All patients were evaluated by clinic automated office BP and morning serum aldosterone and plasma renin activity. Out-of-clinic ambulatory BP monitoring and 24-hour urinary aldosterone, catecholamines, and metanephrines were also measured. Sixty-four patients had MUCH, and the remaining 48 patients had true controlled hypertension. MUCH patients had significantly higher out-of-clinic levels of 24-hour urinary aldosterone, catecholamines, and metanephrines compared with true controlled hypertension. The 2 groups did not differ in serum aldosterone, plasma renin activity, or aldosterone-renin ratio collected in clinic. In addition, 32.8% of MUCH patients had high out-of-clinic 24-hour urinary aldosterone (≥12 µg) but normal clinic serum aldosterone (<15 ng/dL) and aldosterone-renin ratio (<20). Further, in correlation matrix analysis, higher 24-hour urinary catecholamines and metanephrines were associated with higher 24-hour urinary aldosterone and plasma renin activity levels in MUCH patients. Patients with MUCH have higher out-of-clinic urinary aldosterone levels compared with patients with true controlled hypertension. This study suggests that patients with MUCH likely have higher out-of-clinic sympathetic nervous system tone increases aldosterone secretion mediated by increased renin release that may contribute to their higher out-of-clinic BP.

Diagnostic performance of clinic and home blood pressure measurements compared with ambulatory blood pressure: a systematic review and meta-analysis

BACKGROUND

Clinic blood pressure measurement (CBPM) is currently the most commonly used form of screening for hypertension, however it might have a problem detecting white coat hypertension (WCHT) and masked hypertension (MHT). Home blood pressure measurement (HBPM) may be an alternative, but its diagnostic performance is inconclusive relative to CBPM. Therefore, this systematic review aimed to estimate the performance of CBPM and HBPM compared with ambulatory blood pressure measurement(ABPM) and to pool prevalence of WCHT and MHT.

METHODS

Medline, Scopus, Cochrane Central Register of Controlled Trials and WHO's International Clinical Trials Registry Platform databases were searched up to 23rd January 2020. Studies having diagnostic tests as CBPM or HBPM with reference standard as ABPM, reporting sensitivity and specificity of both tests and/or proportion of WCHT or MHT were eligible. Diagnostic performance of CBPM and HBPM were pooled using bivariate mixed-effect regression model. Random effect model was applied to pool prevalence of WCHT and MHT.

RESULTS

Fifty-eight studies were eligible. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of CBPM, when using 24-h ABPM as the reference standard, were 74% (95% CI: 65-82%), 79% (95% CI: 69%, 87%), and 11.11 (95% CI: 6.82, 14.20), respectively. Pooled prevalence of WCHT and MHT were 0.24 (95% CI 0.19, 0.29) and 0.29 (95% CI 0.20, 0.38). Pooled sensitivity, specificity, and DOR of HBPM were 71% (95% CI 61%, 80%), 82% (95% CI 77%, 87%), and 11.60 (95% CI 8.98, 15.13), respectively.

CONCLUSIONS

Diagnostic performances of HBPM were slightly higher than CBPM. However, the prevalence of MHT was high in negative CBPM and some persons with normal HBPM had elevated BP from 24-h ABPM. Therefore, ABPM is still necessary for confirming the diagnosis of HT.

Patterning of educational attainment across inflammatory markers: Findings from a multi-cohort study

BACKGROUND

Evidence suggests that the inflammatory reaction, an adaptive response triggered by a variety of harmful stimuli and conditions involved in the risk and development of many chronic diseases, is a potential pathway through which the socioeconomic environment is biologically embedded. Difficulty in interpreting the role of the inflammatory system in the embodiment dynamic arises because of heterogeneity across studies that use a limited but varied number of inflammatory markers. There is no consensus in the literature as to which inflammatory markers beyond the C-reactive protein and to a lesser extent interleukin 6 are related to the social environment. Accordingly, we aimed to investigate the association between educational attainment, and several markers of inflammation - C-reactive protein, fibrinogen, interleukin 6, interleukin 1β and tumor necrosis factor α- in 6 European cohort studies.

METHODS

Up to 17,470 participants from six European cohort studies with data on educational attainment, health behaviors and lifestyle factors, and at least two different inflammatory markers. Four sub-datasets were drawn with varying numbers of participants to allow pairwise comparison of the social patterning of C-reactive protein and any other inflammatory markers. To evaluate within each sub-dataset the importance of the context and cohort specificities, linear regression-based analyses were performed separately for each cohort and combined in a random effect meta-analysis to determine the relationship between educational attainment and inflammation.

RESULTS

We found that the magnitude of the relationship between educational attainment and five inflammatory biomarkers (C-reactive protein, fibrinogen, interleukin 6 and 1β and tumor necrosis factor α) was variable. By far the most socially patterned biomarker was C-reactive protein, followed by fibrinogen and to lesser extent interleukin 6, where a low educational attainment was associated with higher inflammation even after adjusting for health behaviours and body mass index. No association was found with interleukin 1β and tumor necrosis factor α.

CONCLUSIONS

Our study suggests different educational patterning of inflammatory biomarkers. Further large-scale research is needed to explore social differences in the inflammatory cascade in greater detail and the extent to which these differences contribute to social inequalities in health.

Smoking and overweight associated with masked uncontrolled hypertension: a Hypertension Optimal Treatment (HOT) Sub-Study

PURPOSE

The Hypertension Optimal Treatment (HOT) Study investigated the relationship between target office diastolic blood pressure (BP) ≤80, ≤85 or ≤90 mmHg and cardiovascular morbidity and mortality in 18,790 patients aged 50-80 years. The home BP sub-study enrolled 926 patients and the aim was to clarify whether the separation into the BP target groups in the office prevailed in the out-of-office setting. The present study aimed to identify variables that characterised masked uncontrolled hypertension (MUCH) and white coat uncontrolled hypertension (WUCH).

MATERIAL AND METHODS

The sub-study participants took their home BP when office BP had been up titrated. The cut-off for normal or high BP was set to ≥135/85 mmHg at home and ≥140/90 mmHg in the office. We analysed data by using multivariate and stepwise multivariate logistic regression with home and office BP combinations as the dependent variables.

RESULTS

WUCH was associated with lower body mass index (BMI) (odds ratio (OR) 0.92, 95% confident intervals (CIs) 0.88-0.96, p < 0.001). MUCH was associated with smoking (OR 1.89, 95% CIs 1.25-2.86, p = 0.0025) and with lower baseline heart rate (OR 0.98, 95% CIs 0.97-0.99, p = 0.03) and higher BMI (OR 1.03, CIs 1.00-1.06, p = 0.04). MUCH remained associated with smoking (OR 2.76, 95% CIs 1.76-4.35, p < 0.0001) also when using ≥140/90 mmHg as the cut-off for both home and office BP. MUCH was also associated with higher BMI (OR 1.05, 95% CIs 1.01-1.09, p = 0.009) while WUCH was associated with lower BMI (OR 0.93, 95% CIs 0.90-0.97, p = 0.0005) when using ≥140/90 mmHg as a cut-off.

CONCLUSION

Our data support that 'reversed or masked' treated but uncontrolled hypertension (MUCH) is common and constitutes about 25% of treated hypertensive patients. This entity (MUCH) is rather strongly associated with current smoking and overweight while uncontrolled white coat (office) hypertension (WUCH) is associated with lower BMI.

Ambulatory Blood Pressure in Relation to Plasma and Urinary Manganese

The association of blood pressure (BP) with manganese-an essential trace element required for human health-remains poorly studied. In 734 randomly recruited Swiss participants (mean age, 47.5 years; 51.4% women), we related ambulatory BP to 2 biomarkers, plasma manganese (pMn) and the urinary manganese (uMn) excretion. To allow for diurnal variation, we assessed BP and uMn over 24 hours and during wakefulness and sleep, using split urine samples. Twenty-four-hour, daytime, and nighttime systolic/diastolic BPs averaged 119.8/78.1, 123.8/81.2, and 107.0/68.3 mm Hg; the corresponding median uMn were 199.5, 83.0, and 51.5 μmol and median pMn, 0.52 μg/L. In analyses dichotomized by the median of the biomarkers, greater pMn was associated with higher 24-hour systolic/diastolic BP (+4.1/+2.3 mm Hg; P≤0.0003), greater daytime uMn with lower daytime BP (-3.5/-1.9 mm Hg; P≤0.0067), and greater nighttime uMn with higher nighttime BP (+2.9/+1.2 mm Hg; P≤0.046). In multivariable-adjusted analyses, significance (P≤0.030) was retained for the positive association of 24-hour and daytime diastolic BP with pMn and for systolic BP in relation to uMn at night. The association sizes for a 2-fold increment in the biomarkers amounting to 0.77 mm Hg (95% CI, 0.08-1.47 mm Hg), 0.97 (CI, 0.20-1.76) and 1.33 (CI, 0.20-2.50 mm Hg), respectively. In conclusion, there were positive associations between diastolic BP and pMn over 24 hours and during daytime and between systolic BP and uMn at night.

Mechanisms of life-course socioeconomic inequalities in adult systemic inflammation: Findings from two cohort studies

Disadvantaged socioeconomic conditions in childhood heighten systemic inflammatory levels in adulthood; however, life-course mechanisms underlying this association are largely unknown. In the present observational study, we investigated the roles of adulthood socioeconomic and lifestyle factors in mediating this association. Participants were from two prospective Swiss population-based cohorts (N = 5,152, mean age 60 years). We estimated the total effect of paternal occupational position on adult heightened systemic inflammatory levels (C-reactive protein>3 mg/L), and the indirect effects via adulthood socioeconomic positions (SEPs: education and occupational position), financial hardship, and lifestyle factors (body mass index, smoking status, physical inactivity, and alcohol consumption). We estimated odds ratio (OR) and proportion mediated using counterfactual-based mediation models. Individuals whose father had a low occupational position had an OR of 1.51 [95% confidence interval (CI): 1.25, 1.84] for heightened inflammation compared to their more advantaged counterparts. This was jointly mediated (33 [95% CI: 14, 69]%) by adulthood SEPs, whereby the pathway through education followed by occupational position mediated 30 [95% CI: 11, 64]%, while the pathway via occupational position only mediated 3 [95% CI: 4, 13]%. Individuals with the lowest life-course SEPs had an OR of 2.27 [95% CI: 1.71, 2.98] for heightened inflammation compared to having the highest life-course SEPs. This was jointly mediated (63 [95% CI: 44, 97]%) by financial hardship and lifestyle factors. Our study supports a cumulative effect of life-course SEPs on adult heightened systemic inflammation along the pathway paternal occupational position -> education -> adult occupational position. Financial hardship and lifestyle factors in adulthood mediate half of that effect.

Out-of-Clinic Sympathetic Activity Is Increased in Patients With Masked Uncontrolled Hypertension

Masked uncontrolled hypertension (MUCH) is defined as controlled automated office blood pressure (BP; AOBP <135/85 mm Hg) in-clinic in patients receiving antihypertensive medication(s) but uncontrolled BP out-of-clinic by 24-hour ambulatory BP monitoring (ABPM; awake ≥135/85 mm Hg). We hypothesized that MUCH patients have greater out-of-clinic sympathetic activity compared with true controlled hypertensives. Patients being treated for hypertension were prospectively recruited after 3 or more consecutive clinic visits. All patients were evaluated by in-clinic automated office BP, plasma catecholamines, and spot-urine/plasma metanephrines. In addition, out-of-clinic 24-hour ABPM, 24-hour urinary for catecholamines and metanephrines was done. Out of 237 patients recruited, 169 patients had controlled in-clinic BP of which 156 patients had completed ABPM. Seventy-four were true controlled hypertensives, that is controlled by clinic automated office BP and by out-of-clinic ABPM. The remaining 82 were controlled by clinic automated office BP, but uncontrolled during out-of-clinic ABPM, indicative of MUCH. After exclusion of 4 patients because of inadequate or lack of 24-hour urinary collections, 72 true controlled hypertensive and 80 MUCH patients were analyzed. MUCH patients had significantly higher out-of-clinic BP variability and lower heart rate variability compared with true controlled hypertensives, as well as higher levels of out-of-clinic urinary catecholamines and metanephrines levels consistent with higher out-of-clinic sympathetic activity. In contrast, there was no difference in in-clinic plasma catecholamines and spot-urine/plasma levels of metanephrines between the 2 groups, consistent with similar levels of sympathetic activity while in clinic. MUCH patients have evidence of heightened out-of-clinic sympathetic activity compared with true controlled hypertensives, which may contribute to the development of MUCH.

Masked Uncontrolled Hypertension Is Not Attributable to Medication Nonadherence

Masked uncontrolled hypertension (MUCH) in treated hypertensive patients is defined as controlled automated office blood pressure (BP; <135/85 mm Hg) in-clinic but uncontrolled out-of-clinic BP by ambulatory BP monitoring (awake [daytime] readings ≥135/85 mm Hg or 24-hour readings ≥130/80 mm Hg). To determine whether MUCH is attributable to antihypertensive medication nonadherence. One hundred eighty-four enrolled patients were confirmed to have controlled office BP; of these, 167 patients were with adequate 24-hour ambulatory BP recordings. Of 167 patients, 86 were controlled by in-clinic BP assessment but had uncontrolled ambulatory awake BP, indicative of MUCH. The remaining 81 had controlled in-clinic and ambulatory awake BP, consistent with true controlled hypertension. After exclusion of 9 patients with missing 24-hour urine collections, antihypertensive medication adherence was determined based on the detection of urinary drugs or drug metabolites by high-performance liquid chromatography-tandem mass spectrometry. Of the 81 patients with MUCH, 69 (85.2%) were fully adherent and 12 (14.8%) were partially adherent (fewer medications detected than prescribed). Of the 77 patients with true controlled hypertension, 69 (89.6%) were fully adherent with prescribed antihypertensive medications and 8 (10.4%) were partially adherent. None of the patients in either group were fully nonadherent. There was no statistically significant difference in complete or partial adherence between the MUCH and true controlled groups (P=0.403). Measurement of urinary drug and drug metabolite levels demonstrates a similarly high level of antihypertensive medication adherence in both MUCH and truly controlled hypertensive patients. These findings indicate that MUCH is not attributable to antihypertensive medication nonadherence.

Tumor necrosis factor stimulates fibroblast growth factor 23 levels in chronic kidney disease and non-renal inflammation

Fibroblast growth factor 23 (FGF23) regulates phosphate homeostasis, and its early rise in patients with chronic kidney disease is independently associated with all-cause mortality. Since inflammation is characteristic of chronic kidney disease and associates with increased plasma FGF23 we examined whether inflammation directly stimulates FGF23. In a population-based cohort, plasma tumor necrosis factor (TNF) was the only inflammatory cytokine that independently and positively correlated with plasma FGF23. Mouse models of chronic kidney disease showed signs of renal inflammation, renal FGF23 expression and elevated systemic FGF23 levels. Renal FGF23 expression coincided with expression of the orphan nuclear receptor Nurr1 regulating FGF23 in other organs. Antibody-mediated neutralization of TNF normalized plasma FGF23 and suppressed ectopic renal Fgf23 expression. Conversely, TNF administration to control mice increased plasma FGF23 without altering plasma phosphate. Moreover, in Il10-deficient mice with inflammatory bowel disease and normal kidney function, plasma FGF23 was elevated and normalized upon TNF neutralization. Thus, the inflammatory cytokine TNF contributes to elevated systemic FGF23 levels and also triggers ectopic renal Fgf23 expression in animal models of chronic kidney disease.

Predicted Atherosclerotic Cardiovascular Disease Risk and Masked Hypertension Among Blacks in the Jackson Heart Study

BACKGROUND

Among individuals without hypertension based on clinic blood pressure (BP), it is unclear who should be screened for masked hypertension, defined as having hypertension based on out-of-clinic BP. We hypothesized that individuals with a higher 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk, calculated using the pooled cohort risk equations, have a higher prevalence of masked hypertension.

METHODS AND RESULTS

We analyzed data from the Jackson Heart Study-a population-based cohort of blacks-to determine the association of predicted ASCVD risk with masked hypertension. The sample included 644 participants, 40 to 79 years of age, with clinic systolic/diastolic BP <140/90 mm Hg, who completed ambulatory BP monitoring, were free of cardiovascular disease, and had data on factors needed to calculate ASCVD risk. Ten-year predicted ASCVD risk was calculated using the pooled cohort risk equations. Any masked hypertension was defined as masked daytime hypertension (mean daytime systolic/diastolic BP ≥135/85 mm Hg), masked nighttime hypertension (mean nighttime systolic/diastolic BP ≥120/70 mm Hg), or masked 24-hour hypertension (mean 24-hour systolic/diastolic BP ≥130/80 mm Hg). The prevalence of any masked hypertension was 54.0%. Compared with participants in the lowest (<5%) predicted ASCVD risk category, multivariable-adjusted prevalence ratios (95% confidence interval) for any masked hypertension were 1.36 (1.03-1.79), 1.62 (1.22-2.16), and 1.91 (1.47-2.48) for those with ASCVD risk of 5% to <7.5%, 7.5% to <10%, and ≥10%, respectively. The C statistic for discriminating between participants with versus without any masked hypertension was 0.681 (95% confidence interval, 0.640-0.723) for ASCVD risk and 0.703 (95% confidence interval, 0.663-0.744) for clinic systolic BP and diastolic BP.

CONCLUSIONS

Higher ASCVD risk was associated with an increased prevalence of masked hypertension. Although the discrimination of ASCVD risk for masked hypertension was not superior to clinic BP, risk prediction equations may be useful for identifying the subgroup of individuals with both masked hypertension and high predicted ASCVD risk.

Does fitness improve the cardiovascular risk profile in obese subjects?

BACKGROUND AND AIMS

Good cardiorespiratory fitness has been suggested to reduce the risk of cardiovascular disease in obesity. We explored the association of fitness with the prevalences of major cardiovascular risk factor like hypertension (HT), diabetes and metabolic syndrome (MetS) in overweight and obese subjects.

METHODS AND RESULTS

Clinical data from 491 participants in the FAT associated CardiOvasculaR dysfunction (FATCOR) study were analyzed. Physical fitness was assessed by ergospirometry, and subjects with at least good level of performance for age and sex were classified as fit. HT subtypes were identified from clinic and 24-h ambulatory blood pressure in combination. Diabetes was diagnosed by oral glucose tolerance test. MetS was defined by the American Heart Association and National Heart, Lung and Blood Institute criteria. The participants were on average 48 years old (60% women), and mean body mass index (BMI) was 32 kg/m². 28% of study participants were classified as fit. Fitness was not associated with lower prevalences of HT or HT subtypes, diabetes, MetS or individual MetS components (all p > 0.05). In multivariable regression analysis, being fit was characterized by lower waist circumference, BMI < 30 kg/m², non-smoking and a higher muscle mass (all p < 0.05).

CONCLUSION

In the FATCOR population, fitness was not associated with a lower prevalence of major cardiovascular risk factors like HT, diabetes or MetS. Given the strong association of cardiovascular risk factor burden with risk of clinical cardiovascular disease, these findings challenge the notion that fitness alone is associated with lower risk of cardiovascular disease in obesity.

Socioeconomic indicators in epidemiologic research: A practical example from the LIFEPATH study

Background

Several social indicators have been used in epidemiological research to describe socioeconomic position (SEP) of people in societies. Among SEP indicators, those more frequently used are education, occupational class and income. Differences in the incidence of several health outcomes have been reported consistently, independently from the indicator employed. Main objectives of the study were to present the socioeconomic classifications of the social indicators which will be employed throughout the LIFEPATH project and to compare social gradients in all-cause mortality observed in the participating adult cohorts using the different SEP indicators.

Methods

Information on the available social indicators (education, own and father’s occupational class, income) from eleven adult cohorts participating in LIFEPATH was collected and harmonized. Mortality by SEP for each indicator was estimated by Poisson regression on each cohort and then evaluated using a meta-analytical approach.

Results

In the meta-analysis, among men mortality was significantly inversely associated with both occupational class and education, but not with father’s occupational class; among women, the increase in mortality in lower social strata was smaller than among men and, except for a slight increase in the lowest education category, no significant differences were found.

Conclusions

Among men, the proposed three-level classifications of occupational class and education were found to predict differences in mortality which is consistent with previous research. Results on women suggest that classifying them through their sole SEP, without considering that of their partners, may imply a misclassification of their social position leading to attenuation of mortality differences.

Relation of 24-hour urinary caffeine and caffeine metabolite excretions with self-reported consumption of coffee and other caffeinated beverages in the general population

Background

Caffeine intake is generally estimated by self-reported consumption, but it remains unclear how well self-report associates with metabolite urinary excretion. We investigated the associations of self-reported consumption of caffeinated drinks with urinary excretion of caffeine and its major metabolites in an adult population.

Methods

We used data from the population-based Swiss Kidney Project on Genes in Hypertension (SKIPOGH) study. Consumption of caffeinated coffee, decaffeinated coffee and other caffeinated beverages was assessed by self-administered questionnaire. Quantification of caffeine, paraxanthine, theobromine and theophylline was performed by ultra-high performance liquid chromatography tandem mass spectrometry in 24-h urine. Association of reported consumption of caffeinated drinks with urinary caffeine derived metabolites was determined by quantile regression. We then explored the association between urinary metabolite excretion and dichotomized weekly consumption frequency of caffeinated coffee, with Receiver Operator Characteristic (ROC) analysis.

Results

In the present analysis, we included 598 individuals (52% women, mean age =46 ± 17 years). Self-reported caffeinated coffee intake was positively associated with 24-h urinary excretions of paraxanthine, theophylline and caffeine (p < 0.001), whereas reported intakes of decaffeinated coffee and other caffeinated beverages showed no association. In ROC analysis, optimal discrimination between individuals consuming less than one caffeinated coffee/week, vs. at least one coffee, was obtained for 24-h urinary paraxanthine (Area Under Curve (AUC) = 0.868, 95% Confidence Interval (CI) [0.830;0.906]), with slightly lower performance for theophylline and caffeine, whereas theobromine did not allow any discrimination.

Conclusion

Our results suggest that reported consumption of caffeinated coffee is positively associated with 24-h urinary excretion of caffeine, paraxanthine, and theophylline, and may be used as a marker of caffeine intake for epidemiological studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12986-016-0144-4) contains supplementary material, which is available to authorized users.

Cardiovascular Risk Factors and Masked Hypertension: The Jackson Heart Study

Masked hypertension is associated with increased risk for cardiovascular disease. Identifying modifiable risk factors for masked hypertension could provide approaches to reduce its prevalence. Life's Simple 7 is a measure of cardiovascular health developed by the American Heart Association that includes body mass index, physical activity, diet, cigarette smoking, blood pressure (BP), cholesterol, and glucose. We examined the association between cardiovascular health and masked daytime hypertension in the Jackson Heart Study, an exclusively African American cohort. Life's Simple 7 factors were assessed during a study visit and categorized as poor, intermediate, or ideal. Ambulatory BP monitoring was performed after the study visit. Using BP measured between 10:00 am and 8:00 pm on ambulatory BP monitoring, masked daytime hypertension was defined as mean clinic systolic BP/diastolic BP <140/90 mm Hg and mean daytime systolic BP/diastolic BP ≥135/85 mm Hg. Among the 758 participants with systolic BP/diastolic BP <140/90 mm Hg, 30.5% had masked daytime hypertension. The multivariable-adjusted prevalence ratios for masked daytime hypertension comparing participants with 2, 3, and ≥4 versus ≤1 ideal Life's Simple 7 factors were 0.99 (95% confidence interval [CI], 0.74-1.33), 0.77 (95% CI, 0.57-1.03), and 0.51 (95% CI, 0.33-0.79), respectively. Masked daytime hypertension was less common among participants with ideal versus poor levels of physical activity (ratio, 0.74; 95% CI, 0.56-1.00), ideal or intermediate levels pooled together versus poor diet (prevalence ratio, 0.73; 95% CI, 0.58-0.91), ideal versus poor levels of cigarette smoking (prevalence ratio, 0.61; 95% CI, 0.46-0.82), and ideal versus intermediate levels of clinic BP (prevalence ratio, 0.28, 95% CI, 0.16-0.48). Better cardiovascular health is associated with a lower preva lence of masked hypertension.

Sociodemographic, behavioral and genetic determinants of allostatic load in a Swiss population-based study

Allostatic load (AL) is a marker of physiological dysregulation which reflects exposure to chronic stress. High AL has been related to poorer health outcomes including mortality. We examine here the association of socioeconomic and lifestyle factors with AL. Additionally, we investigate the extent to which AL is genetically determined. We included 803 participants (52% women, mean age 48±16years) from a population and family-based Swiss study. We computed an AL index aggregating 14 markers from cardiovascular, metabolic, lipidic, oxidative, hypothalamus-pituitary-adrenal and inflammatory homeostatic axes. Education and occupational position were used as indicators of socioeconomic status. Marital status, stress, alcohol intake, smoking, dietary patterns and physical activity were considered as lifestyle factors. Heritability of AL was estimated by maximum likelihood. Women with a low occupational position had higher AL (low vs. high OR=3.99, 95%CI [1.22;13.05]), while the opposite was observed for men (middle vs. high OR=0.48, 95%CI [0.23;0.99]). Education tended to be inversely associated with AL in both sexes(low vs. high OR=3.54, 95%CI [1.69;7.4]/OR=1.59, 95%CI [0.88;2.90] in women/men). Heavy drinking men as well as women abstaining from alcohol had higher AL than moderate drinkers. Physical activity was protective against AL while high salt intake was related to increased AL risk. The heritability of AL was estimated to be 29.5% ±7.9%. Our results suggest that generalized physiological dysregulation, as measured by AL, is determined by both environmental and genetic factors. The genetic contribution to AL remains modest when compared to the environmental component, which explains approximately 70% of the phenotypic variance.

Persistence of Masked Hypertension in Chinese Patients

BACKGROUND

Masked hypertension (MH) has 10-15% prevalence and carries risk similar to that of sustained hypertension, but its short-term persistence remains uncertain.

METHODS

Forty-five patients with MH (mean age 52.2 years; 37.8% women) were enrolled in the placebo arm of a randomized clinical trial of Chinese medicine (NCT02156024) and followed up for 4 weeks. MH was office normotension (<140/90mm Hg) and daytime (8:00-18:00) hypertension (≥135/85mm Hg).

RESULTS

At enrolment, office and daytime systolic/diastolic blood pressure (BP) averaged 129.0/80.6mm Hg and 132.9/88.9mm Hg, respectively. Daytime BP thresholds for MH were met in 5 patients (11.1%) for systolic BP, in 25 (55.6%) for diastolic BP and in 15 (33.3%) for both. At follow-up, systolic and diastolic BP had not changed compared with baseline (P ≥ 0.12), except for a 2.1mm Hg decrease in office systolic BP (P = 0.049). MH remained present in 28 patients (62.2%; 95% CI, 48.1-76.3%), whereas 13 (28.9%; 15.7-42.1%) and 4 (8.9%; 0.6-17.2%) converted to normotension (daytime BP <135/85mm Hg) or sustained hypertension (office BP ≥140/90mm Hg), respectively. Substituting daytime by 24-hour BP, using 130/80mm Hg as threshold, produced consistent results. Systolic office BP at baseline independently predicted persistence of MH or progression to sustained hypertension at 4 weeks (odds ratio per 1 - SD increase, 3.49; 95% CI, 1.06-11.2; P = 0.04).

CONCLUSIONS

The information that MH persists over 4 weeks in over two-thirds of this sample of patients should inform future clinical trials and guidelines.

The complexity of masked hypertension: diagnostic and management challenges

Masked hypertension, defined as discordant in-office normotension versus out-of-office hypertension, is present in approximately 10 % to 40 % of patients not receiving antihypertensive treatment. Not only are persons with prehypertension more likely to have masked hypertension, but they also frequently develop target organ damage before transitioning to established sustained hypertension. Moreover, the percentage of persons with masked hypertension increases in the presence of cardiovascular disease, diabetes, or chronic renal failure. The gold standard for diagnosing masked hypertension is the 24-hour ambulatory BP monitor (ABPM), but home BP monitoring (HBPM) has also been a useful alternative procedure. Importantly, initiating antihypertensive treatment exclusively with the use of in-office BP monitoring may result in almost one-third of patients remaining with high-risk masked uncontrolled hypertension, which underscores the importance of HBPM and ABPM as supplements to in-office BP monitoring for the effective treatment of hypertension.

Association between self-perception period of lower urinary tract symptoms and International Prostate Symptom Score: a propensity score matching study

Background

Most studies focusing on progression of BPH have been limited to the relationship between age and BPH progression, and only few studies have focused on the time duration to start treatment. This study aimed to investigate the association between self-perception period (S-PP) of lower urinary tract symptoms (LUTS) and International Prostate Symptom Score (IPSS).

Methods

This study used data from two large-population surveys: a community-based survey and a university hospital outpatient-based interview survey. Both surveys were conducted in male subjects aged 40 years or older who gave consent to the survey questionnaire and voluntarily expressed their intention to participate. Propensity score matching (PSM) was used to organize the population in both surveys into randomized groups to reduce selection bias. After excluding those who had missing values, 483 subjects were assigned to each group by PSM.

Results

The S-PP of LUTS became significantly longer as the severity of LUTS increased. The S-PP was 4.15 years in the mild group, 4.36 years in the moderate group, and 6.23 years in the severe group. These differences were statistically significant. The correlation between S-PP of LUTS and IPSS was measured by partial correlation while controlling for age (correlation coefficient = 0.20, p <0.001). Multiple regression analysis after controlling for age revealed that one-year increase in the S-PP of LUTS significantly (p <0.001) increased IPSS by 0.322 points.

Conclusions

This study clarified the association between S-PP of LUTS and IPSS in a large-scale population. These findings suggest that, from the perspective of public health, S-PP is an important risk factor for LUTS progression.

Rates, amounts, and determinants of ambulatory blood pressure monitoring claim reimbursements among Medicare beneficiaries

Ambulatory blood pressure monitoring (ABPM) can be used to identify white coat hypertension and guide hypertensive treatment. We determined the percentage of ABPM claims submitted between 2007 and 2010 that were reimbursed. Among 1970 Medicare beneficiaries with submitted claims, ABPM was reimbursed for 93.8% of claims that had an International Classification of Diseases, Ninth Revision, diagnosis code of 796.2 ("elevated blood pressure reading without diagnosis of hypertension") versus 28.5% of claims without this code. Among claims without an International Classification of Diseases, Ninth Revision, diagnosis code of 796.2 listed, those for the component (eg, recording, scanning analysis, physician review, reporting) versus full ABPM procedures and performed by institutional versus non-institutional providers were each more than two times as likely to be successfully reimbursed. Of the claims reimbursed, the median payment was $52.01 (25th-75th percentiles, $32.95-$64.98). In conclusion, educating providers on the ABPM claims reimbursement process and evaluation of Medicare reimbursement may increase the appropriate use of ABPM and improve patient care.

Hypertension and its associated risk factors in the kingdom of saudi arabia, 2013: a national survey

Current data on hypertension in the Kingdom of Saudi Arabia are lacking. We conducted a national survey to inform decision-makers on the current magnitude of the epidemic. We measured systolic and diastolic blood pressure of 10,735 Saudis aged 15 years or older and interviewed them through a national multistage survey. We used multivariate logistic regressions to describe sociodemographic characteristics and risk factors of hypertensive, borderline hypertensive, and undiagnosed hypertensive Saudis. We found that 15.2% and 40.6% of Saudis were hypertensive or borderline hypertensive, respectively. Risk of hypertension increased among men, with age, obesity, diabetes, and hypercholesterolemia. 57.8% of hypertensive Saudis were undiagnosed. These were more likely to be male, older, and diagnosed with diabetes. Among participants diagnosed with hypertension, 78.9% reported taking medication for their condition. About 45% of participants on medication for hypertension had their blood pressure controlled. The prevalence of hypertension and borderline hypertension is very high in Saudi Arabia. Moreover, control of hypertension is poor. With the majority of hypertensive Saudis being unaware of their condition, a national plan is needed to increase utilization of freely available screening, preventive, and medical services.