Treatment strategies for resistant arterial hypertension

Risk Factors for Various Cognitive Function Decline Trajectories in Adults Over 40 Years of Age: A Retrospective Cohort Study

OBJECTIVE

The aims of our study were to identify distinct trajectories of cognitive function using the group-based trajectory model. We also investigate which demographic factors act as risk factors for cognitive decline in each group.

METHODS

The data from the Seoul National University Hospital Healthcare System Gangnam Center, from 2005 to 2019. The number of study subjects was 637. We used a group-based model to identify cognitive function trajectories. Multinomial logistic regression was employed to define risk factors for cognitive function decline.

RESULTS

The cognitive function trajectories among adults over 40 years of age were heterogeneous. We identified four trajectories: high (27.3%), medium (41.0%), low (22.7%), and rapid decline (9.1%). Older age, male, low educational level, bad dietary habits, diabetes mellitus, technical worker, and lower income increased the likelihood of a cognitive function decline.

CONCLUSION

A younger age, a higher educational level, professional worker, good dietary habits, no diabetes mellitus, and no obesity improved cognitive function. A combination of these factors can improve "cognitive reserve" and delay cognitive decline. Interventions to prevent cognitive decline are needed after identification of high-risk groups for cognitive decline.

Exercise Hypertension in Athletes

Background: An exaggerated blood pressure response (EBPR) during exercise testing is not well defined, and several blood pressure thresholds are used in different studies and recommended in different guidelines. Methods: Competitive athletes of any age without known arterial hypertension who presented for preparticipation screening were included in the present study and categorized for EBPR according to American Heart Association (AHA), European Society of Cardiology (ESC), and American College of Sports Medicine (ACSM) guidelines as well as the systolic blood pressure/MET slope method. Results: Overall, 1137 athletes (mean age 21 years; 34.7% females) without known arterial hypertension were included April 2020−October 2021. Among them, 19.6%, 15.0%, and 6.8% were diagnosed EBPR according to ESC, AHA, and ACSM guidelines, respectively. Left ventricular hypertrophy (LVH) was detected in 20.5% of the athletes and was approximately two-fold more frequent in athletes with EBPR than in those without. While EBPR according to AHA (OR 2.35 [95%CI 1.66−3.33], p < 0.001) and ACSM guidelines (OR 1.81 [95%CI 1.05−3.09], p = 0.031) was independently (of age and sex) associated with LVH, EBPR defined according to ESC guidelines (OR 1.49 [95%CI 1.00−2.23], p = 0.051) was not. In adult athletes, only AHA guidelines (OR 1.96 [95%CI 1.32−2.90], p = 0.001) and systolic blood pressure/MET slope method (OR 1.73 [95%CI 1.08−2.78], p = 0.023) were independently predictive for LVH. Conclusions: Diverging guidelines exist for the screening regarding EBPR. In competitive athletes, the prevalence of EBPR was highest when applying the ESC (19.6%) and lowest using the ACSM guidelines (6.8%). An association of EBPR with LVH in adult athletes, independently of age and sex, was only found when the AHA guideline or the systolic blood pressure/MET slope method was applied.

Effects and safety of Sacubitril/Valsartan (SV) on heart function and blood pressure in maintenance hemodialysis (MHD) patients

To observe the effects and safety of Sacubitril/Valsartan (SV) on heart function and blood pressure in maintenance hemodialysis (MHD) patients with chronic heart failure (CHF). The clinical data and biochemical parameters of MHD patients were retrospectively analyzed. These MHD patients, who were collected from January 2020 to June 2021 in the Blood Purification Center of the First Affiliated Hospital of Chongqing Medical University, received SV treatment to control heart failure (HF). Altogether 54 MHD patients complicated with CHF who received SV treatment were selected for this self-controlled study. The changes of serum biochemical indexes, left anteroposterior atrial diameter (LAD), left ventricular end diastolic diameter (LVID), left ventricular ejection fraction (LVEF), right atrial transverse diameter (RAD), right anteroposterior ventricular diameter (RVD), blood pressure and antihypertensive drug dosage before and after treatment were assessed. The adverse reactions such as hyperkalemia, hypotension before dialysis, angina pectoris, myocardial infarction, cerebral infarction, cerebral hemorrhage and hospitalization due to HF were recorded before and after treatment. After treatment, LAD and LVID, incidence of angina pectoris, duration of hospitalization for HF, systolic blood pressure and diastolic blood pressure before dialysis, and the calibration value of antihypertensive drugs were all reduced, while LVEF was increased. The incidence of hyperkalemia (serum potassium >5.5 mmol/L) also increased after treatment compared with before treatment (P<0.05). The incidence of hypotension, angina pectoris, myocardial infarction, cerebral infarction and cerebral hemorrhage during treatment was similar to that before treatment (P>0.05). SV can effectively improve left atrial and left ventricular remodeling in MHD patients with CHF, improve LVEF, reduce the incidence of angina pectoris and duration of hospitalization due to HF in MHD patients, which is conducive to the control of blood pressure in MHD patients with hypertension. The incidence of hyperkalemia increased during SV treatment. SV did not increase the incidence of hypotension, myocardial infarction, cerebral infarction, cerebral hemorrhage and other events in MHD patients.

Treatment resistant hypertension--investigation and conservative management

BACKGROUND

The introduction of invasive treatments, some of which are irreversible, for the entity called treatment-resistant hypertension (TRH) creates the need for a comprehensive discussion of the diagnostic evaluation that TRH requires and the available options for its conservative treatment.

METHOD

The pertinent literature is selectively reviewed in the light of the authors' longstanding clinical experience.

RESULTS

Our review of the literature suggests that the high prevalence of TRH in Germany (ca. 20%) can be nearly halved with the aid of more thorough diagnostic evaluation. Such an evaluation should include a review of the patient's antihypertensive drugs (adherence, daily dosing, concomitant medication), investigation for other vascular changes that might affect blood pressure measurement, and exclusion of white-coat hypertension, sleep apnea syndrome, and secondary rather than essential hypertension. As there have been no randomized trials of treatment for TRH, the physician confronted with such cases must devise treatments on the basis of observational data and pathophysiological reasoning (volume status considering renin levels, sympathetic blockade, vasodilatation). Such measures can presumably lower the number of truly treatment-resistant cases still further.

CONCLUSION

To save patients from preventable harm, patients should undergo a thorough diagnostic evaluation and-under close monitoring for side effects-conservative pharmacological and nonpharmacological treatments should be deployed before any invasive treatment is performed.

Association of vitamin D status and blood pressure response after renal denervation

BACKGROUND

Vitamin D deficiency is associated with hypertension; however, it is unclear whether vitamin D influences therapeutic blood pressure reduction. Renal sympathetic denervation (RDN) reduces blood pressure in resistant hypertension. We hypothesized that vitamin D might influence blood pressure response to RDN.

METHODS

Vitamin D was measured in 101 patients with resistant hypertension undergoing RDN. The associations between vitamin D status and systolic blood pressure (SBP) reduction 6 months after RDN were analyzed.

RESULTS

Mean office SBP at baseline was 171.5 ± 2 mmHg. After RDN, mean office SBP was reduced by 28.4 ± 2.3 mmHg (p = 0.007). 85 patients (84.2 %) had SBP reductions >10 mmHg (responders). Vitamin D concentrations were lower in non-responders as compared to responders (9.9 ± 4.5 vs. 13.7 ± 7.4 ng/ml, p = 0.008). Non-responders (n = 16, 15.8 %), more often had a vitamin D concentration below the median as compared to responders (81 vs. 46 %, p = 0.013). The percentage of patients with normal vitamin D concentrations increased with increasing tertiles of SBP reduction (p for trend = 0.020). In patients with vitamin D concentrations below the median, SBP reduction was lower as compared to patients with a vitamin D concentration above the median (23.5 ± 3.2 vs. 33.7 ± 3.2 mmHg, p = 0.026). Baseline vitamin D concentrations correlated with SBP reduction (r = 0.202, p = 0.043).

CONCLUSIONS

In patients with resistant hypertension, low vitamin D concentrations were associated with a decreased SBP response and a higher rate of non-response.

Treating resistant hypertension: role of renal denervation

Arterial hypertension is the most prevalent risk factor associated with increased cardiovascular morbidity and mortality. Although pharmacological treatment is generally well tolerated, 5%–20% of patients with hypertension are resistant to medical therapy, which is defined as blood pressure above goal (>140/90 mmHg in general; >130–139/80–85 mmHg in patients with diabetes mellitus; >130/80 mmHg in patients with chronic kidney disease) despite treatment with ≥3 antihypertensive drugs of different classes, including a diuretic, at optimal doses. These patients are at significantly higher risk for cardiovascular events, in particular stroke, myocardial infarction, and heart failure, as compared with patients with nonresistant hypertension. The etiology of resistant hypertension is multifactorial and a number of risk factors have been identified. In addition, resistant hypertension might be due to secondary causes such as primary aldosteronism, chronic kidney disease, renal artery stenosis, or obstructive sleep apnea. To identify patients with resistant hypertension, the following must be excluded: pseudo-resistance, which might be due to nonadherence to medical treatment; white-coat effect; and inaccurate measurement technique. Activation of the sympathetic nervous system contributes to the development and maintenance of hypertension by increasing renal renin release, decreasing renal blood flow, and enhancing tubular sodium retention. Catheter-based renal denervation (RDN) is a novel technique specifically targeting renal sympathetic nerves. Clinical trials have demonstrated that RDN significantly reduces blood pressure in patients with resistant hypertension. Experimental studies and small clinical studies indicate that RDN might also have beneficial effects in other diseases and comorbidities, characterized by increased sympathetic activity, such as left ventricular hypertrophy, heart failure, metabolic syndrome and hyperinsulinemia, atrial fibrillation, obstructive sleep apnea, and chronic kidney disease. Further controlled studies are required to investigate the role of RDN beyond blood pressure control.

[Heart and kidneys. Renal denervation as therapy for hypertension]

Arterial hypertension is a major cardiovascular risk factor with a high prevalence in western industrial countries and the proportion of patients with blood pressure at target values remains low. Patients with therapy-resistant hypertension, defined as failure to achieve target blood pressure despite a triple antihypertensive drug regimen including a diuretic, are at very high risk which supports the need for greater efforts towards improving hypertension outcomes in this population. Secondary causes of hypertension are often found in patients with resistant hypertension. Activation of the sympathetic nervous system has been identified as a main contributor to the development and progression of high blood pressure. Catheter-based renal denervation offers a new interventional treatment option resulting in a significant long-term reduction in blood pressure (> 36 months) and increased blood pressure control (up to 40% of the treated population). The basis for successful treatment is an appropriate patient selection, including life-style modification, exclusion of pseudoresistance, termination of substances increasing blood pressure and an optimized drug treatment. Further clinical studies are warranted and ongoing to determine the role of renal denervation in antihypertensive treatment.

Major innovations and trends in the medical device sector

Activities related to medical innovation are accelerating and becoming increasingly important due to the demand for better and less invasive therapies, a rapidly aging population in the developed world and a globally larger population able to afford advanced medical care. Medical Innovation is occurring in the fields of pharmacy, diagnostics and therapeutic imaging, surgical products, interventional procedures and devices. Increasing understanding of basic disease processes further opens the opportunities for innovators. Increased knowledge often cause major paradigm shifts in therapeutic methods.