The monthly ESH guide through publications – October/November 2018
Edited by Costas Tsioufis and Alex Kasiakogias
This autumn boasts a large number of intriguing articles covering various fields of hypertension and cardiovascular disease prevention. Let’s see some stimulating picks!
Early cardiovascular protection by initial two-drug fixed-dose combination treatment vs. monotherapy in hypertension
A study on 44534 patients included in the healthcare utilization database of the Lombardy Region (Italy) and had started treatment with one antihypertensive drug or a two-drug fixed-dose combination, compared the risk of hospitalization for CV disease associated with the two treatment strategies. It was shown that compared to initial monotherapy, patients on initial fixed drug combination therapy showed a reduced 1-year risk of hospitalization for any CV event (−21%, P < 0.01).
Poor oral health and blood pressure control among US hypertensive adults. Results from the National Health and Nutrition Examination Survey 2009 to 2014
In this retrospective analysis of treated hypertensive patients older than 30 years of age, it was shown that mean systolic BP was about 2.3 to 3 mm Hg higher in the presence of periodontitis. In addition, periodontitis was associated with unsuccessful antihypertensive treatment after multiple adjustments, with higher odds by disease severity.
Relations between dairy product intake and blood pressure. The INTERnational study on MAcro/micronutrients and blood pressure
In 2694 participants of the INTERnational study on MAcro/micronutrients and blood Pressure cross-sectional associations to BP of dairy product intakes were examined. Low-fat dairy consumption was associated with lower BP, especially among participants with low ACR.
Frequency and associations of prescription nonsteroidal anti-inflammatory drug use among patients with a musculoskeletal disorder and hypertension, heart failure, or chronic kidney disease
In this retrospective cohort study on data from administrative claims databases, an 11% median physician-level prescribing rate among patients with hypertension, heart failure and chronic kidney disease was documented. A total 35552 matched patient pairs each consisting of an exposed and nonexposed patient were examined. No differences in cardiovascular or renal complications or death were identified.
Nocturia and increase in nocturnal blood pressure. The Nagahama study
In this cross-sectional study on 5959 community participants possible associations of sleep characteristics with sleep BP by simultaneous multiday measurements were examined. The frequency of urination showed strong and independent association with smaller nocturnal BP drop in participants with frequent urination. A 3% oxygen desaturation index and the fragmentation index were also associated with BP change.
Elevated blood pressure and risk of aortic valve disease: a cohort analysis of 5.4 million UK adults
In this cohort study of 5.4 million patients with no known cardiovascular disease or aortic valve disease at baseline, the relationship between BP and risk of incident aortic stenosis and regurgitation over a median follow-up of 9.2 years was examined. Systolic BP was continuously related to the risk of aortic valve disease with no evidence of a nadir down to 115 mmHg.
Body silhouette trajectories across the lifespan and vascular aging. The Paris Prospective Study 3
The relationship of lifetime body silhouette trajectories (a marker of weight change across the lifespan) and vascular aging in late adulthood was examined with the use of cross-sectional data from a community-based cohort. Vascular aging was most prominent among individuals who were lean in early life but markedly gained weight during young adulthood and among those who were heavy in early life and maintained weight.
Central haemodynamics in normal pregnancy. A prospective longitudinal study
In this prospective longitudinal study on 100 healthy women having an uncomplicated pregnancy a longitudinal evaluation of central haemodynamic adaptations was performed. A significant fall in cfPWV was observed mid-pregnancy. Brachial pulse pressure was lowest in the final trimester whereas central pulse pressure remained unchanged, resulting in a significant decrease in aorta-to-brachial pulse pressure amplification.
Prognostic value of masked uncontrolled hypertension. Systematic review and meta-analysis
This meta-analysis examined the prognostic value of masked uncontrolled hypertension. Six studies using ambulatory blood pressure monitoring and 5 using home blood pressure measurement were identified and the main result was the composite of cardiovascular outcomes and all-cause mortality. Risk was significantly higher in MUCH than in controlled hypertension independently of follow-up length and types of studied events.
Astronaut Cardiovascular Health and Risk Modification (Astro-CHARM) Coronary Calcium Atherosclerotic Cardiovascular Disease Risk Calculator
This study aimed to develop an atherosclerotic cardiovascular disease risk tool that incorporates coronary artery calcium. Subjects aged 40-65 years from three population-based cohorts were used. The Astro-CHARM tool is the first integrated risk calculator to incorporate risk factors, including high-sensitivity C-reactive protein and family history, and coronary artery calcium data. In comparison with the risk factor model, the Astro-CHARM model resulted in integrated discrimination improvement (0.0252), and net reclassification improvement (0.121; P<0.0001).
Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial
This analysis reports all-cause and cardiovascular mortality rates in the median of 15.7 years of follow-up of patients in the ASCOT trial. Among patients in the blood pressure lowering arm, there was no overall difference in cardiovascular mortality between treatments. Patients on amlodipine-based treatment had fewer stroke deaths and patients on atorvastatin had fewer cardiovascular deaths more than 10 years after trial closure.
Randomized crossover trial of the impact of morning or evening dosing of antihypertensive agents on 24-hour ambulatory blood pressure. The HARMONY Trial
The results of the HARMONY trial have been published. Ninety-five patients were randomized to receive usual therapy either in the morning (6 am–11 am) or evening (6 pm–11 pm) for 12 weeks when participants crossed over to the alternative timing for a further 12 weeks. Mean 24-hour systolic and diastolic blood pressures and mean daytime and nighttime BP did not differ between daytime and evening dosing.
And some reviews and recommendations:
European Society of Hypertension position paper on renal denervation 2018
Recommendations for participation in competitive sports of athletes with arterial hypertension: a position statement from the sports cardiology section of the European Association of Preventive Cardiology (EAPC)
Resistant hypertension: Detection, evaluation, and management: A scientific statement from the American Heart Association
The monthly ESH guide through publications – September 2018
Edited by Costas Tsioufis and Alex Kasiakogias
After an always well welcomed summer and days of vacation for the most of us, we are deep into September and back on track. Apart from the published new ESH/ESC guidelines, there have been lots of interesting new publications. Have a look!
Use of long-term cumulative blood pressure in cardiovascular risk prediction models
A cohort study that included 11767 adults from the Lifetime Risk Pooling Project studied whether including long-term (5- and 10-year) cumulative systolic blood pressure (SBP) in risk equations improves the predictive ability compared with single SBP measurements. It was shown that the use of long-term measures of cumulative BP, instead of single measurements, can modestly improve the ability of cardiovascular disease risk prediction models to correctly classify individuals in terms of their risk for cardiovascular disease.
Achieved diastolic blood pressure and pulse pressure at target systolic blood pressure (120–140 mmHg) and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials
Outcome data from patients age 55 years or older with cardiovascular disease from the ONTARGET and TRANSCEND trials were analysed, in order to examine the association between mean attained diastolic BP (DBP) and cardiovascular (CV) outcomes in patients who achieved an on-treatment SBP in the range of 120 to <140 mmHg. Compared to a DBP of 70 to <80 mmHg, lower and higher DBP was associated with a higher risk in patients achieving a SBP of 120 to <140 mmHg. Associations of DBP and PP to risk were similar notably at controlled SBP.
Ideal blood pressure in patients with atrial fibrillation
The goal of this study was to investigate the impacts of the 2017 ACC/AHA guideline and to determine the ideal BP threshold for the management of high BP in patients with AF. Data analysed were from 298,374 Korean adults with oral anticoagulant–naive, nonvalvular AF obtained from the National Health Insurance Service. Patients with AF and newly redefined hypertension according to the 2017 ACC/AHA guideline were at higher risk of major cardiovascular events. BP of 120 to 129/<80 mm Hg was the optimal BP treatment target for patients with AF undergoing hypertension treatment
Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 13 – benefits and adverse events in older and younger patients with hypertension overview, meta-analyses and meta-regression analyses of randomized trials
In this large meta-analysis of 63 BP-lowering randomized controlled trials in 210508 patients, the blood pressure -lowering treatment associated reduction in cardiovascular outcomes as well as adverse events in older versus younger patients was examined. All cardiovascular outcomes were significantly reduced by treatment both in older and younger individuals, without significant age-dependent differences in relative risk reduction but with significantly higher absolute risk reductions in older individuals. There was no evidence that treatment discontinuations for adverse events or hypotension/syncope were more frequent at age greater than 65.
Fixed low-dose triple combination antihypertensive medication vs usual care for blood pressure control in patients with mild to moderate hypertension in Sri Lanka. A Randomized Clinical Trial
This randomized, open-label trial assessed whether a low-dose triple combination antihypertensive medication (20 mg of telmisartan, 2.5 mg of amlodipine, and 12.5 mg of chlorthalidone) would achieve better blood pressure (BP) control vs usual care among 700 patients with mild to moderate hypertension. Seventy per cent of patients in the triple combination pill therapy group achieved a systolic/diastolic BP of less than 140/90 mm Hg (or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months compared with 55% of patients in the usual care group (P < 0.001). There were no significant between-group differences in the proportion of patient withdrawal from BP-lowering therapy due to adverse events.
Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study
This analysis done in 18 countries participating in The Prospective Urban Rural Epidemiology study, assessed community-level associations between sodium and potassium intake and BP as well as cardiovascular disease and mortality. Overall, mean systolic BP increased by 2.86 mm Hg per 1 g increase in mean sodium intake. Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. All major cardiovascular outcomes decreased with increasing potassium intake.
Orthostatic hypotension and symptomatic subclinical orthostatic hypotension increase risk of cognitive impairment: an integrated evidence review and analysis of a large older adult hypertensive cohort
This analysis studied the relationship between baseline orthostatic hypotension, subclinical orthostatic hypotension and cognitive outcomes among hypertensive patients aged ≥80 years from the Hypertension in the Very Elderly Trial (HYVET) cohort. Orthostatic hypotension was associated with an increased risk of cognitive decline [(HR) 1.36 (1.14–1.59)] and incident dementia [HR 1.34 (0.98–1.84)]. Subclinical orthostatic hypotension was also associated with an increased risk of cognitive decline [HR 1.56 (1.12–2.17)] and dementia [HR 1.79 (1.00–3.20)].
Long-Term cardiovascular risk associated with stage 1 hypertension defined by the 2017 ACC/AHA Hypertension Guideline
In this study on 21,441 participants age ≥35 years and free of cardiovascular disease (CVD) that were followed for up to 20 years in the Chinese Multi-provincial Cohort Study, the authors assessed the relative risk and population-attributable risk of cardiovascular disease associated with stage 1 hypertension as defined by the 2017 American College of Cardiology/American Heart Association hypertension guidelines. Among participants aged 35 to 59 years, the HR comparing stage 1 hypertension to BP <120/<80 mm Hg for CVD incidence was 1.78 (95% confidence interval [CI]: 1.50 to 2.11). Among participants age ≥60 years, however, stage 1 hypertension was not related to an increased risk compared with BP <120/<80 mm Hg.
Atrial fibrillation detection during 24-hour ambulatory blood pressure monitoring
This study assessed the diagnostic accuracy of a novel 24-hour ambulatory blood pressure (ABP) monitor with implemented algorithm for automated atrial fibrillation (AF) detection during each ABP measurement, on one hundred subjects that had simultaneous 24-hour ABP monitoring and 24-hour Holter monitoring. It was shown that in elderly hypertensives, this 24-hour ABP monitor with AF detector has high sensitivity and moderate specificity for AF screening during routine ABP monitoring. There was a strong association between the proportion of false-positive AF readings and that of supraventricular premature beats.
Three-dimensional echocardiographic ventricular mass/end-diastolic volume ratio in native hypertensive patients: relation between stroke volume and geometry
This study investigated the ability of three-dimensional (3D) echocardiography in identifying a phenotype of LV concentric geometry according to the Left Ventricular Mass (LVM)/End Diastolic Volume (EDV) ratio, which when measured by MRI has been associated with higher evidence of myocardial fibrosis and dysfunction in hypertensive patients. It was shown that 3D-echo-derived LVM/EDV ratio identifies a higher prevalence of LV concentric geometry than 2D-relative wall thickness. Stroke volume was independently and negatively associated with the LVM/EDV ratio.
Pregnancy weight gain before diagnosis and risk of preeclampsia. A population-based cohort study in nulliparous women
The aim of this study was to determine whether pregnancy weight gain before the diagnosis of preeclampsia is associated with increased risks of preeclampsia in 62705 nulliparous women. Odds of preeclampsia increased by ≈60% with every 1 z score increase in pregnancy weight gain among normal weight and overweight women and by 20% among obese women. High pregnancy weight gain before diagnosis was more strongly associated with later-onset preeclampsia than early-onset preeclampsia.
Refractory hypertension is not attributable to intravascular fluid retention as determined by intracardiac volumes
The study examined whether refractory hypertension (RfHTN- lack of blood pressure control with ≥5 medications, including a long-acting thiazide and a mineralocorticoid receptor antagonist) is characterized by persistent fluid retention, as indexed by greater intracardiac volumes determined by cardiac magnetic resonance. The findings demonstrate greater left ventricular hypertrophy without chamber enlargement in RfHTN, suggesting that antihypertensive treatment failure is not attributable to intravascular volume retention.
Regression of organ damage following renal denervation in resistant hypertension: a meta-analysis
This study examined the effect of renal denervation on target organ damage by meta-analyzing 17 studies (698 patients). Renal denervation was associated with significant reductions in left ventricular mass index, E wave velocity to E m velocity from tissue Doppler imaging, central augmentation index and carotid−femoral pulse wave velocity.
Office and ambulatory heart rate as predictors of age-related kidney function decline
A population-based cohort study
The study examined whether heart rate (HR) is a risk factor for GFR decline in the general population, using data from 1627 patients in the Renal Iohexol-Clearance Survey in Tromsø 6. In multivariable-adjusted linear mixed models, 10 bpm higher ambulatory 24-hour and daytime HRs and office HR were associated with steeper GFR decline rates of 0.20 to 0.21 mL/min per year (P≤0.01). It is concluded that HR may be a useful biomarker to identify persons at risk of accelerated GFR decline.
Renal denervation in resistant hypertension and obstructive sleep apnea. Randomized proof-of-concept phase II trial
The aim of the present study was to investigate in a prospective randomized trial the effect of RDN on BP and clinical course of OSA. Sixty patients with true resistant hypertension coexisting with moderate-to-severe OSA (apnea/hypopnea index, ≥15) were randomly allocated to RDN group and to control group. At 3 months in the RDN group, both office and ambulatory BP were significantly reduced, and a significant decrease in OSA severity (apnea/hypopnea index, 39.4 versus 31.2 events per hour; P=0.015) was observed.
Blood pressure response to maximal dynamic exercise testing in an athletic population
The study examined the magnitude and distribution of BP response to exercise in athletic populations by performing cycle ergometry in 2419 healthy competitive adolescent, professional and master athletes for preparticipation screening. ESC guidelines of upper limits of maximal SBP were exceeded in 43% in men (>210 mmHg) and 28% in women (>190 mmHg). SBP response was more pronounced in endurance athletes, whereas DBP was slightly higher in strength athletes.
Computed Tomography and Adrenal Venous Sampling in the Diagnosis of Unilateral Primary Aldosteronism
This retrospective multicentre study compared clinical and biochemical postsurgical outcomes of patients with unilateral primary aldosteronism diagnosed by CT or adrenal venous sampling and identify predictors of surgical outcomes. A diagnosis by CT was associated with a decreased likelihood of complete biochemical success compared with AVS.
Impact of blunted nocturnal blood pressure dipping on cardiac systolic function in community participants not receiving antihypertensive therapy
Whether nocturnal BP dipping pattern and nocturnal BP were associated with indexes of cardiac systolic function was assessed in 491 randomly selected community participants not receiving antihypertensive therapy. After adjustments for potential confounders, left ventricular mass index, endocardial fractional shortening, midwall fractional shortening and ejection fraction were associated with nocturnal BP and BP dipping.
Clinical characteristics and risk of hypertension needing treatment in young patients with systolic hypertension identified with ambulatory monitoring
The importance of isolated systolic hypertension (ISH) of the young is not well defined. In 1206, 18–45-year-old participants from the Hypertension and Ambulatory Recording VEnetia Study, the predictive role of ISH for incident hypertension was evaluated. Patients were divided in hypertension types based on 24hr BP data and it was shown that in ISH people younger than 45 years, only mean BP is a predictor of future hypertension needing treatment, whereas the ISH status per se does not necessarily imply an increase in risk.
Electrocardiographic predictors of atrial fibrillation in nonhypertensive and hypertensive individuals
The aim of this study was to compare the predictive value of ECG abnormalities for atrial fibrillation in nonhypertensive versus hypertensive individuals. ECG was recorded and conventional cardiovascular risk factors were measured in a nationwide population-based sample of 5813 Finns who were divided into hypertensives and non-hypertensives and followed for incident atrial fibrillation events. It was shown that several ECG abnormalities associate with incident atrial fibrillation in hypertensive and nonhypertensive individuals but provide only marginal incremental predictive value. Corrected QT interval and T-wave amplitude in lead aVR may relate stronger to incident atrial fibrillation in nonhypertensive than in hypertensive individuals.
The monthly ESH guide through publications – June 2018
Edited by Costas Tsioufis and Alex Kasiakogias
We have enjoyed another great ESH meeting in Barcelona, with the presentation of the new European Hypertension Guidelines being undoubtedly its highlight! Let’s have a look at the recent research that came out in the meantime.
Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomised trial
In this international, randomised, single-blind, sham-control, proof-of-concept trial, patients with uncontrolled hypertension (aged 20–80 years) were randomly assigned to undergo radiofrequency energy renal denervation or sham control. The results for the first 80 patients show that the change in blood pressure was significantly greater at 6 months in the renal denervation group than the sham-control group for office systolic blood pressure (difference −6.8 mmHg), 24 h systolic blood pressure (difference −7.4 mm Hg), office diastolic blood pressure (difference −3.5 mmHg), and 24 h diastolic blood pressure (difference −4.1 mmHg). It is concluded that renal denervation in the main renal arteries and branches significantly reduced blood pressure compared with sham control with no major safety events.
Endovascular ultrasound renal denervation to treat hypertension (RADIANCE-HTN SOLO): a multicentre, international, single-blind, randomised, sham-controlled trial
In the multicentre, international, single-blind, randomised, sham-controlled trial RADIANCE-HTN SOLO, 146 patients with combined systolic-diastolic hypertension and ambulatory blood pressure greater than or equal to 135/85 mm Hg free of antihypertensive medications were randomised to undergo renal denervation (n=74) with endovascular ultrasound or a sham procedure (n=72). The reduction in daytime ambulatory systolic blood pressure was greater with renal denervation (-8.5 mm Hg, SD 9.3) than with the sham procedure (-2.2 mm Hg, SD 10.0; baseline-adjusted difference between groups: -6.3 mm Hg, 95% CI -9.4 to -3.1, p=0·0001). It is concluded that compared with a sham procedure, endovascular ultrasound renal denervation reduced ambulatory blood pressure at 2 months in patients with combined systolic-diastolic hypertension in the absence of medication.
A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea
This meta-analysis of seven RCTs aimed to assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA). It was shown that CPAP use was associated with a non-significant 26% relative risk reduction in MACE. CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF). Subgroup analysis revealed that CPAP adherence time ≥4 hours (h)/night reduced the risk of MACE by 57%.
Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts
The multicentre study PREDIMED in Spain in 7447 patients at high cardiovascular risk followed up for 4.8 years (for an interim analysis) studied the association with major cardiovascular events of a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with mixed nuts, or a control diet (advice to reduce dietary fat). In this revised analysis it was shown that the incidence of major cardiovascular events was lower among those assigned to a Mediterranean diet supplemented with extra-virgin olive oil or nuts than among those assigned to the reduced-fat diet.
Blood pressure variability and risk of cardiovascular events and death in patients with hypertension and different baseline risks
In an analysis of the Valsartan Antihypertensive Long-term Use Evaluation trial, standard deviation (SD) of mean systolic blood pressure from visits from 6 months onward in patients with ≥3 visits and no events during the first 6 months was calculated. Patients in the highest quintile of SD had an increased risk of cardiovascular events [HR 2.1, 95% CI 1.7–2.4], and a 5 mmHg increase in SD of systolic blood pressure was associated with a 10% increase in the risk of death (HR 1.10, 95% CI 1.04–1.17). It is concluded that higher visit-to-visit systolic blood pressure variability is associated with increased risk of cardiovascular events in patients with hypertension, irrespective of baseline risk of cardiovascular events. Associations were stronger in younger patients and in those with lower mean systolic blood pressure.
Status of hypertension in China. Results from the China Hypertension Survey, 2012–2015
Although the prevalence of hypertension (HTN) continues to increase in developing countries, including China, recent data are lacking. In a nationwide survey in China, it was shown that 23.2% of the Chinese adult population ≥18 years of age had HTN, and another 41.3% had pre-HTN according to the Chinese guidelines. Among individuals with HTN, 46.9% were aware of their condition, 40.7% were taking prescribed antihypertensive medications, and 15.3% had controlled HTN.
Antihypertensive drug use in resistant and nonresistant hypertension and in controlled and uncontrolled resistant hypertension
This study on 14264 patients treated with three drugs and in 6974 treated with at least four drugs assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of non-treatment-resistant hypertension (TRH) vs. TRH, and with controlled vs. uncontrolled TRH. It was shown that the use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs. Similar results were observed with specific agents inside each class, being ramipril, olmesartan, chlorthalidone, amlodipine, and bisoprolol those exhibiting significant results. An increased use of these drugs might probably reduce the burden of TRH. uncontrolled resistant hypertension.
Simultaneously measured interarm blood pressure difference and stroke. An individual participants data meta-analysis
This meta-analysis examined the validity of interarm blood pressure difference in simultaneous measurement as a marker to identify subjects with ankle-brachial pressure index <0.90 and to predict future cardiovascular events. Binary logistic regression analysis with adjustments identified interarm blood pressure difference >5 mm Hg as being associated with a significant odds ratio for the presence of ankle-brachial pressure index <0.90 (odds ratio, 2.19; 95% confidence interval, 1.60–3.03; P<0.01). Interarm blood pressure difference >15 mm Hg was associated with a significant Cox stratified adjusted hazard ratio for subsequent stroke (hazard ratio, 2.42; 95% CI, 1.27–4.60; P<0.01). These differences may be useful for identifying subjects with an ankle-brachial pressure index of <0.90 in the overall study population, and also a reliable predictor of future stroke in subjects without a past history of cardiovascular disease.
Association of 24-Hour blood pressure with urinary sodium excretion in healthy adults
In this analysis of 2,899 adults free of cardiovascular disease, diabetes or on BP-lowering treatment, the relationships of 24-hour urinary salt excretion with office and ambulatory BP measurements were assessed. A weak linear association was observed between 24-hour ambulatory systolic BP and urinary sodium excretion (β (95% confidence interval [CI]) per 1 g increase in sodium excretion (0.33 % (0.09; 0.57); P = 0.008). No significant relationships were observed for 24-hour ambulatory diastolic BP. In conclusion, in healthy adults urinary sodium excretion was only weakly associated with systolic 24-hour ambulatory BP.
Associations of initial injury severity and posttraumatic stress disorder diagnoses with long-term hypertension risk after combat injury
The associations between injury severity, posttraumatic stress disorder (PTSD), and development of chronic diseases, such as hypertension, among military service members are not understood. Administrative and clinical databases were used to conduct a retrospective cohort study of 3846 US military casualties. Overall prevalence of PTSD was 42.4%, and prevalence of hypertension was 14.3%. Unadjusted risk of hypertension increased significantly with chronicity of PTSD (1–15 diagnoses: hazard ratio, 1.77; 95% CI, 1.46–2.14; >15 diagnoses: hazard ratio, 2.29; 95% CI, 1.85–2.84) compared with patients never diagnosed with PTSD. It is concluded that in a cohort of service members injured in combat, we found that chronicity of PTSD diagnoses and injury severity were independent risk factors for hypertension.
Association of pulse wave velocity with chronic kidney disease progression and mortality findings from the CRIC Study (Chronic Renal Insufficiency Cohort)
In the prospective cohort study Chronic Renal Insufficiency Cohort of 2795 CKD patients, the relationship between PWV and end-stage kidney disease (ESRD), ESRD or halving of estimated glomerular filtration rate, or death from any cause was examined. Patients with the highest tertile of PWV (>10.3 m/s) were at higher risk for ESRD (hazard ratio 1.37 [1.05–1.80]), ESRD or 50% decline in estimated glomerular filtration rate (hazard ratio 1.25 [0.98–1.58]), or death (hazard ratio 1.72 [1.24–2.38]). It is concluded that PWV is a significant predictor of CKD progression and death in people with impaired kidney function.
Case detection in primary aldosteronism: high-diagnostic value of the aldosterone-to-renin ratio when performed under standardized conditions
In this prospective study on 233 patients, the diagnostic value of the aldosterone-to-renin ratio was assessed by using a highly standardized study protocol and by using a saline infusion test as a reference standard. Correlation of the aldosterone-to-renin ratio (cut-off >5) with primary aldosteronism diagnosis showed a sensitivity of 100% (CI 75.9–100), specificity of 86.7% (CI 81.2–90.7), positive-predictive value of 35.6% (CI 22.3–51.3) and negative-predictive value of 100% (CI 97.5–100.0). These findings show that the aldosterone-to-renin ratio is a good screening modality for primary aldosteronism and is without a high risk of missing a primary aldosteronism diagnosis whenever performed under well standardized conditions.
And a couple of statements:
The role of cardiologists in stroke prevention and treatment: position paper of the European Society of Cardiology Council on Stroke
Obesity and cardiovascular risk: a call for action from the European Society of Hypertension Working Group of Obesity, Diabetes and the High-risk Patient and European Association for the Study of Obesity part A and part B
The monthly ESH guide through publications – May 2018
Edited by Costas Tsioufis and Alex Kasiakogias
With June approaching fast -and with it the 28th European Meeting in Hypertension, in Barcelona- let us have a look at some of the latest research to be up to date!
Relationship between clinic and ambulatory blood-pressure measurements and mortality.
This study examined the associations of blood pressure measured in the clinic (clinic blood pressure) and 24-hour ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of patients in primary care. Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension.
Impact of cardiovascular risk on the relative benefit and harm of intensive treatment of hypertension
The lower rate of primary outcome events in the intensive treatment group in SPRINT (Systolic Pressure Intervention Trial) was associated with increased clinically significant serious adverse events (SAEs). This study investigated the effect of baseline 10-year CVD risk on primary outcome events and all-cause SAEs in SPRINT. Those with lower baseline CVD risk had more harm than benefit from intensive treatment, whereas those with higher risk had more benefit.
Night-time heart rate nondipping: clinical and prognostic significance in the general population
Studies addressing the association between a reduced drop of heart rate (HR) at night with subclinical organ damage and cardiovascular events in the general population are scanty. Among 2021 individuals enrolled in the Pressioni Monitorate E Loro Associazioni study a blunted dipping of nocturnal HR was associated with preclinical cardiac damage in terms of left atrial enlargement and was predictive of cardiovascular morbidity and mortality in the general population.
Age- and sex-specific reference values for media/lumen ratio in small arteries and relationship with risk factors
Small-artery remodeling is an early feature of target organ damage in hypertension and retains a negative prognostic value. The aim of the study is to establish age- and sex-specific reference values for media/lumen in small arteries obtained in humans by biopsy. In a predominantly hypertensive population, media/lumen Z scores were associated with major cardiovascular risk factors, including body mass index, cholesterol, smoking, glucose, and systolic blood pressure. Significant sex differences were observed.
Effect of mineralocorticoid antagonists on blood pressure lowering: overview and meta-analysis of randomized controlled trials in hypertension
Although mineralocorticoid antagonists (MRAs) have been proposed as effective fourth-line blood pressure (BP)-lowering agents in resistant hypertension, this effect in hypertension at-large is unclear. This meta-analysis showed that the extent of BP lowering following treatment with MRAs in patients with and without resistant hypertension was similar and not accompanied by increased rate of treatment-related discontinuations compared with other active comparators.
Effect of mineralocorticoid antagonists on blood pressure lowering: overview and meta-analysis of randomized controlled trials in hypertension.
MicroRNAs in peripheral mononuclear cells as potential biomarkers in hypertensive patients with heart failure with preserved ejection fraction
MicroRNAs (miRs) regulate gene expression and play an important role in ventricular and vascular remodelling. However, there are limited data regarding their role in heart failure with preserved ejection fraction (HFpEF). miR-26b, miR-208b, and miR-499 showed a distinct profile in hypertensive patients with HFpEF that is related with functional capacity. Further studies are needed to assess the role of miRs as prognostic tools or as therapeutic targets in these patients.
Accuracy of self-reported hypertension: a systematic review and meta-analysis
The objective of this meta-analysis was to estimate the sensitivity and specificity of self-reported hypertension (HTN) as compared with the clinical diagnosis in epidemiological studies. Less than half of patients with HTN would not be identified by self-reporting in epidemiological studies. Self-reported HTN has important limitations and may represent an important source of bias in research depending on regional, socioeconomic, and cultural differences.
Preconception blood pressure levels and reproductive outcomes in a prospective cohort of women attempting pregnancy
Elevated blood pressure in young adulthood is an early risk marker for cardiovascular disease. Despite a strong biological rationale, little research has evaluated whether incremental increases in preconception blood pressure have early consequences for reproductive health. Findings from this analysis of the EAGeR trial (Effects of Aspirin on Gestational and Reproduction; 2007-2011) suggest that preconception blood pressure among healthy women is associated with pregnancy loss, and lifestyle interventions targeting blood pressure among young women may favourably impact reproductive health.
Impact of obstructive sleep apnea on cardiac organ damage in patients with acute ischemic stroke
Both obstructive sleep apnea (OSA) and cardiac organ damage have a crucial role in acute ischemic stroke. This study confirms the high prevalence of OSA in stroke patients, suggesting also an association between OSA and cardiac target organ damage. Acute stroke patients with OSA had higher left ventricular mass and showed greater left atrial enlargement than patients without OSA. Our finding of structural LV abnormalities in acute stroke patients with OSA suggests a potential role of OSA as contributing factor in determining both cerebrovascular and cardiac damage, even in absence of clear link with a history of blood pressure elevation.
Association between baseline LDL-C level and total and cardiovascular mortality after LDL-C lowering: A systematic review and meta-analysis
Effects on specific fatal and nonfatal end points appear to vary for low-density lipoprotein cholesterol (LDL-C)-lowering drug trials. In these meta-analyses and meta-regressions, more intensive compared with less intensive LDL-C lowering was associated with a greater reduction in risk of total and cardiovascular mortality in trials of patients with higher baseline LDL-C levels. This association was not present when baseline LDL-C level was less than 100 mg/dL, suggesting that the greatest benefit from LDL-C-lowering therapy may occur for patients with higher baseline LDL-C levels.
Echocardiographic assessment of left ventricular morphology and function in patients with fibromuscular dysplasia: the ARCADIA-POL study
This study sought to provide a comprehensive assessment of left ventricle (LV) structure, and function and to detect alterations in cardiac properties in relationship to presence, subtypes and extent of fibromuscular dysplasia (FMD). In contrast to those with atherosclerotic RAS, it did not show differences in LV morphology and function between FMD patients and matched controls. Although FMD can result in hypertension and serious vascular complications, there is no proof that it can alter LV regardless of FMD type and its extent.
Isolated systolic hypertension in the young: a position paper endorsed by the European Society of Hypertension
Whether isolated systolic hypertension in the young (ISHY) implies a worse outcome and needs antihypertensive treatment is still a matter for dispute. ISHY is thought to have different mechanisms than systolic hypertension in the elderly. Only future clinical trials will elucidate if a benefit can be achieved with pharmacological treatment in some subgroups of ISHY patients with associated risk factors and/or high central blood pressure. Isolated systolic hypertension in the young: a position paper endorsed by the European Society of Hypertension.
The monthly ESH guide through publications – April 2018
Edited by Costas Tsioufis and Alex Kasiakogias
Spring is here along with some good reads. Enjoy!
Effect of dietary sodium restriction on arterial stiffness: systematic review and meta-analysis of the randomized controlled trials
Arterial stiffness is an independent cardiovascular risk factor and sodium intake could be a determinant of arterial stiffness. Nevertheless, the studies that investigated the effect of reducing dietary sodium intake on arterial stiffness in humans provided inconsistent results. The results of this meta-analysis indicate that restriction of dietary sodium intake reduces arterial stiffness. This effect seems be at least in part independent of the changes in blood pressure.
Estimated 24-hour urinary sodium and potassium excretion in US adults.
In 2010, the Institute of Medicine (now the National Academy of Medicine) recommended collecting 24-hour urine to estimate US sodium intake because previous studies indicated 90% of sodium consumed was excreted in urine. In cross-sectional data from a 2014 sample of US adults, estimated mean sodium intake was 3608 mg per day. The findings provide a benchmark for future studies.
The relationship of all-cause mortality to average on-treatment systolic blood pressure is significantly related to baseline systolic blood pressure: implications for interpretation of the Systolic Blood Pressure Intervention Trial study
The SPRINT study demonstrated that targeting systolic blood pressure (SBP) less than 120 mmHg was associated with lower cardiovascular event and mortality rates. In this analysis of LIFE study data, achievement of an average SBP less than 142 mmHg was associated with reduced mortality in patients with baseline SBP 164 mmHg or less but with increased mortality in those with higher baseline SBP. These findings suggest that the lower mortality associated with a lower targeted SBP in SPRINT may not be applicable to patients with considerably higher baseline SBP than SPRINT patients. Further study is necessary to better understand these findings.
Association between chronic or acute use of antihypertensive class of medications and falls in older adults. A systematic review and meta-analysis
Twenty-nine studies of cohort, case-control, case-crossover, cross-sectional, or randomized controlled trial (RCT) design examining association between antihypertensives and falls in people older than 60 years were evaluated. There was no significant association between chronic use of antihypertensives and falls in older adults. Risk of falls is highest on day zero for all antihypertensive medications.
Cocaine exposure increases blood pressure and aortic stiffness via the miR-30c-5p–Malic Enzyme 1–Reactive Oxygen Species pathway
Cocaine abuse increases the risk of cardiovascular mortality and morbidity; however, the underlying molecular mechanisms remain elusive. By using a mouse model for cocaine abuse/use, it was found that repeated cocaine injection led to increased blood pressure and aortic stiffness in mice associated with elevated levels of reactive oxygen species (ROS) in the aortas, a phenomenon similar to that observed in hypertensive humans.
Cause of renal infarction: a retrospective analysis of 186 consecutive cases
The aim of this study was to analyze various renal infarction causes. Renal artery lesion is the most frequent cause of renal infarction. This result underlines the need for extensive arterial exploration to identify the renal infarction mechanism and, in case of renal artery lesion, the underlying vascular disease.
Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial
The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings.
A cluster-randomized trial of blood-pressure reduction in black barbershops
Uncontrolled hypertension is a major problem among non-Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists.
Effects of bariatric surgery in obese patients with hypertension. The GATEWAY randomized trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension)
In this randomized, single-center, nonblinded trial, patients with hypertension and a body mass index between 30.0 and 39.9 kg/m2 were randomized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. Bariatric surgery represented an effective strategy for blood pressure control in this broad population of patients with obesity and hypertension.
Echocardiographic left ventricular reverse remodeling after 18 months of antihypertensive treatment in stage I hypertension. Results from the Prever-Treatment Study
Antihypertensive treatment improves echocardiographic parameters of hypertensive target organ damage in stage II hypertension, but less is known about the effects in stage I hypertension. In a cohort study nested in the randomized double-blind trial PREVER-treatment, treatment of patients with stage I hypertension for 18 months promotes favourable effects in the LA and LV remodelling.
Prognostic value of echocardiography in hypertensive versus nonhypertensive participants from the general population
This study examines the incremental prognostic value of adding echocardiographic parameters to established risk factors in individuals from the general population with and without hypertension. In hypertensive individuals, left ventricular mass index added incremental prognostic value in addition to established risk factors. In nonhypertensive individuals, global longitudinal strain added incremental prognostic value in addition to established risk factors.
The monthly ESH guide through publications- March 2018
Edited by Costas Tsioufis and Alex Kasiakogias
We are already well into 2018, so let’s see a few of the nice papers that have already been published this year:
Spironolactone versus clonidine as a fourth-drug therapy for resistant hypertension.
The ReHOT randomized study (Resistant Hypertension Optimal Treatment)
In this multicentre randomized trial on true treatment resistant hypertensives, clonidine compared to spironolactone presented similar rates of achieving office and 24-hour ambulatory BP control (but the overall BP control was low at about 21%). However, spironolactone promoted greater decrease in 24-h systolic and diastolic BP and diastolic daytime ambulatory BP than clonidine.
Incidence of cardiovascular disease in individuals affected by recent changes to US blood pressure treatment guidelines
An analysis on cohorts from the Framingham and Jackson Heart Studies (FHS and JHS) showed that individuals with treated BP 140–149/<90 mmHg have increased risk of CVD compared with those without hypertension including participants at least 60 years.
Association between urinary sodium and potassium excretion and blood pressure among adults in the United States National Health and Nutrition Examination Survey, 2014
A new cross-sectional analysis from the NHANES survey shows a strong dose-response association between urinary sodium excretion and blood pressure, and an inverse association between urinary potassium excretion and blood pressure.
Prognostic value of average home blood pressure and variability: 19-year follow-up of the Didima study
In an almost 20-year follow-up of the Greek Didima Study on a general population there were three interesting findings: average HBP predicted total mortality and cardiovascular disease as reliably as office BP; only normotension (low office BP ad home BP) was associated with low risk; systolic home BP variability exhibited superior prognostic ability than office BP.
Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline
Another analysis of NHANES data shows that the 2017 ACC/AHA guideline results in a substantial increase in the prevalence of hypertension (45.6%), a small increase in the percentage of US adults recommended for antihypertensive medication (36.2%), and more intensive BP lowering for many adults taking antihypertensive medication.
Effect of continuous positive airway pressure in hypertensive patients with obstructive sleep apnea and high urinary metanephrines
This study examined whether a pathological rise of urinary metanephrines is common among hypertensive OSA patients and, in such a case, whether CPAP may normalize high metanephrines levels. In two thirds of OSA patients urinary metanephrines were above the normal limit and CPAP reduced AHI along with the sympathoadrenal activation.
Influence of baseline diastolic blood pressure on effects of intensive compared with standard blood pressure control
Data from the SPRINT study shows that baseline DBP had a U-shaped association with the hazard of the primary cardiovascular disease outcome but the effects of the intensive SBP intervention on the primary outcome were not influenced by baseline DBP levels.
Achieving target SBP for lowering the risk of major adverse cardiovascular events in persons with diabetes mellitus
In patients with advanced diabetes mellitus a standard SBP goal between 120 and 140 mmHg may prove useful for lowering cardiovascular risk in persons with diabetes mellitus. However, a target SBP less than 120 mmHg does not appear to mitigate risk.
Pulse Wave Velocity predicts the progression of blood pressure and development of hypertension in young adults
In this Finnish study it was shown that in adults 30-45 years old PWV measurement was directly and independently associated with systolic and diastolic blood pressures as well as incident hypertension 5 years later. An extended prediction model including PWV improved the incident hypertension risk prediction beyond traditional cardiovascular risk factors.
Attended versus unattended blood pressure measurement in a real life setting
The unattended Blood pressure measurement method of the SPRINT trial has been a subject of strong debate. In this study, unattended and attended office BP measurements achieve comparable results, if measurements take place at a familiar general practitioner’s office.
Relationships between components of blood pressure and cardiovascular events in patients with stable coronary artery disease and hypertension
In a large cohort from the Clarify registry, the J-shaped relationship between diastolic BP and cardiovascular events in hypertensive patients with coronary artery disease persists in patients within the lowest-risk pulse pressure range and is therefore unlikely to be solely the consequence of an increased PP reflecting advanced vascular disease.
Age modifies the relation between intraindividual measurement-to-measurement variation in blood pressure and cognitive function: the Maine-Syracuse Study
In this longitudinal study on patients over 60 years, intraindividual BP variability as measured by automated BP taken 15 times (five times each in sitting, reclining, and standing positions) was an important predictor of cognition with advancing age.
The optimal night-time home blood pressure monitoring schedule: agreement with ambulatory blood pressure and association with organ damage
Night-time home blood pressure monitoring is proposed as a feasible, reliable and low-cost alternative to ambulatory blood pressure monitoring. In this study, a two-night home BP schedule (six readings) appears to be the minimum requirement for a reliable assessment of night-time home BP, which gives reasonable agreement with ambulatory BP and association with preclinical organ damage.
A Universal Standard for the Validation of Blood Pressure Measuring Devices Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement
In this statement, the key aspects of a validation procedure, which were agreed by the AAMI, ESH, and ISO representatives as the basis for a single universal validation protocol for the validation of blood pressure measuring devices are presented.
2017 Cardiovascular and stroke endpoint definitions for clinical trials
This publication presents uniform definitions for cardiovascular and stroke outcomes as developed by the Standardized Data Collection for Cardiovascular Trials Initiative and the US Food and Drug Administration (FDA).