Safety and efficacy of candesartan versus valsartan combined with amlodipine on peripheral and central blood pressure / Seguridad y eficacia de candesartán frente a valsartán combinado con amlodipino sobre la presión arterial periférica y central

Introduction: “Amlodipine/valsartan” or “amlodipine/candesartan” combinations represent two effective antihypertensive agents with complementary mechanisms of action. Nevertheless, a study has yet to be done to evaluate the effect of amlodipine/candesartan on central blood pressure and compare it with amlodipine/valsartan combination. To see how “amlodipine plus candesartan combination” reduces peripheral and central blood pressure compared to the most studied combination, “amlodipine plus valsartan”. Material and methods: Eighty-six patients were randomized in an open-label, prospective study by 1:1 ratio to two groups. Group I (n=42) received the amlodipine and valsartan combination, and group II (n=44) received the amlodipine and candesartan combination. Peripheral and central blood pressure (CBP) was measured at baseline, at 6 and 12 weeks of follow-up. Discussion: Both treatment groups reduced peripheral systolic, diastolic, and mean blood pressure. There was no significant difference between and within both groups. The amlodipine/candesartan combination showed more reduction in peripheral systolic blood pressure (PSBP) after 12 weeks of treatment (p=<0.001). Both groups decreased CBP without significant differences between groups. The amlodipine/candesartan combination showed additional efficacy in decreasing CSBP after 12 weeks (p=<0.001). The two treatment groups did not exert significant efficacy in lowering heart rate (HR) and augmentation index% (AIx%). Conclusion: To conclude, the amlodipine 10mg/candesartan 16mg combination was non-inferior to the amlodipine 10mg/valsartan 160mg combination in terms of reducing peripheral and CBP over time.(AU)

Introducción: «Las combinaciones de amlodipino/valsartán» o «amlodipino/candesartán» representan 2 agentes antihipertensivos efectivos con mecanismos de acción complementarios. Sin embargo, aún no se ha realizado un estudio para evaluar el efecto del amlodipino/candesartán en la presión arterial central y compararlo con la combinación amlodipino/valsartán. En este estudio, se comparó la reducción de la presión arterial periférica y central entre estas 2 combinaciones. Materiales y métodos: Ochenta y seis pacientes fueron asignados aleatoriamente a 2 grupos: el Grupo I (n=42) recibió amlodipino y valsartán, y el Grupo II (n=44) recibió amlodipino y candesartán. Se midió la presión arterial periférica y central al inicio, a las 6 y 12 semanas de seguimiento. Discusión: Ambos grupos redujeron la presión arterial periférica de manera similar, pero la combinación amlodipino/candesartán mostró una mayor reducción en la presión arterial sistólica periférica después de 12 semanas de tratamiento. Ambas combinaciones también disminuyeron la presión arterial central, pero nuevamente, la combinación amlodipino/candesartán tuvo una mayor eficacia en la reducción de la presión arterial sistólica central después de 12 semanas. No se observaron diferencias significativas en la frecuencia cardíaca ni en el índice de aumento entre los grupos. Conclusión: En conclusión, la combinación de amlodipino 10mg/candesartán 16mg demostró ser tan efectiva como la combinación de amlodipino 10mg/valsartán 160mg en la reducción tanto de la presión arterial periférica como central a lo largo del tiempo.(AU)

A Multilayer Perceptron Neural Network Model to Classify Hypertension in Adolescents Using Anthropometric Measurements: A Cross-Sectional Study in Sarawak, Malaysia.

This study outlines and developed a multilayer perceptron (MLP) neural network model for adolescent hypertension classification focusing on the use of simple anthropometric and sociodemographic data collected from a cross-sectional research study in Sarawak, Malaysia. Among the 2,461 data collected, 741 were hypertensive (30.1%) and 1720 were normal (69.9%). During the data gathering process, eleven anthropometric measurements and sociodemographic data were collected. The variable selection procedure in the methodology proposed selected five parameters: weight, weight-to-height ratio (WHtR), age, sex, and ethnicity, as the input of the network model. The developed MLP model with a single hidden layer of 50 hidden neurons managed to achieve a sensitivity of 0.41, specificity of 0.91, precision of 0.65, F-score of 0.50, accuracy of 0.76, and Area Under the Receiver Operating Characteristic (ROC) Curve (AUC) of 0.75 using the imbalanced data set. Analyzing the performance metrics obtained from the training, validation and testing data sets show that the developed network model is well-generalized. Using Bayes' Theorem, an adolescent classified as hypertensive using this created model has a 66.2% likelihood of having hypertension in the Sarawak adolescent population, which has a hypertension prevalence of 30.1%. When the prevalence of hypertension in the Sarawak population was increased to 50%, the developed model could predict an adolescent having hypertension with an 82.0% chance, whereas when the prevalence of hypertension was reduced to 10%, the developed model could only predict true positive hypertension with a 33.6% chance. With the sensitivity of the model increasing to 65% and 90% while retaining a specificity of 91%, the true positivity of an adolescent being hypertension would be 75.7% and 81.2%, respectively, according to Bayes' Theorem. The findings show that simple anthropometric measurements paired with sociodemographic data are feasible to be used to classify hypertension in adolescents using the developed MLP model in Sarawak adolescent population with modest hypertension prevalence. However, a model with higher sensitivity and specificity is required for better positive hypertension predictive value when the prevalence is low. We conclude that the developed classification model could serve as a quick and easy preliminary warning tool for screening high-risk adolescents of developing hypertension.

Hypertension in the hospitalized patient: An update / Hipertensión en el paciente hospitalizado: una actualización

In-patient hypertension is a common problem seen in the hospital setting. Current evidence-based guidelines define and address management of hypertension in ambulatory care and hypertensive emergencies in the hospital setting. However, they lack guidance for the management of acute asymptomatic/non-emergent hypertension in the hospitalised patient. The risk-benefit of treating inpatient asymptomatic hypertension is largely unknown. In this narrative review, we discuss current evidence-based perspectives to address this clinical entity. (AU)

La hipertensión de los pacientes ingresados es un problema frecuente en el ámbito hospitalario. Las directrices actuales basadas en la evidencia definen y abordan la gestión de la hipertensión en la atención ambulatoria y las urgencias hipertensivas en el ámbito hospitalario. Sin embargo, no hay orientaciones sobre la gestión de la hipertensión aguda asintomática/no urgente en el paciente hospitalizado. Se desconoce en gran medida la relación riesgo-beneficio del tratamiento de la hipertensión asintomática en los pacientes hospitalizados. En esta revisión narrativa analizamos las perspectivas actuales basadas en la evidencia para abordar esta entidad clínica. (AU)

Is relative fat mass a better indicator of high blood pressure levels when compared to other anthropometric indexes? / ¿Es la masa grasa relativa un mejor indicador de los niveles de presión arterial alta en comparación con otros índices antropométricos?

Background: relative fat mass (RFM) has been proposed recently, and the effectiveness in relation to other anthropometric indexes already consolidated regarding the predictive capacity of high blood pressure levels (HBPL) has not been investigated yet. Objectives: the objective was to analyze the predictive capacity of RFM for HBPL, and to compare it with others indexes. Methods: a cross-sectional study was conducted with 896 individuals. Weight, height, hip, waist circunference (WC), and neck circunference measurements were evaluated, and RFM, body mass index (BMI), body adiposity index, waist/hip ratio, and waist/height ratio were calculated. Systolic (SBP) and diastolic (DBP) blood pressures were measured on one occasion. Descriptive statistics, Pearson's correlation, a logistic regression model, and the analysis of the receiver operating characteristic (ROC) curves were used. Results: HBPL proportion was higher in men (34.68 %, p < 0.01). There was a positive correlation (p < 0.01) between all anthropometric measurements and SBP and DBP. WC in males (OR, 3.66; p < 0.01) and BMI in females (OR, 5.06; p < 0.01) showed the greatest associations with HBPL. There was no statistical difference (p > 0.05) in the area under the curve. Conclusions: the findings of our study suggest that RFM is not the best index for predicting HBPL, although it has shown positive associations. (AU)

Introducción: se ha propuesto recientemente la medida de la masa grasa relativa (RFM) como predictor de la hipertensión arterial (HBPL), aunque su valor predictivo y la comparación con otros índices antropométricos está por evaluar. Objetivos: el objetivo fue analizar la capacidad predictiva de la RFM para el HBPL y compararlo con otros índices. Métodos:se realizó un estudio transversal con 896 individuos. Se evaluaron las medidas de peso, talla, cadera, circunferencia de la cadera (CC) y circunferencia del cuello, y se calcularon la RFM, el índice de masa corporal (IMC), el índice de adiposidad corporal, la relación cintura/cadera y la relación cintura/estatura. En una ocasión se midió la presión arterial sistólica (PAS) y diastólica (PAD); se utilizaron la estadística descriptiva, la correlación de Pearson, un modelo de regresión logística y el análisis de las curvas Receiver Operating Characteristic (ROC). Resultados: la proporción de HBPL fue mayor en los hombres (34,68 %; p < 0,01). Hubo una correlación positiva (p < 0.01) entre todas las medidas antropométricas y PAS y PAD. La CC en los hombres (OR: 3,66; p < 0,01) y el IMC en las mujeres (OR: 5,06; p < 0,01) mostraron las mayores asociaciones con los HBPL. No hubo diferencia estadística (p > 0.05) en el área bajo la curva. Conclusiones: los hallazgos de nuestro estudio sugieren que la RFM no es el mejor índice para predecir el HBPL, aunque ha mostrado asociaciones positivas. (AU)

Is relative fat mass a better indicator of high blood pressure levels when compared to other anthropometric indexes?

INTRODUCTION: Background: relative fat mass (RFM) has been proposed recently, and the effectiveness in relation to other anthropometric indexes already consolidated regarding the predictive capacity of high blood pressure levels (HBPL) has not been investigated yet. Objectives: the objective was to analyze the predictive capacity of RFM for HBPL, and to compare it with others indexes. Methods: a cross-sectional study was conducted with 896 individuals. Weight, height, hip, waist circunference (WC), and neck circunference measurements were evaluated, and RFM, body mass index (BMI), body adiposity index, waist/hip ratio, and waist/height ratio were calculated. Systolic (SBP) and diastolic (DBP) blood pressures were measured on one occasion. Descriptive statistics, Pearson's correlation, a logistic regression model, and the analysis of the receiver operating characteristic (ROC) curves were used. Results: HBPL proportion was higher in men (34.68 %, p < 0.01). There was a positive correlation (p < 0.01) between all anthropometric measurements and SBP and DBP. WC in males (OR, 3.66; p < 0.01) and BMI in females (OR, 5.06; p < 0.01) showed the greatest associations with HBPL. There was no statistical difference (p > 0.05) in the area under the curve. Conclusions: the findings of our study suggest that RFM is not the best index for predicting HBPL, although it has shown positive associations.

INTRODUCCIÓN: Introducción: se ha propuesto recientemente la medida de la masa grasa relativa (RFM) como predictor de la hipertensión arterial (HBPL), aunque su valor predictivo y la comparación con otros índices antropométricos está por evaluar. Objetivos: el objetivo fue analizar la capacidad predictiva de la RFM para el HBPL y compararlo con otros índices. Métodos: se realizó un estudio transversal con 896 individuos. Se evaluaron las medidas de peso, talla, cadera, circunferencia de la cadera (CC) y circunferencia del cuello, y se calcularon la RFM, el índice de masa corporal (IMC), el índice de adiposidad corporal, la relación cintura/cadera y la relación cintura/estatura. En una ocasión se midió la presión arterial sistólica (PAS) y diastólica (PAD); se utilizaron la estadística descriptiva, la correlación de Pearson, un modelo de regresión logística y el análisis de las curvas Receiver Operating Characteristic (ROC). Resultados: la proporción de HBPL fue mayor en los hombres (34,68 %; p < 0,01). Hubo una correlación positiva (p < 0.01) entre todas las medidas antropométricas y PAS y PAD. La CC en los hombres (OR: 3,66; p < 0,01) y el IMC en las mujeres (OR: 5,06; p < 0,01) mostraron las mayores asociaciones con los HBPL. No hubo diferencia estadística (p > 0.05) en el área bajo la curva. Conclusiones: los hallazgos de nuestro estudio sugieren que la RFM no es el mejor índice para predecir el HBPL, aunque ha mostrado asociaciones positivas.

Pediatric Ambulatory Blood Pressure Classification: The Case for a Change.

In 1997, Soergel et al1 published the first set of normative values for ambulatory blood pressure monitoring (ABPM) in children. Since then, the clinical utility of ABPM has increased dramatically, and now, ABPM is accepted as the standard method to confirm the diagnosis of hypertension in children. Despite significant progress in the field of pediatric ABPM, many important questions remain unanswered. One of the most controversial issues is how to define ambulatory hypertension in children. The purpose of this review is to discuss the limitations of the current pediatric ABPM classification scheme and to provide the justification and rationale for a new classification.

Hypertension in Chronic Kidney Disease (CKD): Diagnosis, Classification, and Therapeutic Targets.

Blood pressure (BP) in the office is often recorded without standardization of the technique of measurement. When office BP measurement is performed with a research-grade methodology, it can inform better therapeutic decisions. The reference-standard method of ambulatory BP monitoring (ABPM) together with the assessment of BP in the office enables the identification of white-coat and masked hypertension, facilitating the stratification of cardiorenal risk. Compared with general population, the prevalence of resistant hypertension is 2- to 3-fold higher among patients with chronic kidney disease (CKD). The use of ABPM is mandatory in order to exclude the white-coat effect, a common cause of pseudoresistance, and confirm the diagnosis of true-resistant hypertension. After the premature termination of Systolic Blood Pressure Intervention Trial due to an impressive cardioprotective benefit of intensive BP-lowering, the 2017 American Heart Association/American College of Cardiology guideline reappraised the definition of hypertension and recommended a tighter BP target of <130/80 mm Hg for the majority of adults with a high cardiovascular risk profile, inclusive of patients with CKD. However, the benefit/risk ratio of intensive BP-lowering in particular subsets of patients with CKD (i.e., those with diabetes or more advanced CKD) continues to be debated. We explore the controversial issue of BP targets in CKD, providing a critical evaluation of the available clinical-trial evidence and guideline recommendations. We argue that the systolic BP target in CKD, if BP is measured correctly, should be <120 mm Hg.

Identifying Relative Changes in Social Risk Factors: An Analytic Approach.

BACKGROUND: Individuals often report concurrent social risk factors such as food insecurity, unstable housing, and transportation barriers. Comparing relative changes between pairs of social risk factors may identify those that are more resistant to change. OBJECTIVE: The objective of this study was to develop a method to describe relative changes in pairs of social risk factors. RESEARCH DESIGN: This was a prospective cohort study. SUBJECTS: Participants in a randomized controlled trial of hypertension care in an Urban Indian Health Organization. MEASURES: We measured 7 social risk factors (housing, transportation, food, clothing, health care, utilities, and debts) at enrollment, 6, and 12 months among 295 participants in the trial. We hypothesized that pairwise comparisons could identify social risk factors that were less likely to change over time. We used conditional odds ratios (ORs) with 95% confidence intervals (CIs) to rank each pair. RESULTS: Food, clothing, health care, utilities, and debts had more changes between 0 and 6 months relative to housing (OR=2.3, 3.4, 4.7, 3.5, and 3.4, respectively; all 95% CI excluded 1.0). These same social risk factors also had more changes between baseline and 6 months relative to transportation (OR=2.8, 3.4, 4.9, 4.7, and 4.1, respectively; all 95% CI excluded 1.0). Changes in housing and transportation risk factors were comparable (OR=0.7, 95% CI: 0.4-1.4). Relative changes between 6 and 12 months were similar. CONCLUSIONS: Housing and transportation exhibited fewer relative changes than other social risk factors and might be more resistant to change. Awareness of the relationships between social risk factors can help define priorities for intervention.

Perinatal outcomes in women with elevated blood pressure and stage 1 hypertension.

BACKGROUND: Hypertension was redefined in 2017 with lower diagnostic thresholds; elevated blood pressure is defined as systolic blood pressure of 120 to 129 mm Hg with diastolic blood pressure of <80 mm Hg and stage 1 hypertension as systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. These guidelines did not include pregnant women. There is limited information on stage 1 hypertension and pregnancy outcomes. OBJECTIVE: This study aimed to determine whether elevated blood pressure and stage 1 hypertension as newly defined by the 2017 American College of Cardiology and the American Heart Association guidelines are associated with an increased risk of hypertensive disorders of pregnancy and other adverse maternal and neonatal outcomes. STUDY DESIGN: In this retrospective cohort study, 18,801 women with singletons from 2013 to 2019 were categorized as normotensive, prehypertensive (elevated blood pressure), stage 1 hypertensive, or chronic hypertensive. Women with ≥2 systolic blood pressures of 120 to 129 mm Hg before 20 weeks' gestation were classified into the elevated blood pressure group. Women with ≥2 systolic blood pressures of 130 to 139 mm Hg or ≥2 diastolic blood pressures of 80 to 89 mm Hg before 20 weeks' gestation were assigned to the stage 1 hypertension group. Women were classified as chronic hypertensives if they had any of the following: ≥2 systolic blood pressure of ≥140 mm Hg or ≥2 diastolic blood pressure of ≥90 mm Hg before 20 weeks' gestation, a history of chronic hypertension, or antihypertensive medication use before 20 weeks' gestation. Women with pregestational diabetes, lupus, or <2 blood pressures before 20 weeks' gestation were excluded. The association of stage 1 hypertension with the risk of developing hypertensive disorders of pregnancy was estimated using multivariate logistic regression controlling for maternal sociodemographic characteristics, gestational weight gain by prepregnancy body mass index, parity, and aspirin use. Secondary outcomes included subgroups of hypertensive disorders (gestational hypertension, preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome), gestational diabetes, placental abruption, intrauterine growth restriction, preterm birth, neonatal intensive care unit admission, stillbirth and neonatal death, and maternal intensive care unit admission. All outcomes were adjusted for potential confounders. RESULTS: Of the 18,801 women, 13,478 (71.7%) were normotensive, 2659 (14.1%) had elevated blood pressure, 1384 (7.4%) were stage 1 hypertensive, and 1280 (6.8%) were chronic hypertensive. A dose-response relationship was observed: the risk of hypertensive disorders of pregnancy increased from 4.2% in normotensive women to 6.7% (adjusted odds ratio, 1.50; 95% confidence interval, 1.26-1.79) in women with elevated blood pressure, to 10.9% (adjusted odds ratio, 2.54; 95% confidence interval, 2.09-3.08) in women with stage 1 hypertension, and 28.4% (adjusted odds ratio, 7.14; 95% confidence interval, 6.06-8.40) in women with chronic hypertension. Compared with normotensive women, women with stage 1 hypertension had an increased risk of neonatal intensive care unit admissions (15.8% vs 13.0%; adjusted odds ratio, 1.21; 95% confidence interval, 1.03-1.42), preterm birth at <37 weeks' gestation (7.2% vs 5.2%; adjusted odds ratio, 1.45; 95% confidence interval, 1.16-1.81), and gestational diabetes (14.8% vs 6.8%; adjusted odds ratio, 2.68; 95% confidence interval, 2.27-3.17). CONCLUSION: Our study demonstrates that elevated blood pressure and stage 1 hypertension, using the 2017 American College of Cardiology and the American Heart Association guideline definition, are associated with increased maternal and neonatal risk. This group of women warrants further investigation to determine whether pregnancy management can be altered to reduce maternal and neonatal morbidity.

Targeted Metabolomics as a Tool in Discriminating Endocrine From Primary Hypertension.

CONTEXT: Identification of patients with endocrine forms of hypertension (EHT) (primary hyperaldosteronism [PA], pheochromocytoma/paraganglioma [PPGL], and Cushing syndrome [CS]) provides the basis to implement individualized therapeutic strategies. Targeted metabolomics (TM) have revealed promising results in profiling cardiovascular diseases and endocrine conditions associated with hypertension. OBJECTIVE: Use TM to identify distinct metabolic patterns between primary hypertension (PHT) and EHT and test its discriminating ability. METHODS: Retrospective analyses of PHT and EHT patients from a European multicenter study (ENSAT-HT). TM was performed on stored blood samples using liquid chromatography mass spectrometry. To identify discriminating metabolites a "classical approach" (CA) (performing a series of univariate and multivariate analyses) and a "machine learning approach" (MLA) (using random forest) were used.The study included 282 adult patients (52% female; mean age 49 years) with proven PHT (n = 59) and EHT (n = 223 with 40 CS, 107 PA, and 76 PPGL), respectively. RESULTS: From 155 metabolites eligible for statistical analyses, 31 were identified discriminating between PHT and EHT using the CA and 27 using the MLA, of which 16 metabolites (C9, C16, C16:1, C18:1, C18:2, arginine, aspartate, glutamate, ornithine, spermidine, lysoPCaC16:0, lysoPCaC20:4, lysoPCaC24:0, PCaeC42:0, SM C18:1, SM C20:2) were found by both approaches. The receiver operating characteristic curve built on the top 15 metabolites from the CA provided an area under the curve (AUC) of 0.86, which was similar to the performance of the 15 metabolites from MLA (AUC 0.83). CONCLUSION: TM identifies distinct metabolic pattern between PHT and EHT providing promising discriminating performance.

Applying SF-6D to measure health state utilities among the middle and old aged patients with hypertension in China.

PURPOSE: Hypertension is a growing public health problem in China; however, little is known about health-related quality of life (HRQoL) especially health state utility (HSU) of patients with hypertension in rural China. This study aimed to examine the HSU as measured by SF-6D and to investigate its associated factors among middle and old aged patients with hypertension in rural China. METHODS: Data were collected from twelve villages in Shandong Province in 2016. SF-36 was administrated to measure HRQoL of middle and old aged patients with hypertension and was got to the SF-6D values using Hong Kong's tariff. Descriptive analyses, such as demographic characteristics, socio-economic status, and utility, were stratified by hypertension classification. Multiple linear regression models were applied to assess the associated factors of HSU. RESULTS: A total of 933 (response rate:86.4%) middle and old aged patients (69.1 ± 8.2 years) with hypertension participated in the study. 39.4% of participants were male; 44.2% had stage I hypertension; 26.4% had stage II and above. The mean score of SF-6D utility score was 0.743 (SD: 0.14, range: 0.32-1.00, median: 0.756, Interquartile range:0.634-0.859). Being female (ß = -0.046), having two or more comorbidities (2 vs. 1 ß = -0.066; > 3 vs. 1 ß = -0.098) and the health expenditure higher than 2000 RMB (2000-3999 vs.< 2000 ß = -0.042; 4000-5999 vs. < 2000 ß = -0.046; > 6000 vs. < 2000 ß = -0.071) were significantly associated with lower SF-6D overall score; while being farmer (ß = 0.032), having high household income (10,000-14,999 vs. < 5000 ß = 0.045; > 15,000 vs. < 5000 ß = 0.064) and having stage I and above hypertension (stage I vs. Normotensive ß = 0.047; stage II vs. Normotensive ß = 0.079; stage III vs. Normotensive ß = 0.095) were significantly associated with higher SF-6D overall score. CONCLUSION: SF-6D was capable to measure quality of life middle and old aged patients with hypertension in China. And multiple factors were demonstrated to be significantly associated with quality of life.

Genetic-Based Hypertension Subtype Identification Using Informative SNPs.

In this work, we proposed a process to select informative genetic variants for identifying clinically meaningful subtypes of hypertensive patients. We studied 575 African American (AA) and 612 Caucasian hypertensive participants enrolled in the Hypertension Genetic Epidemiology Network (HyperGEN) study and analyzed each race-based group separately. All study participants underwent GWAS (Genome-Wide Association Studies) and echocardiography. We applied a variety of statistical methods and filtering criteria, including generalized linear models, F statistics, burden tests, deleterious variant filtering, and others to select the most informative hypertension-related genetic variants. We performed an unsupervised learning algorithm non-negative matrix factorization (NMF) to identify hypertension subtypes with similar genetic characteristics. Kruskal-Wallis tests were used to demonstrate the clinical meaningfulness of genetic-based hypertension subtypes. Two subgroups were identified for both African American and Caucasian HyperGEN participants. In both AAs and Caucasians, indices of cardiac mechanics differed significantly by hypertension subtypes. African Americans tend to have more genetic variants compared to Caucasians; therefore, using genetic information to distinguish the disease subtypes for this group of people is relatively challenging, but we were able to identify two subtypes whose cardiac mechanics have statistically different distributions using the proposed process. The research gives a promising direction in using statistical methods to select genetic information and identify subgroups of diseases, which may inform the development and trial of novel targeted therapies.

Refractory Hypertension and Risks of Adverse Cardiovascular Events and Mortality in Patients With Resistant Hypertension: A Prospective Cohort Study.

Background The long-term prognosis of refractory hypertension (RfHT), defined as failure to control blood pressure (BP) levels despite an antihypertensive treatment with ≥5 medications including a diuretic and mineraloreceptor antagonist, has never been evaluated. Methods and Results In a prospective cohort study with 1576 patients with resistant hypertension, patients were classified as refractory or nonrefractory based on uncontrolled clinic (or office) and ambulatory BPs during the first 2 years of follow-up. Multivariate Cox analyses examined the associations between the diagnosis of RfHT and the occurrence of total cardiovascular events (CVEs), major adverse CVEs, and cardiovascular and all-cause mortality, after adjustments for other risk factors. In total, 135 patients (8.6%) had RfHT by uncontrolled ambulatory BPs and 167 (10.6%) by uncontrolled clinic BPs. Over a median Follow-Up of 8.9 years, 338 total CVEs occurred (288 major adverse CVEs, including 124 myocardial infarctions, and 96 strokes), and 331 patients died, 196 from cardiovascular causes. The diagnosis of RfHT, using either classification by clinic or ambulatory BPs, was associated with significantly higher risks of major adverse CVEs, cardiovascular mortality, and stroke incidence, with hazard ratios varying from 1.54 to 2.14 in relation to patients with resistant nonrefractory hypertension; however, the classification based on ambulatory BPs was better in identifying higher risk patients than the classification based on clinic BP levels. Conclusions Patients with RfHT, particularly when defined by uncontrolled ambulatory BP levels, had higher risks of major adverse CVEs and mortality in relation to patients with resistant but nonrefractory hypertension, supporting the concept of refractory hypertension as a true extreme phenotype of antihypertensive treatment failure.

Metabolic Syndrome in Children and Adolescents: Is There a Universally Accepted Definition? Does it Matter?

The concept of metabolic syndrome (MetS) as a cluster of cardiovascular risk factors (obesity, altered glucose metabolism, dyslipidemia, and hypertension) has been around for more than 30 years. It is considered to be the result of complex interactions between centrally located fat, insulin resistance, subclinical inflammation, and other factors in genetically predisposed individuals. MetS diagnosis in adults has been linked to increased risk for cardiovascular disease (CVD) and type 2 diabetes mellitus (T2D). However, MetS in children and adolescents remains a controversial issue despite the extensive research in the field. It is still uncertain which definition should be used for its diagnosis in this age group, what is the clinical significance of such a diagnosis, and how reliably it can predict the future risk of developing CVD and T2D. Even if a child is diagnosed with MetS, management includes addressing each of the syndrome's components individually with weight loss and lifestyle modifications as the basic approach. Co-morbid conditions, such as nonalcoholic fatty liver disease, obstructive sleep apnea, and polycystic ovary syndrome should also be considered. It seems that MetS in children and adolescents should be used clinically as a conceptual framework for the identification of risk factors clustered around obesity and insulin resistance rather than a syndrome that needs to be diagnosed by measuring absolute "all-or-none" criteria.

AHA/ACC-defined stage 1 hypertensive adults do not display cutaneous microvascular endothelial dysfunction.

In 2017, the American Heart Association (AHA) and American College of Cardiology (ACC) redefined stage 1 hypertension to systolic blood pressure (BP) 130-139 mmHg or diastolic BP 80-89 mmHg; however, the degree to which microvascular endothelial dysfunction is evident in adults with stage 1 hypertension remains equivocal. We tested the hypotheses that cutaneous microvascular endothelial dysfunction would be present in adults with stage 1 hypertension (HTN1) compared with normotensive adults (NTN; BP <120/<80 mmHg) but would be less severe compared with adults with stage 2 hypertension (HTN2; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) and that this graded impairment would be mediated by reductions in nitric oxide (NO)-dependent dilation. This retrospective analysis included 20 NTN (5 men; 45-64 yr; BP 94-114/60-70 mmHg), 22 HTN1 (11 men; 40-74 yr; BP 110-134/70-88 mmHg), and 44 HTN2 (27 men; 40-74 yr; BP 128-180/80-110 mmHg). BP and nocturnal dipping status were also assessed using 24-h ambulatory BP monitoring. Red cell flux (laser Doppler flowmetry) was measured during intradermal microdialysis perfusion of acetylcholine (ACh; 10-10 to 10-1M) alone and concurrently with the nonspecific nitric oxide (NO) synthase inhibitor NG-nitro-l-arginine methyl ester (l-NAME; 15 mM). ACh-induced dilation was impaired in HTN2 (P < 0.01), but not in HTN1 (P = 0.85), compared with NTN. Furthermore, reductions in NO-dependent dilation were evident in HTN2 (P < 0.01) but not in HTN1 (P = 0.76). Regardless of BP, endothelium-dependent dilation was impaired in nondippers (nighttime drop in systolic BP <10%) compared with dippers (nighttime drop in systolic BP ≥10%, P < 0.05). In conclusion, functional impairments in NO-mediated endothelium-dependent dilation were not evident in HTN1. However, regardless of BP classification, the lack of a nocturnal dip in BP was associated with blunted endothelium-dependent dilation.NEW & NOTEWORTHY This is the first study to pharmacologically assess the mechanistic regulation of endothelial function in adults with hypertension, classified according to the 2017 clinical guidelines set for by the American Heart Association (AHA) and American College of Cardiology (ACC). Compared with that in normotensive adults, nitric oxide-mediated endothelium-dependent dilation is impaired in adults with stage 2, but not stage 1, hypertension. Adults lacking a nighttime dip in blood pressure demonstrated reductions in endothelium-dependent dilation.

Vascular Endothelial Function in Midlife/Older Adults Classified According to 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines.

Background Impaired endothelial function is thought to contribute to the increased cardiovascular risk associated with above-normal blood pressure (BP). However, the association between endothelial function and BP classified by 2017 American College of Cardiology/American Heart Association guidelines is unknown. Our objective was to determine if endothelial function decreases in midlife/older adults across the 2017 American College of Cardiology/American Heart Association guidelines BP classifications and identify associated mechanisms of action. Methods and Results A retrospective analysis of endothelial function (brachial artery flow-mediated dilation) from 988 midlife/older adults (aged 50+ years) stratified by BP status (normal BP; elevated BP; stage 1 hypertension; stage 2 hypertension) was performed. Endothelium-independent dilation (sublingual nitroglycerin), reactive oxygen species-mediated suppression of endothelial function (∆brachial artery flow-mediated dilation with vitamin C infusion), and endothelial cell and plasma markers of oxidative stress and inflammation were assessed in subgroups. Compared with normal BP (n=411), brachial artery flow-mediated dilation was 12% (P=0.04), 15% (P<0.01) and 20% (P<0.01) lower with elevated BP (n=173), stage 1 hypertension (n=248) and stage 2 hypertension (n=156), respectively, whereas endothelium-independent dilation did not differ (P=0.14). Vitamin C infusion increased brachial artery flow-mediated dilation in those with above-normal BP (P≤0.02) but not normal BP (P=0.11). Endothelial cell p47phox (P<0.01), a marker of superoxide/reactive oxygen species-generating nicotinamide adenine dinucleotide phosphate oxidase, and circulating interleukin-6 concentrations (P=0.01) were higher in individuals with above-normal BP. Conclusions Vascular endothelial function is progressively impaired with increasing BP in otherwise healthy adults classified by 2017 American College of Cardiology/American Heart Association guidelines. Impaired endothelial function with above-normal BP is mediated by excessive reactive oxygen species signaling associated with increased endothelial expression of nicotinamide adenine dinucleotide phosphate oxidase and circulating interleukin-6.

Conicity index in people with hypertension followed in the Brazil's Family Health Strategy.

OBJECTIVES: to analyze the conicity index in people with hypertension followed in the Brazil's Family Health Strategy. METHODS: cross-sectional study conducted in a medium-sized municipality located in the state of Paraná. Data collection took place in the first semester of 2016. using an adapted and validated instrument. which addresses attributes of Primary Health Care. Sociodemographic and anthropometric variables and blood pressure were used in the study. The analysis of variance and linear regression was used to analyze the variables. RESULTS: a total of 417 people participated in the study. most were women. elderly. married. with less than eight years of education and retired. Conicity index was prevalent in most of the study population. being significantly associated with the group of people with inadequate blood pressure control and high anthropometric parameters. CONCLUSIONS: most of the study participants had altered conicity index. especially those with inadequate blood pressure control.

Blood Pressure Classification of 2017 Associated With Cardiovascular Disease and Mortality in Young Chinese Adults.

The American College of Cardiology/American Heart Association introduced new guidelines for blood pressure (BP) classification in 2017. We explored associations between the newly defined categories and eventual cardiovascular disease (CVD) events, stroke, and all-cause mortality in young Chinese adults. In the community-based Kailuan Study, 16 006 participants aged 18 to 40 years and examined at baseline in 2006/2007 underwent 2-yearly follow-up examinations up to 2016 to 2017. Taking the highest BP reading recorded by manual sphygmomanometry at baseline in 2006 to 2007, we categorized the BP according to the new guidelines. Outcome parameters were CVD events, stroke, and all-cause mortality. During follow-up (mean: 10.9±0.63 years), we observed 458 events (CVD, 167; stroke, 119; and all-cause death, 172). After multivariable adjustment, hazard ratios for CVD events were for elevated BP 0.80 (95% CI, 0.28-2.30), stage 1 hypertension 1.82 (95% CI, 1.12-2.94), and stage 2 hypertension 3.54 (95% CI, 2.18-5.77) versus normal BP. Similar results were obtained for stroke and all-cause death. In Cox regression analysis with BP category entered as time-dependent covariate, stage 1 hypertension was not associated with increased risk (P>0.10). In the subgroup of individuals taking antihypertensive medication during follow-up, none of the BP categories was significantly associated with the incidence of CVD events. During a mean follow-up of 10.9 years, the newly defined category of stage 1 hypertension in young untreated Chinese adults aged <40 years at baseline was associated with an increased risk for CVD, stroke, and all-cause mortality. This increased risk occurred, however, after progression to stage 2 hypertension. The data may help validating the new BP classification system for young adult Chinese.

The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study.

BACKGROUND: Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease. OBJECTIVE: To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure. DESIGN: Cross-sectional study. SETTING: 4 U.S. academic medical centers. PARTICIPANTS: Participants with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408). MEASUREMENTS: Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 µg/24 h. RESULTS: Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 µg/24 h (95% CI, 5.2 to 7.7 µg/24 h) in normotension, 7.3 µg/24 h (CI, 5.6 to 8.9 µg/24 h) in stage 1 hypertension, 9.5 µg/24 h (CI, 8.2 to 10.8 µg/24 h) in stage 2 hypertension, and 14.6 µg/24 h (CI, 12.9 to 16.2 µg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone-renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism. LIMITATION: Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics. CONCLUSION: The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of "essential" hypertension. PRIMARY FUNDING SOURCE: National Institutes of Health.

Hipertensión arterial en el paciente quirúrgico. Adecuación de la medicación y criterios de suspensión / Arterial hypertension in the surgical patient. Medication adequacy and suspension criteria

La hipertensión arterial (HTA) es un factor de riesgo modificable para las enfermedades cardiovasculares, que puede tener un impacto en las complicaciones perioperatorias, en función del daño orgánico que sufre el paciente. El manejo perioperatorio del tratamiento farmacológico de la hipertensión arterial es un pilar fundamental en la valoración preanestésica previa a cualquier intervención. No parece razonable retrasar la cirugía únicamente por valores de la presión arterial (PA), aunque en pacientes con PA > 180/110mmHg la decisión de realizar una intervención quirúrgica electiva debe ser valorada cuidadosamente

Arterial hypertension (AHT) is a modifiable risk factor for cardiovascular diseases, which may have an impact on perioperative complications, depending on the organ damage suffered by the patient. The perioperative management of treatment of arterial hypertension, is a mainstay in the preoperative assesment prior to any intervention. It doesn't seem reasonable to delay surgery solely due to blood pressure values, although for patients with BP > 180/110mmHg, the decision to perform scheduled surgeries should be carefully assessed