Secondary hypertension: evaluation and management.

PURPOSE OF REVIEW: Hypertension (HTN) that can be attributed to a particular source is known as secondary HTN (SH). Often, SH is difficult to control and thus referred to as resistant HTN, although the two terms are not mutually exclusive. RECENT FINDINGS: A common theme across several contributors to SH are coactivation of the sympathetic drive and hormonal changes, independent of hormonal axis activation. The key to effective management of SH is early recognition and treatment to avoid catastrophic cardiovascular disease effects and mortality. SUMMARY: This review article provides a contemporary summary of the conditions associated with SH and briefly reviews diagnostics and management.

Cardiorenal Protection With the Newer Antidiabetic Agents in Patients With Diabetes and Chronic Kidney Disease: A Scientific Statement From the American Heart Association.

Chronic kidney disease (CKD) with type 2 diabetes (T2D) is a major public health problem, resulting in significant cardiovascular and kidney adverse outcomes worldwide. Despite the widespread use of standard-of-care therapies for CKD with T2D over the past few decades, rates of progression to end-stage kidney disease remain high with no beneficial impact on its accompanying burden of cardiovascular disease. The advent of the newer classes of antihyperglycemic agents, including SGLT2 (sodium glucose cotransporter 2) inhibitors and GLP-1 (glucagon-like peptide-1) receptor agonists, has changed the landscape of therapeutic options for patients with CKD with T2D, with demonstration of significant reductions in cardiovascular adverse events and progression to end-stage kidney disease. Several potential mechanisms exist through which these beneficial effects are achieved in both drug classes, which may be independent of their antihyperglycemic effects. This scientific statement summarizes the current literature on the cardiorenal protective effects with SGLT2 inhibitors and GLP-1 receptor agonists in patients with CKD and T2D. It reviews potential mechanistic pathways that may drive these benefits and summarizes the literature on adverse effects in patients with CKD and T2D at risk for or with established cardiovascular disease. Last, it provides practical guidance on a proposed collaborative care model bridging cardiologists, nephrologists, endocrinologists, and primary care physicians to facilitate the prompt and appropriate integration of these therapeutic classes in the management of patients with T2D and CKD.

Bariatric Surgery in Patients with Obesity and Ventricular Assist Devices Considered for Heart Transplantation: Systematic Review and Individual Participant Data Meta-analysis.

BACKGROUND: Class II obesity (body mass index BMI ≥35 kg/m2) is a contraindication to heart transplantation (HT). Although few single-center studies (case reports/series and small cohorts) have reported promising outcomes of bariatric surgery (BS) in patients with obesity and ventricular assist devices, low sample sizes have made their analysis and interpretation challenging. METHODS AND RESULTS: We conducted a systematic search in ClinicalTrials.gov, Cochrane, Embase, PubMed, Google Scholar, and most relevant bariatric and heart failure journals. We extracted baseline and outcome individual participant data for every ventricular assist device patient undergoing BS with reported postoperative BMI and their respective timepoints when BMI data were measured. Fourteen references with 29 patients were included. The mean age was 41.9 ± 12.2 years, 82.8% underwent laparoscopic sleeve gastrectomy, and 39.3% had reported perioperative adverse events. The mean pre-BS BMI was 45.5 ± 6.6 kg/m2 and decreased significantly during follow-up (rho -0.671; P< .00001). Among 23 patients with documented listing status, 78.3% were listed for HT. Thirteen of 28 patients (46.4%) underwent HT at 14.4 ± 7.0 months. There were no reported deaths for the HT-free 1-year period. Median follow-up was 24 months (interquartile range, 12-30 months). Twenty-two of 28 patients (78.6%) achieved the composite outcome (BMI of<35 kg/m2/HT/listing for HT/myocardial recovery) at 11 months (interquartile range, 3-17 months). Patients with a BMI<45 kg/m2 had a higher chance of achieving the composite outcome (P< .003). CONCLUSIONS: BS may help patients with obesity and ventricular assist devices to lose a significant amount of weight and improve their candidacy for HT or even achieve myocardial recovery.

New aspects in the management of hypertension in the digital era.

PURPOSE OF REVIEW: Hypertension (HTN) is the most common chronic disease impacting over half the US adult population. Our current office-based model of care is failing in its ability to control blood pressure (BP) as only 44% of adult US hypertensives are achieving minimal levels of BP control (< 140/90 mmHg), leading to high rates of preventable cardiovascular events and death. RECENT FINDINGS: Reengineering care delivery using a fully digital platform combined with a dedicated team-based approach to HTN management has demonstrated superior BP control rates, very high levels patient acceptance, and the ability to better diagnose and treat masked and white coat HTN. SUMMARY: A digital medicine program in the clinical care setting can be an effective and convenient mechanism of delivering HTN management, outperforming traditional office-based care, and is well accepted by patients.

Interactions of hypertension, obesity, left ventricular hypertrophy, and heart failure.

PURPOSE OF REVIEW: Hypertension (HTN) and obesity are major risk factors for cardiac remodeling and dysfunction, leading to left ventricular hypertrophy (LVH) and heart failure (HF). In this review, we discuss the complex mechanisms and effects of HTN and obesity, and their treatments in LVH, ventricular function, and HF. RECENT FINDINGS: Obesity and HTN impact the heart through overlapping neurohormonal pathways. However, the relationship between obesity and cardiomyopathy is more complex, and additional metabolic and hemodynamic pathways seem to contribute to cardiac dysfunction in these patients. Weight loss and blood pressure (BP) control help to prevent and reverse at least some of the damage caused by obesity and HTN even beyond what would be expected from solely the hemodynamic changes. SUMMARY: Obesity and HTN cause maladaptive changes in the heart that can lead to LVH and HF. Weight loss and BP control help to, at least partially, reverse some of these changes and improve clinical outcomes in patients with HF.

Prognostic value of cardiopulmonary exercise test after heart transplantation.

BACKGROUND: The clinical utility of cardiopulmonary exercise testing (CPET) has not been extensively studied yet in heart transplantation (HTX) patients. OBJECTIVE: To analyze the predictive value of the CPET on hospitalizations and mortality in HTX recipients. METHODS: A retrospective cohort was performed from a secondary database. Patients > 18 years with HTX who underwent a CPET between 3 and 12 months after transplantation were included. Time to the first primary endpoint (HTX-related hospitalization) was analyzed and adjusted using Cox proportional hazards regression model. RESULTS: A total of 122 patients (mean age 50.1 years, 77.0% men) were included. Fifty-seven patients (46.7%) had the primary endpoint. Peak VO2 (HR .95; CI 95% .90-.99, P = .03), oxygen pulse (HR .57; CI 95% .34-.96, P = .03) and predicted VO2 (HR .97; CI 95% .96-.99, P = .002) were associated with the endpoint. We did not find a significant association between the other variables and the outcome. CONCLUSION: In HTX recipients, peak VO2 , oxygen pulse, and predicted VO2 were independently associated with hospitalizations at follow up.

The Impact of Obesity in Heart Failure.

Obesity has reached worldwide epidemic proportions, adversely impacting health on a global scale. Overweight and obesity adversely impact cardiac structure and function, affecting systolic and diastolic ventricular function. Studies and meta-analyses have documented an obesity paradox in large heart failure cohorts, where overweight and obese individuals with established heart failure have a better short- and medium-term prognosis compared with lean patients; this relationship is strongly impacted by level of cardiorespiratory fitness. There are implications for therapies aimed at increasing lean and muscle mass, and weight loss, for the prevention and treatment of compared with in patients with concomitant obesity.

Management of resistant hypertension.

PURPOSE OF REVIEW: Resistant hypertension is defined as blood pressure above patient goal despite three different antihypertensive agents at optimal dose including a diuretic. Resistant hypertension is increasingly common issue in clinical practice and it is a major risk factor of cardiovascular disease. RECENT FINDINGS: All patients with resistant hypertension should be evaluated for possible correctable factors associated with pseudoresistance, such as poor adherence, white coat hypertension and suboptimal measurement of blood pressure. In patients with resistant hypertension, thiazide diuretics should be considered as one of the first agents, in addition to mineralocorticoids receptor antagonist. SUMMARY: Resistant hypertension can be associated with secondary cause that is why treatment can be challenging and should always include lifestyle modification and evaluation for possible secondary causes, in addition to adding a fourth agent or considering newer interventional therapies, such as renal denervation or other device-based options.

Emerging Therapy in Hypertension.

PURPOSE OF THE REVIEW: Pharmacology remains the mainstay of treatment for hypertension across the globe. In what may seem like a well-trodden field, there are actually an exciting array of new pathways for the treatment of hypertension on the horizon. This review seeks to discuss the most recent research in ongoing areas of drug development in the field of hypertension. RECENT FINDINGS: Novel areas of research in the field of hypertension pharmacology include central nervous system regulators, peripheral noradrenergic inhibitors, gastrointestinal sodium modulators, and a counter-regulatory arm of the renin-angiotensin-aldosterone system. This review discusses these pathways in a look into the current status of emerging pharmacological therapies for hypertension.

Future pharmacological therapy in hypertension.

PURPOSE OF REVIEW: Hypertension (HTN) is a widespread and growing disease, with medication intolerance and side-effect present among many. To address these obstacles novel pharmacotherapy is an active area of drug development. This review seeks to explore future drug therapy for HTN in the preclinical and clinical arenas. RECENT FINDINGS: The future of pharmacological therapy in HTN consists of revisiting old pathways to find new targets and exploring wholly new approaches to provide additional avenues of treatment. In this review, we discuss the current status of the most recent drug therapy in HTN. New developments in well trod areas include novel mineralocorticoid antagonists, aldosterone synthase inhibitors, aminopeptidase-A inhibitors, natriuretic peptide receptor agonists, or the counter-regulatory angiotensin converting enzyme 2/angiotensin (Ang) (1-7)/Mas receptor axis. Neprilysin inhibitors popularized for heart failure may also still hold HTN potential. Finally, we examine unique systems in development never before used in HTN such as Na/H exchange inhibitors, vasoactive intestinal peptide agonists, and dopamine beta hydroxylase inhibitors. SUMMARY: A concise review of future directions of HTN pharmacotherapy.

Improving Provider Adherence to Guideline Recommendations in Heart Failure.

PURPOSE OF REVIEW: Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons. RECENT FINDINGS: Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy. Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.

Coenzyme Q10 and Utility in Heart Failure: Just Another Supplement?

Heart failure affects 5.1 million people in the USA annually. It accounts for a frequent cause of hospitalizations and disability. Patients with congestive heart failure have lower plasma levels of CoQ10, which is an independent predictor of mortality in this patient population. It has been hypothesized that a deficiency of CoQ10 can play a role in the development and worsening of heart failure, and that oral supplementation can possibly improve symptoms and survival in these patients. Based on previous small studies and meta-analyses, the use of CoQ10 in heart failure suggested an improvement ejection fraction, stroke volume, cardiac output, and cardiac index with CoQ10 supplementation, however most of these small studies appeared to be underpowered to result in any significant data. The results of the recent Q-SYMBIO trial demonstrated an improvement in heart failure symptoms with a significant reduction in major adverse cardiovascular events and mortality.

Risks and benefits of weight loss in heart failure.

Obesity adversely affects many cardiovascular disease (CVD) risk factors and increases the risk of most CVD, including heart failure (HF). HF is markedly increased in the setting of obesity. However, obese patients with HF have a better prognosis than lean patients with HF, which has been termed the obesity paradox. Therefore, the role of weight loss, which generally improves ventricular structure, systolic and diastolic ventricular function, and New York Heart Association functional class in HF, remains controversial. This article discusses the pros and cons of weight loss and differentiates purposeful (healthy) from nonpurposeful (unhealthy) weight loss.

Clevidipine in acute heart failure: Results of the A Study of Blood Pressure Control in Acute Heart Failure-A Pilot Study (PRONTO).

BACKGROUND: Rapid blood pressure (BP) control improves dyspnea in hypertensive acute heart failure (AHF). Although effective antihypertensives, calcium-channel blockers are poorly studied in AHF. Clevidipine is a rapidly acting, arterial selective intravenous calcium-channel blocker. Our purpose was to determine the efficacy and safety of clevidipine vs standard-of-care intravenous antihypertensive therapy (SOC) in hypertensive AHF. METHODS: This is a randomized, open-label, active control study of clevidipine vs SOC in emergency department patients with AHF having systolic BP ≥160 mm Hg and dyspnea ≥50 on a 100-mm visual analog scale (VAS). Coprimary end points were median time to, and percent attaining, a systolic BP within a prespecified target BP range (TBPR) at 30 minutes. Dyspnea reduction was the main secondary end point. RESULTS: Of 104 patients (mean [SD] age 61 [14.9] years, 52% female, 80% African American), 51 received clevidipine and 53 received SOC. Baseline mean (SD) systolic BP and VAS dyspnea were 186.5 (23.4) mm Hg and 64.8 (19.6) mm. More clevidipine patients (71%) reached TBPR than did those receiving SOC (37%; P = .002), and clevidipine was faster to TBPR (P = .0006). At 45 minutes, clevidipine patients had greater mean (SD) VAS dyspnea improvement than did SOC patients (-37 [20.9] vs -28 mm [21.7], P = .02), a difference that remained significant up to 3 hours. Serious adverse events (24% vs 19%) and 30-day mortality (3 vs 2) were similar between clevedipine and SOC, respectively, and there were no deaths during study drug administration. CONCLUSIONS: In hypertensive AHF, clevidipine safely and rapidly reduces BP and improves dyspnea more effectively than SOC.

Obesity paradox, cachexia, frailty, and heart failure.

Overweight and obesity adversely affect cardiovascular (CV) risk factors and CV structure and function, and lead to a marked increase in the risk of developing heart failure (HF). Despite this, an obesity paradox exists, wherein those who are overweight and obese with HF have a better prognosis than their leaner counterparts, and the underweight, frail, and cachectic have a particularly poor prognosis. In light of this, the potential benefits of exercise training and efforts to improve cardiorespiratory fitness, as well as the potential for weight reduction, especially in severely obese patients with HF, are discussed.

State of the art on angiotensin-neprilysin inhibitors.

Angiotensin receptor neprilysin inhibitor (ARNI) decreases renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous systems (SNS) activity promoting vasodilation, decreasing myocardial hypertrophy and fibrosis. Beyond the SNS, RAAS and natriuretic peptide systems, ARNI results in increased circulatory and myocardial nitric oxide levels activating cGMP and protein kinase G, which reduces oxidative stress, myocyte hypertrophy, cell death and has anti-thrombotic effects. ARNIs have a class I indication by heart failure (HF) guidelines in HFrEF patients with NYHA class II to III symptoms. Beyond HFrEF, the use of ARNIs has also been expanded to other clinical settings including HF with preserved ejection fraction (EF, HFpEF), acute HF, advanced HF, hypertension, arrhythmias and chronic kidney disease. This paper reviews the clinical benefits of ARNIs in both HF and the aforementioned cardiovascular conditions. We also discuss the combined use of ARNI with SGLT2i and their potential synergistic benefits on cardiovascular outcomes.