Hypertensive crisis: an update on clinical approach and management.

PubMed

Ipek, Emrah; Oktay, Ahmet Afşin; Krim, Selim R

2017-07-01

Here, we review current concepts on hypertensive crisis (HTN-C) with a focus on epidemiology, causes, pathophysiology and prognosis. We also offer a practical approach to the management of HTN-C. HTN-C is characterized by a severe and abrupt increase in blood pressure (BP) with impending or progressive acute end-organ damage (EOD). HTN-C can be divided into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U) based on the presence or absence of acute EOD, respectively. Recent retrospective studies have demonstrated that emergency department (ED) referrals from an outpatient clinic or rapid BP-lowering strategies in the ED do not lead to improved outcomes in patients with HTN-U. HTN-C can be a de-novo manifestation or a complication of essential or secondary HTN. The presence of acute EOD is a major poor prognostic indicator in HTN-C. The main objectives of the management of HTN-C are distinction of HTN-E from HTN-U and appropriate risk stratification, prevention or regression of acute EOD due to severely elevated BP, prevention of recurrence of HTN-C with an effective long-term management plan and avoidance of rapid lowering of BP except in some special circumstances. The majority of patients with asymptomatic HTN-U can be safely managed in the outpatient setting without exposing them to the risks of aggressive BP lowering. However, patients with HTN-E require hospitalization, prompt treatment and close monitoring.

Joint UK societies' 2014 consensus statement on renal denervation for resistant hypertension.

PubMed

Lobo, Melvin D; de Belder, Mark A; Cleveland, Trevor; Collier, David; Dasgupta, Indranil; Deanfield, John; Kapil, Vikas; Knight, Charles; Matson, Matthew; Moss, Jonathan; Paton, Julian F R; Poulter, Neil; Simpson, Iain; Williams, Bryan; Caulfield, Mark J

2015-01-01

Resistant hypertension continues to pose a major challenge to clinicians worldwide and has serious implications for patients who are at increased risk of cardiovascular morbidity and mortality with this diagnosis. Pharmacological therapy for resistant hypertension follows guidelines-based regimens although there is surprisingly scant evidence for beneficial outcomes using additional drug treatment after three antihypertensives have failed to achieve target blood pressure. Recently there has been considerable interest in the use of endoluminal renal denervation as an interventional technique to achieve renal nerve ablation and lower blood pressure. Although initial clinical trials of renal denervation in patients with resistant hypertension demonstrated encouraging office blood pressure reduction, a large randomised control trial (Symplicity HTN-3) with a sham-control limb, failed to meet its primary efficacy end point. The trial however was subject to a number of flaws which must be taken into consideration in interpreting the final results. Moreover a substantial body of evidence from non-randomised smaller trials does suggest that renal denervation may have an important role in the management of hypertension and other disease states characterised by overactivation of the sympathetic nervous system. The Joint UK Societies does not recommend the use of renal denervation for treatment of resistant hypertension in routine clinical practice but remains committed to supporting research activity in this field. A number of research strategies are identified and much that can be improved upon to ensure better design and conduct of future randomised studies. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Obesity-Associated Hypertension: the Upcoming Phenotype in African-American Women.

PubMed

Samson, Rohan; Qi, Andrea; Jaiswal, Abhishek; Le Jemtel, Thierry H; Oparil, Suzanne

2017-05-01

The present obesity epidemic particularly affects African-American women. Whether the obesity epidemic will alter the hypertension phenotype in African-American women is entertained. The prevalence of morbid obesity is steadily increasing in African-American women, who are prone to developing hypertension (HTN) even in the absence of obesity. The obesity-associated hypertension phenotype is characterized by marked sympathetic nervous system activation and resistance/refractoriness to antihypertensive therapy. Weight loss achieved through lifestyle interventions and pharmacotherapy has a modest and rarely sustained antihypertensive effect. In contrast, bariatric surgery has a sustained antihypertensive effect, as evidenced by normalization of hypertension or lessening of antihypertensive therapy. The prevalence of HTN and its obesity-associated phenotype is likely to increase in African-American women over the next decades. Obese African-American women may be increasingly referred for bariatric surgery when hypertension remains uncontrolled despite lifestyle interventions and pharmacological therapy for weight loss and blood pressure (BP) control.

Diabetes mellitus and hypertension: a dual threat.

PubMed

Oktay, Ahmet Afşin; Akturk, Halis Kaan; Jahangir, Eiman

2016-07-01

The following is a review of the current concepts on the relationship between hypertension (HTN) and diabetes mellitus with a focus on the epidemiology and cardiovascular prognostic implications of coexistent HTN and diabetes mellitus, shared mechanisms underlying both conditions and pathophysiology of increased risk of cardiovascular disease, treatment of HTN in individuals with diabetes mellitus, and effects of anti-diabetic medications on blood pressure (BP). Diabetes mellitus and HTN often coexist in the same individual. They share numerous risk factors and underlying pathophysiologic mechanisms, most important of which are insulin resistance and inappropriate activation of the rennin-angiotensin-aldosterone system. Recently updated guidelines recommend a BP goal of 140/90 mmHg in most individuals with diabetes mellitus. A new class of anti-diabetic medications, sodium-glucose co-transporter 2 inhibitors, has shown favorable effects on BP. HTN affects the majority of individuals with diabetes mellitus. Coexistence of diabetes mellitus and HTN, especially if BP is not well controlled, dramatically increases the risk of morbidity and mortality from cardiovascular disease. BP control is an essential part of management of patients with diabetes mellitus, because it is one of the most effective ways to prevent vascular complications and death.

Pathophysiology and Potential Non-Pharmacologic Treatments of Obesity or Kidney Disease Associated Refractory Hypertension.

PubMed

Le Jemtel, Thierry H; Richardson, William; Samson, Rohan; Jaiswal, Abhishek; Oparil, Suzanne

2017-02-01

The review assesses the role of non-pharmacologic therapy for obesity and chronic kidney disease (CKD) associated refractory hypertension (rf HTN). Hypertensive patients with markedly heightened sympathetic nervous system (SNS) activity are prone to develop refractory hypertension (rfHTN). Patients with obesity and chronic kidney disease (CKD)-associated HTN have particularly heightened SNS activity and are at high risk of rfHTN. The role of bariatric surgery is increasingly recognized in treatment of obesity. Current evidence advocates for a greater role of bariatric surgery in the management of obesity-associated HTN. In contrast, renal denervation does not appear have a role in the management of obesity or CKD-associated HTN. The role of baroreflex activation as adjunctive anti-hypertensive therapy remains to be defined.

Current Status of Renal Denervation in Hypertension.

PubMed

Briasoulis, Alexander; Bakris, George L

2016-11-01

Over the past 7 years, prospective cohorts and small randomized controlled studies showed that renal denervation therapy (RDN) in patients with resistant hypertension is safe but associated with variable effects on BP which are not substantially better than medical therapy alone. The failure of the most rigorously designed randomized sham-control study, SYMPLICITY HTN-3, to meet the efficacy endpoints has raised several methodological concerns. However, recently reported studies and ongoing trials with improved procedural characteristics, identification of patients with true treatment-resistant hypertension on appropriate antihypertensive regimens further explore potential benefits of RDN. The scope of this review is to summarize evidence from currently completed studies on RDN and discuss future perspectives of RDN therapy in patients with resistant hypertension.

Hypertension Update: Resistant Hypertension.

PubMed

Viera, Anthony J

2018-06-01

Resistant hypertension is a blood pressure (BP) level that remains above the goal level despite adherence to at least three appropriately dosed antihypertensive drugs of different classes, one of which is a diuretic. Evaluation of suspected resistant hypertension starts with confirming adherence to the drug regimen. White coat hypertension should be ruled out with out-of-office BP level measurements, ideally using 24-hour ambulatory BP monitoring. Obesity, significant alcohol intake, and interfering drugs and other substances can contribute to resistant hypertension. Lifestyle modifications, including exercise and dietary sodium restriction, can be useful in management. Resistant hypertension may be due to secondary etiologies (eg, parenchymal kidney disease, obstructive sleep apnea, hyperaldosteronism). Adequate diuretic treatment is a key part of therapy. In addition to a diuretic, patients with resistant hypertension should take a dihydropyridine calcium channel blocker and an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker. Spironolactone is an effective fourth drug. Other drug options include a beta blocker, a long-acting nondihydropyridine calcium channel blocker, or clonidine or guanfacine. When the BP level is not controlled despite adherence to a four-drug regimen, referral to a hypertension subspecialist should be considered. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

Renal denervation for treatment of drug-resistant hypertension.

PubMed

Esler, Murray

2015-02-01

At the seven-year anniversary of the first catheter-based renal denervation procedure for resistant hypertension, it is timely to reflect on the past, present, and future of the development and clinical application of this treatment. Unresolved procedural and technical questions are central: How much renal denervation is optimal? How can this level of denervation be achieved? What test for denervation can be applied in renal denervation trials? Will renal denervation show a "class effect," with the different energy forms now used for renal nerve ablation producing equivalent blood pressure lowering? When I have assessed renal denervation efficacy, using measurements of the spillover of norepinephrine from the renal sympathetic nerves to plasma, the only test validated to this point, denervation was found to be incomplete and non-uniform between patients. It is probable that the degree of denervation has commonly been suboptimal in renal denervation trials; this criticism applying with special force to the Symplicity HTN-3 trial, where the proceduralists, although expert interventional cardiologists, had no prior experience with the renal denervation technique. Recently presented results from the Symplicity HTN-3 trial confirm that renal denervation was not achieved effectively or consistently. Given this, and other difficulties in the execution of the trial relating to drug adherence, an idea mooted is that the US pivotal trial of the future may be in younger, untreated patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Prevalence, Awareness, Treatment, and Control of Hypertension Among Arab Americans

PubMed Central

Tailakh, Ayman; Mentes, Janet C.; Morisky, Donald E.; Pike, Nancy A.; Phillips, Linda R.; Evangelista, Lorraine S.

2015-01-01

Background Hypertension (HTN) is a major risk factor for heart disease, which is the leading cause of death in the United States. Hypertension detection and blood pressure (BP) control are critically important for reducing the risk of myocardial infarction and strokes. Although there are more than 3.5 million Arab Americans in the United States, there are no national or regional data on HTN prevalence among Arab Americans. Objective This study aims to estimate the prevalence of HTN in a community sample of Arab Americans; assess levels of awareness, treatment, and control in hypertensive patients; and describe and compare lifestyle behaviors (eg, physical activity, nutrition, and weight control). Methods In this cross-sectional, descriptive study, 126 participants completed a self-administered questionnaire to measure physical activity, nutrition, and medical history. Height and weight were measured. Three BP measurements were obtained at 60-second intervals after resting for 5 minutes. Hypertension was defined as a mean systolic BP of 140 mm Hg or higher, or a diastolic BP 90 mm Hg or higher, and/or taking antihypertensive medications. Results Overall, 36.5% of participants had HTN and 39.7% had pre-HTN. Among hypertensive participants, only 67.4% were aware of their high BP, and 52.2% were taking antihypertensive medication. Among those taking medication, 46% had controlled BP. The prevalence of HTN was higher in men than in women (45.9% and 23.2%, respectively; P = .029) and increased with age (P = .01). Hypertensive participants also had higher body mass index (mean, 31.55 kg/m2) compared with normotensive participants (mean, 28.37 kg/m2; P = .01). Conclusion Our results indicate that HTN and pre-HTN are highly prevalent in Arab Americans. Hypertension awareness and control rates were inadequate and low compared with national data. These results emphasize the urgent need to develop public health strategies to improve the prevention, detection, and treatment of

Refractory Hypertension Is not Attributable to Intravascular Fluid Retention as Determined by Intracardiac Volumes.

PubMed

Velasco, Alejandro; Siddiqui, Mohammed; Kreps, Eric; Kolakalapudi, Pavani; Dudenbostel, Tanja; Arora, Garima; Judd, Eric K; Prabhu, Sumanth D; Lloyd, Steven G; Oparil, Suzanne; Calhoun, David A

2018-06-04

Refractory hypertension (RfHTN) is an extreme phenotype of antihypertensive treatment failure defined as lack of blood pressure control with ≥5 medications, including a long-acting thiazide and a mineralocorticoid receptor antagonist. RfHTN is a subgroup of resistant hypertension (RHTN), which is defined as blood pressure >135/85 mm Hg with ≥3 antihypertensive medications, including a diuretic. RHTN is generally attributed to persistent intravascular fluid retention. It is unknown whether alternative mechanisms are operative in RfHTN. Our objective was to determine whether RfHTN is characterized by persistent fluid retention, indexed by greater intracardiac volumes determined by cardiac magnetic resonance when compared with controlled RHTN patients. Consecutive patients evaluated in our institution with RfHTN and controlled RHTN were prospectively enrolled. Exclusion criteria included advanced chronic kidney disease and masked or white coat hypertension. All enrolled patients underwent biochemical testing and cardiac magnetic resonance. The RfHTN group (n=24) was younger (mean age, 51.7±8.9 versus 60.6±11.5 years; P =0.003) and had a greater proportion of women (75.0% versus 43%; P =0.02) compared with the controlled RHTN group (n=30). RfHTN patients had a greater left ventricular mass index (88.3±35.0 versus 54.6±12.5 g/m 2 ; P <0.001), posterior wall thickness (10.1±3.1 versus 7.7±1.5 mm; P =0.001), and septal wall thickness (14.5±3.8 versus 10.0±2.2 mm; P <0.001). There was no difference in B-type natriuretic peptide levels and left atrial or ventricular volumes. Diastolic dysfunction was noted in RfHTN. Our findings demonstrate greater left ventricular hypertrophy without chamber enlargement in RfHTN, suggesting that antihypertensive treatment failure is not attributable to intravascular volume retention. © 2018 American Heart Association, Inc.

Increased extracellular volume and altered mechanics are associated with LVH in hypertensive heart disease, not hypertension alone.

PubMed

Kuruvilla, Sujith; Janardhanan, Rajesh; Antkowiak, Patrick; Keeley, Ellen C; Adenaw, Nebiyu; Brooks, Jeremy; Epstein, Frederick H; Kramer, Christopher M; Salerno, Michael

2015-02-01

The goal of this study was to assess the relationship among extracellular volume (ECV), native T1, and systolic strain in hypertensive patients with left ventricular hypertrophy (HTN LVH), hypertensive patients without LVH (HTN non-LVH), and normotensive controls. Diffuse myocardial fibrosis in HTN LVH patients, as reflected by increased ECV and native T1, may be an underlying mechanism contributing to increased cardiovascular risk compared with HTN non-LVH subjects and controls. Furthermore, increased diffuse fibrosis in HTN LVH subjects may be associated with reduced peak systolic and early diastolic strain rate compared with the other 2 groups. T1 mapping was performed in 20 HTN LVH (mean age, 55 ± 11 years), 23 HTN non-LVH (mean age, 61 ± 12 years), and 22 control subjects (mean age, 54 ± 7 years) on a Siemens 1.5-T Avanto (Siemens Healthcare, Erlangen, Germany) using a previously validated modified look-locker inversion-recovery pulse sequence. T1 was measured pre-contrast and 10, 15, and 20 min after injection of 0.15 mmol/kg gadopentetate dimeglumine, and the mean ECV and native T1 were determined for each subject. Measurement of circumferential strain parameters were performed using cine displacement encoding with stimulated echoes. HTN LVH subjects had higher native T1 compared with controls (p < 0.05). HTN LVH subjects had higher ECV compared with HTN non-LVH subjects and controls (p < 0.05). Peak systolic circumferential strain and early diastolic strain rates were reduced in HTN LVH subjects compared with HTN non-LVH subjects and controls (p < 0.05). Increased levels of ECV and native T1 were associated with reduced peak systolic and early diastolic circumferential strain rate across all subjects. HTN LVH patients had higher ECV, longer native T1 and associated reduction in peak systolic circumferential strain, and early diastolic strain rate compared with HTN non-LVH and control subjects. Measurement of ECV and native T1 provide a noninvasive

Association of the Charlson comorbidity index and hypertension with survival in men with metastatic castration-resistant prostate cancer.

PubMed

Goyal, Jatinder; Pond, Gregory R; Galsky, Matthew D; Hendricks, Ryan; Small, Alexander; Tsao, Che-Kai; Sonpavde, Guru

2014-01-01

The independent prognostic effect of comorbidities on outcomes in men with metastatic castration-resistant prostate cancer (mCRPC) is unclear. We sought to determine whether the Charlson comorbidity index (CCI) and hypertension (HTN) are associated with overall survival (OS) independent of known clinical prognostic factors in mCRPC. A retrospective analysis was conducted on 221 patients with mCRPC treated with docetaxel plus prednisone combined with AT-101 (bcl-2 antagonist) or placebo on a prospective randomized phase II trial. The Cox regression analysis was performed to identify whether the CCI or HTN or both (by medical history) independently predicted OS after adjusting for baseline variables known to be associated with OS. The Wilcoxon rank sum test and the Fisher exact test were used to compare data by comorbidity groups (CCI as a continuous variable, CCI = 6 vs. CCI ≥ 7 and HTN vs. no HTN). The CCI was 6 in 116 patients (52.7%), 7 in 70 (31.8%), 8 in 23 (10.5%), 9 in 4 (1.8%), and 10 in 7 patients (3.2%). HTN was present in 107 (48.6%) patients. Patients with CCI of ≥ 7 were older and exhibited worse performance status and anemia than patients with CCI of 6 (P<0.05). The CCI was not independently predictive of OS on univariable and multivariable analyses. HTN alone or in combination with the CCI was borderline significantly associated with OS (P ~ 0.09) on both univariable and multivariable analyses. The CCI did not predict OS independent of known prognostic factors in mCRPC. Age, performance status, and anemia may adequately capture comorbidities in the context of mCRPC, given their association with higher CCI. Further prospective study of comorbidities in a larger data set may be warranted. The study of HTN in a larger data set may also be warranted given its borderline-independent association with OS. Copyright © 2014 Elsevier Inc. All rights reserved.

MCP-1 Levels are Associated with Cardiac Remodeling but not with Resistant Hypertension.

PubMed

Ritter, Alessandra Mileni Versuti; Faria, Ana Paula Cabral de; Sabbatini, Andrea; Corrêa, Nathalia Batista; Brunelli, Veridiana; Modolo, Rodrigo; Moreno, Heitor

2017-04-01

Hypertension is a chronic, low-grade inflammation process associated with the release of cytokines and development of target organ damage. Deregulated monocyte chemoattractant protein-1 (MCP-1) levels have been associated with high blood pressure and cardiovascular complications; however, the mechanisms involved are complex and not fully understood. This study aimed to compare the levels of MCP-1 in patients with resistant (RH) versus mild-to-moderate (HTN) hypertension and their association with the presence or absence of left ventricular hypertrophy (LVH) in all hypertensive subjects. We enrolled 256 hypertensive subjects: 120 RH and 136 HTN, investigating the relationship between circulating MCP-1 levels and blood pressure, biochemical data, hematologic profile, and cardiac damage within the RH and HTN groups. Plasma MCP-1 levels were measured by ELISA and LVH was assessed by echocardiography. We found no difference in MCP-1 levels between RH and HTN subjects. On the other hand, we encountered lower MCP-1 levels in patients with LVH (105 pg/mL [100 - 260 pg/mL] versus 136 pg/mL (100 - 200 pg/mL), p = 0.005, respectively] compared with those without LVH. A logistic regression model adjusted for body mass index (BMI), age, race, aldosterone levels, and presence of diabetes and RH demonstrated that median levels of MCP-1 (2.55 pg/mL [1.22 - 5.2 pg/mL], p = 0.01) were independently associated with LVH in the entire hypertensive population. Since MCP-1 levels were similar in both RH and HTN subjects and decreased in hypertensive patients with existing LVH, our study suggests a possible downregulation in MCP-1 levels in hypertensive individuals with LVH, regardless of hypertension strata. A hipertensão arterial é um processo crônico de baixo grau inflamatório, associado com liberação de citocinas e desenvolvimento de lesão em órgãos-alvo. A desregulação dos níveis de proteína quimiotática de monócitos-1 (MCP-1) tem sido associada com elevação da press

Resistant hypertension.

PubMed

Wei, Fang-Fei; Zhang, Zhen-Yu; Huang, Qi-Fang; Yang, Wen-Yi; Staessen, Jan A

2018-06-15

The publication of the first non-randomised proof-of-concept trial of renal denervation as a treatment modality in treatment-resistant hypertension set the stage for a search for novel devices with the expectation that technology would reduce the burden of hypertension by reducing or eliminating the costly and lifelong use of blood pressure lowering medications. As we demonstrate in this review, this idea so attractive to manufacturers and invasive cardiologists and radiologists overlooked decades of careful pathophysiological research in a disease, which still remains enigmatic but remains the major cause of cardiovascular mortality worldwide. To make our point, we first reviewed the prevalence and risks associated with treatment-resistant hypertension. Next, we highlighted the key points required for the diagnosis of treatment-resistant hypertension, including the recording of the ambulatory blood pressure and the assessment of adherence to medication. Finally, we summarised new insights in the management of treatment-resistant hypertension by medication and devices and in the future research. Throughout our review, we focused on new evidence became available since 2013. Our conclusion is that optimising medical treatment based on simple algorithms remains the state of the art in treatment-resistant hypertension.

Hypertension: diagnosis, control status and its predictors in general population aged between 15 and 75 years: a community-based study in southeastern Iran.

PubMed

Najafipour, Hamid; Nasri, Hamid Reza; Afshari, Mahdi; Moazenzadeh, Mansoor; Shokoohi, Mostafa; Foroud, Afsaneh; Etemad, Koorosh; Sadeghi, Behnam; Mirzazadeh, Ali

2014-12-01

Hypertension (HTN) is an important cause of cardiovascular related morbidity and mortality. This study aimed at providing the prevalence of pre-HTN, diagnosed and undiagnosed HTN, along with its control and associated factors in an adult population. 5,900 participants aged 15-75 years took part in the study. HTN was verified by examination, self-reported history or using anti-hypertensive drug(s). Pre-hypertension and hypertension were defined as 120-139/80-89 mmHg and >140/>90 mmHg for systolic/diastolic BP, respectively. The prevalence of hypertension was 18.4 % from which 10.5 %were diagnosed and 7.9 % were undiagnosed. The prevalence of pre-HTN was 35.5 %. HTN increased by age (2.4 % in 15-24 to 49 % in 55-64 years). The men had higher pre-HTN (42.7 vs. 28.1 %) and undiagnosed HTN (11.3 vs. 4.6 %). Of those diagnosed, 56.3 % had uncontrolled BP levels. Smoking, anxiety, obesity, and positive family history of HTN were the most significant predictors for HTN. Hypertension affected almost one-fifth of the population. Given the poor control in diagnosed hypertensive patients, it is alarming that the current health system in urban areas in Iran is not effective enough to control the epidemic spread of non-communicable diseases.

[Obstructive sleep apnea syndrome, hypertension and artery].

PubMed

Baguet, Jean-Philippe; Barone-Rochette, Gilles; Pépin, Jean-Louis

2009-04-01

Obstructive sleep apnea syndrome (OSAS), due to upper airway collapse, is frequent but still underestimated. The dose-response relation between OSAS and hypertension (HTN) is now well established. Logically, therefore, blood pressure must be tested in every apneic patient, if necessary by ambulatory blood pressure monitoring. Multiple mechanisms explain this relation, most importantly the increase in sympathetic activity during apnea episodes. OSAS-related hypertension has several characteristics: it is highly prevalent, predominantly diastolic and nocturnal, and frequently affects non-dippers; and the HTN tends to be resistant to treatment. OSAS promotes the formation of arterial lesions (parietal thickening of the carotid artery, increased aortic stiffness, and endothelial dysfunction); the more severe the OSAS, the more severe the lesions. The beneficial effects on blood pressure of continuous positive airway pressure (CPAP), the benchmark treatment for OSAS, are still debated but appear to be significant for untreated or refractory hypertension, for severe OSAS, and when CPAP compliance is good. It also seems promising for the reduction of arterial lesions linked to OSAS.

Hypertension: Renal denervation-promising data from the DENERHTN trial.

PubMed

Yang, Wen-Yi; Staessen, Jan A

2015-05-01

In patients with resistant hypertension, renal denervation plus standardized stepped-care antihypertensive treatment (SSAHT) resulted in significant blood-pressure lowering compared with SSAHT alone. These new data from the DENERHTN trial may indicate that despite the failure of SYMPLICITY HTN-3, there is light at the end of the tunnel for renal denervation.

A multinational clinical approach to assessing the effectiveness of catheter-based ultrasound renal denervation: The RADIANCE-HTN and REQUIRE clinical study designs.

PubMed

Mauri, Laura; Kario, Kazuomi; Basile, Jan; Daemen, Joost; Davies, Justin; Kirtane, Ajay J; Mahfoud, Felix; Schmieder, Roland E; Weber, Michael; Nanto, Shinsuke; Azizi, Michel

2018-01-01

Catheter-based renal denervation is a new approach to treat hypertension via modulation of the renal sympathetic nerves. Although nonrandomized and small, open-label randomized studies resulted in significant reductions in office blood pressure 6months after renal denervation with monopolar radiofrequency catheters, the first prospective, randomized, sham-controlled study (Symplicity HTN-3) failed to meet its blood pressure efficacy end point. New clinical trials with new catheters have since been designed to address the limitations of earlier studies. Accordingly, the RADIANCE-HTN and REQUIRE studies are multicenter, blinded, randomized, sham-controlled trials designed to assess the blood pressure-lowering efficacy of the ultrasound-based renal denervation system (Paradise) in patients with established hypertension either on or off antihypertensive medications, is designed to evaluate patients in 2 cohorts-SOLO and TRIO, in the United States and Europe. The SOLO cohort includes patients with essential hypertension, at low cardiovascular risk, and either controlled on 1 to 2 antihypertensive medications or uncontrolled on 0 to 2 antihypertensive medications. Patients undergo a 4-week medication washout period before randomization to renal denervation (treatment) or renal angiogram (sham). The TRIO cohort includes patients with hypertension resistant to at least 3 antihypertensive drugs including a diuretic. Patients will be stabilized on a single-pill, triple-antihypertensive-drug combination for 4weeks before randomization to treatment or sham. Reduction in daytime ambulatory systolic blood pressure (primary end point) will be assessed at 2months in both cohorts. A predefined medication escalation protocol, as needed for blood pressure control, is implemented between 2 and 6months in both cohorts by a study staff member blinded to the randomization process. At 6months, daytime ambulatory blood pressure and antihypertensive treatment score will be assessed. REQUIRE

Treating resistant hypertension with new devices.

PubMed

Wienemann, H; Meincke, F; Kaiser, L; Heeger, C H; Bergmann, M W

2014-06-01

Arterial hypertension is a frequent, chronic disease, which is one of the main risk factor for cardiovascular and renal diseases such as heart failure, chronic kidney disease, hypertensive heart disease, stroke as well as cardiac arrhythmias. In the clinical setting it remains challenging to accomplish the thresholds of guideline blood pressure (BP) levels now defined as office based BP to be below <140 mmHg. Patients on three or more antihypertensive drugs, with systolic BP values above ≥160 mmHg (≥150 mmHg for patients with type 2 diabetes) are classified as having resistant hypertension. In the past six years the development of interventional sympathetic renal artery denervation (RDN) opened a new treatment option targeting the afferent and efferent sympathetic nerves of the kidney to reduce BP. A large variety of devices are available on the market. Newly developed devices try to focus on new strategies such as ultrasound or irrigated catheters, which might reduce the post-procedural complications and increase the success rate. The first generation SymplicityTM device (Medtronic, Palo Alto, CA, USA) was shown to be safe, with side effects rarely occurring. Clinical trials demonstrate that this procedure is successful in about 70% of patients. However current data from Simplicity HTN-3 with 25% african-americans and a massive BP-lowering effect in the control "sham" group was not able to find a significant effect in the overall patient cohort. Possibly devices which allow to safely destroy sympathetic renal innervation more efficiently might allow for a higher responder rate. Irrigated RDN and ultrasound devices could deliver more energy to deeper tissue levels. This article provides an overview of currently available data on devices.

Impact of hypertension severity on arterial stiffness, cerebral vasoreactivity, and cognitive performance.

PubMed

Muela, Henrique Cotchi Simbo; Costa-Hong, Valeria A; Yassuda, Monica Sanches; Machado, Michel Ferreira; Nogueira, Ricardo de Carvalho; Moraes, Natalia C; Memória, Claudia Maia; Macedo, Thiago A; Bor-Seng-Shu, Edson; Massaro, Ayrton Roberto; Nitrini, Ricardo; Bortolotto, Luiz A

2017-01-01

Aging, hypertension (HTN), and other cardiovascular risk factors contribute to structural and functional changes of the arterial wall. To evaluate whether arterial stiffness (AS) is related to cerebral blood flow changes and its association with cognitive function in patients with hypertension. 211 patients (69 normotensive and 142 hypertensive) were included. Patients with hypertension were divided into 2 stages: HTN stage-1 and HTN stage-2. The mini-mental state examination (MMSE), Montreal Cognitive Assessment (MoCA) and a battery of neuropsychological (NPE) tests were used to determine cognitive function. Pulse wave velocity was measured using the Complior ® . Carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. Middle cerebral artery flow velocity was measured by transcranial Doppler ultrasonography. Both arterial stiffness parameters and cerebral vasoreactivity worsened in line with HTN severity. There was a negative correlation between breath holding index (BHI) and arterial stiffness parameters. Cognitive performance worsened in line with HTN severity, with statistical difference occurring mainly between the HTN-2 and normotension groups on both the MMSE and MoCA. The same tendency was observed on the NPE tests. Hypertension severity was associated with higher AS, worse BHI, and lower cognitive performance.

Impact of hypertension severity on arterial stiffness, cerebral vasoreactivity, and cognitive performance

PubMed Central

Muela, Henrique Cotchi Simbo; Costa-Hong, Valeria A.; Yassuda, Monica Sanches; Machado, Michel Ferreira; Nogueira, Ricardo de Carvalho; Moraes, Natalia C.; Memória, Claudia Maia; Macedo, Thiago A.; Bor-Seng-Shu, Edson; Massaro, Ayrton Roberto; Nitrini, Ricardo; Bortolotto, Luiz A.

2017-01-01

ABSTRACT. Aging, hypertension (HTN), and other cardiovascular risk factors contribute to structural and functional changes of the arterial wall. Objective: To evaluate whether arterial stiffness (AS) is related to cerebral blood flow changes and its association with cognitive function in patients with hypertension. Methods: 211 patients (69 normotensive and 142 hypertensive) were included. Patients with hypertension were divided into 2 stages: HTN stage-1 and HTN stage-2. The mini-mental state examination (MMSE), Montreal Cognitive Assessment (MoCA) and a battery of neuropsychological (NPE) tests were used to determine cognitive function. Pulse wave velocity was measured using the Complior®. Carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. Middle cerebral artery flow velocity was measured by transcranial Doppler ultrasonography. Results: Both arterial stiffness parameters and cerebral vasoreactivity worsened in line with HTN severity. There was a negative correlation between breath holding index (BHI) and arterial stiffness parameters. Cognitive performance worsened in line with HTN severity, with statistical difference occurring mainly between the HTN-2 and normotension groups on both the MMSE and MoCA. The same tendency was observed on the NPE tests. Conclusion: Hypertension severity was associated with higher AS, worse BHI, and lower cognitive performance. PMID:29354219

Safety and efficacy of a multi-electrode renal sympathetic denervation system in resistant hypertension: the EnligHTN I trial

PubMed Central

Worthley, Stephen G.; Tsioufis, Costas P.; Worthley, Matthew I.; Sinhal, Ajay; Chew, Derek P.; Meredith, Ian T.; Malaiapan, Yuvi; Papademetriou, Vasilios

2013-01-01

Aims Catheter-based renal artery sympathetic denervation has emerged as a novel therapy for treatment of patients with drug-resistant hypertension. Initial studies were performed using a single electrode radiofrequency catheter, but recent advances in catheter design have allowed the development of multi-electrode systems that can deliver lesions with a pre-determined pattern. This study was designed to evaluate the safety and efficacy of the EnligHTN™ multi-electrode system. Methods and results We conducted the first-in-human, prospective, multi-centre, non-randomized study in 46 patients (67% male, mean age 60 years, and mean baseline office blood pressure 176/96 mmHg) with drug-resistant hypertension. The primary efficacy objective was change in office blood pressure from baseline to 6 months. Safety measures included all adverse events with a focus on the renal artery and other vascular complications and changes in renal function. Renal artery denervation, using the EnligHTN™ system significantly reduced the office blood pressure from baseline to 1, 3, and 6 months by −28/10, −27/10 and −26/10 mmHg, respectively (P < 0.0001). No acute renal artery injury or other serious vascular complications occurred. Small, non-clinically relevant, changes in average estimated glomerular filtration rate were reported from baseline (87 ± 19 mL/min/1.73 m2) to 6 months post-procedure (82 ± 20 mL/min/1.73 m2). Conclusion Renal sympathetic denervation, using the EnligHTN™ multi-electrode catheter results in a rapid and significant office blood pressure reduction that was sustained through 6 months. The EnligHTN™ system delivers a promising therapy for the treatment of drug-resistant hypertension. PMID:23782649

Altered cellular magnesium responsiveness to hyperglycemia in hypertensive subjects.

PubMed

Barbagallo, M; Dominguez, L J; Bardicef, O; Resnick, L M

2001-09-01

Previous studies by our group have identified ionic aspects of insulin resistance in hypertension, in which cellular responses to insulin were influenced by the basal intracellular ionic environment-the lower the cytosolic free magnesium (Mg(i)), the less Mg(i) increased following insulin stimulation. To investigate whether this ionic insulin resistance represents a more general abnormality of cellular responsiveness in hypertension, we studied Mg(i) responses to nonhormonal signals such as hyperglycemia (15 mmol/L) and used (31)P-nuclear magnetic resonance (NMR) spectroscopy to measure Mg(i) in erythrocytes from normal (NL, n=14) and hypertensive (HTN, n=12) subjects before and 30, 60, 120, and 180 minutes after in vitro glucose incubations. Basal Mg(i) levels were significantly lower in HTN subjects than in NL subjects (169+/-10 versus 205+/-8 micromol.L(-1), P<0.01). In NL cells, hyperglycemia significantly lowered Mg(i), from 205+/-8 micromol.L(-1) (basal, T=0) to 181+/-8, 162+/-6, 152+/-7, and 175+/-9 micromol.L(-1) (T=30, 60, 120, and 180, respectively; P<0.005 versus T=0 at all times). In HTN cells, maximal Mg(i) responses to hyperglycemia were blunted, from 169+/-10 micromol.L(-1) (basal, T=0) to 170+/-11, 179+/-12, 181+/-14, and 173+/-15 micromol.L(-1) (T=30, 60, 120, and 180, respectively; P=NS versus T=0 at all times). For all subjects, Mg(i) responses to hyperglycemia were closely related to basal Mg(i) levels: the higher the Mg(i), the greater the response (n=26, r=0.620, P<0.001). Thus, (1) erythrocytes from hypertensive vis-à-vis normotensive subjects are resistant to the ionic effects of extracellular hyperglycemia on Mg(i) levels, and (2) cellular ionic responses to glucose depend on the basal Mg(i) environment. Altogether, these data support a role for altered extracellular glucose levels in regulating cellular magnesium metabolism and also suggest the importance of ionic factors in determining cellular responsiveness to nonhormonal as well as

Fundus autofluorescence in chronic essential hypertension.

PubMed

Ramezani, Alireza; Saberian, Peyman; Soheilian, Masoud; Parsa, Saeed Alipour; Kamali, Homayoun Koohi; Entezari, Morteza; Shahbazi, Mohammad-Mehdi; Yaseri, Mehdi

2014-01-01

To evaluate fundus autofluorescence (FAF) changes in patients with chronic essential hypertension (HTN). In this case-control study, 35 eyes of 35 patients with chronic essential HTN (lasting >5 years) and 31 eyes of 31 volunteers without history of HTN were included. FAF pictures were taken from right eyes of all cases with the Heidelberg retina angiography and then were assessed by two masked retinal specialists. In total, FAF images including 35 images of hypertensive patients and 31 pictures of volunteers, three apparently abnormal patterns were detected. A ring of hyper-autofluorescence in the central macula (doughnut-shaped) was observed in 9 (25.7%) eyes of the hypertensive group but only in 2 (6.5%) eyes of the control group. This difference was statistically significant (P = 0.036) between two groups. Hypo- and/or hyper-autofluorescence patches outside the fovea were the other sign found more in the hypertensive group (22.9%) than in the control group (6.5%); however, the difference was not statistically significant (P = 0.089). The third feature was hypo-autofluorescence around the disk noticed in 11 (31.4%) eyes of hypertensive patients compared to 8 (25.8%) eyes of the controls (P = 0.615). A ring of hyper-autofluorescence in the central macula forming a doughnut-shaped feature may be a FAF sign in patients with chronic essential HTN.

The Effects of Hypertension on Cognitive Function in Children and Adolescents

PubMed Central

Cha, Stephen D.; Patel, Hiren P.; Hains, David S.; Mahan, John D.

2012-01-01

Hypertension (HTN) is found in about 3-4% of the pediatric population with long-term risks of end organ damage if untreated or poorly controlled. Although children with HTN are being more frequently screened for end organ damage (i.e., LVH), the cognitive effects of HTN and methods to screen for cognitive dysfunction have not been extensively explored. In recent years, there have been a small number of studies that have provided important insights that can guide future research in this area. These studies show that HTN can be associated with headaches, restlessness, sleep disturbance, anxiety, depression, decreased attention, and also poor executive functioning. By increasing the utilization of cognitive tests in hypertensive children and adolescents, important cognitive defects secondary to HTN may be detected. More research is needed in the area, and the results of future studies could have far reaching implications for long-term outcomes in hypertensive children and adolescents. PMID:22518186

Renal sympathetic denervation in therapy resistant hypertension - pathophysiological aspects and predictors for treatment success

PubMed Central

Fengler, Karl; Rommel, Karl Philipp; Okon, Thomas; Schuler, Gerhard; Lurz, Philipp

2016-01-01

Many forms of human hypertension are associated with an increased systemic sympathetic activity. Especially the renal sympathetic nervous system has been found to play a prominent role in this context. Therefore, catheter-interventional renal sympathetic denervation (RDN) has been established as a treatment for patients suffering from therapy resistant hypertension in the past decade. The initial enthusiasm for this treatment was markedly dampened by the results of the Symplicity-HTN-3 trial, although the transferability of the results into clinical practice to date appears to be questionable. In contrast to the extensive use of RDN in treating hypertensive patients within or without clinical trial settings over the past years, its effects on the complex pathophysiological mechanisms underlying therapy resistant hypertension are only partly understood and are part of ongoing research. Effects of RDN have been described on many levels in human trials: From altered systemic sympathetic activity across cardiac and metabolic alterations down to changes in renal function. Most of these changes could sustainably change long-term morbidity and mortality of the treated patients, even if blood pressure remains unchanged. Furthermore, a number of promising predictors for a successful treatment with RDN have been identified recently and further trials are ongoing. This will certainly help to improve the preselection of potential candidates for RDN and thereby optimize treatment outcomes. This review summarizes important pathophysiologic effects of renal denervation and illustrates the currently known predictors for therapy success. PMID:27621771

AGE IS RELEVANT: DISTINCTIVE RISK FACTORS AND PHENOTYPE OF YOUNGER PATIENTS WITH RESISTANT HYPERTENSION

PubMed Central

Ghazi, Lama; Oparil, Suzanne; Calhoun, David A.; Lin, Chee Paul; Dudenbostel, Tanja

2017-01-01

Resistant hypertension, defined as blood pressure >140/90 mmHg despite using ≥3 antihypertensive medications, is a well-recognized clinical entity. Patients with resistant hypertension are at an increased risk of cardiovascular disease compared with those with more easily controlled hypertension. Coronary heart disease mortality rates of younger adults are stagnating or on the rise. The purpose of our study was to characterize the phenotype and risk factors of younger patients with resistant hypertension given the dearth of data on cardiovascular risk profile in this cohort. We conducted a cross sectional analysis with predefined age groups of a large, ethnically diverse cohort of 2170 patients referred to the Hypertension Clinic at the University of Alabama at Birmingham. 2068 patients met the inclusion criteria and were classified by age groups, i.e. ≤40 yrs (12.7 % of total cohort), 41–55 yrs (32.1%), 56–70 yrs (36.1%) and ≥71 yrs (19.1%). Patients ≤40 yrs of age compared with ≥71 yrs, had significantly earlier onset of HTN (24.7±7.4vs 55.0±14.1 yrs, p<0.0001), higher rates of obesity (53.4% vs 26.9%, p<0.0001), and significantly higher levels of plasma aldosterone (11.3±9.8 vs 8.9±7.4 ng/dl, p=0.005), plasma renin activity (4.9±10.2 vs 2.5±5.0 ng/ml/hr, p=0.001), and 24-hr urinary aldosterone (13.4±10.0 vs 8.2±6.2 μg/24hr, p<0.0001) and sodium excretion (195.9±92.0 vs 146.8±67.1 mEq/24hr, p<0.0001). Among patients with resistant hypertension, younger individuals have a distinct phenotype characterized by overlapping risk factors and comorbidities, including obesity, high aldosterone and high dietary sodium intake compared to elderly. PMID:28348010

Search Complexities for HTN Planning

DTIC Science & Technology

2013-01-01

AUTHORS 7. PERFORMING ORGANIZATION NAMES AND ADDRESSES 15. SUBJECT TERMS b . ABSTRACT 2. REPORT TYPE 17. LIMITATION OF ABSTRACT 15. NUMBER OF...43 3.1 Complexity of plan-existence for propositional delete-free STRIPS and HTN planning with various restrictions ( k ...paper, we are concerned with two HTN decision problems: plan-existence, for whether a problem has any solution, and k -length-plan-existence, for whether a

Prevalence, awareness, treatment, control, and risk factors of hypertension among adults: a cross-sectional study in Iran.

PubMed

Eghbali Babadi, Maryam; Khosravi, Alireza; Feizi, Awat; Mansouri, Asieh; Mahaki, Behzad; Sarrafzadegan, Nizal

2018-05-18

hypertension (HTN) is one of important risk factors of cardiovascular disease. Considering the importance of this disease for public health, this study was designed in order to determine the prevalence, awareness, treatment, control and risk factors of hypertension in Iranian adult population. This cross-sectional study was conducted on 2107 residents of Isfahan, Iran. Samples were selected through random, multistage, cluster sampling in 2015-2016. Outcome variable was hypertension determined by measuring right arm blood pressure via an arm digital blood pressure monitor. Awareness, treatment and control of HTN was assessed by a valid and reliable researcher-made questionnaire. Other demographic and clinical variables were assessed via a demographic questionnaire. The overall prevalence of hypertension was 17.3% (18.9% and 15.5% in men and women, respectively). The prevalence of hypertension increased in both genders with age. the prevalence of awareness of HTN among people with HTN was 69.2% of which 92.4% and 59.9% had drug treatment and controlled HTN, respectively. Logistic regression identified age, BMI, having diabetes and hyperlipidemia and positive family history of HTN as determinants of awareness of HTN. The results showed that hypertension is highly prevalent in the community, especially in men and in the middle-aged and older adults. Approximately 30% of patients are unaware of their disease, and there is less awareness among younger adults. Despite high frequency of drug treatment for hypertension, hypertension is uncontrolled in more than 40% of patients. Health policies should therefore consider appropriate preventive and therapeutic strategies for these high-risk groups.

Renal denervation for the management of resistant hypertension

PubMed Central

Patel, Hitesh C; Hayward, Carl; Vassiliou, Vassilis; Patel, Ketna; Howard, James P; Di Mario, Carlo

2015-01-01

Renal sympathetic denervation (RSD) as a therapy for patients with resistant hypertension has attracted great interest. The majority of studies in this field have demonstrated impressive reductions in blood pressure (BP). However, these trials were not randomized or sham-controlled and hence, the findings may have been overinflated due to trial biases. SYMPLICITY HTN-3 was the first randomized controlled trial to use a blinded sham-control and ambulatory BP monitoring. A surprise to many was that this study was neutral. Possible reasons for this neutrality include the fact that RSD may not be effective at lowering BP in man, RSD was not performed adequately due to limited operator experience, patients’ adherence with their anti-hypertensive drugs may have changed during the trial period, and perhaps the intervention only works in certain subgroups that are yet to be identified. Future studies seeking to demonstrate efficacy of RSD should be designed as randomized blinded sham-controlled trials. The efficacy of RSD is in doubt, but many feel that its safety has been established through the thousands of patients in whom the procedure has been performed. Over 90% of these data, however, are for the Symplicity™ system and rarely extend beyond 12 months of follow-up. Long-term safety cannot be assumed with RSD and nor should it be assumed that if one catheter system is safe then all are. We hope that in the near future, with the benefit of well-designed clinical trials, the role of renal denervation in the management of hypertension will be established. PMID:26672761

A controlled trial of renal denervation for resistant hypertension.

PubMed

Bhatt, Deepak L; Kandzari, David E; O'Neill, William W; D'Agostino, Ralph; Flack, John M; Katzen, Barry T; Leon, Martin B; Liu, Minglei; Mauri, Laura; Negoita, Manuela; Cohen, Sidney A; Oparil, Suzanne; Rocha-Singh, Krishna; Townsend, Raymond R; Bakris, George L

2014-04-10

Prior unblinded studies have suggested that catheter-based renal-artery denervation reduces blood pressure in patients with resistant hypertension. We designed a prospective, single-blind, randomized, sham-controlled trial. Patients with severe resistant hypertension were randomly assigned in a 2:1 ratio to undergo renal denervation or a sham procedure. Before randomization, patients were receiving a stable antihypertensive regimen involving maximally tolerated doses of at least three drugs, including a diuretic. The primary efficacy end point was the change in office systolic blood pressure at 6 months; a secondary efficacy end point was the change in mean 24-hour ambulatory systolic blood pressure. The primary safety end point was a composite of death, end-stage renal disease, embolic events resulting in end-organ damage, renovascular complications, or hypertensive crisis at 1 month or new renal-artery stenosis of more than 70% at 6 months. A total of 535 patients underwent randomization. The mean (±SD) change in systolic blood pressure at 6 months was -14.13±23.93 mm Hg in the denervation group as compared with -11.74±25.94 mm Hg in the sham-procedure group (P<0.001 for both comparisons of the change from baseline), for a difference of -2.39 mm Hg (95% confidence interval [CI], -6.89 to 2.12; P=0.26 for superiority with a margin of 5 mm Hg). The change in 24-hour ambulatory systolic blood pressure was -6.75±15.11 mm Hg in the denervation group and -4.79±17.25 mm Hg in the sham-procedure group, for a difference of -1.96 mm Hg (95% CI, -4.97 to 1.06; P=0.98 for superiority with a margin of 2 mm Hg). There were no significant differences in safety between the two groups. This blinded trial did not show a significant reduction of systolic blood pressure in patients with resistant hypertension 6 months after renal-artery denervation as compared with a sham control. (Funded by Medtronic; SYMPLICITY HTN-3 ClinicalTrials.gov number, NCT01418261.).

Resistant hypertension and hyperaldosteronism.

PubMed

Gonzaga, Carolina C; Calhoun, David A

2008-12-01

Resistant hypertension is defined as blood pressure that remains uncontrolled in spite of >or= 3 antihypertensive medications at effective doses, ideally including a diuretic. Although exact prevalence is unknown, clinical trials suggest that 20% to 30% of study participants are resistant. Hyperaldosteronism, obesity, refractory volume expansion, and obstructive sleep apnea are common findings in resistant hypertension patients. Multiple studies indicate that primary aldosteronism (PA) is common (approximately 20%) in patients with resistant hypertension. Screening for PA is recommended for most patients with resistant hypertension, ideally by measurement of 24-hour urinary aldosterone excretion, or by the plasma aldosterone/plasma renin activity ratio. Successful treatment of resistant hypertension is predicated on improvement of lifestyle factors; accurate diagnosis and treatment of secondary causes of hypertension; and use of effective multidrug regimens. A long-acting diuretic, specifically chlorthalidone, is recommended as part of the treatment regimen. Recent studies demonstrate that mineralocorticoid receptor antagonists provide substantial antihypertensive benefit when added to multidrug regimens, even in patients without demonstrable aldosterone excess.

Hypertension Knowledge, Awareness, and Attitudes in a Hypertensive Population

PubMed Central

Oliveria, Susan A; Chen, Roland S; McCarthy, Bruce D; Davis, Catherine C; Hill, Martha N

2005-01-01

OBJECTIVE Improved recognition of the importance of systolic blood pressure (SBP) has been identified as one of the major public health and medical challenges in the prevention and treatment of hypertension (HTN). SBP is a strong independent risk factor for cardiovascular disease but no information is available on whether patients understand the importance of their SBP level. The purpose of this study was to assess HTN knowledge, awareness, and attitudes, especially related to SBP in a hypertensive population. DESIGN/SETTING/PATIENTS We identified patients with HTN (N =2,264) in the primary care setting of a large midwestern health system using automated claims data (International Classification of Diseases, Ninth Revision [ICD-9] codes 401.0–401.9). We randomly selected 1,250 patients and, after excluding ineligible patients, report the results on 826 completed patient telephone interviews (72% response rate [826/1,151]). MAIN RESULTS Ninety percent of hypertensive patients knew that lowering blood pressure (BP) would improve health and 91% reported that a health care provider had told them that they have HTN or high BP. However, 41% of patients did not know their BP level. Eighty-two percent of all patients correctly identified the meaning of HTN as “high blood pressure.” Thirty-four percent of patients correctly identified SBP as the “top” number of their reading; 32% correctly identified diastolic blood pressure (DBP) as the “bottom” number; and, overall, only 30% of patients were able to correctly identify both systolic and diastolic BP measures. Twenty-seven percent of patients with elevated SBP and DBP (as indicated by their medical records) perceived that their BP was high. Twenty-four percent of patients did not know the optimal level for either SBP or DBP. When asked whether the DBP or SBP level was more important in the control and prevention of disease, 41% reported DBP, 13% reported SBP, 30% reported that both were important, and 17% did

HYPEST study: profile of hypertensive patients in Estonia

PubMed Central

2011-01-01

Background More than one third of adult population in Estonia has problems with elevated blood pressure (BP). The Hypertension in Estonia (HYPEST) study represents the country's first hypertension-targeted sample collection aiming to examine the epidemiological and genetic determinants for hypertension (HTN) and related cardiovascular diseases (CVD) in Estonian population. The HYPEST subjects (n = 1,966) were recruited across Estonia between 2004-2007 including clinically diagnosed HTN cases and population-based controls. The present report is focused on the clinical and epidemiological profile of HYPEST cases, and gender-specific effects on the pathophysiology of hypertension. Methods Current analysis was performed on 1,007 clinically diagnosed HTN patients (617 women and 390 men) aged 18-85 years. The hypertensives were recruited to the study by BP specialists at the North Estonia Medical Center, Centre of Cardiology, Tallinn or at the Cardiology Clinic, Tartu University Hospital, Estonia. Longitudinal BP data was extracted retrospectively from clinical records. Current and retrospective data of patient's medical history, medication intake and lifestyle habits were derived from self-administrated questionnaire and each variable was examined separately for men and women. Eleven biochemical parameters were measured from fasting serum samples of 756 patients. Results The distribution of recruited men and women was 39% and 61% respectively. Majority of Estonian HTN patients (85%) were overweight (BMI ≥ 25 kg/m2) and a total of 79% of patients had additional complications with cardiovascular system. In men, the hypertension started almost 5 years earlier than in women (40.5 ± 14.5 vs 46.1 ± 12.7 years), which led to earlier age of first myocardial infarction (MI) and overall higher incidence rate of MI among male patients (men 21.2%, women 8.9%, P < 0.0001). Heart arrhythmia, thyroid diseases, renal tubulo-intestinal diseases and hyperlipidemia were more prevalent

Review of and Updates on Hypertension in Obstructive Sleep Apnea

PubMed Central

Ahmad, Masood; Makati, Devan

2017-01-01

Obstructive sleep apnea (OSA) is a prevalent sleep disorder as is hypertension (HTN) in the 21st century with the rising incidence of obesity. Numerous studies have shown a strong association of OSA with cardiovascular morbidity and mortality. There is overwhelming evidence supporting the relationship between OSA and hypertension (HTN). The pathophysiology of HTN in OSA is complex and dependent on various factors such as sympathetic tone, renin-angiotensin-aldosterone system, endothelial dysfunction, and altered baroreceptor reflexes. The treatment of OSA is multifactorial ranging from CPAP to oral appliances to lifestyle modifications to antihypertensive drugs. OSA and HTN both need prompt diagnosis and treatment to help address the growing cardiovascular morbidity and mortality due to these two entities. PMID:29147581

The relationship between hypertensive disorders in pregnancy and placental maternal and fetal vascular circulation.

PubMed

Kovo, Michal; Bar, Jacob; Schreiber, Letizia; Shargorodsky, Marina

2017-11-01

We examined the impact of chronic hypertension (HTN), gestational HTN, and preeclampsia on placental maternal and fetal vascular circulation. Of the 1047 women who gave birth and underwent a placental histopathologic examination between 2007 and 2013 at Wolfson Medical Center, 140 women were included in the present study: 34 women with preeclampsia, 25 women with chronic HTN, 28 women with gestational HTN, and 53 women without hypertensive disorder, matched by age, gravidity, parity, and mode of delivery.Placental lesions related to maternal vascular malperfusion (MVM) differed significantly across groups (P < .0001) and were highest in subjects with chronic HTN and preeclampsia (72% and 65%, respectively) and lowest in women without hypertensive disorder (26%). Placental fetal vascular malperfusion rate did not differ significantly between groups (P = .767). In the logistic regression analysis, chronic HTN emerged as a significant predictor of placental MVM and increased the risk of this outcome more than sixfold (odds ratio 6.614, 95% confidence interval 2.047-21.37, P = .002). Preeclampsia emerged as a significant predictor of MVM and more than tripled the risk of this outcome (odds ratio 3.468, 95% confidence interval 1.083-11.103, P = .036). Gestational HTN was not significantly associated with increased MVM rate. We demonstrated that chronic HTN and preeclampsia were associated with an increased rate of vascular placental maternal malperfusion and emerged as significant independent predictors of this outcome. Copyright © 2017 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Blood pressure variability in children with primary vs secondary hypertension.

PubMed

Leisman, Daniel; Meyers, Melissa; Schnall, Jeremy; Chorny, Nataliya; Frank, Rachel; Infante, Lulette; Sethna, Christine B

2014-06-01

Increased blood pressure variability (BPV) is correlated with adverse cardiovascular (CV) events in adults. However, there has been limited research on its effect in the pediatric population. Additionally, BPV differences between primary and secondary hypertension (HTN) are not known. Children with primary and secondary HTN underwent 24-hour ambulatory blood pressure monitoring and echocardiography studies. BPV measures of standard deviation (SD), average real variability (ARV), and range were calculated for the 24-hour, daytime, and nighttime periods. Seventy-four patients (median age, 13.5 years; 74% boys) were examined, 40 of whom had primary HTN. Body mass index z score and age were independent predictors of systolic ARV (R(2) =0.14) and SD (R(2) =0.39). There were no statistically significant differences in overall or wake period BPV measures between secondary or primary HTN groups, but sleep period diastolic SD was significantly greater in the secondary HTN group (9.26±3.8 vs 7.1±2.8, P=.039). On multiple regression analysis, secondary HTN was associated with increased sleep period diastolic SD (P=.025). No metrics of BPV in the overall, wake, and sleep periods were found to be significantly associated with left ventricular hypertrophy (LVH). The results of this study do not show a strong relationship between overall or wake BPV with primary vs secondary HTN, but the association of secondary HTN with sleep period diastolic BPV deserves further exploration. Contrary to expectation, the findings of this study failed to indicate a relationship between BPV and LVH for all patients as well for primary hypertensive and secondary hypertensive patients. ©2014 Wiley Periodicals, Inc.

Safety and performance of the second generation EnligHTN™ Renal Denervation System in patients with drug-resistant, uncontrolled hypertension.

PubMed

Worthley, Stephen G; Wilkins, Gerard T; Webster, Mark W; Montarello, Joseph K; Delacroix, Sinny; Whitbourn, Robert J; Warren, Roderic J

2017-07-01

Catheter-based renal denervation for the treatment of drug-resistant hypertension has been intensively investigated in recent years. To date, only limited data have been published using multi-electrode radiofrequency ablation systems that can deliver lesions with a pre-determined pattern. This study was designed to evaluate the safety and performance of the second generation EnligHTN™ Renal Denervation System. This first-in-human, prospective, multi-center, non-randomized study included 39 patients (62% male, mean age 63 years, and mean baseline office blood pressure 174/93 mmHg) with drug-resistant hypertension. The primary safety and performance objectives were to characterize, from baseline to 6 months post procedure, the rate of serious procedural and device related adverse events, as adjudicated by an independent Clinical Events Committee, and the reduction of office systolic blood pressure. Renal artery denervation, using the second generation EnligHTN multi-electrode system significantly reduced office blood pressure from baseline to 1, 3, 6, 12, 18 and 24 months by 19/7, 26/9, 25/7, 23/7, 25/8 and 27/9 mmHg, respectively (p ≤ 0.0005). No serious device or procedure related adverse events affecting the renal arteries or renal function occurred through 24 months of follow-up. Renal sympathetic denervation using the second generation EnligHTN Renal Denervation System resulted in safe, rapid, and significant mean office blood pressure reduction that was sustained through 24 months. Future studies will need to address the utility of this system against an appropriate sham based comparator. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Progression rate from new-onset pre-hypertension to hypertension in Korean adults.

PubMed

Kim, Soo Jeong; Lee, Jakyoung; Nam, Chung Mo; Jee, Sun Ha; Park, Il Soo; Lee, Kyung Jong; Lee, Soon Young

2011-01-01

There are limited studies conducted in Asia to investigate the progression rate to hypertension (HTN). This study was done to estimate the progression rate of new-onset pre-HTN (PreHTN) to HTN during an 8-year follow-up period, and to compare the impact of PreHTN on progression to HTN. A total of 49,228 participants, aged 30 to 54 years with new-onset PreHTN at baseline (1994-1996) from a biennial national medical exam were enrolled and followed up every 2 years until 2004. The incidence rate recorded at each interval and the cumulative incidence rate of HTN were analyzed. Hazard ratio of high-normal and high blood pressure (BP) in men and women was calculated. The cumulative incidence rate for high-normal BP was 27.6% and 26.4% at 2-year follow-up, increased to respectively 64.1% and 55.8% in men and women at the 8-year follow-up. Compared to optimal BP, hazard ratios for men with high-normal BP across all age groups were 3- to 4-fold higher at 2-year, and 2- to 3-fold higher at 8-year follow-up. Hazard ratios for women were about 6-fold higher at 2-year and around 4-fold higher at 8-year follow-up. New PreHTN was a significant predisposing factor for future HTN, in young adults and the effect is more prominent in women.

[Renal denervation in refractory hypertension: joint statement of the German hypertension league DHL eV and the German societies of cardiology, angiology, nephrology and radiology].

PubMed

Vonend, Oliver; Böhm, Michael; Eckert, Siegfried; Hausberg, Martin; Rittger, Harald; Rump, Lars-Christian; Schmieder, Roland; Schulte, Karl-Ludwig; Schunkert, Heribert; Uder, Michael; Veelken, Roland; Vorwerk, Dierk; Weil, Joachim; Wenzel, Ulrich; Mahfoud, Felix

2015-03-01

Arterial hypertension is a major risk factor for cardiovascular mortality and remains insufficiently controlled in Germany. The sham controlled Symplicity HTN-3 trial did meet its primary safety endpoint but failed to meet its primary efficacy endpoint. Renal denervation can not replace established, well-proven therapies. It can only be used in selected truly resistant hypertensive patients as an additive approach and should be performed by specialized centers only. Randomized controlled trials are needed to further evaluate renal denervation. © Georg Thieme Verlag KG Stuttgart · New York.

The prevalence of erectile dysfunction among hypertensive and prehypertensive men aged 25-40 years.

PubMed

Heruti, Rafi J; Sharabi, Yehonatan; Arbel, Yaron; Shochat, Tzipi; Swartzon, Michael; Brenner, Galit; Justo, Dan

2007-05-01

Erectile dysfunction (ED) and hypertension (HTN) are common and associated among men aged 40-70 years. Data on the prevalence of ED among younger hypertensive and prehypertensive men are limited. To study the prevalence of ED in a large-scale population of hypertensive and prehypertensive men aged 25-40 years. ED severity, systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial blood pressures (MAPs). Israel Defense Force personnel, aged 25 years and older, go through routine health checks at the Staff Periodic Health Examination Center (SPEC) every 3-5 years, including measuring blood pressure and completing the Sexual Health Inventory for Men (SHIM) questionnaire in order to detect HTN and ED, respectively, and assess its severity. Pre-HTN was defined as SBP 120-139 mm Hg or DBP 80-89 mm Hg. HTN was defined as SBP >/or140 mm Hg and/or DBP >or=90 mm Hg. During 2001-2004, an overall of 11,252 men, aged 25-40 years, reported to the SPEC, and 5,860 (52.1%) men filled out the SHIM questionnaire. Among responders to the SHIM questionnaire, 1,278 (21.8%) men had low scores (HTN and 557 (9.5%) men had HTN. The prevalence of ED was similar among men with HTN, men with pre-HTN, and men with normal blood pressure: 22.9% vs. 21.3% vs. 22.3%, respectively. In addition, SBPs, DBPs, and MAPs were not associated with the SHIM scores among all men. The prevalence of ED is not increased among hypertensive and prehypertensive men compared with normotensive men aged 25-40 years. Moreover, higher blood pressures are not associated with worse erections among all men in this age group. Apparently, it takes years for HTN to cause ED.

Muscular Strength and Incident Hypertension in Normotensive and Prehypertensive Men

PubMed Central

Maslow, Andréa L.; Sui, Xuemei; Colabianchi, Natalie; Hussey, Jim; Blair, Steven N.

2009-01-01

The protective effects of cardiorespiratory fitness (CRF) on hypertension (HTN) are well known; however, the association between muscular strength and incidence of HTN has yet to be examined. Purpose This study evaluated the strength-HTN association with and without accounting for CRF. Methods Participants were 4147 men (20–82 years) in the Aerobics Center Longitudinal Study for whom an age-specific composite muscular strength score was computed from measures of a 1-repetition maximal leg and a 1-repetition maximal bench press. CRF was quantified by maximal treadmill exercise test time in minutes. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) and 95% confidence intervals of incident HTN events according to exposure categories. Results During a mean follow-up of 19 years, there were 503 incident HTN cases. Multivariable-adjusted (excluding CRF) HRs of hypertension in normotensive men comparing middle and high strength thirds to the lowest third were not significant at 1.17 and 0.84, respectively. Multivariable-adjusted (excluding CRF) HRs of hypertension in baseline prehypertensive men comparing middle and high strength thirds to the lowest third were significant at 0.73 and 0.72 (p=.01 each), respectively. The association between muscular strength and incidence of HTN in baseline prehypertensive men was no longer significant after control for CRF (p=.26). Conclusions The study indicated that middle and high levels of muscular strength were associated with a reduced risk of HTN in prehypertensive men only. However, this relationship was no longer significant after controlling for CRF. PMID:19927030

Tyrosine Kinase Inhibitor-Induced Hypertension.

PubMed

Agarwal, Megha; Thareja, Nidhi; Benjamin, Melody; Akhondi, Andre; Mitchell, George D

2018-06-21

The purpose of this paper is to identify commonly used tyrosine kinase inhibitors (TKIs) that are associated with hypertension, primarily, vascular endothelial growth factor (VEGF) signaling pathway (VSP) inhibitors. We review the incidence, mechanism, and strategies for management of TKI-induced HTN. We hope to provide clinicians with guidance on how to manage similar clinical scenarios. Many of the newer VSP inhibitors are reviewed here, including cediranib, axitinib, pazopanib, and ponatinib. Trials utilizing prophylactic treatment with angiotensin system inhibitors (ASIs) are discussed as well as recent data showing an improvement in overall survival and progression-free survival in patients on ASIs and TKI-induced hypertension. The incidence of TKI-induced HTN among the VEGF inhibitors ranges from 5 to 80% and is dose dependent. Newer generation small-molecule TKIs has a lower incidence. The mechanism of action involves VSP inhibition, leading to decreased nitric oxide and increased endothelin production, which causes vasoconstriction, capillary rarefaction, and hypertension. ASIs and calcium channel blockers are first-line therapy for treatment and are associated with improved overall survival. Nitrates and beta-blockers are associated with in vitro cancer regression; however, there is a paucity of trials regarding their use as an anti-hypertensive agent in the TKI-induced HTN patient population.

Alarmingly high prevalence of hypertension and pre-hypertension in North India-results from a large cross-sectional STEPS survey

PubMed Central

Tripathy, Jaya Prasad; Jeet, Gursimer; Chawla, Sohan; Jain, Sanjay

2017-01-01

Objectives The study was primarily aimed at estimating the prevalence of hypertension and pre-hypertension and the risk factors of hypertension in the North Indian state of Punjab. It also aimed at assessing the magnitude of undiagnosed cases of hypertension in the community and ascertaining the blood pressure control status of those on treatment. Methods A non-communicable disease risk factor survey (based on WHO-STEPS approach) was done in the state of Punjab, India in a multistage stratified sample of 5127 individuals. The study subjects were administered the WHO STEPS-questionnaire and also underwent anthropometric and blood pressure measurements. Results Overall prevalence of HTN among the study participants was found out to be 40.1% (95% CI: 38.8–41.5%) whereas prevalence of pre-hypertension, isolated diastolic and isolated systolic hypertension were 40.8% (39.5–42.2%), 9.2% (8.4–10.0%) and 6.5% (5.9–7.2%) respectively. Age group (45–69 years), male gender, social group, marital status, alcohol use, obesity and salt intake (> = 5 gms/day) were the risk factors significantly associated with HTN. Among all persons with HTN, only 30.1% were known case of HTN or on treatment, among whom nearly 61% had controlled blood pressure. Patients with uncontrolled BP were more frequently male, obese patients, with sedentary lifestyle and patients with diabetes. Conclusions The study reported alarmingly high prevalence of hypertension, especially of undiagnosed or untreated cases amongst the adult population, a significant proportion of whom have uncontrolled blood pressure levels. This indicates the need for systematic screening and awareness program to identify the undiagnosed cases in the community and offer early treatment and regular follow up. PMID:29267338

First report on simplified diagnostic criteria for pre-hypertension and hypertension in a national sample of adolescents from the Middle East and North Africa: the CASPIAN-III study.

PubMed

Kelishadi, Roya; Heshmat, Ramin; Ardalan, Gelayol; Qorbani, Mostafa; Taslimi, Mahnaz; Poursafa, Parinaz; Keramatian, Kasra; Taheri, Majzoubeh; Motlagh, Mohammad-Esmaeil

2014-01-01

This study aimed to simplify the diagnostic criteria of pre-hypertension (pre-HTN) and hypertension (HTN) in the pediatric age group, and to determine the accuracy of these simple indexes in a nationally-representative sample of Iranian children and adolescents. The diagnostic accuracy of the indexes of systolic blood pressure-to-height ratio (SBPHR) and diastolic BPHR (DBPHR) to define pre-HTN and HTN was determined by the area under the curve of the receiver operator characteristic curves. The study population consisted of 5,738 Iranian students (2,875 females) with mean (SD) age of 14.7 (2.4) years. The prevalences of pre-HTN and HTN were 6.9% and 5.6%. The optimal thresholds for defining pre-HTN were 0.73 in males and 0.71 in females for SBPHR, and 0.47 in males and 0.45 in females for DBPHR, respectively. The corresponding figures for HTN were 0.73, 0.71, 0.48, and 0.46, respectively. In both genders, the accuracies of SBPHR and DBPHR in diagnosing pre-HTN and HTN were approximately 80%. BPHR is a valid, simple, inexpensive, and accurate tool to diagnose pre-HTN and HTN in adolescents. The optimal thresholds of SBPHR and DBPHR were consistent with the corresponding figures in other populations of children and adolescents with different racial and ethnic backgrounds. Thus, it is suggested that the use of these indexes can be generalized in programs aiming to screen elevated blood pressure in the pediatric age group. Copyright © 2013 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.

Impact of renal denervation on 24-hour ambulatory blood pressure: results from SYMPLICITY HTN-3.

PubMed

Bakris, George L; Townsend, Raymond R; Liu, Minglei; Cohen, Sidney A; D'Agostino, Ralph; Flack, John M; Kandzari, David E; Katzen, Barry T; Leon, Martin B; Mauri, Laura; Negoita, Manuela; O'Neill, William W; Oparil, Suzanne; Rocha-Singh, Krishna; Bhatt, Deepak L

2014-09-16

Prior studies of catheter-based renal artery denervation have not systematically performed ambulatory blood pressure monitoring (ABPM) to assess the efficacy of the procedure. SYMPLICITY HTN-3 (Renal Denervation in Patients With Uncontrolled Hypertension) was a prospective, blinded, randomized, sham-controlled trial. The current analysis details the effect of renal denervation or a sham procedure on ABPM measurements 6 months post-randomization. Patients with resistant hypertension were randomized 2:1 to renal denervation or sham control. Patients were on a stable antihypertensive regimen including maximally tolerated doses of at least 3 drugs including a diuretic before randomization. The powered secondary efficacy endpoint was a change in mean 24-h ambulatory systolic blood pressure (SBP). Nondipper to dipper (nighttime blood pressure [BP] 10% to 20% lower than daytime BP) conversion was calculated at 6 months. The 24-h ambulatory SBP changed -6.8 ± 15.1 mm Hg in the denervation group and -4.8 ± 17.3 mm Hg in the sham group: difference of -2.0 mm Hg (95% confidence interval [CI]: -5.0 to 1.1; p = 0.98 with a 2 mm Hg superiority margin). The daytime ambulatory SBP change difference between groups was -1.1 (95% CI: -4.3 to 2.2; p = 0.52). The nocturnal ambulatory SBP change difference between groups was -3.3 (95 CI: -6.7 to 0.1; p = 0.06). The percent of nondippers converted to dippers was 21.2% in the denervation group and 15.0% in the sham group (95% CI: -3.8% to 16.2%; p = 0.30). Change in 24-h heart rate was -1.4 ± 7.4 in the denervation group and -1.3 ± 7.3 in the sham group; (95% CI: -1.5 to 1.4; p = 0.94). This trial did not demonstrate a benefit of renal artery denervation on reduction in ambulatory BP in either the 24-h or day and night periods compared with sham (Renal Denervation in Patients With Uncontrolled Hypertension [SYMPLICITY HTN-3]; NCT01418261). Copyright © 2014 American College of Cardiology Foundation. Published by

Renal denervation after Symplicity HTN-3: an update.

PubMed

Persu, Alexandre; Jin, Yu; Fadl Elmula, Fadl Elmula Mohamed; Jacobs, Lotte; Renkin, Jean; Kjeldsen, Sverre

2014-08-01

After three years of excessive confidence, overoptimistic expectations and performance of 15 to 20,000 renal denervation procedures in Europe, the failure of a single well-designed US trial--Symplicity HTN-3--to meet its primary efficacy endpoint has cast doubt on renal denervation as a whole. The use of a sound methodology, including randomisation and blinded endpoint assessment was enough to see the typical 25-30 mmHg systolic blood pressure decrease observed after renal denervation melt down to less than 3 mmHg, the rest being likely explained by Hawthorne and placebo effects, attenuation of white coat effect, regression to the mean and other physician and patient-related biases. The modest blood pressure benefit directly assignable to renal denervation should be balanced with unresolved safety issues, such as potentially increased risk of renal artery stenosis after the procedure (more than ten cases reported up to now, most of them in 2014), unclear long-term impact on renal function and lack of morbidity-mortality data. Accordingly, there is no doubt that renal denervation is not ready for clinical use. Still, renal denervation is supported by a strong rationale and is occasionally followed by major blood pressure responses in at-risk patients who may otherwise have remained uncontrolled. Upcoming research programmes should focus on identification of those few patients with truly resistant hypertension who may derive a substantial benefit from the technique, within the context of well-designed randomised trials and independent registries. While electrical stimulation of baroreceptors and other interventional treatments of hypertension are already "knocking at the door", the premature and uncontrolled dissemination of renal denervation should remain an example of what should not be done, and trigger radical changes in evaluation processes of new devices by national and European health authorities.

Hypertension Due to Toxic White Crystals in the Diet: Should We Blame Salt or Sugar?

PubMed

DiNicolantonio, James J; O'Keefe, James H

The "Salt Hypothesis" is the notion that an increase in salt intake will increase blood pressure and thus increase the risk of cardiovascular disease (CVD),which has been a point of contention for decades. Despite this, numerous health organizations, dietary guidelines, and government policies advocate population-wide salt restriction. However, there is no conclusive proof that restricting salt intake reduces the risk of hypertension (HTN) and/or CVD events; sodium restriction in fact may paradoxically lead to adverse health outcomes. Importantly, another white crystal, sucrose (or table sugar) but also high-fructose corn syrup are much more detrimental food additives. Indeed, added sugars have the ability to induce hypertension via the promotion of inflammation, oxidative stress, insulin resistance, and obesity. Considering that there is no physiologic requirement for dietary carbohydrate, there is little reason to suspect adverse health consequences from cutting back on sugar. This paper reviews the evidence relating to salt and sugar on HTN and CVD. Based on our review of the scientific literature, guidelines should focus more on reducing sugar rather than salt for the prevention and treatment of HTN and its consequences. Copyright © 2016 Elsevier Inc. All rights reserved.

Resistant and Refractory Hypertension: Antihypertensive Treatment Resistance vs Treatment Failure

PubMed Central

Siddiqui, Mohammed; Dudenbostel, Tanja; Calhoun, David A.

2017-01-01

Resistant or difficult to treat hypertension is defined as high blood pressure that remains uncontrolled with 3 or more different antihypertensive medications, including a diuretic. Recent definitions also include controlled blood pressure with use of 4 or more medications as also being resistant to treatment. Recently, refractory hypertension, an extreme phenotype of antihypertensive treatment failure has been defined as hypertension uncontrolled with use of 5 or more antihypertensive agents, including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist. Patients with resistant vs refractory hypertension share similar characteristics and comorbidities, including obesity, African American race, female sex, diabetes, coronary heart disease, chronic kidney disease, and obstructive sleep apnea. Patients with refractory vs resistant hypertension tend to be younger and are more likely to have been diagnosed with congestive heart failure. Refractory hypertension might also differ from resistant hypertension in terms of underlying cause. Preliminary evidence suggests that refractory hypertension is more likely to be neurogenic in etiology (ie, heightened sympathetic tone), vs a volume-dependent hypertension that is more characteristic of resistant hypertension in general. PMID:26514749

Test-retest reliability of the Mandarin versions of the Hypertension Self-Care Profile instrument.

PubMed

Ngoh, Soh Heng Agnes; Lim, Hazel Wai Ling; Koh, Yi Ling Eileen; Tan, Ngiap Chuan

2017-11-01

Self-efficacy in essential hypertension can be measured using scales, such as the "Hypertension Self-Care Profile" (HTN-SCP) questionnaire. It assesses "Behavior", "Motivation", and "Self-efficacy" in 3 domains, respectively. This study aimed to validate the Mandarin version of HTN-SCP instrument (HTN-SCP-Mn) targeted at patients of Chinese ethnicity with hypertension.Our study recruited Chinese patients, aged 40 years and older, with essential hypertension from a public primary healthcare clinic in Singapore. The 60-item HTN-SCP-Mn questionnaire was completed online using a tablet or smartphone on enrolment. A retest was conducted 2 weeks after the initial test. Reliability was assessed by internal consistency and test-retest reliability using Cronbach alpha and intraclass correlation coefficients (ICC). Differences between the overall HTN-SCP-Mn scores of the patients and their self-reported self-management activities were also determined using independent t test.Of the 153 patients who completed the HTN-SCP-Mn during the initial test, 79 responded to the test-retest evaluation. Reliability of the 3 domains "Behavior", "Motivation", and "Self-efficacy" obtained high internal consistency (Cronbach alpha = 0.838, 0.929, and 0.927, respectively). The item total correlation ranged from 0.058 to 0.677 for Behavior, 0.374 to 0.798 for Motivation, and 0.326 to 0.767 for self-efficacy. The ICC indicated fair to good test-retest reliability with scores of 0.643, 0.579, and 0.710 for the respective domains.The results showed face validity of the HTN-SCP-Mn instrument, indicating its potential application in mandarin-proficient patients. Further study is needed to correlate its scores with objective demonstration of self-efficacy.

Cardiovascular dysfunctions and sympathovagal imbalance in hypertension and prehypertension: physiological perspectives.

PubMed

Pal, Gopal Krushna; Pal, Pravati; Nanda, Nivedita; Amudharaj, Dharmalingam; Adithan, Chandrasekaran

2013-01-01

Hypertension (HTN) and prehypertension (pre-HTN) have been identified as independent risk factors for adverse cardiovascular events. Recently, increased psychosocial stress and work stress have contributed to the increased prevalence of HTN and pre-HTN, in addition to the contribution of obesity, diabetes, poor food habits and physical inactivity. Irrespective of the etiology, sympathetic overactivity has been recognized as the main pathophysiologic mechanism in the genesis of HTN and pre-HTN. Sympathovagal imbalance owing to sympathetic overactivity and vagal withdrawal is reported to be the basis of many clinical disorders. However, the role played by vagal withdrawal has been under-reported. In this review, we have analyzed the pathophysiologic involvement of sympathovagal imbalance in the development of HTN and pre-HTN, and the link of sympathovagal imbalance to cardiovascular dysfunctions. We have emphasized that adaptation to a healthier lifestyle will help improve sympathovagal homeostasis and prevent the occurrence of HTN and pre-HTN.

Treatment of sunitinib-induced hypertension in solid tumor by nitric oxide donors☆

PubMed Central

León-Mateos, L.; Mosquera, J.; Antón Aparicio, L.

2015-01-01

Vascular endothelial growth factor (VEGF) and its receptor (VEGFR) are overexpressed in the majority of renal cell carcinomas. This characteristic has supported the rationale of targeting VEGF-driven tumour vascularization, especially in clear cell RCC. VEGF-inhibiting strategies include the use of tyrosine kinase inhibitors (sunitinib, axitinib, pazopanib, and sorafenib) and neutralizing antibodies such as bevacizumab. Hypertension (HTN) is one of the most common adverse effects of angiogenesis inhibitors. HTN observed in clinical trials appears to correlate with the potency of VEGF kinase inhibitor against VEGFR-2: agents with higher potency are associated with a higher incidence of HTN. Although the exact mechanism by tyrosine kinase inhibitors induce HTN has not yet been completely clarified, two key hypotheses have been postulated. First, some studies have pointed to a VEGF inhibitors-induced decrease in nitric oxide synthase (NOS) and nitric oxide (NO) production, that can result in vasoconstriction and increased blood pressure. VEGF, mediated by PI3K/Akt and MAPK pathway, upregulates the endothelial nitric oxide synthase enzyme leading to up-regulation of NO production. So inhibition of signaling through the VEGF pathway would lead to a decrease in NO production, resulting in an increase in vascular resistance and blood pressure. Secondly a decrease in the number of microvascular endothelial cells and subsequent depletion of normal microvessel density (rarefaction) occurs upon VEGF signaling inhibition. NO donors could be successfully used not only for the treatment of developed angiogenesis-inhibitor-induced hypertension but also for preventive effects. PMID:26386874

Hypertension is associated with cognitive decline in elderly people at high risk for dementia.

PubMed

Wysocki, Michael; Luo, Xiaodong; Schmeidler, James; Dahlman, Karen; Lesser, Gerson T; Grossman, Hillel; Haroutunian, Vahram; Beeri, Michal Schnaider

2012-02-01

Cardiovascular risk factors including hypertension (HTN) have been shown to increase the risk of Alzheimer disease. The current study investigated whether individuals with HTN are more susceptible to increased cognitive decline and whether the influence of HTN on cognitive decline varied as a function of dementia severity. A total of 224 nursing home and assisted living residents, with a mean age of 84.9 (±7.6) years, were assessed longitudinally with Mini Mental State Exams (MMSEs) and Clinical Dementia Ratings (CDR). Baseline dementia status was defined by the CDR score. As described in , MMSE scores in persons with HTN and questionable dementia (CDR = 0.5) declined significantly faster than nonhypertensive questionably demented persons. Hypertensive participants did not decline significantly faster than nonhypertensive participants in persons with intact cognition (CDR = 0) or frank dementia (CDR ≥ 1). These results suggest an increased risk of subsequent cognitive decline in hypertensive individuals who are especially vulnerable to developing dementia and raises the possibility that avoiding or controlling HTN might reduce the rate of cognitive decline in cognitively vulnerable individuals, potentially delaying their conversion to full-fledged dementia.

Regression to the Mean in SYMPLICITY HTN-3: Implications for Design and Reporting of Future Trials.

PubMed

Pocock, Stuart J; Bakris, George; Bhatt, Deepak L; Brar, Sandeep; Fahy, Martin; Gersh, Bernard J

2016-11-01

Regression to the mean (RTM) describes the tendency for an extreme measurement on 1 occasion to become less extreme when measured again. RTM may affect clinical trial data interpretation when the outcome measure has high variability. We investigated RTM in the SYMPLICITY HTN-3 (Renal Denervation in Patients With Uncontrolled Hypertension) trial of renal denervation versus a sham procedure. Analysis of covariance was performed on the 6-month change in systolic blood pressure, estimating a mean treatment difference of -4.11 mm Hg (95% confidence interval: -8.44 to 0.22 mm Hg; p = 0.064), which was similar to the unadjusted difference but with a smaller confidence interval. RTM occurred in both arms, but it had a negligible effect on the observed treatment difference. A second example concerns changes in hemoglobin A1c in a nonrandomized study. These findings emphasize the importance of incorporating RTM and analysis of covariance into the design and reporting of clinical studies of how treatments affect time changes in quantitative outcomes. (Renal Denervation in Patients With Uncontrolled Hypertension [SYMPLICITY HTN-3]; NCT01418261). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Rationale and design of the Investigator-Steered Project on Intravascular Renal Denervation for Management of Drug-Resistant Hypertension (INSPiRED) trial.

PubMed

Jin, Yu; Jacobs, Lotte; Baelen, Marie; Thijs, Lutgarde; Renkin, Jean; Hammer, Frank; Kefer, Joelle; Petit, Thibault; Verhamme, Peter; Janssens, Stefan; Sinnaeve, Peter; Lengelé, Jean-Philippe; Persu, Alexandre; Staessen, Jan A

2014-06-01

The SYMPLICITY studies showed that renal denervation (RDN) is feasible as novel treatment for resistant hypertension. However, RDN is a costly and invasive procedure, the long-term efficacy and safety of which has not yet been proven. Therefore, we designed the INSPiRED trial to compare the blood pressure lowering efficacy and safety of RDN vs usual medical therapy. INSPiRED is a randomized controlled trial enrolling 240 treatment-resistant hypertensive patients at 16 expert hypertension centres in Belgium. Eligible patients, aged 20-69 years old, have a 24-h ambulatory blood pressure of 130 mmHg systolic or 80 mmHg diastolic or more, while taking at least three antihypertensive drugs. They are randomized to RDN (EnligHTN(TM), SJM system) plus usual care (intervention group) or usual care alone (control group) in a ratio of 1:1. The primary endpoints for efficacy and safety, measured after 6 months, are the baseline-adjusted between-group differences in 24h systolic blood pressure and in glomerular filtration rate as estimated by the Chronic Kidney Disease Epidemiology Collaboration equation. Follow-up will continue up to 36 months after randomization. INSPiRED is powered to demonstrate a 10-mmHg difference in systolic blood pressure between randomized groups with a two-sided p-value of 0.01 and 90% power. It will generate long-term efficacy and safety data, identify the subset of treatment-resistant hypertensive patients responsive to RDN, provide information on cost-effectiveness, and by doing so INSPiRED will inform guideline committees and health policy makers. ClinicalTrials.gov Identifier: NCT 01505010.

Apparent and true resistant hypertension: definition, prevalence and outcomes

PubMed Central

Judd, E; Calhoun, DA

2014-01-01

Resistant hypertension, defined as blood pressure (BP) remaining above goal despite the use of ≥3 antihypertensive medications at maximally tolerated doses (one ideally being a diuretic) or BP that requires ≥4 agents to achieve control, has received more attention with increased efforts to improve BP control rates and the emergence of device-based therapies for hypertension. This classically defined resistant group consists of patients with true resistant hypertension, controlled resistant hypertension and pseudo-resistant hypertension. In studies where pseudo-resistant hypertension cannot be excluded (for example, 24-h ambulatory BP not obtained), the term apparent resistant hypertension has been used to identify ‘apparent’ lack of control on ≥3 medications. Large, well-designed studies have recently reported the prevalence of resistant hypertension. Pooling prevalence data from these studies and others within North America and Europe with a combined sample size of >600 000 hypertensive participants, the prevalence of resistant hypertension is 14.8% of treated hypertensive patients and 12.5% of all hypertensives. However, the prevalence of true resistant hypertension, defined as uncontrolled both by office and 24-h ambulatory BP monitoring with confirmed medication adherence, may be more meaningful in terms of identifying risk and estimating benefit from newer therapies like renal denervation. Rates of cardiovascular events and mortality follow mean 24-h ambulatory BPs in patients with resistant hypertension, and true resistant hypertension represents the highest risk. The prevalence of true resistant hypertension has not been directly measured in large trials; however, combined data from smaller studies suggest that true resistant hypertension is present in half of the patients with resistant hypertension who are uncontrolled in the office. Our pooled analysis shows prevalence rates of 10.1% and 7.9% for uncontrolled resistant hypertension among

Use of aldosterone antagonists in resistant hypertension.

PubMed

Calhoun, David A

2006-01-01

Resistant hypertension is defined as an elevated blood pressure in spite of treatment with 3 different antihypertensive agents. The prevalence of resistant hypertension is unknown, but recent cross-sectional analyses and hypertension outcome studies suggest it is a common clinical problem and will become even more so with an aging and increasingly heavy population. Secondary causes of hypertension are common in patients with resistant hypertension, in particular, obstructive sleep apnea and hyperaldosteronism. Treatment of resistant hypertension is predicated upon identification and reversal of secondary causes of hypertension, as possible, and effective use of multidrug regimens. Recent clinical studies indicate that aldosterone antagonists, spironolactone and amiloride, provide significant additional blood pressure reduction when added to treatment regimens of patients with resistant hypertension. Both agents are generally well tolerated. Hyperkalemia is an uncommon complication of aldosterone antagonists, but it can occur; therefore, biochemical monitoring is necessary, particularly in high-risk patients.

Characterization of resistant hypertension: association between resistant hypertension, aldosterone, and persistent intravascular volume expansion.

PubMed

Gaddam, Krishna K; Nishizaka, Mari K; Pratt-Ubunama, Monique N; Pimenta, Eduardo; Aban, Inmaculada; Oparil, Suzanne; Calhoun, David A

2008-06-09

Resistant hypertension is a common clinical problem and greatly increases the risk of target organ damage. We evaluated the characteristics of 279 consecutive patients with resistant hypertension (uncontrolled despite the use of 3 antihypertensive agents) and 53 control subjects (with normotension or hypertension controlled by using resistant hypertension vs controls. Of patients with resistant hypertension, men had significantly higher plasma aldosterone (P = .003), aldosterone to renin ratio (P = .02), 24-hour UAldo (P < .001), and urinary cortisol (P < .001) values than women. In univariate linear regression analysis, body mass index (P = .01), serum potassium (P < .001), urinary cortisol (P < .001), urinary sodium (P = .02), and urinary potassium (P < .001) values were correlated with 24-hour UAldo levels. Serum potassium (P = .001), urinary potassium (P < .001), and urinary sodium (P = .03) levels were predictors of 24-hour UAldo levels in multivariate modeling. Aldosterone levels are higher and there is evidence of intravascular volume expansion (higher brain-type and atrial natriuretic peptide levels) in patients with resistant hypertension vs controls. These differences are most pronounced in men. A significant correlation between 24-hour urinary aldosterone levels and cortisol excretion suggests that a common stimulus, such as

Resistant Hypertension and Chronotherapy

PubMed Central

Prkacin, Ingrid; Balenovic, Diana; Djermanovic-Dobrota, Vesna; Lukac, Iva; Drazic, Petra; Pranjic, Iva-Klara

2015-01-01

Resistant hypertension is defined as blood pressure that remains above 140/90 mmHg in spite of the continuous use of three antihypertensive agents in optimal dose, including diuretic, and lifestyle changes. According to data from United States of America and Europe, the prevalence ranges from 10 up to 30% in patients with hypertension. Numerous biological and lifestyle factors can contribute to the development of resistant hypertension: medications, volume overload, obesity, diabetes mellitus, older age, renal parenchymal and renovascular disease, primary aldosteronism, obstructive sleep apnea, pheochormocytoma, Cushing’s syndrome, thyroid diseases, aortic coarctation. For diagnosing patient’s history is important, assessing compliance, regular blood pressure measurement, physical examination, biochemical evaluation and noninvasive imaging. The evaluation including 24h ambulatory monitoring of blood pressure (ABPM) in the identification of “non-dipper” hypertension. Non-dipper has particular importance and the prevalence of abnormally high sleep blood pressure is very often in chronic kidney patients. Therapeutic restoration of normal physiologic blood pressure reduction during night-time sleep (circadial variation) is the most significant independent predictor of decreased risk and the basis for the chronotherapy. The resistant hypertension treatment is achieved with nonpharmacological and pharmacological approach, treating secondary hypertension causes and invasive procedures. PMID:26005390

Hypertension and overall survival in metastatic colorectal cancer patients treated with bevacizumab-containing chemotherapy.

PubMed

Österlund, P; Soveri, L-M; Isoniemi, H; Poussa, T; Alanko, T; Bono, P

2011-02-15

Hypertension (HTN) is a common toxicity of anti-VEGF (vascular endothelial growth factor) antibody treatment. It may be a marker of VEGF signalling pathway inhibition and therefore represent a cancer biomarker in metastatic colorectal cancer (mCRC) patients treated with chemotherapy and bevacizumab. A total of 101 consecutive patients with mCRC were treated with standard chemotherapy combined with bevacizumab at dose of 2.5 mg kg(-1) per week in a single centre. The median follow-up time of the patients alive was 64 months. Blood pressure was measured before each bevacizumab infusion, and HTN was graded according to common toxicity criteria for adverse events version 3.0. Overall, 57 patients (56%) developed ≥grade 1 HTN (median blood pressure 168/97 mm Hg), whereas 44 (44%) remained normotensive when treated with bevacizumab-containing chemotherapy regimen. Overall response rate was higher among patients with HTN (30 vs 20%; P=0.025). Hypertension was associated with improved progression-free survival (10.5 vs 5.3 months; P=0.008) and overall survival (25.8 vs 11.7 months; P<0.001), and development of HTN within 3 months had an independent, prognostic influence in a multivariate landmark survival analysis together with other known mCRC prognostic factors (P=0.007). There was no association between HTN and development of thromboembolic complications. Hypertension may predict outcome of bevacizumab-containing chemotherapy in mCRC. These data require confirmation in prospective studies including pharmacodynamic and pharmacokinetic analyses.

Resistant or difficult-to-treat hypertension.

PubMed

Calhoun, David A

2006-03-01

Resistant hypertension, defined as uncontrolled hypertension on three medications, is becoming an increasingly common problem. In most cases, blood pressure remains elevated because of persistently high systolic blood pressure levels. Common characteristics of patients with resistant hypertension include older age, obesity, excessive dietary salt ingestion, and presence of sleep apnea. The evaluation of patients with resistant hypertension is focused on identifying contributing and secondary causes of hypertension. Treatment should include both lifestyle changes (weight loss, exercise, dietary salt restriction) and the use of effective multidrug regimens, including a diuretic. Recent data indicate that aldosterone antagonists may be effective when added to existing antihypertensive regimens even in the absence of primary aldosteronism.

Renal denervation for resistant hypertension.

PubMed

Almeida, Manuel de Sousa; Gonçalves, Pedro de Araújo; Oliveira, Eduardo Infante de; Carvalho, Henrique Cyrne de

2015-02-01

There is a marked contrast between the high prevalence of hypertension and the low rates of adequate control. A subset of patients with suboptimal blood pressure control have drug-resistant hypertension, in the pathophysiology of which chronic sympathetic hyperactivation is significantly involved. Sympathetic renal denervation has recently emerged as a device-based treatment for resistant hypertension. In this review, the pathophysiological mechanisms linking the sympathetic nervous system and cardiovascular disease are reviewed, focusing on resistant hypertension and the role of sympathetic renal denervation. An update on experimental and clinical results is provided, along with potential future indications for this device-based technique in other cardiovascular diseases. Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Expression and methylation of circulating microRNA-510 in essential hypertension.

PubMed

Krishnan, Ramalingam; Mani, Panagal; Sivakumar, Pethanen; Gopinath, Vincent; Sekar, Durairaj

2017-04-01

Hypertension (HTN) is one of the most common emerging disease in developing countries. It alters endothelial cell structure and function, resulting in several diseases, such as cardiovascular disease, peripheral vasculopathy, cerebrovascular disease and nephropathy. Although much progress has been made in researching HTN in recent years, early diagnosis and treatment of HTN are not yet satisfactory, and progression control/treatment is still poor. MicroRNAs are well-known regulators of the physiological and developmental processes of HTN. Our results revealed that miR-510 was upregulated in blood samples from HTN patients, whereas no significant differences were observed in the control samples. Methylation analyses corroborated the miR-510 upregulation in patient samples. These results suggested that miR-510 can be used as a novel biomarker for diagnosis and as a new therapeutic target for HTN.

Missed opportunities to improve the health of postpartum women: high rates of untreated hypertension in rural Tanzania

PubMed Central

Larson, Elysia; Rabkin, Miriam; Mbaruku, Godfrey M.; Mbatia, Redempta; Kruk, Margaret E.

2017-01-01

Objectives To assess the prevalence of high blood pressure amongst postpartum women in rural Tanzania, and to explore factors associated with hypertension prevalence, awareness of their own hypertension, treatment, and control. Methods We conducted a cross-sectional study of 1,849 women in Tanzania’s Pwani Region who delivered a child in the prior year. We measured blood pressure, administered a structured questionnaire, and assessed factors associated with hypertension (HTN) prevalence, women’s awareness of their own HTN, treatment, and control of HTN using bivariable and multivariable logistic regressions. Findings 26.7% of women had high blood pressure and/or were taking antihypertensive medication. Women were on average 27.5 years old (range 15–54). Nearly all women (99.5%) reported contact with the health system during their pregnancy and delivery, with 97.0% reporting at least one antenatal care visit, 81.4% reporting facility delivery, and an overall average of 5.2 visits for their own care in the past year. Only 23.5% of those with HTN were aware of their diagnosis, 17.4% were taking medication, and only 10.5% had controlled blood pressure. In multivariable analysis, facility delivery, health insurance, and increased distance from a hospital were associated with increased likelihood of HTN awareness; facility delivery and hospital distance were associated with current hypertensive treatment; younger age and increased hospital distance were associated with control of HTN. Conclusion The prevalence of high blood pressure in this postpartum population was high, and despite frequent recent contacts with the health system, awareness, treatment and control of HTN were low. These findings highlight an important missed opportunity to improve women’s health during antenatal and postnatal care. PMID:28120288

Refractory and Resistant Hypertension: Antihypertensive Treatment Failure versus Treatment Resistance

PubMed Central

2016-01-01

Resistant hypertension has for many decades been defined as difficult-to-treat hypertension in order to identify patients who may benefit from special diagnostic and/or therapeutic considerations. Recently, the term "refractory hypertension" has been proposed as a novel phenotype of antihypertensive failure, that is, patients whose blood pressure cannot be controlled with maximal treatment. Early studies of this phenotype indicate that it is uncommon, affecting less than 5% of patients with resistant hypertension. Risk factors for refractory hypertension include obesity, diabetes, chronic kidney disease, and especially, being of African origin. Patients with refractory are at high cardiovascular risk based on increased rates of known heart disease, prior stroke, and prior episodes of congestive heart failure. Mechanisms of refractory hypertension need exploration, but early studies suggest a possible role of heightened sympathetic tone as evidenced by increased office and ambulatory heart rates and higher urinary excretion of norepinephrine compared to patients with controlled resistant hypertension. Important negative findings argue against refractory hypertension being fluid dependent as is typical of resistant hypertension, including aldosterone levels, dietary sodium intake, and brain natriuretic peptide levels being similar or even less than patients with resistant hypertension and the failure to control blood pressure with use of intensive diuretic therapy, including both a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist. Further studies, especially longitudinal assessments, are needed to better characterize this extreme phenotype in terms of risk factors and outcomes and hopefully to identify effective treatment strategies. PMID:27721847

Cardiovascular and Metabolic Predictors of Progression of Prehypertension into Hypertension: The Strong Heart Study

PubMed Central

De Marco, Marina; de Simone, Giovanni; Roman, Mary J; Chinali, Marcello; Lee, Elisa T; Russell, Marie; Howard, Barbara V; Devereux, Richard B

2009-01-01

Prehypertension (defined by JNC-7) frequently evolves to hypertension (HTN) and increases cardiovascular risk. It is unclear whether metabolic and/or cardiac characteristics favor development of HTN in prehypertensive subjects. We evaluated baseline anthropometric, laboratory and echocardiographic characteristics of 625 untreated prehypertensive participants in the Strong Heart Study (SHS), without prevalent cardiovascular disease (63% women; 22% diabetes; mean age 59±7 years) to identify predictors of 4-year incidence of hypertension. Diabetes was assessed by ADA criteria and diabetes-specific definition of hypertension was used. Four-year incidence of HTN was 38%. Incident HTN was independently predicted by baseline systolic blood pressure (OR= 1.60 per 10 mmHg, 95% CI=1.30-2.00; p<0.0001), waist circumference (OR=1.10 per 10 cm, 95% CI=1.01-1.30; p=0.04) and diabetes (OR= 2.73, 95% CI=1.77-4.21; p<0.0001), with no significant effect for age, gender, HbA1c, HOMA index, CRP, fibrinogen, LDL-HDL cholesterol, tryglicerides, plasma creatinine or urine albumin/creatinine. Higher left ventricular mass index (OR=1.15 per 5 g/m2.7, 95% CI=1.01-1.25; p= 0.03) or stroke volume index (OR=1.25 per 5 ml/m2.04, 95% CI=1.10-1.50; p= 0.03) were also identified, together with baseline systolic blood pressure and presence of diabetes, as independent predictors of incident HTN, without additional predictive contribution from other anthropometric, metabolic or echocardiographic parameters (all p>0.10). Thus, progression to HTN in 38% of SHS pre-hypertensive participants could be predicted by higher left ventricular mass and stroke volume in addition to baseline systolic blood pressure and prevalent diabetes. PMID:19720957

Vascular Smooth Muscle Cells From Hypertensive Patient-Derived Induced Pluripotent Stem Cells to Advance Hypertension Pharmacogenomics.

PubMed

Biel, Nikolett M; Santostefano, Katherine E; DiVita, Bayli B; El Rouby, Nihal; Carrasquilla, Santiago D; Simmons, Chelsey; Nakanishi, Mahito; Cooper-DeHoff, Rhonda M; Johnson, Julie A; Terada, Naohiro

2015-12-01

Studies in hypertension (HTN) pharmacogenomics seek to identify genetic sources of variable antihypertensive drug response. Genetic association studies have detected single-nucleotide polymorphisms (SNPs) that link to drug responses; however, to understand mechanisms underlying how genetic traits alter drug responses, a biological interface is needed. Patient-derived induced pluripotent stem cells (iPSCs) provide a potential source for studying otherwise inaccessible tissues that may be important to antihypertensive drug response. The present study established multiple iPSC lines from an HTN pharmacogenomics cohort. We demonstrated that established HTN iPSCs can robustly and reproducibly differentiate into functional vascular smooth muscle cells (VSMCs), a cell type most relevant to vasculature tone control. Moreover, a sensitive traction force microscopy assay demonstrated that iPSC-derived VSMCs show a quantitative contractile response on physiological stimulus of endothelin-1. Furthermore, the inflammatory chemokine tumor necrosis factor α induced a typical VSMC response in iPSC-derived VSMCs. These studies pave the way for a large research initiative to decode biological significance of identified SNPs in hypertension pharmacogenomics. Treatment of hypertension remains suboptimal, and a pharmacogenomics approach seeks to identify genetic biomarkers that could be used to guide treatment decisions; however, it is important to understand the biological underpinnings of genetic associations. Mouse models do not accurately recapitulate individual patient responses based on their genetics, and hypertension-relevant cells are difficult to obtain from patients. Induced pluripotent stem cell (iPSC) technology provides a great interface to bring patient cells with their genomic data into the laboratory and to study hypertensive responses. As an initial step, the present study established an iPSC bank from patients with primary hypertension and demonstrated an effective

Is the failure of SYMPLICITY HTN-3 trial to meet its efficacy endpoint the "end of the road" for renal denervation?

PubMed

Epstein, Murray; de Marchena, Eduardo

2015-02-01

Resistant hypertension is a common medical problem that is increasing with the advent of an increasingly older and heavier population. The etiology of resistant hypertension is almost always multifactorial, but the results of numerous studies indicate that renal sympathetic activation is a particularly common cause of resistance to antihypertensive treatment. Consistent with the belief in a pivotal role of renal sympathetic stimulation, there has been a growing interest in renal denervation (RDN) treatment strategies. The long-awaited results of SYMPLICITY HTN-3 study disclosed that the reduction in blood pressure by the SYMPLICITY device did not differ from that in the sham-procedure arm of the study. In the present article, we identify several factors that explain why the study failed to demonstrate any benefit from the intervention. The reasons are multifactorial and include inadequate screening at entry and frequent medication changes during the study. Additional problems include the lack of experience of many operators with the SYMPLICITY device and procedure variability, as attested to by a diminished number of ablation "quadrants." Also a factor was the inability of the first generation Medtronic device to allow four ablations to be performed simultaneously. We recommend that future RDN studies adhere to more rigorous screening procedures, and utilize newer multi-site denervation systems that facilitate four ablations simultaneously. Drug optimization should be achieved by monitoring adherence throughout the study. Nevertheless, we are optimistic about a future role of RDN. To optimize chances of success, increased efforts are necessary to identify the appropriate patients for RDN and investigators must use second and third generation denervation devices and techniques. Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Non-interventional management of resistant hypertension

PubMed Central

Doumas, Michael; Tsioufis, Costas; Faselis, Charles; Lazaridis, Antonios; Grassos, Haris; Papademetriou, Vasilios

2014-01-01

Hypertension is one of the most popular fields of research in modern medicine due to its high prevalence and its major impact on cardiovascular risk and consequently on global health. Indeed, about one third of individuals worldwide has hypertension and is under increased long-term risk of myocardial infarction, stroke or cardiovascular death. On the other hand, resistant hypertension, the “uncontrollable” part of arterial hypertension despite appropriate therapy, comprises a much greater menace since long-standing, high levels of blood pressure along with concomitant debilitating entities such as chronic kidney disease and diabetes mellitus create a prominent high cardiovascular risk milieu. However, despite the alarming consequences, resistant hypertension and its effective management still have not received proper scientific attention. Aspects like the exact prevalence and prognosis are yet to be clarified. In an effort to manage patients with resistant hypertension appropriately, clinical doctors are still racking their brains in order to find the best therapeutic algorithm and surmount the substantial difficulties in controlling this clinical entity. This review aims to shed light on the effective management of resistant hypertension and provide practical recommendations for clinicians dealing with such patients. PMID:25349652

Effect of 1-Week Yoga-Based Residential Program on Cardiovascular Variables of Hypertensive Patients: A Comparative Study.

PubMed

Metri, Kashinath G; Pradhan, Balaram; Singh, Amit; Nagendra, H R

2018-01-01

Hypertension (HTN) is an important public health concern and a leading cause of morbidity and mortality worldwide. Yoga is a form of mind-body medicine shown to be effective in controlling blood pressure (BP) and reduces cardiac risk factors in HTN. Integrated approach of Yoga therapy (IAYT) is a residential yoga-based lifestyle intervention proven to be beneficial in several health conditions. Aim: To study the efficacy of 1 week of residential IAYT intervention on cardiovascular parameters in hypertensive patients. Twenty hypertensive individuals (7 females) within age range between 30 and 60 years (average; 46.62 ± 9.9 years), who underwent 1 week of IAYT treatment for HTN, were compared with age- gender-matched non-IAYT group (5 females; average age; 47.08 ± 9.69 years) in terms of systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), cardiac output (CO), stroke volume (SV), baroreflex sensitivity (BRS), and total peripheral vascular resistance (TPVR), IAYT program consisted of sessions of asanas, breathing practices, meditation and relaxation techniques, low salt, low-calorie diet, devotional session, and counseling. Individuals in non-IAYT group followed their normal routine. All the variables were assessed before and after one week. Data were analyzed using SPSS version 16. RM-ANOVA was applied to assess within group and between group changes after intervention. There was a significant improvement in SBP ( P = 0.004), DBP ( P = 0.008), MAP (0.03), BRS ( P < 0.001), and TPVR ( P = 0.007) in IAYT, group whereas in control group, we did not find significant difference in any of the variables. Between-group comparison showed a significant improvement in SBP ( P = 0.038), BRS ( P = 0.034), and TPVR ( P = 0.015) in IAYT group as compared to non-IAYT group. One-week IAYT intervention showed an improvement in baroreflex sensitivity, systolic BP, and total peripheral vascular resistance in hypertensive patients. However, further randomized control

Effect of 1-Week Yoga-Based Residential Program on Cardiovascular Variables of Hypertensive Patients: A Comparative Study

PubMed Central

Metri, Kashinath G; Pradhan, Balaram; Singh, Amit; Nagendra, HR

2018-01-01

Introduction: Hypertension (HTN) is an important public health concern and a leading cause of morbidity and mortality worldwide. Yoga is a form of mind–body medicine shown to be effective in controlling blood pressure (BP) and reduces cardiac risk factors in HTN. Integrated approach of Yoga therapy (IAYT) is a residential yoga-based lifestyle intervention proven to be beneficial in several health conditions. Aim: To study the efficacy of 1 week of residential IAYT intervention on cardiovascular parameters in hypertensive patients. Methodology: Twenty hypertensive individuals (7 females) within age range between 30 and 60 years (average; 46.62 ± 9.9 years), who underwent 1 week of IAYT treatment for HTN, were compared with age- gender-matched non-IAYT group (5 females; average age; 47.08 ± 9.69 years) in terms of systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), cardiac output (CO), stroke volume (SV), baroreflex sensitivity (BRS), and total peripheral vascular resistance (TPVR), IAYT program consisted of sessions of asanas, breathing practices, meditation and relaxation techniques, low salt, low-calorie diet, devotional session, and counseling. Individuals in non-IAYT group followed their normal routine. All the variables were assessed before and after one week. Data were analyzed using SPSS version 16. RM-ANOVA was applied to assess within group and between group changes after intervention. Results: There was a significant improvement in SBP (P = 0.004), DBP (P = 0.008), MAP (0.03), BRS (P < 0.001), and TPVR (P = 0.007) in IAYT, group whereas in control group, we did not find significant difference in any of the variables. Between-group comparison showed a significant improvement in SBP (P = 0.038), BRS (P = 0.034), and TPVR (P = 0.015) in IAYT group as compared to non-IAYT group. Conclusion: One-week IAYT intervention showed an improvement in baroreflex sensitivity, systolic BP, and total peripheral vascular resistance in hypertensive

Obesity-hypertension and its relation to other diseases in dogs.

PubMed

Pérez-Sánchez, Alicia Pamela; Del-Angel-Caraza, Javier; Quijano-Hernández, Israel Alejandro; Barbosa-Mireles, Marco Antonio

2015-03-01

Obesity is a chronic disease in which adipose tissue accumulates in such a way that it affects the health of the patient and is associated with a myriad of alterations such as systemic hypertension (HTN). The mechanisms by which obesity causes HTN are complex and involve several organic mechanisms. The objective of this study was to determine the correlation between obesity to HTN in dogs in accordance with recent international protocols (systolic blood pressure >160 mmHg) relating to age, genre, gonadal status, breed and other diseases commonly associated with HTN. A total of 244 dogs were studied, 105 non-obese controls and 139 in the obese group. For both groups, healthy and a variety of diseased dogs were observed; the correlations between pathologies and obesity were studied, paying special attention to diseases whose pathophysiologies could lead to HTN. We conclude that obesity is not a risk factor for dogs to develop HTN, and that HTN present in these patients was related to comorbidities such as chronic kidney disease, cardiopathies and endocrinopathies.

Cardiovascular Hypertensive Crisis: Recent Evidence and Review of the Literature

PubMed Central

Varounis, Christos; Katsi, Vasiliki; Nihoyannopoulos, Petros; Lekakis, John; Tousoulis, Dimitris

2017-01-01

Despite the high prevalence of hypertension (HTN), only a small proportion of the hypertensive patients will ultimately develop hypertensive crisis. In fact, some patients with hypertensive crisis do not report a history of HTN or previous use of antihypertensive medication. The majority of the patients with hypertensive crisis often report non-specific symptoms, whereas heart-related symptoms (dyspnea, chest pain, arrhythmias, and syncope) are less common. Hypertensive crises can be divided into hypertensive emergencies or hypertensive urgencies according to the presence or absence of acute target organ damage, respectively. This differentiation is an extremely useful classification in clinical practice since a different management is needed, which in turn has a significant effect on the morbidity and mortality of these patients. Therefore, it is very crucial for the physician in the emergency department to identify the hypertensive emergencies and to manage them through blood pressure lowering medications in order to avoid further target organ damage or deterioration. The aim of this narrative review is to summarize the recent evidence in an effort to improve the awareness, recognition, risk stratification, and treatment of hypertensive crisis in patients referred to the emergency department. PMID:28119918

Cardiovascular Hypertensive Crisis: Recent Evidence and Review of the Literature.

PubMed

Varounis, Christos; Katsi, Vasiliki; Nihoyannopoulos, Petros; Lekakis, John; Tousoulis, Dimitris

2016-01-01

Despite the high prevalence of hypertension (HTN), only a small proportion of the hypertensive patients will ultimately develop hypertensive crisis. In fact, some patients with hypertensive crisis do not report a history of HTN or previous use of antihypertensive medication. The majority of the patients with hypertensive crisis often report non-specific symptoms, whereas heart-related symptoms (dyspnea, chest pain, arrhythmias, and syncope) are less common. Hypertensive crises can be divided into hypertensive emergencies or hypertensive urgencies according to the presence or absence of acute target organ damage, respectively. This differentiation is an extremely useful classification in clinical practice since a different management is needed, which in turn has a significant effect on the morbidity and mortality of these patients. Therefore, it is very crucial for the physician in the emergency department to identify the hypertensive emergencies and to manage them through blood pressure lowering medications in order to avoid further target organ damage or deterioration. The aim of this narrative review is to summarize the recent evidence in an effort to improve the awareness, recognition, risk stratification, and treatment of hypertensive crisis in patients referred to the emergency department.

Renal denervation for the treatment of resistant hypertension: review and clinical perspective.

PubMed

Iliescu, Radu; Lohmeier, Thomas E; Tudorancea, Ionut; Laffin, Luke; Bakris, George L

2015-10-01

When introduced clinically 6 years ago, renal denervation was thought to be the solution for all patients whose blood pressure could not be controlled by medication. The initial two studies, SYMPLICITY HTN-1 and HTN-2, demonstrated great magnitudes of blood pressure reduction within 6 mo of the procedure and were based on a number of assumptions that may not have been true, including strict adherence to medication and absence of white-coat hypertension. The SYMPLICITY HTN-3 trial controlled for all possible factors believed to influence the outcome, including the addition of a sham arm, and ultimately proved the demise of the initial overly optimistic expectations. This trial yielded a much lower blood pressure reduction compared with the previous SYMPLICITY trials. Since its publication in 2014, there have been many analyses to try and understand what accounted for the differences. Of all the variables examined that could influence blood pressure outcomes, the extent of the denervation procedure was determined to be inadequate. Beyond this, the physiological mechanisms that account for the heterogeneous fall in arterial pressure following renal denervation remain unclear, and experimental studies indicate dependence on more than simply reduced renal sympathetic activity. These and other related issues are discussed in this paper. Our perspective is that renal denervation works if done properly and used in the appropriate patient population. New studies with new approaches and catheters and appropriate controls will be starting later this year to reassess the efficacy and safety of renal denervation in humans. Copyright © 2015 the American Physiological Society.

Renal denervation for the treatment of resistant hypertension: review and clinical perspective

PubMed Central

Iliescu, Radu; Lohmeier, Thomas E.; Tudorancea, Ionut; Laffin, Luke

2015-01-01

When introduced clinically 6 years ago, renal denervation was thought to be the solution for all patients whose blood pressure could not be controlled by medication. The initial two studies, SYMPLICITY HTN-1 and HTN-2, demonstrated great magnitudes of blood pressure reduction within 6 mo of the procedure and were based on a number of assumptions that may not have been true, including strict adherence to medication and absence of white-coat hypertension. The SYMPLICITY HTN-3 trial controlled for all possible factors believed to influence the outcome, including the addition of a sham arm, and ultimately proved the demise of the initial overly optimistic expectations. This trial yielded a much lower blood pressure reduction compared with the previous SYMPLICITY trials. Since its publication in 2014, there have been many analyses to try and understand what accounted for the differences. Of all the variables examined that could influence blood pressure outcomes, the extent of the denervation procedure was determined to be inadequate. Beyond this, the physiological mechanisms that account for the heterogeneous fall in arterial pressure following renal denervation remain unclear, and experimental studies indicate dependence on more than simply reduced renal sympathetic activity. These and other related issues are discussed in this paper. Our perspective is that renal denervation works if done properly and used in the appropriate patient population. New studies with new approaches and catheters and appropriate controls will be starting later this year to reassess the efficacy and safety of renal denervation in humans. PMID:26224718

An Update on Renal Artery Denervation and Its Clinical Impact on Hypertensive Disease

PubMed Central

Kuang, Ye Min; Gan, Gary C. H.; Burgess, David; Denniss, Alan Robert

2015-01-01

Hypertension is a globally prevalent condition, with a heavy clinical and economic burden. It is the predominant risk factor for premature cardiovascular and cerebrovascular disease, and is associated with a variety of clinical disorders including stroke, congestive cardiac failure, ischaemic heart disease, chronic renal failure, and peripheral arterial disease. A significant subset of hypertensive patients have resistant hypertensive disease. In this group of patients, catheter-based renal artery denervation has emerged as a potential therapy, with favourable clinical efficacy and safety in early trials. Additional benefits of this therapy are also being identified and include effects on left ventricular remodeling, cardiac performance, and symptom status in congestive cardiac failure. Utility of renal denervation for the management of resistant hypertension, however, has become controversial since the release of the Symplicity HTN-3 trial, the first large-scale blinded randomised study investigating the efficacy and safety of renal artery denervation. The aim of this paper is to evaluate the history, utility, and clinical efficacy of renal artery denervation technology, including an in-depth appraisal of the current literature and principal trials. PMID:26495305

Prevalence of pseudoresistant hypertension due to inaccurate blood pressure measurement

PubMed Central

Bhatt, Hemal; Siddiqui, Mohammed; Judd, Eric; Oparil, Suzanne; Calhoun, David

2016-01-01

Background The prevalence of pseudoresistant hypertension (HTN) due to inaccurate BP measurement remains unknown. Methods Triage BP measurements and measurements obtained at the same clinic visit by trained physicians were compared in consecutive adult patients referred for uncontrolled resistant HTN (RHTN). Triage BP measurements were taken by the clinic staff during normal intake procedures. BP measurements were obtained by trained physicians using the BpTRU device. The prevalence of uncontrolled RHTN and differences in BP measurements were compared. Results Of 130 patients with uncontrolled RHTN, 33.1% (n=43) were falsely identified as having uncontrolled RHTN based on triage BP measurements. The median (IQR) of differences in systolic BP between pseudoresistant and true resistant groups were 23 (17 – 33) mm Hg and 13 (6 – 21) mm Hg, respectively (P=0.0001). The median (IQR) of differences in diastolic BP between the two groups were 12 (7 – 18) mm Hg and 8 (4 – 11) mm Hg, respectively (P=0.001). Conclusion Triage BP technique overestimated the prevalence of uncontrolled RHTN in approximately 33% of the patients emphasizing the importance of obtaining accurate BP measurements. PMID:27129931

American College of Sports Medicine position stand. Exercise and hypertension.

PubMed

Pescatello, Linda S; Franklin, Barry A; Fagard, Robert; Farquhar, William B; Kelley, George A; Ray, Chester A

2004-03-01

Hypertension (HTN), one of the most common medical disorders, is associated with an increased incidence of all-cause and cardiovascular disease (CVD) mortality. Lifestyle modifications are advocated for the prevention, treatment, and control of HTN, with exercise being an integral component. Exercise programs that primarily involve endurance activities prevent the development of HTN and lower blood pressure (BP) in adults with normal BP and those with HTN. The BP lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise with BP decreasing approximately 5-7 mm HG after an isolated exercise session (acute) or following exercise training (chronic). Moreover, BP is reduced for up to 22 h after an endurance exercise bout (e.g.postexercise hypotension), with greatest decreases among those with highest baseline BP. The proposed mechanisms for the BP lowering effects of exercise include neurohumoral, vascular, and structural adaptations. Decreases in catecholamines and total peripheral resistance, improved insulin sensitivity, and alterations in vasodilators and vasoconstrictors are some of the postulated explanations for the antihypertensive effects of exercise. Emerging data suggest genetic links to the BP reductions associated with acute and chronic exercise. Nonetheless, definitive conclusions regarding the mechanisms for the BP reductions following endurance exercise cannot be made at this time. Individuals with controlled HTN and no CVD or renal complications may participated in an exercise program or competitive athletics, but should be evaluated, treated and monitored closely. Preliminary peak or symptom-limited exercise testing may be warranted, especially for men over 45 and women over 55 yr planning a vigorous exercise program (i.e. > or = 60% VO2R, oxygen uptake reserve). In the interim, while formal evaluation and management are taking place, it is reasonable for the majority of patients to begin moderate intensity

Association between arterial hypertension and nutritional status in adolescents from Goiânia, Goiás, Brazil.

PubMed

de Almeida, Mayara Maria Souza; Guimarães, Rafael Alves; Jardim, Paulo César Brandão Veiga; Sousa, Ana Luiza Lima; de Souza, Márcia Maria

2017-01-01

Adolescents are a population with unique lifestyle challenges, including physical inactivity, inadequate nutrition, and obesity, all of which increase the risk of developing hypertension (HTN). The objective of this study has been to estimate the prevalence of factors associated with hypertension in adolescents in the city of Goiânia City, Central Brazil. Between 2013and2014, a cross-sectional population study on cardiovascular risk in adolescents, was conducted with the participation of 1,586 adolescents in 108 classes at 36 schools (public and private) in Goiânia city. All of the adolescents were interviewed to establish their sociodemographic and behavioral characteristics related to hypertension and nutritional status. Anthropometric and blood pressure data were collected following a protocol. A Poisson regression, stratified by gender, was used to verify the factors associated with HTN. In this mixed-gender group of 1,586 students, the prevalence of HTN was 6.2% (95% CI: 4.6-8.2%) in girls and 14.0% (95% CI: 10.2-18.8%) in boys-about twice as high in boys as in girls (p <0.001). Obesity was independently associated with HTN in both genders. Being overweight was a risk factor for HTN. In addition, there was a positive correlation between the SBP/SBP percentile and the BMI Z-score/Nutritional status (NS)in both genders. A high prevalence of physical inactivity was also observed in the adolescents investigated, especially in the girls. On the other hand, more boys than girls were found to be obese. The results of this investigation revealed the need for strategies to prevent and control HTN and its risk factors, especially in Brazil's schools. In addition to the constant surveillance of HTN prevalence and risk factors (in particular, being overweight or obese), information should be distributed to promote beneficial health behaviors among adolescents.

Hypertension management in the oldest old: Findings from a large long-term care facility.

PubMed

Schwinn, Susan; McKay, Robin; Dinkel, Shirley; Mansfield, Bobbe; Da Cunha, Brooke Faria; Cummins, Savanna; Brunin, Krystal

2017-03-01

The purpose of this quality improvement project was to evaluate hypertension (HTN) management in patients 80 years of age and older who reside in a large, long-term care (LTC) facility. A retrospective chart audit was conducted on 75 charts of patients 80 years of age and older and who had a diagnosis of HTN. Using the 2011 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Expert Consensus Document on Management of Hypertension in the Elderly as a guide, blood pressure readings, significant comorbidities, and antihypertensive medication utilization were analyzed. LTC residents in this sample were often not treated according to expert recommendations. Specifically, analysis revealed overtreatment of uncomplicated HTN and undertreatment of those with comorbid conditions. Additionally, those with diabetes mellitus and chronic kidney disease were infrequently prescribed ace inhibitors/angiotensin receptor blockers, as recommended. Utilizing evidence-based practice (EBP) guidelines affords the best avenue for providing safe and effective treatment of HTN. While expert recommendations are available, researchers seldom recruit frail elders in LTC facilities into treatment investigations. In the absence of population-specific EBP guidelines, nurse practitioners must rely on expert opinion and diagnostic reasoning to individualize HTN treatment to this unique and vulnerable population. ©2016 American Association of Nurse Practitioners.

Renal denervation in treatment-resistant essential hypertension. A randomized, SHAM-controlled, double-blinded 24-h blood pressure-based trial.

PubMed

Mathiassen, Ole N; Vase, Henrik; Bech, Jesper N; Christensen, Kent L; Buus, Niels H; Schroeder, Anne P; Lederballe, Ole; Rickers, Hans; Kampmann, Ulla; Poulsen, Per L; Hansen, Klavs W; Btker, Hans E; Peters, Christian D; Engholm, Morten; Bertelsen, Jannik B; Lassen, Jens F; Langfeldt, Sten; Andersen, Gratien; Pedersen, Erling B; Kaltoft, Anne

2016-08-01

Renal denervation (RDN), treating resistant hypertension, has, in open trial design, been shown to lower blood pressure (BP) dramatically, but this was primarily with respect to office BP. We conducted a SHAM-controlled, double-blind, randomized, single-center trial to establish efficacy data based on 24-h ambulatory BP measurements (ABPM). Inclusion criteria were daytime systolic ABPM at least 145 mmHg following 1 month of stable medication and 2 weeks of compliance registration. All RDN procedures were carried out by an experienced operator using the unipolar Medtronic Flex catheter (Medtronic, Santa Rosa, California, USA). We randomized 69 patients with treatment-resistant hypertension to RDN (n = 36) or SHAM (n = 33). Groups were well balanced at baseline. Mean baseline daytime systolic ABPM was 159 ± 12 mmHg (RDN) and 159 ± 14 mmHg (SHAM). Groups had similar reductions in daytime systolic ABPM compared with baseline at 3 months [-6.2 ± 18.8 mmHg (RDN) vs. -6.0 ± 13.5 mmHg (SHAM)] and at 6 months [-6.1 ± 18.9 mmHg (RDN) vs. -4.3 ± 15.1 mmHg (SHAM)]. Mean usage of antihypertensive medication (daily defined doses) at 3 months was equal [6.8 ± 2.7 (RDN) vs. 7.0 ± 2.5 (SHAM)].RDN performed at a single center and by a high-volume operator reduced ABPM to the same level as SHAM treatment and thus confirms the result of the HTN3 trial. Further, clinical use of RDN for treatment of resistant hypertension should await positive results from double-blinded, SHAM-controlled trials with multipolar ablation catheters or novel denervation techniques.

Task shifting in the management of hypertension in Kinshasa, Democratic Republic of Congo: a cross-sectional study.

PubMed

Lulebo, Aimée M; Kaba, Didine K; Atake, Silvestre E-H; Mapatano, Mala A; Mafuta, Eric M; Mampunza, Julien M; Coppieters, Yves

2017-12-04

The Democratic Republic of the Congo (DRC) is characterized by a high prevalence of hypertension (HTN) and a high proportion of uncontrolled HTN, which is indicative of poor HTN management. Effective management of HTN in the African region is challenging due to limited resources, particularly human resources for health. To address the shortage of health workers, the World Health Organization (WHO) recommends task shifting for better disease management and treatment. Although task shifting from doctors to nurses is being implemented in the DRC, there are no studies, to the best of our knowledge, that document the association between task shifting and HTN control. The aim of this study was to investigate the association between task shifting and HTN control in Kinshasa, DRC. We conducted a cross-sectional study in Kinshasa from December 2015 to January 2016 in five general referral hospitals (GRHs) and nine health centers (HCs). A total of 260 hypertensive patients participated in the study. Sociodemographic, clinical, health care costs and perceived health care quality assessment data were collected using a structured questionnaire. To examine the association between task shifting and HTN control, we assessed differences between GRH and HC patients using bivariate and multivariate analyses. Almost half the patients were female (53.1%), patients' mean age was 59.5 ± 11.4 years. Over three-fourths of patients had uncontrolled HTN. There was no significant difference in the proportion of GRH and HC patients with uncontrolled HTN (76.2% vs 77.7%, p = 0.771). Uncontrolled HTN was associated with co-morbidity (OR = 10.3; 95% CI: 3.8-28.3) and the type of antihypertensive drug used (OR = 4.6; 95% CI: 1.3-16.1). The mean healthcare costs in the GRHs were significantly higher than costs in the HCs (US$ 34.2 ± US$3.34 versus US$ 7.7 ± US$ 0.6, respectively). Uncontrolled HTN was not associated with the type of health facility. This finding suggests that the

2015 Oman Heart Association guidelines for the management of hypertension : practical recommendations from the Oman Heart Association (OHA).

PubMed

El-Deeb, Mohammed H; Sulaiman, Kadhim J; Al-Riyami, Abdullah A; Mohsin, Nabil; Al-Mukhaini, Mohamed; Al-Lamki, Mohamed; Al-Busaidi, Noor; Al-Salmi, Issa; Al-Lawati, Jawad; Al-Rawahi, Najib; Al-Riyami, Mohamed B; Abdul-Rahman, Said; Al-Hinai, Said; Jaffer, Batool; Al-Wahaebi, Ahmed; Al-Khalili, Hanan; Al-Zadjali, Matllooba

2015-03-01

Hypertension (HTN) is a major independent risk factor for the development of stroke, coronary artery disease (CAD), peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD). HTN is a growing public health problem in Oman, almost certainly the most prevalent modifiable risk factor for cardiovascular disease (CVD). The risk of CVD in patients with HTN can be greatly reduced with lifestyle modifications and effective antihypertensive therapy. Randomized trials have shown that blood pressure (BP) lowering produces rapid reductions in CV risk. Several studies have shown that the majority of the hypertensive patients remain uncontrolled. It is well established that the observed poor control of the disease is not only related to poor adherence to medications, but also to limited awareness and adherence to evidence-based management of hypertension among physicians. Several guidelines for the management of patients with hypertension have been published. However, the aim of this document is to provide the busy physicians in Oman with more concise and direct approach towards implementing these guidelines into clinical practice.

Questionnaire survey on pediatric hypertension in Japan and Korea.

PubMed

Yim, Hyung Eun; Lee, Eun Hee; Jang, Gi Young; Yoo, Kee Hwan; Son, Chang Sung; Hong, Young Sook; Lee, Joo Won; Ito, Yuhei; Ikezumi, Yohei; Uchiyama, Makoto

2010-02-01

Hypertension (HTN) is no longer viewed as an adult disease. The purpose of the present study was to understand how hypertensive children are evaluated and managed, by surveying pediatricians in Japan and South Korea. A questionnaire was mailed to 109 Japanese (JA) and 159 Korean (KO) pediatric cardiologists, pediatric nephrologists, and other pediatricians. A total of 127 replies were received (response rate 47%). Most of respondents did not check blood pressure (BP) routinely in outpatient clinics (JA 77%, KO 88%). A mercury sphygmomanometer was the most commonly used method for BP measurements (JA 72%, KO 62%). BP treatment goals were usually set at the 95th percentile for age, gender, and height (JA 47%, KO 54%). More KO used a lower goal in children with primary HTN than JA. KO respondents preferred angiotensin-converting enzyme inhibitors (ACEI) as initial agents regardless of underlying diseases whereas JA respondents chose various medications, that is, calcium channel blockers, diuretics, and ACEI. For BP monitoring, self-monitoring was found to be most frequent in both countries (JA 80%, KO 57%). Ambulatory BP monitoring was not frequently utilized in both countries (JA 33% KO 34%). The current assessment, management and differing trends in pediatric HTN in Japan and Korea have been identified in the present study. Pediatricians should be aware of the growing implications of HTN in children.

Vascular Aging: Lessons From Pediatric Hypertension.

PubMed

Litwin, Mieczyslaw; Feber, Janusz; Ruzicka, Marcel

2016-05-01

Hypertension (HTN) in children is associated with early vascular aging (EVA) and underlying immunologic-metabolic abnormalities and accelerated biological maturation. Morphologic and functional vascular changes underlying EVA and HTN in children resemble those seen in the elderly including but not limited to an increase in intima-media thickness (IMT) and arterial stiffness and endothelial dysfunction. Although progeria syndrome leading to EVA and the development of clinically manifested cardiovascular (CV) disease in the second decade of life is a rare hereditary disorder, primary HTN, which is also associated with EVA, is much more common (reported in up to 10% in adolescents). EVA associated with HTN in children leads to the premature development of target organ injury in childhood and CV events in early adulthood. Limited evidence from prospective observational studies in children and adolescents indicates that early lifestyle measures (low salt/low sugar intake and exercise) or pharmacologic treatment of HTN, or both, partially reverses morphologic and functional changes underlying EVA such as an increase in carotid IMT and pulse wave velocity, a decrease in flow-mediated dilation of the brachial artery, and an increase in oxidative stress and visceral fat. Future mechanistic and therapeutic clinical trials are desirable to assess the mechanisms and treatment strategies of EVA in the context of HTN in children and their effect on CV events in early adulthood. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Racism and hypertension: a review of the empirical evidence and implications for clinical practice.

PubMed

Brondolo, Elizabeth; Love, Erica E; Pencille, Melissa; Schoenthaler, Antoinette; Ogedegbe, Gbenga

2011-05-01

Despite improved hypertension (HTN) awareness and treatment, racial disparities in HTN prevalence persist. An understanding of the biopsychosocial determinants of HTN is necessary to address racial disparities in the prevalence of HTN. This review examines the evidence directly and indirectly linking multiple levels of racism to HTN. Published empirical research in EBSCO databases investigating the relationships of three levels of racism (individual/interpersonal, internalized, and institutional racism) to HTN was reviewed. Direct evidence linking individual/interpersonal racism to HTN diagnosis is weak. However, the relationship of individual/interpersonal racism to ambulatory blood pressure (ABP) is more consistent, with all published studies reporting a positive relationship of interpersonal racism to ABP. There is no direct evidence linking internalized racism to BP. Population-based studies provide some evidence linking institutional racism, in the forms of residential racial segregation (RRS) and incarceration, to HTN incidence. Racism shows associations to stress exposure and reactivity as well as associations to established HTN-related risk factors including obesity, low levels of physical activity and alcohol use. The effects vary by level of racism. Overall the findings suggest that racism may increase risk for HTN; these effects emerge more clearly for institutional racism than for individual level racism. All levels of racism may influence the prevalence of HTN via stress exposure and reactivity and by fostering conditions that undermine health behaviors, raising the barriers to lifestyle change.

Comparison of body mass index, waist circumference, and waist to height ratio in the prediction of hypertension and diabetes mellitus: Filipino-American women cardiovascular study.

PubMed

Battie, Cynthia A; Borja-Hart, Nancy; Ancheta, Irma B; Flores, Rene; Rao, Goutham; Palaniappan, Latha

2016-12-01

The relative ability of three obesity indices to predict hypertension (HTN) and diabetes (DM) and the validity of using Asian-specific thresholds of these indices were examined in Filipino-American women (FAW). Filipino-American women ( n  = 382), 40-65 years of age were screened for hypertension (HTN) and diabetes (DM) in four major US cities. Body mass index (BMI), waist circumference (WC) and waist circumference to height ratio (WHtR) were measured. ROC analyses determined that the three obesity measurements were similar in predicting HTN and DM (AUC: 0.6-0.7). The universal WC threshold of ≥ 35 in. missed 13% of the hypertensive patients and 12% of the diabetic patients. The Asian WC threshold of ≥ 31.5 in. increased detection of HTN and DM but with a high rate of false positives. The traditional BMI ≥ 25 kg/m 2 threshold missed 35% of those with hypertension and 24% of those with diabetes. The Asian BMI threshold improved detection but resulted in a high rate of false positives. The suggested WHtR cut-off of ≥ 0.5 missed only 1% of those with HTN and 0% of those with DM. The three obesity measurements had similar but modest ability to predict HTN and DM in FAW. Using Asian-specific thresholds increased accuracy but with a high rate of false positives. Whether FAW, especially at older ages, should be encouraged to reach these lower thresholds needs further investigation because of the high false positive rates.

Cumulative Association of Obstructive Sleep Apnea Severity and Short Sleep Duration with the Risk for Hypertension

PubMed Central

Priou, Pascaline; Le Vaillant, Marc; Meslier, Nicole; Paris, Audrey; Pigeanne, Thierry; Nguyen, Xuan-Lan; Alizon, Claire; Bizieux-Thaminy, Acya; Leclair-Visonneau, Laurene; Humeau, Marie-Pierre; Gagnadoux, Frédéric

2014-01-01

Obstructive sleep apnea (OSA) and short sleep duration are individually associated with an increased risk for hypertension (HTN). The aim of this multicenter cross-sectional study was to test the hypothesis of a cumulative association of OSA severity and short sleep duration with the risk for prevalent HTN. Among 1,499 patients undergoing polysomnography for suspected OSA, 410 (27.3%) previously diagnosed as hypertensive and taking antihypertensive medication were considered as having HTN. Patients with total sleep time (TST) <6 h were considered to be short sleepers. Logistic regression procedures were performed to determine the independent association of HTN with OSA and sleep duration. Considering normal sleepers (TST ≥6 h) without OSA as the reference group, the odds ratio (OR) (95% confidence intervals) for having HTN was 2.51 (1.35–4.68) in normal sleepers with OSA and 4.37 (2.18–8.78) in short sleepers with OSA after adjustment for age, gender, obesity, diabetes, depression, current smoking, use of thyroid hormones, daytime sleepiness, poor sleep complaint, time in bed, sleep architecture and fragmentation, and study site. The risk for HTN appeared to present a cumulative association with OSA severity and short sleep duration (p<0.0001 for linear trend). The higher risk for HTN was observed in short sleepers with severe OSA (AHI ≥30) (OR, 4.29 [2.03–9.07]). In patients investigated for suspected OSA, sleep-disordered breathing severity and short sleep duration have a cumulative association with the risk for prevalent HTN. Further studies are required to determine whether interventions to optimize sleep may contribute to lower BP in patients with OSA. PMID:25531468

Renal denervation with a percutaneous bipolar radiofrequency balloon catheter in patients with resistant hypertension: 6-month results from the REDUCE-HTN clinical study.

PubMed

Sievert, Horst; Schofer, Joachim; Ormiston, John; Hoppe, Uta C; Meredith, Ian T; Walters, Darren L; Azizi, Michel; Diaz-Cartelle, Juan; Cohen-Mazor, Meital

2015-02-01

To evaluate the safety and efficacy of the balloon-based bipolar Vessix Renal Denervation System in treating patients with resistant hypertension. In this prospective, multicentre, single-arm study, 146 patients (age 58.6±10.5 years; 61% men) with office systolic blood pressure (BP) ≥160 mmHg despite ≥3 antihypertensive medications at maximally tolerated doses were treated with the Vessix System. Efficacy endpoints were reductions in office and 24-hour ambulatory systolic and diastolic BPs at six months. Acute and long-term safety, with a focus on the renal artery and estimated glomerular filtration rate (eGFR), were assessed. Baseline office and ambulatory BPs were 182.4±18.4/100.2±14.0 mmHg and 153.0±15.1/87.5±13.2 mmHg, respectively. No acute renal artery injury requiring intervention or serious periprocedural cardiovascular events occurred. At six months, office BP was reduced by 24.7±22.1/10.3±12.7 mmHg (p<0.0001) and ambulatory BP was reduced by 8.4±14.4/5.9±9.1 mmHg (N=69; p<0.0001). Twenty-six patients (18%) achieved an office systolic BP <140 mmHg. One patient had renal artery stenosis which required stenting. Mean eGFR remained stable. Renal artery denervation with the Vessix System reduced both office and ambulatory BP at six months in patients with resistant hypertension. Renal artery safety and renal function results are favourable.

Effects of Obesity and Hypertension on Pulse Wave Velocity in Children.

PubMed

Kulsum-Mecci, Nazia; Goss, Charles; Kozel, Beth A; Garbutt, Jane M; Schechtman, Kenneth B; Dharnidharka, Vikas R

2017-03-01

Pulse wave velocity (PWV) is a biomarker of arterial stiffness. Findings from prior studies are conflicting regarding the impact of obesity on PWV in children. The authors measured carotid-femoral PWV in 159 children aged 4 to 18 years, of whom 95 were healthy, 25 were obese, 15 had hypertension (HTN), and 24 were both obese and hypertensive. Mean PWV increased with age but did not differ by race or sex. In adjusted analyses in children 10 years and older (n=102), PWV was significantly higher in children with hypertension (PWV±standard deviation, 4.9±0.7 m/s), obesity (5.0±0.9 m/s), and combined obesity-hypertension (5.2±0.6 m/s) vs healthy children (4.3±0.7 m/s) (each group, P<.001 vs control). In our study, obesity and HTN both significantly and independently increased PWV, while African American children did not have a higher PWV than Caucasian children. ©2016 Wiley Periodicals, Inc.

Characteristics of Resistant Hypertension in a Large Ethnically Diverse Hypertension Population of an Integrated Health System

PubMed Central

Sim, John J.; Bhandari, Simran K.; Shi, Jiaxiao; In Liu, Lu A.; Calhoun, David A.; McGlynn, Elizabeth A.; Kalantar-Zadeh, Kamyar; Jacobsen, Steven J.

2013-01-01

Objective To evaluate the prevalence and characterize resistant hypertension from a large representative population with successful hypertension management and reliable health information. Patient and Methods We performed a cross sectional study using clinical encounter, laboratory, and administrative information from the Kaiser Permanente Southern California health system during 1/1/2006–12/31/2007. From individuals age >17 years with hypertension, resistant hypertension was identified and prevalence determined. Multivariable logistic regression was used to calculate odds ratios (OR) with adjustments for demographics, clinical variables, and medication use. Results Among 470,386 hypertensive individuals, 12.8% were identified as resistant representing15.3% of those on medications. Overall, 37,061 (7.9%) had uncontrolled hypertension while on ≥ 3 medicines. OR (95% confidence interval) for resistant hypertension were greater for black race (1.68, 1.62–1.75), older age (1.11, 1.10–1.11 for every 5 year increase), males (1.06, 1.03–1.10), and obesity (1.46, 1.42–1.51). Medication adherence rates were higher in resistant hypertension (93 vs 90%, p<0.001). Chronic kidney disease (1.84, 1.78–1.90), diabetes (1.58, 1.53–1.63), and cardiovascular disease (1.34, 1.30–1.39) were also associated with higher risk for resistant hypertension. Conclusion Within a more standardized hypertension treatment environment, we observed a rate of resistant hypertension comparable to past studies using more fragmented data sources. Past observations have been limited due to non-representative populations, reliability of the data, heterogeneity of the treatment environments, and less than ideal control rates. This cohort which was established with an electronic medical record based approach has the potential to provide a better understanding of resistant hypertension and outcomes. PMID:24079679

Factors associated with systemic hypertension in asthma

PubMed Central

Ferguson, Susan; Teodorescu, Mihai C.; Gangnon, Ronald E.; Peterson, Andrea G.; Consens, Flavia B.; Chervin, Ronald D.; Teodorescu, Mihaela

2015-01-01

Purpose Asthmatics have unique characteristics that may influence cardiovascular morbidity. We tested the association of lower airway caliber, obstructive sleep apnea (OSA) and other asthma-related factors, with systemic hypertension (HTN). Methods Asthma individuals at specialty clinics completed the Sleep Apnea Scale of the Sleep Disorders Questionnaire (SA-SDQ). Medical records were reviewed for diagnosed HTN, OSA and comorbidities, spirometry and current medications. FEV1% predicted was categorized as ≥80 (reference), 70-79, 60-69 and <60. SA-SDQ ≥36 for men and ≥32 for women defined high OSA risk. Results Among 812 asthmatics (mean age±standard deviation: 46±14 years), HTN was diagnosed in 191 (24%), OSA in 65 (8%), and OSA or high OSA risk (combined OSA variable) in 239 (29%). HTN was more prevalent in lower FEV1% categories (p<0.0001), in subjects with OSA, and those with combined OSA variable (55% vs. 21% and 46% vs. 14%, respectively, both p<0.0001). With adjustment for covariates, associations with HTN remained significant for some FEV1% categories (70-79% odds ratio=1.60 [95% CI: 0.90-2.87]; 60-69% 2.73 [1.28-5.79]; <60% 0.96 [0.43-2.14]), and for OSA (2.20 [1.16-4.19]). The combined OSA variable in comparison to OSA alone demonstrated a stronger association with HTN (3.17 [1.99-5.04]) in a reiteration of this model. Inhaled corticosteroids (ICS) at lowest doses, in comparison to no ICS use had an independent “protective” association with HTN (0.44 [0.22-0.90]). Conclusions In this young population, lower airways obstruction and OSA were positively associated with HTN. In contrast, lower ICS doses attenuated likelihood for HTN. Adequate control of airway inflammation at appropriate ICS doses, and screening for OSA may reduce the burden of HTN in asthma. PMID:24920421

Arterial Baroreceptor Reflex Counteracts Long-Term Blood Pressure Increase in the Rat Model of Renovascular Hypertension

PubMed Central

Tsyrlin, Vitaly A.; Galagudza, Michael M.; Kuzmenko, Nataly V.; Pliss, Michael G.; Rubanova, Nataly S.; Shcherbin, Yury I.

2013-01-01

Introduction The present study tested the hypothesis that long-term effects of baroreceptor activation might contribute to the prevention of persistent arterial blood pressure (BP) increase in the rat model of renovascular hypertension (HTN). Methods Repetitive arterial baroreflex (BR) testing was performed in normo- and hypertensive rats. The relationship between initial arterial BR sensitivity and severity of subsequently induced two-kidney one-clip (2K1C) renovascular HTN was studied in Wistar rats. Additionally, the time course of changes in systolic BP (SBP) and cardiac beat-to-beat (RR) interval was studied for 8 weeks after the induction of 2K1C renovascular HTN in the rats with and without sinoaortic denervation (SAD). In a separate experimental series, cervical sympathetic nerve activity (cSNA) was assessed in controls, 2K1C rats, WKY rats, and SHR. Results The inverse correlation between arterial BR sensitivity and BP was observed in the hypertensive rats during repetitive arterial BR testing. The animals with greater initial arterial BR sensitivity developed lower BP values after renal artery clipping than those with lower initial arterial BR sensitivity. BP elevation during the first 8 weeks of renal artery clipping in 2K1C rats was associated with decreased sensitivity of arterial BR. Although SAD itself resulted only in greater BP variability but not in persistent BP rise, the subsequent renal artery clipping invariably resulted in the development of sustained HTN. The time to onset of HTN was found to be shorter in the rats with SAD than in those with intact baroreceptors. cSNA was significantly greater in the 2K1C rats than in controls. Conclusions Arterial BR appears to be an important mechanism of long-term regulation of BP, and is believed to be involved in the prevention of BP rise in the rat model of renovascular HTN. PMID:23762254

Exercise capacity and progression from prehypertension to hypertension.

PubMed

Faselis, Charles; Doumas, Michael; Kokkinos, John Peter; Panagiotakos, Demosthenes; Kheirbek, Raya; Sheriff, Helen M; Hare, Katherine; Papademetriou, Vasilios; Fletcher, Ross; Kokkinos, Peter

2012-08-01

Prehypertension is likely to progress to hypertension. The rate of progression is determined mostly by age and resting blood pressure but may also be attenuated by increased fitness. A graded exercise test was performed in 2303 men with prehypertension at the Veterans Affairs Medical Centers in Washington, DC. Four fitness categories were defined, based on peak metabolic equivalents (METs) achieved. We assessed the association between exercise capacity and rate of progression to hypertension (HTN). The median follow-up period was 7.8 years (mean (± SD) 9.2±6.1 years). The incidence rate of progression from prehypertension to hypertension was 34.4 per 1000 person-years. Exercise capacity was a strong and independent predictor of the rate of progression. Compared to the High-Fit individuals (>10.0 METs), the adjusted risk for developing HTN was 66% higher (hazard ratio, 1.66; 95% CI, 1.2 to 2.2; P=0.001) for the Low-Fit and, similarly, 72% higher (hazard ratio, 1.72; 95% CI, 1.2 to 2.3; P=0.001) for the Least-Fit individuals, whereas it was only 36% for the Moderate-Fit (hazard ratio, 1.36; 95% CI, 0.99 to 1.80; P=0.056). Significant predictors for the progression to HTN were also age (19% per 10 years), resting systolic blood pressure (16% per 10 mm Hg), body mass index (15.3% per 5 U), and type 2 diabetes mellitus (2-fold). In conclusion, an inverse, S-shaped association was shown between exercise capacity and the rate of progression from prehypertension to hypertension in middle-aged and older male veterans. The protective effects of fitness were evident when exercise capacity exceeded 8.5 METs. These findings emphasize the importance of fitness in the prevention of hypertension.

Nocturnal diastolic blood pressure decline is associated with higher 25-hydroxyvitamin D level and standing plasma renin activity in a hypertensive population.

PubMed

Zhang, Mingchen; Xu, Xinjuan; Liu, Haiming; Li, Haixia; Zhang, Junshi; Gao, Min

2017-01-01

Patients with nondipper hypertension are known to carry a high risk of cardiovascular complications. Vitamin D deficiency is associated with hypertension. Because vitamin D deficiency activates the renin-angiotensin-aldosterone system (RAAS), we hypothesized that this vitamin would interact with the RAAS to influence blood pressure (BP) in nondipper hypertensive patients. We performed a cross-sectional analysis of 1,007 outpatients with hypertension (HTN). Dipper and nondipper patterns were detected, and the two groups were matched for clinical, laboratory, 25-hydroxyvitamin D (25OHD) levels, and ambulatory blood pressure recording. Plasma renin activity (PRA), angiotensin II, and plasma aldosterone concentration (PAC) were assessed in 174 patients treated with calcium channel blockers or no medication. The mean 25OHD concentration in the entire study population was 12.3ng/dL, and the prevalence of vitamin D deficiency was 87.0%. Dipper and nondipper HTN were noted in 187 patients (24.6%) and 573 patients (75.4%). 25OHD levels were similar between nondipper and dipper HTN groups. Forward stepwise logistic regression analysis showed that BMI and age were independent predictors of nondipper HTN. Neither 25OHD levels nor RAAS components were included in the model. In correlation analyses, nocturnal decline of diastolic BP was positively associated with 25OHD levels and standing PRA (r = 0.152 p = 0.045, r = 0.165 p = 0.038, respectively). The present study showed that vitamin D deficiency was astonishingly prevalent in hypertensive subjects residing in Xinjiang, China. There may be a weakly association of nocturnal DBP decline with 25OHD levels and standing PRA levels. We found no association between vitamin D deficiency and nondipper HTN.

Exaggerated coronary vasoconstriction limits muscle metaboreflex-induced increases in ventricular performance in hypertension

PubMed Central

Spranger, Marty D.; Kaur, Jasdeep; Sala-Mercado, Javier A.; Krishnan, Abhinav C.; Abu-Hamdah, Rania; Alvarez, Alberto; Machado, Tiago M.; Augustyniak, Robert A.

2017-01-01

Increases in myocardial oxygen consumption during exercise mainly occur via increases in coronary blood flow (CBF) as cardiac oxygen extraction is high even at rest. However, sympathetic coronary constrictor tone can limit increases in CBF. Increased sympathetic nerve activity (SNA) during exercise likely occurs via the action of and interaction among activation of skeletal muscle afferents, central command, and resetting of the arterial baroreflex. As SNA is heightened even at rest in subjects with hypertension (HTN), we tested whether HTN causes exaggerated coronary vasoconstriction in canines during mild treadmill exercise with muscle metaboreflex activation (MMA; elicited by reducing hindlimb blood flow by ~60%) thereby limiting increases in CBF and ventricular performance. Experiments were repeated after α1-adrenergic blockade (prazosin; 75 µg/kg) and in the same animals following induction of HTN (modified Goldblatt 2K1C model). HTN increased mean arterial pressure from 97.1 ± 2.6 to 132.1 ± 5.6 mmHg at rest and MMA-induced increases in CBF, left ventricular dP/dtmax, and cardiac output were markedly reduced to only 32 ± 13, 26 ± 11, and 28 ± 12% of the changes observed in control. In HTN, α1-adrenergic blockade restored the coronary vasodilation and increased in ventricular function to the levels observed when normotensive. We conclude that exaggerated MMA-induced increases in SNA functionally vasoconstrict the coronary vasculature impairing increases in CBF, which limits oxygen delivery and ventricular performance in HTN. NEW & NOTEWORTHY We found that metaboreflex-induced increases in coronary blood flow and ventricular contractility are attenuated in hypertension. α1-Adrenergic blockade restored these parameters toward normal levels. These findings indicate that the primary mechanism mediating impaired metaboreflex-induced increases in ventricular function in hypertension is accentuated coronary vasoconstriction. Listen to this article�

Muscular strength and incident hypertension in normotensive and prehypertensive men.

PubMed

Maslow, Andréa L; Sui, Xuemei; Colabianchi, Natalie; Hussey, Jim; Blair, Steven N

2010-02-01

The protective effects of cardiorespiratory fitness (CRF) on hypertension (HTN) are well known; however, the association between muscular strength and incidence of HTN has yet to be examined. This study evaluated the strength-HTN association with and without accounting for CRF. Participants were 4147 men (age = 20-82 yr) in the Aerobics Center Longitudinal Study for whom an age-specific composite muscular strength score was computed from measures of a one-repetition maximal leg and a one-repetition maximal bench press. CRF was quantified by maximal treadmill exercise test time in minutes. Cox proportional hazards regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals of incident HTN events according to exposure categories. During a mean follow-up of 19 yr, there were 503 incident HTN cases. Multivariable-adjusted (excluding CRF) HR of HTN in normotensive men comparing middle- and high-strength thirds to the lowest third were not significant at 1.17 and 0.84, respectively. Multivariable-adjusted (excluding CRF) HR of HTN in baseline prehypertensive men comparing middle- and high-strength thirds to the lowest third were significant at 0.73 and 0.72 (P = 0.01 each), respectively. The association between muscular strength and incidence of HTN in baseline prehypertensive men was no longer significant after control for CRF (P = 0.26). The study indicated that middle and high levels of muscular strength were associated with a reduced risk of HTN in prehypertensive men only. However, this relationship was no longer significant after controlling for CRF.

Renal functional reserve and renal hemodynamics in hypertensive patients.

PubMed

Gaipov, Abduzhappar; Solak, Yalcin; Zhampeissov, Nurlan; Dzholdasbekova, Aliya; Popova, Nadezhda; Molnar, Miklos Z; Tuganbekova, Saltanat; Iskandirova, Elmira

2016-10-01

The renal functional reserve (RFR) is the ability of the kidneys to increase renal plasma flow and glomerular filtration rate (GFR) in response to protein intake. It is a measure of functional and anatomic integrity of nephrons. It is not known what relation between RFR and kidney Doppler parameters. We aimed to study the relation between the RFR and renal hemodynamic parameters in hypertensive patients with and without nephropathy who had normal kidney function. Twenty-four hypertensive subjects with nephropathy (HTN-n, n = 10) and hypertension without nephropathy (HTN, n = 14) were included in the study. Control group included 11 healthy subjects. Baseline GFR (GFR1) and GFR after intake of egg protein 1 mg/kg of body weight were determined (GFR2). RFR was calculated by the following formula: (GFR2-GFR1)/GFR1 × 100%. Doppler ultrasonography was performed. Arterial blood pressure (BP), body mass index (BMI), and estimated GFR were also recorded. HTN and HTN-n groups had impaired levels of RFR compared with controls (p < 0.05), significantly decreased value of flow velocity parameters (Vmax, Vmin), and increased RRI compared with controls. There was significant negative correlation of RFR with blood pressure levels (sBP, r = -0.435, p = 0.009; dBP, r = -0.504, p = 0.002), RRI (r = -0.456, p = 0.008), micro albuminuria (MAU, r = -0.366, p = 0.031) and positive correlation with Vmax and Vmin (r = 0.556, p = 0.001 and r = 0.643, respectively, p < 0.001). Linear regression showed that RRI and MAU were independent predictors of decreased RFR. RFR is lower in hypertensive patients despite near-normal level of kidney function and is related to particular level of BP. RRI and MAU were independent predictors of decreased RFR.

Left ventricular geometry in children and adolescents with primary hypertension

PubMed Central

Richey, Phyllis A.; DiSessa, Thomas G.; Somes, Grant W.; Alpert, Bruce S.; Jones, Deborah P.

2009-01-01

Objective Children with hypertension (HTN) are at increased risk for left ventricular hypertrophy (LVH). Increased LV mass by the process of remodeling in response to volume or pressure loading may be eccentric (increased LV diameter) or concentric (increased wall thickness). Our objective was to classify LV geometry among children with primary HTN and examine differences in ambulatory blood pressure (ABP). Study design Subjects aged 7-18 years with suspected HTN were enrolled in this cross-sectional study. ABP and LVM index (LVMI) and were measured within the same 24 hour period. LV geometry was classified as normal, concentric remodeling, concentric LVH or eccentric LVH. Results Children with LVH had significantly higher ambulatory systolic and diastolic BP levels and BMI z-score. Sixty-eight children had HTN based upon ABPM. Thirty-eight percent of the hypertensive subjects had LVH, with equal distribution in the concentric and eccentric groups. There were significant differences in the 24-hour diastolic BP (DBP) parameters when the eccentric LVH group was compared to the normal geometry and concentric LVH groups. Relative wall thickness was inversely associated with nighttime DBP parameters. These relationships persisted after controlling for BMI Z-score. Conclusions While the risk for LVH is associated with increased systolic BP and BMI Z-score, those with eccentric LVH had significantly higher DBP. PMID:19851297

Dietary sodium, potassium, and alcohol: key players in the pathophysiology, prevention, and treatment of human hypertension.

PubMed

Koliaki, Chrysi; Katsilambros, Nicholas

2013-06-01

Western industrialized societies are currently experiencing an epidemic expansion of hypertension (HTN), which extends alarmingly even to children and adolescents. HTN constitutes an independent risk factor for cardiorenal disease and represents an extremely common comorbidity of diabetes and obesity. Numerous randomized clinical trials and meta-analyses have provided robust scientific evidence that reduced dietary salt intake, increased dietary potassium intake, moderation of alcohol consumption, optimal weight maintenance, and the adoption of "heart-friendly" dietary patterns such as the Dietary Approaches to Stop Hypertension or the Mediterranean diet can effectively lower blood pressure. Interestingly, the susceptibility of blood pressure to nutritional interventions is greatly variable among individuals, depending on age, race, genetic background, and comorbidities. The purpose of this review is to provide a comprehensive overview of currently available scientific evidence in the constantly evolving field of diet and HTN, placing particular emphasis on the key role of dietary sodium, dietary potassium, and alcohol intake in the pathophysiology, prevention, and treatment of human hypertension. © 2013 International Life Sciences Institute.

Postprandial lipemia in men with metabolic syndrome, hypertensives and healthy subjects

PubMed Central

Kolovou, Genovefa D; Anagnostopoulou, Katherine K; Pavlidis, Antonis N; Salpea, Klelia D; Iraklianou, Stella A; Tsarpalis, Konstantinos; Damaskos, Dimitris S; Manolis, Athanasios; Cokkinos, Dennis V

2005-01-01

Background The metabolic syndrome (MetS), as well as postprandial hypertriglyceridemia, is associated with coronary heart disease. This study aimed to evaluate the postprandial lipemia after oral fat tolerance test (OFTT) in subjects with MetS and compare them to hypertensive (HTN) and healthy subjects. Results OFTT was given to 33 men with MetS (defined by the Adult Treatment Panel III), 17 HTN and 14 healthy men. The MetS group was further divided according to fasting triglycerides (TG) into TG ≥ 150 [MetS+TG, (n = 22)] or <150 mg/dl [MetS-TG (n = 11)], and into those with or without hypertension [MetS+HTN (n = 24), MetS-HTN (n = 9), respectively]. TG concentrations were measured before and at 4, 6 and 8 h after OFTT and the postprandial response was quantified using the area under the curve (AUC) for TG. The postprandial response was significantly higher in MetS compared to HTN and healthy men [AUC (SD) in mg/dl/h; 2534 ± 1016 vs. 1620 ± 494 and 1019 ± 280, respectively, p ≤ 0.001]. The TG levels were increased significantly in MetS+TG compared to MetS-TG subjects at 4 (p = 0.022), 6 (p < 0.001) and 8 hours (p < 0.001). The TG were increased significantly in MetS-TG compared to healthy subjects at 4 (p = 0.011), 6 (p = 0.001) and 8 hours (p = 0.015). In linear regression analysis only fasting TG levels were a significant predictor of the AUC (Coefficient B = 8.462, p < 0.001). Conclusion Fasting TG concentration is the main determinant of postprandial lipemia. However, an exaggeration of TG postprandialy was found in normotriglyceridemic MetS and HTN compared to healthy subjects. This suggests that intervention to lower fasting TG levels should be recommended in MetS subjects. PMID:16197542

Postprandial lipemia in men with metabolic syndrome, hypertensives and healthy subjects.

PubMed

Kolovou, Genovefa D; Anagnostopoulou, Katherine K; Pavlidis, Antonis N; Salpea, Klelia D; Iraklianou, Stella A; Tsarpalis, Konstantinos; Damaskos, Dimitris S; Manolis, Athanasios; Cokkinos, Dennis V

2005-09-30

The metabolic syndrome (MetS), as well as postprandial hypertriglyceridemia, is associated with coronary heart disease. This study aimed to evaluate the postprandial lipemia after oral fat tolerance test (OFTT) in subjects with MetS and compare them to hypertensive (HTN) and healthy subjects. OFTT was given to 33 men with MetS (defined by the Adult Treatment Panel III), 17 HTN and 14 healthy men. The MetS group was further divided according to fasting triglycerides (TG) into TG > or = 150 [MetS+TG, (n = 22)] or < 150 mg/dl [MetS-TG (n = 11)], and into those with or without hypertension [MetS+HTN (n = 24), MetS-HTN (n = 9), respectively]. TG concentrations were measured before and at 4, 6 and 8 h after OFTT and the postprandial response was quantified using the area under the curve (AUC) for TG. The postprandial response was significantly higher in MetS compared to HTN and healthy men [AUC (SD) in mg/dl/h; 2534 +/- 1016 vs. 1620 +/- 494 and 1019 +/- 280, respectively, p < or = 0.001]. The TG levels were increased significantly in MetS+TG compared to MetS-TG subjects at 4 (p = 0.022), 6 (p < 0.001) and 8 hours (p < 0.001). The TG were increased significantly in MetS-TG compared to healthy subjects at 4 (p = 0.011), 6 (p = 0.001) and 8 hours (p = 0.015). In linear regression analysis only fasting TG levels were a significant predictor of the AUC (Coefficient B = 8.462, p < 0.001). Fasting TG concentration is the main determinant of postprandial lipemia. However, an exaggeration of TG postprandialy was found in normotriglyceridemic MetS and HTN compared to healthy subjects. This suggests that intervention to lower fasting TG levels should be recommended in MetS subjects.

Genome-wide study of resistant hypertension identified from electronic health records.

PubMed

Dumitrescu, Logan; Ritchie, Marylyn D; Denny, Joshua C; El Rouby, Nihal M; McDonough, Caitrin W; Bradford, Yuki; Ramirez, Andrea H; Bielinski, Suzette J; Basford, Melissa A; Chai, High Seng; Peissig, Peggy; Carrell, David; Pathak, Jyotishman; Rasmussen, Luke V; Wang, Xiaoming; Pacheco, Jennifer A; Kho, Abel N; Hayes, M Geoffrey; Matsumoto, Martha; Smith, Maureen E; Li, Rongling; Cooper-DeHoff, Rhonda M; Kullo, Iftikhar J; Chute, Christopher G; Chisholm, Rex L; Jarvik, Gail P; Larson, Eric B; Carey, David; McCarty, Catherine A; Williams, Marc S; Roden, Dan M; Bottinger, Erwin; Johnson, Julie A; de Andrade, Mariza; Crawford, Dana C

2017-01-01

Resistant hypertension is defined as high blood pressure that remains above treatment goals in spite of the concurrent use of three antihypertensive agents from different classes. Despite the important health consequences of resistant hypertension, few studies of resistant hypertension have been conducted. To perform a genome-wide association study for resistant hypertension, we defined and identified cases of resistant hypertension and hypertensives with treated, controlled hypertension among >47,500 adults residing in the US linked to electronic health records (EHRs) and genotyped as part of the electronic MEdical Records & GEnomics (eMERGE) Network. Electronic selection logic using billing codes, laboratory values, text queries, and medication records was used to identify resistant hypertension cases and controls at each site, and a total of 3,006 cases of resistant hypertension and 876 controlled hypertensives were identified among eMERGE Phase I and II sites. After imputation and quality control, a total of 2,530,150 SNPs were tested for an association among 2,830 multi-ethnic cases of resistant hypertension and 876 controlled hypertensives. No test of association was genome-wide significant in the full dataset or in the dataset limited to European American cases (n = 1,719) and controls (n = 708). The most significant finding was CLNK rs13144136 at p = 1.00x10-6 (odds ratio = 0.68; 95% CI = 0.58-0.80) in the full dataset with similar results in the European American only dataset. We also examined whether SNPs known to influence blood pressure or hypertension also influenced resistant hypertension. None was significant after correction for multiple testing. These data highlight both the difficulties and the potential utility of EHR-linked genomic data to study clinically-relevant traits such as resistant hypertension.

Characteristics of resistant hypertension in a large, ethnically diverse hypertension population of an integrated health system.

PubMed

Sim, John J; Bhandari, Simran K; Shi, Jiaxiao; Liu, In Lu A; Calhoun, David A; McGlynn, Elizabeth A; Kalantar-Zadeh, Kamyar; Jacobsen, Steven J

2013-10-01

To evaluate the prevalence of and characterize resistant hypertension in a large representative population with successful hypertension management and reliable health information. We performed a cross-sectional study using clinical encounter, laboratory, and administrative information from the Kaiser Permanente Southern California health system between January 1, 2006, and December 31, 2007. From individuals older than 17 years with hypertension, resistant hypertension was identified and prevalence was determined. Multivariable logistic regression was used to calculate odds ratios (ORs), with adjustments for demographic characteristics, clinical variables, and medication use. Of 470,386 hypertensive individuals, 60,327 (12.8%) were identified as having resistant disease, representing 15.3% of those taking medications. Overall, 37,061 patients (7.9%) had uncontrolled hypertension while taking 3 or more medicines. The ORs (95% CIs) for resistant hypertension were greater for black race (1.68 [1.62-1.75]), older age (1.11 [1.10-1.11] for every 5-year increase), male sex (1.06 [1.03-1.10]), and obesity (1.46 [1.42-1.51]). Medication adherence rates were higher in those with resistant hypertension (93% vs 89.8%; P<.001). Chronic kidney disease (OR, 1.84; 95% CI, 1.78-1.90), diabetes mellitus (OR, 1.58; 95% CI, 1.53-1.63), and cardiovascular disease (OR, 1.34; 95% CI, 1.30-1.39) were also associated with higher risk of resistant hypertension. In a more standardized hypertension treatment environment, we observed a rate of resistant hypertension comparable with that of previous studies using more fragmented data sources. Past observations have been limited due to nonrepresentative populations, reliability of the data, heterogeneity of the treatment environments, and less than ideal control rates. This cohort, which was established using an electronic medical record-based approach, has the potential to provide a better understanding of resistant hypertension and outcomes

Hypertension control in industrial employees: findings from SHIMSCO study

PubMed Central

Khosravi, Ali Reza; Rowzati, Mohsen; Gharipour, Mojgan; Fesharaki, Mohammad Gholami; Shirani, Shahin; Shahrokhi, Shahnaz; Jozan, Mahnaz; Khosravi, Elham; Khosravi, Zahra; Sarrafzadegan, Nizal

2012-01-01

BACKGROUND: Hypertension prevention and control are among the most important public health priorities. We evaluated the impacts of a workplace intervention project “Stop Hypertension in Mobarakeh Steel Company” (SHIMSCO) on controlling hypertension in industrial workers. METHODS: The study was carried out in Mobarakeh Steel Company in Isfahan among 7286 male workers and employees. All individuals were evaluated for the presence of hypertension (HTN). According to examinations, 500 subjects with systolic blood pressure (SBP) ≥ 140 mmHg, and/or diastolic blood pressure (DBP) ≥ 90 mmHg, and/or those using antihypertensive medications were confirmed to have HTN and thus included in this study. They were questioned for sociodemographic characteristics, past medical history and medication use. They received an educational program including healthy lifestyle and self-care recommendations of HTN management and control as well as training for accurate blood pressure measurement and home monitoring for two years. SBP, DBP, weight, height and routine lab tests were measured for all hypertensive subjects before and after the interventions. Paired t-test, generalized estimation equation (GEE) and ordinary linear regression (OLR) were used for statistical analysis in SPSS. RESULTS: The comparison of SBP and DBP before and after the educational program showed significant reductions in both parameters (−7.97 ± 14.72 and −2.66 ± 9.96 mmHg, respectively). However, a greater decrease was detected in case of DBP. GEE showed SBP and DBP to decrease about −0.115 and −0.054 mmHg/month. OLR also revealed reductions of 4.88 and 2.57 mmHg respectively in SBP and DBP upon adding each antihypertensive drug. CONCLUSION: SHIMSCO, a 3-year interventional project in workplaces, was effective in reducing SBP and DBP among hypertensive employees and workers. We conclude that implementing simple educational programs in worksites can improve the management and control of

Catheter-Based Radiorefrequency Renal Denervation Lowers Blood Pressure in Obese Hypertensive Dogs

PubMed Central

Henegar, Jeffrey R.; Zhang, Yongxing; Rama, Rita De; Hata, Cary; Hall, Michael E.

2014-01-01

BACKGROUND Obesity-induced hypertension appears to be due, in part, to increased renal sympathetic activity. Catheter-based renal denervation (RD) has been reported to lower arterial blood pressure (BP) in humans with resistant hypertension, many of whom are obese. This study was performed to assess the impact of radiofrequency–induced RD on renal function, BP, renal norepinephrine (NE), and histology of nerves along the renal artery in obese, hypertensive dogs, an experimental model that closely mimics cardiorenal and metabolic changes in obese hypertensive humans. METHODS After control measurements of cardiovascular and renal function were obtained in obese dogs fed a high-fat diet, bilateral RD was performed using the St. Jude Medical EnligHTN RD system. After RD, BP was measured continuously for 8 weeks, and glomerular filtration rate (GFR) was measured biweekly for 6 weeks. At the end of the study, renal arteries were collected for histological analysis, and kidneys were obtained for NE measurement. RESULTS Eight weeks after RD, systolic BP fell from 157±5mm Hg pre-RD to 133±3mm Hg (P < 0.01), and mean arterial pressure decreased by 9mm Hg compared with pre-RD (P < 0.01). There were no significant changes in GFR. Renal nerve injury was most prevalent 0.28–3.5mm from the renal artery lumen. RD caused injury in 46% of the renal nerves observed and reduced renal tissue NE by 42% (P < 0.01). CONCLUSIONS Catheter-based RD with the St. Jude Medical EnligHTN system lowers BP in obese dogs without significantly compromising renal function. PMID:24709437

Diabetes mellitus, hypertension and albuminuria in rural Zambia: a hospital-based survey.

PubMed

Rasmussen, Jon B; Thomsen, Jakúp A; Rossing, Peter; Parkinson, Shelagh; Christensen, Dirk L; Bygbjerg, Ib C

2013-09-01

To assess albuminuria in rural Zambia among patients with diabetes mellitus only (DM group), hypertension only (HTN group) and patients with combined DM and HTN (DM/HTN group). A cross-sectional survey was conducted at St. Francis Hospital in the Eastern province of Zambia. Albumin-creatinine ratio in one urine sample was used to assess albuminuria. Other information obtained included age, sex, body mass index (BMI), waist circumference (WC), blood pressure (BP), glycosylated haemoglobin (HbA1c ), random capillary glucose, time since diagnosis, medication and family history of DM or HTN. A total of 193 participants were included (DM group: n = 33; HTN group: n = 92; DM/HTN group: n = 68). The participants in the DM group used insulin more frequently as diabetes medication than the DM/HTN group (P < 0.05). Furthermore, the DM group was younger and had lower BMI, WC and BP than the two other groups. In the DM group, HTN group and DM/HTN group, microalbuminuria was found in 12.1%, 19.6% and 29.4% (P = 0.11), and macroalbuminuria was found in 0.0%, 3.3% and 13.2% (P = 0.014), respectively. The urine albumin (P = 0.014) and albumin-creatinine ratio (P = 0.0006) differed between the three groups. This hospital-based survey in rural Zambia found a lower frequency of albuminuria among the participants than in previous studies of patients with DM or HTN in urban sub-Saharan Africa. © 2013 John Wiley & Sons Ltd.

Renal Denervation for Treatment of Hypertension: a Second Start and New Challenges.

PubMed

Persu, Alexandre; Kjeldsen, Sverre; Staessen, Jan A; Azizi, Michel

2016-01-01

Following the publication of the randomized controlled but open-label trial Symplicity HTN-2, catheter-based renal sympathetic denervation was proposed as a novel treatment for drug-resistant hypertension. Thousands of procedures were routinely performed in Europe, Australia and Asia, and many observational studies were published. A sudden shift from overoptimistic views to radical scepticism occurred later, when the large US randomized sham-controlled trial Symplicity HTN-3 failed to meet its primary blood pressure lowering efficacy endpoint. Experts are divided on the reasons accounting for the large discrepancy between the results of initial studies and those of Symplicity HTN-3. Indeed, the blood pressure lowering effect associated with renal denervation was overestimated in initial trials due to various patient and physician-related biases, whereas it could have been underestimated in Symplicity HTN-3, which was well designed but not rigorously executed. Still, there is a large consensus on the need to further study catheter-based renal denervation in more controlled conditions, with particular emphasis on identification of predictors of blood pressure response. US and European experts have recently issued very similar recommendations on design of upcoming trials, procedural aspects, drug treatment, patient population and inclusion-exclusion criteria. Application of these new standards may represent a second chance for renal denervation to demonstrate--or not--its efficacy and safety in various patient populations. With its highly standardized treatment regimen, the French trial DENERHTN paved the way for this new approach and may inspire upcoming studies testing novel renal denervation systems in different populations.

Exaggerated Exercise Blood Pressure Response During Treadmill Testing as a Predictor of Future Hypertension in Men: A Longitudinal Study.

PubMed

Jae, Sae Young; Franklin, Barry A; Choo, Jina; Choi, Yoon-Ho; Fernhall, Bo

2015-11-01

The purpose of this study was to evaluate receiver operating characteristic curves to identify optimal cutoff values of exercise systolic blood pressure (SBP) using both peak SBP and relative SBP (peak SBP minus resting SBP) as predictors of future hypertension (HTN). Participants were 3,742 healthy normotensive men who underwent symptom-limited treadmill testing at baseline. Incident HTN was defined as SBP/diastolic blood pressure greater than 140/90 mm Hg and/or diagnosed HTN by a physician. During an average 5-year follow-up, 364 (9.7%) new cases of HTN were observed. The most discriminatory cutoff values for peak SBP and relative SBP for predicting incident HTN were 181 mm Hg (areas under the curve (AUC) = 0.644, sensitivity = 54%, and specificity = 69%) and 52 mm Hg (AUC = 0.549, sensitivity = 64.3%, and specificity = 44.6%), respectively. Participants with peak SBP greater than 181 mm Hg and relative SBP greater than 52 mm Hg had 1.54-fold (95% CI: 1.23-1.93) and 1.44-fold (95% CI: 1.16-1.80) risks of developing HTN after adjusting for potential confounding variables. When these 2 variables were entered simultaneously into the Cox proportional hazards regression model with adjustment for potential confounding variables, only peak SBP (relative risk: 1.39, 95% CI: 1.02-1.89) was a predictor of the development of HTN. The most accurate discriminators for peak and relative SBP during treadmill exercise testing to predict incident HTN were greater than 181 and 52 mm Hg, respectively, in normotensive men. A peak SBP greater than 181 mm Hg during treadmill exercise testing may provide a useful predictor for the development of HTN in clinical practice. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension.

PubMed

Pedrosa, Rodrigo P; Drager, Luciano F; Gonzaga, Carolina C; Sousa, Marcio G; de Paula, Lílian K G; Amaro, Aline C S; Amodeo, Celso; Bortolotto, Luiz A; Krieger, Eduardo M; Bradley, T Douglas; Lorenzi-Filho, Geraldo

2011-11-01

Recognition and treatment of secondary causes of hypertension among patients with resistant hypertension may help to control blood pressure and reduce cardiovascular risk. However, there are no studies systematically evaluating secondary causes of hypertension according to the Seventh Joint National Committee. Consecutive patients with resistant hypertension were investigated for known causes of hypertension irrespective of symptoms and signs, including aortic coarctation, Cushing syndrome, obstructive sleep apnea, drugs, pheochromocytoma, primary aldosteronism, renal parenchymal disease, renovascular hypertension, and thyroid disorders. Among 125 patients (age: 52±1 years, 43% males, systolic and diastolic blood pressure: 176±31 and 107±19 mm Hg, respectively), obstructive sleep apnea (apnea-hypopnea index: >15 events per hour) was the most common condition associated with resistant hypertension (64.0%), followed by primary aldosteronism (5.6%), renal artery stenosis (2.4%), renal parenchymal disease (1.6%), oral contraceptives (1.6%), and thyroid disorders (0.8%). In 34.4%, no secondary cause of hypertension was identified (primary hypertension). Two concomitant secondary causes of hypertension were found in 6.4% of patients. Age >50 years (odds ratio: 5.2 [95% CI: 1.9-14.2]; P<0.01), neck circumference ≥41 cm for women and ≥43 cm for men (odds ratio: 4.7 [95% CI: 1.3-16.9]; P=0.02), and presence of snoring (odds ratio: 3.7 [95% CI: 1.3-11]; P=0.02) were predictors of obstructive sleep apnea. In conclusion, obstructive sleep apnea appears to be the most common condition associated with resistant hypertension. Age >50 years, large neck circumference measurement, and snoring are good predictors of obstructive sleep apnea in this population.

Treatment-emergent hypertension and efficacy in the phase 3 Study of (E7080) lenvatinib in differentiated cancer of the thyroid (SELECT).

PubMed

Wirth, Lori J; Tahara, Makoto; Robinson, Bruce; Francis, Sanjeev; Brose, Marcia S; Habra, Mouhammed Amir; Newbold, Kate; Kiyota, Naomi; Dutcus, Corina E; Mathias, Elton; Guo, Matthew; Sherman, Steven I; Schlumberger, Martin

2018-06-01

Hypertension (HTN) is an established class effect of vascular endothelial growth factor receptor (VEGFR) inhibition. In the phase 3 Study of (E7080) Lenvatinib in Differentiated Cancer of the Thyroid (SELECT) trial, HTN was the most frequent adverse event of lenvatinib, an inhibitor of VEGFR1, VEGFR2, VEGFR3, fibroblast growth factor receptor 1 (FGFR1), FGFR2, FGFR3, FGFR4, platelet-derived growth factor receptor α (PDGFRα), ret proto-oncogene (RET), and stem cell factor receptor (KIT). This exploratory analysis examined treatment-emergent hypertension (TE-HTN) and its relation with lenvatinib efficacy and safety in SELECT. In the multicenter, double-blind SELECT trial, 392 patients with progressive radioiodine-refractory differentiated thyroid cancer (RR-DTC) were randomized 2:1 to lenvatinib (24 mg/d on a 28-day cycle) or placebo. Survival endpoints were assessed with Kaplan-Meier estimates and log-rank tests. The influence of TE-HTN on progression-free survival (PFS) and overall survival (OS) was analyzed with univariate and multivariate Cox proportional hazards models. Overall, 73% of lenvatinib-treated patients and 15% of placebo-treated patients experienced TE-HTN. The median PFS for lenvatinib-treated patients with (n = 190) and without TE-HTN (n = 71) was 18.8 and 12.9 months, respectively (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.39-0.88; P = .0085). For lenvatinib-treated patients, the objective response rate was 69% with TE-HTN and 56% without TE-HTN (odds ratio, 1.72; 95% CI, 0.98-3.01). The median change in tumor size for patients with and without TE-HTN was -45% and -40%, respectively (P = .2). The median OS was not reached for patients with TE-HTN; for those without TE-HTN, it was 21.7 months (HR, 0.43; 95% CI, 0.27-0.69; P = .0003). Although HTN is a clinically significant adverse event that warrants monitoring and management, TE-HTN was significantly correlated with improved outcomes in patients with RR-DTC, indicating that HTN

Aerobic exercise reduces blood pressure in resistant hypertension.

PubMed

Dimeo, Fernando; Pagonas, Nikolaos; Seibert, Felix; Arndt, Robert; Zidek, Walter; Westhoff, Timm H

2012-09-01

Regular physical exercise is broadly recommended by current European and American hypertension guidelines. It remains elusive, however, whether exercise leads to a reduction of blood pressure in resistant hypertension as well. The present randomized controlled trial examines the cardiovascular effects of aerobic exercise on resistant hypertension. Resistant hypertension was defined as a blood pressure ≥140/90 mm Hg in spite of 3 antihypertensive agents or a blood pressure controlled by ≥4 antihypertensive agents. Fifty subjects with resistant hypertension were randomly assigned to participate or not to participate in an 8- to 12-week treadmill exercise program (target lactate, 2.0±0.5 mmol/L). Blood pressure was assessed by 24-hour monitoring. Arterial compliance and cardiac index were measured by pulse wave analysis. The training program was well tolerated by all of the patients. Exercise significantly decreased systolic and diastolic daytime ambulatory blood pressure by 6±12 and 3±7 mm Hg, respectively (P=0.03 each). Regular exercise reduced blood pressure on exertion and increased physical performance as assessed by maximal oxygen uptake and lactate curves. Arterial compliance and cardiac index remained unchanged. Physical exercise is able to decrease blood pressure even in subjects with low responsiveness to medical treatment. It should be included in the therapeutic approach to resistant hypertension.

Patients with a hypertensive response to exercise have impaired left ventricular diastolic function.

PubMed

Takamura, Takeshi; Onishi, Katsuya; Sugimoto, Tadafumi; Kurita, Tairo; Fujimoto, Naoki; Dohi, Kaoru; Tanigawa, Takashi; Isaka, Naoki; Nobori, Tsutomu; Ito, Masaaki

2008-02-01

An exaggerated increase in systolic blood pressure prolongs myocardial relaxation and increases left ventricular (LV) chamber stiffness, resulting in an increase in LV filling pressure. We hypothesize that patients with a marked hypertensive response to exercise (HRE) have LV diastolic dysfunction leading to exercise intolerance, even in the absence of resting hypertension. We recruited 129 subjects (age 63+/-9 years, 64% male) with a preserved ejection fraction and a negative stress test. HRE was evaluated at the end of a 6-min exercise test using the modified Bruce protocol. Patients were categorized into three groups: a group without HRE and without resting hypertension (control group; n=30), a group with HRE but without resting hypertension (HRE group; n=25), and a group with both HRE and resting hypertension (HTN group; n=74). Conventional Doppler and tissue Doppler imaging were performed at rest. After 6-min exercise tests, systolic blood pressure increased in the HRE and HTN groups, compared with the control group (226+/-17 mmHg, 226+/-17 mmHg, and 180+/-15 mmHg, respectively, p<0.001). There were no significant differences in LV ejection fraction, LV end-diastolic diameter, and early mitral inflow velocity among the three groups. However, early diastolic mitral annular velocity (E') was significantly lower and the ratio of early diastolic mitral inflow velocity (E) to E' (E/E') was significantly higher in patients of the HRE and HTN groups compared to controls (E': 5.9+/-1.6 cm/s, 5.9+/-1.7 cm/s, 8.0+/-1.9 cm/s, respectively, p<0.05). In conclusion, irrespective of the presence of resting hypertension, patients with hypertensive response to exercise had impaired LV longitudinal diastolic function and exercise intolerance.

Association of ACE, FABP2 and GST genes polymorphism with essential hypertension risk among a North Indian population.

PubMed

Abbas, Shania; Raza, Syed Tasleem; Chandra, Anu; Rizvi, Saliha; Ahmed, Faisal; Eba, Ale; Mahdi, Farzana

2015-01-01

Hypertension has a multi-factorial background based on genetic and environmental interactive factors. ACE, FABP2 and GST genes have been suggested to be involved in the development of hypertension. However, the results have been inconsistent. The present study was carried out to investigate the association of ACE (rs4646994), FABP2 (rs1799883) and GST (GSTM1 null or positive genotype and GSTT1 null or positive genotype) genes polymorphism with essential HTN cases and controls. This study includes 138 essential hypertension (HTN) patients and 116 age-, sex- and ethnicity-matched control subjects. GST (GSTM1 null or positive genotype and GSTT1 null or positive genotype) genes polymorphisms were evaluated by multiplex PCR, ACE (rs4646994) gene polymorphisms by PCR and FABP2 (rs1799883) gene polymorphisms by PCR-RFLP method. Significant differences were obtained in the frequencies of ACE DD, II genotype (p = 0.006, 0.003), GSTT1 null, GSTM1 positive genotype (p = 0.048, 0.010) and FABP2 Ala54/Ala54 genotype (p = 0.049) between essential HTN cases and controls. It is concluded that ACE (rs 4646994), FABP2 (rs1799883) and GST (GSTM1 null or positive genotype and GSTT1 null or positive genotype) genes polymorphism are associated with HTN. Further investigation with a larger sample size may be required to validate this study.

Beta-Adrenergic Receptor Blockers in Hypertension: Alive and Well.

PubMed

Frishman, William H

Beta-adrenergic receptor blockers (β-blockers) are an appropriate treatment for patients having systemic hypertension (HTN) who have concomitant ischemic heart disease (IHD), heart failure, obstructive cardiomyopathy, aortic dissection or certain cardiac arrhythmias. β-Blockers can be used in combination with other antiHTN drugs to achieve maximal blood pressure control. Labetalol can be used in HTN emergencies and urgencies. β-Blockers may be useful in HTN patients having a hyperkinetic circulation (palpitations, tachycardia, HTN, and anxiety), migraine headache, and essential tremor. β-Blockers are highly heterogeneous with respect to various pharmacologic properties: degree of intrinsic sympathomimetic activity, membrane stabilizing activity, β 1 selectivity, α 1 -adrenergic blocking effects, tissue solubility, routes of systemic elimination, potencies and duration of action, and specific properties may be important in the selection of a drug for clinical use. β-Blocker usage to reduce perioperative myocardial ischemia and cardiovascular (CV) complications may not benefit as many patients as was once hoped, and may actually cause harm in some individuals. Currently the best evidence supports perioperative β-blocker use in two patient groups: patients undergoing vascular surgery with known IHD or multiple risk factors for it, and for those patients already receiving β-blockers for known CV conditions. Copyright © 2016 Elsevier Inc. All rights reserved.

Undiagnosed hypertensive participants demonstrate the largest blood pressure improvements from a community based lifestyle intervention: implications for addressing the silent hypertension epidemic

USDA-ARS?s Scientific Manuscript database

Introduction: It is important to understand effective strategies to reach and treat individuals who lack awareness of or have uncontrolled hypertension (HTN). The objectives of this secondary analysis from a community-based participatory research initiative, HUB City Steps, were to quantify the pre...

Renal denervation in the management of resistant hypertension: current evidence and perspectives.

PubMed

Jin, Yu; Persu, Alexandre; Staessen, Jan A

2013-09-01

Catheter-based renal denervation has emerged as a novel treatment modality for resistant hypertension. This review summarizes the current evidence on this procedure in treatment of resistant hypertension, limitations of available evidence and questions to be answered. The SYMPLICITY studies showed that renal denervation is feasible in treating resistant hypertension, but failed to provide conclusive evidence on the size and durability of the antihypertensive, renal and sympatholytic effects, as well as the long-term safety. The definition of resistant hypertension was loose in the SYMPLICITY studies and the management of resistant hypertension was suboptimal. Future studies should have a randomized design and enroll truly resistant hypertension patients by excluding secondary hypertension, white-coat hypertension and nonadherent patients. Questions to be addressed by the ongoing and future trials include the long-term efficacy and safety of this procedure, identification of responders and uncovering of the underlying mechanisms. Only well-designed, randomized clinical trials addressing the limitations of the SYMPLICITY studies will be able to demonstrate whether renal denervation is an efficacious treatment modality in resistant hypertension and in which patients. For now, renal denervation remains an experimental procedure and should only be offered to truly resistant hypertensive patients in a research context after careful selection.

Therapy of Treatment-Related Hypertension in Metastatic Renal-Cell Cancer Patients Receiving Sunitinib.

PubMed

Ivanyi, Philipp; Beutel, Gernot; Drewes, Nicole; Pirr, Jens; Kielstein, Jan T; Morgan, Michael; Ganser, Arnold; Grünwald, Viktor

2017-04-01

Treatment-related hypertension (tHTN) is frequent during sunitinib treatment. However, data on risk factors and treatment of tHTN remain scarce. Patients with metastatic renal-cell carcinoma treated with sunitinib from June 2004 to December 2011 were included. Medical records were retrospectively analyzed for tHTN risk factors and antihypertensive treatments (AHT). Descriptive statistics, Cox regression, and competitive risk models were applied. A total of 51 (70.8%) of 72 patients developed tHTN after a median sunitinib treatment of 28 days. Mean blood pressure increased from 130/75 (range, 90 to 190/58 to 101) mm Hg on day 1 to 140/80 (range, 90 to 190/60 to 120, P < .001) mm Hg on day 28. Standard dose of sunitinib, age > 50 years, and prehypertension were identified as independent risk factors for tHTN. Thirty-eight patients (72.5%) in the tHTN subgroup received modification of AHT. Calcium channel blockers (CCB) were identified as the best at controlling tHTN compared to other drugs (P = .045). The combination of AHT was more potent than a dose increase of a single-drug AHT, and early AHT intervention was more efficacious than delayed start of therapy. Patients at risk for tHTN require more rigorous blood pressure measurement. CCB seemed to be most potent and efficient, and an early combination of different classes of AHT was more efficacious than full-dose, single-agent AHT. Copyright © 2016 Elsevier Inc. All rights reserved.

Catheter-based renal denervation for treatment of resistant hypertension

PubMed Central

Hatipoglu, Emine; Ferro, Albert

2013-01-01

Hypertension is a common disease associated with important cardiovascular complications. Persistent blood pressure of 140/90 or higher despite combined use of a reninangiotensin system blocker, calcium channel blocker and a diuretic at highest tolerated doses constitutes resistant hypertension. Excess sympathetic activity plays an important pathogenic role in resistant hypertension in addition to contributing to the development of metabolic problems, in particular diabetes. Reduction of renal sympathetic activity by percutaneous catheter-based radiofrequency ablation via the renal arteries has been shown in several studies to decrease blood pressure in patients with resistant hypertension, and importantly is largely free of significant complications. However, longer term follow-up is required to confirm both long-term safety and efficacy. PMID:24175081

Results of a randomized controlled pilot trial of intravascular renal denervation for management of treatment-resistant hypertension.

PubMed

Jacobs, Lotte; Persu, Alexandre; Huang, Qi-Fang; Lengelé, Jean-Philippe; Thijs, Lutgarde; Hammer, Frank; Yang, Wen-Yi; Zhang, Zhen-Yu; Renkin, Jean; Sinnaeve, Peter; Wei, Fang-Fei; Pasquet, Agnès; Fadl Elmula, Fadl Elmula M; Carlier, Marc; Elvan, Arif; Wunder, Cora; Kjeldsen, Sverre E; Toennes, Stefan W; Janssens, Stefan; Verhamme, Peter; Staessen, Jan A

2017-12-01

Previous trials of catheter-based renal-artery denervation (RDN) as treatment modality in resistant hypertension (rHT) generated unconvincing results. In the Investigator-Steered Project on Intravascular Denervation for Management of Treatment-Resistant Hypertension (INSPiRED; NCT01505010), we optimized selection and management of rHT patients. With ethical clearance to randomize 18 patients, three Belgian hypertension centers screened 29 rHT patients on treatment with ≥3 drugs, of whom 17 after optimization of treatment (age <70 years; systolic/diastolic office blood pressure (BP) ≥ 140/90 mm Hg; 24-h BP ≥130/80 mm Hg; glomerular filtration rate [eGFR] ≥ 45 mL/min/1.73 m 2 ; body mass index <40kg/m 2 ) were randomized and 15 were analyzed 6 months later, while medical treatment was continued (n = 9) or combined with RDN by the EnligHTN™ multi-electrode system (n = 6). The baseline-adjusted between-group differences amounted to 19.5/10.4 mm Hg (change in control vs. intervention group, +7.6/+2.2 vs. -11.9/-8.2 mm Hg; P = .088) for office BP, 22.4/13.1 mm Hg (+0.7/+0.3 vs. -21.7/-12.8; mm Hg; P ≤ .049) for 24-h BP, the primary efficacy endpoint, and 2.5 mL/min/1.73 m 2 (+1.5 vs. -1.1 mL/min/1.73 m 2 ; P = .86) for eGFR, the primary safety endpoint. At 6 month, ECG voltages and the number of prescribed drugs (P ≤ .036) were lower in RDN patients, but quality of life and adherence, captured by questionnaire and urine analysis were similar in both groups. Changes in BP and adherence were unrelated. No major complications occurred. The INSPiRED pilot suggests that RDN with the EnligHTN ™ system is effective and safe and generated insights useful for the design of future RDN trials.

[Resistant hypertension: An update].

PubMed

Renna, N F

2018-02-04

An estimated 10% to 20% of hypertensive patients could be considered resistant to treatment (RH). These are patients who are not controlled using three drugs, at the maximum tolerated doses, including a diuretic, as well as those with high blood pressure controlled using four or more drugs. The term is used to identify patients that might benefit from special diagnostic and/or therapeutic consideration. The term 'refractory hypertension' has recently been proposed as a novel phenotype of antihypertensive failure. It refers to patients whose blood pressure cannot be controlled with maximum treatment. The first studies of this phenotype indicate that it is rare and affects less than 5% of patients with RH. Adherence to or compliance with medical treatment is key to defining resistant hypertension. Closer attention has been paid to clinical and experimental research since the first scientific statement for the diagnosis, assessment and treatment of RH from the American Heart Association, and in the European guidelines, was published in 2008. This review will set out the concepts relating to prevalence, prognosis and compliance and cover the latest developments on this subject. Copyright © 2018 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.

Incident Hypertension in Older Women and Men with or at-risk for HIV Infection

PubMed Central

Factor, SH; Lo, Y; Schoenbaum, EE; Klein, RS

2015-01-01

Objectives Antiretroviral (ARV) therapy has prolonged the life expectancy of HIV-infected persons, increasing their risk of age-associated diseases including atherosclerosis (AS). Decreased risk of AS has been associated with the prevention and control of hypertension (HTN). We conducted a cohort study of perimenopausal women and older men with or at-risk of HIV infection to identify risk factors for incident HTN. Methods Standardized interviews, physical examinations, and laboratory examinations were scheduled at 6-month intervals. Interview data included demographics, medical, family, sexual behavior, and drug use histories, and physical activity. Results There were 330 women and 329 men eligible persons; 27% and 35% of participants developed HTN during a median follow-up of 1080 and 1071 days, respectively. In gender-stratified analysis, adjusting for traditional HTN risk factors (age, race, BMI, smoking, diabetes, family history of HTN, alcohol dependence, physical activity, and high cholesterol), HIV infection was not associated with incident HTN in women or men [HR= 1.31, 95%CI (0.56, 3.06); HR = 1.67, 95%CI (0.75, 3.74), respectively]. Among HIV-infected women, although exposure to ARV's was not significantly associated with incident HTN [HR=0.72, 95%CI (0.26, 1.99)], CD4+ T-cell count was positively associated with incident HTN [HR=1.15 per 100 cells, 95%CI (1.03, 1.28)]. Among physically active HIV-infected men, exposure to ARV's was negatively associated with incident HTN [HR=0.15, 95%CI (0.03, 0.78)]. Conclusions HIV infection was not associated with incident HTN in older men or women. This study provides additional evidence supporting a causal relationship between immune function and incident HTN, which warrants further study. PMID:23294666

Decoding resistant hypertension signalling pathways.

PubMed

Parreira, Ricardo Cambraia; Lacerda, Leandro Heleno Guimarães; Vasconcellos, Rebecca; Lima, Swiany Silveira; Santos, Anderson Kenedy; Fontana, Vanessa; Sandrim, Valéria Cristina; Resende, Rodrigo Ribeiro

2017-12-01

Resistant hypertension (RH) is a clinical condition in which the hypertensive patient has become resistant to drug therapy and is often associated with increased cardiovascular morbidity and mortality. Several signalling pathways have been studied and related to the development and progression of RH: modulation of sympathetic activity by leptin and aldosterone, primary aldosteronism, arterial stiffness, endothelial dysfunction and variations in the renin-angiotensin-aldosterone system (RAAS). miRNAs comprise a family of small non-coding RNAs that participate in the regulation of gene expression at post-transcriptional level. miRNAs are involved in the development of both cardiovascular damage and hypertension. Little is known of the molecular mechanisms that lead to development and progression of this condition. This review aims to cover the potential roles of miRNAs in the mechanisms associated with the development and consequences of RH, and explore the current state of the art of diagnostic and therapeutic tools based on miRNA approaches. © 2017 The Author(s). Published by Portland Press Limited on behalf of the Biochemical Society.

Hypertension and cardiac arrhythmias: executive summary of a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE).

PubMed

Lip, Gregory Y H; Coca, Antonio; Kahan, Thomas; Boriani, Giuseppe; Manolis, Antonis S; Olsen, Michael Hecht; Oto, Ali; Potpara, Tatjana S; Steffel, Jan; Marín, Francisco; de Oliveira Figueiredo, Márcio Jansen; de Simone, Giovanni; Tzou, Wendy S; En Chiang, Chern; Williams, Bryan

2017-10-01

Hypertension (HTN) is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease (CAD), stroke, peripheral artery disease and chronic renal failure. Hypertensive heart disease can manifest as many types of cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in HTN patients, especially in those with left ventricular hypertrophy (LVH), CAD, or HF. In addition, high doses of thiazide diuretics commonly used to treat HTN, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesaemia), contributing further to arrhythmias, while effective blood pressure control may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between HTN and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit of comprehensively reviewing the available evidence and publishing a joint consensus document on HTN and cardiac arrhythmias, and providing up-to-date consensus recommendations for use in clinical practice. The ultimate judgment on the care of a specific patient must be made by the healthcare provider and the patient in light of all individual factors presented. This is an executive summary of the full document co-published by EHRA in EP-Europace. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For Permissions, please email: journals.permissions@oup.com.

Interventional Therapies for Resistant Hypertension: A Brief Update

PubMed Central

Brandon, Lisa

2016-01-01

Resistant hypertension remains a clinical challenge with few management options beyond maximisation of medications. Catheter- based renal artery denervation (RDN) was proposed in 2009 as a possible therapy for resistant hypertension and early feasibility trials caused excitement among cardiologists and antihypertensive specialists, showing remarkable and sustained blood pressure reductions. In 2014, enthusiasm for RDN dampened following the SYMPLICITY 3 trial results, which showed no statistically significant difference in blood pressure between the intervention and control arms. However, hope remains for the improved management of resistant hypertension; procedural understanding, technological advancements and alternative targets – such as baroreceptor activation therapy and arteriovenous shunts – may aid the identification of those patients for whom specific interventional therapies will be effective. PMID:29588709

[Renal denervation in resistant hypertension: proposal for a common multidisciplinary attitude].

PubMed

Muller, Olivier; Qanadli, Salah D; Waeber, Bernard; Wuerzner, Grégoire

2012-05-30

The prevalence of resistant hypertension ranges between 5-30%. Patients with resistant hypertension are at increased risk of cardiovascular events. Radiofrequency renal denervation is a recent and promising technique that can be used in the setting of resistant hypertension. However, long-term safety and efficacy data are lacking and evidence to use this procedure outside the strict setting of resistant hypertension is missing. The aim of the article is to propose a common work-up for nephrologists, hypertensiologists, cardiologists and interventional radiologists in order to avoid inappropriate selection of patients and a possible misuse of this procedure.

Hypertension risk and clinical care in patients with bipolar disorder or schizophrenia; a systematic review and meta-analysis.

PubMed

Ayerbe, Luis; Forgnone, Ivo; Addo, Juliet; Siguero, Ana; Gelati, Stefano; Ayis, Salma

2018-01-01

A higher cardiovascular morbidity and mortality has been observed in patients with bipolar disorder (BPD) or schizophrenia, partly due to an increased risk of hypertension (HTN), or a less effective care of it. This systematic review and meta-analysis, presents a critical appraisal and summary of the studies addressing the risk of HTN, or the differences in its care, for those with schizophrenia or BPD. Prospective studies were searched in PubMed, Embase, PsycINFO, Scopus, and the Web of Science, from database inception to June 2017. A meta-analysis was undertaken to obtain pooled estimates of the risk of HTN. Five studies reporting the risk of HTN, and five studies presenting differences in its clinical care, were identified. An increased risk of HTN was observed for BPD patients, with an overall Incidence Rate Ratio 1.27(1.15-1.40). The pooled Incidence Rate Ratio of HTN for those with schizophrenia was 0.94 (0.75 - 1.14). A poorer care of HTN (lower rates of screening, prescription, and adherence) was reported in four studies of schizophrenia, and two of BPD patients, compared to people without these conditions. reduced number of studies on risk and care of HTN on patients with BPD or schizophrenia. Limited evidence suggests that patients with BPD have a higher risk of HTN. Patients with schizophrenia and BPD receive poor care of HTN. Understanding the risk of HTN, and the differences in its care, is essential for clinicians to reduce the cardiovascular morbidity and overall mortality of these patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Clinical significance of blood pressure ratios in hypertensive crisis in children.

PubMed

Wu, Han-Ping; Yang, Wen-Chieh; Wu, Yung-Kang; Zhao, Lu-Lu; Chen, Chun-Yu; Fu, Yun-Ching

2012-03-01

Hypertensive crisis is categorised into hypertensive urgency and hypertensive emergency. The present work aimed to determine the effect of different gradings of blood pressure (BP) ratios in predicting the severity of paediatric hypertensive crisis. This was a retrospective case series, based in the paediatric emergency departments of the Changhua Christian Hospital and the Tzu-Chi General Hospital, Taiwan. From 1995 to 2010, the correlation between the severity of hypertension (HTN) and the difference in elevated systolic BP and 99th percentile plus 5 mm Hg (dSBP), the difference in elevated diastolic BP and 99th percentile plus 5 mm Hg (dDBP), dSBP ratio (dSBP/99th percentile plus 5 mm Hg) and dDBP ratio were analysed. A total of 110 children with a first attack of hypertensive crisis were recruited. Patients with hypertensive crisis caused by essential HTN had lower dDBP ratios than the other causes (p=0.033), while those with an oncological aetiology had the highest dSBP and dDBP ratios among all the aetiologies. For clinical presentations, patients with nausea/vomiting and visual impairment presented with higher dSBP ratios than those without the symptoms (both p<0.05), but patients with altered consciousness had higher dSBP and dDBP ratios than those who had clear consciousness (p<0.05). Children with hypertensive urgency had lower dSBP and dDBP ratios than those with hypertensive emergency (both p<0.05). dDBP and dSBP ratios may serve as BP parameters in predicting the severity of paediatric hypertensive crisis. A dSBP ratio greater than 20% may indicate a critical point for severe hypertensive crisis in children.

Renal denervation in the era of HTN-3. Comprehensive review and glimpse into the future.

PubMed

Silva, Joana Delgado; Costa, Marco; Gersh, Bernard J; Gonçalves, Lino

2016-08-01

The pathophysiological role of sympathetic overactivity in conditions such as hypertension has been well documented. Catheter-based renal denervation (RDN) is a minimally invasive percutaneous procedure which aims to disrupt sympathetic nerve afferent and efferent activity through the application of radiofrequency energy directly within the renal artery wall. This technique has emerged as a very promising treatment with dramatic effects on refractory hypertension but also in other conditions in which a sympathetic influence is present. Several studies have evaluated the safety and efficacy of this procedure, presently surrounded by controversy since the recent outcome of Symplicity HTN-3, the first randomized, sham-control trial, which failed to confirm RDN previous reported benefits on BP and cardiovascular risk lowering. Consequently, although some centers halted their RDN programs, research continues and both the concept of denervation and treatment strategies are being redefined to identify patients who can drive the most benefit from this technology. In the United States, the Food and Drug Administration (FDA) has appropriately mandated that RDN remains an investigative procedure and a new generation of sham-controlled trials are ongoing and aimed to assess not only its efficacy against pharmacotherapy but also trials in drug free patients with the objective of demonstrating once and for all whether the procedure actually does lower BP in comparison to a placebo arm. In this article, we present an overview of the sympathetic nervous system and its role in hypertension, examine the current data on RDN, and share some insights and future expectations. Copyright © 2016 American Society of Hypertension. All rights reserved.

Uric acid, hypertension, and chronic kidney disease among Alaska Eskimos: the Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) study.

PubMed

Jolly, Stacey E; Mete, Mihriye; Wang, Hong; Zhu, Jianhui; Ebbesson, Sven O E; Voruganti, V Saroja; Comuzzie, Anthony G; Howard, Barbara V; Umans, Jason G

2012-02-01

It is unknown what role uric acid (UA) may play in the increasing rates of cardiovascular disease (CVD) among Alaska Eskimos. UA is associated with both hypertension (HTN) and chronic kidney disease (CKD). The authors analyzed 1078 Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) participants. Estimated glomerular filtration rate (eGFR) was calculated from serum creatinine measures using the Modification of Diet in Renal Disease equation. CKD was defined by an eGFR of <60 mL/min/1.73 m(2) . The authors adjusted for age, sex, education, diabetes, hypertension (or eGFR), obesity, lipids, and smoking status; 7% (n=75) had prevalent CKD. eGFR decreased with increasing tertiles of serum UA (P<.001). UA was independently associated with prevalent CKD (adjusted odds ratio [OR] and 95% confidence interval [CI] of 2.04 (1.62-2.56), respectively). Twenty-one percent (n=230) had prevalent HTN and UA was independently associated with prevalent HTN (adjusted OR, 1.2; 95% CI, 1.1-1.5). UA is independently associated with prevalent CKD and HTN in this population. © 2011 Wiley Periodicals, Inc.

Longitudinal relationship of parental hypertension with body mass index, blood pressure, and cardiovascular reactivity in children.

PubMed

Li, Rongling; Alpert, Bruce S; Walker, Sammie S; Somes, Grant W

2007-05-01

To investigate whether parental hypertension (HTN) affects children's body mass index (BMI) and cardiovascular reactivity (CVR) over time. A longitudinal study of 315 students (black: 23 females, 19 males; white: 142 females, 131 males) was conducted in the public schools of Obion County, Tennessee, between 1987 and 1992. BMI and BMI z scores were calculated. The CVR task was a series of video games (taking approximately 10 minutes to play) given to the same students in their third-, fourth-, fifth-, seventh-, and eighth-grade years. CVR was defined as the change in blood pressure (delta_BP) or heart rate (delta_HR) between before playing and while playing the video game. Positive parental history of HTN (27.6%) was defined as at least 1 parent with HTN. Multivariable regression analyses were performed to estimate the effects of parental HTN on children's BMI and CVR over time. Children with parental HTN had significant higher BMI, BMI z score, and R_BP than did children without parental HTN (BMI: 21.6 vs 19.9, P = .001; BMI z score: 1.6 vs 1.1, P = .003; R_SBP: 112.6 vs 110.4 mm Hg, P = .01; R_DBP 62.7 vs 60.6 mm Hg, P = .003) after adjustment for covariates. Increased CVR was observed in children with parental HTN compared with children without parental HTN but was statistically significant only for SBP (delta_SBP: 17.2 vs 14.9 mm Hg; P = .01) after adjustment for covariates. Parental HTN independently predicted children's BMI, BMI z score, resting BP, and BP reactivity.

Heart rate recovery after maximal exercise is blunted in hypertensive seniors.

PubMed

Best, Stuart A; Bivens, Tiffany B; Dean Palmer, M; Boyd, Kara N; Melyn Galbreath, M; Okada, Yoshiyuki; Carrick-Ranson, Graeme; Fujimoto, Naoki; Shibata, Shigeki; Hastings, Jeffrey L; Spencer, Matthew D; Tarumi, Takashi; Levine, Benjamin D; Fu, Qi

2014-12-01

Abnormal heart rate recovery (HRR) after maximal exercise may indicate autonomic dysfunction and is a predictor for cardiovascular mortality. HRR is attenuated with aging and in middle-age hypertensive patients, but it is unknown whether HRR is attenuated in older-age adults with hypertension. This study compared HRR among 16 unmedicated stage 1 hypertensive (HTN) participants [nine men/seven women; 68 ± 5 (SD) yr; awake ambulatory blood pressure (BP) 149 ± 10/87 ± 7 mmHg] and 16 normotensive [control (CON)] participants (nine men/seven women; 67 ± 5 yr; 122 ± 4/72 ± 5 mmHg). HR, BP, oxygen uptake (V̇o2), cardiac output (Qc), and stroke volume (SV) were measured at rest, at two steady-state work rates, and graded exercise to peak during maximal treadmill exercise. During 6 min of seated recovery, the change in HR (ΔHR) was obtained every minute and BP every 2 min. In addition, HRR and R-R interval (RRI) recovery kinetics were analyzed using a monoexponential function, and the indexes (HRRI and RRII) were calculated. Maximum V̇o2, HR, Qc, and SV responses during exercise were not different between groups. ΔHR was significantly different (P < 0.001) between the HTN group (26 ± 8) and the CON group (36 ± 12 beats/min) after 1 min of recovery but less convincing at 2 min (P = 0.055). BP recovery was similar between groups. HRRI was significantly lower (P = 0.016), and there was a trend of lower RRII (P = 0.066) in the HTN group compared with the CON group. These results show that in older-age adults, HRR is attenuated further with the presence of hypertension, which may be attributable to an impairment of autonomic function. Copyright © 2014 the American Physiological Society.

Heart rate recovery after maximal exercise is blunted in hypertensive seniors

PubMed Central

Best, Stuart A.; Bivens, Tiffany B.; Dean Palmer, M.; Boyd, Kara N.; Melyn Galbreath, M.; Okada, Yoshiyuki; Carrick-Ranson, Graeme; Shibata, Shigeki; Hastings, Jeffrey L.; Spencer, Matthew D.; Tarumi, Takashi; Levine, Benjamin D.; Fu, Qi

2014-01-01

Abnormal heart rate recovery (HRR) after maximal exercise may indicate autonomic dysfunction and is a predictor for cardiovascular mortality. HRR is attenuated with aging and in middle-age hypertensive patients, but it is unknown whether HRR is attenuated in older-age adults with hypertension. This study compared HRR among 16 unmedicated stage 1 hypertensive (HTN) participants [nine men/seven women; 68 ± 5 (SD) yr; awake ambulatory blood pressure (BP) 149 ± 10/87 ± 7 mmHg] and 16 normotensive [control (CON)] participants (nine men/seven women; 67 ± 5 yr; 122 ± 4/72 ± 5 mmHg). HR, BP, oxygen uptake (V̇o2), cardiac output (Qc), and stroke volume (SV) were measured at rest, at two steady-state work rates, and graded exercise to peak during maximal treadmill exercise. During 6 min of seated recovery, the change in HR (ΔHR) was obtained every minute and BP every 2 min. In addition, HRR and R-R interval (RRI) recovery kinetics were analyzed using a monoexponential function, and the indexes (HRRI and RRII) were calculated. Maximum V̇o2, HR, Qc, and SV responses during exercise were not different between groups. ΔHR was significantly different (P < 0.001) between the HTN group (26 ± 8) and the CON group (36 ± 12 beats/min) after 1 min of recovery but less convincing at 2 min (P = 0.055). BP recovery was similar between groups. HRRI was significantly lower (P = 0.016), and there was a trend of lower RRII (P = 0.066) in the HTN group compared with the CON group. These results show that in older-age adults, HRR is attenuated further with the presence of hypertension, which may be attributable to an impairment of autonomic function. PMID:25301897

Impact of Mother-Daughter Relationship on Hypertension Self-management and Quality of Life: Testing Dyadic Dynamics Using the Actor-Partner Interdependence Model.

PubMed

Shawler, Celeste; Edward, Jean; Ling, Jiying; Crawford, Tim N; Rayens, Mary Kay

Although hypertension (HTN) treatment rates are similar across age groups of women, effective control is significantly worse among older women. Only 20% of hypertensive women aged 70 to 79 years have controlled blood pressure. The purpose of this longitudinal study was to test the effects of the quality of mother-daughter relationship, inner strength, and control on HTN self-management and health-related quality of life (HRQOL) for both members of the dyad at 6 months. The Actor-Partner Interdependence Model was used to examine the direct ("actor") and indirect ("partner") effects of 46 dyads. The mothers' perceived relationship quality with daughters directly impacted their own self-management of HTN and HRQOL while also indirectly affecting their daughters' self-management. Similarly, the daughters' perceived strength of their relationship with their mothers directly influenced their self-management and HRQOL and indirectly affected their mothers' self-management and HRQOL.

Relationship of plasminogen activator inhibitor 1 gene 4G/5G polymorphisms to hypertension in Korean women.

PubMed

Kim, Kyu-nam; Kim, Kwang-min; Kim, Bom-taeck; Joo, Nam-seok; Cho, Doo-yeoun; Lee, Duck-joo

2012-04-01

Hypertension (HTN) is a major determinant of various cardiovascular events. Plasma levels of plasminogen activator inhibitor 1 (PAI-1) modulate this risk. A deletion/insertion polymorphism within the PAI-1 loci (4G/4G, 4G/5G, 5G/5G) affects the expression of this gene. The present study investigated the association between PAI-1 loci polymorphisms and HTN in Korean women. Korean women (n = 1312) were enrolled in this study to evaluate the association between PAI-1 4G/5G gene polymorphisms and HTN as well as other metabolic risk factors. PAI-1 loci polymorphisms were investigated using polymerase chain reaction amplification and single-strand conformation polymorphism analysis. The three genotype groups differed with respect to systolic blood pressure (P = 0.043), and diastolic blood pressure (P = 0.009) but not with respect to age, body mass index, total cholesterol, low or high density lipoprotein cholesterol, triglycerides, or fasting blood glucose. Carriers of the PAI-1 4G allele had more hypertension significantly (PAI-1 4G/5G vs. PAI-1 5G/5G, P = 0.032; PAI-1 4G/4G vs. PAI-1 5G/5G, P = 0.034). When stratified according to PAI-1 4G/5G polymorphism, there was no significant difference in all metabolic parameters among PAI-1 genotype groups in patients with HTN as well as subjects with normal blood pressure. The estimated odds ratio of the 4G/4G genotype and 4G/5G for HTN was 1.7 (P = 0.005), and 1.6 (P = 0.015), respectively. These findings might indicate that PAI-1 loci polymorphisms independently contribute to HTN and that gene-environmental interaction may be not associated in Korean women.

The prevalence of hypertension in relation with the normal albuminuria range in type 2 diabetes mellitus within the South Korean population: The Korean National Health and Nutrition Examination Survey, 2011-2012.

PubMed

Shin, Koh-Eun; Roh, Yong-Kyun; Cho, Kyung-Hwan; Han, Kyung-Do; Park, Yong-Gyu; Kim, Do-Hoon; Kim, Yang-Hyun

2017-06-01

The coexistence of hypertension (HTN) and diabetes mellitus (DM) increases the risk of cardiovascular disease. In some studies, normal albuminuria has also been associated with cardiovascular disease and HTN. Therefore, we examined the relationships between albuminuria and the prevalence of HTN and its control rate in type 2 DM patients. We analyzed data from the 2011-2012 Korea National Health and Nutrition Examination Survey, and 1188 subjects with type 2 DM were included in the study. We divided albuminuria into 3 albuminuria tertiles (T): T1: <4.82mg/g; T2: 4.82-17.56mg/g; and T3: ≥17.56mg/g. The systolic and diastolic blood pressure were positively correlated with the albumin to creatinine ratio (ACR) after adjusting for all covariates (P<0.001). Type 2 DM subjects with hypertension had more ACR T3 (odds ratio=2.018, 95% confidence interval=1.445-2.818) than subjects without HTN. Subjects with controlled HTN had less ACR T3 than subjects without controlled HTN (odds ratio=0.566, 95% confidence interval=0.384-0.836). When, we redivided albuminuria by <10, 10-30 (high normal albuminuria), 30-300mg/g (microalbuminuria), and 300mg/g≤(macroalbuminuria), the odds ratio for high normal albuminuria and microalbuminuria was 1.52 and 2.24, respectively in the presence of HTN, however, high normal albuminuria was not associated with HTN control. In conclusion, albuminuria within the high normal range was associated with the prevalence of HTN in South Korean patients with type 2 DM. Copyright © 2017 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Associations of rotational shift work and night shift status with hypertension: a systematic review and meta-analysis.

PubMed

Manohar, Sandhya; Thongprayoon, Charat; Cheungpasitporn, Wisit; Mao, Michael A; Herrmann, Sandra M

2017-10-01

The reported risks of hypertension (HTN) in rotating shift and night shift workers are controversial. The objective of this meta-analysis was to assess the association between shift work status and HTN. A literature search was performed using MEDLINE, EMBASE and Cochrane Database from inception through October 2016. Studies that reported odds ratios (OR) comparing the risk of HTN in shift workers were included. A prespecified subgroup analysis by rotating shift and night shift statuses were also performed. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. The protocol for this study is registered with International Prospective Register of Systematic Reviews; no. CRD42016051843. Twenty-seven observational studies (nine cohort and 18 cross-sectional studies) with a total of 394 793 individuals were enrolled. The pooled ORs of HTN in shift workers in cohort and cross-sectional studies were 1.31 (95% CI, 1.07-1.60) and 1.10 (95% CI, 1.00-1.20), respectively. When meta-analysis was restricted only to cohort studies in rotating shift, the pooled OR of HTN in rotating shift workers was 1.34 (95% CI, 1.08-1.67). The data regarding night shift and HTN in cohort studies was limited. The pooled OR of HTN in night shift workers in cross-sectional studies was 1.07 (95% CI, 0.85-1.35). Based on the findings of our meta-analysis, shiftwork status may play an important role in HTN, as there is a significant association between rotating shift work and HTN. However, there is no significant association between night shift status and risk of HTN.

Perceptions of family history and genetic testing and feasibility of pedigree development among African Americans with hypertension

PubMed Central

Pettey, Christina M; McSweeney, Jean C; Stewart, Katharine E; Price, Elvin T; Cleves, Mario A; Heo, Seongkum; Souder, Elaine

2016-01-01

Background Pedigree development, family history, and genetic testing are thought to be useful in improving outcomes of chronic illnesses such as hypertension (HTN). However, the clinical utility of pedigree development is still unknown. Further, little is known about African Americans’ (AAs’) perceptions of family history and genetic testing. Aims This study examined the feasibility of developing pedigrees for AAs with HTN and explored perceptions of family history and genetic research among AAs with HTN. Methods The US Surgeon General’s My Family Health Portrait was administered, and 30–60 minute in-person individual interviews were conducted. Descriptive statistics were used to analyze pedigree data. Interview transcripts were analyzed with content analysis and constant comparison. Results Twenty-nine AAs with HTN were recruited from one free clinic (15 women, 14 men; mean age 49 years, SD 9.6). Twenty-six (90%) reported their family history in sufficient detail to develop a pedigree. Perceptions of family history included knowledge of HTN in the family, culturally influenced family teaching about HTN, and response to family history of HTN. Most participants agreed to future genetic testing and DNA collection because they wanted to help others; some said they needed more information and others expressed a concern for privacy. Conclusion The majority of AAs in this sample possessed extensive knowledge of HTN within their family and were able to develop a three generation pedigree with assistance. The majority were willing to participate in future genetic research. PMID:25322748

Perceptions of family history and genetic testing and feasibility of pedigree development among African Americans with hypertension.

PubMed

Pettey, Christina M; McSweeney, Jean C; Stewart, Katharine E; Price, Elvin T; Cleves, Mario A; Heo, Seongkum; Souder, Elaine

2015-02-01

Pedigree development, family history, and genetic testing are thought to be useful in improving outcomes of chronic illnesses such as hypertension (HTN). However, the clinical utility of pedigree development is still unknown. Further, little is known about the perceptions of African Americans (AAs) of family history and genetic testing. This study examined the feasibility of developing pedigrees for AAs with HTN and explored perceptions of family history and genetic research among AAs with HTN. The US Surgeon General's My Family Health Portrait was administered, and 30-60 min in-person individual interviews were conducted. Descriptive statistics were used to analyze pedigree data. Interview transcripts were analyzed with content analysis and constant comparison. Twenty-nine AAs with HTN were recruited from one free clinic (15 women, 14 men; mean age 49 years, standard deviation (SD) 9.6). Twenty-six (90%) reported their family history in sufficient detail to develop a pedigree. Perceptions of family history included knowledge of HTN in the family, culturally influenced family teaching about HTN, and response to family history of HTN. Most participants agreed to future genetic testing and DNA collection because they wanted to help others; some said they needed more information and others expressed a concern for privacy. The majority of AAs in this sample possessed extensive knowledge of HTN within their family and were able to develop a three-generation pedigree with assistance. The majority were willing to participate in future genetic research. © The European Society of Cardiology 2014.

Specific Transcriptome Changes Associated with Blood Pressure Reduction in Hypertensive Patients After Relaxation Response Training.

PubMed

Bhasin, Manoj K; Denninger, John W; Huffman, Jeff C; Joseph, Marie G; Niles, Halsey; Chad-Friedman, Emma; Goldman, Roberta; Buczynski-Kelley, Beverly; Mahoney, Barbara A; Fricchione, Gregory L; Dusek, Jeffery A; Benson, Herbert; Zusman, Randall M; Libermann, Towia A

2018-05-01

Mind-body practices that elicit the relaxation response (RR) have been demonstrated to reduce blood pressure (BP) in essential hypertension (HTN) and may be an adjunct to antihypertensive drug therapy. However, the molecular mechanisms by which the RR reduces BP remain undefined. Genomic determinants associated with responsiveness to an 8-week RR-based mind-body intervention for lowering HTN in 13 stage 1 hypertensive patients classified as BP responders and 11 as nonresponders were identified. Transcriptome analysis in peripheral blood mononuclear cells identified 1771 genes regulated by the RR in responders. Biological process- and pathway-based analysis of transcriptome data demonstrated enrichment in the following gene categories: immune regulatory pathways and metabolism (among downregulated genes); glucose metabolism, cardiovascular system development, and circadian rhythm (among upregulated genes). Further in silico estimation of cell abundance from the microarray data showed enrichment of the anti-inflammatory M2 subtype of macrophages in BP responders. Nuclear factor-κB, vascular endothelial growth factor, and insulin were critical molecules emerging from interactive network analysis. These findings provide the first insights into the molecular mechanisms that are associated with the beneficial effects of the RR on HTN.

Specific Transcriptome Changes Associated with Blood Pressure Reduction in Hypertensive Patients After Relaxation Response Training

PubMed Central

Bhasin, Manoj K.; Denninger, John W.; Huffman, Jeff C.; Joseph, Marie G.; Niles, Halsey; Chad-Friedman, Emma; Goldman, Roberta; Buczynski-Kelley, Beverly; Mahoney, Barbara A.; Fricchione, Gregory L.; Dusek, Jeffery A.; Benson, Herbert; Zusman, Randall M.

2018-01-01

Abstract Objective: Mind–body practices that elicit the relaxation response (RR) have been demonstrated to reduce blood pressure (BP) in essential hypertension (HTN) and may be an adjunct to antihypertensive drug therapy. However, the molecular mechanisms by which the RR reduces BP remain undefined. Design: Genomic determinants associated with responsiveness to an 8-week RR-based mind–body intervention for lowering HTN in 13 stage 1 hypertensive patients classified as BP responders and 11 as nonresponders were identified. Results: Transcriptome analysis in peripheral blood mononuclear cells identified 1771 genes regulated by the RR in responders. Biological process- and pathway-based analysis of transcriptome data demonstrated enrichment in the following gene categories: immune regulatory pathways and metabolism (among downregulated genes); glucose metabolism, cardiovascular system development, and circadian rhythm (among upregulated genes). Further in silico estimation of cell abundance from the microarray data showed enrichment of the anti-inflammatory M2 subtype of macrophages in BP responders. Nuclear factor-κB, vascular endothelial growth factor, and insulin were critical molecules emerging from interactive network analysis. Conclusions: These findings provide the first insights into the molecular mechanisms that are associated with the beneficial effects of the RR on HTN. PMID:29616846

Aldosterone antagonists: effective add-on therapy for the treatment of resistant hypertension.

PubMed

Gaddam, Krishna K; Pratt-Ubunama, Monique N; Calhoun, David A

2006-05-01

Resistant hypertension is defined as blood pressure that remains above target levels despite treatment with three different antihypertensive agents. Cross-sectional analyses and hypertension outcome studies indicate that it is a common clinical problem, which will undoubtedly become increasingly prevalent with an aging and increasingly overweight population. Secondary causes of hypertension are common in patients with resistant hypertension, particularly hyperaldosteronism, with a prevalence of approximately 15-20%. This, however, is likely to be an underestimation of the role excess aldosterone plays in causing resistance to treatment. In subjects with resistant hypertension, suppressed renin levels are common, exceeding 60% in studies conducted by the authors and from centers elsewhere in the world, suggesting occurrence of excess aldosterone beyond cases of true primary aldosteronism. Recent clinical studies indicate that aldosterone antagonists provide significant additional blood pressure reduction when added to treatment regimens of patients with resistant hypertension independent of aldosterone levels. These agents are generally well tolerated. Hyperkalemia is an uncommon complication of aldosterone antagonists, but it can occur. Therefore, biochemical monitoring is necessary, particularly in high-risk patients.

Hypertension Analysis of stress Reduction using Mindfulness meditatiON and Yoga (The HARMONY Study): study protocol of a randomised control trial.

PubMed

Blom, Kimberly; How, Maxine; Dai, Monica; Baker, Brian; Irvine, Jane; Abbey, Susan; Abramson, Beth L; Myers, Martin; Perkins, Nancy; Tobe, Sheldon W

2012-01-01

Hypertension (HTN) is a leading risk factor for preventable cardiovascular disease, with over one in five adults affected worldwide. Lifestyle modification is a key strategy for the prevention and treatment of HTN. Stress has been associated with greater cardiovascular risk, and stress management is a recommended intervention for hypertensives. Stress reduction through relaxation therapies has been shown to have an effect on human physiology, including lowering blood pressure (BP). However, individualised behavioural interventions are resource intensive, and group stress management approaches have not been validated for reducing HTN. The HARMONY Study is a pilot randomised controlled trial designed to determine if mindfulness-based stress reduction (MBSR), a standardised group therapy, is an effective intervention for lowering BP in stage 1 unmedicated hypertensives. Men and women unmedicated for HTN with mean daytime ambulatory blood pressure (ABP) ≥135/85 mm Hg or 24 h ABP ≥130/80 mm Hg are included in the study. Subjects are randomised to receive MBSR immediately or after a wait-list control period. The primary outcome measure is mean awake and 24 h ABP. The primary objective of the HARMONY Study is to compare ABP between the treatment and wait-list control arm at the 12-week primary assessment period. Results from this study will determine if MBSR is an effective intervention for lowering BP in early unmedicated hypertensives. This research project was approved by the Sunnybrook Research Ethics Board and the University Health Network Research Ethics Board (Toronto, Canada). Planned analyses are in full compliance with the principles of the Declaration of Helsinki. Data collection will be completed by early spring 2012. Primary and secondary analysis will commence immediately after data monitoring is completed; dissemination plans include preparing publications for submission during the summer of 2012. This study is registered with http

Sleep disturbances and resistant hypertension: association or causality?

PubMed

Genta-Pereira, Daniel Castanho; Pedrosa, Rodrigo P; Lorenzi-Filho, Geraldo; Drager, Luciano F

2014-08-01

Two main sleep disturbances, namely obstructive sleep apnea (OSA) and sleep deprivation, have gained growing interest in the field of hypertension research. This fact is supported not only by evidence that both disturbances are quite common in modern societies but also that OSA and sleep deprivation are associated with several pathways that may contribute to a predisposition to hypertension or even exacerbate blood pressure levels in hypertensive patients. In the present review, we will discuss current evidence supporting a potential role of these sleep disturbances in the resistant hypertension scenario.

Assessing the risk of incident hypertension and chronic kidney disease after exposure to shockwave lithotripsy and ureteroscopy

PubMed Central

Denburg, Michelle R.; Jemielita, Thomas; Tasian, Gregory; Haynes, Kevin; Mucksavage, Phillip; Shults, Justine; Copelovitch, Lawrence

2015-01-01

In this study we sought to determine if among individuals with urolithiasis, extracorporeal shock wave lithotripsy (SWL) and ureteroscopy are associated with a higher risk of incident arterial hypertension (HTN) and/or chronic kidney disease (CKD). This was measured in a population-based retrospective study of 11,570 participants with incident urolithiasis and 127,464 without urolithiasis in The Health Improvement Network. Patients with pre-existing HTN and CKD were excluded. The study included 1319 and 919 urolithiasis patients with at least one SWL or URS procedure, respectively. Multivariable Cox regression was used to estimate the hazard ratio for incident CKD stage 3–5 and HTN in separate analyses. Over a median of 3.7 and 4.1 years, 1423 and 595 of urolithiasis participants developed HTN and CKD, respectively. Urolithiasis was associated with a significant hazard ratio each for HTN of 1.42 (95% CI: 1.35, 1.51) and for CKD of 1.82 (1.67, 1.98). SWL was associated with a significant increased risk of HTN 1.34 (1.15, 1.57), while ureteroscopy was not. When further stratified as SWL to the kidney or ureter, only SWL to the kidney was significantly and independently associated with HTN 1.40 (1.19, 1.66). Neither SWL nor ureteroscopy was associated with incident CKD. Since urolithiasis itself was associated with a hazard ratio of 1.42 for HTN, an individual who undergoes SWL to the kidney can be expected to have a significantly increased hazard ratio for HTN of 1.96 (1.67, 2.29) compared to an individual without urolithiasis. PMID:26509587

Evaluation and Treatment of Essential Hypertension During Short Duration Space Flight

NASA Technical Reports Server (NTRS)

Rossum, Alfred C.; Baisden, Dennis L.

2000-01-01

During the last four decades of manned space flight, two individuals have successfully flown in space with the preflight diagnosis of essential hypertension (HTN). Treatment of this disease process in the astronaut population warrants special consideration particularly when selecting medication for a mission. A retrospective review of data offers two different clinical scenarios involving the treatment, or lack thereof, for essential hypertension during space flight. Case I; A Caucasian quinquagenerian diagnosed with HTN one year prior to the mission obtained flight certification after a negative diagnostic workup. The patient was placed on a diuretic. Preflight isolated blood pressure (BP) measurements averaged 138/102. Inflight, the patient electively declined medication. A 36-hour BP monitor revealed an average value of 124/87. Postflight, BP measurements returned to preflight BP values. Case II: A Caucasian quatrogenerian diagnosed with HTN 6 months prior to launch completed flight training after a negative diagnostic workup. The patient was placed on an ACE inhibiter. Preflight BP measurements averaged 130/80. Inflight, isolated BP measurements were considerably less. Normotensive values were obtained postflight. In both cases, BP values inflight were lower than pre or postflight values. Yelle et al has confirmed similar findings in the normotensive astronaut population. Spaceflight may result in fluid shifting, mild dehydration, electrolyte imbalance, orthostatic hypotension, and increased heart rates. Based on these factors, certain classes of antihypertensive agents such as vasodilators, beta-blockers, and diuretics are excluded from consideration as a primary therapeutic modality. To date, Ace Inhibitors are viewed as the more acceptable drug of choice during spaceflight. Newer classes of drugs may also provide additional choices. Presently, astronauts developing uncomplicated HTN may continue their careers when treated with the appropriate class of

Culturally adaptive storytelling method to improve hypertension control in Vietnam - "We talk about our hypertension": study protocol for a feasibility cluster-randomized controlled trial.

PubMed

Allison, Jeroan J; Nguyen, Hoa L; Ha, Duc A; Chiriboga, Germán; Ly, Ha N; Tran, Hanh T; Phan, Ngoc T; Vu, Nguyen C; Kim, Minjin; Goldberg, Robert J

2016-01-14

Vietnam is experiencing an epidemiologic transition with an increased prevalence of non-communicable diseases. At present, the major risk factors for cardiovascular disease (CVD) are either on the rise or at alarming levels in Vietnam; inasmuch, the burden of CVD will continue to increase in this country unless effective prevention and control measures are put in place. A national survey in 2008 found that the prevalence of hypertension (HTN) was approximately 25 % among Vietnamese adults and it increased with advancing age. Therefore, novel, large-scale, and sustainable interventions for public health education to promote engagement in the process of detecting and treating HTN in Vietnam are urgently needed. A feasibility randomized trial will be conducted in Hung Yen province, Vietnam to evaluate the feasibility and acceptability of a novel community-based intervention using the "storytelling" method to enhance the control of HTN in adults residing in four rural communities. The intervention will center on stories about living with HTN, with patients speaking in their own words. The stories will be obtained from particularly eloquent patients, or "video stars," identified during Story Development Groups. The study will involve two phases: (i) developing a HTN intervention using the storytelling method, which is designed to empower patients to facilitate changes in their lifestyle practices, and (ii) conducting a feasibility cluster-randomized trial to investigate the feasibility, acceptability, and potential efficacy of the intervention compared with usual care in HTN control among rural residents. The trial will be conducted at four communes, and within each commune, 25 individuals 50 years or older with HTN will be enrolled in the trial resulting in a total sample size of 100 patients. This feasibility trial will provide the necessary groundwork for a subsequent large-scale, fully powered, cluster-randomized controlled trial to test the efficacy of our novel

Evaluation of hypertension and proteinuria as markers of efficacy in antiangiogenic therapy for metastatic colorectal cancer.

PubMed

Khoja, Leila; Kumaran, Gireesh; Zee, Ying Kiat; Murukesh, Nishanth; Swindell, Ric; Saunders, Mark P; Clamp, Andrew R; Valle, Juan W; Wilson, Greg; Jayson, Gordon C; Hasan, Jurjees

2014-01-01

The vascular endothelial growth factor pathway is strongly implicated in cancer-related angiogenesis. Antiangiogenic agents such as bevacizumab commonly cause hypertension (HTN) and proteinuria (PTN), which may be biomarkers of response and clinical outcome. We conducted a retrospective analysis of patients with histologically proven metastatic colorectal cancer (mCRC) treated with either bevacizumab or a tyrosine kinase inhibitor in combination with chemotherapy at The Christie Hospital from January 2006 to September 2009. Of 90 patients evaluated, 50 were eligible. Seventeen (34%), 4 (8%), and 3 (6%) patients developed Common Toxicity Criteria (v 3.0) grades 1, 2, and 3 HTN, respectively. Response rates were 42% for patients with grades 0 to 1 HTN compared with 86% for patients with ≥grade 2 HTN (P=0.043). Median overall survival was 21.6 months for patients with grades 0 to 1 HTN and 25.2 months for patients with ≥grade 2 HTN (P=0.270). Twelve patients (24%) developed grade 1 PTN and 4 patients (8%) developed ≥grade 2 PTN. Median overall survival was 23.9 months for patients with grades 0 to 1 PTN and 4.2 months for those with ≥grade 2 PTN (P=0.028). To our knowledge, this is the first study to demonstrate the utility of PTN as a surrogate marker of outcome in antiangiogenic therapy for metastatic colorectal cancer. Although HTN is predictive of a significantly higher response rate, the development of PTN during treatment with bevacizumab or tyrosine kinase inhibitor portends poorer survival and should be evaluated prospectively.

Pathophysiology and Treatment of Resistant Hypertension: The Role of Aldosterone and Amiloride-Sensitive Sodium Channels

PubMed Central

Judd, Eric K.; Calhoun, David A.; Warnock, David G.

2015-01-01

Summary Resistant hypertension is a clinically distinct subgroup of hypertension defined by the failure to achieve blood pressure control on optimal dosing of at least 3 antihypertensive medications of different classes, including a diuretic. The pathophysiology of hypertension can be attributed to aldosterone excess in more than 20% of patients with resistant hypertension. Existing dogma attributes the increase in blood pressure seen with increases in aldosterone to its antinatriuretic effects in the distal nephron. However, emerging research, which has identified and has begun to define the function of amiloride-sensitive sodium channels and mineralocorticoid receptors in the systemic vasculature, challenges impaired natriuresis as the sole cause of aldosterone-mediated resistant hypertension. This review integrates these findings to better define the role of the vasculature and aldosterone in the pathophysiology of resistant hypertension. In addition, a brief guide to the treatment of resistant hypertension is presented. PMID:25416662

Pathophysiology and treatment of resistant hypertension: the role of aldosterone and amiloride-sensitive sodium channels.

PubMed

Judd, Eric K; Calhoun, David A; Warnock, David G

2014-01-01

Resistant hypertension is a clinically distinct subgroup of hypertension defined by the failure to achieve blood pressure control on optimal dosing of at least 3 antihypertensive medications of different classes, including a diuretic. The pathophysiology of hypertension can be attributed to aldosterone excess in more than 20% of patients with resistant hypertension. Existing dogma attributes the increase in blood pressure seen with increases in aldosterone to its antinatriuretic effects in the distal nephron. However, emerging research, which has identified and has begun to define the function of amiloride-sensitive sodium channels and mineralocorticoid receptors in the systemic vasculature, challenges impaired natriuresis as the sole cause of aldosterone-mediated resistant hypertension. This review integrates these findings to better define the role of the vasculature and aldosterone in the pathophysiology of resistant hypertension. In addition, a brief guide to the treatment of resistant hypertension is presented.

2015 EAL evidence-based nutrition practice guildeline for the management of hypertension in adults

USDA-ARS?s Scientific Manuscript database

Hypertension (HTN) or high blood pressure (BP) is one of the most prevalent forms of cardiovascular disease and occurs in approximately one of every three adults in the United States. Nutrition therapy is an important component of treatment. The purpose of this Evidence Analysis Library (EAL) gui...

Practice Level Costs of Office-Based Hypertension Performance Improvement: The Heart Healthy Lenoir Study.

PubMed

Primary care practice leaders who consider engaging in quality improvement (QI) need to understand the practice level costs incurred when asking staff to take on new tasks. The Heart Healthy Lenoir study is a prospective cohort trial in which QI methods were used to enhance hypertension (HTN) care and reduce racial disparities in blood pressure control in small rural primary care practices in North Carolina. As part of this effort, we performed an activity-based costing analysis to describe the costs incurred to develop, implement, and maintain key tasks.We interviewed 20 practice stakeholders and phone-based health coaches during 2012-2014. We calculated the time invested by individuals to perform each task within each study phase and applied national hourly wages to generate cost estimates. Our descriptive analyses focus on four of the most widely used practices. Activities included time to abstract HTN control data, participate in project meetings, identify patients with uncontrolled HTN, create standardized work, and provide additional health coaching for patients with uncontrolled HTN. Despite practice and staffing differences, the developmental phase costs were similar, ranging from $879 to $1,417. Implementation costs varied more widely as practices took different approaches to identifying patients with uncontrolled HTN. Practice-specific phone health coaching costs ranged from $19,508 to more than $38,000. This study adds to the growing literature regarding practice level costs of engaging in systems change. Understanding these costs and balancing them against practice incentives may be helpful as stakeholders make decisions regarding HTN QI.

Using a Web-Based Approach to Assess Test-Retest Reliability of the "Hypertension Self-Care Profile" Tool in an Asian Population: A Validation Study.

PubMed

Koh, Yi Ling Eileen; Lua, Yi Hui Adela; Hong, Liyue; Bong, Huey Shin Shirley; Yeo, Ling Sui Jocelyn; Tsang, Li Ping Marianne; Ong, Kai Zhi; Wong, Sook Wai Samantha; Tan, Ngiap Chuan

2016-03-01

Essential hypertension often requires affected patients to self-manage their condition most of the time. Besides seeking regular medical review of their life-long condition to detect vascular complications, patients have to maintain healthy lifestyles in between physician consultations via diet and physical activity, and to take their medications according to their prescriptions. Their self-management ability is influenced by their self-efficacy capacity, which can be assessed using questionnaire-based tools. The "Hypertension Self-Care Profile" (HTN-SCP) is 1 such questionnaire assessing self-efficacy in the domains of "behavior," "motivation," and "self-efficacy." This study aims to determine the test-retest reliability of HTN-SCP in an English-literate Asian population using a web-based approach. Multiethnic Asian patients, aged 40 years and older, with essential hypertension were recruited from a typical public primary care clinic in Singapore. The investigators guided the patients to fill up the web-based 60-item HTN-SCP in English using a tablet or smartphone on the first visit and refilled the instrument 2 weeks later in the retest. Internal consistency and test-retest reliability were evaluated using Cronbach's Alpha and intraclass correlation coefficients (ICC), respectively. The t test was used to determine the relationship between the overall HTN-SCP scores of the patients and their self-reported self-management activities. A total of 160 patients completed the HTN-SCP during the initial test, from which 71 test-retest responses were completed. No floor or ceiling effect was found for the scores for the 3 subscales. Cronbach's Alpha coefficients were 0.857, 0.948, and 0.931 for "behavior," "motivation," and "self-efficacy" domains respectively, indicating high internal consistency. The item-total correlation ranges for the 3 scales were from 0.105 to 0.656 for Behavior, 0.401 to 0.808 for Motivation, 0.349 to 0.789 for Self-efficacy. The corresponding

A barber-based intervention for hypertension in African American men: design of a group randomized trial.

PubMed

Victor, Ronald G; Ravenell, Joseph E; Freeman, Anne; Bhat, Deepa G; Storm, Joy S; Shafiq, Moiz; Knowles, Patricia; Hannan, Peter J; Haley, Robert; Leonard, David

2009-01-01

Barbershops constitute potential sites for community health promotion programs targeting hypertension (HTN) in African American men but such programs previously have not been formally evaluated. A randomized trial (ClinicalTrials.gov no. NCT00325533) will test whether a continuous HTN detection and medical referral program conducted by influential peers (barbers) in a receptive community setting (barbershops) can promote treatment-seeking behavior and thus lower blood pressure (BP) among the regular customers with HTN. Barbers will offer a BP check with each haircut and encourage appropriate medical referral using real stories of other customers modeling the desired behaviors. A cohort of 16 barbershops will go through a pretest/posttest group-randomization protocol. Serial cross-sectional data collection periods (10 weeks each) will be conducted by interviewers to obtain accurate snapshots of HTN control in each barbershop before and after 10 months of either barber-based intervention or no active intervention. The primary outcome is BP control: BP <135/85 mm Hg (nondiabetic subjects) and <130/80 mm Hg (diabetic subjects) measured in the barbershop during the 2 data collection periods. The multilevel analysis plan uses hierarchical models to assess the effect of covariates on HTN control and secondary outcomes while accounting for clustering of observations within barbershops. By linking community health promotion to the health care system, this program could serve as a new model for HTN control and cardiovascular risk reduction in African American men on a nationwide scale.

[Resistant arterial hypertension and coarctation of the aorta].

PubMed

Martínez-Quintana, Efrén; Rossique-Delmas, Pilar; Rodríguez-González, Fayna

2014-01-01

Coarctation of the aorta accounts for around 5 percent of all congenital heart defects. Many of these patients develop arterial hypertension, and occasionally resistant arterial hypertension, despite adequate correction. This may lead to potentially fatal complications such as heart failure, aortic dissection, cerebrovascular events, or myocardial infarction. Therefore, a correct diagnosis must be made and an appropriate treatment started to reduce arterial hypertension, arteriosclerotic vascular disease, as well as the increased risk of cardiovascular morbidity and mortality. Copyright © 2014 Sociedad Española de Arteriosclerosis. Published by Elsevier España. All rights reserved.

Renin Angiotensin Aldosterone System Inhibitors in Hypertension: Is There Evidence for Benefit Independent of Blood Pressure Reduction?

PubMed

Bavishi, Chirag; Bangalore, Sripal; Messerli, Franz H

The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in the pathogenesis of hypertension (HTN). Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are first line anti-HTN drug classes that are potent, effective and largely safe. Direct renin inhibitors (DRIs) have shown similar blood pressure (BP) reduction but more side effects. The efficacy of ACEIs and ARBs (for cardiovascular, cerebrovascular and renal protection) has been promoted to extend beyond what could be explained by BP reduction alone. In the current review, we will briefly discuss the (1) pathophysiology of renin-angiotensin-aldosterone system (RAAS) system, (2) clinical evidence for ACEIs, ARBs and DRIs in HTN, (3) comparison of ACEIs vs. ARBs and combination therapy, (4) role of RAAS inhibitors in specific patient populations, (5) safety profile of RAAS inhibitors, and (6) guideline recommendations and future perspectives. Closer scrutiny of outcome data shows little, if any, evidence that the efficacy of RAAS blockers in HTN extends beyond BP reduction. Copyright © 2016 Elsevier Inc. All rights reserved.

Spironolactone Versus Clonidine as a Fourth-Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment).

PubMed

Krieger, Eduardo M; Drager, Luciano F; Giorgi, Dante M A; Pereira, Alexandre C; Barreto-Filho, José Augusto Soares; Nogueira, Armando R; Mill, José Geraldo; Lotufo, Paulo A; Amodeo, Celso; Batista, Marcelo C; Bodanese, Luiz C; Carvalho, Antônio C C; Castro, Iran; Chaves, Hilton; Costa, Eduardo A S; Feitosa, Gilson S; Franco, Roberto J S; Fuchs, Flávio D; Guimarães, Armênio C; Jardim, Paulo C; Machado, Carlos A; Magalhães, Maria E; Mion, Décio; Nascimento, Raimundo M; Nobre, Fernando; Nóbrega, Antônio C; Ribeiro, Antônio L P; Rodrigues-Sobrinho, Carlos R; Sanjuliani, Antônio F; Teixeira, Maria do Carmo B; Krieger, Jose E

2018-04-01

The aim of this study is to compare spironolactone versus clonidine as the fourth drug in patients with resistant hypertension in a multicenter, randomized trial. Medical therapy adherence was checked by pill counting. Patients with resistant hypertension (no office and ambulatory blood pressure [BP] monitoring control, despite treatment with 3 drugs, including a diuretic, for 12 weeks) were randomized to an additional 12-week treatment with spironolactone (12.5-50 mg QD) or clonidine (0.1-0.3 mg BID). The primary end point was BP control during office (<140/90 mm Hg) and 24-h ambulatory (<130/80 mm Hg) BP monitoring. Secondary end points included BP control from each method and absolute BP reduction. From 1597 patients recruited, 11.7% (187 patients) fulfilled the resistant hypertension criteria. Compared with the spironolactone group (n=95), the clonidine group (n=92) presented similar rates of achieving the primary end point (20.5% versus 20.8%, respectively; relative risk, 1.01 [0.55-1.88]; P =1.00). Secondary end point analysis showed similar office BP (33.3% versus 29.3%) and ambulatory BP monitoring (44% versus 46.2%) control for spironolactone and clonidine, respectively. However, spironolactone promoted greater decrease in 24-h systolic and diastolic BP and diastolic daytime ambulatory BP than clonidine. Per-protocol analysis (limited to patients with ≥80% adherence to spironolactone/clonidine treatment) showed similar results regarding the primary end point. In conclusion, clonidine was not superior to spironolactone in true resistant hypertensive patients, but the overall BP control was low (≈21%). Considering easier posology and greater decrease in secondary end points, spironolactone is preferable for the fourth-drug therapy. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01643434. © 2018 American Heart Association, Inc.

The Prevalence of Japanese Outpatients with Hypertension Who Meet the Definition of Treatment Resistant Hypertension and Are Eligible for Enrolment in Clinical Trials of Endovascular Ultrasound Renal Denervation.

PubMed

Okamura, Keisuke; Shirai, Kazuyuki; Okuda, Tetsu; Urata, Hidenori

2018-01-01

Objective A clinical trial (REQUIRE) was started to investigate the use of an ultrasound renal denervation system in the treatment of resistant hypertension (RHT). We analyzed the prevalence of patients who were eligible for inclusion in this cross-sectional study at the time of screening. Methods Nine-hundred ninety-nine consecutive hypertension (HT) patients who were treated in our hospital as outpatients were classified into the following categories: patients treated with at least 3 types of antihypertensive drugs including diuretic agents who were eligible for enrolment in SYMPLICITY HTN-Japan (SH-J) with an office systolic blood pressure (SBP) of ≥160 mmHg, who were ≤80 years of age, and an estimated glomerular filtration rate (eGFR) of ≥45 mL/min/1.73 m 2 (RHT-S); and patients who were treated similar medications and who were eligible for enrolment in REQUIRE, with an SBP of ≥150 mmHg, ≤75 years of age, and an eGFR of ≥40 mL/min/1.73 m 2 (RHT-R). We investigated the proportion of patients in each category. We also investigated HT patients (1,423 cases) who were enrolled in the Chikushi Anti-Hypertension Trial (CHAT), a research network that includes general practitioners. Results Eleven patients (1.1%) with RHT-S and 18 patients (1.8%) with RHT-R were identified. After the exclusion of patients with secondary HT and a diastolic blood pressure (DBP) of <90 mmHg (applied in REQUIRE), 5 patients (0.5%) with RHT-S and 4 patients (0.4%) with RHT-R remained. In the analysis of the CHAT study, only 2 (0.1%) patients with RHT-R remained. Conclusion The number of eligible patients in the REQUIRE trial was decreased, largely due to the strict age restriction and the new DBP limitation. The prevalence of eligible patients in REQUIRE was estimated to be approximately 0.5 to 0.8 times that in SH-J. Since patient enrollment will be difficult, drastic measures may be required to recruit eligible patients.

Essential pediatric hypertension: defining the educational needs of primary care pediatricians.

PubMed

Cha, Stephen D; Chisolm, Deena J; Mahan, John D

2014-07-27

In order to better understand the educational needs regarding appropriate recognition, diagnosis and management of pediatric hypertension (HTN), we asked practicing pediatricians questions regarding their educational needs and comfort level on this topic. We conducted 4 focus group sessions that included 27 participants representing pediatric residents, adolescent medicine physicians, clinic based pediatricians and office based pediatricians. Each focus group session lasted for approximately an hour and 90 pages of total transcriptions were produced verbatim from audio recordings. Four reviewers read each transcript and themes were elucidated from these transcripts. Overall, 5 major themes related to educational needs and clinical concerns were found: utilization of resources to define blood pressure (BP), correct BP measurement method(s), co-morbidities, barriers to care, and experience level with HTN. Six minor themes were also identified: differences in BP measurement, accuracy of BP, recognition of HTN, practice pattern of care, education of families and patients, and differences in level of training. The focus group participants were also questioned on their preferences regarding educational methods (i.e. e-learning, small group sessions, self-study, large group presentations) and revealed varied teaching and learning preferences. There are multiple methods to approach education regarding pediatric HTN for primary care pediatricians based on provider preferences and multiple educational activities should be pursued to achieve best outcomes. Based on this data, the next direction will be to develop and deliver multiple educational methods and to evaluate the impact on practice patterns of care for children and adolescents with HTN.

Essential pediatric hypertension: defining the educational needs of primary care pediatricians

PubMed Central

2014-01-01

Background In order to better understand the educational needs regarding appropriate recognition, diagnosis and management of pediatric hypertension (HTN), we asked practicing pediatricians questions regarding their educational needs and comfort level on this topic. Methods We conducted 4 focus group sessions that included 27 participants representing pediatric residents, adolescent medicine physicians, clinic based pediatricians and office based pediatricians. Each focus group session lasted for approximately an hour and 90 pages of total transcriptions were produced verbatim from audio recordings. Results Four reviewers read each transcript and themes were elucidated from these transcripts. Overall, 5 major themes related to educational needs and clinical concerns were found: utilization of resources to define blood pressure (BP), correct BP measurement method(s), co-morbidities, barriers to care, and experience level with HTN. Six minor themes were also identified: differences in BP measurement, accuracy of BP, recognition of HTN, practice pattern of care, education of families and patients, and differences in level of training. The focus group participants were also questioned on their preferences regarding educational methods (i.e. e-learning, small group sessions, self-study, large group presentations) and revealed varied teaching and learning preferences. Conclusions There are multiple methods to approach education regarding pediatric HTN for primary care pediatricians based on provider preferences and multiple educational activities should be pursued to achieve best outcomes. Based on this data, the next direction will be to develop and deliver multiple educational methods and to evaluate the impact on practice patterns of care for children and adolescents with HTN. PMID:25063988

Effect of gestational diabetes and hypertensive disorders of pregnancy on postpartum cardiometabolic risk

PubMed Central

Li, Ling-Jun; Aris, Izzuddin M; Su, Lin Lin; Chong, Yap Seng; Wong, Tien Yin; Tan, Kok Hian; Wang, Jie Jin

2018-01-01

Aims The cumulative effect of gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) on postpartum cardio-metabolic diseases is equivocal. We aimed to assess the associations of GDM and HDP’s individual and synergic contribution to risks of postpartum cardio-metabolic diseases (metabolic syndrome (MetS), abnormal glucose metabolism and hypertension (HTN)). Methods Of participants from a Singapore birth cohort, 276 mothers attending the 5-year postpartum visit were included in this study. During this visit, we collected mothers’ history of GDM and HDP in all live births in a chronicle sequence and assessed the cardio-metabolic risks based on blood pressure, anthropometry and a panel of serum biomarkers. We diagnosed MetS, abnormal glucose metabolism and HTN according to Adult Treatment Panel III 2000 and World Health Organization guidelines. Results Of 276 mothers, 157 (56.9%) had histories of GDM while 23 (8.3%) had histories of HDP. After full adjustment, we found associations of GDM episodes with postpartum abnormal glucose metabolism (single episode: relative risk (RR) 2.9 (95% CI: 1.7, 4.8); recurrent episodes (≥2): RR = 3.8 (2.1–6.8)). Also, we found association between histories of HDP and HTN (RR = 3.6 (1.5, 8.6)). Having either (RR 2.6 (1.7–3.9)) or both gestational complications (RR 2.7 (1.6–4.9)) was associated with similar risk of postpartum cardio-metabolic disease. Conclusions Mothers with GDM or HDP had a threefold increased risk of postpartum abnormal glucose metabolism or HTN, respectively. Having both GDM and HDP during past pregnancies was not associated with additional risk of postpartum cardio-metabolic diseases beyond that associated with either complication alone. PMID:29444890

[Sleep apnea syndrome -- cause of resistance to treatment of arterial hypertension].

PubMed

Frenţ, Stefan; Tudorache, Voicu; Ardelean, Carmen; Dimitriu, Diana; Lighezan, Daniel; Gaiţă, Dan; Mihăicuţă, Stefan

2011-01-01

The prevalence of sleep apnea syndrome is relatively high in population (5%). The mortality is significantly higher in those with apnea-hypopnea index >20. There is an increased rate of car accidents in the subjects with OSA compared to those who don't have this syndrome (31% versus 6%). The impact of OSA on mortality is also given by its association with a significant number of cardiovascular diseases. The association between OSA and hypertension has been much debated. The prevalence of hypertension among patients with OSA varies between 50-58%, while the prevalence of OSA in hypertensive patients is 30%. A particular association is OSA and resistant hypertension, i.e. blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, one to be a diuretic and all pharmacological agents being prescribed at recommended doses. Secondary causes of hypertension are common in patients with resistant hypertension. Among these causes, one of the most frequent is sleep apnea syndrome. Some of the mechanisms by which sleep apnea contributes to the development of hypertension are intermittent hypoxia and/or increased upper airway resistance associated with sleep apnea that induces a sustained increase in sympathetic nervous system activity. Treatment of sleep apnea with continuous positive airway pressure devices (CPAP) improves blood pressure control, although the benefit of CPAP evaluated in clinical trials is variable.

Hypertension Analysis of stress Reduction using Mindfulness meditatiON and Yoga (The HARMONY Study): study protocol of a randomised control trial

PubMed Central

How, Maxine; Dai, Monica; Baker, Brian; Irvine, Jane; Abbey, Susan; Abramson, Beth L; Myers, Martin; Perkins, Nancy; Tobe, Sheldon W

2012-01-01

Introduction Hypertension (HTN) is a leading risk factor for preventable cardiovascular disease, with over one in five adults affected worldwide. Lifestyle modification is a key strategy for the prevention and treatment of HTN. Stress has been associated with greater cardiovascular risk, and stress management is a recommended intervention for hypertensives. Stress reduction through relaxation therapies has been shown to have an effect on human physiology, including lowering blood pressure (BP). However, individualised behavioural interventions are resource intensive, and group stress management approaches have not been validated for reducing HTN. The HARMONY Study is a pilot randomised controlled trial designed to determine if mindfulness-based stress reduction (MBSR), a standardised group therapy, is an effective intervention for lowering BP in stage 1 unmedicated hypertensives. Methods and analysis Men and women unmedicated for HTN with mean daytime ambulatory blood pressure (ABP) ≥135/85 mm Hg or 24 h ABP ≥130/80 mm Hg are included in the study. Subjects are randomised to receive MBSR immediately or after a wait-list control period. The primary outcome measure is mean awake and 24 h ABP. The primary objective of the HARMONY Study is to compare ABP between the treatment and wait-list control arm at the 12-week primary assessment period. Results from this study will determine if MBSR is an effective intervention for lowering BP in early unmedicated hypertensives. Ethics and dissemination This research project was approved by the Sunnybrook Research Ethics Board and the University Health Network Research Ethics Board (Toronto, Canada). Planned analyses are in full compliance with the principles of the Declaration of Helsinki. Data collection will be completed by early spring 2012. Primary and secondary analysis will commence immediately after data monitoring is completed; dissemination plans include preparing publications for submission during the

Link between insulin resistance and hypertension: What is the evidence from evolutionary biology?

PubMed

Zhou, Ming-Sheng; Wang, Aimei; Yu, Hong

2014-01-31

Insulin resistance and hypertension are considered as prototypical "diseases of civilization" that are manifested in the modern environment as plentiful food and sedentary life. The human propensity for insulin resistance and hypertension is a product, at least in part, of our evolutionary history. Adaptation to ancient lifestyle characterized by a low sodium, low-calorie food supply and physical stress to injury response has driven our evolution to shape and preserve a thrifty genotype, which is favorite with energy-saving and sodium conservation. As our civilization evolved, a sedentary lifestyle and sodium- and energy-rich diet, the thrifty genotype is no longer advantageous, and may be maladaptive to disease phenotype, such as hypertension, obesity and insulin resistance syndrome. This article reviews human evolution and the impact of the modern environment on hypertension and insulin resistance.

Neighborhood stressors and race/ethnic differences in hypertension prevalence (the Multi-Ethnic Study of Atherosclerosis).

PubMed

Mujahid, Mahasin S; Diez Roux, Ana V; Cooper, Richard C; Shea, Steven; Williams, David R

2011-02-01

The reasons for racial/ethnic disparities in hypertension (HTN) prevalence in the United States are poorly understood. Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we investigated whether individual- and neighborhood-level chronic stressors contribute to these disparities in cross-sectional analyses. The sample consisted of 2,679 MESA participants (45-84 years) residing in Baltimore, New York, and North Carolina. HTN was defined as systolic or diastolic blood pressure ≥140 or 90 mm Hg, or taking antihypertensive medications. Individual-level chronic stress was measured by self-reported chronic burden and perceived major and everyday discrimination. A measure of neighborhood (census tract) chronic stressors (i.e., physical disorder, violence) was developed using data from a telephone survey conducted with other residents of MESA neighborhoods. Binomial regression was used to estimate associations between HTN and race/ethnicity before and after adjustment for individual and neighborhood stressors. The prevalence of HTN was 59.5% in African Americans (AAs), 43.9% in Hispanics, and 42.0% in whites. Age- and sex-adjusted relative prevalences of HTN (compared to whites) were 1.30 (95% confidence interval (CI): 1.22-1.38) for AA and 1.16 (95% CI: 1.04-1.31) for Hispanics. Adjustment for neighborhood stressors reduced these to 1.17 (95% CI: 1.11-1.22) and 1.09 (95% CI: 1.00-1.18), respectively. Additional adjustment for individual-level stressors, acculturation, income, education, and other neighborhood features only slightly reduced these associations. Neighborhood chronic stressors may contribute to race/ethnic differences in HTN prevalence in the United States.

Integrative Blood Pressure Response to Upright Tilt Post Renal Denervation

PubMed Central

Howden, Erin J.; East, Cara; Lawley, Justin S.; Stickford, Abigail S.L.; Verhees, Myrthe; Fu, Qi

2017-01-01

Abstract BACKGROUND Whether renal denervation (RDN) in patients with resistant hypertension normalizes blood pressure (BP) regulation in response to routine cardiovascular stimuli such as upright posture is unknown. We conducted an integrative study of BP regulation in patients with resistant hypertension who had received RDN to characterize autonomic circulatory control. METHODS Twelve patients (60 ± 9 [SD] years, n = 10 males) who participated in the Symplicity HTN-3 trial were studied and compared to 2 age-matched normotensive (Norm) and hypertensive (unmedicated, HTN) control groups. BP, heart rate (HR), cardiac output (Qc), muscle sympathetic nerve activity (MSNA), and neurohormonal variables were measured supine, and 30° (5 minutes) and 60° (20 minutes) head-up-tilt (HUT). Total peripheral resistance (TPR) was calculated from mean arterial pressure and Qc. RESULTS Despite treatment with RDN and 4.8 (range, 3–7) antihypertensive medications, the RDN had significantly higher supine systolic BP compared to Norm and HTN (149 ± 15 vs. 118 ± 6, 108 ± 8 mm Hg, P < 0.001). When supine, RDN had higher HR, TPR, MSNA, plasma norepinephrine, and effective arterial elastance compared to Norm. Plasma norepinephrine, Qc, and HR were also higher in the RDN vs. HTN. During HUT, BP remained higher in the RDN, due to increases in Qc, plasma norepinephrine, and aldosterone. CONCLUSION We provide evidence of a possible mechanism by which BP remains elevated post RDN, with the observation of increased Qc and arterial stiffness, as well as plasma norepinephrine and aldosterone levels at approximately 2 years post treatment. These findings may be the consequence of incomplete ablation of sympathetic renal nerves or be related to other factors. PMID:28338768

Insulin resistance in offspring of hypertensive subjects.

PubMed

Mino, D; Wacher, N; Amato, D; Búrbano, G; Fonseca, M E; Revilla, C; Gordon, F; Lifshitz, A

1996-10-01

To assess whether apparently healthy subjects with a family history of systemic hypertension have a higher risk of presenting the insulin resistance syndrome. Three hundred and eighty-six subjects aged 20-65 years. A middle socio-economic class urban community from Mexico City. All subjects and, when necessary, their first-degree relatives, answered a questionnaire and underwent a physical examination with measurement of height, weight and blood pressure. Serum insulin, glucose, cholesterol and triglycerides were measured during fasting and 2 h after an oral load of 75 g glucose. A family history of systemic hypertension was present for 167 (43%) of the subjects, of whom 123 (31%) were obese. Subjects with a family history of hypertension had higher systolic blood pressures than did those without such a history (120 +/- 15 versus 115 +/- 10 mmHg). In the logistic regression model, the body mass index and age showed statistically significant effects on the fasting glucose:insulin ratio and on serum insulin levels after an oral load of glucose. When men and women were analysed separately, only in men were higher systolic and mean blood pressures and lower glucose:insulin ratios observed. In the logistic regression analysis the body mass index was a significant predictor of the glucose:insulin ratio and serum insulin levels after an oral load of glucose, especially in men. Apparently healthy male offspring of hypertensive parents have higher blood pressure levels and lower insulin sensitivities than do offspring of normotensive parents. Insulin resistance was related to obesity, but not to a family history of hypertension, as had previously been reported by other research groups.

Trisomy 13 and the risk of gestational hypertensive disorders: a population-based study.

PubMed

Dotters-Katz, Sarah K; Humphrey, Whitney M; Senz, Kayli L; Lee, Vanessa R; Shaffer, Brian L; Kuller, Jeffrey A; Caughey, Aaron B

2018-08-01

To describe the rate and severity of gestational hypertensive disorders (GHDs) in pregnancies complicated by trisomy 13 (T13). Retrospective cohort study of singleton deliveries in California from 2005 to 2008 using vital statistics and ICD-9 data. We were interested in gestational hypertension (gHTN), preeclampsia with and without severe features (sPREX and PREX), and gestational age at delivery. Pregnancies and maternal complications affected by prenatally diagnosed T13 were compared to unaffected pregnancies. Regression models were used to compute adjusted odds ratios for pregnancy outcomes by T13 status. Of the 2,029,004 deliveries, 142 women had prenatally diagnosed T13. A diagnosis of GHD occurred in 26.8% of the T13 pregnancies versus 6% of the non-T13 pregnancies (p < .001). This remained true for gHTN (9.2% versus 3.2%, p=.001), PREX (12% versus 2.2%, p < .001), and sPREX (8.5% versus 0.9%, p < .001). After adjusting for confounders, T13 pregnancies were 6.3-times more likely to be affected by GHD, and 12.5-times more likely to have sPREX. Delivery <37 and <32 weeks in the setting of GHD was 14.1-times and 11.2-times likely among women with T13. Women with T13 pregnancies were significantly more likely to have gHTN, preeclampsia, sPREX, and to deliver <32 weeks.

[Resistant hypertension by unadvertised non-compliance detected by psychiatric expertise and drug dosages].

PubMed

Didier, R; Gilard, M; Denolle, T

2018-06-01

The management of patients with resistant hypertension remains a major challenge in daily clinical practice in order to limit macro and microvascular impact. However, lack of compliance often remains one of the main etiologies of resistant hypertension. Through a clinical case of complex therapeutic non-compliance, we will detail the frequency, the screening and the management of therapeutic non-compliance. Finally, we will specify the contribution of drug dosages and psychological expertise in screening non-observant patients with presumed resistant hypertension. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Potassium Intake, Bioavailability, Hypertension, and Glucose Control

PubMed Central

Stone, Michael S.; Martyn, Lisa; Weaver, Connie M.

2016-01-01

Potassium is an essential nutrient. It is the most abundant cation in intracellular fluid where it plays a key role in maintaining cell function. The gradient of potassium across the cell membrane determines cellular membrane potential, which is maintained in large part by the ubiquitous ion channel the sodium-potassium (Na+-K+) ATPase pump. Approximately 90% of potassium consumed (60–100 mEq) is lost in the urine, with the other 10% excreted in the stool, and a very small amount lost in sweat. Little is known about the bioavailability of potassium, especially from dietary sources. Less is understood on how bioavailability may affect health outcomes. Hypertension (HTN) is the leading cause of cardiovascular disease (CVD) and a major financial burden ($50.6 billion) to the US public health system, and has a significant impact on all-cause morbidity and mortality worldwide. The relationship between increased potassium supplementation and a decrease in HTN is relatively well understood, but the effect of increased potassium intake from dietary sources on blood pressure overall is less clear. In addition, treatment options for hypertensive individuals (e.g., thiazide diuretics) may further compound chronic disease risk via impairments in potassium utilization and glucose control. Understanding potassium bioavailability from various sources may help to reveal how specific compounds and tissues influence potassium movement, and further the understanding of its role in health. PMID:27455317

Potassium Intake, Bioavailability, Hypertension, and Glucose Control.

PubMed

Stone, Michael S; Martyn, Lisa; Weaver, Connie M

2016-07-22

Potassium is an essential nutrient. It is the most abundant cation in intracellular fluid where it plays a key role in maintaining cell function. The gradient of potassium across the cell membrane determines cellular membrane potential, which is maintained in large part by the ubiquitous ion channel the sodium-potassium (Na+-K+) ATPase pump. Approximately 90% of potassium consumed (60-100 mEq) is lost in the urine, with the other 10% excreted in the stool, and a very small amount lost in sweat. Little is known about the bioavailability of potassium, especially from dietary sources. Less is understood on how bioavailability may affect health outcomes. Hypertension (HTN) is the leading cause of cardiovascular disease (CVD) and a major financial burden ($50.6 billion) to the US public health system, and has a significant impact on all-cause morbidity and mortality worldwide. The relationship between increased potassium supplementation and a decrease in HTN is relatively well understood, but the effect of increased potassium intake from dietary sources on blood pressure overall is less clear. In addition, treatment options for hypertensive individuals (e.g., thiazide diuretics) may further compound chronic disease risk via impairments in potassium utilization and glucose control. Understanding potassium bioavailability from various sources may help to reveal how specific compounds and tissues influence potassium movement, and further the understanding of its role in health.

Minoxidil: an underused vasodilator for resistant or severe hypertension.

PubMed

Sica, Domenic A

2004-05-01

Minoxidil is a direct vasodilator introduced in the early 1970s for the treatment of hypertension. It is capable of reducing blood pressure in most persons with resistant hypertension where therapy has failed with multidrug regimens. Minoxidil's effect can be limited because of an increase in pulse rate and/or sodium (and water) retention. The latter may prove quite debilitating in some patients. Thus, minoxidil is generally administered with both a diuretic and an agent that can keep pulse rate in check, such as a beta blocker or a combined alpha-beta blocker. The prominent tachycardia with minoxidil can aggravate myocardial ischemia and, if long-standing, leads to left ventricular hypertrophy. Minoxidil has a particularly annoying side effect of hypertrichosis that may limit its use, particularly among women. Minoxidil use is infrequently associated with the idiosyncratic onset of a pericardial effusion. If a patient's hypertension is severe enough to warrant minoxidil therapy, a hypertension specialist should probably become involved in the patient's care. The use of this medication should be limited in view of the availability of effective agents with fewer side effects. There is, however, a place for minoxidil in the treatment of resistant hypertension especially in patients with advanced renal disease.

Hypertension prevalence, awareness, and control in Arab countries: A systematic review

PubMed Central

Tailakh, Ayman; Evangelista, Lorraine S.; Mentes, Janet C.; Pike, Nancy A.; Phillips, Linda R.; Morisky, Donald E.

2015-01-01

One billion of the world’s population has hypertension, resulting in four million deaths per year. Data on the prevalence of hypertension in the Arab world are very limited. This review summarizes existing knowledge regarding prevalence, awareness, and control of hypertension in Arab countries. The PubMed, Cochrane Library, Scopus, and CINAHL databases were searched for publications on HTN among Arab people from 1980 to January 2011. Only 13 studies were identified in the literature from 10 Arab countries. The overall estimated prevalence of hypertension was 29.5% (n = 45 379), which indicates a higher prevalence of hypertension among Arabs compared to people from the USA (28%) and sub-Saharan African (27.6%). Awareness of hypertension was reported for 46% of the studies and varied from 18% (Jordan) to 79.8% (Syria). The control rate varied from 56% (Tunisia) to 92% (Egypt and Syria). The prevalence of hypertension was found to increase with age, occurring more frequently in Arab women. PMID:24118852

Prevalence and risk factors of obesity and hypertension among students at a central university in the West Bank.

PubMed

Tayem, Yasin I; Yaseen, Nagham A; Khader, Wiam T; Abu Rajab, Lama O; Ramahi, Ahmad B; Saleh, Mohammad H

2012-01-01

We aimed to determine the prevalence and correlates of obesity and hypertension (HTN) among students at a central university in the West Bank. This cross-sectional study targeted a cohort of 553 students (59.5% males, 40.5% females) aged 17-26 years (median = 21) from Al-Quds University. Body mass index (BMI) and blood pressure (BP) were measured. Participants completed a questionnaire on physical activity, sedentary behavior, dietary factors, smoking and family history of obesity, HTN, and coronary artery disease. The magnitude of correlation was assessed by Spearman's rho (r(s)) and Chi-square tests. The prevalence of overweight was 25% (31.1% males, 15.6% females) and obesity 7.2% (9.4% males, 4% females). Obesity and overweight were associated with family history of obesity in both genders (p<0.001) and physical activity in males (r(s)= - 0.162, p<0.005). No correlation was demonstrated between participants' BMI and sedentary lifestyle or consumption of fast food. Pre-HTN was detected in 27.1% (38% males, 11.2% females) and HTN in 2.2% (3.3% males, 0.4% females). Pre-HTN and HTN were associated with obesity (r(s)=0.252, p<0.001) and smoking (p<0.05). No relationship was detected between students' BP and sedentary behavior, family history of HTN/CAD, or consumption of fast food. The prevalence of increased BMI and BP among males was significantly higher than females (p<0.001). We detected a high prevalence of elevated BP and excess weight gain among students at Al-Quds University. An interventional program is urgently needed to control these cardiovascular risk factors in this community.

Verbal fluency in elderly with and without hypertension and diabetes from the FIBRA study in Ermelino Matarazzo

PubMed Central

Morelli, Nathalia Lais; Cachioni, Meire; Lopes, Andrea; Batistoni, Samila Sathler Tavares; Falcão, Deusivania Vieira da Silva; Neri, Anita Liberalesso; Yassuda, Monica Sanches

2017-01-01

ABSTRACT. Background: There are few studies on the qualitative variables derived from the animal category verbal fluency test (VF), especially with data originating from low-income samples of community-based studies. Objective: To compare elderly with and without hypertension (HTN) and diabetes mellitus (DM) regarding the total number of animals spoken, number of categories, groups and category switches on the VF test. Methods: We used the database of the FIBRA (Frailty in Brazilian Elderly) community-based study. The variables number of Categories, Groups and Category Switches were created for each participant. The total sample (n = 384) was divided into groups of elderly who reported having HTN, DM, both HTN and DM, or neither of these conditions. Results: There were no significant differences between the groups with and without these chronic diseases for VF total score or for the qualitative variables. Conclusion: Among independent community-dwelling elderly, the qualitative variables derived from the VF animal category may not add information regarding the cognitive profile of elderly with chronic diseases. Total VF score and the qualitative variables Category, Group and Switching did not differentiate elderly with and without HTN and DM. PMID:29354222

Resistant Hypertension: Time to Consider the Best Fifth Anti-Hypertensive Treatment.

PubMed

Pio-Abreu, Andrea; Drager, Luciano F

2018-06-16

Resistant hypertension (RH) is a growing clinical condition worldwide associated with target-organ damage and poor prognosis compared to non-resistant counterparts. The purpose of this review is to perform a critical evaluation of preferable drug choices for managing RH highlighting the evidence that significant proportion of patients remained uncontrolled despite using four anti-hypertensive drugs. Until recently, the fourth drug therapy was main derived from personal opinion or small interventional studies. The recent data derived from two multicentric randomized trials, namely PATHWAY-2 and ReHOT, pointed spironolactone as the preferable fourth drug therapy in patients with confirmed RH as compared to bisoprolol and doxazosin (PATHWAY-2) as well as clonidine (ReHOT). However, significant proportion of patients (especially observed in ReHOT trial that used 24-h ambulatory blood pressure monitoring) did not achieve optimal blood pressure with the fourth drug. This finding underscores the need of new approaches and treatment options in this important research area. The current evidence pointed that significant proportion of RH patients are requiring more than four drugs for controlling BP. This statement is particularly true considering the new criteria proposed by the 2017 Guidelines for diagnosing RH (> 130 × 80 mmHg). New combinations, drugs, or treatments should be tested aiming to reduce the RH burden. Based on the aforementioned multicentric trials, we proposed the first five preferable anti-hypertensive classes in the overall context of RH.

Differences in fat and sodium intake across hypertension subgroups in the Mississippi Communities for Healthy Living (MCHL) Nutrition Intervention

USDA-ARS?s Scientific Manuscript database

The objective of this study is to examine differences between self-reported intakes of sodium, trans-fat, and total fat among hypertension (HTN) subgroups of participants in Mississippi Communities for Healthy Living nutrition education intervention. Dietary intake was measured using a food frequenc...

Oxygenation-sensitive cardiovascular magnetic resonance in hypertensive heart disease with left ventricular myocardial hypertrophy and non-left ventricular myocardial hypertrophy: Insight from altered mechanics and cardiac BOLD imaging.

PubMed

Chen, Bing-Hua; Wu, Rui; An, Dong-Aolei; Shi, Ruo-Yang; Yao, Qiu-Ying; Lu, Qing; Hu, Jiani; Jiang, Meng; Deen, James; Chandra, Ankush; Xu, Jian-Rong; Wu, Lian-Ming

2018-05-07

BOLD (blood oxygen level dependent) MRI can detect regional condition of myocardial oxygen supply and demand by means of paramagnetic properties. Noninvasive assessment of myocardial oxygenation by BOLD MRI in hypertensive patients with hypertension (HTN) left ventricular myocardial hypertrophy (LVMH) and HTN non-LVMH and its correlation with myocardial mechanics were performed. Prospective. Twenty patients with HTN LVMH, 21 patients with HTN non-LVMH, and 23 normotensive controls were enrolled. Cine imaging, T2* and T1 mapping sequences were achieved at 3.0T. Dedicated T1 mapping, T2*, and cine imaging analysis were performed by two radiologists using cvi42. One-way analysis of variance, Kruskal-Wallis test, Bland-Altman analysis, Pearson's correlation coefficient, Spearman's rank correlation. T2* values of HTN LVMH group were significantly lower versus the controls (23.78 ± 3.09 versus 30.77 ± 2.71; P < 0.001) and HTN non-LVMH group (23.78 ± 3.09 versus 28.64 ± 4.23; P < 0.001). Left ventricular peak circumferential strain were reduced in HTN LVMH patients compared with other two groups (-11.32 [-15.64, -10.3], -16.78 [-19.35, -15.34], and -19.73 [-20.57, -18.73]; P < 0.05); and longitudinal strain of HTN LVMH patients were lower than other two groups (-11.31 ± 2.91, -15.1 ± 3.06, and -18.85 ± 1.85; P < 0.05); radial strain of HTN LVMH patients were also lower than other two groups (25.03 ± 16, 40.95 ± 17.5 and 47.9 ± 10.23; P < 0.05). Extracellular volume correlated with peak circumferential, longitudinal, and radial strain (spearman rho = 0.6, 0.64, and -0.69; P < 0.05), respectively; T2* negatively correlated with peak circumferential and longitudinal strain (spearman rho = -0.43 and -0.49; P < 0.05), respectively. Patients with lower T2* values had significant decreases in myocardial mechanics (P < 0.05). HTN LVMH patients have both impaired myocardial mechanics and

[Economic efficiency of renal denervation in patients with resistant hypertension: results of Markov modeling].

PubMed

Kontsevaia, A V; Suvorova, E I; Khudiakov, M B

2014-01-01

Aim of this study was to evaluate the cost-effectiveness of renal denervation (RD) in resistant arterial hypertension (AH) in Russia. Modeling of Markov conducted economic impact of RD on the Russian population of patients with resistant hypertension in combination with optimal medical therapy (OMT) compared with OMT using a model developed by American researchers based on the results of international research. The model contains data on Russian mortality, and costs of major complications of hypertension. The simulation results showed a significant reduction in relative risk reduction of adverse outcomes in patients with resistant hypertension for 10 years (risk of stroke is reduced by 30%, myocardial infarction - 32%). RD saves 0.9 years of quality-adjusted life (QALY) by an average of 1 patient with resistant hypertension. Costs for 1 year stored in the application of quality of life amounted to RD 203 791.6 rubles. Which is below the 1 gross domestic product and therefore indicates the feasibility of this method in Russia.

The Rising Burden of Diabetes and Hypertension in Southeast Asian and African Regions: Need for Effective Strategies for Prevention and Control in Primary Health Care Settings

PubMed Central

Mohan, Viswanathan; Seedat, Yackoob K.; Pradeepa, Rajendra

2013-01-01

Aim. To review the available literature on burden of diabetes mellitus (DM) and hypertension (HTN) and its coexistence in Southeast Asian (SEA) and the African (AFR) regions and to suggest strategies to improve DM and HTN prevention and control in primary health care (PHC) in the two regions. Methods. A systematic review of the papers published on DM, HTN, and prevention/control of chronic diseases in SEA and AFR regions between 1980 and December 2012 was included. Results. In the year 2011, SEA region had the second largest number of people with DM (71.4 million), while the AFR region had the smallest number (14.7 million). Screening studies identified high proportions (>50%) of individuals with previously undiagnosed HTN and DM in both of the SEA and AFR regions. Studies from both regions have shown that DM and HTN coexist in type 2 DM ranging from 20.6% in India to 78.4% in Thailand in the SEA region and ranging from 9.7% in Nigeria to 70.4% in Morocco in the AFR region. There is evidence that by lifestyle modification both DM and HTN can be prevented. Conclusion. To meet the twin challenge of DM and HTN in developing countries, PHCs will have to be strengthened with a concerted and multipronged effort to provide promotive, preventive, curative, and rehabilitative services. PMID:23573413

Resistant hypertension revisited: a comparison of two university-based cohorts.

PubMed

Garg, Jay P; Elliott, William J; Folker, Amy; Izhar, Munavvar; Black, Henry R

2005-05-01

More than a decade ago, we found that a suboptimal medication regimen was the leading cause of resistant hypertension (RH) among patients referred to a tertiary care clinic. Since then, lower blood pressure (BP) goals have been recommended, suggesting that more patients may have RH. To assess whether the reasons for and treatment of RH have changed, we determined the frequency of various causes of resistance, the proportion of patients achieving goal BP, and the changes made in antihypertensive regimens. The charts of all new patients seen at the RUSH University Hypertension Center between January 1, 1993, and November 1, 2001, were reviewed for strict criteria for RH: 1) physician referral for uncontrolled hypertension; 2) BP > or =140/90 mmHg despite use of three antihypertensive drugs; and 3) at least one follow-up visit. Patients were followed-up until goal BP was achieved on two consecutive visits or their last visit or until March 2002. Of 1281 patients, 141 met criteria for RH. A cause of resistance was found in 94% of cases, including the following: drug-related causes (58%); nonadherence (16%); psychological causes (9%); office resistance (ie, in-clinic BP readings that were higher than goal despite treatment with antihypertensive medications and despite normotensive BP outside of the clinic as demonstrated by 24-h ambulatory BP monitoring) (6%); and secondary hypertension (5%). Overall, 53% of patients had their BP controlled to <140/90 mmHg, largely from regimen optimization and intensification, proper use of diuretics, and on average 4.1 +/- 1 antihypertensive medications (3.7 +/- 0.9 on referral). These data are strikingly similar to those from our previous study of RH, in which a suboptimal medication regimen was the most common reason for resistance. Goal BP was most commonly achieved after optimizing the diuretic regimen and increasing the number of medications, suggesting that physicians should use these measures to attain the recommended lower BP

Ethnobotanical study of medicinal plants used in the management of diabetes mellitus and hypertension in the Central Region of Togo.

PubMed

Karou, Simplice Damintoti; Tchacondo, Tchadjobo; Djikpo Tchibozo, Micheline Agassounon; Abdoul-Rahaman, Saliou; Anani, Kokou; Koudouvo, Koffi; Batawila, Komlan; Agbonon, Amegnona; Simpore, Jacques; de Souza, Comlan

2011-12-01

The Tem tribe in the Central Region of Togo is a population with an extensive knowledge of medicinal plants. However, little is known about their medical practices, principally the use of plants in the management of diabetes mellitus (DM) and hypertension (HTN). The present study documented the indigenous medicinal plant utilization for the management of DM and HTN in the Togo Central Region. From March to October 2010, 55 traditional healers were interviewed about their knowledge on the use of plants for DM and HTN treatment. The results revealed that 35/55 (63.64%) healers had treated at least one case of DM and/or HTN. They highlighted the use of 64 species belonging to 31 families in the treatment of DM and/or HTN. The most used plants against diabetes were Psidium guajava L. (Myrtaceae), Khaya senegalensis A. Juss. (Meliaceae), Sarcocephalus latifolius (Sm.) E.A. Bruce (Rubiaceae), Annona muricata L. (Annonaceae), Bridelia ferruginea Benth. (Phyllanthaceae), and Securidaca longepedunculata Fresen. (Polygalacae), while Allium sativum L. (Liliaceae) and Parkia biglobosa Benth. (Fabaceae), followed by Khaya senegalensis A. Juss. (Meliaceae), Gardenia ternifolia Schumach. (Rubiaceae), and Persea americana Mill. (Lauraceae) were the most commonly cited as antihypertensive. The issue revealed that traditional healers of the above mentioned region have basic knowledge regarding herbal medicine for DM and HTN in comparison with previous published reports. Further pharmacological screening of the identified plants should be conducted to ascertain the effectiveness of these plants.

Pathophysiology of resistant hypertension in chronic kidney disease.

PubMed

Campese, Vito M

2014-01-01

Hypertension associated with chronic kidney diseases often is resistant to drug treatment. This review deals with two main aspects of the management of CKD patients with hypertension: the role of sodium/volume and the need for dietary salt restriction, as well as appropriate use of diuretics and what currently is called sequential nephron blockade; the second aspect that is addressed extensively in this review is the role of the sympathetic nervous system and the possible clinical use of renal denervation.

MRI and Neuropsychological Correlates in African Americans with Hypertension and left vEntricular Hypertrophy.

PubMed

Waldron-Perrine, B; Kisser, J E; Brody, A; Haacke, E M; Dawood, R; Millis, S; Levy, P

2018-04-17

African Americans (AA) are at high risk for hypertension (HTN) and poor blood pressure (BP) control. Persistently elevated BP contributes to cardiovascular morbidity. White matter hyperintensities (WMH) are a definable magnetic resonance imaging (MRI) marker of cerebrovascular injury linked to impairments in higher level thinking (i.e., executive functions), memory formation and speed of perceptual-motor processing. This sub-investigation evaluated neuropsychological functioning in association with WMH on brain MRIs in 23 otherwise healthy hypertensive AAs participating in an NIH-funded study of the effects of Vitamin D on BP and cardiac remodeling in AA patients 30-74 years of age with HTN and left ventricular hypertrophy. Neuropsychological assessment included psychomotor processing speed [(Symbol Digit Modality Test (SDMT) and Trail Making Test], executive functioning (Controlled Oral Word Association Test and Trail Making Test Part B), memory (Rey Auditory Verbal Learning Test), and fine motor functioning (Finger Tapping). Significant correlations (p< .05) were found between volume of periventricular lesions and Trails A (r = .51) and dominant hand finger tapping speed (r = -.69) and between subcortical lesion volume and Trails A (r = .60), both dominant (r = -.62) and non-dominant hand finger tapping speed (r = -.76) and oral SDMT (r = -.60); higher lesion volumes correlated to worse neuropsychological performance. Psychomotor tests including the Trail Making Test and finger tapping speed are sensitive indicators of subclinical deficits in mental processing speed and could serve as early markers of deep subcortical cerebrovascular injury in otherwise-healthy individuals with uncontrolled chronic HTN.

Obesity-related hypertension: is there a role for selective leptin resistance?

PubMed

Correia, Marcelo L G; Haynes, William G

2004-06-01

Obesity is a risk factor for cardiovascular diseases, in particular for hypertension. Serum leptin levels and sympathetic nerve activity are both increased in obesity. Leptin has been demonstrated to increase sympathetic nerve activity. Thus, leptin-dependent sympathoactivation might contribute to obesity-related hypertension. However, leptin resistance occurs in obesity. One possibility is that leptin resistance is selective to the metabolic effects of leptin, sparing its sympathoexcitatory actions. In this article, we review experimental evidence supporting the novel concept of selective leptin resistance. We also discuss the sympathetic actions of leptin that are relevant to blood pressure modulation and potential mechanisms of leptin resistance. Disruption of leptin intracellular signaling pathways and resistance of specific leptin-responsive neural networks provide theoretic models of selective leptin resistance. However, most information about leptin-sympathetic actions and leptin-resistance mechanisms derive from in vitro and animal studies. Future research in humans is widely awaited.

Catheter-Based Renal Denervation for Resistant Hypertension: Will It Ever Be Ready for "Prime Time"?

PubMed

Laffin, Luke J; Bakris, George L

2017-09-01

The year 2014 was a turning point for the field of renal denervation (RDN) and its potential use to treat resistant hypertension. Tremendous enthusiasm shifted to sober reflection on the efficacy of a technology once touted as the cure to resistant hypertension. The following review highlights 2 major questions: First, does catheter-based RDN lower blood pressure and, second, will RDN using catheter-directed therapy for the treatment of resistant hypertension ever become more than an investigational technology. © American Journal of Hypertension, Ltd 2016. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Comparative effectiveness of fourth-line anti-hypertensive agents in resistant hypertension: A systematic review and meta-analysis.

PubMed

Sinnott, Sarah-Jo; Tomlinson, Laurie A; Root, Adrian A; Mathur, Rohini; Mansfield, Kathryn E; Smeeth, Liam; Douglas, Ian J

2017-02-01

Aim We assessed the effectiveness of fourth-line mineralocorticoid receptor antagonists in comparison with other fourth-line anti-hypertensive agents in resistant hypertension. Methods and results We systematically searched Medline, EMBASE and the Cochrane library from database inception until January 2016. We included randomised and non-randomised studies that compared mineralocorticoid receptor antagonists with other fourth-line anti-hypertensive agents in patients with resistant hypertension. The outcome was change in systolic blood pressure, measured in the office, at home or by ambulatory blood pressure monitoring. Secondary outcomes were changes in serum potassium and occurrence of hyperkalaemia. We used random effects models and assessed statistical heterogeneity using the I 2 test and corresponding 95% confidence intervals. From 2,506 records, 5 studies met our inclusion criteria with 755 included patients. Two studies were randomised and three were non-randomised. Comparative fourth-line agents included bisoprolol, doxazosin, furosemide and additional blockade of the renin angiotensin-aldosterone system. Using data from randomised studies, mineralocorticoid receptor antagonists reduced blood pressure by 7.4 mmHg (95%CI 3.2 - 11.6) more than the active comparator. When limited to non-randomised studies, mineralocorticoid receptor antagonists reduced blood pressure by 11.9 mmHg (95% CI 9.3 - 14.4) more than the active comparator. Conclusion On the basis of this meta-analysis, mineralocorticoid receptor antagonists reduce blood pressure more effectively than other fourth-line agents in resistant hypertension. Effectiveness stratified by ethnicity and comorbidities, in addition to information on clinical outcomes such as myocardial infarction and stroke, now needs to be determined.

Managing resistant hypertension: focus on mineralocorticoid-receptor antagonists

PubMed Central

Yugar-Toledo, Juan Carlos; Modolo, Rodrigo; de Faria, Ana Paula; Moreno, Heitor

2017-01-01

Mineralocorticoid-receptor antagonists (MRAs) have proven to be effective in some types of hypertension, especially in resistant hypertension (RHTN). In this phenotype of hypertension, the renin–angiotensin–aldosterone pathway plays an important role, with MRAs being especially effective in reducing blood pressure. In this review, we show the relevance of aldosterone in RHTN, as well as some clinical characteristics of this condition and the main concepts involving its pathophysiology and cardiovascular damage. We analyzed the mechanisms of action and clinical effects of two current MRAs – spironolactone and eplerenone – both of which are useful in RHTN, with special attention to the former. RHTN represents a significant minority (10%–15%) of hypertension cases. However, primary-care physicians, cardiologists, nephrologists, neurologists, and geriatricians face this health problem on a daily basis. MRAs are likely one of the best pharmacological options in RHTN patients; however, they are still underused. PMID:29081661

Resistant hypertension and aldosterone: an update.

PubMed

Clark, Donald; Ahmed, Mustafa I; Calhoun, David A

2012-05-01

Resistant hypertension (RHTN) is defined as a blood pressure remaining above goal despite the concurrent use of 3 antihypertensive medications of different classes, including, ideally a diuretic. RHTN is an important health problem with a prevalence rate expected to increase as populations become older, more obese, and at higher risk of having diabetes and chronic kidney disease, all of which are important risk factors for development of RHTN. The role of aldosterone has gained increasing recognition as a significant contributor to antihypertensive treatment resistance. In prospective studies, the prevalence of primary aldosteronism (PA) has ranged from 14%-21% in patients with RHTN, which is considerably higher than in the general hypertensive population. Furthermore, marked antihypertensive effects are seen when mineralocorticoid antagonists are added to the treatment regimen of patients with RHTN, further supporting aldosterone excess as an important cause of RHTN. A close association exists between hyperaldosteronism, RHTN, and obstructive sleep apnea (OSA) based upon recent studies which indicate that OSA is worsened by aldosterone-mediated fluid retention. This interaction is supported by preliminary data which demonstrates improvement in OSA severity after treatment with spironolactone. Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Hypertension, poor glycemic control, and microalbuminuria in Cuban Americans with type 2 diabetes.

PubMed

Zarini, Gustavo G; Exebio, Joel C; Gundupalli, Deva; Nath, Subrata; Huffman, Fatma G

2011-01-01

To investigate to what degree the presence of hypertension (HTN) and poor glycemic control (GC) influences the likelihood of having microalbuminuria (MAU) among Cuban Americans with type 2 diabetes (T2D). A cross-sectional study conducted in Cuban Americans (n = 179) with T2D. Participants were recruited from a randomly generated mailing list purchased from Knowledge-Base Marketing, Inc. Blood pressure (BP) was measured twice and averaged using an adult size cuff. Glycosylated hemoglobin (A1c) levels were measured from whole blood samples with the Roche Tina-quant method. First morning urine samples were collected from each participant to determine MAU by a semiquantitative assay (ImmunoDip). MAU was present in 26% of Cuban Americans with T2D. A significantly higher percentage of subjects with MA had HTN (P = 0.038) and elevated A1C (P = 0.002) than those with normoalbuminuria. Logistic regression analysis showed that after controlling for covariates, subjects with poor GC were 6.76 times more likely to have MAU if they had hypertension compared with those without hypertension (P = 0.004; 95% confidence interval [CI]: 1.83, 23.05). The clinical significance of these findings emphasizes the early detection of MAU in this Hispanic subgroup combined with BP and good GC, which are fundamentals in preventing and treating diabetes complications and improving individuals' renal and cardiovascular outcomes.

Prevalence and risk factors of obesity and hypertension among students at a central university in the West Bank

PubMed Central

Tayem, Yasin I.; Yaseen, Nagham A.; Khader, Wiam T.; Abu Rajab, Lama O.; Ramahi, Ahmad B.; Saleh, Mohammad H.

2012-01-01

Objectives We aimed to determine the prevalence and correlates of obesity and hypertension (HTN) among students at a central university in the West Bank. Materials and methods This cross-sectional study targeted a cohort of 553 students (59.5% males, 40.5% females) aged 17–26 years (median = 21) from Al-Quds University. Body mass index (BMI) and blood pressure (BP) were measured. Participants completed a questionnaire on physical activity, sedentary behavior, dietary factors, smoking and family history of obesity, HTN, and coronary artery disease. The magnitude of correlation was assessed by Spearman's rho (r s) and Chi-square tests. Results The prevalence of overweight was 25% (31.1% males, 15.6% females) and obesity 7.2% (9.4% males, 4% females). Obesity and overweight were associated with family history of obesity in both genders (p<0.001) and physical activity in males (rs= − 0.162, p<0.005). No correlation was demonstrated between participants’ BMI and sedentary lifestyle or consumption of fast food. Pre-HTN was detected in 27.1% (38% males, 11.2% females) and HTN in 2.2% (3.3% males, 0.4% females). Pre-HTN and HTN were associated with obesity (rs=0.252, p<0.001) and smoking (p<0.05). No relationship was detected between students’ BP and sedentary behavior, family history of HTN/CAD, or consumption of fast food. The prevalence of increased BMI and BP among males was significantly higher than females (p<0.001). Conclusions We detected a high prevalence of elevated BP and excess weight gain among students at Al-Quds University. An interventional program is urgently needed to control these cardiovascular risk factors in this community. PMID:23077467

Evidence and Perspectives on the 24-hour Management of Hypertension: Hemodynamic Biomarker-Initiated 'Anticipation Medicine' for Zero Cardiovascular Event.

PubMed

Kario, Kazuomi

There are notable differences between Asians and Westerners regarding hypertension (HTN) and the relationship between HTN and cardiovascular disease (CVD). Asians show greater morning surges in blood pressure (BP) and a steeper slope illustrating the link between higher BP and the risk of CVD events. It is thus particularly important for Asian hypertensives to achieve 24-h BP control, including morning and night-time control. There are three components of 'perfect 24-h BP control:' the 24-h BP level, nocturnal BP dipping, and BP variability (BPV), such as the morning BP surge that can be assessed by ambulatory BP monitoring. The morning BP-guided approach using home BP monitoring (HBPM) is the first step toward perfect 24-h BP control, followed by the control of nocturnal HTN. We have been developing new HBPM devices that can measure nocturnal BP. BPV includes different time-phase variability from the shortest beat-by-beat, positional, diurnal, day-by-day, visit-to-visit, seasonal, and yearly changes. The synergistic resonance of each type of BPV would produce a great dynamic BP surge (resonance hypothesis), which triggers a CVD event, especially in the high-risk patients with systemic hemodynamic atherothrombotic syndrome (SHATS). In the future, the innovative management of HTN based on the simultaneous assessment of the resonance of all of the BPV phenotypes using a beat by beat wearable 'surge' BP monitoring device (WSP) and an information and communication technology (ICT)-based data analysis system will produce a paradigm shift from 'dots' BP management to 'seamless' ultimate individualized 'anticipation medication' for reaching a zero CVD event rate. Copyright © 2016 The Author. Published by Elsevier Inc. All rights reserved.

[Assessment of resistant hypertension with home blood pressure monitoring].

PubMed

Marui, Fabiane Rosa Rezende H; Bombig, Maria Teresa Nogueira; Francisco, Yoná Afonso; Thalenberg, José Marcos; Fonseca, Francisco Antonio Helfenstein; Souza, Dilma de; Costa, Francisco de Assis; Izar, Maria Cristina; Carvalho, Antonio Carlos de Camargo; Póvoa, Rui

2010-10-01

ambulatory blood pressure monitoring (ABPM) is considered the gold standard for the diagnostic confirmation of resistant hypertension (RH). However, home blood pressure monitoring (HBPM) has been considered an option, because of its lower cost and greater comfort. to compare the values obtained by HBPM with those obtained by ABPM in the identification of patients with resistant hypertension. a total of 51 consecutive patients with resistant hypertension were selected. All were adults of both genders and were undergoing treatment in an outpatient referral clinic from January 2007 to September 2009. Casual office blood pressure (BP), 24-hour ABPM, and HBPM were performed according to current guidelines, with a maximum two-week interval between the methods. the comparison of ABPM (mean daytime) with HBPM showed a good correlation between them, both for systolic blood pressure (SBP) and for diastolic blood pressure (DBP): SBP r = 0.70, CI = 0.51-0.82, DBP r = 0.69, CI = 0.52-0.81. RH was confirmed by ABPM in 33 patients and by HBPM in 37, with no significant difference between the methods. according to the results obtained, we conclude that HBPM is a method that can be used as an alternative to ABPM for the diagnostic confirmation of RH.

Temporal Relationship Between Hyperuricemia and Insulin Resistance and Its Impact on Future Risk of Hypertension.

PubMed

Han, Tianshu; Lan, Li; Qu, Rongge; Xu, Qian; Jiang, Ruyue; Na, Lixin; Sun, Changhao

2017-10-01

Although hyperuricemia and insulin resistance significantly correlated, their temporal sequence and how the sequence influence on future risk of hypertension are largely unknown. This study assessed temporal relationship between uric acid and insulin resistance and its impact on future risk of hypertension by examining a longitudinal cohort including 8543 subjects aged 20 to 74 years from China, with an average follow-up of 5.3 years. Measurements of fasting uric acid, as well as fasting and 2-hour serum glucose and insulin, were obtained at baseline and follow-up. Indicators of hepatic and peripheral insulin resistance were calculated. Cross-lagged panel and mediation analysis were used to examine the temporal relationship between uric acid and insulin resistance and its impact on follow-up hypertension. After adjusting for covariates, the cross-lagged path coefficients ( β 1 values) from baseline uric acid to follow-up insulin resistance indices were significantly greater than path coefficients ( β 2 values) from baseline insulin resistance indices to follow-up uric acid ( β 1 =0.110 versus β 2 =0.017; P <0.001, for hepatic insulin resistance; β 1 =-0.208 versus β 2 =-0.021; P <0.001, for peripheral insulin resistance). The path coefficients from baseline uric acid to follow-up insulin resistance indices in the hypertensive group were significantly greater than that in the normotensive group ( P <0.001 for the difference of β 1 values in the 2 groups). Insulin resistance partially mediated the effect of uric acid on subsequent hypertension, and the mediation effect of peripheral insulin resistance was significantly greater than that of hepatic insulin resistance (31.3% versus 13.2%; P <0.001, for the difference of mediation effects). These findings provide evidence that higher uric acid levels probably precede insulin resistance, and peripheral insulin resistance likely plays a more important role in the development of hypertension than hepatic insulin

Factors related to medication non-adherence for patients with hypertension in Taiwan.

PubMed

Li, Wen-Wen; Kuo, Chi-Tai; Hwang, Shiow-Li; Hsu, Hsin-Tien

2012-07-01

To characterise a Taiwanese population and to examine the prevalence of antihypertensive medication non-adherence and how the cultural/clinical factors were associated with non-adherence in Taiwan. Antihypertensive medication non-adherence is a significant clinical issue in the United States. However, little is known about hypertension (HTN) control and cultural/clinical factors related to non-adherence in Taiwan. A convenience sample survey design was used. Data were gathered from a convenience sample of 200 subjects recruited from a large teaching hospital. Medication non-adherence and cultural/clinical factors were recorded using various self-administered questionnaires, and blood pressure was taken twice for each participant. The mean age of the participants was 60.4 (SD 11.5 years) including 62% men. Two-thirds had less than a high school education (64.5%), and the majority of them were married (86·0%) and lived with family or close friends (93.5%). The average length of HTN diagnosis was 8.6 years (SD 9.0 years). Medication non-adherence rate was 47·5%, and uncontrolled HTN rate was 49.0%. Some participants (17.0%) used Chinese herbs for treating their disease (e.g. cough) and promoting health in addition to their regular antihypertensive medications. Two factors were found to be statistically significant for predicting medication non-adherence: Lower Perceived Susceptibility to Specific Diseases [OR = 1.15 (95%CI, 1.01-1.31)] and Longer Length of HTN Diagnosis [OR = 1.06 (95%CI, 1.01-1.12)]. Taiwanese at risk of non-adherence included those who perceived lower susceptibility to specific diseases and had been diagnosed with HTN for a longer time. Those using herbs need to be studied for an impact of herbs on their adherence behaviour. These findings can help guide the development of culturally sensitive and clinically appropriate nursing interventions for HTN management in Taiwan. © 2012 Blackwell Publishing Ltd.

Assessing Mobile Health Capacity and Task Shifting Strategies to Improve Hypertension Among Ghanaian Stroke Survivors.

PubMed

Nichols, Michelle; Sarfo, Fred Stephen; Singh, Arti; Qanungo, Suparna; Treiber, Frank; Ovbiagele, Bruce; Saulson, Raelle; Patel, Sachin; Jenkins, Carolyn

2017-12-01

There has been a tremendous surge in stroke prevalence in sub-Saharan Africa. Hypertension (HTN), the most potent, modifiable risk factor for stroke, is a particular challenge in sub-Saharan Africa. Culturally sensitive, efficacious HTN control programs that are timely and sustainable are needed, especially among stroke survivors. Mobile health (mHealth) technology and task-shifting offer promising approaches to address this need. Using a concurrent triangulation design, we collected data from stroke survivors, caregivers, community leaders, clinicians and hospital personnel to explore the barriers, facilitators and perceptions toward mHealth related to HTN management among poststroke survivors in Ghana. Exploration included perceptions of a nurse-led navigational model to facilitate care delivery and willingness of stroke survivors and caregivers to use mHealth technology. Two hundred stroke survivors completed study surveys while focus groups (n = 4) were conducted with stroke survivors, caregivers and community leaders (n = 28). Key informant interviews were completed with clinicians and hospital personnel (n = 10). A total of 93% of survey respondents had HTN (60% uncontrolled). Findings support mHealth strategies for poststroke care delivery and HTN management and for task-shifting through a nurse-led model. Of survey and focus group participants, 76% and 78.6%, respectively, have access to mobile phones and 90% express comfort in using mobile phones and conveyed assurance that task-shifting through a nurse-led model could facilitate management of HTN. Findings also identified barriers to care delivery and medication adherence across all levels of the social ecological model. Participants strongly supported enhanced care delivery through mobile health and were receptive toward a nurse-led navigational model. Copyright © 2017 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.

Effects of One Resistance Exercise Session on Vascular Smooth Muscle of Hypertensive Rats

PubMed Central

da Silva, Tharciano Luiz Teixeira Braga; Mota, Marcelo Mendonça; Fontes, Milene Tavares; Araújo, João Eliakim dos Santos; Carvalho, Vitor Oliveira; Bonjardim, Leonardo Rigoldi; Santos, Márcio Roberto Viana

2015-01-01

Background Hypertension is a public health problem and increases the incidence of cardiovascular diseases. Objective To evaluate the effects of a resistance exercise session on the contractile and relaxing mechanisms of vascular smooth muscle in mesenteric arteries of NG-nitro L-arginine methyl ester (L-NAME)-induced hypertensive rats. Methods Wistar rats were divided into three groups: control (C), hypertensive (H), and exercised hypertensive (EH). Hypertension was induced by administration of 20 mg/kg of L-NAME for 7 days prior to experimental protocols. The resistance exercise protocol consisted of 10 sets of 10 repetitions and intensity of 40% of one repetition maximum. The reactivity of vascular smooth muscle was evaluated by concentration‑response curves to phenylephrine (PHEN), potassium chloride (KCl) and sodium nitroprusside (SNP). Results Rats treated with L-NAME showed an increase (p < 0.001) in systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) compared to the initial period of induction. No difference in PHEN sensitivity was observed between groups H and EH. Acute resistance exercise reduced (p < 0.001) the contractile response induced by KCl at concentrations of 40 and 60 mM in group EH. Greater (p < 0.01) smooth muscle sensitivity to NPS was observed in group EH as compared to group H. Conclusion One resistance exercise session reduces the contractile response induced by KCl in addition to increasing the sensitivity of smooth muscle to NO in mesenteric arteries of hypertensive rats. PMID:26107814

Effects of one resistance exercise session on vascular smooth muscle of hypertensive rats.

PubMed

Silva, Tharciano Luiz Teixeira Braga da; Mota, Marcelo Mendonça; Fontes, Milene Tavares; Araújo, João Eliakim Dos Santos; Oliveira Carvalho, Vitor; Bonjardim, Leonardo Rigoldi; Santos, Márcio Roberto Viana

2015-08-01

Hypertension is a public health problem and increases the incidence of cardiovascular diseases. To evaluate the effects of a resistance exercise session on the contractile and relaxing mechanisms of vascular smooth muscle in mesenteric arteries of NG-nitro L-arginine methyl ester (L-NAME)-induced hypertensive rats. Wistar rats were divided into three groups: control (C), hypertensive (H), and exercised hypertensive (EH). Hypertension was induced by administration of 20 mg/kg of L-NAME for 7 days prior to experimental protocols. The resistance exercise protocol consisted of 10 sets of 10 repetitions and intensity of 40% of one repetition maximum. The reactivity of vascular smooth muscle was evaluated by concentration‑response curves to phenylephrine (PHEN), potassium chloride (KCl) and sodium nitroprusside (SNP). Rats treated with L-NAME showed an increase (p < 0.001) in systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) compared to the initial period of induction. No difference in PHEN sensitivity was observed between groups H and EH. Acute resistance exercise reduced (p < 0.001) the contractile response induced by KCl at concentrations of 40 and 60 mM in group EH. Greater (p < 0.01) smooth muscle sensitivity to NPS was observed in group EH as compared to group H. One resistance exercise session reduces the contractile response induced by KCl in addition to increasing the sensitivity of smooth muscle to NO in mesenteric arteries of hypertensive rats.

Dietary nitrate lowers ambulatory blood pressure in treated, uncontrolled hypertension: a 7-d, double-blind, randomised, placebo-controlled, cross-over trial.

PubMed

Kerley, Conor P; Dolan, Eamon; James, Philip E; Cormican, Liam

2018-03-01

Dietary nitrate has been shown to increase nitrate/nitrite levels and decrease blood pressure (BP) in multiple populations. There are few reports among hypertensives and these reports have provided conflicting evidence. We aimed to assess the effect of daily nitrate compared with placebo in subjects with uncontrolled hypertension (HTN). On day 0, hypertensives wore an ambulatory BP monitor (ABPM) for 24 h and blood was taken. Subjects were then randomised to 7-d nitrate-rich beetroot juice (NO3 -) (12·9 mmol nitrate) followed by 7-d nitrate-depleted beetroot juice (0·5 mmol nitrate) or vice versa. ABPM and blood were assessed before and after both conditions. In all, twenty subjects with treated yet uncontrolled HTN entered and completed the trial (mean age=62·5 years, mean BMI=30·7 kg/m2). Baseline BP was 137/80 (sd 7/7) mmHg. Dietary nitrate was well tolerated and resulted in significantly increased plasma nitrite (P=0·0004) and decreased 24-h systolic BP and diastolic BP compared with placebo (-8 mmHg; P=0·012 and -4 mmHg; P=0·018, respectively). Our results support the existing data suggesting an anti-hypertensive effect of dietary nitrate in treated yet uncontrolled hypertensives. Targeted dietary strategies appear promising contributors to BP control.

Increased systemic vascular resistance in neonates with pulmonary hypertension.

PubMed

Milstein, J M; Goetzman, B W; Riemenschneider, T A; Wennberg, R P

1979-11-01

The time necessary for aortic diastolic pressure to decrease to 50 percent of an initially selected value after dissipation of the dicrotic notch (T 1/2) was determined in newborn infants with and without pulmonary hypertension. The mean T 1/2 was 671 +/- 167 msec in seven infants with clinical evidence of pulmonary hypertension and documented right to left ductus arteriosus shunting; 849 +/- 243 msec in nine infants with clinical evidence of pulmonary hypertension but no documented right to left ductus arteriosus shunting; and 457 +/- 66 msec in eight infants with hyaline membrane disease and no clinical evidence of pulmonary hypertension or a patent ductus arteriosus. The mean T 1/2 values in the former two groups were significantly different from that in the group with no pulmonary hypertension (P less than 0.01). An evaluation of factors affecting T 1/2 leads to the conclusion that the patients with pulmonary hypertension had increased systemic vascular resistance as well. This finding has important diagnostic, etiologic and therapeutic implications.

Stress, abdominal obesity and intrarenal resistive index in essential hypertension.

PubMed

Trovato, G M; Pace, P; Martines, G F; Trovato, F M; Pirri, C; Catalano, D

2012-07-01

Although it is commonly believed that a strong causal link exists between psychological stress and hypertension, as well with other factors, such as obesity, just what kind of empirical evidence supports this assumption is still controversial. The aim of the study is to investigate if perceived stress have any interference with intrarenal resistance and hence with mechanisms related to Essential Hypertension (EH) and if Anxiety, Depression, Self efficacy and Illness Perception can account for perceived stress. Obesity, insulin resistance (HOMA), Doppler Renal Resistive Index (RRI) and glomerular filtration rate (GFR) are studied along with Psychological Stress Measure (PSM), Illness Perception Questionnaire (IPQ-R), Generalized Self-Efficacy scale (GSE) and Hospital Anxiety and Depression Scale (HADS) in 119 hypertensive patients referred for stable lasting EH, and 150 normal controls. Lower salt/lower calories Mediterranean diet, physical activity increase and smoking withdrawal counseling were provided. By Odds Ratios, higher risk of EH is associated with greater perceived stress, older age, lower GFR, obesity, greater RRI and insulin resistance. By Multiple Linear Regression the most significant variable that accounts for higher RRI are abdominal obesity and arterial pulse pressure; the only significant independent psychological variable that accounts for abdominal obesity are PSM and identity IPQ subscale. Self-Efficacy anxiety and Illness perception subscales (IPQr), accounts significantly for 62.0% of the variance to PSM, with possible effects on RRI and on the pathophysiological hypertension cascade. Worst identity and treatment control perceptions of EH, and a lower self-efficacy are the main psychological factors accounting for a greater stress. Interventions aimed to reduce perceived stress can be warranted in EH.

Performance of modified blood pressure-to-height ratio for identifying hypertension in Chinese and American children.

PubMed

Zhang, Yuanyuan; Ma, Chuanwei; Yang, Lili; Bovet, Pascal; Xi, Bo

2018-04-06

Blood pressure-to-height ratio (BPHR) has been reported to perform well for identifying hypertension (HTN) in adolescents but not in young children. Our study was aimed to evaluate the performance of BPHR and modified BPHR (MBPHR) for screening HTN in children. A total of 5268 Chinese children (boys: 53.1%) aged 6-12 years and 5024 American children (boys: 48.1%) aged 8-12 years were included in the present study. BPHR was calculated as BP/height (mmHg/cm). MBPHR7 was calculated as BP/(height + 7*(13-age)). MBPHR3 was calculated as BP/(height + 3*(13-age)). We used receiver-operating characteristic curve analysis to assess the performance of the three ratios for identifying HTN in children as compared to the 2017 U.S. clinical guideline as the "gold standard". The prevalence of HTN in Chinese and American children was 9.4% and 5.4%, respectively, based on the 2017 U.S. guideline. The AUC was larger for MBPHR3 than BPHR and MBPHR7. All three ratios had optimal negative predictive value (~100%). The positive predictive value (PPV) was higher for MBPHR3 than BPHR in both Chinese (43.9% vs. 37.9%) and American (39.1% vs. 26.3%) children. In contrast, the PPV was higher for MBPHR7 than BPHR in Chinese children (47.4% vs. 37.9%) but not in American children (24.8% vs. 26.3%). In summary, MBPHR3 overall performed better than MBPHR7 and BPHR for identifying HTN in children. However, the three ratios had low PPV (<50%) as compared to the 2017 U.S. guidelines, which makes these ratios of limited use for HTN screening in children.

Longitudinal association of dairy consumption with the changes in blood pressure and the risk of incident hypertension: the Framingham Heart Study

USDA-ARS?s Scientific Manuscript database

We aimed to examine the longitudinal association of dairy consumption with the changes in blood pressure (BP) and the risk of incident hypertension (HTN) among adults. This study included 2636 Framingham Heart Study Offspring Cohort members who participated in the 5th through 8th examinations (1991-...

Impact of Clinical Factors on the Achievement of Target Blood Pressure in Hypertensive Patients from Ivanovo Region of Russia: Data of 2015.

PubMed

Kiselev, A R; Posnenkova, O M; Belova, O A; Romanchuk, S V; Popova, Y V; Prokhorov, M D; Gridnev, V I

2017-12-01

In Russia, blood pressure (BP) control is below the optimal. The little is known about regional features and barriers to adequate BP control in Russian primary care. To evaluate the impact of clinical factors on achieving the target BP in hypertensive patients in one region of Russia. Retrospective medical data of 2015 on 11,129 patients (31.4% male) with hypertension (Htn) from Ivanovo region of Russia were examined. Achievement of target BP was assessed in all patients. We study association between BP control and clinical factors. 45.9% of studied patients with Htn had controlled BP. The frequency of achieving the target BP in subsets of hypertensive patients was 37.8% in patients with diabetes, 39.5% in patients with coronary artery disease, and 29.9% in patients with chronic heart failure. The main clinical factors associated with achieving the target BP in studied hypertensive patients were the advice on alcohol consumption, advice on smoking cessation, and advice on weight reduction. Therapy with main antihypertensive drugs (in particular, beta-blockers and thiazide diuretics) were also factors of optimal BP control in these patients. Comorbidities (chronic heart failure and cardiovascular diseases requiring the prescription of aspirin and statins) and family history of coronary artery disease were associated with inadequate BP control. A negative effect of some antihypertensive drugs (potassium sparing diuretics, ARBs, ACE-Is, and dihydropyridine CCBs) on BP control that was found out in our study requires further investigation. Other studied factors had no influence on BP control in patients with Htn from Ivanovo region. We identified regional factors of BP control in hypertensive patients from Ivanovo region of Russia. It is shown that individual medical education (in particular, medical advices) is the most important factor of optimal BP control. The intervention with antihypertensive therapy (beta-blockers and thiazide diuretics) facilitates the

Accuracy of Blood Pressure-to-Height Ratio to Define Elevated Blood Pressure in Children and Adolescents: The CASPIAN-IV Study.

PubMed

Kelishadi, Roya; Bahreynian, Maryam; Heshmat, Ramin; Motlagh, Mohammad Esmail; Djalalinia, Shirin; Naji, Fatemeh; Ardalan, Gelayol; Asayesh, Hamid; Qorbani, Mostafa

2016-02-01

The aim of this study was to propose a simple practical diagnostic criterion for pre-hypertension (pre-HTN) and hypertension (HTN) in the pediatric age group. This study was conducted on a nationally representative sample of 14,880 students, aged 6-18 years. HTN and pre-HTN were defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ≥ 95 and 90-95th percentile for age, gender, and height, respectively. By using the area under the curve (AUC) of the receiver operator characteristic curves, we estimated the diagnostic accuracy of two indexes of SBP-to-height ratio (SBPHR) and DBP-to-height (DBPHR) to define pre-HTN and HTN. Overall, SBPHR performed relatively well in classifying subjects to HTN (AUC 0.80-0.85) and pre-HTN (AUC 0.84-0.90). Likewise, DBPHR performed relatively well in classifying subjects to HTN (AUC 0.90-0.97) and pre-HTN (AUC 0.70-0.83). Two indexes of SBPHR and DBPHR are considered as valid, simple, inexpensive, and accurate tools to diagnose pre-HTN and HTN in pediatric age group.

Race, obesity, and the renin-angiotensin-aldosterone system: treatment response in children with primary hypertension.

PubMed

South, Andrew M; Arguelles, Lester; Finer, Gal; Langman, Craig B

2017-09-01

Pediatric primary hypertension (HTN) is increasingly recognized, but the effect of patient characteristics such as obesity and race on treatment outcomes is not well described. The renin-angiotensin-aldosterone system (RAAS) may also contribute to HTN. We hypothesized patient parameters of these factors, including baseline RAAS, influence blood pressure (BP) response to pharmacological treatment in HTN. This was a retrospective cohort of 102 consecutive patients with HTN. Primary outcomes were changes per year in systolic and diastolic BP (SBP, DBP). Secondary outcome was change per year in left ventricular mass index (LVMI). We evaluated whether baseline plasma renin activity (PRA), aldosterone, renin-to-aldosterone ratio, overweight/obesity, race, initial drug choice, and multidrug therapy were associated with the outcomes using general linear regression models adjusted for confounding variables. Racially diverse (43% Hispanic, 28% black, 25% white) and predominantly overweight/obese (75%) patients were studied. Median length of follow-up was 14.5 months. Higher baseline aldosterone was associated with decreased SBP (-1.03 mmHg/year), DBP (-0.95 mmHg/year), and DBP z score (-0.07/year) during the study period. Higher baseline PRA was associated with decreased SBP z score (-0.04/year) and LVMI (-2.89 g/m 2.7 /year). Stratified analyses revealed the relationships between baseline aldosterone and PRA, and annual reductions in outcomes were strengthened in nonobese and white patients. Pretreatment aldosterone and PRA predicted short-term follow-up BP and LVMI, especially in nonobese and white patients. The RAAS profile could guide treatment of HTN and suggests consideration of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers as first-line treatment options.

Fasting insulin, insulin resistance and risk of hypertension in the general population: A meta-analysis.

PubMed

Wang, Feng; Han, Lili; Hu, Dayi

2017-01-01

Studies on the association of fasting insulin concentrations or insulin resistance with subsequent risk of hypertension have yielded conflicting results. To quantitatively assess the association of fasting insulin concentrations or homeostasis model assessment insulin resistance (HOMA-IR) with incident hypertension in a general population by performing a meta-analysis. We searched the PubMed and Embase databases until August 31, 2016 for prospective observational studies investigating the elevated fasting insulin concentrations or HOMA-IR with subsequent risk of hypertension in the general population. Pooled risk ratio (RR) and 95% confidence interval (CI) of hypertension was calculated for the highest versus the lowest category of fasting insulin or HOMA-IR. Eleven studies involving 10,230 hypertension cases were identified from 55,059 participants. Meta-analysis showed that the pooled adjusted RR of hypertension was 1.54 (95% CI 1.34-1.76) for fasting insulin concentrations and 1.43 (95% CI 1.27-1.62) for HOMA-IR comparing the highest to the lowest category. Subgroup analysis results showed that the association of fasting insulin concentrations with subsequent risk of hypertension seemed more pronounced in women (RR 2.07; 95% CI 1.19-3.60) than in men (RR 1.48; 95% CI 1.17-1.88). This meta-analysis suggests that elevated fasting insulin concentrations or insulin resistance as estimated by homeostasis model assessment is independently associated with an exacerbated risk of hypertension in the general population. Early intervention of hyperinsulinemia or insulin resistance may help clinicians to identify the high risk of hypertensive population. Copyright © 2016 Elsevier B.V. All rights reserved.

Resistant hypertension optimal treatment trial: a randomized controlled trial.

PubMed

Krieger, Eduardo M; Drager, Luciano F; Giorgi, Dante Marcelo Artigas; Krieger, Jose Eduardo; Pereira, Alexandre Costa; Barreto-Filho, José Augusto Soares; da Rocha Nogueira, Armando; Mill, José Geraldo

2014-01-01

The prevalence of resistant hypertension (ReHy) is not well established. Furthermore, diuretics, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and calcium channel blockers are largely used as the first 3-drug combinations for treating ReHy. However, the fourth drug to be added to the triple regimen is still controversial and guided by empirical choices. We sought (1) to determine the prevalence of ReHy in patients with stage II hypertension; (2) to compare the effects of spironolactone vs clonidine, when added to the triple regimen; and (3) to evaluate the role of measuring sympathetic and renin-angiotensin-aldosterone activities in predicting blood pressure response to spironolactone or clonidine. The Resistant Hypertension Optimal Treatment (ReHOT) study (ClinicalTrials.gov NCT01643434) is a prospective, multicenter, randomized trial comprising 26 sites in Brazil. In step 1, 2000 patients will be treated according to hypertension guidelines for 12 weeks, to detect the prevalence of ReHy. Medical therapy adherence will be checked by pill count monitoring. In step 2, patients with confirmed ReHy will be randomized to an open label 3-month treatment with spironolactone (titrating dose, 12.5-50 mg once daily) or clonidine (titrating dose, 0.1-0.3 mg twice daily). The primary endpoint is the effective control of blood pressure after a 12-week randomized period of treatment. The ReHOT study will disseminate results about the prevalence of ReHy in stage II hypertension and the comparison of spironolactone vs clonidine for blood pressure control in patients with ReHy under 3-drug standard regimen. © 2013 Wiley Periodicals, Inc.

[Prevalence of target organ damage and metabolic abnormalities in resistant hypertension].

PubMed

Armario, Pedro; Oliveras, Anna; Hernández Del Rey, Raquel; Ruilope, Luis Miguel; De La Sierra, Alejandro

2011-10-15

Patients with resistant hypertension (RH) are relatively frequently visited in specialized units of hypertension. The aim of this study was to assess the prevalence of target organ damage, central obesity and metabolic syndrome in a cohort of patients with RH consecutively included in the Register of Resistant Hypertension of the Spanish Society of Hypertension (SHE-LELHA). Cross-sectional, multicenter epidemiologic study in usual clinical practice conditions. Patients with clinical diagnosis of resistant hypertension, that is, office systolic and diastolic blood pressure ≥ 140 mm Hg and/or ≥ 90 mm Hg, respectively, despite a prescribed therapeutic schedule with an appropriate combination of three or more full-dose antihypertensive drugs, including a diuretic, were consecutively recruited from specialized hypertension units spread through Spain. Demographic and anthropometric characteristics as well as cardiovascular risk factors and associated conditions were recorded, and all the subjects underwent 24-h ambulatory blood pressure monitoring. Left ventricular hypertrophy was considered as a left ventricular mass index ≥ 125 g/m(2) in males and ≥ 110 g/m(2) in females. Left atrial enlargement was defined as an indexed left atrium diameter ≥ 26 mm/m(2). Microalbuminuria was defined as a urinary albumin/creatinine ratio ≥ 22 mg/g in males and ≥ 31 mg/g in females. 513 patients were included, aged 64±11 years old, 47% women. Central obesity was present in 65.7% (CI 95% 61.6-69.9), 38.6% (CI 95% 34.4-42.8) had diabetes and 63.7% (CI 95% 59.4-67.9) had metabolic syndrome. The prevalence of left ventricular hypertrophy and left atrial enlargement, determined by echocardiography was 57.1% (CI 95% 50.8-63.5) and 10.0% (CI 95% 6.3-13.7) respectively. Microalbuminuria was found in 46.6% (CI 95% 41.4-51.8) of the subjects. Patients with metabolic syndrome were significantly older (65.4±11 and 62.5±12 years; P=.0052), presented a higher prevalence of diabetes

Transcatheter renal denervation for the treatment of resistant arterial hypertension: the Swiss expert consensus.

PubMed

Wuerzner, Gregoire; Muller, Olivier; Erne, Paul; Cook, Stéphane; Sudano, Isabella; Lüscher, Thomas F; Noll, Georg; Kaufmann, Urs; Rickli, Hans; Waeber, Bernard; Kaiser, Christophe; Sticherling, Christian; Pechère-Bertschi, Antoinette; Baumgartner, Iris; Jacob, Augustinus L; Burnier, Michel; Qanadli, Salah D

2014-03-20

Transcatheter (or percutaneous) renal denervation is a novel technique developed for the treatment of resistant hypertension. So far, only one randomised controlled trial has been published, which has shown a reduction of office blood pressure. The Swiss Society of Hypertension, the Swiss Society of Cardiology, The Swiss Society of Angiology and the Swiss Society of Interventional Radiology decided to establish recommendations to practicing physicians and specialists for good clinical practice. The eligibility of patients for transcatheter renal denervation needs (1.) confirmation of truly resistant hypertension, (2.) exclusion of secondary forms of hypertension, (3.) a multidisciplinary decision confirming the eligibility, (4.) facilities that guarantee procedural safety and (5.) a long-term follow-up of the patients, if possible in cooperation with a hypertension specialist. These steps are essential until long-term data on safety and efficacy are available.

Different impacts of hypertension and diabetes mellitus on all-cause and cardiovascular mortality in community-dwelling older adults: the Rancho Bernardo Study.

PubMed

Oh, Jee-Young; Allison, Matthew A; Barrett-Connor, Elizabeth

2017-01-01

Although the prevalence rates of hypertension (HTN) and diabetes mellitus are slowing in some high-income countries, HTN and diabetes mellitus remain as the two major risk factors for atherosclerotic cardiovascular disease (CVD), the leading cause of death in the United States and worldwide. We aimed to observe the association of HTN and diabetes mellitus with all-cause and CVD mortality in older white adults. All community-dwelling Rancho Bernardo Study participants who were at least 55 years old and had carefully measured blood pressure and plasma glucose from 75-g oral glucose tolerance test at the baseline visit (1984-1987, n = 2186) were followed up until death or the last clinic visit in 2013 (median 14.3 years, interquartile range 8.4-21.3). In unadjusted analyses, diabetes mellitus was associated with all-cause mortality [hazard ratio 1.40, 95% confidence interval (CI) 1.23-1.60] and CVD mortality (hazard ratio 1.67, 95% CI 1.39-2.00); HTN with all-cause mortality [hazard ratio 1.93 (1.73-2.15)] and CVD mortality [hazard ratio 2.45 (2.10-2.93)]. After adjustment for cardiovascular risk factors, including age, BMI, triglycerides, HDL-cholesterol, smoking, exercise, and alcohol consumption, diabetes mellitus was associated with CVD mortality only (hazard ratio 1.25, P = 0.0213). Conversely, HTN was associated with both all-cause (hazard ratio 1.34, P < 0.0001) and CVD mortality (hazard ratio 1.40, P = 0.0003). Having both diabetes mellitus and HTN was associated with all-cause (hazard ratio 1.38, P = 0.0002) and CVD mortality (hazard ratio 1.70, P < 0.0001). We report the novel finding that HTN is more strongly associated with all-cause and CVD mortality than diabetes mellitus. Having both confers a modest increase in the hazards for these types of mortality.

Complementary and alternative medicine (CAM) use among hypertensive patients in Palestine.

PubMed

Ali-Shtayeh, Mohammed S; Jamous, Rana M; Jamous, Rania M; Salameh, Nihaya M Y

2013-11-01

To explore the frequency of CAM use among hypertensive patients in Palestine, determine demographic characteristics that may increase the likelihood of CAM use and to find out how benefits were perceived by patients. Across-sectional survey of patients attending outpatient hypertension clinics. The method was based on a semi-structured questionnaire. Of the 4575 hypertensive patients interviewed, 85.7% respondents used at least one type of CAM. Of the 3921 CAM users, 62.13% reported taking herbs. Most of these users were >50 years old, of low educational level, and had a family history of HTN, 62.9% claimed to have obtained the desired effect from taking these herbs; however, 68.1% did not disclose this fact to their health care providers, 83 plant taxa were reported by these patients, Allium sativum was the most commonly used herb. The use of CAM, particularly herbal therapies for hypertension treatment, is highly prevalent in Palestine. Copyright © 2013 Elsevier Ltd. All rights reserved.

Dietary sodium to potassium ratio and the incidence of hypertension and cardiovascular disease: A population-based longitudinal study.

PubMed

Mirmiran, Parvin; Bahadoran, Zahra; Nazeri, Pantea; Azizi, Fereidoun

2018-01-30

There is an interaction between dietary sodium/potassium intake in the pathogenesis of hypertension (HTN) and cardiovascular disease (CVD). The aim of this study was to investigate the association of dietary sodium to potassium (Na/K) ratio and the risk of HTN and CVD in a general population of Iranian adults. In this prospective cohort study, adults men and women with complete baseline data were selected from among participants of the Tehran Lipid and Glucose Study and were followed up for 6.3 years for incidence of HTN and CVD outcomes. Dietary sodium and potassium were assessed using a valid and reliable 168-item food frequency questionnaire. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between dietary sodium, potassium and their ratio and risk of outcomes. During the study follow-up, 291 (15.1%) and 79 (5.0%) new cases of HTN and CVD were identified, respectively. No significant association was observed between usual intakes of sodium, potassium and dietary Na/K ratio with the incidence of HTN. There was no significant association between dietary intakes of sodium and potassium per se and the risk of CVD, whereas when dietary sodium to potassium ratio was considered as exposure in the fully-adjusted Cox regression model, and participants in the highest compared to lowest tertile had a significantly increased risk of CVD (HR = 2.19, 95% CI = 1.16-4.14). Our findings suggest that high dietary Na/K ratio could contribute to increased risk of CVD events.

Spironolactone reduces severity of obstructive sleep apnoea in patients with resistant hypertension: a preliminary report.

PubMed

Gaddam, K; Pimenta, E; Thomas, S J; Cofield, S S; Oparil, S; Harding, S M; Calhoun, D A

2010-08-01

Obstructive sleep apnoea (OSA) and hyperaldosteronism are very common in subjects with resistant hypertension. We hypothesized that aldosterone-mediated chronic fluid retention may influence OSA severity in patients with resistant hypertension. We tested this in an open-label evaluation by assessing the changes in the severity of OSA in patients with resistant hypertension after treatment with spironolactone. Subjects with resistant hypertension (clinical blood pressure (BP) >or=140/90 mm Hg on >or=3 antihypertensive medications, including a thiazide diuretic and OSA (defined as an apnoea-hypopnoea index (AHI) >or=15) had full diagnostic, polysomnography before and 8 weeks after spironolactone (25-50 mg a day) was added to their ongoing antihypertensive therapy. In all, 12 patients (mean age 56 years and body mass index 36.8 kg m(-2)) were evaluated. After treatment with spironolactone, the AHI (39.8+/-19.5 vs 22.0+/-6.8 events/h; P<0.05) and hypoxic index (13.6+/-10.8 vs 6.7+/-6.6 events/h; P<0.05), weight and clinic and ambulatory BP were significantly reduced. Plasma renin activity (PRA) and serum creatinine were significantly higher. This study provides preliminary evidence that treatment with a mineralocorticoid receptor antagonist substantially reduces the severity of OSA. If confirmed in a randomized assessment, it will support aldosterone-mediated chronic fluid retention as an important mediator of OSA severity in patients with resistant hypertension.

Prevalence of and risk factors for primary aldosteronism among patients with resistant hypertension in China.

PubMed

Sang, Xiaojing; Jiang, Yiran; Wang, Weiqing; Yan, Li; Zhao, Jiasheng; Peng, Yongde; Gu, Wei; Chen, Gang; Liu, Wei; Ning, Guang

2013-07-01

It is estimated that there are more than 16 million adults with drug-resistant hypertension in China. Nevertheless, the prevalence of and risk factors for primary aldosteronism, a highly curable condition among adults with drug-resistant hypertension, has not been fully investigated. Between January 2010 and October 2011, a multicenter epidemiologic study was conducted among 1656 patients with resistant hypertension in 11 provinces of China. Serum aldosterone and plasma renin activity were measured in every participant and aldosterone-to-renin ratio (ARR) was calculated. Patients with ARR more than 20 underwent an intravenous (i.v.) sodium infusion test, and diagnosis of primary aldosteronism was established by the presence of unsuppressed postinfusion aldosterone (>8 ng/dl). Patients with biochemically proved primary aldosteronism then underwent adrenal computed tomography (CT) scanning and adrenal vein sampling (AVS) for subtype classification. Among the 1656 patients, 494 (29.8%) had ARR greater than 20 and underwent i.v. sodium infusion. Of these 494, 118 were diagnosed as primary aldosteronism, yielding a prevalence of 7.1% (95% confidential interval 5.9-8.3%). Seventy of the 118 patients were categorized into unilateral (39) and bilateral (31) by AVS. Generalized additive regression analysis revealed that among all the factors investigated (age of hypertension onset, BMI, family history of hypertension, cigarette smoking, alcohol consumption, diabetes, serum potassium, hyperlipidemia, and creatinine), only age of hypertension onset and serum potassium were independently associated with the presence of primary aldosteronism. The prevalence of primary aldosteronism among Chinese patients with resistant hypertension is relatively lower than that reported previously for other ethnic populations. The screening for primary aldosteronism should be focused on those with early onset hypertension and/or hypokalemia.

Protocol of randomized control trial for effectiveness of angiotensin receptor blockers on blood pressure control among euvolemic hypertensive hemodialysis patients

PubMed Central

Aftab, Raja Ahsan; Khan, Amer Hayat; Syed Sulaiman, Syed Azhar; Khan, Tahir Mehmood; Adnan, Azreen Syazril

2017-01-01

Abstract Introduction: Volume overload and the renin–aldosterone–angiotensin system (RAAS) are 2 major factors contributing to hypertension (HTN) among hemodialysis (HD) patients. Although volume-dependent components of HTN can be corrected by appropriate volume removal, a proportion of HD patients experience elevated blood pressure (BP) despite achieving euvolemic and ideal dry weight. Method and analysis: A single center, prospective, randomized, parallel design, single-blind trial will be conducted in the Malaysian state of Kelantan among postdialysis euvolemic hypertensive patients that are on regular dialysis at least 3 times a week. The primary outcome of the trial will be to note the effectiveness of losartan (RAAS inhibitor) in reducing systolic BP < 140 mm Hg compared to standard non-RAAS-inhibitor antihypertensive therapy. The secondary outcome will be to look at all causes of mortality. A body composition monitor (BCM) will be used to assess postdialysis volume and dry weight. Postdialysis euvolemic patients that have systolic BP > 140 mm Hg will be randomized using Covariate Adaptive Randomization to standard or treatment arm. Participants in the treatment arm will be given 50 mg of losartan once daily except on dialysis days, whereas the standard arm patients will be prescribed non-RAAS antihypertensive agents. The study participants will be followed for a period of 12 months. A Wilcoxon statistical test will be performed to note the difference in BP from baseline up to 12 months using Statistical Package for the Social Sciences (SPSS) 20. Ethical and trial registration: The study protocols are approved from the Ethical and Research Committee of the Universiti Sains Malaysia (USM/JEPeM/15050173). The trial is registered under the Australia New Zealand Clinical Trial Registry (ACTRN12615001322527). The trial was registered on 2/12/2015 and the 1st patient was enrolled on 10/12/2015. The trial was formally initiated on 16

Comparative risk of renal, cardiovascular, and mortality outcomes in controlled, uncontrolled resistant, and non-resistant hypertension

PubMed Central

Sim, John J.; Bhandari, Simran K.; Shi, Jiaxiao; Reynolds, Kristi; Calhoun, David A.; Kalantar-Zadeh, Kamyar; Jacobsen, Steven J.

2015-01-01

We sought to compare the risk of end stage renal disease (ESRD), ischemic heart event (IHE), congestive heart failure (CHF), cerebrovascular accident (CVA), and all-cause mortality among 470,386 individuals with resistant and nonresistant hypertension (non-RH). Resistant hypertension (60,327 individuals) was sub-categorized into 2 groups; 23,104 patients with cRH (controlled on 4 or more medicines) and 37,223 patients with uRH (uncontrolled on 3 or more medicines) in a 5 year retrospective cohort study. Cox proportional hazard modeling was used to estimate hazard ratios adjusting for age, gender, race, body mass index, chronic kidney disease (CKD), and co-morbidities. Resistant hypertension (cRH and uRH) compared to non-RH, had multivariable adjusted hazard ratios (95% confidence intervals) of 1.32 (1.27–1.37), 1.24 (1.20–1.28), 1.46 (1.40–1.52), 1.14 (1.10–1.19), and 1.06 (1.03–1.08) for ESRD, IHE, CHF, CVA, and mortality, respectively. Comparison of uRH to cRH had hazard ratios of 1.25 (1.18–1.33), 1.04 (0.99–1.10), 0.94 (0.89–1.01), 1.23 (1.14–1.31), and 1.01 (0.97–1.05) for ESRD, IHE, CHF, CVA, and mortality, respectively. Males and Hispanics had greater risk for ESRD within all 3 cohorts. Resistant hypertension had greater risk for ESRD, IHE, CHF, CVA, and mortality. The risk of ESRD and CVA and were 25% and 23% greater, respectively, in uRH compared to cRH supporting the linkage between blood pressure and both outcomes. PMID:25945406

Role of natural herbs in the treatment of hypertension

PubMed Central

Tabassum, Nahida; Ahmad, Feroz

2011-01-01

Hypertension (HTN) is the medical term for high blood pressure. It is dangerous because it makes the heart work too hard and contributes to atherosclerosis (hardening of arteries), besides increasing the risk of heart disease and stroke. HTN can also lead to other conditions such as congestive heart failure, kidney disease, and blindness. Conventional antihypertensives are usually associated with many side effects. About 75 to 80% of the world population use herbal medicines, mainly in developing countries, for primary health care because of their better acceptability with human body and lesser side effects. In the last three decades, a lot of concerted efforts have been channeled into researching the local plants with hypotensive and antihypertensive therapeutic values. The hypotensive and antihypertensive effects of some of these medicinal plants have been validated and others disproved. However, ayurvedic knowledge needs to be coupled with modern medicine and more scientific research needs to be done to verify the effectiveness, and elucidate the safety profile of such herbal remedies for their antihypertensive potential. PMID:22096316

Persistent hypertension after adrenalectomy for an aldosterone-producing adenoma: weight as a critical prognostic factor for aldosterone’s lasting effect on the cardiac and vascular systems

PubMed Central

Carter, Yvette; Roy, Madhuchhanda; Sippel, Rebecca S.; Chen, Herbert

2012-01-01

Background Primary aldosteronism caused by an aldosterone producing adrenal tumor/aldosteronoma (APA), is a potentially curable form of hypertension, via unilateral adrenalectomy. Resolution of hypertension (HTN) is not as prevalent after tumor resection, as are the normalization of aldosterone secretion, hypokalemia, and other metabolic abnormalities. Here, we review the immediate and long term medical outcomes of laparoscopic adrenalectomy in patients with an APA, and attempt to identify any distinctive gender differences in the management of resistant hypertension. Materials and Methods We performed a retrospective review of the prospective Adrenal database at the University of Wisconsin between January 2001 and October 2010. Of the 165 adrenalectomies performed, thirty-two were for the resection of an aldosteronoma (APA). Patients were grouped according to their post-operative hypertension status. Those patients with normal blood pressure (<120/80 mmHg) and on no anti-hypertensive medication (CURE) were compared to those who continued to required medication for blood pressure control (HTN). We evaluated gender, age, body mass index (BMI), tumor size, duration of time with high blood pressure, and the differences in systolic and diastolic blood pressure following adrenalectomy. Statistical analysis was performed utilizing student’s t test. Statistical significance was defined as a p value < 0.05. Results We identified 32 patients with an APA based on biochemical and radiographic studies, two patients were excluded, due to missing data. There were 19 males (63%) and 11 (37%) females, with a mean age was 48.3 ± 2.1 years, and mean tumor size was 24 ± 3 mm. Post-operatively, patients required significantly fewer anti-hypertensive medications (1.5 ± 0.2 vs. 3.3 ± 0.3, p<0.001). Nine patients (31%) had complete resolution of their hypertension, requiring no post-operative anti-hypertensive medication. The only significant difference between the genders, was a

Spironolactone and doxazosin treatment in patients with resistant hypertension.

PubMed

Rodilla, Enrique; Costa, José A; Pérez-Lahiguera, Francisco; Baldó, Emilio; González, Carmen; Pascual, José M

2009-02-01

The aim of this study was to evaluate the use of spironolactone and doxazosin as treatment for patients with resistant hypertension. This retrospective study involved 181 outpatients with resistant hypertension (defined as a failure of blood pressure [BP] control despite treatment with three drugs, one of which was a diuretic) who received additional spironolactone (n=88) or doxazosin (n=93). Mean systolic BP in the spironolactone group fell by 28 mmHg (95% confidence interval [CI], 24-32 mmHg; P< .001) and mean diastolic BP fell by 12 mmHg (95% CI, 9-14 mmHg; P< .001). The corresponding falls in the doxazosin group were 16 mmHg (95% CI, 13-20 mmHg; P< .001) and 7 mmHg (95% CI, 5-9 mmHg; P< .001), respectively. The decrease was significantly greater with spironolactone for both systolic (P< .001) and diastolic (P=.003) pressures. At the end of follow-up, 30% of all patients had achieved BP control, with control being more frequent with spironolactone (39%) than doxazosin (23%; P=.02). Multivariate logistic regression analysis showed that the only factors that significantly influenced the achievement of BP control were diabetes (odds ratio=0.17; 95% CI, 0.08-0.39; P< .001) and baseline systolic BP <165 mmHg (odds ratio=2.56; 95% CI, 1.11-5.90; P=.03). In patients with resistant hypertension, the addition of either spironolactone or doxazosin resulted in a significant decrease in BP, though the decrease appeared to be greater with spironolactone. The presence of diabetes complicated BP control.

Renal Artery Stenting in Patients With Documented Resistant Hypertension and Atherosclerotic Renal Artery Stenosis (ANDORRA)

ClinicalTrials.gov

2018-01-24

Hypertension; Hypertension Resistant to Conventional Therapy; Angiographically Proven Grade III Unilateral or Bilateral Atherosclerotic Renal Artery Stenosis (ARAS) Greater Than or Equal to 60 Percent

Feasibility of catheter ablation renal denervation in "mild" resistant hypertension.

PubMed

Chen, Shaojie; Kiuchi, Marcio Galindo; Acou, Willem-Jan; Derndorfer, Michael; Wang, Jiazhi; Li, Ruotian; Kollias, Georgios; Martinek, Martin; Kiuchi, Tetsuaki; Pürerfellner, Helmut; Liu, Shaowen

2017-04-01

Renal denervation (RDN) has been proposed as a novel interventional antihypertensive technique. However, existing evidence was mainly from patients with severe resistant hypertension. The authors aimed to evaluate the efficacy of RDN in patients with resistant hypertension with mildly elevated blood pressure (BP). Studies of RDN in patients with mild resistant hypertension (systolic office BP 140-160 mm Hg despite treatment with three antihypertensive drugs including one diuretic, or mean systolic BP by 24-hour ambulatory BP measurement [ABPM] 135-150 mm Hg) were included. Two observational and one randomized cohort were identified (109 patients in the RDN group and 36 patients in the control group). Overall, the mean age of patients was 62±10 years, and 69.7% were male. Before-after comparison showed that RDN significantly reduced ABPM as compared with the baseline systolic ABPM, from 146.3±13 mm Hg at baseline to 134.6±14.7 mm Hg at 6-month follow-up and diastolic ABPM from 80.8±9.4 mm Hg at baseline to 75.5±9.8 mm Hg at 6-month follow up (both P<.001). This significant effect was not observed in the control group. Between-group comparison showed a greater change in ABPM in the RDN group as compared with that in the control group (change in systolic ABPM: -11.7±9.9 mm Hg in RDN vs -3.5±9.6 mm Hg in controls [P<.001]; change in diastolic ABPM: -5.3±6.3 mm Hg in RDN vs -2.1±5.5 mm Hg in control [P=.007]). RDN was also associated with a significantly decreased office systolic/diastolic BP and reduced number of antihypertensive medications. No severe adverse events were found during follow-up. RDN seems feasible to treat patients with mild resistant hypertension. ©2017 Wiley Periodicals, Inc.

Pharmacoepidemiology of Clinically Relevant Hypothyroidism and Hypertension from Sunitinib and Sorafenib

PubMed Central

Aubert, Ronald E.; La‐Beck, Ninh M.; Clore, Gosia; Herrera, Vivian; Kourlas, Helen; Epstein, Robert S.; McLeod, Howard L.

2017-01-01

Abstract Background. Thyroid dysfunction and hypertension (HTN) have been sporadically reported with sunitinib (SUN) and sorafenib (SOR). Determination of the side effect incidence will enhance monitoring and management recommendations. Methods. An observational cohort study was performed using deidentified pharmacy claims data from a 3‐year period to evaluate patients prescribed SUN, SOR, or capecitabine (CAP; comparison group). The primary outcome was time to first prescription for thyroid replacement or HTN treatment. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox proportional hazards models. Results. A total of 20,061 patients were eligible for evaluation of thyroid replacement therapy, which was initiated in 11.6% of those receiving SUN (HR, 16.77; 95% CI, 13.54–20.76), 2.6% of those receiving SOR (HR, 3.47; 95% CI, 2.46–4.98), and 1% of those receiving CAP, with median time to initiation of 4 months (range, 1–35 months). A total of 14,468 patients were eligible for evaluation of HTN therapy, which was initiated in 21% of SUN recipients (HR, 4.91; 95% CI, 4.19–5.74), 14% of SOR recipients (HR, 3.25; 95% CI, 2.69–3.91), and 5% of CAP recipients, with median time to initiation of 1 month (range, 1–18 months) for SOR and 2 months (range, 1–25 months) for SUN. Conclusion. SUN and SOR significantly increased the risk for clinically relevant hypothyroidism; the risk was at least 4 times greater with SUN than with SOR. Patients receiving SUN and SOR had a similar elevated risk for clinically relevant HTN. These data provide robust measures of the incidence and time to onset of these clinically actionable adverse events. Implications for Practice. The side effect profiles for novel therapies are typically used to create monitoring and management recommendations using clinical trial data from patient populations that may not represent those seen in standard clinical practice. This analysis using a large pharmacy claims

Factors associated with elevated blood pressure or hypertension in Afro-Caribbean youth: a cross-sectional study.

PubMed

Ferguson, Trevor S; Younger-Coleman, Novie O M; Tulloch-Reid, Marshall K; Bennett, Nadia R; Rousseau, Amanda E; Knight-Madden, Jennifer M; Samms-Vaughan, Maureen E; Ashley, Deanna E; Wilks, Rainford J

2018-01-01

Although several studies have identified risk factors for high blood pressure (BP), data from Afro-Caribbean populations are limited. Additionally, less is known about how putative risk factors operate in young adults and how social factors influence the risk of high BP. In this study, we estimated the relative risk for elevated BP or hypertension (EBP/HTN), defined as BP ≥ 120/80 mmHg, among young adults with putative cardiovascular disease (CVD) risk factors in Jamaica and evaluated whether relative risks differed by sex. Data from 898 young adults, 18-20 years old, were analysed. BP was measured with a mercury sphygmomanometer after participants had been seated for 5 min. Anthropometric measurements were obtained, and glucose, lipids and insulin measured from a fasting venous blood sample. Data on socioeconomic status (SES) were obtained via questionnaire. CVD risk factor status was defined using standard cut-points or the upper quintile of the distribution where the numbers meeting standard cut-points were small. Relative risks were estimated using odds ratios (OR) from logistic regression models. Prevalence of EBP/HTN was 30% among males and 13% among females ( p  < 0.001 for sex difference). There was evidence for sex interaction in the relationship between EBP/HTN and some of risk factors (obesity and household possessions), therefore we report sex-specific analyses. In multivariable logistic regression models, factors independently associated with EBP/HTN among men were obesity (OR 8.48, 95% CI [2.64-27.2], p  < 0.001), and high glucose (OR 2.01, CI [1.20-3.37], p  = 0.008), while high HOMA-IR did not achieve statistical significance (OR 2.08, CI [0.94-4.58], p  = 0.069). In similar models for women, high triglycerides (OR 1.98, CI [1.03-3.81], p  = 0.040) and high HOMA-IR (OR 2.07, CI [1.03-4.12], p  = 0.039) were positively associated with EBP/HTN. Lower SES was also associated with higher odds for EBP/HTN (OR 4.63, CI [1.31-16.4], p  = 0

Gamma-glutamyltransferase, fatty liver index and hepatic insulin resistance are associated with incident hypertension in two longitudinal studies.

PubMed

Bonnet, Fabrice; Gastaldelli, Amalia; Pihan-Le Bars, Florence; Natali, Andrea; Roussel, Ronan; Petrie, John; Tichet, Jean; Marre, Michel; Fromenty, Bernard; Balkau, Beverley

2017-03-01

We hypothesized that liver markers and the fatty liver index (FLI) are predictive of incident hypertension and that hepatic insulin resistance plays a role. The association between liver markers and incident hypertension was analysed in two longitudinal studies of normotensive individuals, 2565 from the 9-year data from an epidemiological study on the insulin resistance cohort and the 321 from the 3-year 'Relationship between Insulin Sensitivity and Cardiovascular disease' cohort who had a measure of endogenous glucose production. The FLI is calculated from BMI, waist circumference, triglycerides and gamma-glutamyltransferase (GGT) and the hepatic insulin resistance index from endogenous glucose production and fasting insulin. The incidence of hypertension increased across the quartiles groups of both baseline GGT and alanine aminotransferase. After adjustment for sex, age, waist circumference, fasting glucose, smoking and alcohol intake, only GGT was significantly related with incident hypertension [standardized odds ratio: 1.21; 95% confidence interval (1.10-1.34); P = 0.0001]. The change in GGT levels over the follow-up was also related with an increased risk of hypertension, independently of changes in body weight. FLI analysed as a continuous value, or FLI at least 60 at baseline were predictive of incident hypertension in the multivariable model. In the RISC cohort, the hepatic insulin resistance index was positively related with the risk of 3-year incident hypertension [standardized odds ratio: 1.54 (1.07-2.22); P = 0.02]. Baseline GGT and FLI, as well as an increase in GGT over time, were associated with the risk of incident hypertension. Enhanced hepatic insulin resistance predicted the onset of hypertension and may be a link between liver markers and hypertension.

Genetic, physiological and comparative genomic studies of hypertension and insulin resistance in the spontaneously hypertensive rat.

PubMed

Coan, Philip M; Hummel, Oliver; Garcia Diaz, Ana; Barrier, Marjorie; Alfazema, Neza; Norsworthy, Penny J; Pravenec, Michal; Petretto, Enrico; Hübner, Norbert; Aitman, Timothy J

2017-03-01

We previously mapped hypertension-related insulin resistance quantitative trait loci (QTLs) to rat chromosomes 4, 12 and 16 using adipocytes from F2 crosses between spontaneously hypertensive (SHR) and Wistar Kyoto (WKY) rats, and subsequently identified Cd36 as the gene underlying the chromosome 4 locus. The identity of the chromosome 12 and 16 genes remains unknown. To identify whole-body phenotypes associated with the chromosome 12 and 16 linkage regions, we generated and characterised new congenic strains, with WKY donor segments introgressed onto an SHR genetic background, for the chromosome 12 and 16 linkage regions. We found a >50% increase in insulin sensitivity in both the chromosome 12 and 16 strains. Blood pressure and left ventricular mass were reduced in the two congenic strains consistent with the congenic segments harbouring SHR genes for insulin resistance, hypertension and cardiac hypertrophy. Integrated genomic analysis, using physiological and whole-genome sequence data across 42 rat strains, identified variants within the congenic regions in Upk3bl , RGD1565131 and AABR06087018.1 that were associated with blood pressure, cardiac mass and insulin sensitivity. Quantitative trait transcript analysis across 29 recombinant inbred strains showed correlation between expression of Hspb1 , Zkscan5 and Pdgfrl with adipocyte volume, systolic blood pressure and cardiac mass, respectively. Comparative genome analysis showed a marked enrichment of orthologues for human GWAS-associated genes for insulin resistance within the syntenic regions of both the chromosome 12 and 16 congenic intervals. Our study defines whole-body phenotypes associated with the SHR chromosome 12 and 16 insulin-resistance QTLs, identifies candidate genes for these SHR QTLs and finds human orthologues of rat genes in these regions that associate with related human traits. Further study of these genes in the congenic strains will lead to robust identification of the underlying genes and

Genetic, physiological and comparative genomic studies of hypertension and insulin resistance in the spontaneously hypertensive rat

PubMed Central

Hummel, Oliver; Garcia Diaz, Ana; Barrier, Marjorie; Alfazema, Neza; Norsworthy, Penny J.; Pravenec, Michal; Petretto, Enrico; Hübner, Norbert

2017-01-01

ABSTRACT We previously mapped hypertension-related insulin resistance quantitative trait loci (QTLs) to rat chromosomes 4, 12 and 16 using adipocytes from F2 crosses between spontaneously hypertensive (SHR) and Wistar Kyoto (WKY) rats, and subsequently identified Cd36 as the gene underlying the chromosome 4 locus. The identity of the chromosome 12 and 16 genes remains unknown. To identify whole-body phenotypes associated with the chromosome 12 and 16 linkage regions, we generated and characterised new congenic strains, with WKY donor segments introgressed onto an SHR genetic background, for the chromosome 12 and 16 linkage regions. We found a >50% increase in insulin sensitivity in both the chromosome 12 and 16 strains. Blood pressure and left ventricular mass were reduced in the two congenic strains consistent with the congenic segments harbouring SHR genes for insulin resistance, hypertension and cardiac hypertrophy. Integrated genomic analysis, using physiological and whole-genome sequence data across 42 rat strains, identified variants within the congenic regions in Upk3bl, RGD1565131 and AABR06087018.1 that were associated with blood pressure, cardiac mass and insulin sensitivity. Quantitative trait transcript analysis across 29 recombinant inbred strains showed correlation between expression of Hspb1, Zkscan5 and Pdgfrl with adipocyte volume, systolic blood pressure and cardiac mass, respectively. Comparative genome analysis showed a marked enrichment of orthologues for human GWAS-associated genes for insulin resistance within the syntenic regions of both the chromosome 12 and 16 congenic intervals. Our study defines whole-body phenotypes associated with the SHR chromosome 12 and 16 insulin-resistance QTLs, identifies candidate genes for these SHR QTLs and finds human orthologues of rat genes in these regions that associate with related human traits. Further study of these genes in the congenic strains will lead to robust identification of the underlying

Renal Denervation: a Field in Flux.

PubMed

Laffin, Luke J; Bakris, George L

2016-07-01

SYMPLICITY HTN-3 was a pivotal moment for renal denervation as a treatment option for resistant hypertension. Prior unblinded studies were called into question given the negative results of the first sham-controlled trial of renal denervation. Reevaluation of the renal denervation procedure demonstrated that a more precise approach was needed to adequately denervate the kidney. This new approach has been implemented in two ongoing clinical trials, one on and one off medications to assess the new procedure's efficacy and safety. These and other ongoing trials will be discussed in the context of older studies in this field. We focus on novel findings published following the release of SYMPLICITY HTN-3 data in early 2014 and look to the future of renal denervation in the treatment of primary hypertension.

Joint associations of physical activity and hypertension with the development of type 2 diabetes among urban men and women in Mainland China.

PubMed

Xu, Fei; Ware, Robert S; Tse, Lap Ah; Wang, YouFa; Wang, ZhiYong; Hong, Xin; Chan, Emily Ying Yang; Dunstan, David W; Owen, Neville

2014-01-01

Physical activity (PA) and hypertension (HTN) are important influences on the development of type 2 diabetes (T2D). However, the joint impact of PA and HTN on T2D development is unknown. Two community-based prospective cohort studies, with the same protocols, instruments and questionnaires, were conducted among adults in urban areas of Nanjing, China, during 2004-2007 and 2007-2010. T2D was defined using World Health Organization criteria based on physicians' diagnosis and fasting blood glucose concentration. PA level (sufficient/insufficient) and blood pressure status (hypertensive/normotensive) were assessed at baseline and the third year of follow-up. We pooled and analyzed data from these two studies. Among 4550 participants aged 35 years or older, the three-year cumulative incidence of T2D was 5.1%. After adjusting for potential confounders, participants with sufficient PA were less likely to develop T2D than those with insufficient PA (OR = 0.43, 95%CI = 0.27, 0.68) and those who were normotensive were less likely to develop T2D than those who were hypertensive (OR = 0.39, 95%CI = 0.29, 0.51). Compared to participants with insufficient PA and who were hypertensive, those with sufficient PA and hypertension were at lower risk of developing T2D (OR = 0.36, 95%CI = 0.19, 0.69), as were those with insufficient PA who were normotensive (OR = 0.37, 95%CI = 0.28, 0.50) and those with sufficient PA who were normotensive (OR = 0.19, 95%CI = 0.10, 0.37). Insufficient PA was found to be associated with the development of T2D among adults with and without hypertension. These findings support a role for promoting higher physical activity levels to lower T2D risk in both hypertensive and non-hypertensive individuals.

Resistance training alone reduces systolic and diastolic blood pressure in prehypertensive and hypertensive individuals: meta-analysis.

PubMed

de Sousa, Evitom Corrêa; Abrahin, Odilon; Ferreira, Ana Lorena Lima; Rodrigues, Rejane Pequeno; Alves, Erik Artur Cortinhas; Vieira, Rodolfo Paula

2017-11-01

The purpose of this study was to evaluate the effects of resistance training alone on the systolic and diastolic blood pressure in prehypertensive and hypertensive individuals. Our meta-analysis, followed the guidelines of PRISMA. The search for articles was realized by November 2016 using the following electronic databases: BIREME, PubMed, Cochrane Library, LILACS and SciELO and a search strategy that included the combination of titles of medical affairs and terms of free text to the key concepts: 'hypertension' 'hypertensive', 'prehypertensive', 'resistance training', 'strength training', and 'weight-lifting'. These terms were combined with a search strategy to identify randomized controlled trials (RCTs) and identified a total of 1608 articles: 644 articles BIREME, 53 SciELO, 722 PubMed, 122 Cochrane Library and 67 LILACS. Of these, five RCTs met the inclusion criteria and provided data on 201 individuals. The results showed significant reductions for systolic blood pressure (-8.2 mm Hg CI -10.9 to -5.5;I 2 : 22.5% P valor for heterogeneity=0.271 and effect size=-0.97) and diastolic blood pressure (-4.1 mm Hg CI -6.3 to -1.9; I 2 : 46.5% P valor for heterogeneity=0.113 and effect size=-0.60) when compared to group control. In conclusion, resistance training alone reduces systolic and diastolic blood pressure in prehypertensive and hypertensive subjects. The RCTs studies that investigated the effects of resistance training alone in prehypertensive and hypertensive patients support the recommendation of resistance training as a tool for management of systemic hypertension.

Evaluation and management of the patient with difficult-to-control or resistant hypertension.

PubMed

Viera, Anthony J; Hinderliter, Alan L

2009-05-15

High blood pressure is often difficult to control. Resistant hypertension is blood pressure above goal despite adherence to a combination of at least three antihypertensive medications of different classes, optimally dosed and usually including a diuretic. The approach to blood pressure that is apparently difficult to control begins with an assessment of the patient's adherence to the management plan, including lifestyle modifications and medications. White-coat hypertension may need to be ruled out. Suboptimal therapy is the most common reason for failure to reach the blood pressure goal. Once-daily fixed-dose combination pills may improve control through the synergism of antihypertensive agents from different classes and improved adherence. Truly drug-resistant hypertension is commonly caused by chronic kidney disease, obstructive sleep apnea, or hyperaldosteronism, all of which can lead to fluid retention. Higher doses of diuretics (or a change to a loop diuretic) are usually needed. Other strategies include adding an alpha blocker, alpha-beta blocker, clonidine, or an aldosterone antagonist (e.g., spironolactone). Particularly in patients with diabetes or renal disease, combining a long-acting nondihydropyridine with a dihydropyridine calcium channel . blocker can also be considered. Obesity, heavy alcohol intake, high levels of dietary sodium, and interfering substances (especially nonsteroidal anti-inflammatory drugs) contribute to hypertension that is resistant or difficult to control.

Intrahepatic upregulation of MRTF-A signaling contributes to increased hepatic vascular resistance in cirrhotic rats with portal hypertension.

PubMed

Zheng, Lei; Qin, Jun; Sun, Longci; Gui, Liang; Zhang, Chihao; Huang, Yijun; Deng, Wensheng; Huang, An; Sun, Dong; Luo, Meng

2017-06-01

Portal hypertension in cirrhosis is mediated, in part, by increased intrahepatic resistance, reflecting massive structural changes associated with fibrosis and intrahepatic vasoconstriction. Activation of the Rho/MRTF/SRF signaling pathway is essential for the cellular regulatory network of fibrogenesis. The aim of this study was to investigate MRTF-A-mediated regulation of intrahepatic fibrogenesis in cirrhotic rats. Portal hypertension was induced in rats via an injection of CCl 4 oil. Hemodynamic measurements were obtained using a polyethylene PE-50 catheter and pressure transducers. Expression of hepatic fibrogenesis was measured using histological staining. Expression of protein was measured using western blotting. Upregulation of MRTF-A protein expression in the livers of rats with CCl 4 -induced cirrhosis was relevant to intrahepatic resistance and hepatic fibrogenesis in portal hypertensive rats with increased modeling time. Inhibition of MRTF-A by CCG-1423 decelerated hepatic fibrosis, decreased intrahepatic resistance and portal pressure, and alleviated portal hypertension. Increased intrahepatic resistance in rats with CCl 4 -induced portal hypertension is associated with an upregulation of MRTF-A signaling. Inhibition of this pathway in the liver can decrease hepatic fibrosis and intrahepatic resistance, as well as reduce portal pressure in cirrhotic rats with CCl 4 -induced portal hypertension. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Protocol for a prospective longitudinal study of risk factors for hypertension incidence in a Mexico City population: the Tlalpan 2020 cohort

PubMed Central

Colín-Ramírez, Eloisa; Rivera-Mancía, Susana; Infante-Vázquez, Oscar; Cartas-Rosado, Raúl; Vargas-Barrón, Jesús; Madero, Magdalena; Vallejo, Maite

2017-01-01

Introduction Systemic hypertension (HTN) is a common risk factor for cardiovascular disease. In Mexico, HTN prevalence has increased over time and is currently 31%. Nonetheless, information about the country's HTN incidence and its associated risk factors is scarce. Understanding this condition is a priority for identifying the scope of primary prevention. The main objective of this study is to evaluate the effect of traditional and non-traditional risk factors on the incidence of HTN in a cohort of healthy Mexico City residents under biannual follow-up for 10 years. Methods and analysis A prospective longitudinal study is proposed in which clinically healthy residents of Mexico City between 20 and 50 years old will be recruited; the participants will be evaluated every 2 years over a period of 10 years or until they develop HTN. Evaluations regarding sociodemographic, clinical, anthropometric, biochemical, diet, physical activity, stress, sleep quality, alcohol and tobacco consumption factors will be performed. The participants will be recruited from the 16 municipalities of Mexico City through promotional strategies aimed at the community and will be clinically evaluated at a tertiary care institution, Instituto Nacional de Cardiología Ignacio Chávez (National Institute of Cardiology Ignacio Chavez), located in Mexico City, Mexico. Sample size estimated for this study is 3436, and the Cox proportional hazards model will be used to estimate HRs for the association between explanatory variables and HTN using both raw and adjusted data. Ethics and dissemination This study was approved by the Institutional Bioethics Committee of the Instituto Nacional de Cardiología Ignacio Chávez (National Institute of Cardiology Ignacio Chavez) under number 13-802. Findings from this study will be disseminated through scientific papers and research conferences. PMID:28760800

Protocol for a prospective longitudinal study of risk factors for hypertension incidence in a Mexico City population: the Tlalpan 2020 cohort.

PubMed

Colín-Ramírez, Eloisa; Rivera-Mancía, Susana; Infante-Vázquez, Oscar; Cartas-Rosado, Raúl; Vargas-Barrón, Jesús; Madero, Magdalena; Vallejo, Maite

2017-07-31

Systemic hypertension (HTN) is a common risk factor for cardiovascular disease. In Mexico, HTN prevalence has increased over time and is currently 31%. Nonetheless, information about the country's HTN incidence and its associated risk factors is scarce. Understanding this condition is a priority for identifying the scope of primary prevention. The main objective of this study is to evaluate the effect of traditional and non-traditional risk factors on the incidence of HTN in a cohort of healthy Mexico City residents under biannual follow-up for 10 years. A prospective longitudinal study is proposed in which clinically healthy residents of Mexico City between 20 and 50 years old will be recruited; the participants will be evaluated every 2 years over a period of 10 years or until they develop HTN. Evaluations regarding sociodemographic, clinical, anthropometric, biochemical, diet, physical activity, stress, sleep quality, alcohol and tobacco consumption factors will be performed. The participants will be recruited from the 16 municipalities of Mexico City through promotional strategies aimed at the community and will be clinically evaluated at a tertiary care institution, Instituto Nacional de Cardiología Ignacio Chávez (National Institute of Cardiology Ignacio Chavez), located in Mexico City, Mexico. Sample size estimated for this study is 3436, and the Cox proportional hazards model will be used to estimate HRs for the association between explanatory variables and HTN using both raw and adjusted data. This study was approved by the Institutional Bioethics Committee of the Instituto Nacional de Cardiología Ignacio Chávez (National Institute of Cardiology Ignacio Chavez) under number 13-802. Findings from this study will be disseminated through scientific papers and research conferences. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise

[Resistant arterial hypertension in Primary Care patients in Spain. PRESCAP Study 2010].

PubMed

Cinza-Sanjurjo, S; Alonso-Moreno, F J; Prieto-Díaz, M Á; Divisón-Garrote, J A; Rodríguez-Roca, G C; Llisterri-Caro, J L

2015-04-01

To determine the prevalence and clinical and epidemiological characteristics of Primary Care patients with resistant hypertension (RHT) in Spain. A cross-sectional multicenter study was conducted on hypertensive patients aged 18 or over and seen in a Primary Care clinic. RHT was considered as the presence of uncontrolled blood pressure in patients treated with at least 3 drugs, one of which is a diuretic. Of the 12,961 hypertensive patients in the PRESCAP 2010 study, 962 (7.4%) fulfilled criteria for RHT, of whom 51% were women, and with a mean age (SD) 68.8 [11.4] years. Patients with RHT were older (68.80 [10.69] years vs. 66.06 [11.44] years, P<.001), had a higher prevalence of obesity (55.2 vs. 38.6%, P<.001), a higher waist circumference (103.90 [13.89] vs. 99.32 [13.69] cm, P<.001), and a higher prevalence of DM (48.3 vs. 29.5%, P<.001). The prevalence of target organ damage (73.0 vs. 61.4%, P<.001) and cardiovascular disease (46.7 vs. 26.8%, P<.001) were higher in patients with resistant hypertension. The multivariate analysis showed that the variables associated with resistant hypertension were the presence of cardiovascular disease, diabetes mellitus, sedentary life style, microalbuminuria, body mass index, duration of AHT, and triglycerides. The prevalence of RHT in Primary Care patients is related to inappropriate lifestyles, the presence of target organ damage, and cardiovascular disease. Copyright © 2014 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.

Distinctive Risk Factors and Phenotype of Younger Patients With Resistant Hypertension: Age Is Relevant.

PubMed

Ghazi, Lama; Oparil, Suzanne; Calhoun, David A; Lin, Chee Paul; Dudenbostel, Tanja

2017-05-01

Resistant hypertension, defined as blood pressure >140/90 mm Hg despite using ≥3 antihypertensive medications, is a well-recognized clinical entity. Patients with resistant hypertension are at an increased risk of cardiovascular disease compared with those with more easily controlled hypertension. Coronary heart disease mortality rates of younger adults are stagnating or on the rise. The purpose of our study was to characterize the phenotype and risk factors of younger patients with resistant hypertension, given the dearth of data on cardiovascular risk profile in this cohort. We conducted a cross-sectional analysis with predefined age groups of a large, ethnically diverse cohort of 2170 patients referred to the Hypertension Clinic at the University of Alabama at Birmingham. Patients (n=2068) met the inclusion criteria and were classified by age groups, that is, ≤40 years (12.7% of total cohort), 41 to 55 years (32.1%), 56 to 70 years (36.1%), and ≥71 years (19.1%). Patients aged ≤40 years compared with those aged ≥71 years had significantly earlier onset of hypertension (24.7±7.4 versus 55.0±14.1 years; P <0.0001), higher rates of obesity (53.4% versus 26.9%; P <0.0001), and significantly higher levels of plasma aldosterone (11.3±9.8 versus 8.9±7.4 ng/dL; P =0.005), plasma renin activity (4.9±10.2 versus 2.5±5.0 ng/mL per hour; P =0.001), 24-hour urinary aldosterone (13.4±10.0 versus 8.2±6.2 µg/24 h; P <0.0001), and sodium excretion (195.9±92.0 versus 146.8±67.1 mEq/24 h; P <0.0001). Among patients with resistant hypertension, younger individuals have a distinct phenotype characterized by overlapping risk factors and comorbidities, including obesity, high aldosterone, and high dietary sodium intake compared with elderly. © 2017 American Heart Association, Inc.

Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research.

PubMed

Calhoun, David A; Jones, Daniel; Textor, Stephen; Goff, David C; Murphy, Timothy P; Toto, Robert D; White, Anthony; Cushman, William C; White, William; Sica, Domenic; Ferdinand, Keith; Giles, Thomas D; Falkner, Bonita; Carey, Robert M

2008-06-24

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of

Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research.

PubMed

Calhoun, David A; Jones, Daniel; Textor, Stephen; Goff, David C; Murphy, Timothy P; Toto, Robert D; White, Anthony; Cushman, William C; White, William; Sica, Domenic; Ferdinand, Keith; Giles, Thomas D; Falkner, Bonita; Carey, Robert M

2008-06-01

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of

Medication adherence in patients with apparent resistant hypertension: findings from the SYMPATHY trial.

PubMed

de Jager, Rosa L; van Maarseveen, Erik M; Bots, Michiel L; Blankestijn, Peter J

2018-01-01

Hypertension is only controlled in approximately 35% of the patients, which could be partially due to nonadherence. Recently, bioanalytical assessment of adherence to blood pressure (BP) lowering drugs has gaining interest. Our aim was to explore possible determinants of nonadherence in treatment resistant hypertension, assessed by objective screening for antihypertensive agents in serum. The secondary aim was to study the effect of adherence on the change in BP. This project was a substudy of SYMPATHY; an open-label randomized-controlled trial to assess the effect of renal denervation on BP 6 months after treatment compared to usual care in patients with resistant hypertension. Stored serum samples were screened for antihypertensive agents to assess adherence at baseline and 6 months after intervention, using liquid chromatography-tandem mass spectrometry. Office and 24-h BP were measured on the same day as blood was sampled. Patients and physicians were unaware of adherence measurements. Ninety-eight baseline and 83 6-month samples were available for analysis. Sixty-eight percent [95% confidence interval (CI) 59-78%] of the patients was nonadherent (n = 67). For every onw pill more prescribed, 0.785 [95%CI 0.529-0.891] prescribed pill was less detected in blood. A decrease of one pill in adherence between baseline and 6 months was associated with a significant rise in office systolic BP of 4 (95%CI 0.230-8.932) mmHg. Objective measurement of BP lowering drugs in serum, as a tool to assess adherence, showed that nonadherence was very common in patients with apparent resistant hypertension. Furthermore, the assessment results were related to (changes in) blood pressure. Our findings provide direct and objective methodology to help the physician to understand and to improve the condition of apparent resistant hypertension. © 2017 The British Pharmacological Society.

Blood pressure control in resistant hypertension: new therapeutic options.

PubMed

Grassi, Guido; Quarti-Trevano, Fosca; Brambilla, Gianmaria; Seravalle, Gino

2010-11-01

Resistant hypertension, namely the hypertensive state characterized by the inability of multiple antihypertensive drug interventions to lower blood pressure to goal levels, represents a condition frequently detected in clinical practice. Its main features are represented by its heterogeneous etiology as well as its very high cardiovascular risk. This latter peculiarity has implemented the research for new approaches to the treatment of the disease. This article will focus on two of them, namely carotid baroreceptor electric stimulation and the renal denervation procedure. Clinical studies and large-scale clinical trials are presently ongoing with the aim of defining the long-term efficacy and safety profile of the two interventions.

Progression of Renal Insufficiency in Patients with Essential Hypertension Treated with Renin Angiotensin Aldosterone System Blockers: An Electrocardiographic Correlation.

PubMed

Rodriguez-Padial, Luis; Akerström, Finn; Barderas, María G; Vivanco, Fernando; Arias, Miguel A; Segura, Julian; Ruilope, Luis M

2017-12-08

There is a frequent association between renal insufficiency and cardiovascular disease in patients with essential hypertension (HTN). The aim of this study was to analyze the relationship between ECG parameters and the progress of renal damage in patients with treated HTN. 109 patients with HTN had their microalbuminuria monitored over a 3-year time frame. During the last 3 months of follow-up, an ECG was recorded. Patients were divided into 3 groups according to the deterioration of their renal function: normoalbuminuria during the study period (normo-normo; n = 51); normoalbuminuria developing microalbuminuria (normo-micro; n = 29); and microalbuminuria at baseline (micro-micro; n = 29). There were no differences in presence of left ventricular hypertrophy between the 3 groups. RV6/RV5 >1 was observed more frequently as renal function declined ( p = 0.025). The 12-lead QRS-complex voltage-duration product was significantly increased in patients without microalbuminuria at baseline who went on to develop microalbuminuria ( p = 0.006). Patients who developed microalbuminuria during follow-up, with positive Cornell voltage criteria, showed a lesser degree of progression of microalbuminuria when compared with the rest of the subgroups ( p = 0.044). Furthermore, patients with microalbuminuria at baseline treated with angiotensin receptor blockers and diuretics, and positive Cornell voltage criteria, showed a higher degree of microalbuminuria compared to those with negative Cornell voltage criteria ( p = 0.016). In patients with HTN, we identified some ECG parameters, which predict renal disease progression in patients with HTN, which may permit the identification of patients who are at risk of renal disease progression, despite optimal antihypertensive pharmacotherapy.

Assessment of cardiovascular risk and vascular age in overweight/obese adults with primary hypertension: the EXERDIET-HTA study.

PubMed

Gorostegi-Anduaga, Ilargi; Pérez-Asenjo, Javier; Aispuru, Gualberto Rodrigo; Fryer, Simon M; Alonso-Colmenero, Ainara; Romaratezabala, Estíbaliz; Maldonado-Martín, Sara

2017-06-01

Hypertension (HTN), obesity and low cardiorespiratory fitness (CRF) are associated with an increased risk for a cardiovascular event. Enrolling overweight/obese individuals with HTN, the current study aimed to estimate cardiovascular risk (CVR) and vascular age (VA) profiles analyzing potential sex differences, determine whether VA is higher than chronological age, and whether CVR is associated with a low level of CRF. Overweight/obese non-Hispanic White participants (n=209; 141 men and 68 women) with primary HTN had their CVR and VA determined using the New Pooled Cohort Risk Equations and The Framingham method, respectively. Considering values of peak oxygen uptake, participants were divided into tertiles for each sex. The CVR, but not VA (P=0.339), was higher (P<0.001) in men compared with women irrespective of age. Irrespective of sex, VA was higher than chronological age (P<0.001). Age and BMI were higher (P<0.05) in the low CRF group compared with that in other groups. There were no differences in CVR (P=0.907) and VA (P=1.643) when values were separated into CRF groups. Pooled Cohort Equations could underestimate the risk of suffering a cardiovascular event in the following 10 years in overweight/obese non-Hispanic White women with HTN compared with men. The VA appears to be a useful tool in communicating CVR in this population irrespective of sex. The CRF alone may not be enough to moderate the CVR.

Sunitinib-induced hypertension, neutropaenia and thrombocytopaenia as predictors of good prognosis in patients with metastatic renal cell carcinoma.

PubMed

Rautiola, Juhana; Donskov, Frede; Peltola, Katriina; Joensuu, Heikki; Bono, Petri

2016-01-01

To evaluate the clinical significance of hypertension (HTN), neutropaenia and thrombocytopaenia as possible new biomarkers of sunitinib efficacy in non-trial patients with metastatic renal cell carcinoma (mRCC). In all, 181 consecutive patients with mRCC were treated with sunitinib; 39 (22%) received sunitinib 50 mg/day 4 weeks on/2 weeks off, 80 (44%) received 37.5 mg/day continuously and 62 (34%) received 25 mg/day continuously as their starting dose. Treatment-induced adverse events (AEs) and their impact on outcome were analysed on multiple sunitinib doses. During sunitinib treatment 60 patients (33%) developed ≥grade 2 HTN, 88 (49%) ≥grade 2 neutropaenia and 135 (75%) ≥grade 1 thrombocytopaenia. These AEs were associated significantly with longer progression-free survival (PFS; 15.7 vs 6.7; 14.6 vs 6.9; 10.4 vs 4.2 months, respectively; P < 0.001) and overall survival (OS; 37.5 vs 16.2; 33.7 vs 13.2; 22.3 vs 13.2 months, respectively, P ≤ 0.008). Although only neutropaenia was associated with a significantly improved PFS and OS in all sunitinib doses, a similar trend was also seen with HTN and thrombocytopaenia in all sunitinib doses. In multivariate analysis, HTN and neutropaenia were significantly associated with PFS and OS and thrombocytopaenia was significantly associated with PFS. In a 12-week landmark analysis, HTN and thrombocytopaenia were significantly associated with PFS and OS. Patients who developed all three AEs (a favourable biomarker profile) had significantly better outcome than patients without these AEs (a poor biomarker profile); response rate 47% vs 4%, median PFS 27.1 vs 3.5 months and OS not reached vs 5.3 months (all P < 0.001). HTN, neutropaenia and thrombocytopaenia were all biomarkers of sunitinib efficacy in patients with mRCC. Our results may help to individualise sunitinib dosing during therapy based on these common sunitinib-related AEs. © 2014 The Authors BJU International © 2014 BJU International Published by John

Lysine-specific demethylase 1: an epigenetic regulator of salt-sensitive hypertension.

PubMed

Williams, Jonathan S; Chamarthi, Bindu; Goodarzi, Mark O; Pojoga, Luminita H; Sun, Bei; Garza, Amanda E; Raby, Benjamin A; Adler, Gail K; Hopkins, Paul N; Brown, Nancy J; Jeunemaitre, Xavier; Ferri, Claudio; Fang, Rui; Leonor, Thiago; Cui, Jinrui; Guo, Xiuqing; Taylor, Kent D; Ida Chen, Yii-Der; Xiang, Anny; Raffel, Leslie J; Buchanan, Thomas A; Rotter, Jerome I; Williams, Gordon H; Shi, Yujiang

2012-07-01

Hypertension (HTN) represents a complex heritable disease in which environmental factors may directly affect gene function via epigenetic mechanisms. The aim of this study was to test the hypothesis that dietary salt influences the activity of a histone-modifying enzyme, lysine-specific demethylase 1 (LSD-1), which in turn is associated with salt-sensitivity of blood pressure (BP). Animal and human studies were performed. Salt-sensitivity of LSD-1 expression was assessed in wild-type (WT) and LSD-1 heterozygote knockout (LSD-1(+/-)) mice. Clinical relevance was tested by multivariate associations between single-nuclear polymorphisms (SNPs) in the LSD-1 gene and salt-sensitivity of BP, with control of dietary sodium, in a primary African-American hypertensive cohort and two replication hypertensive cohorts (Caucasian and Mexican-American). LSD-1 expression was modified by dietary salt in WT mice with lower levels associated with liberal salt intake. LSD-1(+/-) mice expressed lower LSD-1 protein levels than WT mice in kidney tissue. Similar to LSD-1(+/-) mice, African-American minor allele carriers of two LSD-1 SNPs displayed greater change in systolic BP (SBP) in response to change from low to liberal salt diet (rs671357, P = 0.01; rs587168, P = 0.005). This association was replicated in the Hispanic (rs587168, P = 0.04) but not the Caucasian cohort. Exploratory analyses demonstrated decreased serum aldosterone concentrations in African-American minor allele carriers similar to findings in the LSD-1(+/-) mice, decreased α-EnaC expression in LSD-1(+/-) mice, and impaired renovascular responsiveness to salt loading in minor allele carriers. The results of this translational research study support a role for LSD-1 in the pathogenesis of salt-sensitive HTN.

First-in-Man Experience with a Novel Catheter-Based Renal Denervation System of Ultrasonic Ablation in Patients with Resistant Hypertension.

PubMed

Chernin, Gil; Szwarcfiter, Iris; Scheinert, Dierk; Blessing, Erwin; Diehm, Nicolas; Dens, Jo; Walton, Antony; Verheye, Stefan; Shetty, Sharad; Jonas, Michael

2018-06-16

To report results of renal denervation (RDN) with the first catheter-based, non-balloon occlusion ultrasonic system in patients with resistant hypertension. In a multicenter, single-arm trial, 39 patients with resistant hypertension (defined as uncontrolled hypertension while taking ≥ 3 antihypertensive medications) were treated. The cohort consisted of 4 groups: severe resistant hypertension (office systolic blood pressure [OSBP] ≥ 160 mm Hg) treated with a unidirectional catheter (group 1; n = 14); severe resistant hypertension treated with a multidirectional catheter (group 2; n = 18); moderate resistant hypertension (OSBP 140-159 mm Hg) treated with a multidirectional catheter (group 3; n = 5); and recurrent severe resistant hypertension, after an initial response to RF RDN (group 4; n = 2). Blood pressure monitoring was performed for 6 months. Severe adverse events were not noted immediately after the procedure or during follow-up. Treatment time was longer with unidirectional than with multidirectional catheters (36.7 min ± 9.6 vs 11.9 min ± 5.8; P < .001). Mean reductions in office blood pressure (systolic/diastolic) at 1, 3, and 6 months were -26.1/-9.6 mm Hg, -28.0/-9.9 mm Hg, and -30.6/-14.1 mm Hg (P < .01 for all). Per-group analysis showed significant OSBP reduction for groups 1 and 2. Patients with isolated systolic hypertension had a significantly smaller reduction in OSBP after 6 months compared with patients with combined systolic/diastolic hypertension (-16.2 mm Hg ± 18.5 vs -9.9 mm Hg ± 33.4; P < .005). Use of the RDN system was feasible and safe in this phase I study. Significant blood pressure reductions were observed over 6 months, although less in patients with isolated systolic hypertension. Copyright © 2018 SIR. All rights reserved.

Misdiagnosis of resistant hypertension: Real frequency of true resistant hypertension in patients with suspected resistance to treatment.

PubMed

Doménech, Mónica; Sastre, Enric; Camafort, Miguel; Sierra, Cristina; Coca, Antonio

2018-01-12

Resistant hypertension(RH) has been defined as failure to control office blood pressure (BP) despite the use of≥3 different antihypertensive agents at optimal doses, including, ideally, a diuretic. Apparent RH, defines patients with an incorrect diagnosis of RH due to different causes. The objective was to determine whether most patients with RH in fact have apparent but not true RH. Observational study involving 93 patients with suspected RH, being 60 patients finally included. Screening for secondary causes of hypertension was perfomed. True RH was defined as office BP>140/90mmHg despite full doses of 3 antihypertensive drugs including a diuretic. Mean age 63.7±9.8years, 68.3%were male. Office BP 154.3±14.4/84.4±13.7mmHg. Of the 60 patients, 23.3% had white coat effect, 3.3% didn't have a diuretic and 8.3% were non-adherent-to-treatment. Accordingly, 58.3% were classified as true RH. Spironolactone was added in 62.5% of patients of whom 78.4% achieved ambulatory BP control. Almost half of the patients with suspected RH were not really true RH. We provide more evidence of excess of fluid retention as an underlying cause of lack of BP control in patients with RH, reinforce the relevant paper of spironolactone for the management in those patients. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Genetics of Resistant Hypertension: the Missing Heritability and Opportunities.

PubMed

Teixeira, Samantha K; Pereira, Alexandre C; Krieger, Jose E

2018-05-19

Blood pressure regulation in humans has long been known to be a genetically determined trait. The identification of causal genetic modulators for this trait has been unfulfilling at the least. Despite the recent advances of genome-wide genetic studies, loci associated with hypertension or blood pressure still explain a very low percentage of the overall variation of blood pressure in the general population. This has precluded the translation of discoveries in the genetics of human hypertension to clinical use. Here, we propose the combined use of resistant hypertension as a trait for mapping genetic determinants in humans and the integration of new large-scale technologies to approach in model systems the multidimensional nature of the problem. New large-scale efforts in the genetic and genomic arenas are paving the way for an increased and granular understanding of genetic determinants of hypertension. New technologies for whole genome sequence and large-scale forward genetic screens can help prioritize gene and gene-pathways for downstream characterization and large-scale population studies, and guided pharmacological design can be used to drive discoveries to the translational application through better risk stratification and new therapeutic approaches. Although significant challenges remain in the mapping and identification of genetic determinants of hypertension, new large-scale technological approaches have been proposed to surpass some of the shortcomings that have limited progress in the area for the last three decades. The incorporation of these technologies to hypertension research may significantly help in the understanding of inter-individual blood pressure variation and the deployment of new phenotyping and treatment approaches for the condition.

Evaluation of Effectiveness and Cost‐Effectiveness of a Clinical Decision Support System in Managing Hypertension in Resource Constrained Primary Health Care Settings: Results From a Cluster Randomized Trial

PubMed Central

Anchala, Raghupathy; Kaptoge, Stephen; Pant, Hira; Di Angelantonio, Emanuele; Franco, Oscar H.; Prabhakaran, D.

2015-01-01

Background Randomized control trials from the developed world report that clinical decision support systems (DSS) could provide an effective means to improve the management of hypertension (HTN). However, evidence from developing countries in this regard is rather limited, and there is a need to assess the impact of a clinical DSS on managing HTN in primary health care center (PHC) settings. Methods and Results We performed a cluster randomized trial to test the effectiveness and cost‐effectiveness of a clinical DSS among Indian adult hypertensive patients (between 35 and 64 years of age), wherein 16 PHC clusters from a district of Telangana state, India, were randomized to receive either a DSS or a chart‐based support (CBS) system. Each intervention arm had 8 PHC clusters, with a mean of 102 hypertensive patients per cluster (n=845 in DSS and 783 in CBS groups). Mean change in systolic blood pressure (SBP) from baseline to 12 months was the primary endpoint. The mean difference in SBP change from baseline between the DSS and CBS at the 12th month of follow‐up, adjusted for age, sex, height, waist, body mass index, alcohol consumption, vegetable intake, pickle intake, and baseline differences in blood pressure, was −6.59 mm Hg (95% confidence interval: −12.18 to −1.42; P=0.021). The cost‐effective ratio for CBS and DSS groups was $96.01 and $36.57 per mm of SBP reduction, respectively. Conclusion Clinical DSS are effective and cost‐effective in the management of HTN in resource‐constrained PHC settings. Clinical Trial Registration URL: http://www.ctri.nic.in. Unique identifier: CTRI/2012/03/002476. PMID:25559011

Accessory renal arteries: Prevalence in resistant hypertension and an important role in nonresponse to radiofrequency renal denervation.

PubMed

VonAchen, Paige; Hamann, Jason; Houghland, Thomas; Lesser, John R; Wang, Yale; Caye, David; Rosenthal, Kristi; Garberich, Ross F; Daniels, Mary; Schwartz, Robert S

The aim of this study was to understand the role of accessory renal arteries in resistant hypertension, and to establish their role in nonresponse to radiofrequency renal denervation (RDN) procedures. Prior studies suggest a role for accessory renal arteries in hypertensive syndromes, and recent clinical trials of renal denervation report that these anomalies are highly prevalent in resistant hypertension. This study evaluated the relationships among resistant hypertension, accessory renal arteries, and the response to radiofrequency (RF) renal denervation. Computed Tomography Angiography (CTA) and magnetic resonance imaging (MRI) scans from 58 patients with resistant hypertension undergoing RF renal denervation (RDN) were evaluated. Results were compared with CT scans in 57 healthy, normotensive subjects undergoing screening as possible renal transplant donors. All scans were carefully studied for accessory renal arteries, and were correlated with long term blood pressure reduction. Accessory renal arteries were markedly more prevalent in the hypertensive patients than normotensive renal donors (59% vs 32% respectively, p=0.004). RDN had an overall nonresponse rate of 29% (response rate 71%). Patients without accessory vessels had a borderline higher response rate to RDN than those with at least one accessory vessel (83% vs 62% respectively, p=0.076) and a higher RDN response than patients with untreated accessory arteries (83% vs 55%; p=0.040). For accessory renal arteries and nonresponse, the sensitivity was 76%, specificity 49%, with positive and negative predictive values 38% and 83% respectively. Accessory renal arteries were markedly over-represented in resistant hypertensives compared with healthy controls. While not all patients with accessory arteries were nonresponders, nonresponse was related to both the presence and non-treatment of accessory arteries. Addressing accessory renal arteries in future clinical trials may improve RDN therapeutic efficacy

[Renal denervation a treatment for resistant hypertension: a French experience].

PubMed

Benamer, H; Mylotte, D; Garcia-Alonso, C; Unterseeh, T; Garot, P; Louvard, Y; Lefevre, T; Morice, M-C

2013-12-01

Arterial hypertension is the largest single contributor to global mortality, and is poorly controlled in approximately 50% of patients despite lifestyle and pharmacologic interventions. Randomized clinical trials have demonstrated that catheter-based renal sympathetic denervation reduces blood pressure (BP) in patients with resistant hypertension. We sought to evaluate the efficacy of this novel therapy in "Real World" clinical practice. Consecutive patients with treatment-resistant primary hypertension, as defined as home BP>160 mmHg despite treatment with ≥3 antihypertensive drugs, were selected for denervation following renal artery screening. Ambulatory and home BP monitoring was performed in all patients prior to and following percutaneous renal sympathetic denervation. In total, 35 patients were selected for catheter-based renal sympathetic denervation. The mean age was 63.6 ± 11.7 years, 37.1% were women, 37.1% were diabetic, and 11.4% had renal impairment (GFR<45 mL/min). The basal BP (home or ambulatory) was 179.1 ± 20.75/99.66 ± 19.76 mmHg, despite an average of 4.91 ± 0.98 medications per patient. Successful bilateral sympathetic denervation was performed in 33/35 patients (1 renal artery stenosis on angiography [not ablated], 1 patient with renal artery spasm [unilateral denervation]), with an average 5.9 ± 1.6 ablations per renal artery. No procedural complications occurred. At 6 months, blood pressure was 15.5 ± 22.37/87.76 ± 13.97 mmHg (P<0.01). At 2 years follow-up, systolic blood pressure (ABPM or Home BP) was 143.8 ± 15.30 mmHg (P<0.0001) and diastolic 83.42 ± 12.80 mmHg (P=0.0004). There were no adverse events during follow-up, and no deterioration in renal function was observed. Catheter-based renal denervation is safe and efficacious treatment, which results in significant reductions in blood pressure in patients with treatment-resistant hypertension, stable at 2 years follow-up. These results are applicable to real-world patient

Severity of Obstructive Sleep Apnea is Related to Aldosterone Status in Subjects with Resistant Hypertension

PubMed Central

Gonzaga, Carolina C.; Gaddam, Krishna K.; Ahmed, Mustafa I.; Pimenta, Eduardo; Thomas, S. Justin; Harding, Susan M.; Oparil, Suzanne; Cofield, Stacey S.; Calhoun, David A.

2010-01-01

Background: We previously described a significant correlation between plasma aldosterone concentration (PAC) and severity of obstructive sleep apnea (OSA) in patients with resistant hypertension. This investigation examines the relationship between aldosterone status and OSA in patients with resistant hypertensive—with and without hyperaldosteronism. Methods and Results: One hundred and nine consecutive patients with resistant hypertension were prospectively evaluated with plasma renin activity (PRA), PAC, 24-hour urinary aldosterone excretion (UAldo), and polysomnography. Hyperaldosteronism (PRA < 1 ng·mL-1·h-1 and UAldo ≥ 12 μg/24-h) prevalence was 28% and OSA prevalence was 77%. In patients with hyperaldosteronism, OSA prevalence was 84%, compared with 74% in hypertensive patients with normal aldosterone levels. There were no significant differences in body mass index or neck circumference between aldosterone groups. PAC and UAldo were both significantly correlated with apnea-hypopnea index (AHI) in the high-aldosterone group (ρ = 0.568, p = 0.0009; ρ = 0.533, p = 0.002, respectively). UAldo correlated weakly with apnea-hypopnea index in the normal-aldosterone group, but there was no significant correlation between PAC and AHI in the normal-aldosterone group (ρ = 0.224, p = 0.049; ρ = 0.015, p = 0.898, respectively). Conclusions: Our analysis of patients with resistant hypertension confirms a markedly high prevalence of OSA in this group. Furthermore, severity of OSA was greater in those patients with hyperaldosteronism and related to the degree of aldosterone excess. The correlation between OSA severity and aldosterone supports the hypothesis that aldosterone excess contributes to greater severity of OSA. Citation: Gonzaga CC; Gaddam KK; Ahmed MI; Pimenta E; Thomas SJ; Harding SM; Oparil S; Cofield SS; Calhoun DA. Severity of obstructive sleep apnea is related to aldosterone status in subjects with resistant hypertension. J Clin Sleep Med 2010

Prevalence and clinical characteristics of patients with true resistant hypertension in central and Eastern Europe: data from the BP-CARE study.

PubMed

Brambilla, Gianmaria; Bombelli, Michele; Seravalle, Gino; Cifkova, Renata; Laurent, Stephane; Narkiewicz, Krzysztof; Facchetti, Rita; Redon, Josep; Mancia, Giuseppe; Grassi, Guido

2013-10-01

Scanty information is available on the clinical characteristics of resistant hypertension in Central and East European countries. The Blood Pressure (BP) control rate and CArdiovascular Risk profilE (BP-CARE) study allowed us to assess the prevalence and the main clinical features of resistant hypertension in this population. The study was carried out in 1312 treated hypertensive patients living in nine Central and East European countries. Four hundred and twenty-three patients had apparent resistant hypertension, of whom 168 had pseudo-resistant hypertension (noncompliant/white-coat) and 255 were true treatment-resistant hypertension patients (TRH). Clinical BP values in TRH amounted to 157.4±16.9/91.8±10.0 mmHg despite the daily use of 3.6±0.7 drugs. Their 24-h BP values were 149.5±16.5/97.5±9.8 mmHg. Compared to controlled hypertensive patients (n=368) and uncontrolled nonresistant hypertensive patients (n=521), TRH were older with a greater prevalence of women. They showed a higher rate of previous cardiovascular events and a very high cardiovascular risk profile. Estimated glomerular filtration rate was significantly lower in TRH as compared to controlled hypertensive patients and uncontrolled nonresistant hypertensive patients. Overall, target organ damage was more frequently detected in TRH than in controlled hypertensive patients and uncontrolled nonresistant hypertensive patients. The factor most frequently associated with TRH was severity of hypertension followed by age, total cholesterol, BMI and history of heart failure. The present study provides evidence that the prevalence of TRH in Central and East European countries is similar to that found in Western Europe and USA. It also shows the very high cardiovascular risk of TRH and the elevated association of this condition with obesity, renal failure, organ damage and history of cardiovascular events.

Maintaining an outward image: a Korean immigrant's life with type 2 diabetes mellitus and hypertension.

PubMed

Pistulka, Gina M; Winch, Peter J; Park, Hyunjeong; Han, Hae-Ra; Kim, Miyong T

2012-06-01

Type 2 diabetes mellitus (DM) and hypertension (HTN) disproportionately affect minority populations in the United States, including Korean American immigrants (KAI). We conducted qualitative interviews with middle-aged KAI in Maryland living with DM and HTN to examine the illness experience to inform future intervention strategies. Study results show that participants utilized strategies to maintain respect and Korean identity, including an image of being healthy and in control of their behavior in the public arena. These strategies included the lack of disclosure of their illness, even to family members, and avoiding outside assistance when engaging in problem solving. Maintaining an outward image of health was a common goal that affected the self-care of KAI in this study, a finding that might prove significant in the management of other chronic illnesses affecting this population. The study findings demonstrate the importance of in-depth understanding of specific populations when treating chronic illness, and caretakers' sensitivity to each population's unique cultural issues regarding identity, image, and disclosure.

Body Mass Index Predicts 24-Hour Urinary Aldosterone Levels in Patients With Resistant Hypertension.

PubMed

Dudenbostel, Tanja; Ghazi, Lama; Liu, Mingchun; Li, Peng; Oparil, Suzanne; Calhoun, David A

2016-10-01

Prospective studies indicate that hyperaldosteronism is found in 20% of patients with resistant hypertension. A small number of observational studies in normotensive and hypertensive patients suggest a correlation between aldosterone levels and obesity while others could not confirm these findings. The correlation between aldosterone levels and body mass index (BMI) in patients with resistant hypertension has not been previously investigated. Our objective was to determine whether BMI is positively correlated with plasma aldosterone concentration, plasma renin activity, aldosterone:renin ratio, and 24-hour urinary aldosterone in black and white patients. We performed a cross-sectional analysis of a large diverse cohort (n=2170) with resistant hypertension. The relationship between plasma aldosterone concentration, plasma renin activity, aldosterone:renin ratio, 24-hour urinary aldosterone, and BMI was investigated for the entire cohort, by sex and race (65.3% white, 40.3% men). We demonstrate that plasma aldosterone concentration and aldosterone:renin ratio were significantly correlated to BMI (P<0.0001) across the first 3 quartiles, but not from the 3rd to 4th quartile of BMI. Plasma renin activity was not correlated with BMI. Twenty-four-hour urinary aldosterone was positively correlated across all quartiles of BMI for the cohort (P<0.0001) and when analyzed by sex (men P<0.0001; women P=0.0013) and race (P<0.05), and stronger for men compared with women (r=0.19, P<0.001 versus r=0.05, P=0.431, P=0.028) regardless of race. In both black and white patients, aldosterone levels were positively correlated to increasing BMI, with the correlation being more pronounced in black and white men. These findings suggest that obesity, particularly the abdominal obesity typical of men, contributes to excess aldosterone in patients with resistant hypertension. © 2016 American Heart Association, Inc.

[Safety and short-term efficacy of renal sympathetic denervation in the treatment of resistant hypertension].

PubMed

Jiang, Xiong-jing; Liang, Tuo; Dong, Hui; Peng, Meng; Ma, Wen-jun; Guan, Ting; Zhang, Hui-min; Bian, Jin; Xu, Bo; Gao, Run-lin

2012-12-11

Transcatheter renal sympathetic denervation (RDN) is a novel technology/therapy in treating resistant hypertension. The present study aims to evaluate the safety and short-term efficacy of RDN for the treatment of resistant hypertension in a Chinese population. This prospective single-center pilot study was the first one conducted in China with Medtronic Ardian Symplicity Catheter System. Eight patients (6 males and 2 females) with resistant hypertension underwent RDN at our hospital from February to April 2012. All patients were followed up at one month and three months post-RDN. Blood pressure, use of antihypertensive medications, renal function and complications were recorded and analyzed. At one month and three months post-RDN, 24-hour ambulatory blood pressure monitoring showed mean systolic blood pressure and diastolic blood pressure decreased 10 (0 - 18) 13 (3 - 19) and 8 (-2 - 15), 9 (2 - 16) mm Hg throughout 24 hours respectively (P < 0.05, vs baseline). The number of drugs decreased from 4.3 ± 0.5 to 2.8 ± 0.9 and 2.5 ± 0.7 post-RSD respectively (P < 0.01). There was no significant change of renal function (P > 0.05). No complications were observed. The preliminary results revealed that RDN was safe and effective for the treatment of resistant hypertension in the Chinese population during a 3-month follow-up. Further large and long-term studies are warranted.

Comparison between supervised and partly supervised cardiac rehabilitation protocols in hypertensive patients: a randomized controlled trial.

PubMed

Parreira, Larissa Barreto; de Oliveira Vitorino, Priscila Valverde; Jardim, Paulo Cesar Brandao Veiga; Sousa, Ana Luiza Lima; Jardim, Thiago Veiga; de Moura Sousa, Watila; Justo, Alberto Fenrando Oliveira; Barroso, Weimar Kunz Sebba

2018-04-13

Hypertension (HTN) is the main cause of cardiovascular diseases accounting for one third of global mortality. Physical exercise reduces the incidence and prevalence of HTN and cardiovascular morbidity and mortality. Exercises recommended for hypertensive patients include supervised cardiac rehabilitation, which occurs in rehabilitation centers, and partly supervised rehabilitation, with individual prescription of exercises conducted at patients' residences. Compare clinical and functional parameters of hypertensive patients subjected to two cardiac rehabilitation protocols: supervised and partly supervised. Hypertensive patients stage I or II were randomly divided into group one (G1) (partly supervised cardiac rehabilitation) and group two (G2) (supervised cardiac rehabilitation). All patients performed warm-up, aerobic exercise, strength training and cool-down. Participants' assessments conducted before and after intervention included: physical examination, six-minute walk test, cardiac stress test, metabolic tests, and central and peripheral blood pressure measurements. A total of 61 patients (mean age 60.3±11.3 years , 78.7% women) were randomized (30 in G1 and 31 in G2). At the end of the intervention, G1 increased 30.6 meters (p=0.004) and G2 increased 55.0 meters (p>0.001) the distance covered in the six-minute walk test. G2 showed an increase in the maximum oxygen consumption from 24.7±8.6 mlO2/Kg/min to 28.4±7.5 mlO2/Kg/min (p=0.003). Compliance with the intervention was similar in G1 and G2 (77.5±11% x 82±10%; p=0.654). Participants from both groups improved their physical fitness and showed satisfactory compliance and tolerability to the interventions. Supervised exercise was more effective in improving muscle strength and some physical fitness parameters. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Clinical outcome of renal artery stenting for hypertension and chronic kidney disease up to 12 months in the J-RAS Study – prospective, single-arm, multicenter clinical study.

PubMed

Fujihara, Masahiko; Yokoi, Yoshiaki; Abe, Takaaki; Soga, Yoshimitsu; Yamashita, Takehiro; Miyashita, Yusuke; Nakamura, Masato; Yokoi, Hiroyoshi; Ito, Sadayoshi

2015-01-01

Atherosclerotic renal artery stenosis (ARAS) causes renovascular hypertension (HTN) and impairs renal function, leading to chronic kidney disease (CKD). The J-RAS study was a prospective, multicenter study to assess the clinical outcome of renal artery stenting for up to 1 year in Japanese patients with ARAS. One hundred and forty-nine patients were enrolled between November 2010 and January 2013. The patients were classified into an HTN (n=121) group and a CKD (n=108) group in the primary analysis. The primary efficacy endpoints were change in blood pressure for the HTN group and change in estimated glomerular filtration rate (eGFR) for the CKD group at 1 months. The primary safety endpoint was freedom from major cardiovascular or renal events at 12 months. In the HTN group, the mean systolic blood pressure (SBP) significantly decreased from 161.6 ± 21 mmHg at baseline to 137.0 ± 21 mmHg (P<0.0001). In the CKD group, there was no significant difference in eGFR from 40.7 ± 10 ml·min(-1)·1.73 m(-2)at baseline to 40.8 ± 13 ml·min(-1)·1.73 m(-2)(P=0.32). The primary safety endpoint was 89.4% at 12 months. In the J-RAS trial, significant SBP reduction was seen in the HTN group, and stabilization of renal function in the CKD group. Renal artery stenting for ARAS is safe and effective in Japanese patients.

Treatment of spontaneously hypertensive rats with rosiglitazone and/or enalapril restores balance between vasodilator and vasoconstrictor actions of insulin with simultaneous improvement in hypertension and insulin resistance.

PubMed

Potenza, Maria A; Marasciulo, Flora L; Tarquinio, Mariela; Quon, Michael J; Montagnani, Monica

2006-12-01

Spontaneously hypertensive rats (SHRs) exhibit endothelial dysfunction and insulin resistance. Reciprocal relationships between endothelial dysfunction and insulin resistance may contribute to hypertension by causing imbalanced regulation of endothelial-derived vasodilators (e.g., nitric oxide) and vasoconstrictors (e.g., endothelin-1 [ET-1]). Treatment of SHRs with rosiglitazone (insulin sensitizer) and/or enalapril (ACE inhibitor) may simultaneously improve hypertension, insulin resistance, and endothelial dysfunction by rebalancing insulin-stimulated production of vasoactive mediators. When compared with WKY control rats, 12-week-old vehicle-treated SHRs were hypertensive, overweight, and insulin resistant, with elevated fasting levels of insulin and ET-1 and reduced serum adiponectin levels. In mesenteric vascular beds (MVBs) isolated from vehicle-treated SHRs and preconstricted with norepinephrine (NE) ex vivo, vasodilator responses to insulin were significantly impaired, whereas the ability of insulin to oppose vasoconstrictor actions of NE was absent (versus WKY controls). Three-week treatment of SHRs with rosiglitazone and/or enalapril significantly reduced blood pressure, insulin resistance, fasting insulin, and ET-1 levels and increased adiponectin levels to values comparable with those observed in vehicle-treated WKY controls. By restoring phosphatidylinositol 3-kinase-dependent effects, rosiglitazone and/or enalapril therapy of SHRs also significantly improved vasodilator responses to insulin in MVB preconstricted with NE ex vivo. Taken together, our data provide strong support for the existence of reciprocal relationships between endothelial dysfunction and insulin resistance that may be relevant for developing novel therapeutic strategies for the metabolic syndrome.

Resistance training controls arterial blood pressure in rats with L-NAME- induced hypertension.

PubMed

Araujo, Ayslan Jorge Santos de; Santos, Anne Carolline Veríssimo dos; Souza, Karine dos Santos; Aires, Marlúcia Bastos; Santana-Filho, Valter Joviniano; Fioretto, Emerson Ticona; Mota, Marcelo Mendonça; Santos, Márcio Roberto Viana

2013-04-01

Arterial hypertension is a multifactorial chronic condition caused by either congenital or acquired factors. To evaluate the effects of Resistance Training (RT) on arterial pressure, and on vascular reactivity and morphology, of L-NAME-treated hypertensive rats. Male Wistar rats (200 - 250 g) were allocated into Sedentary Normotensive (SN), Sedentary Hypertensive (SH) and Trained Hypertensive (TH) groups. Hypertension was induced by adding L-NAME (40 mg/Kg) to the drinking water for four weeks. Arterial pressure was evaluated before and after RT. RT was performed using 50% of 1RM, 3 sets of 10 repetitions, 3 times per week for four weeks. Vascular reactivity was measured in rat mesenteric artery rings by concentration-response curves to sodium nitroprusside (SNP); phenylephrine (PHE) was also used for histological and stereological analysis. Resistance training inhibited the increase in mean and diastolic arterial pressures. Significant reduction was observed in Rmax (maximal response) and pD2 (potency) of PHE between SH and TH groups. Arteries demonstrated normal intima, media and adventitia layers in all groups. Stereological analysis demonstrated no significant difference in luminal, tunica media, and total areas of arteries in the SH and TH groups when compared to the SN group. Wall-to-lumen ratio of SH arteries was significantly different compared to SN arteries (p<0.05) but there was no difference when compared to TH arteries. RT was able to prevent an increase in blood pressure under the conditions in this study. This appears to involve a vasoconstrictor regulation mechanism and maintenance of luminal diameter in L-NAME induced hypertensive rats.

COMPARATIVE MICROARRAY EXPRESSION ANALYSIS OF SELECTED CANCER RELEVANT GENES IN HYPERTENSIVE RESISTANT VERSUS SUSCEPTIBLE RODENT STRAINS

EPA Science Inventory

Hypertension and cancer are prevalent diseases. Epidemiological studies suggest that hypertension may increase the long term risk of cancer. Identification of resistance and/or susceptibility genes using rodent models could provide important insights into the management and treat...

Cost-effectiveness of renin-guided treatment of hypertension.

PubMed

Smith, Steven M; Campbell, Jonathan D

2013-11-01

A plasma renin activity (PRA)-guided strategy is more effective than standard care in treating hypertension (HTN). However, its clinical implementation has been slow, presumably due in part to economic concerns. We estimated the cost effectiveness of a PRA-guided treatment strategy compared with standard care in a treated but uncontrolled HTN population. We estimated costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of PRA-guided therapy compared to standard care using a state-transition simulation model with alternate patient characteristic scenarios and sensitivity analyses. Patient-specific inputs for the base case scenario, males average age 63 years, reflected best available data from a recent clinical trial of PRA-guided therapy. Transition probabilities were estimated using Framingham risk equations or derived from the literature; costs and utilities were derived from the literature. In the base case scenario for males, the lifetime discounted costs and QALYs were $23,648 and 12.727 for PRA-guided therapy and $22,077 and 12.618 for standard care, respectively. The base case ICER was $14,497/QALY gained. In alternative scenario analyses varying patient input parameters, the results were sensitive to age, gender, baseline systolic blood pressure, and the addition of cardiovascular risk factors. Univariate sensitivity analyses demonstrated that results were most sensitive to varying the treatment effect of PRA-guided therapy and the cost of the PRA test. Our results suggest that PRA-guided therapy compared with standard care increases QALYs and medical costs in most scenarios. PRA-guided therapy appears to be most cost effective in younger persons and those with more cardiovascular risk factors. © American Journal of Hypertension, Ltd 2013. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Renal sympathetic denervation for treatment of resistant hypertension: Egyptian experience.

PubMed

Hamza, Mohamed; Khamis, Hazem

2014-08-01

Among the Egyptian population with essential hypertension, a minority are under control (systolic pressure <140 mmHg and diastolic pressure <90 mmHg), despite the use of multiple antihypertensive medications. In this article, we describe our experience with percutaneous treatment using renal artery radiofrequency (RF) ablation. To evaluate the feasibility, efficacy, and safety of catheter-based radiofrequency renal sympathetic denervation for treatment of resistant hypertension in Egyptian patients. Patients with essential hypertension unresponsive to at least 3 types of antihypertensive medical therapy (baseline office systolic blood pressure ≥160 mmHg) (n = 55) were enrolled between February 2012 and June 2013 and received percutaneous RF ablation. Patients were followed up for 6 months after treatment to detect any change in office-based measurement of blood pressure. Urine and blood samples were taken to evaluate the effects on renal function. A reduction of mean office blood pressure was seen from 174/103 ± 9/5 mmHg at baseline to 150/91 ± 8/5 mmHg at 6 months follow-up (P = 0.001). Also, we noted a significant decrease in plasma renin activity (3.66 ± 0.64 vs. 3.37 ± 0.47 ng/mL per hour; P = 0.003), and there were no periprocedural complications, no adverse events, and no change in renal function during the follow-up period. Also, no change was noted in the number of medications after 6 months (3.95 ± 1.64 vs. 3.67 ± 0.72; P = 0.27). In this observational study, catheter-based renal denervation causes sustained blood pressure reduction in patients with resistant hypertension, without serious adverse events. © 2014, Wiley Periodicals, Inc.

Prevalence of treatment-resistant hypertension after considering pseudo-resistance and morbidity: a cross-sectional study in Irish primary care.

PubMed

Hayes, Peter; Casey, Monica; Glynn, Liam G; Molloy, Gerard J; Durand, Hannah; O'Brien, Eoin; Dolan, Eamon; Newell, John; Murphy, Andrew W

2018-06-01

To confirm treatment-resistant hypertension (TRH), ambulatory blood pressure measurement (ABPM) must exclude white-coat hypertension (WCH), three or more medications should be prescribed at the optimal doses tolerated, and non-adherence and lifestyle should be examined. Most previous studies have not adequately considered pseudo-resistance and merely provide an apparent TRH (aTRH) prevalence figure. To conduct a cross-sectional study of the prevalence of aTRH in general practice, and then consider pseudo-resistance and morbidity. With support, 16 practices ran an anatomical therapeutic chemical (ATC) drug search, identifying patients on any possible hypertensive medications, and then a search of individual patients' electronic records took place. ABPM was used to rule out WCH. The World Health Organization-defined daily dosing guidelines determined adequate dosing. Adherence was defined as whether patients requested nine or more repeat monthly prescriptions within the past year. Sixteen practices participated ( n = 50 172), and 646 patients had aTRH. Dosing was adequate in 19% of patients, 84% were adherent to medications, as defined by prescription refill, and 43% had ever had an ABPM. Using a BP cut-off of 140/90 mmHg, the prevalence of aTRH was 9% (95% confidence interval [CI] = 9.0 to 10.0). Consideration of pseudo-resistance further reduced prevalence rates to 3% (95% CI = 3.0 to 4.0). Reviewing individual patient records results in a lower estimate of prevalence of TRH than has been previously reported. Further consideration for individual patients of pseudo-resistance additionally lowers these estimates, and may be all that is required for management in the vast majority of cases. © British Journal of General Practice 2018.

Association between Modified Shuttle Walk Test and cardiorespiratory fitness in overweight/obese adults with primary hypertension: EXERDIET-HTA study.

PubMed

Jurio-Iriarte, Borja; Gorostegi-Anduaga, Ilargi; Aispuru, G Rodrigo; Pérez-Asenjo, Javier; Brubaker, Peter H; Maldonado-Martín, Sara

2017-04-01

The aims of the study were to evaluate the relationship between Modified Shuttle Walk Test (MSWT) with peak oxygen uptake (V˙O 2peak ) in overweight/obese people with primary hypertension (HTN) and to develop an equation for the MSWT to predict V˙O 2peak . Participants (N = 256, 53.9 ± 8.1 years old) with HTN and overweight/obesity performed a cardiorespiratory exercise test to peak exertion on an upright bicycle ergometer using an incremental ramp protocol and the 15-level MSWT. The formula of Singh et al was used as a template to predict V˙O 2peak , and a new equation was generated from the measured V˙O 2peak -MSWT relationship in this investigation. The correlation between measured and predicted V˙O 2peak for Singh et al equation was moderate (r = 0.60, P < .001) with a standard error of the estimate (SEE) of 4.92 mL·kg -1  minute -1 , SEE% = 21%. The correlation between MSWT and measured V˙O 2peak as well as for the new equation was strong (r = 0.72, P < .001) with a SEE of 4.35 mL·kg -1  minute -1 , SEE% = 19%. These results indicate that MSWT does not accurately predict functional capacity in overweight/obese people with HTN and questions the validity of using this test to evaluate exercise intolerance. A more accurate determination from a new equation in the current study incorporating more variables from MSWT to estimate V˙O 2peak has been performed but still results in substantial error. Copyright © 2017 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Associations among health behaviors, body mass index, hypertension, and diabetes mellitus: A path analysis.

PubMed

Min, Deulle; Cho, Eunhee

2018-06-01

Hypertension (HTN) and type 2 diabetes are common diseases; however, the effects of health behavior and body mass index (BMI) on their incidence and relationship are unclear. The purpose of this study was to investigate the associations among health behaviors, BMI, HTN, and type 2 diabetes.This study was a secondary data analysis using Korean Longitudinal Study of Aging data between 2010 and 2014 (third and fifth). The sample consisted of 3481 people aged 45 years or older. Path analysis was conducted using the generalized structural equation modeling of STATA 13.1 that enabled analyzing the types of binary variables and logit links.There were 129 underweight, 1714 normal, and 1638 overweight and obese individuals. In underweight and normal groups who had regular meals (B = 0.670, P < .001), BMI was higher. However, for those who were older (B = -0.041, P < .001) and female (B = -0.229, P = .021), BMI was lower. The incidence of HTN increased with age (B = 0.038, P = .001). In addition, the incidence of type 2 diabetes increased with age (B = 0.051, P = .005) and smoking (B = 1.539, P = .001). However, the incidence of type 2 diabetes was lower (B = -1.077, P = .036) for those who had regular meals. In the normal and overweight groups, BMI decreased with age (B = -0.033, P < .001). The incidence of HTN increased with age (B = 0.042, P < .001) and BMI (B = 0.145, P < .001). Moreover, the incidence of type 2 diabetes increased with age (B = 0.046, P < .001), smoking (B = 0.682, P = .020), and higher BMI (B = 0.151, P = .001).In the underweight and normal group, health behaviors were related to BMI. In the normal and overweight group, health behaviors were not related to BMI, but high BMI was related to the incidence of HTN and type 2 diabetes. Smoking has a direct effect on the incidence of type 2 diabetes. Thus, the importance of maintaining an ideal BMI and

Hypertensive renal disease: susceptibility and resistance in inbred hypertensive rat lines.

PubMed

Braun, Michael C; Herring, Stacy M; Gokul, Nisha; Monita, Monique; Bell, Rebecca; Hicks, M John; Wenderfer, Scott E; Doris, Peter A

2013-10-01

Spontaneously hypertensive rat (SHR) lines differ in their susceptibility to hypertensive end-organ disease and may provide an informative model of genetic risk of disease. Lines derived from the original SHR-B and SHR-C clades are highly resistant to hypertensive end-organ disease, whereas lines derived from the SHR-A clade were selected for stroke susceptibility and experience hypertensive renal disease. Here we characterize the temporal development of progressive renal injury in SHR-A3 animals consuming 0.3% sodium in the diet and drinking water. SHR-A3 rats demonstrate albuminuria, glomerular damage, tubulointerstitial injury, and renal fibrosis that emerge at 18 weeks of age and progress. Mortality of SHR-A3 animals was 50% at 40 weeks of age, and animals surviving to this age had reduced renal function. In contrast SHR-B2, which are 87% genetically identical to SHR-A3, are substantially protected from renal injury and demonstrate only moderate changes in albuminuria and renal histological injury over this time period. At 40 weeks of age, electron microscopy of the renal glomerulus revealed severe podocyte effacement in SHR-A3, but slit diaphragm architecture in SHR-B2 at this age was well preserved. Renal injury traits in the F1 and F2 progeny of an intercross between SHR-A3 and SHR-B2 were measured to determine heritability of renal injury in this model. Heritability of albuminuria, glomerular injury, and tubulointerstitial injury were estimated at 48.9, 66.5 and 58.6%, respectively. We assessed the relationship between blood pressure and renal injury measures in the F2 animals and found some correlation between these variables that explain up to 26% of the trait variation. Quantitative trait locus (QTL) mapping was performed using over 200 single nucleotide polymorphism markers distributed across the 13% of the genome that differs between these two closely related lines. Mapping of albuminuria, tubulointerstitial injury, and renal fibrosis failed to

Renal denervation: What happened, and why?

PubMed

Shishehbor, Mehdi H; Hammad, Tarek A; Thomas, George

2017-09-01

Despite promising results in initial trials, renal denervation failed to achieve its efficacy end points as a treatment for resistant hypertension in the SYMPLICITY HTN-3 trial, the largest trial of this treatment to date (N Engl J Med 2014; 370:1393-1401). Is renal denervation dead, or will future trials and newer technology revive it? Copyright © 2017 Cleveland Clinic.

Preoperative partitioning of pulmonary vascular resistance correlates with early outcome after thromboendarterectomy for chronic thromboembolic pulmonary hypertension.

PubMed

Kim, Nick H S; Fesler, Pierre; Channick, Richard N; Knowlton, Kirk U; Ben-Yehuda, Ori; Lee, Stephen H; Naeije, Robert; Rubin, Lewis J

2004-01-06

Pulmonary thromboendarterectomy (PTE) is the preferred treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but persistent pulmonary hypertension after PTE, as a result of either inaccessible distal thrombotic material or coexistent intrinsic small-vessel disease, remains a major determinant of poor outcome. Conventional preoperative evaluation is unreliable in identifying patients at risk for persistent pulmonary hypertension or predicting postoperative hemodynamic outcome. We postulated that pulmonary arterial occlusion pressure waveform analysis, a technique that has been used for partitioning pulmonary vascular resistance, might identify CTEPH patients with significant distal, small-vessel disease. Twenty-six patients underwent preoperative right heart catheterization before PTE. Pulmonary artery occlusion waveform recordings were performed in triplicate. Postoperative hemodynamics after PTE were compared with preoperative partitioning of pulmonary vascular resistance derived from the occlusion data. Preoperative assessment of upstream resistance (Rup) correlated with both postoperative total pulmonary resistance index (R2=0.79, P<0.001) and postoperative mean pulmonary artery pressure (R2=0.75, P<0.001). All 4 postoperative deaths occurred in patients with a preoperative Rup <60%. Pulmonary arterial occlusion pressure waveform analysis may identify CTEPH patients at risk for persistent pulmonary hypertension and poor outcome after PTE. Patients with CTEPH and Rup value <60% appear to be at highest risk.

Effects of aerobic exercise intensity on ambulatory blood pressure and vascular responses in resistant hypertension: a crossover trial.

PubMed

Santos, Lucas P; Moraes, Ruy S; Vieira, Paulo J C; Ash, Garrett I; Waclawovsky, Gustavo; Pescatello, Linda S; Umpierre, Daniel

2016-07-01

Resistant hypertension often exposes patients to poor blood pressure (BP) control, resulting in clinical vulnerability, possible need for device-based procedures (denervation) and increased therapy costs. Regular exercise markedly benefits patients with hypertension, including resistant patients. However, little is known about short-term exercise effects in resistant hypertension. To evaluate acute hemodynamic effects of exercise in resistant hypertension. After maximal exercise testing, 20 patients (54.0 ± 5.7 years, 30.2 ± 4.9 kg/m) with resistant hypertension participated in three crossover interventions, in random order, and on separate days: control (45' of rest), and light intensity and moderate intensity (45' of aerobic exercise at 50 and 75% of maximum heart rate, respectively). Ambulatory BP, forearm blood flow (with subsequent calculation of vascular resistance), and reactive hyperemia were measured before and after interventions trough venous occlusion plethysmography. Compared with control, both exercise intensities reduced ambulatory systolic pressure over 5 h (light: -7.7 ± 2.4 mmHg and moderate: -9.4 ± 2.8 mmHg, P < 0.01), whereas only light intensity reduced diastolic pressure (-5.7 ± 2.2 mmHg, P < 0.01). Light intensity also lowered systolic and diastolic pressures over 10-h daytime (-3.8 ± 1.3 and -4.0 ± 1.3 mmHg, respectively, P < 0.02), night-time (-6.0 ± 2.4 and -6.1 ± 1.6 mmHg, respectively, P < 0.05), and diastolic pressure over 19 h (-4.8 ± 1.2 mmHg, P < 0.01). Forearm blood flow changed (decreased) compared with baseline only at 50 min after light intensity (P < 0.05). After the control and light intensity sessions, vascular resistance increased at the end of 1 h, and after moderate intensity, it decreased only at the moment (∼2 min) immediately after intervention (P < 0.05). A single session of light or moderate aerobic exercise acutely

Addictive salt may not be solely responsible for causing hypertension: A sweet and fatty hypothesis.

PubMed

Mehta, V

2017-09-16

In literature, since many decades, it is often believed and condoned that excessive common salt (Nacl) ingestion can lead to hypertension. Hence, every health organisation, agencies and physicians have been advising salt restriction to hypertensive patients. However, there is no concrete evidence suggesting that salt restriction can reduce the risk of hypertension (HTN). The present article is based on the current literature search which was performed using MEDLINE, EMBASE, Google Scholar and PubMed. The meta-analysis, randomised control trials, clinical trials and review articles were chosen. The present review article suggests that consumption of high salt diet does not lead to hypertension and there are other factors which can lead to hypertension, sugar and fats being the main reasons. Salt can however lead to addiction and generally, these salty food items have a larger proportion of sugar and fats, which if over-consumed has a potential to cause obesity, hyperlipidaemia and subsequently, hypertension and other cardiovascular disorders. Hence, through the present review, I would like to suggest all the physicians to ask the hypertensive patients to cut down the intake of sugar and fat containing food items and keep a check on addiction of salty food items. Copyright © 2017 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.

Hyperthyroidism, but not hypertension, impairs PITX2 expression leading to Wnt-microRNA-ion channel remodeling

PubMed Central

Lozano-Velasco, Estefanía; Wangensteen, Rosemary; Quesada, Andrés; Garcia-Padilla, Carlos; Osorio, Julia A.; Ruiz-Torres, María Dolores; Aranega, Amelia

2017-01-01

PITX2 is a homeobox transcription factor involved in embryonic left/right signaling and more recently has been associated to cardiac arrhythmias. Genome wide association studies have pinpointed PITX2 as a major player underlying atrial fibrillation (AF). We have previously described that PITX2 expression is impaired in AF patients. Furthermore, distinct studies demonstrate that Pitx2 insufficiency leads to complex gene regulatory network remodeling, i.e. Wnt>microRNAs, leading to ion channel impairment and thus to arrhythmogenic events in mice. Whereas large body of evidences has been provided in recent years on PITX2 downstream signaling pathways, scarce information is available on upstream pathways influencing PITX2 in the context of AF. Multiple risk factors are associated to the onset of AF, such as e.g. hypertension (HTN), hyperthyroidism (HTD) and redox homeostasis impairment. In this study we have analyzed whether HTN, HTD and/or redox homeostasis impact on PITX2 and its downstream signaling pathways. Using rat models for spontaneous HTN (SHR) and experimentally-induced HTD we have observed that both cardiovascular risk factors lead to severe Pitx2 downregulation. Interesting HTD, but not SHR, leads to up-regulation of Wnt signaling as well as deregulation of multiple microRNAs and ion channels as previously described in Pitx2 insufficiency models. In addition, redox signaling is impaired in HTD but not SHR, in line with similar findings in atrial-specific Pitx2 deficient mice. In vitro cell culture analyses using gain- and loss-of-function strategies demonstrate that Pitx2, Zfhx3 and Wnt signaling influence redox homeostasis in cardiomyocytes. Thus, redox homeostasis seems to play a pivotal role in this setting, providing a regulatory feedback loop. Overall these data demonstrate that HTD, but not HTN, can impair Pitx2>>Wnt pathway providing thus a molecular link to AF. PMID:29194452

Morphological and functional renovascular changes as cause of resistant arterial hypertension - case report and literature review.

PubMed

Costache, Irina Iuliana; Costea, Claudia Florida; Fotea, Vasile; Rusu, Victor Laurian; Aursulesei, Viviana; Al Namat, Razan; Costache, Dan Alexandru; Dumitrescu, Nicoleta; Buzdugă, Cătălin Mihai; Dumitrescu, Gabriela Florenţa; Sava, Anca; Bogdănici, Camelia Margareta

2018-01-01

Resistant hypertension is defined by the inability to maintain within normal limits the blood pressure values of an individual, while he is under treatment with maximal tolerated doses of three antihypertensive agents. One of the most common types of resistant hypertension is renovascular hypertension (RVH), which is caused by the narrowing of the renal arteries, in the context of existing atherosclerotic plaques at that level. We are presenting the case of a hypertensive 56-year-old man admitted in the Clinic of Cardiology for a sudden rise of his blood pressure values, despite undergoing the scheduled treatment. The abdominal bruit discovered at the clinical examination and the hypokalemia, together with the mild impairment of the renal function raised the suspicion of an existing stenosis of the main renal blood vessels. Simple grey scale kidney ultrasound, Doppler ultrasound of the renal arteries, abdominal computed tomography and magnetic resonance angiography of the renal arteries, along with invasive renal angiography demonstrated a smaller right kidney, adrenal incidentalomas, reduced vascular diameter of renal arteries due to atheromatous lesions, thrombosis of the infrarenal segment of the abdominal aorta, and reduced vascular hemodynamics in the same territories. After the renal arteries revascularization and with minimal antihypertensive treatment, the patient had a favorable outcome, with normalization of blood pressure and renal function. Atherosclerotic disease causing renal artery stenosis is essential to be taken into consideration in the etiopathogenesis of resistant hypertension especially because RVH is a potentially curable disease.

Losartan improves resistance artery lesions and prevents CTGF and TGF-beta production in mild hypertensive patients.

PubMed

Gómez-Garre, D; Martín-Ventura, J L; Granados, R; Sancho, T; Torres, R; Ruano, M; García-Puig, J; Egido, J

2006-04-01

Although structural and functional changes of resistance arteries have been proposed to participate in arterial hypertension (HTA) outcome, not all therapies may correct these alterations, even if they normalize the blood pressure (BP). The aim of this study was to investigate the mechanisms of the protection afforded by the angiotensin receptor antagonist losartan in resistance arteries from patients with essential HTA. In all, 22 untreated hypertensive patients were randomized to receive losartan or amlodipine for 1 year and the morphological characteristics of resistance vessels from subcutaneous biopsies were evaluated. Protein expression of connective tissue growth factor (CTGF), transforming growth factor beta (TGF-beta), and collagens III and IV was detected by immunohistochemistry. In comparison with normotensive subjects, resistance arteries from hypertensive patients showed a significant media:lumen (M/L) ratio increment and a higher protein expression of CTGF, TGF-beta, and collagens. After 1 year of treatment, both losartan and amlodipine similarly controlled BP. However, M/L only decreased in patients under losartan treatment, whereas in the amlodipine-treated group this ratio continued to increase significantly. The administration of losartan prevented significant increments in CTGF, TGF-beta, and collagens in resistance arteries. By contrast, amlodipine-treated patients showed a higher vascular CTGF, TGF-beta, and collagen IV staining than before treatment. Our results show that the administration of losartan, but not amlodipine, to hypertensive patients improves structural abnormalities and prevents the production of CTGF and TGF-beta in small arteries, despite similar BP lowering. These data may explain the molecular mechanisms of the better vascular protection afforded by drugs interfering with the renin-angiotensin system.

Review of the State of Renal Nerve Ablation for Patients with Severe and Resistant Hypertension

PubMed Central

Gulati, Vinay; White, William B.

2013-01-01

Through modulation of renin secretion, glomerular filtration rate and renal absorption of sodium, the sympathetic innervation of the kidneys plays an important role in the pathogenesis of hypertension. Renal nerve ablation technology is being developed for treatment of drug-treatment resistant hypertension worldwide. Preliminary research with the use of radiofrequency based renal denervation systems have demonstrated encouraging results with significant reduction of blood pressure in patients inadequately controlled despite nearly maximal drug therapy regimens. From work done thus far, the renal denervation procedure has not been associated with serious adverse effects. Long term efficacy and safety still needs to be established for renal nerve ablation. This review focuses on the impact of the renal sympathetic system on blood pressure regulation, the clinical rationale for renal nerve ablation in severe and drug-treatment resistant hypertension and current evidence from the more advanced renal denervation devices. PMID:23953998

Acute and chronic effects of aerobic exercise on blood pressure in resistant hypertension: study protocol for a randomized controlled trial.

PubMed

Nascimento, L S; Santos, A C; Lucena, Jms; Silva, Lgo; Almeida, Aem; Brasileiro-Santos, M S

2017-06-02

Resistant hypertension is a specific condition that affects approximately 10% of subjects with hypertension, and is characterized by persistently high blood pressure levels even using therapy of three or more antihypertensive agents or with blood pressure control using therapy with four or more antihypertensive agents. Changes in lifestyle, such as physical exercise, are indicated for controlling blood pressure. However, investigating studies about this therapy in individuals with resistant hypertension are few. This is a randomized controlled clinical trial. Forty-eight patients with resistant hypertension will be submitted to perform four short-term interventions: aerobic exercise sessions (mild-, moderate- and high-intensity) and control session, in random order and on separate days. After the short-term sessions, the patients will be randomly allocated into four groups for 8 weeks of follow-up: mild-, moderate- and high-intensity aerobic exercise, and a control group. The primary outcome is the occurrence of blood pressure reduction (office and ambulatory analysis, and acute and chronic effects). Secondary outcomes are autonomic and hemodynamic mechanisms: cardiac and vasomotor autonomic modulation, spontaneous baroreflex sensitivity, forearm blood flow and vascular resistance. The importance of exercise for hypertension has been known for decades, but little is known about the effects on patients with resistant hypertension. This study will help to understand whether different aerobic exercise intensities can induce different responses, as well as by what mechanisms adjustments in blood pressure levels may occur. ClinicalTrials.gov, ID: NCT02670681 . Registered on 28 January 2016 (first version); Brazilian Registry Platform Clinical Trials: protocol RBR-5q24zh . Registered on 24 June 2015.

Cost-effectiveness of renal denervation therapy for the treatment of resistant hypertension in The Netherlands.

PubMed

Henry, Thea L; De Brouwer, Bonnie F E; Van Keep, Marjolijn M L; Blankestijn, Peter J; Bots, Michiel L; Koffijberg, Hendrik

2015-01-01

Safety and efficacy data for catheter-based renal denervation (RDN) in the treatment of resistant hypertension have been used to estimate the cost-effectiveness of this approach. However, there are no Dutch-specific analyses. This study examined the cost-effectiveness of RDN from the perspective of the healthcare payer in The Netherlands. A previously constructed Markov state-transition model was adapted and updated with costs and utilities relevant to the Dutch setting. The cost-effectiveness of RDN was compared with standard of care (SoC) for patients with resistant hypertension. The efficacy of RDN treatment was modeled as a reduction in the risk of cardiovascular events associated with a lower systolic blood pressure (SBP). Treatment with RDN compared to SoC gave an incremental quality-adjusted life year (QALY) gain of 0.89 at an additional cost of €1315 over a patient's lifetime, resulting in a base case incremental cost-effectiveness ratio (ICER) of €1474. Deterministic and probabilistic sensitivity analyses (PSA) showed that treatment with RDN therapy was cost-effective at conventional willingness-to-pay thresholds (€10,000-80,000/QALY). RDN is a cost-effective intervention for patients with resistant hypertension in The Netherlands.

Electronic compliance monitoring in resistant hypertension: the basis for rational therapeutic decisions.

PubMed

Burnier, M; Schneider, M P; Chioléro, A; Stubi, C L; Brunner, H R

2001-02-01

Incomplete compliance is one of several possible causes of uncontrolled hypertension. Yet, non-compliance remains largely unrecognized and is falsely interpreted as treatment resistance, because it is difficult to confirm or exclude objectively. The goal of this study was to evaluate the potential benefits of electronic monitoring of drug compliance in the management of patients with resistant hypertension. Forty-one hypertensive patients resistant to a three-drug regimen (average blood pressure 156/ 106 +/- 23/11 mmHg, mean +/- SD) were studied prospectively. They were informed that for the next 2 months, their presently prescribed drugs would be provided in electronic monitors, without any change in treatment, so as to provide the treating physician with a measure of their compliance. Thereafter, patients were offered the possibility of prolonging the monitoring of compliance for another 2 month period, during which treatment was adapted if necessary. Monitoring of compliance alone was associated with a significant improvement of blood pressure at 2 months (145/97 +/- 20/15 mmHg, P < 0.01). During monitoring, blood pressure was normalized (systolic < 140 mmHg or diastolic < 90 mmHg) in one-third of the patients and insufficient compliance was unmasked in another 20%. When analysed according to tertiles of compliance, patients with the lowest compliance exhibited significantly higher achieved diastolic blood pressures (P = 0.04). In 30 patients, compliance was monitored up to 4 months and drug therapy was adapted whenever necessary. In these patients, a further significant decrease in blood pressure was obtained (from 150/100 +/- 18/15 to 143/94 +/- 22/11 mmHg, P = 0.04/0.02). These results suggest that objective monitoring of compliance using electronic devices may be a useful step in the management of patients with refractory hypertension, as it enables physicians to take rational decisions based on reliable and objective data of drug compliance and hence to

The effects of napping on the risk of hypertension: a systematic review and meta-analysis.

PubMed

Cheungpasitporn, Wisit; Thongprayoon, Charat; Srivali, Narat; Vijayvargiya, Priya; Andersen, Carl A; Kittanamongkolchai, Wonngarm; Sathick, Insara J Jaffer; Caples, Sean M; Erickson, Stephen B

2016-11-01

The risk of hypertension in adults who regularly take a nap is controversial. The objective of this meta-analysis was to assess the associations between napping and hypertension. A literature search was performed using MEDLINE, EMbase and The Cochrane Database of Systematic Reviews from inception through October, 2015. Studies that reported relative risks, odd ratios or hazard ratios comparing the risk of hypertension in individuals who regularly take nap were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Nine observational studies with 112,267 individuals were included in the analysis to assess the risk of hypertension in nappers. The pooled RR of hypertension in nappers was 1.13 with 95% CI (0.98 to 1.30). When meta-analysis was limited only to studies assessing the risk of hypertension in daytime nappers, the pooled RR of hypertension was 1.19 with 95% CI (1.06 to 1.35). The data on association between nighttime napping in individuals who work night shift and hypertension were limited, only one observational study reported reduced risk of hypertension in nighttime nappers with odds ratio of 0.79 with 95% CI (0.63 to 1.00). Our meta-analysis demonstrates a significant association between daytime napping and hypertension. Future study is needed to assess the potential benefits of HTN screening for daytime nappers. © 2016 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.

Tertiary work-up of apparent treatment-resistant hypertension.

PubMed

Heimark, Sondre; Eskås, Per Anders; Mariampillai, Julian Eek; Larstorp, Anne Cecilie K; Høieggen, Aud; Fadl Elmula, Fadl Elmula M

2016-10-01

Treatment-resistant hypertension (TRH) has regained attention with development of new methods for treatment. However, the prevalence of TRH varies considerably from primary to secondary and tertiary care. We aimed to assess the prevalence of true TRH in a population of patients with apparent TRH in a university hospital setting of tertiary work-up and also investigate reasons for poor BP control and evaluate how work-up can be performed in general practice and secondary care. In this cohort study, we characterize a study population from Oslo Renal Denervation (RDN) Study. Patients (n = 83) were referred for RDN from secondary care. All patients underwent thorough medical investigation and 24-h ambulatory blood pressure measurements (24ABPM) after directly observed therapy (DOT). We then assessed reasons for lack of BP control. Fifty-three of 83 patients did not have true TRH. Main reasons for non-TRH were poor drug adherence (32%), secondary hypertension (30%) and white coat hypertension (15%). Forty-seven percent achieved blood pressure control after DOT with subsequent 24ABPM. There were otherwise no statistically significant differences in patient characteristics between the true TRH and the non-TRH group. Despite being a highly selected cohort referred for tertiary work-up of apparent TRH, BP control was achieved or secondary causes were identified in almost two thirds of the patients. Thorough investigation according to guidelines and DOT with subsequent 24ABPM is needed in work-up of apparent TRH.

Minoxidil for Treatment of Resistant Hypertension in Chronic Kidney Disease--A Retrospective Cohort Analysis.

PubMed

Mundt, Heiko M; Matenaer, Matthias; Lammert, Alexander; Göttmann, Uwe; Krämer, Bernhard K; Birck, Rainer; Benck, Urs

2016-11-01

Resistant hypertension is still a challenge and reserve antihypertensive agents are often necessary to achieve blood pressure control. One reserve antihypertensive is minoxidil, a direct vasodilator that is known for its strong blood pressure-lowering effect, but contemporary studies are sparse. The authors retrospectively analyzed 54 inpatients with uncontrolled hypertension despite the combined use of current antihypertensive agents. To investigate the effect of minoxidil when added to other antihypertensive agents, blood pressure was evaluated at the time minoxidil treatment was initiated and at discharge. Minoxidil treatment was associated with a significant reduction in blood pressure from 162.4±15.1/83.2±12.7 mm Hg to 135.8±12.2/72.8±6.9 mm Hg (P<.0001). This effect was sustained across all analyzed subgroups. Although the well-known adverse events of minoxidil limit its widespread use, these data show that minoxidil as a reserve antihypertensive agent still has a niche indication in the particular subgroup of patients with treatment-resistant or uncontrolled hypertension. ©2016 Wiley Periodicals, Inc.

[Physician knowledge and attitudes on the clinical evaluation and treatment of resistant hypertension: The RESIST study].

PubMed

Coca, A

Resistant hypertension (RH) is associated with a high risk of cardiovascular and renal complications. The purpose of this study was to assess the knowledge and attitudes of Primary Care physicians, general medicine doctors, and clinical cardiologists on the management of this condition. A multicentre, descriptive, observational study based on an ad hoc questionnaire distributed to Primary Care physicians (n=1017) and general medicine physicians/clinical cardiologists (n=457). To establish the diagnosis of resistant hypertension, 69.1% of physicians confirm that systolic/diastolic blood pressure is above 140/90 mmHg, despite treatment. Furthermore, 64.9% only consider this diagnosis if the patient is treated with at least 3 medications, and 50.3% also requires that one of them is a thiazide diuretic (56.7% among specialists, P=.0004). To establish a definite diagnosis of true RH, 89.6% perform 24-h ambulatory blood pressure monitoring (93.3% of specialists, P=.0017), looking specifically for «white-coat» effect in 70.2% of cases. In addition, 79.3% verify that adherence to treatment is adequate. Between 87 and 95% of physicians indicate examinations to exclude causes of secondary hypertension. Up to 54.3% of physicians (71.3% specialists, P<.0001) consider adding a fourth drug and insisting on lifestyle interventions as a priority therapeutic measure. These data show that physician knowledge regarding the management of patients with RH is good. Interestingly, this knowledge is somewhat higher among specialists than among Primary Care physicians. Copyright © 2016 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.

Safety and usefulness of Laghu shankha prakshalana in patients with essential hypertension: A self controlled clinical study

PubMed Central

Mashyal, Prakash; Bhargav, Hemant; Raghuram, Nagarathna

2014-01-01

Background: Yoga and Ayurveda texts emphasize the role of cleansing the bowel as an important component of management of hypertension (HTN). Observations during our clinical experience and pilot studies on Laghu shankha prakshalana kriya (LSP), a yogic bowel cleansing technique, appeared to be safe and complimentary. Objective: To test the safety and effectiveness of LSP in patients with essential hypertension. Materials and Methods: This self control study recruited 32 patients with mild to moderate essential HTN admitted for a week long residential integrated yoga therapy program at the integrative health home in Bengaluru. Patients had a daily routine of 6 hours of integrated approach of yoga therapy (IAYT) module for HTN that included physical postures, relaxation sessions, pranayama and meditations. LSP, an additional practice, that involved drinking of luke-warm water (with or without a herbal combination, triphala) followed by a set of specific yoga postures that activates defecation reflex, was administered on 2nd (LSP without triphala) and 5th day (LSP with triphala). Assessments (sitting blood pressure and pulse rate) were done just before and after both the sessions of LSP. Secondary outcome measures such as body mass index (BMI), symptom scores, medication scores, fatigue, state and trait anxiety, general health and quality of life were assessed on 1st and 6th day of IAYT intervention. Results: There was significant (P < 0.001, paired t test) reduction in blood pressure (systolic and diastolic) and pulse rate immediately after both the sessions (LSP with and without triphala). There were no adverse effects reported during or after LSP. There was no significant difference between the two techniques (P < 0.505, independent samples t test), although the percentage change appeared to be higher after triphala LSP session. The number of visits to clear the bowel during the procedure was significantly (P < 0.001, independent samples t test) higher after LSP

Atorvastatin calcium plus amlodipine for the treatment of hypertension.

PubMed

Delgado-Montero, Antonia; Zamorano, Jose L

2012-12-01

Hypertension (HTN) and dyslipemia (DYL) are two of the major modifiable cardiovascular (CV) risk factors, determinants in the development of cerebrovascular and coronary heart disease (CHD). Many patients have both risk factors which increase their total CV risk compared with patients with only one risk factor. Treatment guideline recommendations are poorly implemented in real practice, in part due to numerous and complicated drug regimes which hamper patient´s adherence. In this article the authors describe the first combined fixed-dose pill of an antihypertensive and a lipid-lowering agent, the single-pill combination of amlodipine besylate and atorvastatin calcium (SPAA). They summarize the pharmacokinetic and pharmacodynamic properties of both compounds and the main randomized clinical studies, as well as real-world observational studies, made with the new combined formulation. The use of the single-pill amlodipine and atorvastatin is an adequate option for the clinician to treat hypertensive patients with DYL or high CV risk burden, with proven efficacy, tolerability, cost-effectiveness, and the advantage of improving patient treatment compliance.

Proceedings from Duke resistant hypertension think tank.

PubMed

Vemulapalli, Sreekanth; Ard, Jamy; Bakris, George L; Bhatt, Deepak L; Brown, Alan S; Cushman, William C; Ferdinand, Keith C; Flack, John M; Fleg, Jerome L; Katzen, Barry T; Kostis, John B; Oparil, Suzanne; Patel, Chet B; Pepine, Carl J; Piña, Ileana L; Rocha-Singh, Krishna J; Townsend, Raymond R; Peterson, Eric D; Califf, Robert M; Patel, Manesh R

2014-06-01

To identify patients at increased risk for cardiovascular outcomes, apparent treatment resistant hypertension (aTRH) is defined as having a blood pressure (BP) above goal despite the use of ≥3 antihypertensive therapies of different classes at maximally tolerated doses, ideally including a diuretic. In light of growing scientific interest in the treatment of this group, a multistakeholder think tank was convened to discuss the current state of knowledge, improve the care of these patients, and identify appropriate study populations for future observational and randomized trials in the field. Although recent epidemiologic studies in selected populations estimate that the prevalence of aTRH is 10% to 15% of hypertensive patients, further large-scale observational studies will be needed to better elucidate risk factors. To spur the development of therapies for aTRH, the development of an "aTRH" label for pharmacologic and device therapies with a developmental pathway including treatment added to the use of existing therapies is favored. Although demonstration of adequate BP lowering should be sufficient to gain Food and Drug Administration approval for therapies targeting aTRH, assessment of improvement in quality of life and cardiovascular outcomes is also desirable and considered in Centers for Medicare and Medicaid Services coverage decisions. Device trials under the aTRH label will need uniform and consistent processes for defining appropriate patient populations as well as postapproval registries assessing both long-term safety and duration of responses. Finally, patients with aTRH are likely to benefit from evaluation by a hypertension team to assure proper patient identification, diagnostic work-up, and therapeutic management before consideration of advanced or novel therapies to lower BP. Copyright © 2014 Mosby, Inc. All rights reserved.

An analysis of the blood pressure and safety outcomes to renal denervation in African Americans and Non-African Americans in the SYMPLICITY HTN-3 trial.

PubMed

Flack, John M; Bhatt, Deepak L; Kandzari, David E; Brown, David; Brar, Sandeep; Choi, James W; D'Agostino, Ralph; East, Cara; Katzen, Barry T; Lee, Lilian; Leon, Martin B; Mauri, Laura; O'Neill, William W; Oparil, Suzanne; Rocha-Singh, Krishna; Townsend, Raymond R; Bakris, George

2015-10-01

SYMPLICITY HTN-3, the first trial of renal denervation (RDN) versus sham, enrolled 26% African Americans, a prospectively stratified cohort. Although the 6-month systolic blood pressure (SBP) reduction in African Americans (AAs) was similar in the RDN group (-15.5 ± 25.4 mm Hg, n = 85 vs. -17.8 ± 29.2, n = 49, P = .641), the sham SBP response was 9.2 mm Hg greater (P = .057) in AAs than non-AAs. In multivariate analyses, sham SBP response was predicted by an interaction between AA and a complex antihypertensive regimen (at least one antihypertensive medication prescribed ≥3 times daily), while in the RDN group, SBP response was predicted by an interaction between AA race and baseline BP ≥ 180 mm Hg. AA race did not independently predict SBP response in either sham or RDN. There appears to be effect modification by race with individual-level patient characteristics in both treatment arms that affect the observed pattern of SBP responses. Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Adherence to recommended lifestyle modifications and factors associated for hypertensive patients attending chronic follow-up units of selected public hospitals in Addis Ababa, Ethiopia

PubMed Central

Tibebu, Abel; Mengistu, Daniel; Negesa, Lemma

2017-01-01

Introduction One of the most prevalent noncommunicable diseases is hypertension (HTN). The availability of effective antihypertensive medications does not result in the expected outcomes in terms of controlling blood pressure. The rationale for these and other findings of uncontrolled HTN points toward poor adherence. The most neglected causes of uncontrolled HTN are unhealthy lifestyles. Few studies have been conducted to show the gap and magnitude of self-management adherence. Objective This study aimed to assess adherence to recommended lifestyle modifications of hypertensive patients undergoing follow-up at chronic follow-up units of public health hospitals in Addis Ababa, Ethiopia, 2016. Methods Institutional-based cross-sectional study was conducted in four public health hospitals which were selected by drawing lots. Systematic random sampling was used to select study subjects. The results of the descriptive statistics were expressed as percentages and frequencies. Associations between lifestyle modification and independent variables were ana-lyzed using bivariate and multivariate logistic regression analysis. The study was conducted from February 15, 2016 to April 15, 2016. Results The study included 404 respondents with a 97% response rate; 210 (52%) were male and the mean age was 54.00±10.77 years. The respondents’ adherence to lifestyle modifications was 23%. The lifestyle adherence was found to be better in females, patients who had comorbidities, and had been knowledgeable about the disease and was poor among young adult respondents. Conclusion The rates of adherence to lifestyle changes were generally found to be low. Educational sessions that especially focus on lifestyle modifications and ongoing support for patients should be designed and studies which assess all the components of self-management should be conducted for comparison among different subgroups. PMID:28280305

Vascular reactivity of rabbit isolated renal and femoral resistance arteries in renal wrap hypertension.

PubMed

Khammy, Makhala M; Angus, James A; Wright, Christine E

2016-02-15

In rabbits with cellophane renal wrap hypertension, hindquarter and total vascular resistance changes to pressor and depressor agents are amplified compared to those of normotensive rabbits. The aim of the present study was to evaluate the in vitro pharmacodynamics of hypertensive and normotensive rabbit small artery segments isolated from the renal and hindquarter vascular beds. Using wire myography, the full range (Emax) and sensitivity (EC50) to a range of agonists of segments of renal interlobar (≈ 600 µm i.d.), renal arcuate (≈ 250 µm i.d.) and deep femoral branch (≈ 250 µm i.d.) arteries were assessed under normalised conditions of passive tension. Interlobar arteries from hypertensive rabbits were more sensitive (EC50) than those from normotensive rabbits to noradrenaline (6-fold), methoxamine (3-fold) and angiotensin II (3-fold). Arcuate artery reactivity was largely unaffected by hypertension. Deep femoral arteries from hypertensive rabbits had enhanced sensitivity only to noradrenaline (2-fold) and methoxamine (4-fold). Sensitivity to relaxation by acetylcholine was unaffected by hypertension in all arteries. Deep femoral arteries from hypertensive rabbits were more sensitive to sodium nitroprusside than normotensive counterparts. Adenosine caused little relaxation in renal arteries, but full relaxation in deep femoral arteries, unaltered by hypertension. This study found substantial heterogeneity in the pharmacodynamic profile of vessels isolated from different vascular beds and between arterial segments within the kidney. These profiles were differentially affected by hypertension suggesting that hypertension per se is not a resultant of general vascular dysfunction. Copyright © 2016 Elsevier B.V. All rights reserved.

Randomized sham-controlled trial of renal sympathetic denervation in mild resistant hypertension.

PubMed

Desch, Steffen; Okon, Thomas; Heinemann, Diana; Kulle, Konrad; Röhnert, Karoline; Sonnabend, Melanie; Petzold, Martin; Müller, Ulrike; Schuler, Gerhard; Eitel, Ingo; Thiele, Holger; Lurz, Philipp

2015-06-01

Few data are available with regard to the effectiveness of renal sympathetic denervation in patients with resistant hypertension yet only mildly elevated blood pressure (BP). Patients with resistant hypertension and slightly elevated BP (day-time systolic pressure, 135-149 and diastolic pressure, 90-94 mm Hg on 24-hour ambulatory measurement) were randomized in a 1:1 ratio to renal sympathetic denervation with the Symplicity Flex Catheter (Medtronic) or an invasive sham procedure. The primary efficacy end point was the change in 24-hour systolic BP at 6 months between groups in the intention to treat population. A total of 71 patients underwent randomization. Baseline day-time systolic BP was 144.4±4.8 mm Hg in patients assigned to denervation and 143.0±4.7 mm Hg in patients randomized to the sham procedure. The mean change in 24-hour systolic BP in the intention to treat cohort at 6 months was -7.0 mm Hg (95% confidence interval, -10.8 to -3.2) for patients undergoing denervation and -3.5 mm Hg (95% confidence interval, -6.7 to -0.2) in the sham group (P=0.15). In the per protocol population, the change in 24-hour systolic BP at 6 months was -8.3 mm Hg (95% confidence interval, -11.7 to -5.0) for patients undergoing denervation and -3.5 mm Hg (95% confidence interval, -6.8 to -0.2) in the sham group (P=0.042). In patients with mild resistant hypertension, renal sympathetic denervation failed to show a significant reduction in the primary end point of 24-hour systolic BP at 6 months between groups in the intention to treat analysis. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01656096. © 2015 American Heart Association, Inc.

Hypertension, dyslipidemia, and insulin resistance: links in a chain or spokes on a wheel?

PubMed

Hopkins, P N; Hunt, S C; Wu, L L; Williams, G H; Williams, R R

1996-08-01

Rather than a link in a causal chain leading to hypertension, insulin resistance and resultant hyperinsulinemia may be 'spokes on a wheel', with central or visceral obesity as the postulated hub of the wheel. Hypertension, hypertriglyceridemia and high density lipoprotein cholesterol are depicted as other spokes. Newly identified metabolic pathways in adipose tissue or the modulating effects of various predisposing genes may lead to variable expression of various components of the multiple metabolic syndrome in individuals with a predisposition to the collection of visceral fat.

Renal denervation therapy for the treatment of resistant hypertension: a position statement by the Canadian Hypertension Education Program.

PubMed

Khan, Nadia A; Herman, Robert J; Quinn, Robert R; Rabkin, Simon W; Ravani, Pietro; Tobe, Sheldon W; Feldman, Ross D; Wijeysundera, Harindra C; Padwal, Raj S

2014-01-01

Renal denervation is a novel catheter-based, percutaneous procedure using radiofrequency energy to ablate nerves within the renal arteries. This procedure might help to significantly lower blood pressure (BP) in patients with resistant hypertension, defined as BP > 140/90 mm Hg (> 130/80 mm Hg for those with diabetes) despite use of ≥ 3 optimally dosed antihypertensive agents, ideally including 1 diuretic agent. The Canadian Hypertension Education Program Recommendations Task Force reviewed the current evidence on safety and efficacy of this procedure. Eleven studies on renal denervation were examined and most of the evidence evaluating renal denervation was derived from the Symplicity studies. In patients with systolic BP ≥ 160 mm Hg (≥ 150 mm Hg for patients with type 2 diabetes) despite use of ≥ 3 antihypertensive agents, bilateral renal denervation was associated with significantly lower BP (-22/11 to -34/13 mm Hg) at 6 months with a low periprocedural complication rate. Few patients underwent 24-hour ambulatory BP monitoring and ambulatory BP monitoring showed more modest BP lowering (0 to -11/7 mm Hg). Although early results on short-term safety and blood pressure-lowering are encouraging, there are no long-term efficacy and safety data, or hard cardiovascular end point data. The discrepancy between office BP reductions and 24-hour ambulatory BP monitor reductions needs to be further investigated. Until more data are available, renal sympathetic denervation should be considered as a treatment option of last resort for patients with resistant hypertension who have exhausted all other available medical management options. Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Renal denervation for mild-moderate treatment-resistant hypertension : A timely intervention?

PubMed

Chen, S; Kiuchi, M G; Schmidt, B; Hoye, N A; Acou, W-J; Liu, S; Chun, K R J; Pürerfellner, H

2017-12-18

Renal denervation (RDN) has been proposed as a novel antihypertensive intervention for treating resistant hypertension. It remains to be investigated which patient groups can potentially benefit from RDN. The present study aimed to evaluate the efficacy and safety of RDN in patients with mild-moderate resistant hypertension, i. e., systolic office blood pressure (BP) of 140-160 mm Hg despite treatment with three antihypertensive drugs including one diuretic, or mean systolic BP by ambulatory BP monitoring (ABPM) of 135-150 mm Hg. We evaluated data from four relevant clinical studies, all conducted in Europe, comprising 185 eligible patients. The patients' age was 62.1 ± 10.3 years and 73% were male (RDN group n = 149, control group n = 36). A self-control comparison showed that RDN led to significantly reduced ABPM at the 6‑month follow-up (systolic ABPM: 147.3 ± 13.4 mm Hg vs. 136.9 ± 15.5 mm Hg; diastolic ABPM: 81.1 ± 9.6 mm Hg vs. 76.2 ± 9.7 mm Hg; p < 0.001). RDN was associated with a greater improvement in ABPM as compared with that in the control group (∆systolic-ABPM: -10.4 ± 9.4 vs. -3.5 ± 9.6 mm Hg, p < 0.001; ∆diastolic-ABPM: -5 ± 5.8 vs. -2.1 ± 5.5 mm Hg; p = 0.005, respectively). The decrease of office BP in the RDN group was also statistically significant. RDN led to a reduced number of antihypertensive medications. No severe adverse events were found during follow-up. Regression analysis showed that the available baseline characteristics did not correlate with the ABPM improvement after RDN. RDN appears to be a safe and effective intervention for patients with mild-moderate resistant hypertension; however, randomized studies are warranted.

Renin angiotensin aldosterone system altered in resistant hypertension in Sub-Saharan African diabetes patients without evidence of primary hyperaldosteronism.

PubMed

Edinga-Melenge, Bertille Elodie; Ama Moor, Vicky J; Nansseu, Jobert Richie N; Nguetse Djoumessi, Romance; Mengnjo, Michel K; Katte, Jean-Claude; Noubiap, Jean Jacques N; Sobngwi, Eugene

2017-01-01

The renin-angiotensin-aldosterone system may be altered in patients with resistant hypertension. This study aimed to evaluate the relation between renin-angiotensin-aldosterone system activity and resistant hypertension in Cameroonian diabetes patients with resistant hypertension. We carried out a case-control study including 19 diabetes patients with resistant hypertension and 19 diabetes patients with controlled hypertension matched to cases according to age, sex and duration of hypertension since diagnosis. After collection of data, fasting blood was collected for measurement of sodium, potassium, chloride, active renin and plasma aldosterone of which the aldosterone-renin ratio was derived to assess the activity of renin-angiotensin-aldosterone system. Then, each participant received 2000 ml infusion of saline solution after which plasma aldosterone was re-assayed. Potassium levels were lower among cases compared to controls (mean: (4.10 ± 0.63 mmol/l vs. 4.47 ± 0.58 mmol/l), though nonsignificant (p = 0.065). Active renin, plasma aldosterone both before and after the dynamic test and aldosterone-renin ratio were comparable between cases and controls (all p values > 0.05). Plasma aldosterone significantly decreased after the dynamic test in both groups (p < 0.001), but no participant exhibited a post-test value>280 pmol/l. We found a significant negative correlation between potassium ion and plasma aldosterone (ρ = -0.324; p  = 0.047), the other correlations being weak and unsignificant. Although this study failed to show an association between RH and primary hyperaldosteronism in our context, there was a hyperactivity of renin-angiotensin-aldosterone system. Moreover, this study confirms the importance of potassium dosage when screening the renin-angiotensin-aldosterone system.

Raised urinary glucocorticoid and adrenal androgen precursors in the urine of young hypertensive patients: possible evidence for partial glucocorticoid resistance

PubMed Central

Shamim, W; Yousufuddin, M; Francis, D; Gualdiero, P; Honour, J; Anker, S; Coats, A

2001-01-01

OBJECTIVE—To evaluate urinary glucocorticoid excretion profiles in a cohort of recently diagnosed young hypertensive patients.
METHODS—After excluding patients with secondary causes, 60 individuals with premature hypertension were recruited (diagnosed by ambulatory blood pressure monitoring before the age of 36 years). In addition, 30 older hypertensive controls (age of onset > 36 years, "middle aged hypertensive controls"), and 30 normal controls (age matched to the young hypertensive group) were studied. All provided 24 hour urine collections for mass spectrometry for total cortisol metabolites and total androgen metabolites by gas chromatography.
RESULTS—Among male patients, those with premature hypertension had higher total urinary excretion of cortisol metabolites (mean (SD), 13 332 (6472) µg/day) than age matched normal controls (7270 (1788) µg/day; p = 0.00001) or middle aged hypertensive controls (8315 (3565) µg/day; p = 0.002). A similar increase was seen among the female patients, although the absolute concentrations were lower. There was no significant difference between middle aged hypertensive patients and normal controls. Urinary total androgen excretion profiles in female patients also showed an unusual increase in the premature hypertension group (2958 (1672) µg/day) compared with the other groups (middle aged hypertensive controls, 1373 (748) µg/day, p = 0.0003; normal controls, 1687 (636) µg/day, p = 0.002). In all subjects, serum sodium and creatinine concentrations were within the normal range; serum potassium concentrations were found to be low before the start of treatment.
CONCLUSIONS—Individuals presenting with premature hypertension have an abnormally high excretion of glucocorticoid metabolites in the urine. While the mechanism remains uncertain, these findings are compatible with partial resistance of the glucocorticoid receptors, with a compensatory increase in cortisol and androgen

Influence of endurance and resistance exercise order on the postexercise hemodynamic responses in hypertensive women.

PubMed

Menêses, Annelise Lins; Forjaz, Cláudia Lúcia de Moraes; de Lima, Paulo Fernando Marinho; Batista, Rafael Marinho Falcão; Monteiro, Maria de Fátima; Ritti-Dias, Raphael Mendes

2015-03-01

The study aims to evaluate the effects of the order of endurance and resistance exercises on postexercise blood pressure (BP) and hemodynamics in hypertensive women. Nineteen hypertensive women underwent 3 sessions: control (50 minutes rest), endurance (50-60% of heart rate reserve) followed by resistance exercise (50% of 1 repetition maximum) (E + R), and resistance followed by endurance exercise (R + E). Before and 30 minutes after each session, BP, peripheral vascular resistance, cardiac output, stroke volume, and heart rate were measured. Postexercise increases in systolic (E + R: +1 ± 3 mm Hg and R + E: +3 ± 3 mm Hg), diastolic (E + R: +3 ± 1 mm Hg and R + E: +3 ± 2 mm Hg), and mean BP (E + R: +3 ± 1 mm Hg and R + E: +3 ± 2 mm Hg) were significantly lower after the exercise sessions compared with the control session (p ≤ 0.05). The exercise sessions abolished the increases in peripheral vascular resistance (E + R: +0.00 ± 0.04 mm Hg·min·L and R + E: +0.05 ± 0.05 mm Hg·min·L) and the decreases in cardiac output (E + R: +0.04 ± 0.28 L·min and R + E: -0.26 ± 0.28 L·min) observed after the control session (p ≤ 0.05). After the exercise sessions, stroke volume decreased (E + R: -14 ± 3 ml and R + E: -9 ± 4 ml) and heart rate increased (E + R: +5 ± 1 b·min and R + E: +4 ± 1 b·min) in comparison with the control session (p ≤ 0.05). For all the variables, there were no significant differences between the exercise sessions. Regardless of the order of endurance and resistance exercises, combined exercise sessions abolished increases in BP observed in a control condition due to a reduction in peripheral vascular resistance and increases in cardiac output. Thus, combined exercises should be prescribed to individuals with hypertension to control their BP, regardless of the order they are accomplished.

Potential lifetime cost-effectiveness of catheter-based renal sympathetic denervation in patients with resistant hypertension.

PubMed

Dorenkamp, Marc; Bonaventura, Klaus; Leber, Alexander W; Boldt, Julia; Sohns, Christian; Boldt, Leif-Hendrik; Haverkamp, Wilhelm; Frei, Ulrich; Roser, Mattias

2013-02-01

Recent studies have demonstrated the safety and efficacy of catheter-based renal sympathetic denervation (RDN) for the treatment of resistant hypertension. We aimed to determine the cost-effectiveness of this approach separately for men and women of different ages. A Markov state-transition model accounting for costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness was developed to compare RDN with best medical therapy (BMT) in patients with resistant hypertension. The model ran from age 30 to 100 years or death, with a cycle length of 1 year. The efficacy of RDN was modelled as a reduction in the risk of hypertension-related disease events and death. Analyses were conducted from a payer's perspective. Costs and QALYs were discounted at 3% annually. Both deterministic and probabilistic sensitivity analyses were performed. When compared with BMT, RDN gained 0.98 QALYs in men and 0.88 QALYs in women 60 years of age at an additional cost of €2589 and €2044, respectively. As the incremental cost-effectiveness ratios increased with patient age, RDN consistently yielded more QALYs at lower costs in lower age groups. Considering a willingness-to-pay threshold of €35 000/QALY, there was a 95% probability that RDN would remain cost-effective up to an age of 78 and 76 years in men and women, respectively. Cost-effectiveness was influenced mostly by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN non-responders, and the procedure costs of RDN. Renal sympathetic denervation is a cost-effective intervention for patients with resistant hypertension. Earlier treatment produces better cost-effectiveness ratios.

[The Use of Telemedicine Interventions to Improve Hypertension Management Among Racial Ethnic Minorities: A Systematic Review].

PubMed

Li, Wen-Wen; Lai, Wei-Shu

2016-08-01

Racial ethnic minorities are one of the fastest growing populations in Taiwan. In recent years, there has been an increase in literature addressing the efficacy of home blood-pressure (BP) management that uses telemedicine interventions in general healthcare and community settings. However, no study or systematic literature review has yet assessed the effectiveness of using telemedicine HTN interventions in Taiwan's indigenous, new-immigrant, and other minority populations. The purpose of the present paper is to review the current literature on the use of telemedicine interventions to assist HTN management among racial ethnic minorities. A comprehensive literature search was conducted for full-text articles that were published between January 2000 and December 2015 using the following databases: PubMed, WEB of Science, CINAHL (Cumulative Index to Nursing & Allied Health Literature), PsycINFO, Science Direct, ProQuest, Medline, Cochrane Library, National Dissertations and Theses, and airiti Library. The search used the following key search terms both alone and in combination: hypertension, blood pressure, management, telemedicine, telehealth, ehealth, and digital health. The studies were thoroughly assessed under the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 6 articles met the criteria for using keywords related to racial ethnic minority populations and were used in the present review. Findings of this systematic review show that telemedicine interventions significantly improve HTN management. The intervention that combined home telemonitoring with culturally competent nurse counseling calls was identified as the best intervention for reducing BP. As the current literature on this topic is limited to African-Americans, more research is necessary to validate our findings. Future studies should target racial ethnic minorities in Taiwan in order to better understand how to provide culturally appropriate

Chemical denervation of the renal artery with vincristine for the treatment of resistant arterial hypertension: first-in-man application.

PubMed

Stefanadis, Christodoulos; Toutouzas, Konstantinos; Vlachopoulos, Charalambos; Tsioufis, Costas; Synetos, Andreas; Pietri, Panagiota; Tousoulis, Dimitris; Tsiamis, Eleftherios

2013-01-01

Renal artery denervation has recently emerged as a novel therapy for patients with resistant hypertension. Clinical results from renal sympathetic denervation support the safety and efficacy of this method over a period of 18 months. However, several limitations have been reported. Previous studies have shown that chemical denervation by vincristine is safe and effective in an experimental model. We describe the first-in-man application of chemical denervation with vincristine in a 74-year-old male patient with resistant arterial hypertension.

The effect of spironolactone in patients with resistant arterial hypertension in relation to baseline blood pressure and secondary causes of hypertension.

PubMed

Vaclavik, Jan; Sedlak, Richard; Jarkovsky, Jiri; Kocianova, Eva; Taborsky, Milos

2013-03-01

There are currently limited data about whether the effect of spironolactone in patients with resistant arterial hypertension depends on baseline blood pressure and the presence of a secondary cause of hypertension. Patients with office systolic blood pressure (BP) >140 mmHg or diastolic BP >90 mmHg, despite treatment with at least 3 antihypertensive drugs including a diuretic, were randomly assigned to receive spironolactone or a placebo for 8 weeks in a double-blind, placebo-controlled, multicentre trial (ASPIRANT). Analyses were done with 55 patients treated with spironolactone. The degree of BP reduction after 8 weeks of spironolactone treatment did not differ significantly between the three tertiles of baseline systolic BP and patients with and without a secondary cause of hypertension. The reduction of office systolic, office diastolic BP and office pulse pressure was significantly lower in the highest tertile with baseline diastolic BP > 97 mmHg. Spironolactone treatment is effective to a similar extent both in patients with and without a secondary cause of hypertension and regardless of the baseline value of systolic BP. Less effect of spironolactone was found in patients with the highest baseline diastolic BP.

Renal sympathetic denervation in hypertension.

PubMed

Doumas, Michael; Faselis, Charles; Papademetriou, Vasilios

2011-11-01

Despite the abundance of antihypertensive drugs, resistant hypertension remains a major clinical problem. Recent technological advances render interventional management of resistant hypertension one of the hottest topics in the hypertension field. The aim of this review is to present the pathophysiologic background and the mechanisms mediating blood pressure reduction after renal sympathetic denervation, to analyze recent findings with this fascinating approach and to critically suggest future research directions. Catheter-based, ablation-induced renal sympathetic denervation was initially studied in 45 patients with resistant hypertension in a proof-of-concept study. Impressive blood pressure reductions of about 30/15  mmHg were achieved at 6 months, without serious complications. A second, controlled, randomized (but not blinded) study confirmed the results, verifying the efficacy and safety of the procedure. A recent report revealed the 2-year durability of blood pressure reduction. Data published so far indicate that ablation-induced renal denervation is a feasible, effective, and well tolerated interventional approach for the management of resistant hypertension. The groundbreaking studies of renal denervation in drug-resistant hypertension pave the way for further research in other disease conditions in which sympathetic overactivity seems to play a critical role. This initial wave of enthusiasm needs to be followed by rigorous investigation, for the proper identification of the potential and the limitations, indications, and contraindications of this approach.

Elevated plasma migration inhibitory factor in hypertension–hyperlipidemia patients correlates with impaired endothelial function

PubMed Central

Zhou, Boda; Ren, Chuan; Zu, Lingyun; Zheng, Lemin; Guo, Lijun; Gao, Wei

2016-01-01

Abstract Migration inhibitory factor (MIF) has been shown to be critical in the pathology of early artherosclerosis; this article aim to investigate the plasma levels of MIF in hypertension plus hyperlipidemia patients. A total of 39 hypertension plus hyperlipidemia patients without any previous treatment were enrolled (HTN-HLP). Twenty-five healthy subjects were enrolled as the healthy control group (HEALTHY). Plasma MIF was measured by ELISA; laboratory and clinical characteristics were analyzed. HUVECs were treated with pooled plasma from HTN-HLP and HEALTHY groups, and the protein levels of adhesion molecules VCAM-1 and ICAM-1 were determined by ELISA. We found that plasma MIF was significantly elevated in the HTN-HLP group. Serum NO and eNOS levels were significantly lower; serum ET-1 (endothelin) levels were significantly higher in the HTN-HLP group. Furthermore, blood pressure, baPWV (brachial–ankle pulse wave velocity), and serum ET-1 level were significantly positively; serum NO and eNOS levels were negatively correlated with plasma MIF levels. Plasma from HTN-HLP significantly stimulated VCAM-1 and ICAM-1 protein expression on the surface of HUVECs. Plasma MIF was elevated in HTN-HLP patients and correlates with impaired endothelial function. PMID:27787379

Adiponectin, insulin resistance, and left ventricular structure in dipper and nondipper essential hypertensive patients.

PubMed

Della Mea, Paolo; Lupia, Mario; Bandolin, Valentina; Guzzon, Samuele; Sonino, Nicoletta; Vettor, Roberto; Fallo, Francesco

2005-01-01

Adiponectin is an adipocyte-derived protein with insulin-sensitizing and antiatherogenic properties. Failure to decrease blood pressure (BP) normally during night in hypertensive patients has been independently associated with left ventricular hypertrophy. We examined the relationship between adiponectin levels, insulin sensitivity, and left ventricular structure in 40 newly diagnosed never-treated patients with essential hypertension, including 20 patients with a normal night-time pressure decrease (ie, dippers) and 20 patients with BP persistently elevated throughout the 24-h period (ie, nondippers). All subjects had grade 1-2 hypertension, aged 18 to 65 years, no diabetes mellitus, no obesity, no hyperlipidemia, and no cardiopulmonary, renal, or hepatic disease. The two groups of patients were similar for age, sex, body mass index, and had no differences for clinic, 24-h, and diurnal BP, and 24-h, diurnal, and nocturnal heart rate, as well as glucose, total cholesterol, and triglyceride levels. Plasma insulin and homeostasis model assessment (HOMA index) were higher (P < .01), and adiponectin levels were lower (P < .005) in nondippers than in dippers. Adiponectin correlated inversely with HOMA index and insulin levels (r = -0.58, and r = -0.62, respectively, P < .001) in the entire population. Nondippers showed left ventricular mass, relative wall thickness, and measure of early and late diastolic peak flow velocity ratio similar to those of dippers. In the absence of major cardiovascular risk factors, nondipper essential hypertensive patients show more prominent insulin resistance and lower adiponectin compared to dippers. Therapeutic modulation of adiponectin or insulin resistance might provide additional benefit to the conventional antihypertensive treatment.

[Diagnostic of secondary hypertension in clinical practice].

PubMed

Somlóová, Z; Rosa, J; Petrák, O; Strauch, B; Zelinka, T; Holaj, R; Widimský, J

2011-09-01

Arterial hypertension is a common worldwide disease with a prevalence of approximately 26%. Secondary cause is known in 5-10% of patients with hypertension. We should think of secondary hypertension in all patients with resistant hypertension, in patients with sudden deterioration in the control of hypertension and in patients with laboratory and clinical signs of diseases associated with secondary hypertension. It is important to distinguish between secondary hypertension and pseudo-resistance (noncompliance to treatment, white coat syndrome). Secondary causes of hypertension can be divided into endocrine (primary aldosteronism, pheochromocytoma, hypercortisolism, hyperparathyreoidism), renal - renovascular and renal parenchymal hypertension, and other causes as sleep apnoe syndrome, hypertension in pregnancy, coarctation of the aorta and intracranial tumors.

Insulin resistance and GLUT-4 glucose transporter in adipocytes from hypertensive rats.

PubMed

Chiappe De Cingolani, Gladys E; Caldiz, Claudia I

2004-03-01

To investigate the mechanisms that cause insulin resistance in hypertension, experiments were performed to study the effect of insulin on glucose transport, GLUT-4 translocation from intracellular to plasma membranes and GLUT-4 phosphorylation in isolated adipocytes from normotensive Wistar (W) and spontaneously hypertensive rats (SHR). Glucose transport was measured in adipocytes incubated with 3-O-d[Methyl-(3)H] glucose with and without insulin (0.1 to 5 nmol/L). GLUT-4 protein was determined by Western blot immunoanalysis with GLUT-4 antibody. Phosphorylation of GLUT-4 was measured by immunoprecipitation with GLUT-4 antibody followed by immunoanalysis with phosphoserine or phosphothreonine antibodies. Compared with adipocytes from W, insulin-stimulated glucose transport was lower in the SHR (P <.05). GLUT-4 protein expression was similar in adipocytes from W and SHR. Insulin increased GLUT-4 translocation from intracellular to plasma membranes in both groups. This effect was lower in the SHR (P <.05). The effect of insulin on GLUT-4 serine phosphorylation showed no changes in plasma membranes from W and decreased in the SHR (P <.05). In intracellular membranes, insulin increased specific GLUT-4 serine phosphorylation in both groups (P <.05), but the increase was lower in the SHR (P <.05). The results suggest that a deficient GLUT-4 translocation to plasma membranes in response to insulin shown in adipocytes from SHR, which was accompanied by a decrease in GLUT-4 phosphorylation at serine site, could be one of the causes of insulin resistance in hypertension.

Endothelin-1 exacerbates development of hypertension and atherosclerosis in modest insulin resistant syndrome

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lin, Yan-Jie; Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan; Juan, Chi-Chang

Endothelin-1 (ET-1) is known as potent vasoconstrictor, by virtue of its mitogenic effects, and may deteriorate the process of hypertension and atherosclerosis by aggravating hyperplasia and migration in VSMCs. Our previous study demonstrated that insulin infusion caused sequential induction of hyperinsulinemia, hyperendothelinemia, insulin resistance, and then hypertension in rats. However, the underlying mechanism of ET-1 interfere insulin signaling in VSMCs remains unclear. To characterize insulin signaling during modest insulin resistant syndrome, we established and monitored rats by feeding high fructose-diet (HFD) until high blood pressure and modest insulin resistance occurred. To explore the role of ET-1/ET{sub A}R during insulin resistance,more » ET{sub A}R expression, ET-1 binding, and insulin signaling were investigated in the HFD-fed rats and cultured A-10 VSMCs. Results showed that high blood pressure, tunica medial wall thickening, plasma ET-1 and insulin, and accompanied with modest insulin resistance without overweight and hyperglycemia occurred in early-stage HFD-fed rats. In the endothelium-denuded aorta from HFD-fed rats, ET{sub A}R expression, but not ET{sub B}R, and ET-1 binding in aorta were increased. Moreover, decreasing of insulin-induced Akt phosphorylation and increasing of insulin-induced ERK phosphorylation were observed in aorta during modest insulin resistance. Interestingly, in ET-1 pretreated VSMCs, the increment of insulin-induced Akt phosphorylation was decreased whereas the increment of insulin-induced ERK phosphorylation was increased. In addition, insulin potentiated ET-1-induced VSMCs migration and proliferation due to increasing ET-1 binding. ETAR antagonist reversed effects of ET-1 on insulin-induced signaling and VSMCs migration and proliferation. In summary, modest insulin resistance syndrome accompanied with hyperinsulinemia leading to the potentiation on ET-1-induced actions in aortic VSMCs. ET-1 via ET{sub A}R pathway

Resistant hypertension: risk factors, subclinical atherosclerosis, and comorbidities among adults-the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

PubMed

Lotufo, Paulo A; Pereira, Alexandre C; Vasconcellos, Paulo S; Santos, Itamar S; Mill, Jose Geraldo; Bensenor, Isabela M

2015-01-01

The frequency of resistant hypertension-defined as blood pressure (BP) ≥140/90 mm Hg with proven use of three antihypertensive medications, or as the use of four antihypertensive drug classes regardless of BP-is unknown in low-middle-income countries. Using data from the Brazilian Longitudinal Study of Adult Health, a cohort of 15,105 civil servants aged 35 to 74 years, the authors identified 4116 patients taking treatment for hypertension, 11% of who had resistant hypertension. These participants were more likely to be older, black, less educated, poorer, and obese. The adjusted prevalence ratios (95% confidence intervals) were diabetes, 1.44 (1.20-1.72); glomerular filtration rate (<60 mL/min/1.72 m(2) ), 1.95 (1.60-2.38); albumin-to-creatinine ratio (>300 mg/g), 2.43 (1.70-3.50); carotid-femoral pulse-wave velocity, 1.07 m/s (1.03-1.11 m/s); common carotid intima-media thickness, 2.57 mm (1.64-4.00 mm); left ventricular hypertrophy, 2.08 (1.21-3.57); and atrial fibrillation, 3.55 (2.02-6.25). Thus, the prevalence of resistant hypertension in Brazil is high and associated with subclinical markers of end-organ cardiovascular damage. © 2014 Wiley Periodicals, Inc.

The effect of an L/N-type calcium channel blocker on intradialytic blood pressure in intradialytic hypertensive patients.

PubMed

Ito, Takayasu; Fujimoto, Naoki; Ishikawa, Eiji; Dohi, Kaoru; Fujimoto, Mika; Murata, Tomohiro; Kiyohara, Michiyo; Takeuchi, Hideyuki; Koyabu, Sukenari; Nishimura, Hiroyuki; Takeuchi, Toshiaki; Ito, Masaaki

2018-03-27

Intradialytic hypertension (HTN), which is one of the poor prognostic markers in patients undergoing hemodialysis, may be associated with sympathetic overactivity. The L/N-type calcium channel blocker, cilnidipine, has been reported to suppress sympathetic nerves activity in vivo. Therefore, we hypothesized that cilnidipine could attenuate intradialytic systolic blood pressure (SBP) elevation. Fifty-one patients on chronic hemodialysis who had intradialytic-HTN (SBP elevation ≥10 mmHg during hemodialysis) and no fluid overload were prospectively randomized into two groups: control and cilnidipine groups. Cilnidipine group patients took cilnidipine (10 mg/day) for 12 weeks. The primary endpoint was the change in the intradialytic SBP elevation before and after the 12-week intervention. Before the intervention, no differences were observed in age, sex or pre-dialytic SBP (148.5 ± 12.9 vs. 148.3 ± 19.3 mmHg) between the two groups. Intradialytic SBP elevation was unchanged in the control group. Cilnidipine significantly lowered the post-dialytic SBP with an attenuation of the intradialytic SBP elevation from 12.0 ± 15.4 mmHg to 4.8 ± 10.1 mmHg. However, the observed difference in the intradialytic SBP elevation by cilnidipine did not reach statistical significance (group×time interaction effect p = 0.25). Cathecolamine levels were unaffected by the intervention in both groups. Cilnidipine lowers both the pre- and post-dialytic SBP and might attenuate intradialytic SBP elevation. Therefore, cilnidipine may be effective in lowering SBP during HD in patients with intradialytic-HTN.

Short-term endurance training after coronary artery bypass grafting improves insulin resistance parameters in patients with hypertension.

PubMed

Borowicz-Bieńkowska, Sławomira; Przywarska, Izabela; Dylewicz, Piotr; Pilaczyńska-Szcześniak, Łucja; Rychlewski, Tadeusz; Wilk, Małgorzata; Rózańska, Anna

2004-05-01

It has been shown that short-term exercise training improves insulin resistance parameters in patients with ischaemic heart disease. The effects of such a rehabilitation programme in patients with hypertension have not been well established. To assess whether short-term endurance training after coronary artery bypass grafting (CABG) may improve metabolic parameters and reduce blood pressure in patients with hypertension. The study group consisted of 30 male patients (15 with hypertension and 15 normotensive) aged 55+/-2.1 years who underwent CABG 1 to 6 months before the initiation of a 3-week endurance training. Glucose, insulin and C-peptide blood levels as well as binding and degradation of 125I-insulin by erythrocyte receptors were assessed before and after the training programme. The effects of training on blood pressure values were also evaluated. A significant improvement (p<0.01) in the insulin resistance parameters, i.e. binding and degradation of labelled insulin was noted only in patients with hypertension. This was accompanied by a significant (p<0.05) increase in the HDL-cholesterol level. In the subgroup with hypertension, both the exercise systolic and diastolic pressures decreased significantly (p<0.05 and p<0.01, respectively), and similar changes were noted in the resting systolic and diastolic blood pressures values (p<0.05). Rehabilitation after CABG based on the endurance training was especially effective in patients with hypertension in whom beneficial changes in some metabolic risk factors of ischaemic heart disease as well as the reduction in the blood pressure values were observed.

Role of genetic variation in insulin-like growth factor 1 receptor on insulin resistance and arterial hypertension.

PubMed

Sookoian, Silvia; Gianotti, Tomas Fernandez; Gemma, Carolina; Burgueño, Adriana L; Pirola, Carlos J

2010-06-01

To perform a two-stage study to explore the role of gene variants in the risk of insulin resistance and arterial hypertension. The selection of variants was performed by a first stage of in-silico analysis of the original genome-wide association data sets on genes involved in metabolic syndrome components, granted by the Diabetes Genetics Initiative and the Wellcome Trust Case-Control Consortium. We started by identifying single-nucleotide polymorphisms with a cutoff for association (P < 0.05) in both data sets after the application of a computational algorithm of gene prioritization. Among the more promising variants, six single-nucleotide polymorphisms in IGF1R (rs11247362, rs10902606, rs1317459, rs11854132, rs2684761, and rs2715416) were selected for further evaluation in our population. Altogether, 1094 men, aged 34.4 +/- 8.6 years, were included in a population-based study. Genotypes of rs2684761 showed significant association with insulin resistance (as a discrete trait, odds ratio per G allele 1.27, 95% confidence interval 1.03-1.56, P = 0.026; and homeostasis model assessment-insulin resistance as a continuous trait, P = 0.01). A significant association of rs2684761 with arterial hypertension was also observed (odds ratio per G allele 1.29, 95% confidence interval 1.02-1.64, P = 0.037) after adjusting for age and homeostasis model assessment-insulin resistance. Our study suggests for the first time a putative role of IGF1R variants in individual susceptibility to metabolic syndrome-related phenotypes, in particular on the risk of having insulin resistance and arterial hypertension.

Resistant Hypertension, Patient Characteristics, and Risk of Stroke

PubMed Central

Hung, Chen-Ying; Wang, Kuo-Yang; Wu, Tsu-Juey; Hsieh, Yu-Cheng; Huang, Jin-Long; Loh, El-Wui; Lin, Ching-Heng

2014-01-01

Background Little is known about the prognosis of resistant hypertension (RH) in Asian population. This study aimed to evaluate the impacts of RH in Taiwanese patients with hypertension, and to ascertain whether patient characteristics influence the association of RH with adverse outcomes. Methods and Results Patients aged ≥45 years with hypertension were identified from the National Health Insurance Research Database. Medical records of 111,986 patients were reviewed in this study, and 16,402 (14.6%) patients were recognized as having RH (continuously concomitant use of ≥3 anti-hypertensive medications, including a diuretic, for ≥2 years). Risk of major adverse cardiovascular events (MACE, a composite of all-cause mortality, acute coronary syndrome, and stroke [included both fatal and nonfatal events]) in patients with RH and non-RH was analyzed. A total of 11,856 patients experienced MACE in the follow-up period (average 7.1±3.0 years). There was a higher proportion of females in the RH group, they were older than the non-RH (63.1 vs. 60.5 years) patients, and had a higher prevalence of cardiovascular co-morbidities. Overall, patients with RH had higher risks of MACE (adjusted HR 1.17; 95%CI 1.09–1.26; p<0.001). Significantly elevated risks of stroke (10,211 events; adjusted HR 1.17; 95%CI 1.08–1.27; p<0.001), especially ischemic stroke (6,235 events; adjusted HR 1.34; 95%CI 1.20–1.48; p<0.001), but not all-cause mortality (4,594 events; adjusted HR 1.06; 95%CI 0.95–1.19; p = 0.312) or acute coronary syndrome (2,145 events; adjusted HR 1.17; 95%CI 0.99–1.39; p = 0.070) were noted in patients with RH compared to those with non-RH. Subgroup analysis showed that RH increased the risks of stroke in female and elderly patients. However, no significant influence was noted in young or male patients. Conclusions Patients with RH were associated with higher risks of MACE and stroke, especially ischemic stroke. The risks were greater in female and

Urinary albumin excretion is associated with nocturnal systolic blood pressure in resistant hypertensives.

PubMed

Oliveras, Anna; Armario, Pedro; Martell-Clarós, Nieves; Ruilope, Luis M; de la Sierra, Alejandro

2011-03-01

Microalbuminuria is a known marker of subclinical organ damage. Its prevalence is higher in patients with resistant hypertension than in subjects with blood pressure at goal. On the other hand, some patients with apparently well-controlled hypertension still have microalbuminuria. The current study aimed to determine the relationship between microalbuminuria and both office and 24-hour ambulatory blood pressure. A cohort of 356 patients (mean age 64 ± 11 years; 40.2% females) with resistant hypertension (blood pressure ≥ 140 and/or 90 mm Hg despite treatment with ≥ 3 drugs, diuretic included) were selected from Spanish hypertension units. Patients with estimated glomerular filtration rate <30 mL/min/1.73 m(2) were excluded. All patients underwent clinical and demographic evaluation, complete laboratory analyses, and good technical-quality 24-hour ambulatory blood pressure monitoring. Urinary albumin/creatinine ratio was averaged from 3 first-morning void urine samples. Microalbuminuria (urinary albumin/creatinine ratio ≥ 2.5 mg/mmol in males or ≥ 3.5 mg/mmol in females) was detected in 46.6%, and impaired renal function (estimated glomerular filtration rate <60 mL/min/1.73 m(2)) was detected in 26.8%. Bivariate analyses showed significant associations of microalbuminuria with older age, reduced estimated glomerular filtration rate, increased nighttime systolic blood pressure, and elevated daytime, nighttime, and 24-hour diastolic blood pressure. In a logistic regression analysis, after age and sex adjustment, elevated nighttime systolic blood pressure (multivariate odds ratio, 1.014 [95% CI, 1.001 to 1.026]; P=0.029) and reduced estimated glomerular filtration rate (multivariate odds ratio, 2.79 [95% CI, 1.57 to 4.96]; P=0.0005) were independently associated with the presence of microalbuminuria. We conclude that microalbuminuria is better associated with increased nighttime systolic blood pressure than with any other office and 24-hour ambulatory blood

Post-resistance exercise hypotension in spontaneously hypertensive rats is mediated by nitric oxide.

PubMed

Lizardo, J H F; Silveira, E A A; Vassallo, D V; Oliveira, E M

2008-07-01

1. Postexercise hypotension (PEH) plays an important role in the non-pharmacological treatment of hypertension. It is characterized by a decrease in blood pressure (BP) after a single bout of exercise in relation to pre-exercise levels. 2. The present study investigated the effect of a single session of resistance exercise, as well as the effect of nitric oxide (NO) and the autonomic nervous system (ANS), in PEH in spontaneously hypertensive rats (SHR). 3. Catheters were inserted into the left carotid artery and left jugular vein of male SHR (n = 37) for the purpose of measuring BP or heart rate (HR) and drug or vehicle administration, respectively. Haemodynamic measurements were made before and after acute resistance exercise. The roles of NO and the ANS were investigated by using N(G)-nitro-L-arginine methyl ester (L-NAME; 15 mg/kg, i.v.) and hexamethonium (20 mg/kg, i.v.) after a session of acute resistance exercise. 4. Acute resistance exercise promoted a pronounced reduction in systolic and diastolic BP (-37 +/- 1 and -8 +/- 1 mmHg, respectively; P < 0.05), which was suppressed after treatment with L-NAME. The reduction in systolic BP caused by exercise (-37 +/- 1 mmHg) was not altered by the administration of hexamethonium (-38 +/- 2 mmHg; P > 0.05). After exercise, the decrease in diastolic BP was greater with hexamethonium (-26 +/- 1 mmHg; P < 0.05) compared with the decrease caused by exercise alone. 5. The results suggest that acute resistance exercise has an important hypotensive effect on SHR and that NO plays a crucial role in this response.

[Benefits of spironolactone as the optimal treatment for drug resistant hypertension. Pathway-2 trial review].

PubMed

Prado, J C; Ruilope, L M; Segura, J

Pathway-2 is the first randomised, double-blind and crossover trial that compares spironolactone as a fourth drug with alfa-blocker, beta-blocker and placebo. This study shows that spironolactone is the drug with more possibilities of success for the management of patients with difficult-to-treat hypertension in patients with a combination of three drugs and poor control. The results validate the widespread treatment with mineralocorticoid receptor antagonists in resistant hypertension. Copyright © 2016 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.

[What are the pharmacological options for treating resistant hypertension?

PubMed

Martell-Claros, N; Abad-Cardiel, M

2017-01-01

When treating a patient with resistant hypertension therapy should be optimize in order to prescribe three antihypertensive drugs at full doses, being powerful drugs, having 24-hour coverage, and showing synergistic effects. Diuretic therapy is of special relevance. The fourth drug should be an aldosterone antagonists. In the case of intolerance, or when control is not achieved, drugs from other type of antihypertensive drugs should be, sometimes allowing adequate blood pressure control. Copyright © 2017 Sociedad Española de Hipertension-Liga Española para la Lucha de la Hipertensión Arterial (SEH-LELHA). Publicado por Elsevier España, S.L.U. All rights reserved.

Developing an Integrated Treatment Pathway for a Post-Coronary Artery Bypass Grating (CABG) Geriatric Patient with Comorbid Hypertension and Type 1 Diabetes Mellitus for Treating Acute Hypoglycemia and Electrolyte Imbalance.

PubMed

Naqvi, Atta Abbas; Shah, Amna; Ahmad, Rizwan; Ahmad, Niyaz

2017-01-01

The ailments afflicting the elderly population is a well-defined specialty of medicine. It calls for an immaculately designed health-care plan to treat diseases in geriatrics. For chronic illnesses such as diabetes mellitus (DM), coronary heart disease, and hypertension (HTN), they require proper management throughout the rest of patient's life. An integrated treatment pathway helps in treatment decision-making and improving standards of health care for the patient. This case describes an exclusive clinical pharmacist-driven designing of an integrated treatment pathway for a post-coronary artery bypass grafting (CABG) geriatric male patient with DM type I and HTN for the treatment of hypoglycemia and electrolyte imbalance. The treatment begins addressing the chief complaints which were vomiting and unconsciousness. Biochemical screening is essential to establish a diagnosis of electrolyte imbalance along with blood glucose level after which the integrated pathway defines the treatment course. This individualized treatment pathway provides an outline of the course of treatment of acute hypoglycemia, electrolyte imbalance as well as some unconfirmed diagnosis, namely, acute coronary syndrome and respiratory tract infection for a post-CABG geriatric patient with HTN and type 1 DM. The eligibility criterion for patients to be treated according to treatment pathway is to fall in the defined category.

Comparisons of sleep apnoea rate and outcomes among patients with resistant and non-resistant hypertension.

PubMed

Bhandari, Simran K; Shi, Jiaxiao; Molnar, Miklos Z; Rasgon, Scott A; Derose, Stephen F; Kovesdy, Csaba P; Calhoun, David A; Kalantar-Zadeh, Kamyar; Jacobsen, Steven J; Sim, John J

2016-11-01

We directly compared sleep apnoea (SA) rates and risk of cardiovascular and mortality outcomes among SA patients with resistant hypertension (RH) and non-RH within a large diverse hypertension population. A retrospective cohort study between 1 January 2006 and 31 December 2010 among hypertensive adults (age ≥ 18 years) was performed within an integrated health system. Rates of SA in RH and non-RH were determined. Multivariable logistic regression analyses were used to calculate OR for SA. Cox proportional hazard modelling was used to estimate hazard ratios (HRs) for cardiovascular and mortality outcomes between SA in RH versus SA in non-RH adjusting for age, gender, race, BMI, chronic kidney disease and other comorbidities. SA was identified in 33 682 (7.2%) from 470 386 hypertensive individuals. SA in RH accounted for 5806 (9.6%) compared to SA in non-RH 27 876 individuals (6.8%). Multivariable OR (95% CI) for SA was 1.16 (1.12, 1.19), 3.57 (3.47, 3.66) and 2.20 (2.15, 2.25) for RH versus non-RH, BMI ≥ 30, and males, respectively. Compared to SA in non-RH individuals, SA in RH had a multivariable adjusted HR (95% CI) of 1.24 (1.13, 1.36), 1.43 (1.28, 1.61), 0.98 (0.85, 1.12) and 1.04 (0.95, 1.14) for ischaemic heart event (IHE), congestive heart failure (CHF), stroke and mortality, respectively. We observed a modest increase in likelihood for SA among RH compared to non-RH patients. Risks for IHE and CHF were higher for SA in RH compared to SA in non-RH patients; however, there were no differences in risk for stroke and mortality. © 2016 Asian Pacific Society of Respirology.

Effects of supervised exercise and dietary nitrate in older adults with controlled hypertension and/or heart failure with preserved ejection fraction.

PubMed

Shaltout, Hossam A; Eggebeen, Joel; Marsh, Anthony P; Brubaker, Peter H; Laurienti, Paul J; Burdette, Jonathan H; Basu, Swati; Morgan, Ashley; Dos Santos, Patricia C; Norris, James L; Morgan, Timothy M; Miller, Gary D; Rejeski, W Jack; Hawfield, Amret T; Diz, Debra I; Becton, J Thomas; Kim-Shapiro, Daniel B; Kitzman, Dalane W

2017-09-30

Aerobic exercise training is an effective therapy to improve peak aerobic power (peak VO 2 ) in individuals with hypertension (HTN, AHA/ACC class A) and heart failure patients with preserved ejection fraction (HFpEF). High nitrate containing beetroot juice (BRJ) also improves sub-maximal endurance and decreases blood pressure in both HTN and HFpEF. We hypothesized that combining an aerobic exercise and dietary nitrate intervention would result in additive or even synergistic positive effects on exercise tolerance and blood pressure in HTN or HFpEF. We report results from two pilot studies examining the effects of supervised aerobic exercise combined with dietary nitrate in patients with controlled HTN (n = 26, average age 65 ± 5 years) and in patients with HFpEF (n = 20, average age 69 ± 7 years). All patients underwent an aerobic exercise training regimen; half were randomly assigned to consume a high nitrate-containing beet juice beverage (BRJ containing 6.1 mmol nitrate for the HFpEF study consumed three times a week and 8 mmol nitrate for the HTN study consumed daily) while the other half consumed a beet juice beverage with the nitrate removed (placebo). The main result was that there was no added benefit observed for any outcomes when comparing BRJ to placebo in either HTN or HFpEF patients undergoing exercise training (p ≥ 0.14). There were within-group benefits. In the pilot study in patients with HFpEF, aerobic endurance (primary outcome), defined as the exercise time to volitional exhaustion during submaximal cycling at 75% of maximal power output, improved during exercise training within each group from baseline to end of study, 369 ± 149 s vs 520 ± 257 s (p = 0.04) for the placebo group and 384 ± 129 s vs 483 ± 258 s for the BRJ group (p = 0.15). Resting systolic blood pressure in patients with HFpEF also improved during exercise training in both groups, 136 ± 16 mm Hg vs 122 ± 3 mm Hg for the placebo group (p

Nitroglycerin-mediated, but not flow-mediated vasodilation, is associated with blunted nocturnal blood pressure fall in patients with resistant hypertension.

PubMed

Fontes-Guerra, Priscila C A; Cardoso, Claudia R L; Muxfeldt, Elizabeth S; Salles, Gil F

2015-08-01

Endothelial function by flow-mediated (FMD) and nitroglycerin-mediated vasodilations (NMD) was scarcely investigated in resistant hypertension. We aimed to assess the independent correlates of FMD and NMD in resistant hypertensive patients, particularly their associations with ambulatory blood pressures (BP) and nocturnal BP fall patterns. In a cross-sectional study, 280 resistant hypertensive patients performed 24-h ambulatory BP monitoring, carotid-femoral pulse wave velocity, polysomnography, and brachial artery FMD and NMD by high-resolution ultrasonography. Independent correlates of FMD, NMD, and brachial artery diameter (BAD) were assessed by multiple linear and logistic regressions. Median (interquartile range) FMD was 0.75% (-0.6 to +4.4%) and NMD was 11.8% (7.1-18.4%). Baseline BAD and diabetes were independently associated with both FMD and NMD. Older age and prior cardiovascular diseases were associated with altered FMD, whereas higher night-time SBP and lower nocturnal SBP fall were associated with impaired NMD. Moreover, there was a significant gradient of impaired NMD according to blunted nocturnal BP decline patterns. BAD was independently associated with age, sex, BMI, albuminuria, and nocturnal SBP fall. Further adjustments to blood flow velocity, aortic stiffness, plasma aldosterone concentration, and sleep apnea did not change these relationships. NMD, but not FMD, is independently associated with unfavorable night-time BP levels and nondipping patterns, and may be a better cardiovascular risk marker in patients with resistant hypertension. BAD also may provide additional prognostic information.

The effect of different volumes of acute resistance exercise on elderly individuals with treated hypertension.

PubMed

Scher, Luria M L; Ferriolli, Eduardo; Moriguti, Julio C; Scher, Ricardo; Lima, Nereida K C

2011-04-01

Acute resistance exercise can reduce the blood pressure (BP) of hypertensive subjects. The aim of this study was to evaluate the effect of different volumes of acute low-intensity resistance exercise over the magnitude and the extent of BP changes in treated hypertensive elderly individuals. Sixteen participants (7 men, 9 women), with mean age of 68 ± 5 years, performed 3 independent randomized sessions: Control (C: 40 minutes of rest), Exercise 1 (E1: 20 minutes, 1 lap in the circuit), and Exercise 2 (E2: 40 minutes, 2 laps in the circuit) with the intensity of 40% of 1 repetition maximum. Blood pressure was measured before (during 20 minutes) and after each session (every 5 minutes during 60 minutes) using both a mercury sphygmomanometer and a semiautomatic device (Omrom-HEM-431). After that, 24-hour ambulatory blood pressure monitoring was performed (Dyna-MAPA). Blood pressure decreased during the first 60 minutes (systolic: p < 0.01, diastolic: p < 0.05) after all exercise sessions. Only the highest volume session promoted a reduction of mean systolic 24-hour BP and awake BP (p < 0.05) after exercise, with higher diastolic BP during sleep (p < 0.05). Diastolic 24-hour BP and both systolic and diastolic BP during sleep were higher after E1 (p < 0.05). Concluding, acute resistive exercise sessions in a circuit with different volumes reduced BP during the first 60 minutes after exercise in elderly individuals with treated hypertension. However, only the highest volume promoted a reduction of mean 24-hour and awake systolic BP.

Ambulatory blood pressure and adherence monitoring: diagnosing pseudoresistant hypertension.

PubMed

Burnier, Michel; Wuerzner, Gregoire

2014-01-01

A small proportion of the treated hypertensive population consistently has a blood pressure greater than 140/90 mm Hg despite a triple therapy including a diuretic, a calcium channel blocker, and a blocker of the renin-angiotensin system. According to guidelines, these patients have so-called resistant hypertension. The prevalence of this clinical condition is higher in tertiary than primary care centers and often is associated with chronic kidney disease, diabetes, obesity, and sleep apnea syndrome. Exclusion of pseudoresistant hypertension using ambulatory or home blood pressure monitoring is a crucial step in the investigation of patients with resistant hypertension. Thus, among the multiple factors to consider when investigating patients with resistant hypertension, ambulatory blood pressure monitoring should be performed very early. Among other factors to consider, physicians should investigate patient adherence to therapy, assess the adequacy of treatment, exclude interfering factors, and, finally, look for secondary forms of hypertension. Poor adherence to therapy accounts for 30% to 50% of cases of resistance to therapy depending on the methodology used to diagnose adherence problems. This review discusses the clinical factors implicated in the pathogenesis of resistant hypertension with a particular emphasis on pseudoresistance, drug adherence, and the use of ambulatory blood pressure monitoring for the diagnosis and management of resistant hypertension.

[Significance of insulin resistance in the pathogenesis of sarcopenia and chronic heart failure in elderly hypertensive patients].

PubMed

Gorshunova, N K; Medvedev, N V

2016-01-01

To determine the pathogenic role of insulin resistance in the formation of involutive sarcopenia and chronic heart failure (CHF) were examined 88 elderly patients with arterial hypertension (AH) and 32 elderly patients without cardiovascular disease by methods of carbohydrate metabolism and the level of brain natriuretic peptide precursor evaluation, muscle mass and strength measuring, echocardiography, 6 minute walking test. It was found that in the group of hypertensive patients with low mass and muscle strength significantly increased indices of insulin resistance and more expressed signs of the left ventricle myocardial dysfunction and functional class of heart failure, probably as a result of disorders of energy homeostasis, resulting from the deterioration of glucose into the muscle cells of the heart and skeletal muscles.

Lifestyle Modification for Resistant Hypertension: The TRIUMPH Randomized Clinical Trial

PubMed Central

Blumenthal, James A.; Sherwood, Andrew; Smith, Patrick J.; Mabe, Stephanie; Watkins, Lana; Lin, Pao-Hwa; Craighead, Linda W.; Babyak, Michael; Tyson, Crystal; Young, Kenlyn; Ashworth, Megan; Kraus, William; Liao, Lawrence; Hinderliter, Alan

2015-01-01

Background Resistant hypertension (RH) is a growing health burden in this country affecting as many as one in five adults being treated for hypertension. RH is associated with increased risk of adverse cardiovascular disease (CVD) events and all-cause mortality. Strategies to reduce blood pressure in this high risk population are a national priority. Methods TRIUMPH is a single site, prospective, randomized clinical trial (RCT) to evaluate the efficacy of a center-based lifestyle intervention consisting of exercise training, reduced sodium and calorie DASH eating plan, and weight management compared to standardized education and physician advice in treating patients with RH. Patients (N=150) will be randomized in a 2:1 ratio to receive either a 4-month supervised lifestyle intervention delivered in the setting of a cardiac rehabilitation center or to a standardized behavioral counseling session to simulate real-world medical practice. The primary end point is clinic blood pressure; secondary endpoints include ambulatory blood pressure and an array of CVD biomarkers including left ventricular hypertrophy, arterial stiffness, baroreceptor reflex sensitivity, insulin resistance, lipids, sympathetic nervous system activity, and inflammatory markers. Lifestyle habits, blood pressure and CVD risk factors also will be measured at one year follow-up. Conclusions The TRIUMPH randomized clinical trial (ClinicalTrials.gov NCT02342808) is designed to test the efficacy of an intensive, center-based lifestyle intervention compared to a standardized education and physician advice counseling session on blood presssure and CVD biomarkers in patients with RH after 4 months of treatment, and will determine whether lifestyle changes can be maintained for a year. PMID:26542509

Development of hypertension in animals with reduced total peripheral resistance.

PubMed

Huang, M; Hester, R L; Coleman, T G; Smith, M J; Guyton, A C

1992-12-01

The object of the present study was to determine whether deoxycorticosterone acetate (DOCA)-salt hypertension can be produced in rats in the presence of low total peripheral resistance (TPR) induced by long-term administration of minoxidil, a vasodilator. The rats were divided into four groups: sham-control, DOCA-salt, minoxidil, and DOCA-salt with minoxidil. The rats in both DOCA groups had DOCA pellets implanted subcutaneously and were given saline to drink. The rats in both minoxidil groups were given minoxidil (3 mg/day) in the drinking water throughout the experiment. Final measurements, including mean arterial blood pressure, cardiac index, and renal blood flow were made after 4-6 weeks. Flow measurements were made using radioactive microspheres. Cardiac index (ml.min-1.100 g-1) in sham-control rats averaged 18 +/- 2 and was higher in the other groups: 23 +/- 4 (DOCA-salt), 25 +/- 2 (minoxidil), and 30 +/- 2 (DOCA-salt plus minoxidil). Mean arterial pressure (mm Hg) was increased in both DOCA-salt rats (160 +/- 8) and DOCA-salt plus minoxidil rats (153 +/- 5) as compared with sham-control (116 +/- 2) and minoxidil (113 +/- 3) rats. There was no significant difference in TPR between the sham-control and DOCA-salt rats, but TPR in minoxidil and DOCA-salt plus minoxidil rats was 30% and 28% lower than that in untreated sham-control and DOCA-salt hypertensive rats, respectively. In contrast, renal vascular resistance was significantly increased in both DOCA-salt groups as compared with non-DOCA-salt groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities

PubMed Central

Cooper, Lisa A.; Purnell, Tanjala S.; Ibe, Chidinma A.; Halbert, Jennifer P.; Bone, Lee R.; Carson, Kathryn A.; Hickman, Debra; Simmons, Michelle; Vachon, Ann; Robb, Inez; Martin-Daniels, Michelle; Dietz, Katherine B.; Golden, Sherita Hill; Crews, Deidra C.; Hill-Briggs, Felicia; Marsteller, Jill A.; Boulware, L. Ebony; Miller, Edgar R. III; Levine, David M.

2016-01-01

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O’Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center’s approach to stakeholder engagement in research and community outreach efforts to achieve health equity. PMID:27440977

New drug therapies interfering with the renin-angiotensin-aldosterone system for resistant hypertension.

PubMed

Monge, Matthieu; Lorthioir, Aurélien; Bobrie, Guillaume; Azizi, Michel

2013-12-01

There is a persistent need for the development of new antihypertensive drugs, because the control of blood pressure is still not achievable in a significant proportion of hypertensive patients. Since the approval in 2007 of aliskiren, no other new antihypertensive based on new mechanism(s) of action have been approved. In fact, the development of promising novel drugs has been stopped for safety, efficacy or marketing reasons. Despite these difficulties, the pipeline is not dry and different new antihypertensive strategies targeting the renin-angiotensin-aldosterone pathway, are in clinical development stage. The dual angiotensin II receptor-neprilysin inhibitor LCZ696, a single molecule synthetized by cocrystallisation of valsartan and the neprilysin inhibitor prodrug AHU377 is in development for resistant hypertension and for heart failure. Daglutril is a dual neprylisin-endothelin converting enzyme inhibitor which was shown to decrease BP in patients with type 2 diabetic nephropathy. Aldosterone synthase inhibitors and the third and fourth generation non-steroidal dihydropyridine based mineralocorticoid receptors blockers are new ways to target the multiple noxious effects of aldosterone in the kidney, vessels and heart. Centrally acting aminopeptidase A inhibitors block brain angiotensin III formation, one of the main effector peptides of the brain renin angiotensin system. However, a long time will be still necessary to evaluate extensively the efficacy and safety of these new approaches. In the mean time, using appropriate and personalized daily doses of available drugs, decreasing physician inertia, improving treatment adherence, improving access to healthcare and reducing treatment costs remain major objectives to reduce the incidence of resistant hypertension.

Effects of chronic baroreceptor stimulation on the autonomic cardiovascular regulation in patients with drug-resistant arterial hypertension.

PubMed

Wustmann, Kerstin; Kucera, Jan P; Scheffers, Ingrid; Mohaupt, Markus; Kroon, Abraham A; de Leeuw, Peter W; Schmidli, Jürg; Allemann, Yves; Delacrétaz, Etienne

2009-09-01

In patients with drug-resistant hypertension, chronic electric stimulation of the carotid baroreflex is an investigational therapy for blood pressure reduction. We hypothesized that changes in cardiac autonomic regulation can be demonstrated in response to chronic baroreceptor stimulation, and we analyzed the correlation with blood pressure changes. Twenty-one patients with drug-resistant hypertension were prospectively included in a substudy of the Device Based Therapy in Hypertension Trial. Heart rate variability and heart rate turbulence were analyzed using 24-hour ECG. Recordings were obtained 1 month after device implantation with the stimulator off and after 3 months of chronic electric stimulation (stimulator on). Chronic baroreceptor stimulation decreased office blood pressure from 185+/-31/109+/-24 mm Hg to 154+/-23/95+/-16 mm Hg (P<0.0001/P=0.002). Mean heart rate decreased from 81+/-11 to 76+/-10 beats per minute(-1) (P=0.001). Heart rate variability frequency-domain parameters assessed using fast Fourier transformation (FFT; ratio of low frequency:high frequency: 2.78 versus 2.24 for off versus on; P<0.001) were significantly changed during stimulation of the carotid baroreceptor, and heart rate turbulence onset was significantly decreased (turbulence onset: -0.002 versus -0.015 for off versus on; P=0.004). In conclusion, chronic baroreceptor stimulation causes sustained changes in heart rate variability and heart rate turbulence that are consistent with inhibition of sympathetic activity and increase of parasympathetic activity in patients with drug-resistant systemic hypertension; these changes correlate with blood pressure reduction. Whether the autonomic modulation has favorable cardiovascular effects beyond blood pressure control should be investigated in further studies.

Effectiveness of the selective aldosterone blocker, eplerenone, in patients with resistant hypertension.

PubMed

Calhoun, David A; White, William B

2008-01-01

Resistant hypertension is defined as uncontrolled hypertension despite intensive treatment with at least three antihypertensive agents, one of which ideally should be a diuretic. To determine the efficacy and safety of the selective aldosterone antagonist eplerenone in this population, we studied patients with resistant hypertension (clinic blood pressure [BP] >140 mm Hg systolic or >90 mm Hg diastolic on maximal doses of more than three antihypertensive agents, including a loop or thiazide diuretic). At baseline and after 12 weeks of eplerenone therapy (50 to 100 mg daily titrated to effect), patients underwent clinic and 24-hour BP measurements, serum potassium, plasma renin activity, and serum aldosterone measurements. Patients (n = 52) completing the trial averaged 62 +/- 10 years of age, were overweight (mean body mass index, 32.1 +/- 5.5 kg/m(2)), and had variable renal function (glomerular filtration rate, 106 +/- 38 mL/minute); 70% were men and 74% were non-Black. The mean number of antihypertensive agents at baseline was 3.7 +/- 0.8 (range, three to seven drugs) to achieve a clinic BP of 150.5/84.1 mm Hg. The mean serum aldosterone was 12.9 +/- 7.6 ng/mL and plasma renin activity was 2.3 +/- 2.7 ng/mL/hour. After eplerenone, the change from baseline in the clinic BP was -17.6/-7.9 mm Hg (P < .0001 for both systolic blood pressure [SBP] and diastolic blood pressure [DBP]) and in 24-hour BP was -12.2/-6.0 mm Hg (P < .0001 for both). The number of antihypertensive drugs decreased to 3.3 +/- 0.9 (range, one to seven agents). Plasma potassium increased by 0.30 +/- 0.45 mEq/L (P < .001), but there were only three instances in two patients of mild hyperkalemia (potassium >5.5 mEq/L, but <6.0 mEq/L), despite all patients being on a background therapy that included an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Reductions in clinic and ambulatory BP were related to baseline clinic and ambulatory BP values (r(2) > 0.3 for both SBP and

Post-pregnancy aspirin resistance appears not to be related with recurrent hypertensive disorders of pregnancy.

PubMed

Abheiden, Carolien N H; Fuijkschot, Wessel W; Arduç, Arda; van Diemen, Jeske J K; Harmsze, Ankie M; de Boer, Marjon A; Thijs, Abel; de Vries, Johanna I P

2017-03-01

The FRUIT-RCT concluded that low-molecular-weight heparin added to aspirin compared to treatment with aspirin alone is beneficial in the prevention of early-onset hypertensive disorders of pregnancy (HD) in women with inheritable thrombophilia and prior HD and/or a small-for-gestational age (SGA) infant leading to delivery before 34 weeks gestation. The aim of this study is to answer the question whether aspirin resistance is associated with recurrent HD. Women with and without recurrent HD matched for age, study arm, and chronic hypertension were invited for this follow-up study 6-16 years after they participated in the FRUIT-RCT. Aspirin resistance was tested after 10days of aspirin intake using three complementary tests: PFA-200, VerifyNow ® and serum thromboxane B 2 (TXB 2 ). An independent t-test, Mann-Whitney U test, Fisher's Exact test and Chi 2 test were used for the statistical analyses. Thirteen of 24 women with recurrent HD and 16 of 24 women without recurrent HD participated. The prevalence of laboratory aspirin resistance was 34.5% according to the PFA-200, 3.4% according to the VerifyNow ® and 24.1% according to TXB 2 . The prevalence of aspirin resistance by any test was 51.7%. Aspirin resistance per individual test did not differ between women with and without recurrent HD. Aspirin resistance measured by any test occurred more frequently in women without recurrent HD (p<0.01), irrespective of low-molecular-weight heparin. No relation could be demonstrated between recurrent HD and aspirin resistance per test, measured up to 16 years after pregnancy. On the contrary, complementary aspirin resistance measurements were encountered more frequently in women without recurrent HD. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Assessment of hypertension management in primary health care settings in Kinshasa, Democratic Republic of Congo.

PubMed

Lulebo, Aimée M; Mapatano, Mala A; Kayembe, Patrick K; Mafuta, Eric M; Mutombo, Paulin B; Coppieters, Yves

2015-12-24

Hypertension-related complications have become more diagnosed at secondary and tertiary care levels, in the Democratic Republic of the Congo (DRC), probably indicative of poor management of hypertensive patients at primary health care level. This study aimed to assess the management of hypertension in primary health care settings by using guidelines of the International Forum for Prevention and Control of HTN in Africa (IFHA). A multi-center cross-sectional study was carried out in primary health care settings. A total of 102 nurses were surveyed using a structured interview. Mean and proportion comparisons were performed using the t Student test and the Chi-square test respectively. The Kinshasa Primary Health Care network facilities were compared with non-Kinshasa Primary Health Care network facilities. From the 102 nurses surveyed; 52.9% were female with a mean age of 41.1, (SD = 10) years, merely 9.5% benefited from in-job training on cardiovascular diseases or their risk factors, and 51.7% had guidelines on the management of hypertension. Less than a quarter of the nurses knew the cut-off values of hypertension, diabetes and obesity. Merely 14.7% knew the therapeutic goals for uncomplicated hypertension. Several of the indicators for immediate referral recommended by IFHA were unmentioned. The content of patient education was lacking, avoiding stress being the best advice provided to hypertensive patients. The antihypertensive most used were unlikely to be recommended by the IFHA. This study showed a considerable gap of knowledge and practices in the management of hypertensive patients at primary health care facilities in Kinshasa pertaining to the IFHA guidelines. We think that task-shifting for management of hypertension is feasible if appropriate guidelines are provided and nurses trained.

Skeletal muscle insulin resistance in salt-sensitive hypertension: role of angiotensin II activation of NFκB.

PubMed

Zhou, Ming-Sheng; Liu, Chang; Tian, Runxia; Nishiyama, Akira; Raij, Leopoldo

2015-05-01

We have previously shown that in hypertensive Dahl salt-sensitive (DS) rats, impaired endothelium-dependent relaxation to acetylcholine and to insulin is mechanistically linked to up-regulation of angiotensin (Ang) II actions and the production of reactive oxygen species (ROS) and to activation of the proinflammatory transcription factor (NF)κB. Here we investigated whether Ang II activation of NFκB contributed to insulin resistance in the skeletal muscle of this animal model. DS rats were fed either a normal (NS, 0.5% NaCl) or high (HS, 4% NaCl) salt diet for 6 weeks. In addition, 3 separate groups of HS rats were given angiotensin receptor 1 blocker candesartan (ARB, 10 mg/kg/day in drinking water), antioxidant tempol (1 mmol/L in drinking water) or NFκB inhibitor PDTC (150 mg/kg in drinking water). DS rats manifested an increase in soleus muscle Ang II content, ROS production and phosopho-IκBα/IκBα ratio, ARB or tempol reduced ROS and phospho-IκBα/IκBα ratio. Hypertensive DS rats also manifested a reduction in glucose infusion rate, impaired insulin-induced Akt phosphorylation and Glut-4 translocation in the soleus muscle, which were prevented with treatment of either ARB, tempol, or PDTC. Data from the rat diabetes signaling pathway PCR array showed that 8 genes among 84 target genes were altered in the muscle of hypertensive rats with the increase in gene expression of ACE1 and 5 proinflammatory genes, and decrease of 2 glucose metabolic genes. Incubation of the muscle with NFκB SN50 (a specific peptide inhibitor of NFκB) ex vivo reversed changes in hypertension-induced gene expression. The current findings strongly suggest that the activation of NFκB inflammatory pathway by Ang II play a critical role in skeletal muscle insulin resistance in salt-sensitive hypertension.

Resistant Hypertension On Treatment (ResHypOT): sequential nephron blockade compared to dual blockade of the renin-angiotensin-aldosterone system plus bisoprolol in the treatment of resistant arterial hypertension - study protocol for a randomized controlled trial.

PubMed

Cestário, Elizabeth do Espirito Santo; Fernandes, Letícia Aparecida Barufi; Giollo-Júnior, Luiz Tadeu; Uyemura, Jéssica Rodrigues Roma; Matarucco, Camila Suemi Sato; Landim, Manoel Idelfonso Paz; Cosenso-Martin, Luciana Neves; Tácito, Lúcia Helena Bonalume; Moreno, Heitor; Vilela-Martin, José Fernando; Yugar-Toledo, Juan Carlos

2018-02-12

Resistant hypertension is characterized when the blood pressure (BP) remains above the recommended goal after taking three antihypertensive drugs with synergistic actions at their maximum recommended tolerated doses, preferably including a diuretic. Identifying the contribution of intravascular volume and serum renin in maintaining BP levels could help tailor more effective hypertension treatment, whether acting on the control of intravascular volume or sodium balance, or acting on the effects of the renin-angiotensin-aldosterone system (RAAS) on the kidney. This is a randomized, open-label, clinical trial is designed to compare sequential nephron blockade and its contribution to the intravascular volume component with dual blockade of the RAAS plus bisoprolol and the importance of serum renin in maintaining BP levels. The trial has two arms: sequential nephron blockade versus dual blockade of the RAAS (with an angiotensin converting enzyme (ACE) inhibitor plus a beta-blocker) both added-on to a thiazide diuretic, a calcium-channel blocker and an angiotensin receptor-1 blocker (ARB). Sequential nephron blockade consists in a progressive increase in sodium depletion using a thiazide diuretic, an aldosterone-receptor blocker, furosemide and, finally, amiloride. On the other hand, the dual blockade of the RAAS consists of the progressive addition of an ACE inhibitor until the maximum dose and then the administration of a beta-blocker until the maximum dose. The primary outcomes will be reductions in the systolic BP, diastolic BP, mean BP and pulse pressure (PP) after 20 weeks of treatment. The secondary outcomes will evaluate treatment safety and tolerability, biochemical changes, evaluation of renal function and recognition of hypotension (ambulatory BP monitoring (ABPM)). The sample size was calculated assuming an alpha error of 5% to reject the null hypothesis with a statistical power of 80% giving a total of 40 individuals per group. In recent years, the cost of

Research and Development of Information and Communication Technology-based Home Blood Pressure Monitoring from Morning to Nocturnal Hypertension.

PubMed

Kario, Kazuomi; Tomitani, Naoko; Matsumoto, Yuri; Hamasaki, Haruna; Okawara, Yukie; Kondo, Maiko; Nozue, Ryoko; Yamagata, Hiromi; Okura, Ayako; Hoshide, Satoshi

2016-01-01

Asians have specific characteristics of hypertension (HTN) and its relationship with cardiovascular disease. The morning surge in blood pressure (BP) in Asians is more extended, and the association slope between higher BP and the risk for cardiovascular events is steeper in this population than in whites. Thus, 24-hour BP control including at night and in the morning is especially important for Asian patients with HTN. There are 3 components of "perfect 24-hour BP control": the 24-hour BP level, adequate dipping of nocturnal BP (dipper type), and adequate BP variability such as the morning BP surge. The morning BP-guided approach using home BP monitoring (HBPM) is the first step toward perfect 24-hour BP control. After controlling morning HTN, nocturnal HTN is the second target. We have been developing HBPM that can measure nocturnal BP. First, we developed a semiautomatic HBPM device with the function of automatic fixed-interval BP measurement during sleep. In the J-HOP (Japan Morning Surge Home Blood Pressure) study, the largest nationwide home BP cohort, we successfully measured nocturnal home BP using this device with data memory, 3 times during sleep (2, 3, and 4 am), and found that nocturnal home BP is significantly correlated with organ damage independently of office and morning BP values. The second advance was the development of trigger nocturnal BP (TNP) monitoring with an added trigger function that initiates BP measurements when oxygen desaturation falls below a variable threshold continuously monitored by pulse oximetry. TNP can detect the specific nocturnal BP surges triggered by hypoxic episodes in patients with sleep apnea syndrome. We also added the lowest heart rate-trigger function to TNP to detect the "basal nocturnal BP," which is determined by the circulating volume and structural cardiovascular system without any increase in sympathetic tonus. This double TNP is a novel concept for evaluating the pathogenic pressor mechanism of nocturnal BP

Gut–Brain Axis in Regulation of Blood Pressure

PubMed Central

Yang, Tao; Zubcevic, Jasenka

2017-01-01

Hypertension (HTN) is an escalating health issue worldwide. It is estimated that 1.56 billion people will suffer from high blood pressure (BP) by 2025. Recent studies reported an association between gut dysbiosis and HTN, thus proposing interesting avenues for novel treatments of this condition. The sympathetic nervous system (SNS) and the immune system (IS) play a recognized role in the onset and progression of HTN, while reciprocal communication between gut microbiota and the brain can regulate BP by modulating the interplay between the IS and SNS. This review presents the current state of the science implicating brain-gut connection in HTN, highlighting potential pathways of their interaction in control of BP. PMID:29118721

Fundamentals of management of acute postoperative pulmonary hypertension.

PubMed

Taylor, Mary B; Laussen, Peter C

2010-03-01

In the last several years, there have been numerous advancements in the field of pulmonary hypertension as a whole, but there have been few changes in the management of children with pulmonary hypertension after cardiac surgery. Patients at particular risk for postoperative pulmonary hypertension can be identified preoperatively based on their cardiac disease and can be grouped into four broad categories based on the mechanisms responsible for pulmonary hypertension: 1) increased pulmonary vascular resistance; 2) increased pulmonary blood flow with normal pulmonary vascular resistance; 3) a combination of increased pulmonary vascular resistance and increased blood flow; and 4) increased pulmonary venous pressure. In this review of the immediate postoperative management of pulmonary hypertension, various strategies are discussed including medical therapies, monitoring, ventilatory strategies, and weaning from these supports. With early recognition of patients at particular risk for severe pulmonary hypertension, management strategies can be directed at preventing or minimizing hemodynamic instability and thereby prevent the development of ventricular dysfunction and a low output state.

Endoplasmic reticulum stress inhibition reduces hypertension through the preservation of resistance blood vessel structure and function.

PubMed

Carlisle, Rachel E; Werner, Kaitlyn E; Yum, Victoria; Lu, Chao; Tat, Victor; Memon, Muzammil; No, Yejin; Ask, Kjetil; Dickhout, Jeffrey G

2016-08-01

Our purpose was to determine if endoplasmic reticulum stress inhibition lowers blood pressure (BP) in hypertension by correcting vascular dysfunction. The spontaneously hypertensive rat (SHR) was used as a model of human essential hypertension with its normotensive control, the Wistar Kyoto rat. Animals were subjected to endoplasmic reticulum stress inhibition with 4-phenylbutyric acid (4-PBA; 1 g/kg per day, orally) for 5 weeks from 12 weeks of age. BP was measured weekly noninvasively and at endpoint with carotid arterial cannulation. Small mesenteric arteries were removed for vascular studies. Function was assessed with a Mulvany-Halpern style myograph, and structure was assessed by measurement of medial-to-lumen ratio in perfusion fixed vessels as well as three-dimensional confocal reconstruction of vessel wall components. Endoplasmic reticulum stress was assessed by quantitative real time-PCR and western blotting; oxidative stress was assessed by 3-nitrotyrosine and dihydroethidium staining. 4-PBA significantly lowered BP in SHR (vehicle 206.1 ± 4.3 vs. 4-PBA 178.9 ± 3.1, systolic) but not Wistar Kyoto. 4-PBA diminished contractility and augmented endothelial-dependent vasodilation in SHR small mesenteric arteries, as well as reducing media-to-lumen ratio. 4-PBA significantly reduced endoplasmic reticulum stress in SHR resistance vessels. Normotensive resistance vessels, treated with the endoplasmic reticulum stress-inducing agent, tunicamycin, show decreased endothelial-dependent vasodilation; this was improved with 4-PBA treatment. 3-Nitrotyrosine and dihydroethidium staining indicated that endoplasmic reticulum stress leads to reactive oxygen species generation resolvable by 4-PBA treatment. Endoplasmic reticulum stress caused endothelial-mediated vascular dysfunction contributing to elevated BP in the SHR model of human essential hypertension.

Cost-effectiveness of treating resistant hypertension with an implantable carotid body stimulator

PubMed Central

Young, KC; Teeters, JC; Benesch, CG; Bisognano, JD; Illig, KA

2013-01-01

Introduction The purposes of this study are to investigate the cost-effectiveness of an implantable carotid body stimulator (Rheos®) for treating resistant hypertension and determine the range of starting systolic blood pressure (SBP) values where the device remains cost-effective. Methods A Markov model compared a 20 mmHg drop in SBP from an initial level of 180 with Rheos® to failed medical management in a hypothetical 50-year old cohort. Direct costs (2007$), utilities and event rates for future myocardial infarction, stroke, heart failure and end-stage renal disease were modeled. Sensitivity analyses tested the assumptions in the model. Results The incremental cost-effectiveness ratio (ICER) for Rheos® was $64,400 per quality-adjusted life-year (QALY) using Framingham-derived event probabilities. The ICER was <$100,000/QALY for SBPs ≥142. A probability of device removal of <1% per year or SBP reductions of ≥24 mmHg were variables that decreased the ICER below $50,000/QALY. For cohort characteristics similar to ASCOT-BPLA trial participants, the ICER became $26,700/QALY. Two-way sensitivity analyses demonstrated that lowering SBP 12 mmHg from 220 or 21 mmHg from 140 were required. Conclusions Rheos® may be cost-effective, with an ICER between $50,000-$100,000/QALY. Cohort characteristics and efficacy are key to the cost-effectiveness of new therapies for resistant hypertension. PMID:19817936

Renal artery stenting in a 2-year-old child with resistant hypertension and neurofibromatosis.

PubMed

Varghese, Kiron; Adhyapak, Srilakshmi M; Lohitashwa, S B; Pais, Priya; Iyengar, Arpana A

2017-07-01

The occurrence of vascular lesions in neurofibromatosis is uncommon but well documented. These vascular lesions when present, occur predominantly in the kidneys, endocrine glands, heart and gastrointestinal tract, causing stenosis or obliteration of the lumen. We report a case of uncontrolled resistant hypertension in a 2-year-old child presenting with neurofibromatosis who was found to have a high-grade ostial left renal artery stenosis and obliteration of the right renal artery. As the right kidney was small and hypo-functioning, and its renal artery was totally occluded, we subjected the child to a left renal angioplasty and bailout stenting. Following stenting, the blood pressure decreased with anti-hypertensive treatment. Based on a review of the literature, and to the best of our knowledge, this is the youngest child to have undergone renal artery stenting.

Resistant hypertension: Renal denervation or intensified medical treatment?

PubMed

Morganti, Alberto; Mancia, Giuseppe

2018-04-01

Resistant hypertension (RH) can be diagnosed if blood pressure (BP) is not controlled with the combination of three antihypertensive drugs, including a diuretic, all at effective doses. Patients affected by this condition exhibit a marked increase in the risk of cardiovascular and renal morbid and fatal events. They also exhibit an increased activity of the sympathetic nervous system which is likely to importantly contribute at the renal and other vascular levels to the hypertensive state. Almost 10years ago renal denervation (RDN) by radiofrequency thermal energy delivery to the walls of the renal arteries was proposed for the treatment of RH. Several uncontrolled studies initially reported that this procedure substantially reduced the elevated BP values but this conclusion has not been supported by a recent randomized control trial, which has almost marginalized this therapeutic approach. A revival, however, is under way because of recent positive findings and technical improvement that hold promise to make renal denervation more complete. The antihypertensive efficacy and overall validity of RDN will have to be tested against drug treatment of RH. Several studies indicate that an excess of aldosterone production contributes to RH and recent evidence documents indisputably that anti-aldosterone agents such as spironolactone can effectively control BP in many RH patients, although with some side effects that require close patients' monitoring. At present, it is advisable to treat RH with the addition of an anti-aldosterone agent. If BP control is not achieved or serious side effects become manifest RDN may then be considered. Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Spironolactone versus sympathetic renal denervation to treat true resistant hypertension: results from the DENERVHTA study - a randomized controlled trial.

PubMed

Oliveras, Anna; Armario, Pedro; Clarà, Albert; Sans-Atxer, Laia; Vázquez, Susana; Pascual, Julio; De la Sierra, Alejandro

2016-09-01

Both renal denervation (RDN) and spironolactone have been proposed for the treatment of resistant hypertension. However, they have not been compared in a randomized clinical trial. We aimed to compare the efficacy of spironolactone versus RDN in patients with resistant hypertension. A total of 24 patients with office SBP at least 150 mmHg and 24-h SBP at least 140 mmHg despite receiving at least three full-dose antihypertensive drugs, one a diuretic, but without aldosterone antagonists, were randomized to receive RDN or spironolactone (50 mg) as add-on therapy. Primary endpoint was change in 24-h SBP at 6 months. Comparisons between treatment groups were performed using generalized linear models adjusted by age, sex, and baseline values. Spironolactone was more effective than RDN in reducing 24-h SBP and 24-h DBP: mean baseline-adjusted differences between the two groups were -17.9 mmHg (95%CI -30.9 to -4.9); P = 0.010 and -6.6 mmHg (95%CI -12.9 to -0.3); P = 0.041, for 24-h SBP and 24-h DBP, respectively. As regards changes in office blood pressure, mean baseline-adjusted differences between the two groups were -12.1 mmHg (95%CI -29.1 to 5.1); P = 0.158 and of -5.3 mmHg (95%CI -16.3 to 5.8); P = 0.332, for office SBP and office DBP, respectively. Otherwise, the decrease of estimated glomerular filtration rate was greater in the spironolactone group; mean baseline-adjusted difference between the two groups was -10.7 ml/min per 1.73 m (95%CI -20.1 to -1.4); P = 0.027. We conclude that spironolactone is more effective than RDN to reduce 24-h SBP and 24-h DBP in patients with resistant hypertension. Therefore, spironolactone should be the fourth antihypertensive drug to prescribe if deemed well tolerated' in all patients with resistant hypertension before considering RDN.

Does exercise pulmonary hypertension exist?

PubMed

Lau, Edmund M; Chemla, Denis; Whyte, Kenneth; Kovacs, Gabor; Olschewski, Horst; Herve, Philippe

2016-09-01

The exercise definition of pulmonary hypertension using a mean pulmonary artery pressure threshold of greater than 30 mmHg was abandoned following the 4th World Pulmonary Hypertension Symposium in 2008, as this definition was not supported by evidence and healthy individuals frequently exceed this threshold. Meanwhile, the clinical value of exercise pulmonary hemodynamic testing has also been questioned. Recent data support the notion that an abnormal pulmonary hemodynamic response during exercise (or exercise pulmonary hypertension) is associated with symptoms and exercise limitation. Pathophysiologic mechanisms accounting for the development of exercise pulmonary hypertension include increased vascular resistance, excessive elevation in left atrial pressure and/or increased volume of trapped air during exercise, resulting in a steep rise in pulmonary artery pressure relative to cardiac output. Recent evidence suggests that exercise pulmonary hypertension may be defined by a mean pulmonary artery pressure surpassing 30 mmHg together with a simultaneous total pulmonary resistance exceeding 3 WU. Exercise pulmonary hypertension is a clinically relevant entity and an improved definition has been suggested based on new evidence. Exercise pulmonary hemodynamics may help unmask early or latent disease, particularly in populations that are at high risk for the development of pulmonary hypertension.

Novel Approaches for the Treatment of the Patient with Resistant Hypertension: Renal Nerve Ablation

PubMed Central

Gulati, Vinay; White, William B.

2013-01-01

Sympathetic innervation of the kidneys plays a major role in the pathogenesis of hypertension through modulation of renin secretion, glomerular filtration rate and renal absorption of sodium. Targeted interventions for renal nerve ablation are being developed for treatment of drug resistant hypertension in the USA and rest of the world. Early studies with the use of radiofrequency based renal denervation systems have shown encouraging results with significant reduction of blood pressure in patients inadequately controlled despite nearly maximal drug therapy regimens. Thus far, the renal denervation procedure has been associated with minimal side effects. Long term efficacy and safety beyond 3 years needs to be determined for renal nerve ablation. This review focuses on the physiology of the renal sympathetic system, the rationale for renal nerve ablation and current evidence in support of the available therapeutic renal denervation systems. PMID:24244757

Association of Hypertension, Body Mass Index, and Waist Circumference with Fluoride Intake; Water Drinking in Residents of Fluoride Endemic Areas, Iran.

PubMed

Yousefi, Mahmood; Yaseri, Mehdi; Nabizadeh, Ramin; Hooshmand, Elham; Jalilzadeh, Mohsen; Mahvi, Amir Hossein; Mohammadi, Ali Akbar

2018-03-14

Hypertension is becoming a global epidemic for both rural and urban populations; it is a major public health challenge in Iran. Fluoride can be a risk factor for hypertension. Cross-sectional analysis was conducted in two study areas to assess the relation of fluoride with blood pressure prevalence, BMI, waist circumference, and waist-to-hip ratio (WHR) among different age groups in both sexes. The mean value of fluoride concentration in the drinking water from the four study villages varied from 0.68 to 10.30 mg/L. The overall prevalence of HTN and prehypertension in all subjects was 40.7%. The prevalence of isolated systolic hypertension, isolated diastolic hypertension, systolic-diastolic hypertension, and prehypertension in the total sample population was 1.15, 0.28, 9.53, and 29.76%, respectively. The odd ratio of hypertension in residents who drank water with high fluoride levels was higher than that in residents who drank water with lower level of fluoride (OR 2.3, 1.03-5.14). Logistic regression results showed that age (P < 0.001), sex (P = 0.018), BMI (P = 0.015), and the fluoride level in drinking water (P = 0.041) had a significant relationship with increased blood pressure. There were no statistically significant correlations between fluoride and BMI, hip circumference, and waist to hip ratio (WHR). The findings of this study are important for health care personnel and policymakers.

Resistance exercise with different volumes: blood pressure response and forearm blood flow in the hypertensive elderly

PubMed Central

Brito, Aline de Freitas; de Oliveira, Caio Victor Coutinho; Brasileiro-Santos, Maria do Socorro; Santos, Amilton da Cruz

2014-01-01

Background The purpose of this study was to evaluate the effect of two sessions of resistance exercise with different volumes on post-exercise hypotension, forearm blood flow, and forearm vascular resistance in hypertensive elderly subjects. Methods The study was conducted with ten hypertensive elderly (65±3 years, 28.7±3 kg/m2) subjected to three experimental sessions, ie, a control session, exercise with a set (S1), and exercise with three sets (S3). For each session, the subjects were evaluated before and after intervention. In the pre-intervention period, blood pressure, forearm blood flow, and forearm vascular resistance were measured after 10 minutes of rest in the supine position. Thereafter, the subjects were taken to the gym to perform their exercise sessions or remained at rest during the same time period. Both S1 and S3 comprised a set of ten repetitions of ten exercises, with an interval of 90 seconds between exercises. Subsequently, the measurements were again performed at 10, 30, 50, 70, and 90 minutes of recovery (post-intervention) in the supine position. Results Post-exercise hypotension was greater in S3 than in S1 (systolic blood pressure, −26.5±4.2 mmHg versus −17.9±4.7 mmHg; diastolic blood pressure, −13.8±4.9 mmHg versus −7.7±5 mmHg, P<0.05). Similarly, forearm blood flow and forearm vascular resistance changed significantly in both sessions with an increase and decrease, respectively, that was more evident in S3 than in S1 (P<0.05). Conclusion Resistance exercises with higher volume were more effective in causing post-exercise hypotension, being accompanied by an increase in forearm blood flow and a reduction of forearm vascular resistance. PMID:25540580

Effects of short-term heated water-based exercise training on systemic blood pressure in patients with resistant hypertension: a pilot study.

PubMed

Guimarães, Guilherme V; Cruz, Lais G B; Tavares, Aline C; Dorea, Egidio L; Fernandes-Silva, Miguel M; Bocchi, Edimar A

2013-12-01

High blood pressure (BP) increases the risk of cardiovascular diseases, and its control is a clinical challenge. Regular exercise lowers BP in patients with mild-to-moderate hypertension. No data are available on the effects of heated water-based exercise in hypertensive patients. Our objective was to evaluate the effects of heated water-based exercise on BP in patients with resistant hypertension. We tested the effects of 60-min heated water-based exercise training three times per week in 16 patients with resistant hypertension (age 55±6 years). The protocol included walking and callisthenic exercises. All patients underwent 24-h ambulatory blood pressure monitoring (ABPM) before and after a 2-week exercise program in a heated pool. Systolic office BP was reduced from 162 to 144 mmHg (P<0.004) after heated-water training. After the heated-water exercise training during 24-h ABPM, systolic BP decreased from 135 to 123 mmHg (P=0.02), diastolic BP decreased from 83 to 74 mmHg (P=0.001), daytime systolic BP decreased from 141 to 125 mmHg (P=0.02), diastolic BP decreased from 87 to 77 mmHg (P=0.009), night-time systolic BP decreased from 128 to 118 mmHg (P=0.06), and diastolic BP decreased from 77 to 69 mmHg (P=0.01). In addition, BP cardiovascular load was reduced significantly during the 24-h daytime and night-time period after the heated water-based exercise. Heated water-based exercise reduced office BP and 24-h daytime and night-time ABPM levels. These effects suggest that heated water-based exercise may have a potential as a new therapeutic approach to resistant hypertensive patients.

Prevention of fructose-induced hypertension by dietary vitamins.

PubMed

Vasdev, Sudesh; Longerich, Linda; Gill, Vicki

2004-01-01

Essential hypertension in humans may develop through a combination of genetic and environmental factors. Diet has long been under investigation as a potential effector of blood pressure. A diet high in sucrose or fructose can give rise to hyperlipidemia, insulin resistance and hypertension. Insulin resistance, glucose intolerance and oxidative stress are common features of hypertension. If glucose metabolism through the glycolytic pathway is impaired, as in insulin resistance, there will be a build-up of glyceraldehyde, glyceraldehyde-3-phosphate and dihydroxyacetone phosphate with further metabolism to methylglyoxal, a highly reactive ketoaldehyde. Excess aldehydes can bind sulfhydryl groups of membrane proteins, altering membrane calcium channels, increasing cytosolic free calcium, peripheral vascular resistance and blood pressure. The presence of reactive aldehydes can also lead to oxidative stress. Dietary management through lower sucrose or fructose intake and increased consumption of vitamins improves glucose metabolism, lowers tissue aldehydes, increases anti-oxidant capacity and may also prevent hypertension.

Sustained effect of resistance training on blood pressure and hand grip strength following a detraining period in elderly hypertensive women: a pilot study

PubMed Central

Nascimento, Dahan da Cunha; Tibana, Ramires Alsamir; Benik, Franklin M; Fontana, Keila Elizabeth; Neto, Frederico Ribeiro; de Santana, Frederico Santos; Santos-Neto, Leopoldo; Silva, Renato André Sousa; Silva, Alessandro Oliveira; Farias, Darlan Lopes; Balsamo, Sandor; Prestes, Jonato

2014-01-01

Introduction Hypertension is the most prevalent modifiable risk factor with a high prevalence among older adults. Exercise is a nonpharmacological treatment shown to benefit all patients with hypertension. Objective This study examined the effects of a 14-week moderate intensity resistance training program (RT) on the maintenance of blood pressure and hand grip strength during an extended detraining period in elderly hypertensive women. Methods Twelve hypertensive sedentary elderly women completed 14 weeks of whole body RT at a moderate perceived exertion following a detraining period of 14 weeks. Results Following the training period, participants demonstrated an increase in absolute hand grip strength (P=0.001), relative hand grip strength (P=0.032) and a decrease of systolic (P=0.001), diastolic (P=0.008), and mean blood pressure (P=0.002) when compared to pre-exercise values. In addition, these effects were sustained after 14 weeks of detraining. Conclusion Resistance training may be a valuable method to improve muscular strength and blood pressure in elderly people with benefits being maintained up to 14 weeks following training cessation. PMID:24477221

[Spironolactone in patients with resistant hypertension].

PubMed

Rodilla, Enrique; Costa, José A; Pérez-Lahiguera, Francisco; González, Carmen; Pascual, José M

2008-10-04

The aim of the study was to assess the effect of adding spironolactone to hypertensive resistant (HTR) patients and characterize those who respond effectively. Observational retrospective study on outpatients with HTR (being treated with at least 3 drugs at full doses, one of these being a diuretic) not achieving blood pressure (BP) goals, with normal creatinine values (< 1.6 mg/dl for males and < 1.4 mg/dl in women). A total of 95 patients (70% male), average (standard deviation) age of 66 (12) years (40% diabetics), were treated with spironolactone during 4 months (range: 2-13). Mean systolic and diastolic BP fell from 170/86 (20/14) mmHg, by 29/12 mmHg (95% confidence interval [CI], 25 to 33/10 to 14 mmHg; p = 0.001). At the end of follow-up, 38% of all patients achieved the goal of BP control. Initial systolic BP < 165 mmHg (odds ratio [OR] = 3,97; 95% CI, 1.52-10.37; p = 0.005), and diabetes (OR = 0.33; 95% CI, 0.13-0.86; p = 0.02) were the only independent factors related to BP control in a logistic regression analysis. The addition of spironolactone effectively lowers BP in patients with HTR treated with 3 drugs. BP control is more difficult to achieve in diabetics.

Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy.

PubMed

Ghazi, Lama; Drawz, Paul

2017-01-01

The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice.

Combined aerobic and resistance training: are there additional benefits for older hypertensive adults?

PubMed Central

Lima, Leandra G.; Bonardi, José T.M.; Campos, Giulliard O.; Bertani, Rodrigo F.; Scher, Luria M.L.; Moriguti, Júlio C.; Ferriolli, Eduardo; Lima, Nereida K.C.

2017-01-01

OBJECTIVES: The objective of this study was to compare the effects of a combination of aerobic and resistance training to those of isolated aerobic training on blood pressure, body composition, and insulin sensitivity in hypertensive older adults. METHOD: Forty-four patients were randomly assigned to the aerobic group, resistance and aerobic group, and control group. Before and after 10 weeks, the following data were obtained: 24-hour ambulatory blood pressure data, abdominal circumference, waist circumference, body mass index, lean mass, fat mass, and insulin sensitivity. The study was conducted with 3 training sessions per week. RESULTS: Comparison revealed significant reductions in the body mass index, abdominal and waist circumferences, and ambulatory blood pressure (24-hour, wakefulness and sleep systolic/diastolic blood pressures) in both the aerobic group and the resistance and aerobic (combined) group. The fat mass only changed in the combined group. There was no difference in the insulin sensitivity in any group. CONCLUSIONS: The combined treatment and aerobic treatment alone were equally effective in reducing the blood pressure, body mass index, and abdominal and waist circumferences, although the addition of the resistance component also helped reduce the fat mass. PMID:28658436

Renal Denervation vs. Spironolactone in Resistant Hypertension: Effects on Circadian Patterns and Blood Pressure Variability.

PubMed

de la Sierra, Alejandro; Pareja, Julia; Armario, Pedro; Barrera, Ángela; Yun, Sergi; Vázquez, Susana; Sans, Laia; Pascual, Julio; Oliveras, Anna

2017-01-01

Sympathetic renal denervation (SRD) has been proposed as a therapeutic alternative for patients with resistant hypertension not controlled on pharmacological therapy. Two studies have suggested an effect of SRD in reducing short-term blood pressure variability (BPV). However, this has not been addressed in a randomized comparative trial. We aimed to compare the effects of spironolactone and SRD on circadian BP and BPV. This is a post-hoc analysis of a randomized trial in 24 true resistant hypertensive patients (15 men, 9 women; mean age 64 years) comparing 50mg of spironolactone (n = 13) vs. SRD (n = 11) on 24-hour BP. We report here the comparative effects on daytime (8 am-10 pm) and nighttime (0 am-6 am) BP, night-to-day ratios and BP and heart rate variabilities (SD and coefficient of variation of 24-hour, day and night, as well as weighted SD and average real variability (ARV)). Spironolactone was more effective than SRD in reducing daytime systolic (P = 0.006), daytime diastolic (P = 0.006), and nighttime systolic (P = 0.050) BP. No differences were observed in the night-to-day ratios. In contrast, SRD-reduced diastolic BPV (24 hours, daytime, nighttime, weighted, and ARV; all P < 0.05) with respect to spironolactone, without significant differences in systolic BPV. Spironolactone is more effective than SRD in reducing ambulatory BP. However, BPV is significantly more reduced with SRD. This effect could be important in terms of potential prevention beyond BP reduction and deserves further investigation. © American Journal of Hypertension, Ltd 2016. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Endocrine and haemodynamic changes in resistant hypertension, and blood pressure responses to spironolactone or amiloride: the PATHWAY-2 mechanisms substudies.

PubMed

Williams, Bryan; MacDonald, Thomas M; Morant, Steve V; Webb, David J; Sever, Peter; McInnes, Gordon T; Ford, Ian; Cruickshank, J Kennedy; Caulfield, Mark J; Padmanabhan, Sandosh; Mackenzie, Isla S; Salsbury, Jackie; Brown, Morris J

2018-06-01

In the PATHWAY-2 study of resistant hypertension, spironolactone reduced blood pressure substantially more than conventional antihypertensive drugs. We did three substudies to assess the mechanisms underlying this superiority and the pathogenesis of resistant hypertension. PATHWAY-2 was a randomised, double-blind crossover trial done at 14 UK primary and secondary care sites in 314 patients with resistant hypertension. Patients were given 12 weeks of once daily treatment with each of placebo, spironolactone 25-50 mg, bisoprolol 5-10 mg, and doxazosin 4-8 mg and the change in home systolic blood pressure was assessed as the primary outcome. In our three substudies, we assessed plasma aldosterone, renin, and aldosterone-to-renin ratio (ARR) as predictors of home systolic blood pressure, and estimated prevalence of primary aldosteronism (substudy 1); assessed the effects of each drug in terms of thoracic fluid index, cardiac index, stroke index, and systemic vascular resistance at seven sites with haemodynamic monitoring facilities (substudy 2); and assessed the effect of amiloride 10-20 mg once daily on clinic systolic blood pressure during an optional 6-12 week open-label runout phase (substudy 3). The PATHWAY-2 trial is registered with EudraCT, number 2008-007149-30, and ClinicalTrials.gov, number NCT02369081. Of the 314 patients in PATHWAY-2, 269 participated in one or more of the three substudies: 126 in substudy 1, 226 in substudy 2, and 146 in substudy 3. Home systolic blood pressure reduction by spironolactone was predicted by ARR (r 2 =0·13, p<0·0001) and plasma renin (r 2 =0·11, p=0·00024). 42 patients had low renin concentrations (predefined as the lowest tertile of plasma renin), of which 31 had a plasma aldosterone concentration greater than the mean value for all 126 patients (250 pmol/L). Thus, 31 (25% [95% CI 17-33]) of 126 patients were deemed to have inappropriately high aldosterone concentrations. Thoracic fluid content was reduced by 6·8% from

The Pharmacogenomics of Anti-Hypertensive Therapy.

PubMed

Padmanabhan, Sandosh; Paul, Laura; Dominczak, Anna F

2010-06-01

Hypertension is a major public health problem, but measures to reduce blood pressure and thus cardiovascular risk are complicated by the high prevalence of treatment resistance, despite the availability of multiple drugs. Drug side-effects contribute considerably to suboptimal blood pressure control. Clinicians must often rely on empirical methods to match patients with effective drug treatment. Hypertension pharmacogenomics seeks to find genetic predictors of response to drugs that lower blood pressure and to translate this knowledge into clinical practice. In this review we summarise the current status of hypertension pharmacogenetics from monogenic hypertension to essential hypertension and discuss the issues that need to be considered in a hypertension pharmacogenomic study.

Extra-adrenal phaeochromocytoma—a case report of refractory hypertension

PubMed Central

Singh, V.P.; Singh, Manjeet; Malhotra, Mridul; Kumar, Ashok; Agarwal, A.K.

2012-01-01

There are at least 5% of all hypertensive patients whose blood pressure (BP) remains elevated despite adequate treatment. In these cases, the clinician is forced to search for a secondary cause of the chronic BP elevation. Certain environmental factors are known to induce resistant-hypertension. Additionally, there may be pseudo-resistance occurring or the patient may be suffering from a secondary form of hypertension such as renovascular or endocrinological hypertension (phaeochromocytoma, Cushing's syndrome, etc.). We report a case of extra-adrenal phaeochromocytoma who was on adequate antihypertensive medications but remained refractory to treatment prior to the exact diagnosis. PMID:22572502

Novel and nonpharmacologic approaches to cardio-protection in hypertension.

PubMed

Donazzan, Luca; Mahfoud, Felix; Linz, Dominik; Ewen, Sebastian; Ukena, Christian; Böhm, Michael

2014-05-01

Hypertension has wide (30-45 %) prevalence in the general population and is related to important increases in overall cardiovascular morbidity and mortality. Despite lifestyle modifications and optimal medical therapy (three drugs, one being diuretic), about 5-20 % of hypertensives are affected by resistant hypertension. Chronic high blood pressure has adverse effects on the heart and other organs such as the kidneys and vasculature. Renal sympathetic denervation and baroreceptor stimulation are invasive approaches initially investigated to treat resistant hypertension. Their pleiotropic effects appear promising in cardiovascular remodeling, heart failure and arrhythmias and could potentially affect cardiovascular morbidity and mortality.

Hyperkalemia in the Hypertensive Patient.

PubMed

Lakkis, Jay Ian; Weir, Matthew R

2018-03-01

Hyperkalemia develops in a patient with systemic arterial hypertension (HTN) if one or more risk factors are present, namely chronic kidney disease (CKD) (especially severe stage 4-5 CKD), diabetes mellitus (DM), heart failure (HF), or pharmacological therapies that interfere with potassium homeostasis, mainly through renin-angiotensin-aldosterone inhibition (RAASi). Hyperkalemia is a considerable reason of morbidity (emergency department (ED) visits and hospitalizations) and portends a higher mortality risk in patients at risk; for instance, hyperkalemia increases the risk of mortality within 1 day of a hyperkalemic event. This review aims to identify the risk factors for high-serum potassium, highlight the risk versus benefit of RAASi in certain patient populations, and outline preventive as well as therapeutic strategies for hyperkalemia. A growing body of evidence supports the safety and efficacy of cation-exchange resins, patiromer, or sodium zirconium cyclosilicate, in patients with a compelling indication for RAASi, yet in whom such therapy was complicated by hyperkalemia, allowing these patients to benefit from continued RAASi therapy. In summary, novel cation exchange polymers present the clinician with a new and safe strategy to address hyperkalemia in patients with a compelling indication for ongoing RAASi therapy instead of withdrawal of such therapy.

Time-dependent changes in autonomic control of splanchnic vascular resistance and heart rate in ANG II-salt hypertension.

PubMed

Kuroki, Marcos T; Guzman, Pilar A; Fink, Gregory D; Osborn, John W

2012-02-01

Previous studies suggest that ANG II-induced hypertension in rats fed a high-salt (HS) diet (ANG II-salt hypertension) has a neurogenic component dependent on an enhanced sympathetic tone to the splanchnic veins and independent from changes in sympathetic nerve activity to the kidney or hind limb. The purpose of this study was to extend these findings and test whether altered autonomic control of splanchnic resistance arteries and the heart also contributes to the neurogenic component. Mean arterial pressure (MAP), heart rate (HR), superior mesenteric artery blood flow, and mesenteric vascular resistance (MVR) were measured during 4 control days, 14 days of ANG II delivered subcutaneously (150 ng·kg(-1)·min(-1)), and 4 days of recovery in conscious rats fed a HS (2% NaCl) or low-salt (LS; 0.1% NaCl) diet. Autonomic effects on MAP, HR, and MVR were assessed by acute ganglionic blockade with hexamethonium (20 mg/kg iv) on day 3 of control, days 1, 3, 5, 7, 10, and 13 of ANG II, and day 4 of recovery. MVR increased during ANG II infusion in HS and LS rats but remained elevated only in HS rats. Additionally, the MVR response to hexamethonium was enhanced on days 10 and 13 of ANG II selectively in HS rats. Compared with LS rats, HR in HS rats was higher during the 2nd wk of ANG II, and its response to hexamethonium was greater on days 7, 10, and 13 of ANG II. These results suggest that ANG II-salt hypertension is associated with delayed changes in autonomic control of splanchnic resistance arteries and the heart.

Rationale and design of the Investigator-Steered Project on intravascular Renal Denervation for Management of Drug-Resistant Hypertension (INSPiRED) trial

PubMed Central

Jin, Yu; Jacobs, Lotte; Baelen, Marie; Thijs, Lutgarde; Renkin, Jean; Hammer, Frank; Kefer, Joelle; Petit, Thibault; Verhamme, Peter; Janssens, Stefan; Sinnaeve, Peter; Lengelé, Jean-Philippe; Persu, Alexandre

2014-01-01

The SYMPLICITY studies showed that renal denervation (RDN) is feasible as novel treatment for resistant hypertension. However, RDN is a costly and invasive procedure, the long-term efficacy and safety of which has not yet been proven. Therefore, we designed the INSPiRED trial to compare the blood pressure lowering efficacy and safety of RDN vs usual medical therapy. INSPiRED is a randomized controlled trial enrolling 240 treatment-resistant hypertensive patients at 16 expert hypertension centres in Belgium. Eligible patients, aged 20–69 years old, have a 24-h ambulatory blood pressure of 130 mmHg systolic or 80 mmHg diastolic or more, while taking at least three antihypertensive drugs. They are randomized to RDN (EnligHTNTM, SJM system) plus usual care (intervention group) or usual care alone (control group) in a ratio of 1:1. The primary endpoints for efficacy and safety, measured after 6 months, are the baseline-adjusted between-group differences in 24h systolic blood pressure and in glomerular filtration rate as estimated by the Chronic Kidney Disease Epidemiology Collaboration equation. Follow-up will continue up to 36 months after randomization. INSPiRED is powered to demonstrate a 10-mmHg difference in systolic blood pressure between randomized groups with a two-sided p-value of 0.01 and 90% power. It will generate long-term efficacy and safety data, identify the subset of treatment-resistant hypertensive patients responsive to RDN, provide information on cost-effectiveness, and by doing so INSPiRED will inform guideline committees and health policy makers. Trial registration: ClinicalTrials.gov Identifier: NCT 01505010. PMID:24742341

Antihypertensive drug use in resistant and nonresistant hypertension and in controlled and uncontrolled resistant hypertension.

PubMed

de la Sierra, Alejandro; Armario, Pedro; Oliveras, Anna; Banegas, José R; Gorostidi, Manuel; Vinyoles, Ernest; de la Cruz, Juan J; Segura, Julián; Ruilope, Luis M

2018-07-01

Treatment-resistant hypertension (TRH) is associated with particular clinical features, nonadherence, and suboptimal treatment. We assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of non-TRH vs. TRH, and with controlled vs. uncontrolled TRH. Comparisons were done in 14 264 patients treated with three drugs (non-TRH: 2988; TRH: 11 276) and in 6974 treated with at least four drugs (controlled TRH: 1383; uncontrolled TRH: 5591). Associations were adjusted for age, sex, and previous cardiovascular event. In both groups of patients treated with three or with at least four drugs, aldosterone antagonists among drug classes [adjusted odds ratio (OR): 1.82 and 1.41, respectively], and ramipril (OR: 1.28 and 1.30), olmesartan (OR: 1.31 and 1.37), and amlodipine (OR: 1.11 and 1.41) inside each class were significantly associated with blood pressure control (non-TRH or controlled TRH). In patients treated with three drugs, non-TRH was also associated with the use of chlorthalidone (OR: 1.50) and bisoprolol (OR: 1.19), whereas in patients treated with at least four drugs, controlled TRH was significantly associated with the triple combination of a renin-angiotensin system blocker, a calcium channel blocker, and a diuretic (OR: 1.17). The use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs. Similar results are 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.

Treatment-time regimen of hypertension medications significantly affects ambulatory blood pressure and clinical characteristics of patients with resistant hypertension.

PubMed

Hermida, Ramón C; Ríos, María T; Crespo, Juan J; Moyá, Ana; Domínguez-Sardiña, Manuel; Otero, Alfonso; Sánchez, Juan J; Mojón, Artemio; Fernández, José R; Ayala, Diana E

2013-03-01

Patients with resistant hypertension (RH) are at greater risk for stroke, renal insufficiency, and cardiovascular disease (CVD) events than are those for whom blood pressure (BP) is responsive to and well controlled by therapeutic interventions. Although all chronotherapy trials have compared the effects on BP regulation of full daily doses of medications when ingested in the morning versus at bedtime, prescription of the same medications in divided doses twice daily (BID) is frequent. Here, we investigated the influence of hypertension treatment-time regimen on the circadian BP pattern, degree of BP control, and relevant clinical and laboratory medicine parameters of RH patients evaluated by 48-h ambulatory BP monitoring (ABPM). This cross-sectional study evaluated 2899 such patients (1701 men/1198 women), 64.2 ± 11.8 (mean ± SD) yrs of age, enrolled in the Hygia Project. Among the participants, 1084 were ingesting all hypertension medications upon awakening (upon-awakening regimen), 1436 patients were ingesting the full daily dose of ≥1 of them at bedtime (bedtime regimen), and 379 were ingesting split doses of ≥1 medications BID upon awakening and at bedtime (BID regimen). Patients of the bedtime regimen compared with the other two treatment-time regimens had lower likelihood of microalbuminuria and chronic kidney disease; significantly lower albumin/creatinine ratio, glucose, total cholesterol, and low-density lipoprotein (LDL) cholesterol; plus higher estimated glomerular filtration rate and high-density lipoprotein (HDL) cholesterol. The bedtime regimen was also significantly associated with lower asleep systolic (SBP) and diastolic (DBP) BP means than the upon-awakening and BID regimens. The sleep-time relative SBP and DBP decline was significantly attenuated by the upon-awakening and BID regimens (p < .001), resulting in significantly higher prevalence of non-dipping in these two treatment-time regimen groups (80.5% and 77.3%, respectively

Role of Adding Spironolactone and Renal Denervation in True Resistant Hypertension: One-Year Outcomes of Randomized PRAGUE-15 Study.

PubMed

Rosa, Ján; Widimský, Petr; Waldauf, Petr; Lambert, Lukáš; Zelinka, Tomáš; Táborský, Miloš; Branny, Marian; Toušek, Petr; Petrák, Ondřej; Čurila, Karol; Bednář, František; Holaj, Robert; Štrauch, Branislav; Václavík, Jan; Nykl, Igor; Krátká, Zuzana; Kociánová, Eva; Jiravský, Otakar; Rappová, Gabriela; Indra, Tomáš; Widimský, Jiří

2016-02-01

This randomized, multicenter study compared the relative efficacy of renal denervation (RDN) versus pharmacotherapy alone in patients with true resistant hypertension and assessed the effect of spironolactone addition. We present here the 12-month data. A total of 106 patients with true resistant hypertension were enrolled in this study: 52 patients were randomized to RDN and 54 patients to the spironolactone addition, with baseline systolic blood pressure of 159±17 and 155±17 mm Hg and average number of drugs 5.1 and 5.4, respectively. Twelve-month results are available in 101 patients. The intention-to-treat analysis found a comparable mean 24-hour systolic blood pressure decline of 6.4 mm Hg, P=0.001 in RDN versus 8.2 mm Hg, P=0.002 in the pharmacotherapy group. Per-protocol analysis revealed a significant difference of 24-hour systolic blood pressure decline between complete RDN (6.3 mm Hg, P=0.004) and the subgroup where spironolactone was added, and this continued within the 12 months (15 mm Hg, P= 0.003). Renal artery computed tomography angiograms before and after 1 year post-RDN did not reveal any relevant changes. This study shows that over a period of 12 months, RDN is safe, with no serious side effects and no major changes in the renal arteries. RDN in the settings of true resistant hypertension with confirmed compliance is not superior to intensified pharmacological treatment. Spironolactone addition (if tolerated) seems to be more effective in blood pressure reduction. © 2015 American Heart Association, Inc.

[Hepatopulmonary syndrome and portopulmonary hypertension].

PubMed

Marcu, Cristina; Schiffer, Eduardo; Aubert, John-David; Vionnet, Julien; Yerly, Patrick; Deltenre, Pierre; Marot, Astrid

2017-08-30

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are two frequent pulmonary complications of liver disease. Portal hypertension is a key element in the pathogenesis of both disorders, which are however distinct in terms of pathogenesis, diagnosis and treatment. HPS corresponds to an abnormal arterial oxygenation in relation with the development of intrapulmonary vascular dilatations. POPH is a pulmonary arterial hypertension in the setting of portal hypertension and elevated pulmonary vascular resistance. As both diseases are associated with an increased risk of morbidity and mortality, it is important to screen and evaluate the severity of these two disorders particularly in liver transplant candidates.

Relationship of autonomic imbalance and circadian disruption with obesity and type 2 diabetes in resistant hypertensive patients

PubMed Central

2011-01-01

Background Hypertension, diabetes and obesity are not isolated findings, but a series of interacting interactive physiologic derangements. Taking into account genetic background and lifestyle behavior, AI (autonomic imbalance) could be a common root for RHTN (resistant hypertension) or RHTN plus type 2 diabetes (T2D) comorbidity development. Moreover, circadian disruption can lead to metabolic and vasomotor impairments such as obesity, insulin resistance and resistant hypertension. In order to better understand the triggered emergence of obesity and T2D comorbidity in resistant hypertension, we investigated the pattern of autonomic activity in the circadian rhythm in RHTN with and without type 2 diabetes (T2D), and its relationship with serum adiponectin concentration. Methods Twenty five RHTN patients (15 non-T2D and 10 T2D, 15 males, 10 females; age range 34 to 70 years) were evaluated using the following parameters: BMI (body mass index), biochemical analysis, serum adiponectinemia, echocardiogram and ambulatory electrocardiograph heart rate variability (HRV) in time and frequency domains stratified into three periods: 24 hour, day time and night time. Results Both groups demonstrated similar characteristics despite of the laboratory analysis concerning T2D like fasting glucose, HbA1c levels and hypertriglyceridemia. Both groups also revealed disruption of the circadian rhythm: inverted sympathetic and parasympathetic tones during day (parasympathetic > sympathetic tone) and night periods (sympathetic > parasympathetic tone). T2D group had increased BMI and serum triglyceride levels (mean 33.7 ± 4.0 vs 26.6 ± 3.7 kg/m2 - p = 0.00; 254.8 ± 226.4 vs 108.6 ± 48.7 mg/dL - p = 0.04), lower levels of adiponectin (6729.7 ± 3381.5 vs 10911.5 ± 5554.0 ng/mL - p = 0.04) and greater autonomic imbalance evaluated by HRV parameters in time domain compared to non-T2D RHTN patients. Total patients had HRV correlated positively with serum adiponectin (r = 0.37 [95% CI -0

The combined exercise stress echocardiography and cardiopulmonary exercise test for identification of masked heart failure with preserved ejection fraction in patients with hypertension.

PubMed

Nedeljkovic, Ivana; Banovic, Marko; Stepanovic, Jelena; Giga, Vojislav; Djordjevic-Dikic, Ana; Trifunovic, Danijela; Nedeljkovic, Milan; Petrovic, Milan; Dobric, Milan; Dikic, Nenad; Zlatar, Milan; Beleslin, Branko

2016-01-01

Heart failure with preserved ejection fraction (HFpEF) is commonly associated with hypertension (HTN). However, resting echocardiography (ECHO) can underestimate the severity of disease. Exercise stress echocardiography (ESE) and the cardiopulmonary exercise testing (CPX) appeared to be useful tests in dynamic assessment of HFpEF. The value of combined exercise stress echocardiography cardiopulmonary testing (ESE-CPX) in the identification of masked HFpEF is still undetermined. The purpose of this study was to analyse the value of the combined ESE-CPX in the identification of masked HFpEF in patients with HTN, dyspnoea and normal resting left ventricular (LV) systolic and diastolic function. We studied 87 patients with HTN, exertional dyspnoea and normal resting LV function. They all underwent ESE-CPX testing (supine bicycle, ramp protocol, 15 W/min). ECHO measurements were performed at rest, and at peak load. Achievement of peak E/e' ratio>15 was a marker for masked HFpEF. Increase of E/e'>15 occurred in 8/87 patients (9.2%) during ESE-CPX. Those patients had the lower peak VO2 (p = 0.012), the lower VO2 at anaerobic threshold (p = 0.025), the lower workload (p = 0.026), the lower peak partial pressure end tidal carbon dioxide (PetCO2) (p < 0.0001), and the higher VE/VCO2 slope (p < 0.0001) which was an independent multivariate predictor of HFpEF (p = 0.021), with the cut-off value of 32.95 according to the receiver-operator characteristic (ROC) curve (sensitivity (Sn) 100%, specificity (Sp) 90%). The combined ESE-CPX test is feasible and reliable test that can unmask HFpEF and may become an important aid in the early diagnosis of HFpEF, excluding the other causes of exertional dyspnoea. © The European Society of Cardiology 2015.

Hypercortisolism in obesity-associated hypertension.

PubMed

Varughese, Amy G; Nimkevych, Oksana; Uwaifo, Gabriel I

2014-07-01

Obesity is prevalent worldwide and associated with co-morbidities that result in increased cardiovascular risk. Hypertension is the most prevalent obesity comorbidity associated with increased cardiovascular risk. Obesity hypertension is a distinct subtype of essential hypertension. While endogenous Cushing's syndrome is an uncommon cause of both obesity and hypertension, the recent recognition of other hypercortisolemic states has raised the profile of hypercortisolism as an important contributor in obesity hypertension. The high prevalence of exogenous, iatrogenic, pseudo, and subclinical Cushing's syndromes makes hypercortisolism an important diagnostic consideration in the evaluation and management of patients with obesity hypertension who are resistant to conventional management. Available data suggest that the renin-angiotensin-aldosterone system modulating antihypertensives have the best efficacy in hypercortisolism-mediated obesity hypertension. Strategies aimed at reducing cortisol production and action also have utility. This review provides a comprehensive overview of the epidemiology, etiopathogenesis and management options available for glucocorticoid-mediated obesity hypertension.

Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy

PubMed Central

Ghazi, Lama; Drawz, Paul

2017-01-01

The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice. PMID:28413612

Effects of losartan on whole-body, skeletal muscle, and vascular insulin responses in obesity/insulin resistance without hypertension

PubMed Central

Lteif, AA; Chisholm, RL; Gilbert, K; Considine, RV; Mather, KJ

2011-01-01

Aims Renin-angiotensin system antagonists have been found to improve glucose metabolism in obese hypertensive and type 2 diabetic subjects. The mechanism of these effects is not well understood. We hypothesized that the angiotensin receptor antagonist losartan would improve insulin-mediated vasodilation, and thereby improve insulin-stimulated glucose uptake in skeletal muscle of insulin resistant subjects. Materials and Methods We studied subjects with obesity and insulin resistance but without hypertension, hypercholesterolemia or dysglycemia (age 39.0±9.6 yrs [mean±SD], BMI 33.2±5.9 kg/m2, BP 115.8±12.2/70.9±7.2 mmHg, LDL 2.1±0.5 mmol/L). Subjects were randomized to 12 weeks’ double-blind treatment with losartan 100 mg once daily (n=9) or matching placebo (n=8). Before and after treatment, under hyperinsulinemic euglycemic clamp conditions we measured whole-body insulin stimulated glucose disposal, insulin-mediated vasodilation, and insulin-stimulated leg glucose uptake by the limb balance technique. Results Whole-body insulin-stimulated glucose disposal was not significantly increased by losartan. Insulin-mediated vasodilation was augmented following both treatments (increase in leg vascular conductance: pre-treatment 0.7±0.3 L*min−1*mmHg−1[losartan, mean ±SEM] and 0.9±0.3 [placebo], post-treatment 1.0±0.4 [losartan] and 1.3±0.6 [placebo]) but not different between treatment groups (p=0.53). Insulin’s action to augment NO production and to augment endothelium-dependent vasodilation were also not improved. Leg glucose uptake was not significantly changed by treatments, and not different between groups (p=0.11). Conclusions These findings argue against the hypothesis that losartan might improve skeletal muscle glucose metabolism by improving insulin-mediated vasodilation in normotensive insulin resistant obese subjects. The metabolic benefits of angiotensin receptor blockers may require the presence of hypertension in addition to obesity

Biology of portal hypertension.

PubMed

McConnell, Matthew; Iwakiri, Yasuko

2018-02-01

Portal hypertension develops as a result of increased intrahepatic vascular resistance often caused by chronic liver disease that leads to structural distortion by fibrosis, microvascular thrombosis, dysfunction of liver sinusoidal endothelial cells (LSECs), and hepatic stellate cell (HSC) activation. While the basic mechanisms of LSEC and HSC dysregulation have been extensively studied, the role of microvascular thrombosis and platelet function in the pathogenesis of portal hypertension remains to be clearly characterized. As a secondary event, portal hypertension results in splanchnic and systemic arterial vasodilation, leading to the development of a hyperdynamic circulatory syndrome and subsequently to clinically devastating complications including gastroesophageal varices and variceal hemorrhage, hepatic encephalopathy from the formation of portosystemic shunts, ascites, and renal failure due to the hepatorenal syndrome. This review article discusses: (1) mechanisms of sinusoidal portal hypertension, focusing on HSC and LSEC biology, pathological angiogenesis, and the role of microvascular thrombosis and platelets, (2) the mesenteric vasculature in portal hypertension, and (3) future directions for vascular biology research in portal hypertension.

Current Perspectives on Systemic Hypertension in Heart Failure with Preserved Ejection Fraction.

PubMed

Tam, Marty C; Lee, Ran; Cascino, Thomas M; Konerman, Matthew C; Hummel, Scott L

2017-02-01

Heart failure with preserved ejection fraction (HFpEF) is a prevalent but incompletely understood syndrome. Traditional models of HFpEF pathophysiology revolve around systemic HTN and other causes of increased left ventricular afterload leading to left ventricular hypertrophy (LVH) and diastolic dysfunction. However, emerging models attribute the development of HFpEF to systemic proinflammatory changes secondary to common comorbidities which include HTN. Alterations in passive ventricular stiffness, ventricular-arterial coupling, peripheral microvascular function, systolic reserve, and chronotropic response occur. As a result, HFpEF is heterogeneous in nature, making it difficult to prescribe uniform therapies to all patients. Nonetheless, treating systemic HTN remains a cornerstone of HFpEF management. Antihypertensive therapies have been linked to LVH regression and improvement in diastolic dysfunction. However, to date, no therapies have definitive mortality benefit in HFpEF. Non-pharmacologic management for HTN, including dietary modification, exercise, and treating sleep disordered breathing, may provide some morbidity benefit in the HFpEF population. Future research is need to identify effective treatments, perhaps in more specific subgroups, and focus may need to shift from reducing mortality to improving exercise capacity and symptoms. Tailoring antihypertensive therapies to specific phenotypes of HFpEF may be an important component of this strategy.

Spironolactone versus sympathetic renal denervation to treat true resistant hypertension: results from the DENERVHTA study – a randomized controlled trial

PubMed Central

Oliveras, Anna; Armario, Pedro; Clarà, Albert; Sans-Atxer, Laia; Vázquez, Susana; Pascual, Julio; De la Sierra, Alejandro

2016-01-01

Objective: Both renal denervation (RDN) and spironolactone have been proposed for the treatment of resistant hypertension. However, they have not been compared in a randomized clinical trial. We aimed to compare the efficacy of spironolactone versus RDN in patients with resistant hypertension. Methods: A total of 24 patients with office SBP at least 150 mmHg and 24-h SBP at least 140 mmHg despite receiving at least three full-dose antihypertensive drugs, one a diuretic, but without aldosterone antagonists, were randomized to receive RDN or spironolactone (50 mg) as add-on therapy. Primary endpoint was change in 24-h SBP at 6 months. Comparisons between treatment groups were performed using generalized linear models adjusted by age, sex, and baseline values. Results: Spironolactone was more effective than RDN in reducing 24-h SBP and 24-h DBP: mean baseline-adjusted differences between the two groups were −17.9 mmHg (95%CI −30.9 to −4.9); P = 0.010 and −6.6 mmHg (95%CI −12.9 to −0.3); P = 0.041, for 24-h SBP and 24-h DBP, respectively. As regards changes in office blood pressure, mean baseline-adjusted differences between the two groups were −12.1 mmHg (95%CI −29.1 to 5.1); P = 0.158 and of −5.3 mmHg (95%CI −16.3 to 5.8); P = 0.332, for office SBP and office DBP, respectively. Otherwise, the decrease of estimated glomerular filtration rate was greater in the spironolactone group; mean baseline-adjusted difference between the two groups was −10.7 ml/min per 1.73 m2 (95%CI −20.1 to −1.4); P = 0.027. Conclusion: We conclude that spironolactone is more effective than RDN to reduce 24-h SBP and 24-h DBP in patients with resistant hypertension. Therefore, spironolactone should be the fourth antihypertensive drug to prescribe if deemed well tolerated’ in all patients with resistant hypertension before considering RDN. PMID:27327441

Ruling out secondary causes of hypertension.

PubMed

Ott, Christian; Schneider, Markus P; Schmieder, Roland E

2013-05-01

In the majority of hypertensive patients, no particular cause for abnormal blood pressure is evident (primary or essential hypertension). In contrast, in the minority of patients with secondary hypertension a specific underlying cause is responsible for the elevated blood pressure. The prevalence of secondary hypertension is higher in patients with resistant hypertension than in the general hypertensive population and increases with age. The list of secondary forms of hypertension is long and prevalence of the individual causes of secondary hypertension varies. Hence, this review divides them into two categories: common causes and rare causes. If appropriately diagnosed and treated, patients with a secondary form of hypertension might be cured, or at least show an improvement in their blood pressure control. Consequently, screening for secondary causes of hypertension plays an essential part in the care of patients with arterial hypertension. If the basal work-up raises the suspicion of a secondary cause of hypertension, specific diagnostic procedures become necessary, some of which can be performed by primary care physicians, while others require specialist input.