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Ambulatory blood pressure monitoring and diabetes complications: Targeting morning blood pressure surge and nocturnal dipping.
Najafi, MT, Khaloo, P, Alemi, H, Jaafarinia, A, Blaha, MJ, Mirbolouk, M, Mansournia, MA, Afarideh, M, Esteghamati, S, Nakhjavani, M, et al
Medicine. 2018;(38):e12185
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Abstract
Ambulatory blood pressure monitoring (ABPM) correlates more closely to organ damages than clinic blood pressure (BP). In the current study we aimed to investigate the association between micro- and macrovascular complications of diabetes and both diurnal and nocturnal variability in BP.A total of 192 patients with type 2 diabetes (T2DM) who had complete data on ABPM were selected. BP categories were defined based on 2017 ACC/American Heart Association BP guideline. The cross-sectional association between different BP phenotypes and diabetes complications including cardiovascular disease (CVD), nephropathy, retinopathy, and neuropathy was assessed using multiple logistic regression models adjusted for age, sex, body mass index, hypertension (HTN), hemoglobin A1c, fasting blood glucose (FBG), triglyceride (TG), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and total cholesterol.Approximately 48.9% of participants with T2DM had 24-hour HTN. The prevalence of daytime, nighttime, and clinic HTN were 35.9%, 96.3%, and 53.1%, respectively. Approximately 54.2% of participants had nondipping nocturnal pattern and 28.6% were risers. Nondipping nocturnal BP was associated with CVD, neuropathy, and retinopathy (P = .05, .05, and .014, respectively). Sleep trough morning blood pressure surge (MBPS) was associated with neuropathy (P = .023). Neuropathy was also associated with other components of MBPS (P < .05).We demonstrated that diabetic neuropathy was associated with all the components of MBPS and abnormal dipping status. Our results indicated loss of nocturnal BP dipping but not MBPS as a risk factor for CVD and retinopathy in patients with T2DM. Our findings once again highlighted the importance of ambulatory BP monitoring and targeted antihypertensive therapy directed toward to restore normal circadian BP in patients with T2DM.
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Effect of high dose folic acid supplementation in pregnancy on pre-eclampsia (FACT): double blind, phase III, randomised controlled, international, multicentre trial.
Wen, SW, White, RR, Rybak, N, Gaudet, LM, Robson, S, Hague, W, Simms-Stewart, D, Carroli, G, Smith, G, Fraser, WD, et al
BMJ (Clinical research ed.). 2018;:k3478
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Abstract
OBJECTIVE To determine the efficacy of high dose folic acid supplementation for prevention of pre-eclampsia in women with at least one risk factor: pre-existing hypertension, prepregnancy diabetes (type 1 or 2), twin pregnancy, pre-eclampsia in a previous pregnancy, or body mass index ≥35. DESIGN Randomised, phase III, double blinded international, multicentre clinical trial. SETTING 70 obstetrical centres in five countries (Argentina, Australia, Canada, Jamaica, and UK). PARTICIPANTS 2464 pregnant women with at least one high risk factor for pre-eclampsia were randomised between 2011 and 2015 (1144 to the folic acid group and 1157 to the placebo group); 2301 were included in the intention to treat analyses. INTERVENTION Eligible women were randomised to receive either daily high dose folic acid (four 1.0 mg oral tablets) or placebo from eight weeks of gestation to the end of week 16 of gestation until delivery. Clinicians, participants, adjudicators, and study staff were masked to study treatment allocation. MAIN OUTCOME MEASURE The primary outcome was pre-eclampsia, defined as hypertension presenting after 20 weeks' gestation with major proteinuria or HELLP syndrome (haemolysis, elevated liver enzymes, low platelets). RESULTS Pre-eclampsia occurred in 169/1144 (14.8%) women in the folic acid group and 156/1157 (13.5%) in the placebo group (relative risk 1.10, 95% confidence interval 0.90 to 1.34; P=0.37). There was no evidence of differences between the groups for any other adverse maternal or neonatal outcomes. CONCLUSION Supplementation with 4.0 mg/day folic acid beyond the first trimester does not prevent pre-eclampsia in women at high risk for this condition. TRIAL REGISTRATION Current Controlled Trials ISRCTN23781770 and ClinicalTrials.gov NCT01355159.
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Twenty-four-hour systolic blood pressure variability and renal function decline in elderly male hypertensive patients with well-controlled blood pressure.
Wang, X, Wang, F, Chen, M, Wang, X, Zheng, J, Qin, A
Clinical interventions in aging. 2018;:533-540
Abstract
PURPOSE Increased variability in blood pressure (BP) is known to be closely associated with the development, progression and severity of renal damage in patients with chronic kidney disease. However, little is known about the association of BP variability (BPV) with the decline of renal function in elderly hypertensive patients with well-controlled BP. We, therefore, aimed to investigate the association between BPV and glomerular filtration rate in hypertensive elderly (age >60 years) and very elderly (age >80 years) male patients with BP controlled within the normal range by antihypertensive therapy. PATIENTS AND METHODS This study involved 484 hospitalized elderly male hypertensive patients with BP controlled within the normal range by antihypertensive therapy. BPV was defined as the SD from mean BP over a 24 h period. Renal function was estimated by estimated glomerular filtration rate (eGFR) which was calculated by the Chinese modified Modification of Diet in Renal Disease Equation. Participants were divided into three groups according to their eGFR data. Multivariate linear regression was then used to analyze the correlation between eGFR and BPV. RESULTS The 24 h systolic BP (SBP) variability increased as eGFR decreased. There was no significant difference in 24 h SBP variability when compared between elderly and very elderly hypertensive patients. Multivariate linear regression analysis showed that SBP variability demonstrated a negative linear relationship with eGFR (P<0.05) after adjustment for potential confounding factors. CONCLUSION Among the parameters of 24 h ambulatory BP monitoring, 24 h SBP variability is the only independent risk factor for a decline in renal function in elderly and very elderly male hypertensive patients with well-controlled BP.
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Dietary Phytoestrogen Intake is Inversely Associated with Hypertension in a Cohort of Adults Living in the Mediterranean Area.
Godos, J, Bergante, S, Satriano, A, Pluchinotta, FR, Marranzano, M
Molecules (Basel, Switzerland). 2018;(2)
Abstract
BACKGROUND Dietary polyphenols, including phytoestrogens are abundantly present in a balanced diet. Evidence for their role in preventing non-communicable diseases is emerging. METHODS We examined the association between estimated habitual intakes of dietary phytoestrogens and hypertension in a cohort study. The baseline data included 1936 men and women aged 18 years and older. Intakes of total phytoestrogens, isoflavones, and lignans were calculated from validated food frequency questionnaire. Data on the polyphenols content in foods were retrieved from the Phenol-Explorer database. RESULTS Individuals in the highest quartile of dietary phytoestrogens intake were less likely to be hypertensive (OR: 0.66, 95% CI: 0.44-0.98); moreover, the association showed a significant decreasing trend. Isoflavones and lignans were not associated with lower odds of hypertension; however, some individual compounds, such as biochanin A and pinoresinol showed an independent inverse association with hypertension. CONCLUSIONS Dietary phytoestrogens are associated with lower likelihood of hypertension in adults living in the Mediterranean area. Future studies are needed to confirm the present findings (i.e., prospective cohort studies) and to better understand the mechanisms underlying such associations.
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Hyperkalemia in the Hypertensive Patient.
Lakkis, JI, Weir, MR
Current cardiology reports. 2018;(2):12
Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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.
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Epicardial Left Atrial Appendage Exclusion Reduces Blood Pressure in Patients With Atrial Fibrillation and Hypertension.
Turagam, MK, Vuddanda, V, Verberkmoes, N, Ohtsuka, T, Akca, F, Atkins, D, Bommana, S, Emmert, MY, Gopinathannair, R, Dunnington, G, et al
Journal of the American College of Cardiology. 2018;(12):1346-1353
Abstract
BACKGROUND Percutaneous left atrial appendage exclusion (LAAE) has evolved as an alternative strategy for stroke prevention in atrial fibrillation (AF). Recent observational data have suggested that epicardial LAAE can have substantial impact on arrhythmia burden and hemodynamic profile. OBJECTIVES The authors aimed to study the impact of epicardial versus endocardial LAAE on systemic blood pressure in hypertensive AF patients. METHODS This was a prospective, nonrandomized study comparing 247 patients who underwent epicardial LAAE with 124 patients with endocardial exclusion. Clinical outcomes were measured at 3 months and 1 year. Primary outcome was improvement in systolic blood pressure (SBP) between both groups compared with baseline. Secondary outcome included changes in diastolic pressures (DBP), serum electrolytes, and creatinine. RESULTS There was no significant difference in baseline SBP between epicardial and endocardial groups. SBP was significantly lower in the epicardial group both at 3 months (122 ± 11.8 mm Hg vs. 129.7 ± 8.2 mm Hg; p < 0.001) and 1 year (123 ± 11.6 mm Hg vs. 132.2 ± 8.8 mm Hg; p < 0.001) compared with the endocardial group. An adjusted multivariate linear mixed effects model demonstrated that epicardial LAAE significantly decreased SBP by 7.4 mm Hg at 3 months and by 8.9 mm Hg at 1 year (p < 0.0001). There was a trend toward lower DBP with epicardial LAAE at 3 months by 1.3 mm Hg (p = 0.2) and at 1 year by 1.8 mm Hg (p = 0.09). There was no significant difference in serum electrolytes and creatinine between both groups. CONCLUSIONS In hypertensive AF patients, epicardial LAAE significantly decreases SBP both at 3 and 12 months compared with endocardial exclusion.
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Novel Medical Treatments for Hypertension and Related Comorbidities.
Davis, J, Oparil, S
Current hypertension reports. 2018;(10):90
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the most recent data available on advances in development of novel medical treatments for hypertension and related comorbidities. RECENT FINDINGS Approximately half of all hypertensive patients have not achieved goal blood pressure with current available antihypertensive medications. Recent landmark studies and new hypertension guidelines have called for stricter blood pressure control, creating a need for better strategies for lowering blood pressure. This has led to a shift in focus, in recent years, to the development of combination pills as a means of achieving improved blood pressure control by increasing adherence to prescribed medications along with further research and development of promising novel drugs based on discovery of new molecular targets such as the counter-regulatory renin-angiotensin system. Fixed-dose combination pills and novel treatments based on recently discovered pathogenic mechanisms of hypertension that have demonstrated promising results as treatments for hypertension and related comorbidities will be discussed in this review.
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Blockade of the angiotensin system improves mental health domain of quality of life: A meta-analysis of randomized clinical trials.
Brownstein, DJ, Salagre, E, Köhler, C, Stubbs, B, Vian, J, Pereira, C, Chavarria, V, Karmakar, C, Turner, A, Quevedo, J, et al
The Australian and New Zealand journal of psychiatry. 2018;(1):24-38
Abstract
OBJECTIVE It is unclear whether blockade of the angiotensin system has effects on mental health. Our objective was to determine the impact of angiotensin converting enzyme inhibitors and angiotensin II type 1 receptor (AT1R) blockers on mental health domain of quality of life. STUDY DESIGN Meta-analysis of published literature. DATA SOURCES PubMed and clinicaltrials.gov databases. The last search was conducted in January 2017. STUDY SELECTION Randomized controlled trials comparing any angiotensin converting enzyme inhibitor or AT1R blocker versus placebo or non-angiotensin converting enzyme inhibitor or non-AT1R blocker were selected. Study participants were adults without any major physical symptoms. We adhered to meta-analysis reporting methods as per PRISMA and the Cochrane Collaboration. DATA SYNTHESIS Eleven studies were included in the analysis. When compared with placebo or other antihypertensive medications, AT1R blockers and angiotensin converting enzyme inhibitors were associated with improved overall quality of life (standard mean difference = 0.11, 95% confidence interval = [0.08, 0.14], p < 0.0001), positive wellbeing (standard mean difference = 0.11, 95% confidence interval = [0.05, 0.17], p < 0.0001), mental (standard mean difference = 0.15, 95% confidence interval = [0.06, 0.25], p < 0.0001), and anxiety (standard mean difference = 0.08, 95% confidence interval = [0.01, 0.16], p < 0.0001) domains of QoL. No significant difference was found for the depression domain (standard mean difference = 0.05, 95% confidence interval = [0.02, 0.12], p = 0.15). CONCLUSIONS Use of angiotensin blockers and inhibitors for the treatment of hypertension in otherwise healthy adults is associated with improved mental health domains of quality of life. Mental health quality of life was a secondary outcome in the included studies. Research specifically designed to analyse the usefulness of drugs that block the angiotensin system is necessary to properly evaluate this novel psychiatric target.
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Effects of salt substitute on home blood pressure differs according to age and degree of blood pressure in hypertensive patients and their families.
Hu, J, Zhao, L, Thompson, B, Zhang, Y, Wu, Y
Clinical and experimental hypertension (New York, N.Y. : 1993). 2018;(7):664-672
Abstract
BACKGROUND It is known that home blood pressure (HBP) is a more reliable assessment of hypertension treatments than clinical blood pressure (BP). Despite this, HBP response to a salt substitute has only been evaluated by one study which, did not look at the salt substitute's effect on family members and did not analyze by age, gender, or BP degree. The aim of this current study was to assess the effects of a low-sodium and high-potassium salt substitute on HBP among hypertensive patients and their family members. METHODS A total of 220 households (including 220 hypertensive patients and 380 their families) were randomly assigned to the regular salt or salt substitute groups. HBP was measured at the beginning, 3rd, 6th, and 12th months. Among the patients (n = 220), only home systolic blood pressure (HSBP) was significantly reduced, by an adjusted baseline BP of 4.2 mm Hg (95% CI: 1.3-7.0 mm Hg), in the salt substitute group compared with those in the regular salt group at each visit (all P < 0.05). There were no detectable differences between groups for home diastolic blood pressure (HDBP) at any visit. Among the family members, HSBP and HDBP were not significantly different between the groups. Furthermore, Individuals ≥60 years old, hypertensive patients with stage-2 hypertension, family members with hypertension, and women experienced greater HSBP reduction. CONCLUSIONS Older subjects, those with higher blood pressure, and women experienced greater home blood pressure reduction from the salt substitute compared to regular salt.
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Single-Pill Combinations in the Treatment of Hypertension in Adults: Beyond Convenience.
Imbeault, B, Vallée, M
Canadian journal of diabetes. 2018;(2):205-208
Abstract
Adequate blood pressure control in patients with hypertension remains the pillar of cardiovascular-event prevention. Smoking cessation, reduced dietary salt intake, physical exercise and weight loss contribute to better blood pressure control and reduced cardiovascular morbidity, but alone, they are often insufficient in doing so, and their success is highly dependent on individual patient motivation. Pharmacologic therapy, thus, remains necessary for most patients, and our conception of the optimal way of approaching this therapy has evolved over the past decade. Traditionally, monotherapy using a first-line drug was initiated and uptitrated, with the addition of other antihypertensive agents as needed. The latest Hypertension Canada guidelines, however, now recommend first-line treatment with single-pill combinations in patients without compelling indications for treatment. In this review, we discuss the evidence behind this recommendation and how single-pill combinations can improve patient care.