Prevalence and prognosis of the 2018 vs 2008 AHA definitions of apparent treatment‐resistant hypertension in high‐risk hypertension patients

Resistant hypertension was defined according to the 2008 scientific statement as office blood pressure ≥ 140/90 mm Hg and the 2018 scientific statement as office blood pressure ≥ 130/80 mm Hg. We investigated the prognostic significance of lowered blood pressure threshold for defining resistant hypertension in the 2018 American Heart Association scientific statement compared with that in the 2008 scientific statement. The participants of this prospective cohort were enrolled from December 2013 to November 2018. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiovascular death, non‐fatal myocardial infarction, non‐fatal stroke, and heart failure hospitalization. Renal event was defined as a ≥ 50% decline in estimated glomerular filtration rate or progression to end‐stage renal disease. A total of 206 patients among 2018 (10.2%) were diagnosed with resistant hypertension by the previous definition (≥140/90 mm Hg), and 276 patients among 2011 (13.7%) were diagnosed with resistant hypertension by the updated definition (≥130/80 mm Hg). During a median follow‐up of 4.5 years, 33 MACEs (3.7 per 1000 patient‐years) and 164 renal events (19.9 per 1000 patient‐years) occurred in the study population. Treatment‐resistant hypertension groups had a higher incidence rate of MACEs and renal events than the control groups. In multivariate Cox proportional hazards regression analysis, resistant hypertension by both definitions was significantly associated with increased risk of MACE and renal event. Both the previous and updated definitions of resistant hypertension were significant predictors of MACEs and renal events. This finding supports the adoption of the updated criteria for resistant hypertension in clinical practice.     

Focus on blood pressure levels and variability in the early phase of acute ischemic stroke with hypertension and carotid stenosis

To investigate the optimal blood pressure (BP) levels and relative importance of BP and BP variability in the early phase of acute ischemic stroke (AIS) for hypertensive patients with carotid artery stenosis (CAS). A single‐center cohort study included 750 AIS patients with hypertension and tests were performed for CAS. Participants were categorized to Group 1 (SBP < 140 mm Hg and DBP < 90 mm Hg), Group 2: (SBP: 140–159 mm Hg and or DBP: 90–99 mm Hg), and Group 3: (SBP ≥160 mm Hg and/or DBP ≥100 mm Hg) according to the guidelines. The associations of mean BP levels and variability with outcomes (recurrent stroke, all‐cause death and the composite cardiovascular events) at 6 months were analyzed by Cox proportional hazard models. The associations of BP variability with BP levels and cerebral blood flow (CBF) were analyzed by linear regression and generalized additive models. Both for primary and secondary outcome, more events occurred in Group 1 compared with Group 2, while no significant difference was found in Group 3 with higher BP levels. Lower systolic BP variability showed better prognosis and higher CBF. The associations were more significant in patients with CAS ≥50%. BP variability exhibited a linear negative relationship with BP levels. In the early phase of AIS with hypertension and CAS, maintaining low blood pressure variability may be important to improve outcomes while low BP levels (SBP/DBP < 140/90 mm Hg) were harmful, especially in those patients with CAS ≥ 50%.     

The effect of frailty on the 24‐hour blood pressure pattern in the very elderly

Frailty plays a crucial role in the management of hypertension in the very elderly and has a strong association with cardiovascular diseases. Nevertheless, its influence on the 24‐hour blood pressure pattern, including elevated asleep systolic blood pressure (BP) and the lack of BP fall during sleep (non‐dipping) has not been explored in a population above 80 years.Patients older than 80 years were classified into frail or robust subtypes by the five item frailty phenotype criteria. All participants were submitted to office blood pressure measurements and ambulatory BP monitoring over a 24‐hour period. Nocturnal dipping was defined as nighttime BP fall ≥10%.Thirty‐eight frail and 36 non‐frail individuals (mean age 85.3 ± 3.7 years; 67% females) were analyzed. Awake systolic and diastolic BP were similar for frail and robust individuals. Frail patients had higher systolic BP during sleep (128 ± 15 mm Hg vs. 122 ±13 mm Hg p = .04) and reduced systolic BP fall [1 (‐4.5 – 5)% vs. 6.8 (2.1 – 12.8)% p < .01]. Frailty was independently associated with higher risk of non‐dipping (OR 12.4; CI 1.79 – 85.9) and reduced nighttime systolic BP fall (‐6.1%; CI ‐9.6 – ‐2.6%). In conclusions, frailty has a substantial influence on nighttime BP values and pattern in patients older than 80 years.     

Peak blood pressure‐guided monitoring may serve as an effective approach for blood pressure control in the out‐of‐office setting

We aimed to explore whether diurnal blood pressure (BP) peak characteristics have a significant influence on the association between left ventricular damage with the two BP components (morning BP vs. afternoon peak BP) in untreated hypertensives. This cross‐sectional study included 1084 hypertensives who underwent echocardiography and 24‐h ambulatory BP monitoring. Participants were stratified according to the relationship between morning systolic BP (MSBP; average SBP within 2 h of waking up) and afternoon peak systolic BP (ASBP; average SBP between 16:00 and 18:00). Afternoon and morning hypertension was defined as ≥ 135/85 mm Hg. The morning and afternoon peak BPs occurred at around 7:00 and 17:00, respectively. In general hypertensives, morning BP and afternoon peak BP are significantly different in absolute values (for binary SBP, McNemar''s χ² = 6.42; p = .014). ASBP was more pronounced than MSBP in 602 patients (55.5%), in whom 24‐h SBP showed higher consistency with ASBP than with MSBP (Kappa value: 0.767 vs 0.646, both p < .01). In subjects with ASBP ≥ MSBP, ASBP was associated with left ventricular hypertrophy independent of MSBP (logistic regression analysis odds ratio: 1.046, p < .01), and left ventricular mass index was more strongly correlated with ASBP than with MSBP (multiple regression coefficient β: 0.453, p < .01), in which the relationships held true independently of 24‐h SBP. The opposite results were obtained in subjects with MSBP > ASBP. Peak BP‐guided monitoring may serve as an effective approach to out‐of‐office hypertension monitoring and control, providing the best consistency with 24‐h average SBP and highest discrimination performance for target organ damage, independently of 24‐h SBP.     

Algorithm for diagnosing hypertension using out‐of‐office blood pressure measurements

The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut‐off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut‐off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP‐ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP‐HBP‐ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP‐ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1–80.9) for office BP alone and 76.2% (95%CI 70.5–81.3) for home BP alone as follows: 96.5% (95%CI: 93.4–98.4) for OBP‐ABP, 93.4% (95%CI: 89.6–96.1) for OBP‐HBP‐ABP, and 94.9% (95%CI: 91.5–97.3%) for HBP‐ABP.  In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.     

Office blood pressure threshold of 130/80 mmHg better predicts uncontrolled out‐of‐office blood pressure in apparent treatment‐resistant hypertension

The objective of this study was to compare the diagnostic accuracy of office blood pressure (BP) threshold of 140/90 and 130/80 mmHg for correctly identifying uncontrolled out‐of‐office BP in apparent treatment‐resistant hypertension (aTRH). We analyzed 468 subjects from a prospectively enrolled cohort of patients with resistant hypertension in South Korea (clinicaltrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT03540992","term_id":"NCT03540992"}}NCT03540992). Resistant hypertension was defined as office BP ≥ 130/80 mmHg with three different classes of antihypertensive medications including thiazide‐type/like diuretics, or treated hypertension with four or more different classes of antihypertensive medications. We conducted different types of BP measurements including office BP, automated office BP (AOBP), home BP, and ambulatory BP. We defined uncontrolled out‐of‐office BP as daytime BP ≥ 135/85 mmHg and/or home BP ≥ 135/85 mmHg. Among subjects with office BP < 140/90 mmHg and subjects with office BP < 130/80 mmHg, 66% and 55% had uncontrolled out‐of‐office BP, respectively. The prevalence of controlled and masked uncontrolled hypertension was lower, and the prevalence of white‐coat and sustained uncontrolled hypertension was higher, with a threshold of 130/80 mmHg than of 140/90 mmHg, for both office BP and AOBP. The office BP threshold of 130/80 mmHg was better able to diagnose uncontrolled out‐of‐office BP than 140/90 mmHg, and the net reclassification improvement (NRI) was 0.255. The AOBP threshold of 130/80 mmHg also revealed better diagnostic accuracy than 140/90 mmHg, with NRI of 0.543. The office BP threshold of 130/80 mmHg showed better than 140/90 mmHg in terms of the correspondence to out‐of‐office BP in subjects with aTRH.     

Sex differences in the blood pressure level associated with increased risks of cardiovascular events: a Korean nationwide population‐based cohort study

Hypertension is a leading risk factor for cardiovascular events and death. Despite differences in clinical implications of hypertension between men and women, guidelines establishing optimal blood pressure (BP) targets are still debated. The aim of this study was to investigate sex differences in the BP level associated with increased risks of major adverse cardiac and cerebral events (MACCEs) among antihypertensive‐treated patients. Using data from the Korean National Health Insurance Service‐National Sample Cohort, we enrolled antihypertensive‐treated patients and divided them into four categories: Group 1: SBP < 120 and DBP < 80 mm Hg; Group 2: 120 ≤ SBP < 130 and DBP < 80 mm Hg; Group 3: 130 ≤ SBP < 140 or 80 ≤ DBP < 90 mm Hg; and Group 4: SBP ≥ 140 or DBP ≥ 90 mm Hg. We performed time‐dependent cox regression analysis to investigate sex differences in the BP levels that increased the risk of MACCEs. Most of the 98 267 patients fell into Group 3 (53.2% men and 52.8% women) and Group 4 (30.5% men and 28.1% women). During 8.34 ± 2.07 years, there were 8,813 MACCEs and 791 deaths. The incidences of MACCEs and death tended to increase as the BP increased in both sexes. Compared to Group 1, the risk of MACCEs significantly increased only in Group 4 for men, while it significantly increased in Groups 3 and 4 for women. This study shows that there are sex differences in the BP level at which the risk of MACCEs increases. Our finding suggests that sex should be significantly considered when determining the optimal BP target in patients undergoing hypertension treatment.     

Simplified hypertension screening approaches with low misclassification and high efficiency in the United States,Nepal, and India

Standard triplicate blood pressure (BP) measurements pose time barriers to hypertension screening, especially in resource‐limited settings. We assessed the implications of simplified approaches using fewer measurements with adults (≥18 years old) not using anti‐hypertensive medications from the US National Health and Nutrition Examination Survey 1999‐2016 (n = 30 614), and two datasets from May Measurement Month 2017‐2018 (n = 14 795 for Nepal and n = 6 771 for India). We evaluated the proportion of misclassification of hypertension when employing the following simplified approaches: using only 1st BP, only 2nd BP, 2nd if 1st BP in a given range (otherwise using 1st), and average of 1st and 2nd BP. Hypertension was defined as average of 2nd and 3rd systolic BP ≥140 and/or diastolic BP ≥90 mm Hg. Using only the 1st BP, the proportion of missed hypertension ranged from 8.2%–12.1% and overidentified hypertension from 4.3%–9.1%. Using only 2nd BP reduced the misclassification considerably (corresponding estimates, 4.9%–6.4% for missed hypertension and 2.0%–4.4% for overidentified hypertension) but needed 2nd BP in all participants. Using 2nd BP if 1st BP ≥130/80 demonstrated similar estimates of missed hypertension (3.8%–8.1%) and overidentified hypertension (2.0%–3.9%), but only required a 2nd BP in 33.8%–59.8% of participants. In conclusion, a simplified approach utilizing 1st BP supplemented by 2nd BP in some individuals has low misclassification rates and requires approximately half of the total number of measurements compared to the standard approach, and thus can facilitate screening in resource‐constrained settings.     

Optimal blood pressure for patients with end‐stage renal disease following coronary interventions

Hypertension is a frequent manifestation of chronic kidney disease but the ideal blood pressure (BP) target in patients with coronary artery disease (CAD) with end‐stage renal disease (ESRD) (eGFR < 15 ml/min/1.73m²) still unclear. The authors aimed to investigate the ideal achieved BP in ESRD patients with CAD after coronary intervention. Five hundred and seventy‐five ESRD patients who had undergone percutaneous coronary interventions (PCIs) were enrolled and their clinical outcomes were analyzed according to the category of systolic BP (SBP) and diastolic BP (DBP) achieved. The clinical outcomes included major cardiovascular events (MACE) and MACE plus hospitalization for congestive heart failure (total cardiovascular (CV) event).The mean systolic BP was 135.0 ± 24.7 mm Hg and the mean diastolic BP was 70.7 ± 13.1 mm Hg. Systolic BP 140–149 mm Hg and diastolic BP 80–89 mm Hg had the lowest MACE (11.0%; 13.2%) and total CV event (23.3%; 21.1%). Patients with systolic BP < 120 mm Hg had a higher risk of MACE (HR: 2.01; 95% CI: 1.17–3.46, p = .008) than those with systolic BP 140–149 mm Hg. Patients with systolic BP ≥ 160 mm Hg (HR: 1.84; 95% CI, 3.27–1.04, p = .04) and diastolic blood BP ≥ 90 mm Hg (HR: 2.19; 95% CI: 1.15–4.16, p = .02) had a higher risk of total CV event rate when compared to those with systolic BP 140–149 mm Hg and diastolic BP 80–89 mm Hg. A J‐shaped association between systolic (140–149 mm Hg) and diastolic (80–89 mm Hg) BP and decreased cardiovascular events for CAD was found in patients with ESRD after undergoing PCI in non‐Western population.     

Home blood pressure control status in 2017‐2018 for hypertension specialist centers in Asia: Results of the Asia BP@Home study

A self‐measured home blood pressure (BP)‐guided strategy is an effective practical approach to hypertension management. The Asia BP@Home study is the first designed to investigate current home BP control status in different Asian countries/regions using standardized home BP measurements taken with the same validated home BP monitoring device with data memory. We enrolled 1443 medicated hypertensive patients from 15 Asian specialist centers in 11 countries/regions between April 2017 and March 2018. BP was relatively well controlled in 68.2% of patients using a morning home systolic BP (SBP) cutoff of <135 mm Hg, and in 55.1% of patients using a clinic SBP cutoff of <140 mm Hg. When cutoff values were changed to the 2017 AHA/ACC threshold (SBP <130 mm Hg), 53.6% of patients were well controlled for morning home SBP. Using clinic 140 mm Hg and morning home 135 mm Hg SBP thresholds, the proportion of patients with well‐controlled hypertension (46%) was higher than for uncontrolled sustained (22%), white‐coat (23%), and masked uncontrolled (9%) hypertension, with significant country/regional differences. Home BP variability in Asian countries was high, and varied by country/region. In conclusion, the Asia BP@Home study demonstrated that home BP is relatively well controlled at hypertension specialist centers in Asia. However, almost half of patients remain uncontrolled for morning BP according to new guidelines, with significant country/regional differences. Strict home BP control should be beneficial in Asian populations. The findings of this study are important to facilitate development of health policies focused on reducing cardiovascular complications in Asia.     

Effect of canagliflozin on nocturnal home blood pressure in Japanese patients with type 2 diabetes mellitus: The SHIFT‐J study

Sodium‐glucose cotransporter 2 (SGLT2) inhibitors have beneficial effects on several cardiometabolic biomarkers, but this is not sufficient to fully explain the significant reduction in cardiovascular risk and mortality reported with SGLT2 inhibitor treatment in patients with diabetes mellitus. The 8‐week, randomized, open‐label SHIFT‐J study investigated the effects of adding canagliflozin vs intensified antihyperglycemic therapy on nocturnal home blood pressure (BP) in patients with poorly controlled type 2 diabetes and nocturnal BP on existing therapy. Patients were randomized to oral canagliflozin 100 mg/d or control (increased hypoglycemic dosage/addition of another hypoglycemic agent). The efficacy analysis included 78 patients (mean 69 years; 59% male). Nocturnal home systolic BP [HSBP] decreased by 5.23 mm Hg in the canagliflozin group and by 1.04 mm Hg in the control group (P = 0.078 for between‐group difference in change from baseline to week 8 [primary endpoint]); corresponding decreases in HSBP from baseline to week 4 were 5.08 and 1.38 mm Hg, respectively (P = 0.054). Reductions in morning HSBP from baseline to week 4 (−6.82 mm Hg vs −1.26 mm Hg, P = 0.038) and evening HSBP from baseline to week 8 (−8.74 mm Hg vs −2.36 mm Hg, P = 0.012) were greater in the canagliflozin group than in the control group. Body mass index (P < 0.001) and N‐terminal pro B‐type natriuretic peptide level (NT‐proBNP; P = 0.023) decreased more in the canagliflozin group than in the control group. Glycemic control improved comparably in both groups. Reduction of HSBP and NT‐proBNP level may be potential mechanism by which SGLT2 inhibitors reduce cardiovascular event risk.     

24‐h ambulatory blood pressure variability and hypertensive nephropathy in Han Chinese hypertensive patients

Blood pressure (BP) is characterized by spontaneous oscillation over time, which is described as BP variability (BPV). The current study aimed to investigate whether short‐term BPV was correlated with hypertensive nephropathy in Han Chinese individuals with hypertension. A single‐center prospective cohort study of 300 Han Chinese participants with hypertension was conducted in Taiwan. Five different BPV parameters were derived from ambulatory BP monitoring (ABPM), including standard deviation (SD), weighted SD (wSD), coefficient of variation (CoV), successive variation (SV), and average real variability (ARV). Renal event was defined as > 50% reduction in baseline estimated glomerular filtration rate (eGFR). The average age of the participants was 63.5 years. The baseline eGFR was 84.5 mL/min/1.73 m². The participants were divided into two groups according to the wSD of systolic BP (SBP). Survival was assessed via a Kaplan‐Meier analysis. During the 4.2‐year follow‐up, the participants with the highest SBP wSD tertile had a greater number of renal events (6.0%) than their counterparts (0.5%) (log‐rank test, p = .007). The Cox proportional hazard regression model was used to assess the independent effects of BPV, and results showed that 24‐h SBP (HR = 1.105; 95% CI = 1.020–1.197, p = .015) and 24‐h DBP (HR = 1.162; 95% CI = 1.004–1.344, p = .044) were independently associated with renal events. However, BPV parameters were only associated with renal events univariately, but not after adjusting for baseline characteristics, 24‐h mean BP, and office BP. Therefore, the risk of hypertensive nephropathy was independently associated with 24‐h mean BP, but not with ambulatory BPV, in Han Chinese participants with hypertension.     

Blood pressure measurement protocol determines hypertension phenotypes in a Middle Eastern population

Clinic blood pressure (BP) measurement remains a crucial step in managing hypertension. While the number of measures recorded in different settings varies, with typically 1‐3 measures, there has been no prior justification for the actual number of measures required. We investigated the pattern of BP variability over 5 consecutive automated readings (R1‐R5) and the influence of patient characteristics on this pattern to identify the phenotype of hypertension in a Middle Eastern population. There were 1389 outpatients (51% men, 49% women), age range (18‐87 y) who had 5 unattended automated consecutive BP measurements with one‐minute intervals using the validated Datascope Mindray Passport V Monitor with the patient blinded from the results. Mean (±SEM) SBP for R1 (136.0 ± 2 mm Hg) was similar to R2 (136.2 ± 2 mm Hg). Thereafter SBP progressively declined till R5 by total of 5.5 mm Hg. The SBP decline was less (4.2 mm Hg) in older (>50 years) vs younger participants (8.1 mm Hg; P < .001) and was blunted in diabetic and hypertensive participants. Overall, 43% of participants had R2 > R1, and 24% additionally had R5 > R1. Age was a strong independent predictor of having both R2 > R1 and R5 > R1, as well as diabetes. Diastolic blood pressure (DBP) decreased by average 2.8 mm Hg from R1 to R5. Females had a 5‐fold greater total decline in DBP vs males (P < .001). Using the mean of 5 BP measures resulted in fewer participants being classified as hypertensive (36% of the population) compared to using one measurement (46%), or established BP guidelines which use different combinations of R1‐R3 (37%‐42%). Our findings in a Middle Eastern population highlight the importance of the BP measurement protocol in combination with patient characteristics in determining whether a patient is diagnosed with hypertension. Protocols that rely on different combinations of only 3 measures (R1‐3) will classify more participants as hypertensive, compared to using 5 measures or disregarding a high R2.     

Association between hypertensive disorders during pregnancy and elevated blood pressure in offspring: A systematic review and meta‐analysis

Hypertensive disorders during pregnancy (HDP) are associated with cardiovascular disease among mothers and offspring. This meta‐analysis was conducted to further explore the associations between maternal HDP and offspring blood pressure (BP). The authors performed a search strategy in PubMed, Embase, Web of Science, and Cochrane library from database inception to January 2022. Twenty‐four studies regarding HDP were included, with pregnancy‐associated hypertension (PAH), preeclampsia (PE), gestational hypertension (GH), and chronic hypertension included in 12, 16, 6, and 3 studies, respectively. Offspring who were exposed to HDP and PAH in utero had higher systolic BP (2.46 mm Hg, 95% CI: 1.88–3.03 mm Hg; 2.70 mm Hg 95% CI: 1.89–3.51 mm Hg) and diastolic BP (1.38 mm Hg 95% CI: 0.94–1.83 mm Hg; 1.39 mm Hg 95% CI: 0.71–2.06 mm Hg) than those birthed to normotensive mothers. The offspring exposure to PE, GH, and chronic hypertension had higher systolic BP by 1.90 mm Hg (95% CI: 1.39–2.40 mm Hg), 2.47 mm Hg (95% CI: 1.59–3.35 mm Hg), and 7.85 mm Hg (95% CI: 4.10–11.61 mm Hg), respectively, and higher diastolic BP by 0.99 mm Hg (95% CI: 0.50–1.49 mm Hg), 1.04 mm Hg (95% CI: 0.60–1.47 mm Hg), and 2.92 mm Hg (95% CI: 0.98–4.86 mm Hg), respectively. An Egger test and funnel plot confirmed no significant publication bias. In conclusion, offspring exposure to all subtypes of HDP in utero led to higher BP than no exposure. It is necessary to investigate the potential mechanisms to clarify the roles of genetic and environmental factors in these associations, which could provide insight on preventing hypertension and related cardiovascular disease.     

Assessment of suitable antihypertensive therapies: Combination with high‐dose amlodipine/irbesartan vs triple combination with amlodipine/irbesartan/indapamide (ASAHI‐AI study)

Angiotensin receptor blockers (ARBs) plus calcium channel blockers (CCBs) are a widely used combination therapy for hypertensive patients. In order to determine which combination was better as the next‐step therapy for standard‐dose combination of ARBs and CCBs, a combination with high‐dose CCBs or a triple combination with diuretics, the authors conducted a prospective, randomized, open‐label trial to determine which of the following combination is better as the next‐step treatment: a combination with high‐dose CCBs or a triple combination with diuretics. Hypertensive outpatients who did not achieve their target blood pressure (BP) with usual dosages of ARBs and amlodipine 5 mg were randomly assigned to treatment with irbesartan 100 mg/amlodipine 10 mg (Group 1: n = 48) or indapamide 1 mg in addition to ARBs plus amlodipine 5 mg (Group 2: n = 46). The primary end point was changes in the systolic BP (SBP) and diastolic BP (DBP) after the 12‐week treatment period, while secondary end points were changes in BP after the 24‐week treatment period and laboratory values. At 12 weeks, the SBP/DBP significantly decreased from 152.1/83.4 mm Hg to 131.5/76.1 mm Hg in Group 1 and 153.9/82.1 mm Hg to 132.7/75.9 mm Hg in Group 2. Although both groups produced a similar efficacy in reducing the SBP/DBP (−19.2/‐9.2 mm Hg in Group 1 and −21.6/‐8.8 mm Hg in Group 2; SBP P = .378, DBP P = .825), high‐dose CCBs combined with ARBs controlled hypertension without elevation of serum uric acid. These results will provide new evidence for selecting optimal combination therapies for uncontrolled hypertensive patients.     

Identifying and treating resistant hypertension in PRECISION: A randomized long‐term clinical trial with aprocitentan

The design and baseline data of the PRECISION study, which evaluates the effect of the dual endothelin receptor antagonist aprocitentan on blood pressure (BP) in patients with resistant hypertension (RHT) are presented. The study is a blinded, randomized, parallel‐group Phase 3 study and its three‐part design assesses the short‐term and sustained long‐term effects of aprocitentan on BP. Results are expected in 2022.Patients with uncontrolled BP (measured as unattended automated office BP) despite the use of three or more antihypertensive medications for at least 1 year were screened. They were switched to a single‐tablet triple fixed combination antihypertensive therapy for at least 4 weeks before entering a single‐blind placebo run‐in period. The 4‐week placebo run‐in period further excluded placebo responders. The randomization period consisted of three sequential parts: (1) a 4‐week double‐blind part with aprocitentan 12.5 mg, 25 mg, or placebo (1:1:1 ratio); (2) a 32‐week single‐blind part with aprocitentan 25 mg; and (3) a 12‐week randomized withdrawal part with aprocitentan 25 mg or placebo (1:1 ratio). The purpose was to demonstrate the BP lowering effect of aprocitentan in RHT (Part 1) and the persistence of this effect (Parts 2 and 3).Out of 1965 screened patients, 730 were randomized resulting in an overall inclusion failure rate of 62.8%. The most common reason for exclusion (44.4% of all screened patients) was failure to meet the BP inclusion criteria. These results underline the high proportion of pseudoresistant hypertension among patients referred for RHT.     

Isolated systolic hypertension and central blood pressure: Implications from the national nutrition and health survey in Taiwan

We aimed to investigate the association between isolated systolic hypertension (ISH) and central blood pressure (BP) in a nationally representative population, with a focus on the young and middle‐aged adults (<50 years old). A total of 2029 adults without taking antihypertensive medications, aged ≥ 19 years old, participated in the 2013–2016 National Nutrition and Health Survey in Taiwan. Central and brachial BP were simultaneously measured using a cuff‐based stand‐alone central blood pressure monitor purporting to measure invasive central BP (type II device). Central hypertension was defined by central systolic (SBP)/diastolic BP (DBP) ≥130 or 90 mm Hg, and ISH was defined by brachial SBP ≥ 140 and DBP < 90 mm Hg. Overall, the prevalence rates of ISH, isolated diastolic hypertension (IDH, brachial SBP < 140 and DBP ≥ 90 mmHg), and systolic/diastolic hypertension (SDH, brachial SBP ≥ 140 and DBP ≥ 90 mmHg) were 6.51%, 1.92%, and 4.34%, respectively. ISH subjects had significantly higher central pulse pressure (PP) (62.8 ± 9.7 mm Hg for age < 50 years and 72.4 ± 13.5 mmHg for age ≥ 50 years) than those subjects with either IDH (44.7 ± 10.7 and 44.9 ± 10.6 mmHg) or SDH (55.2 ± 14.0 and 62.6 ± 17.1 mmHg). All ISH adults had central hypertension, and a higher prevalence of central obesity than the normotensives (80.95% vs. 26.15%, for age < 50 years; and 63.96% vs. 43.37% for age ≥ 50 years). All untreated subjects with ISH, whether younger or older, had central hypertension and had significantly higher central PP than those with IDH or SDH. Central obesity was one of the major characteristics of ISH, especially in the young‐ and middle‐aged adults.     

Clinical outcomes of laparoscopic‐based renal denervation plus adrenalectomy vs adrenalectomy alone for treating resistant hypertension caused by unilateral aldosterone‐producing adenoma

Previous studies describing renal denervation (RDN) from the intima of the renal artery for the treatment of resistant hypertension have reported variable efficacies, and RDN triggers renal intimal injury and atherosclerosis. This study aimed to evaluate the efficacy and safety of RDN from the adventitia of renal artery plus unilateral laparoscopic adrenalectomy to treat patients with resistant hypertension caused by unilateral aldosterone‐producing adenoma (APA). A total of 60 consecutive patients with resistant hypertension caused by unilateral APA were enrolled in this study. Patients were randomly assigned to undergo RDN from the adventitia of the renal artery plus adrenalectomy (RDN group, n = 30) or adrenalectomy alone (control group, n = 30) and were followed up for 12 months. The primary efficacy end point was the change in 24‐hours mean ambulatory systolic blood pressure (SBP) from baseline to 12 months. At the 12‐month follow‐up, the mean reduction of 24‐hours average SBP and office SBP in the RDN group was 20.7 ± 15.2 and 37.1 ± 26.0 mm Hg, respectively, which was significantly higher than the mean reduction of 24‐hours average SBP (11.9 ± 11.1 mm Hg, P = .017) and the office SBP (25.9 ± 16.8 mm Hg, P = .035) in the control group. Serum potassium levels returned to normal 12 months post‐procedure. Patients in the RDN group had higher proportion of cured clinical and biochemical outcomes than those in the control group (35.7% vs 17.9% in clinical outcome; 96.4% vs 89.3% in biochemical outcome, respectively). There were no procedural‐, device‐, or treatment‐related safety events during the 12‐month follow‐up period between the groups. In conclusion, RDN from the adventitia of the renal artery plus unilateral laparoscopic adrenalectomy is more effective than adrenalectomy alone for treating resistant hypertension caused by unilateral APA.     

Home‐based transcutaneous electrical acupoint stimulation for high‐normal blood pressure: A randomized controlled trial

The authors investigated the effectiveness of home‐based transcutaneous electrical acupoint stimulation (TEAS) combined with lifestyle modification on blood pressure (BP) control and explored the feasibility of the trial design in this prospective, randomized controlled trial. The authors recruited individuals with high‐normal BP who had a systolic blood pressure (SBP) of 120–139 mm Hg and a diastolic blood pressure (DBP) of 80–89 mm Hg, or both. Participants were randomly assigned to receive either lifestyle modification combined with TEAS four times weekly for 12 weeks at home (intervention group) or solely lifestyle modification (control group). The primary outcome was the change in mean SBP at week 12 from the baseline measurement. A total of 60 participants were randomized in a 1:1 ratio, and an intention‐to‐treat analysis was performed on all of the outcomes. The mean difference in the change in SBP for the intervention group (compared to the control) at week 12 was −3.85 mm Hg (95% CI: −7.58 to −.12; p = .043); for the DBP, the change was −2.27 mm Hg (95% CI: −5.76 to 1.23; p = .199). There was no difference in the proportion of progression to hypertension, quality of life, body mass index (BMI) or waist circumference. In addition, two participants reported TEAS‐related adverse events. The authors found a reduction in SBP control in the pragmatic, home‐based intervention by using TEAS combined with lifestyle modification in adults with high‐normal BP. Trial Registration: The study was registered in the Chinese Clinical Trial Registry (ChiCTR 1900024982) on August 6, 2019.