Mediation effect of obesity on the association between triglyceride‐glucose index and hyperuricemia in Chinese hypertension adults

The triglyceride glucose (TyG) index was regarded as a simple surrogate marker of insulin resistance (IR). It is confirmed that IR was significantly associated with hyperuricemia, and obesity was the risk factor for IR and hyperuricemia. However, the relationship between the TyG index and hyperuricemia and the potential role of obesity in Han Chinese hypertension are not entirely elucidated. A community‐based cross‐sectional study was conducted in 4551 hypertension patients aged 40–75 years with clinical and biochemical data. The TyG index was calculated as ln [fasting triglyceride (mg/dl) × fasting plasma glucose (mg/dl)/2]. Hyperuricemia was determined as serum uric acid ≥357μmol/L (6 mg/dl) for females and ≥417μmol/L (7 mg/dl) for males. Our study suggested that the TyG index was higher in patients with hyperuricemia than in those without (8.99±0.61, 8.70±0.59, p < .001). The prevalence of hyperuricemia in patients with the lowest (≤8.32), second (8.33–8.66), third (8.67–9.07) and the highest quartile (≥9.08) of the TyG index was 6.0%, 10.4%, 15.4%, 21.4%, respectively. Logistic regression analysis suggested that the higher quartile of TyG index was associated with increased hyperuricemia risk whether in crude or adjusted models (p < .05). Mediation analysis showed that all of our obesity indexes partially mediated the association between the TyG index and hyperuricemia to some extent. In Conclusions, the TyG index is significantly associated with hyperuricemia in hypertension patients among Han Chinese, obesity plays a partial mediation role in this relationship.     

Usefulness of ankle‐brachial index calculated using diastolic blood pressure for prediction of mortality in patients with acute myocardial infarction

A low ankle‐brachial index (ABI) calculated using systolic blood pressure (SBP) (ABIsbp) is associated with poor cardiovascular outcome in patients with acute myocardial infarction (AMI). ABI is always calculated using SBP clinically. However, there was no study investigating ABI calculated using mean artery pressure (MAP)(ABImap) and diastolic blood pressure (DBP)(ABIdbp) for mortality prediction in AMI patients. Therefore, our study was aimed to investigate the issue. 199 AMI patients were enrolled. Different ABIs were measured by an ABI‐form device. The median follow‐up to mortality was 64 months. There were 40 cardiovascular and 137 all‐cause mortality. The best cutoff values of ABImbp and ABIdbp for mortality prediction were 0.91 and 0.78, respectively. After multivariate analysis, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular mortality (P ≤ .047). However, all of six ABI parameters, including ABIsbp, ABImap, ABIdbp, ABIsbp < 0.90, ABImap < 0.91, and ABIdbp < 0.78, could predict all‐cause mortality (P ≤ .048). In a direct comparison of six ABI models for prediction of all‐cause mortality, basic model + ABIdbp <0.78 had the highest predictive value (P ≤ .025). In conclusion, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular and all‐cause mortality after multivariate analysis in our study. Furthermore, when adding into a basic model, ABIdbp < 0.78 had the highest additively predictive value for all‐cause mortality in the six ABI parameters. Hence, calculation of ABI using DBP except SBP might provide an extra benefit in prediction of cardiovascular and all‐cause mortality in AMI patients.     

Factors associated with hypertension among stroke‐free indigenous Africans: Findings from the SIREN study

Hypertension is one of the most important risk factors for stroke and cardiovascular diseases (CVD) globally. Understanding risk factors for hypertension among individuals with matching characteristics with stroke patients may inform primordial/primary prevention of hypertension and stroke among them. This study identified the risk factors for hypertension among community‐dwelling stroke‐free population in Ghana and Nigeria. Data for 4267 community‐dwelling stroke‐free controls subjects in the Stroke Investigative Research and Education Network (SIREN) study in Nigeria and Ghana were used. Participants were comprehensively assessed for sociodemographic, lifestyle and metabolic factors using standard methods. Hypertension was defined as a previous diagnosis by a health professional or use of an anti‐hypertensive drug or mean systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Logistic regression analysis was used to estimate adjusted odds ratios (aOR) of hypertension and their 95% confidence intervals (CI) at p < .05. Overall, 56.7% of the participants were hypertensive with a higher proportion among respondents aged ≥60 years (53.0%). Factors including physical inactivity (aOR: 9.09; 95% CI: 4.03 to 20.53, p < .0001), diabetes (aOR: 2.70; CI: 1.91 to 3.82, p < .0001), being ≥60 years (aOR: 2.22; 95% CI: 1.78 to 2.77, p < .0001), and family history of CVD (aOR 2.02; CI: 1.59 to 2.56, p < .0001) were associated with increased aOR of hypertension. Lifestyle factors were associated with hypertension in the current population of community‐dwelling stroke‐free controls in west Africa. Community‐oriented interventions to address sedentary lifestyles may benefit this population and reduce/prevent hypertension and stroke among them.     

Reclassification of adolescent hypertension by ambulatory blood pressure monitoring using adult norms and association with left ventricular hypertrophy

2017 pediatric blood pressure (BP) guidelines applied adult BP norms to define clinic hypertension (HTN) in patients ≥ 13 years. 2014 pediatric ambulatory BP monitor (ABPM) guidelines recommend age‐ and sex‐specific percentile norms for patients < 18 years. The authors evaluated reclassification of HTN when applying adult ABPM norms in patients ≥ 13 years and assessed the association of left ventricular hypertrophy (LVH) with HTN. Charts of patients 13–17 years with ABPM 9/2018–5/2019 were reviewed for sex, age, height, weight, BP medication, ABPM results, and left ventricular mass index (LVMI). American Heart Association 2005 (AHA 2005), AHA 2017 (AHA 2017), and European Society of Hypertension 2018 (ESH 2018) guidelines for adult ABPM were compared with 2014 AHA pediatric norms (pABPM). HTN was defined by each guideline using only ABPM. ABPM and clinic BP were used to classify white coat hypertension (WCH) and masked hypertension (MH). LVH was defined as LVMI > 51 g/m^2.7. 272 patients had adequate ABPM. 124 patients also had echocardiogram. All adult norms resulted in significant reclassification of HTN. LVMI correlated significantly with systolic BP only. The odds of a patient with HTN having LVH was significant using AHA 2005 (OR: 8.75 [2.1, 36.4], p = .03) and ESH 2018 (OR: 4.94 [1, 24.3], p = .002). Significant reclassification of HTN occurs with all adult norms. HTN is significantly associated with LVH using AHA 2005 and ESH 2018. Applying pediatric norms for ABPM while using adult norms for clinic BP causes confusion. Guideline selection should balance misdiagnosis with over‐diagnosis.     

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.     

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.     

Association of optimal blood pressure with mortality in patients taking antihypertensive medications

We investigated the relationship between blood pressure (BP) and mortality in patients taking antihypertensive medications in the Korean using data from the 2007‐2015 Korean National Health and Nutrition Examination Surveys. A total of 6601 patients aged 30‐74 years were included. Systolic BP (SBP) and diastolic BP (DBP) were both divided into four groups as follows: SBP < 120, 120 ≤ SBP ≤ 129 130 ≤ SBP ≤ 139, and SBP ≥ 140; DBP < 70, 70 ≤ DBP ≤ 79, 80 ≤ DBP ≤ 89, and DBP ≥ 90. The survival rates and hazard ratios were evaluated using Kaplan‐Meier curves and multivariable Cox regression analyses. To evaluate the predictability of all‐cause mortality according to SBP and/or DBP, we calculated Harrell''s concordance‐index. The lowest DBP group had a high risk of mortality regardless of the SBP status. The group with DBP < 70 mm Hg and SBP ≥ 140 mm Hg showed the highest mortality. The discriminatory ability calculated using Harrell''s C‐indexes was greater for the combination of SBP and DBP compared to DBP or SBP alone. These results suggest that it is more effective to simultaneously evaluate the effect of SBP and DBP to predict mortality; clinicians should manage DBP < 70 mm Hg when treating hypertensive patients.     

Relationship between resting heart rate and incident heart failure in patients with hypertension: The Kailuan Cohort Study in China

An elevated heart rate increases the risk of cardiovascular disease, but the relationship between resting heart rate (RHR) and the risk of heart failure (HF) in hypertensive patients is unclear. This study was performed to assess the relationship between elevated RHR and incident HF in hypertensive patients. In total, 16 286 hypertensive patients from the Kailuan cohort were enrolled and underwent three physical examinations. According to mean RHR based on quartile, the hypertensive patients were divided into four groups: Q1 (mean RHR ≤ 69 bpm), Q2 (69 bpm < mean RHR ≤ 74 bpm), Q3 (74 bpm < mean RHR ≤ 79 bpm), and Q4 (mean RHR > 79 bpm). The cumulative mortality rate was analyzed by using the Kaplan–Meier method, with comparisons among RHR quartiles. Cox proportional hazards regression models and restricted cubic spline models were established to evaluate the association between RHR and risk of incident HF. After adjustment for confounders, the hazard ratio (HR) for HF was 1.97(95% CI: 1.28‐3.04, P < .001) in the fourth quartile compared to the first quartile. Each 1‐standard deviation [10 (beats/min)] increase in RHR was associated with a 40% increase in the risk of incident HF. Restricted cubic spline models presented a linear relationship between RHR and incident HF. Our study suggests that elevated RHR is associated with an enhanced risk of HF in hypertensive patients.     

Nocturnal heart rate rising is a risk factor for poor renal outcomes in patients with chronic kidney disease and hypertension

The association of heart rate (HR) dipping pattern with renal outcomes in chronic kidney disease (CKD) patients with hypertension has never been investigated. In order to demonstrate if HR dipping pattern is a risk factor for renal outcomes, cardiovascular (CV) diseases, and mortality in hypertensive patients with CKD, we conducted the prospective longitudinal observational study. Patients were divided into three groups according to their nocturnal HR: HR dippers (night–day HR ratio ≤ 0.9), HR non‐dippers (0.9 < night–day HR ratio ≤ 1.0), and HR risers (night–day HR ratio > 1.0). The primary outcome was renal endpoint, a composite outcome of progression to end‐stage renal disease (ESRD) or estimated glomerular filtration rate (eGFR) decline ≥ 50%; the secondary outcomes included poor renal outcomes, CV events, and death. A total of 34 (11.3%) patients reached renal endpoint after a follow‐up of 34 ± 17 months. Both HR non‐dippers and HR risers were predictive to renal endpoint (hazard ratio 2.58, 95% confidence interval (CI) 1.04‐ 6.4, P = .04; hazard ratio 3.95, 95% CI 1.33‐ 11.79, P = .01, respectively), while only HR risers was shown to be correlated with a decline in eGFR≥ 50% (hazard ratio 5.28, 95% CI 1.45–19.16, P < .05), and decline in eGFR (β ‐0.17, 95% CI ‐0.33‐ ‐0.01, P = .04). No predictive value was found for HR dipping pattern to mortality and CV events. In conclusion, our study provided the first evidence that HR non‐dippers, especially risers were a risk factor for poor renal outcomes in hypertensive patients with CKD.     

Prevalence of high ankle-brachial index (ABI) in general population of Southern Italy, risk factor profiles and systemic cardiovascular co-morbidity: An epidemiological study

Many studies have been carried out to assess the prevalence, risk factors and co-morbidities of peripheral artery disease (PAD). By contrast, to date there is a lack of data on patients with high-ABI. This study aimed at estimating the prevalence of increased ABI (ABI > 1.4) and to evaluate the involvement of traditional cardiovascular (CV) risk factors and the atherosclerotic burden (peripheral and carotid arteries) of these patients in a population of Southern Italy. We invited 9647 subjects, age ranging from 30 to 80, by letters to undergo an ABI measurement. Consequently, in patients with ABI > 1.4, an ultrasound evaluation of the peripheral and carotid arteries was performed. An ABI > 1.4 was found in 260 of 3412 subjects (7.6%). Statistically significant differences were reported in age, diabetes and hypertension, body mass index (BMI) and waist circumference (WC). No differences in sex distribution, dyslipidemia and smoke prevalence were observed. Moreover, 67.9% of ABI > 1.4 patients showed a peripheral intima-media thickness (IMT) > 0.9 mm; at linear regression it was correlated with ABI values; 25% of patients showed peripheral plaques. A carotid IMT > 0.9 mm was reported in 78.6% of high-ABI patients and 32.1% were affected by atherosclerotic plaques. The observed increased-ABI prevalence of 7.6% was higher than previously reported. This was more prevalent in an older population with diabetes, hypertension and obesity. Moreover, these patients are characterized by an extended atherosclerotic involvement. Further studies are needed to clarify this evidence, a longitudinal observation of this clinical outcome, as we are performing, could provide a number of interesting elements.     

The relationship of endothelial function and arterial stiffness with subclinical target organ damage in essential hypertension

This study aimed to explore whether brachial‐ankle pulse wave velocity (baPWV) and brachial artery flow‐mediated dilation (FMD) or the interaction of both parameters are associated with subclinical target organ damage (STOD) indices in patients with essential hypertension. A total of 4618 patients registered from January 2015 to October 2020 were included. baPWV and FMD were measured to evaluate arterial stiffness and endothelial dysfunction. Whereas left ventricular hypertrophy (LVH), urine albumin‐creatinine ratio (UACR), and carotid intima‐media thickness (CIMT) were obtained as STOD indicators. On multivariable logistic regression analysis with potential confounders, higher quartiles of baPWV and FMD were significantly associated with an increased risk of STOD. In patients <65 years of age, the odds ratio (OR) of LVH, UACR, and CIMT ≥.9 mm for the fourth versus the first quartile of baPWV were 1.765 (1.390–2.240), 2.832 (2.014–3.813), and 3.075 (2.315–4.084), respectively. In interaction analysis, an increase in baPWV shows a progressively higher risk of STOD across the quartiles of FMD. Also, the estimated absolute risks of LVH, UACR, and CIMT ≥.9 mm for the first to fourth quartile of baPWV increased from 1.88 to 2.75, 2.35 to 4.44, and 3.10 to 6.10, respectively, in patients grouped by FMD quartiles. The addition of baPWV to FMD slightly improved risk prediction for STOD. BaPWV and FMD were independently associated with an increased risk of STOD in patients with essential hypertension especially among patients <65 years of age. Patients with elevated baPWV and decreased FMD parameters are at increased risk of STOD.     

Clinical impact of medication adherence on 10‐year cardio‐cerebrovascular mortality in newly diagnosed hypertensive patients

The purpose of this study is to evaluate the impact of medication adherence on cardio‐cerebrovascular (CCV) mortality in newly diagnosed hypertensive patients. The authors retrospectively reviewed data from 20,836 patients who newly diagnosed hypertension from January 1, 2003 to December 31, 2005. Medication adherence was calculated from the compliance ratio (CR) during the first year after the diagnosis of hypertension. CCV mortality for 10 years was assessed according to the presence or absence of complications of hypertension. The risk of CCV death was significantly reduced in the CR ≥ 70% group than in the CR < 70% group (hazard ratio, 0.70; p = .004) for 10 years. In the patients without complications, the risk of CCV death was significantly lower in the CR ≥ 70% group than in the CR < 70% group (hazard ratio, 0.56; p = .014). However, in patients with complications, there was no significant difference in risk of CCV death between the CR ≥ 70% group and the CR < 70% group (hazard ratio, 0.79; p = .100). Only the CR ≥ 90% group had a significantly lower risk of CCV death (hazard ratio, 0.56; p < .001) for those with complications. Medication adherence is significantly associated with CCV mortality during 10 years in newly diagnosed hypertensives patients. Patients with complications of hypertension have to continue a high adherence rate (CR ≥ 90) for better long‐term clinical outcomes.     

Comparison of carotid‐femoral and brachial‐ankle pulse wave velocity in association with carotid plaque in a Chinese community‐based population

Pulse wave velocity (PWV) is the most widely used measurement of arterial stiffness in clinical practice. This study aimed to evaluate and compare the relationships between carotid‐femoral pulse wave velocity (cfPWV) and brachial‐ankle PWV (baPWV) and the presence of carotid plaque. This study was designed cross‐sectionally and included 6027 participants from a community‐based cohort in Beijing. Logistic regression analyses were performed to evaluate and compare the associations of cfPWV and baPWV with the presence of carotid plaque. The mean (SD) cfPWV and baPWV were 8.55 ± 1.83 and 16.79 ± 3.36, respectively. The prevalence of carotid plaque was 45.26% (n = 2728). Both cfPWV (per 1 m/s increase: OR = 1.11, 95% CI: 1.07–1.16) and baPWV (OR = 1.04, 95% CI: 1.02–1.06) were independently associated with carotid plaque after adjusting for various confounders. Compared with bottom quartile (cfPWV ≤7.31 m/s and baPWV ≤14.44 m/s), the top quartile of cfPWV and baPWV had a significantly higher prevalence of carotid plaque (for cfPWV: OR = 1.59, 95% CI: 1.32–1.92; for baPWV: OR = 1.53, 95% CI: 1.26–1.86). However, the relationship of baPWV and carotid plaque was nonlinear, with a positive trend only when baPWV < 16.85 m/s. When comparing relationships between PWV indices and carotid plaque in one model, both cfPWV and baPWV were significantly associated with carotid plaque in participants with baPWV < 16.85 m/s; however, only cfPWV was independently associated with carotid plaque in participants with baPWV ≥16.85 m/s. Both cfPWV and baPWV were significantly associated with carotid plaque in the Chinese community‐based population. Furthermore, cfPWV was more strongly correlated with carotid plaque than baPWV in participants with baseline baPWV ≥16.85 m/s.     

Automatically assessed P‐wave predicts cardiac events independently of left atrial enlargement in patients with cardiovascular risks: The Japan Morning Surge‐Home Blood Pressure Study

A prolonged P‐wave in electrocardiography (ECG) reflects atrial remodeling and predicts the development of atrial fibrillation (AF). The authors enrolled 810 subjects in the Japan Morning Surge Home Blood Pressure (J‐HOP) study who had ≥1 cardiovascular (CV) risk factor. The duration of P‐wave was automatically analyzed by standard 12‐lead electrocardiogram. Left atrial (LA) enlargement and left ventricular hypertrophy (LVH) were measured on echocardiography. The primary end points were fatal/nonfatal cardiac events: myocardial infarction, sudden death, and hospitalization for heart failure. The maximum P‐wave duration (Pmax) from the 12 leads was selected for analysis. The authors compared four prolonged P‐wave cutoffs (Pmax = 120, 130, 140, 150 ms) and cardiac events. LA diameter and left ventricular mass index (LVMI) were significantly associated with Pmax (r = 0.08, P = .02 and r = 0.17, P < .001, respectively). When the cutoff level was Pmax 120 or 130 ms, prolonged P‐wave was not associated with cardiac events (P = .45 and P = .10), but when a prolonged P‐wave was defined as Pmax ≥ 140 ms (n = 50) or Pmax ≥ 150 ms (n = 19), the patients in those groups had significantly higher incidence of cardiac events than others (P < .001 and P = .03). A Cox proportional hazards model including age, gender, body mass index, smoking, regular drinker, hypertension, dyslipidemia, diabetes, office systolic blood pressure, heart rate, LA enlargement, and LVH revealed that prolonged P‐wave defined as Pmax ≥ 140 ms was independently associated with cardiac events (hazard ratio: 4.23; 95% confidence interval: 1.30–13.77; P = .02). In conclusion, the automatically assessed prolonged P‐wave was associated with cardiac events independently of LA enlargement and LVH in Japanese patients with CV risks.     

Arterial stiffness and contralateral differences in blood pressure: The Atherosclerosis Risk in Communities (ARIC) study

A large interarm difference in brachial systolic blood pressure (SBP) (≥10 or ≥15 mmHg) is strongly associated with elevated cardiovascular events and mortality. Evidence demonstrating whether such contralateral differences in SBP occur in ankle blood pressure and its association with arterial stiffness is scarce. The aims of this study were to characterize arm and ankle contralateral SBP differences in a sample of community‐dwelling older adults (5077), and to determine whether this difference is associated with arterial stiffness assessed by pulse wave velocity (PWV) between the heart and ankle (haPWV), femoral artery and ankle (faPWV), and brachial artery and ankle (baPWV) in the right and left sides. Prevalence of interarm SBP differences ≥10 and ≥15 mmHg was 5.1% and .7%, respectively; the corresponding prevalence for interankle SBP was 24.9% and 12.0%. Higher BMI and lower ankle‐brachial index (ABI) were significantly correlated with greater interarm SBP differences. Increased age, higher BMI, lower ABI, and greater contralateral differences in haPWV, faPWV, and baPWV were significantly correlated to greater interankle SBP differences. Interankle SBP difference ≥15 mmHg was significantly associated with contralateral differences of >80 cm/s in haPWV (OR = 1.94 [95% CI = 1.52–2.49]), >165 cm/s in faPWV (OR = 1.64 [95% CI = 1.27–2.12]), and >240 cm/s in baPWV (OR = 2.43 [95% CI = 1.94–3.05]). The associations remained significant after adjustment for age, sex, race, BMI, smoking status, and ABI. Compared with interarm differences, interankle differences in SBP are common in older adults. The magnitude of interankle, but not interarm, differences in SBP is associated with various measures of arterial stiffness.     

Development and implementation of blood pressure screening and referral guidelines for German community pharmacists

Involvement of community pharmacists in the detection and control of hypertension improves patient care. However, current European or North‐American guidelines do not provide specific guidance how to implement collaboration between pharmacists and physicians, especially when and how to refer patients with undetected or uncontrolled hypertension to a physician. The German Society of Cardiology and the ABDA – Federal Union of German Associations of Pharmacists developed and tested referral recommendations for community pharmacists, embedded in two guideline worksheets. The project included a guideline‐directed blood pressure (BP) measurement and recommendations when patients should be referred to their physician. A “red flag” referral within 4 weeks was recommended when SBP was >140 mm Hg or DBP >90 mm Hg (for subjects <80 years), and >160 mm Hg or >90 mm Hg (≥80 years) in undetected individuals, or >130 mm Hg or >80 mm Hg (<65 years) and >140 mm Hg or >80 mm Hg (≥65 years) in treated patients. BP was measured in 187 individuals (86 with known hypertension, mean [±SD] age 62 ± 15 years, 64% female, and 101 without known hypertension, 47 ± 16 years, 75% female) from 17 community pharmacies. In patients with hypertension, poorly controlled BP was detected in 55% (n = 47) and were referred. A total of 16/101 subjects without a history of hypertension were referred to their physician because of uncontrolled BP. Structured BP testing in pharmacies identified a significant number of subjects with undetected/undiagnosed hypertension and patients with poorly controlled BP. Community pharmacists could play a significant role in collaboration with physicians to improve the management of hypertension.     

Nighttime mean arterial pressure is associated with left ventricular hypertrophy in white‐coat hypertension

White‐coat hypertension (WCH) is associated with increased cardiovascular risks. To investigate the relationship between WCH and left ventricular hypertrophy (LVH), the authors recruited 706 participants who underwent anthropometric measurements, blood laboratory analysis, 24h ambulatory blood pressure monitoring (ABPM), and echocardiography. The authors defined WCH as elevated office BP but normal ABPM over 24h, daytime, and nighttime periods. The authors compared the proportion of LVH between the true normotension (NT) and the WCH population, and further assessed the associations between BP indexes and LVH in the two groups, respectively. The proportion of LVH was significantly higher in the WCH group than in NT participants (19.70% vs. 13.12%, P = .036). In the NT group, 24h SBP, 24h PP, daytime SBP, daytime PP and SD of nighttime SBP were associated with LVH after adjustment for demographic and blood biochemical data (all P < .05). In the WCH population, LVH was associated with 24h SBP, nighttime SBP, nighttime MAP, and office SBP after adjustment (all P < .05). However, on forward logistic regression analysis with all the BP indexes listed above, only 24h SBP (OR = 1.057, 1.017–1.098, P < .001) in the NT group, and nighttime MAP (OR = 1.114, 1.005–1.235, P < .05) and office SBP (OR = 1.067, 1.019–1.117, P < .001) in the WCH group were still significantly associated with LVH. Our study suggests that the proportion of LVH is higher in WCH patients than in the NT population. Furthermore, elevated nighttime MAP and office SBP may play critical roles in the development of LVH in the WCH population.     

Associations of Left Ventricular Hypertrophy and Geometry with Adverse Outcomes in Patients with CKD and Hypertension

Background and objectives

Left ventricular hypertrophy (LVH) and abnormal left ventricular (LV) geometry predict adverse outcomes in the general and hypertensive populations, but findings in CKD are still inconclusive.

Design, setting, participants, & measurements

We enrolled 445 patients with hypertension and CKD stages 2–5 in two academic nephrology clinics in 1999–2003 who underwent both echocardiography and ambulatory BP monitoring. LVH (LV mass >100 g/m² [women] and >131 g/m² [men]) and relative wall thickness (RWT) were used to define LV geometry: no LVH and RWT≤0.45 (normal), no LVH and RWT>0.45 (remodeling), LVH and RWT≤0.45 (eccentric), and LVH and RWT>0.45 (concentric). We evaluated the prognostic role of LVH and LV geometry on cardiovascular (CV; composite of fatal and nonfatal events) and renal outcomes (composite of ESRD and all-cause death).

Results

Age was 64.1±13.8 years old; 19% had diabetes, and 22% had CV disease. eGFR was 39.9±20.2 ml/min per 1.73 m². LVH was detected in 249 patients (56.0%); of these, 125 had concentric LVH, and 124 had eccentric pattern, whereas 71 patients had concentric remodeling. Age, women, anemia, and nocturnal hypertension were independently associated with both concentric and eccentric LVH, whereas diabetes and history of CV disease associated with eccentric LVH only, and CKD stages 4 and 5 associated with concentric LVH only. During follow-up (median, 5.9 years; range, 0.04–15.3), 188 renal deaths (112 ESRD) and 103 CV events (61 fatal) occurred. Using multivariable Cox analysis, concentric and eccentric LVH was associated with higher risk of CV outcomes (hazard ratio [HR], 2.59; 95% confidence interval [95% CI], 1.39 to 4.84 and HR, 2.79; 95% CI, 1.47 to 5.26, respectively). Similarly, greater risk of renal end point was detected in concentric (HR, 2.33; 95% CI, 1.44 to 3.80) and eccentric (HR, 2.30; 95% CI, 1.42 to 3.74) LVH. Sensitivity analysis using LVH and RWT separately showed that LVH but not RWT was associated with higher cardiorenal risk.

Conclusions

In patients with CKD, LVH is a strong predictor of the risk of poor CV and renal outcomes independent from LV geometry.     

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.     

Comparison of the efficiency between electrocardiogram and echocardiogram for left ventricular hypertrophy evaluation in patients with hypertension: Insight from the Korean Hypertension Cohort Study

In patients with hypertension, left ventricular hypertrophy (LVH) represents a risk factor for cardiovascular disease and asymptomatic organ damage. Currently, electrocardiography (ECG) and two‐dimensional echocardiography (Echo) are the most widely used methods for LVH evaluation. This study aimed to compare the long‐term outcomes of LVH, as evaluated by ECG and Echo, in patients with hypertension. Patients diagnosed with hypertension as a primary disease between 2006 and 2011 were enrolled in the Korean Hypertension Cohort study. The study finally included 1743 patients who underwent both ECG and Echo. The primary endpoint was defined as the composite of major adverse cardiovascular events (MACEs) or death. Overall, LVH was identified in 747 patients. The patients were categorized into four groups according to the detection of LVH by ECG or Echo: No LVH (n = 996), LVH diagnosed by ECG alone (n = 181), LVH diagnosed by Echo alone (n = 415), LVH diagnosed by both ECG and Echo (n = 151). After adjusting for variables, the incidence of MACEs or death was significantly greater in patients with LVH diagnosed by ECG alone (hazards ratio [HR]: 1.69; 95% confidence interval [CI]: 1.22–2.35; P = .001), LVH diagnosed by Echo alone (HR: 1.54; 95% CI: 1.16–2.05; P = .002), and LVH diagnosed by both ECG and Echo (HR: 1.87; 95% CI: 1.18–2.94; P = .002) than in those with no LVH. Both ECG and Echo are efficient diagnostic tools for LVH and useful for long‐term risk stratification. Additional Echo evaluation for LVH is helpful for predicting long‐term outcomes only in patients without LVH diagnosis by ECG.