Arterial Stiffness in Hypertension: an Update

Purpose of Review

To update and review novel insights into the mechanisms, measurements, and therapeutic approaches to arterial stiffness.

Recent Findings

Arterial (e.g., vascular) stiffness has been shown over time to prognosticate for cardiovascular and kidney outcomes. In this context, there has been increased interest behind the mechanisms that drive arterial stiffness beyond aging and interest in how to apply newer technologies in measurement of arterial stiffness. Pulse wave velocity has been the gold standard for measurement but industry has been innovating to improve measurement with use of single-point PWV as well as pharmacologic approaches with anti-hypertensives and oral hypoglycemic agents. Emerging data on the role of the mineralocorticoid receptor, the endothelial sodium channel (EnNaC), and uric acid in arterial stiffness are promising a number of potential therapies.

Summary

Newer techniques of measuring PWV for arterial stiffness and novel therapies may soon lead to better outcomes from hypertension complications.

     

Hypertension in the Postpartum Woman: Clinical Update for the Hypertension Specialist

Hypertension can persist from pregnancy or present de novo in the postpartum period and continue to pose a risk to maternal well‐being. These risks are magnified as many patients present after hospital discharge and go unrecognized because of decreased medical surveillance after delivery. Guidelines for the management of postpartum hypertension are lacking, often resulting in imprecise diagnoses and incorrect treatment strategies. As hypertension specialists are called upon to provide advice to obstetricians regarding the management of hypertension in the postpartum period, it becomes important for the hypertension specialist to develop expertise in the evaluation and treatment of hypertensive women during the postpartum period. The purpose of this clinical review article is to provide an approach to the management of postpartum hypertension.     

Psychosocial Factors in Diabetes and Cardiovascular Risk

Type 2 diabetes is a chronic disease that is increasing in prevalence globally. Cardiovascular disease is a major cause of mortality and morbidity in diabetes, and lifestyle and clinical risk factors do not fully account for the link between the conditions. This article provides an overview of the evidence concerning the role of psychosocial stress factors in diabetes risk, as well as in cardiovascular complications in people with existing diabetes. Several types of psychosocial factors are discussed including depression, other types of emotional distress, exposure to stressful conditions, and personality traits. The potential behavioral and biological pathways linking psychosocial factors to diabetes are presented and implications for patient care are highlighted.     

Psychosocial Risk Factors for HIV Transmission in Female Drug Abusers

The authors studied the influences of domains of psychosocial risk factors on needle-sharing with familiar people and with strangers in a cohort of female injecting drug users (IDUs). Subjects were 119 female IDUs, 46% of whom were HIV+. Subjects were given individually administered questionnaire interviews. Using Pearson correlation coefficients and multiple hierarchical regression analyses, the authors found that personality, family, and peer attributes related to needle-sharing in women were similar to those found in men, with certain exceptions. The role of the family, particularly the Significant Other, was more important and proximal in its effect on needle-sharing behavior in women than in men. There was a main effect as well as a mediating effect of family in women, buffering risk factors leading to needle-sharing.     

An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature

Purpose of Review

This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc).

Recent Findings

PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor.

Summary

Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.

     

Needle-Sharing: A Longitudinal Study of Psychosocial Risk and Protective Factors

The authors examined the psychosocial correlates of needle-sharing behavior at two points in time (T₁ and T₂) by use of a prospective longitudinal design. Subjects were 278 male intravenous drug users, 111 of whom were HIV-positive. All subjects were given structured questionnaires by trained, ethnically matched interviewers. Pearson correlation coefficients (rs) and hierarchical regression analyses were done to examine interrelationships among T₁ psychosocial domains, T₁ needle-sharing, and T₂ needle-sharing. T₁ psychosocial/personality factors predicting T₂ needle-sharing included unconventionality, poor emotional control, and poor intrapsychic functioning. The relationship of T₁ needle-sharing to T₂ needle-sharing was buffered by the T₁ psychosocial protective factors. The findings supported a mediational model, in which personality and peer factors predicted T₁ needle-sharing, which served as the mediator for T₂ needle-sharing. (American Journal on Addictions 1996; 5:209–219)     

Autoimmune Lymphoproliferative Syndrome: an Update and Review of the Literature

Autoimmune lymphoproliferative syndrome (ALPS) is characterized by immune dysregulation due to a defect in lymphocyte apoptosis. The clinical manifestations may be noted in multiple family members and include lymphadenopathy, splenomegaly, increased risk of lymphoma, and autoimmune disease, which typically involves hematopoietic cell lines manifesting as multilineage cytopenias. Since the disease was first characterized in the early 1990s, there have been many advances in the diagnosis and management of this syndrome. The inherited genetic defect of many ALPS patients has involved (FAS) pathway signaling proteins, but there remain those patients who carry undefined genetic defects. Despite ALPS having historically been considered a primary immune defect presenting in early childhood, adult onset presentation is increasingly becoming recognized and more so in genetically undefined patients and those with somatic FAS mutations. Thus, future research may identify novel pathways and/or regulatory proteins important in lymphocyte activation and apoptosis.     

Examination of Several Physiological and Psychosocial Factors Potentially Associated With Masked Hypertension Among Low‐Risk Adults

The authors examined the association of factors, in addition to prehypertensive office blood pressure (BP) level, that might improve detection of masked hypertension (MH), defined as nonelevated office BP with elevated out‐of‐office BP average, among individuals at otherwise low risk. This sample of 340 untreated adults 30 years and older with average office BP <140/90 mm Hg all had two sets of paired office BP measurements and 24‐hour ambulatory BP monitoring (ABPM) sessions 1 week apart. Other than BP levels, the only factors that were associated (at P<.10) with MH at both sets were male sex (75% vs 66%) and working outside the home (72% vs 59% for the first set and 71% vs 45% for the second set). Adding these variables to BP level in the model did not appreciably improve detection of MH. No demographic, clinical, or psychosocial measures that improved upon prehypertension as a potential predictor of MH in this sample were found.     

Evidence for Psychosocial Risk Factors and Behavioral Interventions in Cardiovascular Disease

Over nearly a half century, epidemiologic studies have shown a strong relationship between several psychosocial variables and the risk of coronary heart disease. Key factors include negative thought patterns and emotions, specifically depressive syndromes, anxiety syndromes, hostility and anger, worry and pessimism. Chronic stress factors include work stress, social isolation, and low socioeconomic status. Positive psychological factors include optimism, social support and sense of purpose. Clinical trials involving behavioral interventions such as those focusing on type A behavior or depression, have had mixed results. Simple psychosocial evaluation recommended includes an inventory for assessing depression given its predominance as a psychosocial factor consistently associated with cardiovascular disease risk. Screening for other factors of psychosocial stress as well as carefully planned multidisciplinary management is also recommended to maximize the likelihood of adherence.     

Update on the metabolic syndrome: Hypertension

The presence of the metabolic syndrome identifies an individual at increased risk for diabetes, cardiovascular disease, and early mortality. However, the increased risk may vary by the absence or presence of hypertension. Current guidelines for the management of high blood pressure in the metabolic syndrome emphasize lifestyle modification as a first-line strategy. Pharmacologic treatment of elevated blood pressure in the metabolic syndrome may be necessary in the presence of other cardiovascular risk factors or to achieve adequate blood pressure control. Currently, there is no consensus as to which antihypertensive therapy should be used to treat hypertension in patients with the metabolic syndrome; it remains unclear whether achieving tight blood pressure control should outweigh the potential for development of glucose intolerance. Future research must focus on this issue given the high prevalence of the syndrome among hypertensive patients and high rates of progression to diabetes among those with the metabolic syndrome.     

Device-Based Therapy for Drug-Resistant Hypertension: An Update

Drug-resistant hypertension (RH) remains a significant and common cardiovascular risk despite the availability of multiple potent antihypertensive medications. Uncontrolled resistant hypertension contributes substantially to excessive cardiovascular and renal morbidity and mortality. Clinical and experimental evidence suggest that sympathetic nervous system over-activity is the main culprit for the development and maintenance of drug-resistant hypertension. Both medical and interventional strategies, targeting the sympathetic over-activation, have been designed in patients with hypertension over the past few decades. Minimally invasive, catheter-based, renal sympathetic denervation (RDN) and carotid baroreceptor activation therapy (BAT) have been extensively evaluated in patients with RH in clinical trials. Current trial outcomes, though at times impressive, have been mostly uncontrolled trials in need of validation. Device-based therapy for drug-resistant hypertension has the potential to provide alternative treatment options to certain groups of patients who are refractory or intolerant to current antihypertensive medications. However, more research is needed to prove its efficacy in both animal models and in humans. In this article, we will review the evidence from recent renal denervation, carotid baroreceptor stimulation therapy, and newly emerged central arteriovenous anastomosis trials to pinpoint the weak links, and speculate on potential alternative approaches.     

心率与血压及高血压危险因素的关系

目的 探讨心率与血压及高血压危险因素的关系,以及性别与年龄对这种相关性的影响.方法 测定4 501 例在本院行健康体检的人群的心率、血压、血糖、血脂,按年龄及性别分组后行心率与血压及高血压危险因素的相关性分析.结果 ≥65 岁组和＜65岁组的血压均随心率的增快而增高.偏相关分析显示＜65 岁组的心率与性别、血压及血糖呈显著正相关,与年龄呈显著负相关.≥65岁组的心率仅与收缩压、舒张压呈显著正相关.经多因素回归分析显示＜65岁组中性别、年龄、收缩压、舒张压及血糖与心率的关联差异均有显著统计学意义(均P＜0.01).≥65岁组分析仅发现收缩压及舒张压与心率的关联差异有统计学意义(P＜0.05).结论 老年人的血压随心率的增快而升高,提示老年高血压患者同样存在交感活性的增加,对此类老年高血压患者使用RAS 抑制剂与β受体阻剂同样是合理的.     

Epidemiology and Risk Factors for Pulmonary Hypertension in Systemic Sclerosis

The morphogen pathways Wnt, hedgehog, and Notch are key regulators of organ development and tissue homeostasis. In adults, the tightly regulated activity of morphogen pathways is essential for cell renewal and tissue regeneration. Loss of control and persistent activation of morphogen pathways, however, can lead to a variety of diseases, including malignancy and fibrotic disorders. In recent years, pathological activation of Wnt, hedgehog, and Notch pathways have been described in systemic sclerosis (SSc) and other fibrotic diseases. Experimental models reveal that morphogen pathways drive fibroblast activation and collagen release. In these model systems, genetic or pharmacological blockade of morphogen pathways inhibits collagen release and reduces experimental fibrosis. Importantly, inhibitors for Wnt, hedgehog, and Notch are already in clinical evaluation, thereby emphasizing the translational implications of these findings. Further experimental studies, however, should deepen our knowledge before initiating clinical trials with inhibitors of morphogen pathways.     

Psychosocial Risk and Protective Factors for Condom Use Among Female Injection Drug Users

The authors examined the influences of domains of psychosocial risk and protective factors on male-partner condom use in a cohort of 209 female HIV-positive (HIV+) and HIV-negative (HIV-) injection drug users (IDUs) by use of a cross-sectional, retrospective design. Information collected from a structured questionnaire included data on psychosocial risk and protective factors in the personality, family, and peer domains; HIV status; and condom use. Among HIV+ IDUs, personality risk factors (e.g., unconventionality), family (e.g., low maternal identification), and peer factors were related to less male-partner condom use. Resources and condom availability were associated with greater male condom use with both HIV+ and HIV- IDUs. The psychosocial domains affected male condom use with both HIV+ and HIV- female IDU patients via two different mediational models. The findings suggest the need to use specific psychosocial interventions for risky sexual behavior among HIV+ and HIV- female IDUs. (Am J Addict 1998; 7:115–127)     

Psychosocial Risk Factors and Condom Use in Intravenous Drug Abusers

The authors studied psychosocial risk and protective factors in HIV transmission in a population of intravenous drug abusers (IVDAs), with a focus on needle-sharing. The authors examined high-risk sexual behavior in the same population by looking at factors affecting the individual IVDA's condom use. The volunteer sample was 300 male IVDAs who were patients at AIDS or methadone clinics in a large city hospital. All subjects were individually interviewed regarding condom use for vaginal intercourse, with a structured questionnaire analyzed by means of multiple hierarchical regressions and Pearson correlation coefficients. Parental and peer factors and coping measures were associated with more condom use. The findings supported a mediational model for condom use. Family factors were associated with good coping and with the selection of friends who support condom use. These factors in turn were associated with planning to use and actually using condoms.