Association Between Nondipper Behavior and Serum Calcium in Hypertensive Patients with Mild-to-Moderate Chronic Renal Dysfunction

A nondipping BP pattern has been shown to be predictive of end-organ damage, cardiovascular events, and mortality. The mechanisms of blunted nocturnal BP fall are multifactorial. We assessed whether total corrected serum calcium and ionic calcium (iCa) are associated with a blunted nocturnal BP fall in both treated and untreated hypertensive patients with stages 1–3 of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI). Clinical data and 24-hour ambulatory blood pressure monitoring were obtained in a cohort of 231 essential hypertensive patients. Among the entire cohort, 107 were nondippers and 124 were dippers. Only in nondippers, we found significant correlations between iCa and 24-hour systolic blood pressure (SBP; r = 0.21, P < .03), diurnal SBP (r = 0.21, P < .03), and 24-hour pulse pressure (PP; r = 0.23, P < .02). The ambulatory arterial stiffness index (AASI) was significantly related with 24-hour PP in both dippers and nondippers after adjusting for age. Both AASI and 24-hour PP were higher in nondippers than in dippers. In addition, in nondippers, the prevalence of estimated glomerular filtration rate (eGFR) <60 mL/minute/1.73 m² was higher than in dippers (50% vs. 33.7%, P < .02). Logistic regression showed that patients with eGFR ≥60 mL/minute/1.73 m² had lower risk of nondipper status than patients with eGFR <60 mL/minute/1.73 m² (odds ratio = 2.445; 95% confidence interval = 1.398–4.277, P < .002). In conclusion, serum iCa could participate in the pathogenesis of nondipping pattern. Increased large artery stiffness may be a mechanism of the deleterious influence of nondipping on cardiovascular outcome. Hypertensive subjects with stage 3 of NKF KDOQI had a greater loss of circadian BP rhythm than those in stages 1 and 2.     

Association of Arterial Stiffness With Obesity in Australian Women: A Pilot Study

This study investigated the arterial stiffness status in overweight/obese Australian women compared with their lean counterparts. Twenty‐six Caucasian women were designated into one of two groups: overweight/obese (body mass index [BMI] 25–34.9 kg/m²[ n=12]) and lean (BMI 18.5–24.9 kg/m² [n=14]) groups. Participants were assessed for clinical, anthropometric, metabolic, and augmentation index (AIx) measurements. Age was similar between groups (P=.482). BMI was significantly higher in overweight/obese compared with lean participants (30.26±1.09 vs 21.62±0.52 kg/m², P=.001) as well as the percentage of body fat (40.60±2.43 vs 21.57±1.13, P=.001), waist circumference (91.47±2.77 vs 70.67±1.60, P=.001), and waist/hip ratio (0.81±0.04 vs 0.71±0.03, P=.036). Overweight/obese group showed higher total cholesterol, triglyceride, low‐density lipoprotein cholesterol, and fasting glucose levels compared with the lean group (all P<.05). Both systolic (122.92±3.18 mm Hg vs 108.14±2.42 mm Hg, P=.001) and diastolic (83.58±2.43 mm Hg vs 72.43±1.29 mm Hg, P=.0001) blood pressures, as well as AIx (50.08±4.7 vs 120.79±2.17, P=.001) were significantly higher in the overweight/obese group compared with the lean group. AIx was positively associated with measurements of body composition (P<.05), triglycerides (r=0.361, P=.035) and glucose levels (r=0.371, P=.031), and systolic and diastolic blood pressure (r=0.793 and r=0.718, respectively; P=.0001). This data suggests that arterial stiffness is associated with obesity, along with other metabolic abnormalities in Australian women. J Clin Hypertens (Greenwich). 2012;00:00–00.©2012 Wiley Periodicals, Inc.     

Comparative efficacy of aliskiren/valsartan vs valsartan in nocturnal dipper and nondipper hypertensive patients: a pooled analysis

This pooled analysis of ambulatory blood pressure (BP) monitoring data from two 8-week randomized controlled trials compared the antihypertensive efficacy and safety of combination aliskiren/valsartan vs valsartan alone in hypertensive patients (nocturnal dippers or nondippers). At study end, patients were taking aliskiren/valsartan 300/320 mg or valsartan 320 mg. In dippers (n=138) and nondippers (n=132), aliskiren/valsartan provided significantly (P<.05) greater reductions from baseline to week 8 than valsartan in 24-hour, daytime, and last-4-hour mean ambulatory systolic BP (maSBP). Treatment differences were more pronounced in nondippers. Nighttime maSBP reductions with aliskiren/valsartan were significantly greater vs valsartan in nondippers (-17.0 mm Hg vs -8.9 mm Hg; P<.05) but not dippers (-7.6 mm Hg vs -4.5 mm Hg; P=.16). In all time periods, combination therapy was generally associated with BP reductions that were greater in nondippers than dippers. Conversion from nondipper to dipper status was 32% vs 22% for aliskiren/valsartan vs valsartan (P=.48). Both treatments were similarly well tolerated. Although the addition of aliskiren to valsartan did not significantly alter dipper status, our data suggest an increased contribution of the renin-angiotensin-aldosterone system to the nondipper status of hypertensive patients.     

Clinical impact of dipping and nocturnal blood pressure patterns in newly diagnosed,never-treated patients with essential hypertension

The significance of nondipping and increased nighttime systolic blood pressure (SBP) in established hypertension is well defined. We investigated whether these factors alone or combined correlate with vascular damage in early-stage hypertension. Newly diagnosed, untreated hypertensives were classified as dippers and nondippers according to ambulatory blood pressure (BP). Twenty-four–hour urinary albumin excretion and markers of arterial stiffness (pulse wave velocity, augmentation index, central and peripheral pulse pressure, central BP) and atherosclerosis (carotid intima-media thickness) were assessed. Serum asymmetric dimethylarginine, an index of endothelial dysfunction, was measured in a study subgroup; 10-year cardiovascular risk was calculated. Among 222 hypertensives, only urinary albumin excretion was increased in nondippers, compared to dippers (P = .026). When dippers were further stratified according to nighttime SBP (<120 or ≥120 mm Hg), the first group demonstrated the lowest levels of office, aortic, 24-hour, daytime and nighttime BP, compared to dippers with elevated nighttime SBP and nondippers. Although vascular measurements and asymmetric dimethylarginine were comparable between these groups, dippers with normal nighttime SBP exhibited the lowest cardiovascular risk score (P = .050). In early-stage hypertension, nondipping was accompanied by microvascular, yet not macrovascular and endothelial dysfunction. Dippers with elevated nighttime SBP appear as a distinct group with increased hemodynamic pressure load and cardiovascular risk.     

Creatine Kinase as Predictor of Blood Pressure and Hypertension. Is It All About Body Mass Index? A Follow‐Up Study of 250 Patients

The correlation between creatine kinase (CK) and blood pressure (BP) was examined prospectively in 120 patients with persistent high CK and 130 individuals with normal CK. Hypertension was defined as systolic BP (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg or current use of antihypertensive medication. Baseline CK was weakly correlated with SBP (r=0.11, P=.07) and DBP (r=0.16, P=.01) at follow‐up. Persons with persistent high CK had higher SBP (140.8 mm Hg vs 138.2 mm Hg) and DBP (83.2 mm Hg vs 81.0 mm Hg, P=.06) values and were more likely to have hypertension (66.7% vs 55.5%, P=.05) than individuals with normal CK. In age‐ and sex‐adjusted analysis, a 1‐unit change in logCK was associated with a 4.9‐mm Hg higher SBP, a 3.3‐mm Hg higher DBP, and a 2.2‐higher odds for having hypertension at follow‐up (P=.1, .07, and .06, respectively). When including body mass index (BMI) to the model, BMI was a strong and independent predictor for SBP, DBP, and hypertension at follow‐up and the CK effect on blood pressure was substantially attenuated. This study showed that the CK effect on blood pressure is clearly modified by BMI.     

Comparison of two noninvasive devices for measurement of central systolic blood pressure with invasive measurement during cardiac catheterization

J Clin Hypertens (Greenwich). 2012; 14:575–579. © 2012 Wiley Periodicals, Inc. Recently, a new device for noninvasive assessment of central systolic blood pressure (cSBP) (BPro device with A‐Pulse) was approved by the US Food and Drug Administration, but available data are limited. In 52 patients undergoing invasive elective cardiac evaluation, central hemodynamics were measured invasively. Immediately thereafter, radial artery waveforms were sampled by two noninvasive techniques, the BPro and, as a comparator, the SphygmoCor System. Then, central hemodynamics were measured invasively for a second time. The invasively recorded cSBP (137±27 mm Hg) did not differ with both noninvasively assessed cSBP by BPro (136±21 mm Hg, P=.627 vs invasive cSBP) and by SphygmoCor (136 ± 23 mm Hg, P=.694 vs invasive cSBP) and correlated highly between invasively recorded and both noninvasively assessed cSBP. However, using Bland‐Altman plots, spreading of compared data of both devices can be found (BPro: 0.87±13 mm Hg vs invasive cSBP; SphygmoCor: 0.77±14 mm Hg vs invasive cSBP). There was an excellent correlation of both noninvasive devices for the calculation of cSBP (r=0.961, P<.001). cSBP differed by only 0.1±6 mm Hg (P=.913) between the two noninvasive devices. Therefore, both noninvasive devices showed an accurate agreement in cSBP compared with invasively measured cSBP.     

Blunted nocturnal fall in blood pressure and left ventricular mass in elderly individuals with recently diagnosed isolated systolic hypertension

BackgroundFew studies have investigated the relationship between the lack of or reduction of nocturnal blood pressure (BP) fall and left ventricular mass (LVM) in elderly individuals with isolated systolic hypertension (ISH), notwithstanding the fact that ISH is the most frequent subtype of uncontrolled hypertension and a powerful risk factor for organ damage. The aim of this study was to identify the relationship between blunted nocturnal BP fall and LVM in elderly individuals with ISH that was recently diagnosed (within 2 years) and had never been treated.MethodsA total of 64 elderly patients with recent ISH were recruited among the outpatients of the Hypertension Unit at 1st Institute of Medicine of “La Sapienza” University in Rome, and they underwent 24-h ambulatory BP monitoring (ABPM). According to exclusion criteria, 37 patients were selected for the study. Based on the presence or absence of an almost 10% reduction in systolic BP (SBP) and diastolic BP (DBP) from day to night, 21 so-called dippers and 16 nondippers, respectively, were identified. All of these 37 patients underwent echocardiography. Relationships between BP recordings and echocardiographic parameters were assessed by univariate analysis. Dippers and nondippers were compared with respect to LVM.ResultsNighttime SBP was closely associated with indexed LVM (LVM/h^2.7) (r = 0.564; P=.001). Nondippers showed significantly higher LVM/h^2.7 compared with dippers (62.43 ± 15.39 g/m^2.7 v 51.33 ± 12.68 g/m^2.7 respectively; P= .021).ConclusionsAn association between blunted nocturnal SBP fall and increased LVM was observed in the early phases of ISH in the elderly. This finding may have important prognostic implications.     

Influence of Kidney Function on Blood Pressure Response to Lifestyle Modifications: Secondary Analysis From the Exercise and Nutritional Interventions for Cardiovascular Health (ENCORE) Trial

The kidney is an important regulator of blood pressure (BP). To determine whether BP response to lifestyle modification varies across normal ranges of kidney function, the authors examined the moderating role of estimated glomerular filtration rate (eGFR) on clinic and ambulatory systolic BP (SBP) response in overweight and obese adults with unmedicated high BP. Among 144 participants of the Exercise and Nutritional Interventions for Cardiovascular Health (ENCORE) trial, mean age was 52.0±9.6 years and median eGFR was 89.1 (53–146) mL/min/1.73m². After multivariable regression, the interaction between eGFR and weight loss was significant for clinic (P=.023) and ambulatory SBP (P=.041). Similarly, the interaction between eGFR and improved fitness was significant for clinic (P=.041) and ambulatory SBP (P=.044). The relationship between reduced dietary sodium and SBP was not moderated by eGFR. SBP findings were inconsistent for adherence to the Dietary Approaches to Stop Hypertension (DASH) diet. These findings suggest that the effects of lifestyle modifications on SBP may be influenced by eGFR, even when kidney function is preserved.     

Add‐On Use of Eplerenone Is Effective for Lowering Home and Ambulatory Blood Pressure in Drug‐Resistant Hypertension

The authors aimed to investigate the blood pressure (BP)–lowering ability of eplerenone in drug‐resistant hypertensive patients. A total of 57 drug‐resistant hypertensive patients whose home BP was ≥135/85 mm Hg were investigated. The patients were randomized to either an eplerenone group or a control group and followed for 12 weeks. The efficacy was evaluated by clinic, home, and ambulatory BP monitoring. Urinary albumin, pulse wave velocity, and flow‐mediated vasodilation (FMD) were also evaluated. Home morning systolic BP (148±15 vs 140±15 mm Hg) and evening systolic BP (137±16 vs 130±16 mm Hg) were significantly lowered in the eplerenone group (n=35) compared with baseline (both P<.05), while unchanged in the control group (n=22). BP reductions in the eplerenone group were most pronounced for ambulatory awake systolic BP (P=.04), awake diastolic BP (P=.004), and 24‐hour diastolic BP (P=.02). FMD was significantly improved in the eplerenone group. In patients with drug‐resistant hypertension, add‐on use of eplerenone was effective in lowering BP, especially home and ambulatory awake BP.     

Benefits and Risks of Aliskiren Treatment in Patients With Type 2 Diabetes: Analyses of the 3A Registry

The authors sought to retrospectively analyze the real‐world evidence on aliskiren in diabetic patients with or without concomitant renin‐angiotensin system (RAS) blocker use based on the Registry for Ambulant Therapy With RAS Inhibitors in Hypertension Patients in Germany (3A). Of 14,986 patients included, 3772 patients had diabetes and 28.5% received aliskiren, 14.3% received angiotensin‐converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), 35.4% received aliskiren plus an ACE inhibitor/ARB, and 10.5% received other drugs. Ambulatory blood pressure (BP) monitoring (baseline BP 148±15.8/84.0±10.9 mm Hg) revealed stronger diastolic BP reduction for aliskiren plus ACE inhibitor/ARB than aliskiren alone in the low (2.8±0.5 vs 0.6±0.6; P=.004) and intermediate (5.9±0.5 vs 4.5±0.5; P=.04) baseline BP groups. There was a lesser ambulatory BP reduction observed for patients receiving non‐RAS in the high baseline category for both systolic (12.5±1.8 vs 17.1±1.0; P=.02) and diastolic (6.9±1.0 vs 9.8±0.6; P=.01) BP. In patients with hypertension and type 2 diabetes, aliskiren was beneficial in lowering BP, with no observed increases in major adverse effects compared with RAS‐blocking therapy alone.     

Nocturnal blood pressure patterns and cardiovascular outcomes in patients with masked hypertension

Masked hypertension (MHT) is characterized by normal clinic and above normal 24‐hour ambulatory blood pressure (BP) levels. We evaluated clinical characteristics and CV outcomes of different nocturnal patterns of MHT. We analyzed data derived from a large cohort of adult individuals, who consecutively underwent home, clinic, and ambulatory BP monitoring at our Hypertension Unit between January 2007 and December 2016. MHT was defined as clinic BP <140/90 mm Hg and 24‐hour BP ≥ 130/80 mm Hg, and stratified into three groups according to dipping status: (a) dippers, (b) nondippers, and (c) reverse dippers. From an overall sample of 6695 individuals, we selected 2628 (46.2%) adult untreated individuals, among whom 153 (5.0%) had MHT. In this group, 67 (43.8%) were nondippers, 65 (42.5%) dippers, and 21 (13.7%) reverse dippers. No significant differences were found among groups regarding demographics, clinical characteristics, and prevalence of risk factors, excluding older age in reverse dippers compared to other groups (P < 0.001). Systolic BP levels were significantly higher in reverse dippers than in other groups at both 24‐hour (135.6 ± 8.5 vs 130.4 ± 6.0 vs 128.2 ± 6.8 mm Hg, respectively; P < 0.001) and nighttime periods (138.2 ± 9.1 vs 125.0 ± 6.3 vs 114.5 ± 7.7 mm Hg; P < 0.001). Reverse dipping was associated with a significantly higher risk of stroke, even after correction for age, gender, BMI, dyslipidemia, and diabetes (OR 18.660; 95% IC [1.056‐33.813]; P = 0.046). MHT with reverse dipping status was associated with higher burden of BP and relatively high risk of stroke compared to both dipping and nondipping profiles, although a limited number of CV outcomes have been recorded during the follow‐up.     

Effects of aliskiren-based therapy on ambulatory blood pressure profile, central hemodynamics, and arterial stiffness in nondiabetic mild to moderate hypertensive patients

J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc. Aliskiren is a direct renin inhibitor that exerts its effect at the rate‐limiting step of the renin‐angiotensin system. This study was performed to examine the beneficial effects of aliskiren‐based antihypertensive therapy on the ambulatory blood pressure (BP) profile, central hemodybamics, and arterial stiffness in untreated Japanese patients with mild to moderate hypertension. Twenty‐one Japanese nondiabetic patients with untreated mild to moderate essential hypertension were initially given aliskiren once daily at 150 mg, and the dose was titrated up to 300 mg as needed. After 12 weeks of aliskiren‐based therapy, the clinic, ambulatory, and central BP values as well as brachial‐ankle pulse wave velocity (baPWV) were all significantly decreased compared with baseline (clinic systolic BP, 151±11 mm Hg vs 132±11 mm Hg; clinic diastolic BP, 91±13 mm Hg vs 82±9 mm Hg; 24‐hour systolic BP, 144±12 mm Hg vs 133±11 mm Hg; 24‐hour diastolic BP, 88±8 mm Hg vs 81±9 mm Hg; central BP, 162±16 mm Hg vs 148±14 mm Hg; baPWV, 1625±245 cm/s vs 1495±199 cm/s; P<.05). These results show that aliskiren, as a first‐line regimen, improves the ambulatory BP profile and may have protective vascular effects in Japanese nondiabetic patients with untreated mild to moderate essential hypertension.     

Patients with type 2 diabetes have exaggerated brachial and central exercise blood pressure: relation to left ventricular relative wall thickness

BACKGROUND: A hypertensive response to exercise has prognostic significance. Patients with type 2 diabetes have vascular abnormalities which may predispose to exaggerated brachial and central blood pressure (BP) during exercise. This study aimed to test this hypothesis and to determine the clinical significance of high exercise BP by examining its relation to left ventricular (LV) mass. METHODS: Brachial and central BP were recorded at rest and in response to maximal exercise in 73 diabetic patients (aged 54 +/- 10 years) and 73 controls (aged 53 +/- 12 years). Brachial BP was recorded using mercury sphygmomanometry and LV mass using 2D-echocardiography. Central BP was estimated by radial tonometry using an exercise-validated generalized transfer function. RESULTS: At rest there were no significant (P > 0.05) differences between groups in brachial or central BP. The diabetic patients had significantly increased exercise brachial systolic BP (SBP: 199 +/- 25 mm Hg vs. 185 +/- 21 mm Hg; P = 0.002) and central SBP (158 +/- 17 mm Hg vs. 149 +/- 15 mm Hg; P = 0.002). There was a significantly higher prevalence of an exaggerated exercise BP response (> or =210/105 mm Hg; men and > or =190/105 mm Hg; women) in the diabetic patients (51% vs. 22%; P < 0.01). Compared with those with normal exercise BP, LV relative wall thickness (RWT) was significantly higher (0.41 +/- 0.09 vs. 0.36 +/- 0.08; P < 0.05) and LV hypertrophy was more prevalent (35% vs. 16%; P < 0.05) in those with a hypertensive response. After accounting for other confounding variables, exercise central SBP remained independently associated with LV RWT (beta = 0.22; P = 0.006). CONCLUSION: Diabetic patients are more likely to exhibit exaggerated exercise BP. Regardless of disease status, high exercise central SBP may contribute to cardiovascular risk via adverse cardiac remodeling.     

A Hypertensive Response to Exercise Is Prominent in Patients With Obstructive Sleep Apnea and Hypertension: A Controlled Study

Blood pressure (BP) behavior during exercise is not clear in hypertensive patients with obstructive sleep apnea (OSA). The authors studied 57 men with newly diagnosed essential hypertension and untreated OSA (apnea‐hypopnea index [AHI] ≥5) but without daytime sleepiness (Epworth Sleepiness Scale score ≤10), and an equal number of hypertensive controls without OSA matched for age, body mass index, and office systolic BP. All patients underwent ambulatory BP measurements, transthoracic echocardiography, and exercise treadmill testing according to the Bruce protocol. A hypertensive response to exercise (HRE) was defined as peak systolic BP ≥210 mm Hg. Patients with OSA and control patients had similar ambulatory and resting BP, ejection fraction, and left ventricular mass. Peak systolic BP was significantly higher in patients with OSA (197.6±25.6 mm Hg vs 187.8±23.6 mm Hg; P=.03), while peak diastolic BP and heart rate did not differ between groups. Furthermore, an HRE was more prevalent in patients with OSA (44% vs 19%; P=.009). Multiple logistic regression revealed that an HRE is independently predicted by both the logAHI and minimum oxygen saturation during sleep (odds ratio, 3.94; confidence interval, 1.69–9.18; P=.001 and odds ratio, 0.94; confidence interval, 0.89–0.99; P=.02, respectively). Exaggerated BP response is more prevalent in nonsleepy hypertensives with OSA compared with their nonapneic counterparts. This finding may have distinct diagnostic and prognostic implications.     

Risk of Methylphenidate‐Induced Prehypertension in Normotensive Adult Smokers With Attention Deficit Hyperactivity Disorder

The authors studied predictors of methylphenidate‐induced increases in blood pressure (BP). In this secondary analysis of a randomized, double‐blind, placebo‐controlled smoking cessation trial, nonhypertensive adult smokers with attention deficit hyperactivity disorder randomized to osmotic‐release oral system methylphenidate (OROS‐MPH) (n=115) were matched one‐to‐one on baseline systolic BP (SBP) (±5 mm Hg) with participants randomized to placebo (n=115) and followed for 10 weeks. In adjusted mixed linear models of SBP and diastolic BP (DBP), baseline normal SBP (P<.0001) and DBP (P<.0001) were associated with significant OROS‐MPH–induced increases compared with placebo, whereas significant increases were not observed in participants with baseline prehypertensive SBP (P=.27) and DBP (P=.79). Participants randomized to OROS‐MPH with baseline normal BP had increased odds of developing either systolic (odds ratio [OR], 3.32; 95% confidence interval [CI], 1.41–8.37; P=.006) or diastolic prehypertension (OR, 4.32; 95% CI, 1.56–14.0; P=.004) compared with placebo using simple logistic regression. The authors demonstrated an augmented OROS‐MPH–induced BP elevation and risk of prehypertension in adults with baseline normal BP. Significantly increased BP was not observed in adults with baseline prehypertension. J Clin Hypertens (Greenwich). 2012; 00:00–00. ©2012 Wiley Periodicals, Inc.     

Age-Related Differences in the Mechanism of Nondipping Among Patients with Obstructive Sleep Apnea Syndrome

The frequency of nondipper (those lacking the normal drop in nocturnal blood pressure [BP]) is high in patients with obstructive sleep apnea syndrome (OSAS). The objective of this study is to investigate age-related differences in the nocturnal BP profile of patients with OSAS. The study subjects included 214 patients with polysomnography-diagnosed OSAS. The status of dipper or nondipper was determined by 24-hour ambulatory BP measurements. We divided the subjects into three groups by age (younger, middle-aged, and elderly) and compared the frequency and sleep profiles of nondippers in the different age groups. The prevalence of nondippers was significantly higher in the elderly OSAS group than in the younger and middle-aged OSAS groups (69% vs. 45%, 47%; P < .05). In the younger OSAS group, nondippers, when compared with dippers, were characterized by higher apnea–hypopnea index (AHI, 48.2 ± 27.1 vs. 37.4 ± 23.0 times/h, P < .05), whereas in the middle-aged and elderly OSAS groups, the AHI of nondippers was almost identical to that of dippers. On the other hand, in the elderly OSAS group, nondippers, when compared with dippers, had shorter periods of slow wave sleep as measured by nonrapid eye movement stage 3–4, whereas nondippers and dippers in the other two age groups were not different in terms of slow wave sleep. These results indicate age-related differences in major mechanisms leading to nondipping. Severe apnea causes nondipping only in young OSAS patients, whereas disturbance of sleep quality plays a more important role in elderly OSAS patients.     

Excessive pulse pressure response to standing in community population with orthostatic systolic hypertension

The postural change of pulse pressure (PP) in the persons with orthostatic hypertension (OHT) is unclear. This study included 2849 (65.0 ± 9.3 years) community participants. Blood pressures (BPs) in supine and standing positions were measured. The differences between upright and supine BP and PP were recorded as ΔBP and ΔPP. The criteria for OHT was ΔBP ≥10 mm Hg, for orthostatic hypotension (OH) was ≤−10 mm Hg and for orthostatic normotension (ONT) was −9 to 9 mm Hg. Fasting blood lipids and glucose were measured. The supine SBP of the sOHT group were similar to that of sONT group (140.9 ± 20.2 mm Hg vs 138.2 ± 19.7 mm Hg), but significantly lower than that of sOH group (151.9 ± 19.2 mm Hg; P < .05). Their PPs were 65.3 ± 15.9, 62.8 ± 14.7, and 71.1 ± 15.1 mm Hg, respectively, and with the similar group difference like SBP. When the position changed from supine to standing, the sOHT group showed PP rise, while sOH and sONT groups showed PP reduction (3.8 ± 7.1 mm Hg vs −17.0 ± 8.5 mm Hg and −5.8 ± 6.6 mm Hg; both P < .05). Thus, the standing PP in the sOHT group was significantly higher than in the sONT (69.1 ± 18.0 mm Hg vs 57.0 ± 15.8 mm Hg; P < .05) and in the sOH (54.2 ± 15.2 mm Hg; P < .05) groups. The postural PP profile varies with the postural responses of SBP. The sOHT group has obviously increased PP and significantly higher standing PP compared with the sONT group.     

Blood Pressure Effects of Combined β-Blocker and Angiotensin-Converting Enzyme Inhibitor Therapy Compared With the Individual Agents: A Placebo-Controlled Study With Nebivolol and Lisinopril

J Clin Hypertens (Greenwich). 2012; 14:588–592. © 2012 Wiley Periodicals, Inc. Blood pressure (BP) reductions when combining blockers of the renin‐angiotensin system (RAS) and β‐blockers have generally not been shown to be greater than for individual agents, possibly because of overlapping mechanisms of action. The authors tested the additivity of the β‐blocker nebivolol, which has vasodilating activity, with the angiotensin‐converting enzyme inhibitor lisinopril in patients with stage 2 diastolic hypertension. The BP effects of placebo (n=93), nebivolol 5 mg to 20 mg daily (n=185), lisinopril 10 mg to 40 mg daily (n=189), and nebivolol 5 mg to 20 mg + lisinopril 10 mg to 40 mg (n=189) during 6 weeks of treatment were compared. The primary end point was change in diastolic BP (DBP). For the full cohort, baseline BP was 163.8/104.4 mm Hg, mean age was 49.2 years, 58% were men, 62% were white, and 34% were black. DBP fell by 17.2±10.2 mm Hg with the combination, greater than placebo (8.0±9.2, P<.0001), nebivolol (13.3±8.9, P=.0010), and lisinopril (12.0±9.8, P<.0001). For systolic BP, corresponding reductions were 19.2±19.8 mm Hg, 9.9±16.4 (P<.0001 vs combination), 14.4±14.1 (P=.0470), and 16.1±17.2 (P=.0704). Adverse event rates were similar in all groups. This study demonstrated the potential antihypertensive benefits of combining nebivolol with a RAS blocker.     

Arterial Stiffness and Peripheral and Central Blood Pressure in Patients With Sickle Cell Disease

Blood pressure (BP) in patients with sickle cell disease (SCD) has been reported to be lower than in persons in the general population. Data on arterial stiffness, which is an important risk factor for the progression of BP, are inconclusive for this patient population. Forty‐five adult patients with SCD and 40 controls matched for sex, age, and body mass index were studied. Brachial systolic BP (SBP) and diastolic BP (DBP) were significantly lower in the patient group (SBP 115.1±13.8 mm Hg vs 121.9±11.3 mm Hg and DBP 68.5±8.0 mm Hg vs 80.6±9.1 mm Hg, P<.05, respectively). Augmentation index (AIx), however, was significantly higher in SCD patients compared with healthy controls (24.9±9.6 for patients vs 12.4±10.8 for controls, P<.001), while carotid femoral pulse wave velocity was comparable between the two groups. The study shows that mechanisms other than arterial elasticity are involved in the low BP phenotype of patients with SCD.     

Neurohumoral characteristics of older hypertensive patients with abnormal nocturnal blood pressure dipping

Abnormal patterns of diurnal blood pressure (BP) variation have been reported to be related to advanced target organ damage and poor cardiovascular prognosis. However, the neurohumoral characteristics of patients with such variation have not been fully investigated. We measured BP and plasma levels of neurohumoral factors (norepinephrine [NE], epinephrine, renin, and arginine vasopressin [VP]) during the 70 degree head-up tilt test (10 min supine and 15 min tilting) in 120 older subjects (mean age 71 years) who had sustained hypertension as determined by ambulatory BP monitoring. They who were subclassified according to the nocturnal systolic BP fall as follows: 28 extreme dippers with >20% nocturnal BP fall; 78 dippers with >0% but <20% fall; and 14 nondippers with <0% fall. Plasma renin activity (r = 0.22, P = .02) and VP level (r = 0.36, P < .0001) after tilting were positively associated with the nocturnal systolic BP fall. Plasma NE levels were significantly higher in nondippers than in dippers in both the supine and tilting positions (supine 519 v 315 pg/mL, P = .001; tilting 803 v 550 ng/mL, P < .01), whereas the increase of NE induced by tilting was comparable in the two groups. Plasma renin activity in both the supine and tilting positions was comparable in the three groups, but the increase of this activity caused by tilting was less marked in the nondippers than in the extreme dippers (0.05 v 0.26 ng/mL/min, P = .02) and dippers (0.21 ng/mL/min, P = .07). Plasma VP was markedly increased after tilting in the extreme dippers compared with dippers (3.8 v 2.6 pg/mL, P < .001) and nondippers (v 2.0 pg/mL, P < .001), whereas the levels in the supine position were comparable in the three groups (2.0 pg/mL for extreme dippers, 1.9 pg/mL for dippers, 1.6 pg/mL for nondippers). In conclusion, diurnal BP variation in elderly hypertensive individuals was significantly associated with neurohumoral factors regulating circulating blood volume. Increased VP after tilting in extreme dippers might counteract reduced circulating blood volume, whereas nondippers appear to have alpha- and beta-adrenergic subsensitivity that may be induced by their chronic exposure to high NE levels.