Latest Research in HTN

A recent study published in the Scientific Reports journal just 2 days ago revealedthat hypertension was not a predictor of perioperative cardiac arrest. This finding is surprizing and totally unexpected. Read the whole article for more data. 

Sci Rep. 2022 Aug 12;12(1):13709. doi: 10.1038/s41598-022-17916-3.

A retrospective study of mortality for perioperative cardiac arrests toward a personalized treatment

Huijie Shang 1 2 , injun Chu 3, Muhuo Ji , Jin Guo 1, Haotian e , Shasha Zheng 5, ianjun Yang 6

Abstract

Perioperative cardiac arrest (POCA) is associated with a high mortality rate. This work aimed  o study   s prognostic factors   r risk mitigation by   ans of care     nagementand  lanning. A database of  380,919 surgeries was reviewed, and 150 POCAs were curated. The main outcome was mortality prior to hospital discharge. Patient  demographic, medical history, and clinical characteristics (anesthesia and surgery)
were the main features. Six machine learning (ML) algorithms, including LR, SVC, RF, GBM, AdaBoost, and VotingClassifier, were explored. The last algorithm was an  ensemble of the first five algorithms. k-fold cross-validation and bootstrapping minimized the prediction bias and variance, respectively. Explainers (SHAP and LIME) were used to interpret the predictions. The ensemble provided the most accurate and
robust predictions (AUC = 0.90 [95% CI, 0.78-0.98]) across various age groups. The risk factors were identified by order of importance. Surprisingly, the comorbidity of hypertension was found to have a protective effect on survival, which was reported by a recent study for the first time to our knowledge. The validated ensemble classifier in aid of the explainers improved the predictive differentiation, thereby deepening our understanding of POCA prognostication. It offers a holistic model-based approach for personalized anesthesia and surgical treatment.

Modified Snacks Reduce LDL Cholesterol

A new, randomized crossover study shows that individuals who ate specifically formulated snacks high in certain ingredients including fiber, phytosterols, and antioxidants reduced their LDL cholesterol, even in the absence of other dietary or lifestyle changes.
           Investigators randomized 54 adults to receive either the specially formulated snacks made by Step One Foods or control snacks from the grocery store that were similar in calories and packaging.
Participants were instructed to consume the snacks twice a day as a substitute for something they were already eating and to make no other changes in diet or lifestyle. None of the patients were receiving statin drugs either before or during the study period.
           After the first 4 weeks, a 4-week washout period ensued, and then the original control group crossed over to receive the specially formulated snacks, while the experimental group now received the control snacks.
           LDL cholesterol levels fell by almost 9% and total cholesterol (TC) by 5% in those receiving treatment foods compared with those receiving control foods.

          Authors noted that what you eat is very important, and you can eat foods that will lower your cholesterol. Based on their study findings, this type of ‘food-as-medicine’ approach expands the options for medical professionals and patients, as many patients are either unwilling or unable to take statins drugs and may be able to manage their hyperlipidemia with realistic food-based interventions.

 

The study was published online January 2022 in The Journal of Nutrition

 

Current ‘Safe’ Alcohol Consumption Levels Potentially Harmful

A new research, published in Clinical Nutrition , suggests that even following the current alcohol consumption guidance             

    from the UK’s Chief Medical Officers – which advises: “To keep health risks from alcohol to a low level, both men and women are advised not to regularly drink more than 14 units a week” – will potentially increase a person’s risk of fatal and non-fatal cardiovascular events, ischemic heart disease, and cerebrovascular disease.
For their study the researchers analysed data from the UK Biobank study of 333,259 people who drank alcohol, and 21,710 never drinkers, recording those patients who had been hospitalized due to a cardiovascular event.
       Those participants who were included in the study were asked about their overall weekly alcohol intake and their intake of specific types of alcohol including beer, wine and spirits.
       The researchers found that for those participants who reported keeping within the current alcohol guidance, drinking less than 14 units a week, the risk of suffering a cardiovascular event was increased by 23% for each additional 1.5 pints of 4% strength beer.

        The authors pointed out that the acceptance of the J-shaped curve, which suggests that low to moderate alcohol consumption can be health beneficial, is wrong, and is the result of biases in existing epidemiological data.

 

Statin Intolerance ‘Overestimated and Overdiagnosed’

 

Statin intolerance is far less common than previously reported, according to a new meta-analysis, with data on more than 4 million adults from around the world, looking at reported statin adverse effects.

        The study puts the prevalence of statin intolerance at 6% to 10%, meaning that statin intolerance is “overestimated and overdiagnosed” in most cases.
It also means that “around 93% of patients on statin therapy can be treated effectively, with very good tolerability and without any safety issues. The reported prevalence of statin intolerance varies widely, from 2% to 3% to as high as 50%, chiefly because there is still a lack of a clear and easy way to apply the definition of statin intolerance.

         The study, conducted on behalf of the Lipid and Blood Pressure Meta-Analysis Collaboration and the International Lipid Expert Panel, and was published recently online in the European Heart Journal.

 

What Is the Healthiest Salt for You?

When we refer to “regular table salt,” it is most commonly in the form of sodium chloride, which is also a major constituent of packaged and ultraprocessed foods.
The best approach to finding the “healthiest salt” which really means the lowest in sodium is to look for the amount on the label. “Sodium-free” usually indicates less than 5 mg of sodium per serving, and “low-sodium” usually means 140 mg or less per serving. In contrast, regular table salt can contain as much as 560 mg of sodium in one serving.

       Other en vogue salts, such as pink Himalayan salt, sea salt, and kosher salt, are high in sodium content like regular table salt, but because of their larger crystal size, less sodium is delivered per serving. Most salt substitutes are reduced in sodium, with the addition of potassium chloride instead.

       The key to which salt is healthiest depends on the person. Our bodies need some sodium to function, just not in large amounts.

 

FDA Issues Guidance on Reducing Salt


Currently, the US sodium dietary guidelines for persons older than 14 stipulate 2300 mg/d, which is equivalent to 1 teaspoon a day. However it is estimated that the average person in the United States consumes more than this —around 3400 mg of sodium daily.

   In October 2021, the US Food and Drug Administration (FDA) published guidance on voluntary sodium limitations in commercially processed, packaged, and prepared food. The FDA’s short-term approach is to slowly reduce exposure to sodium in processed and restaurant food by 2025, on the basis that people will eventually get used to less salt, as has happened in the United Kingdom and other countries.

    Such strategies to reduce salt intake are now being used in national programs in several countries. Many of these successful initiatives include active engagement with the food industry to reduce the amount of sodium added to processed food, as well as public awareness campaigns to alert consumers to the dangers of eating too much salt. This includes increasing potassium in manufactured foods, primarily to target hypertension and heart disease.

Journal of Clinical Hypertension, Feb 2022

 

Striking’ Differences in BP When Wrong Cuff Size Is Used


Strong new evidence on the need to use an appropriately sized cuff in blood pressure (BP) measurement has come from the cross-sectional randomized trial Cuff (SZ).

     The study found that in people in whom a small adult cuff was appropriate, systolic BP readings were on average 3.6 mm Hg lower when a regular adult size cuff was used.

      However, systolic readings were on average 4.8 mm Hg higher when a regular cuff was used in people who required a large adult cuff and 19.5 mm Hg higher in those needing an extra-large cuff based on their mid-arm circumference. The diastolic readings followed a similar pattern (-1.3 mm Hg, 1.8 mm Hg, 7.4 mm Hg, respectively).
 

    Authors found that using the regular adult cuff in all individuals had striking differences in blood pressure.


EPI/Lifestyle 2022. Abstract. Presented March 2022

 

Get More Sleep, Lose More Weight: A Randomized Trial


I was fascinated reading this paper, which brings into the real world data that previously only existed in highly controlled laboratory experiments. When people sleep less, they eat more.

          Prior research in the field has been very consistent. If you take an individual and put them in a sleep lab and force them to sleep only 4 or 5 hours a night, they will eat more calories the next day. The mechanism of this relationship, the hormones, cytokines, and other substances that drive the sleep-hunger axis is still being worked out, but the relationship is clear.

          To figure it all out, researchers randomized 80 individuals, all of whom were overweight and getting less than 6.5 hours of sleep a night, to receive personalized sleep recommendations (sleep extension) to boost the time spent snoozing, or nothing. The recommendations were pretty straight forward — stuff we could all do a bit better: decreasing ambient light, creating a bedtime routine, limiting phone and TV use in bed, decreasing caffeine intake, and increasing exercise. Importantly, each participant was given a goal bedtime and wake-time schedule as an adherence goal.

           And the recommendations worked. After a 2-week run-in period, the intervention group got about 1.5 extra hours a night as documented by wrist monitors and stayed that way for the rest of the 2 weeks in the study.

          That’s not the interesting part, though. The researchers then dug into the energy balance in these individuals the calories they were taking in and those they were putting out using doubly labeled water to get accurate measurements. They found that the group randomized to sleep longer had a significant decrease in total energy intake (that’s calories in) during the study period, to the tune of around 150 fewer calories per day. They had no difference in total energy expenditure (calories out). And, since calories in went down and calories out stayed the same, the intervention group lost weight about a pound over 2 weeks.

In this review article, authors explore the famous pressure-natriuresis mechanism of salt and
water balance. This mechanism is the basis to understand how high dietary salt could increase
incidence of hypertension.
The article is published in the Electrolyte Blood Pressure journal and is available for free
through the following link https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8715224/

Electrolyte Blood Press. 2021 Dec;19(2):38-45.
doi: 10.5049/EBP.2021.19.2.38. Epub 2021 Dec 23.

Current Understanding of Pressure Natriuresis

Eun Ji Baek 1 , Sejoong Kim1 2
Affiliations
•1Department of Internal Medicine, Seoul National University Bundang Hospital,
Seongnam, Republic of Korea.
•2Department of Internal Medicine, Seoul National University College of Medicine,
Seoul, Republic of Korea.
• PMID: 35003284

 

Abstract

Pressure natriuresis refers to the concept that increased renal perfusion pressure leads to a decrease in tubular reabsorption of sodium and an increased sodium excretion. The set point of blood pressure is the point at which pressure natriuresis and extracellular fluid volume are in equilibrium. The term “abnormal pressure
natriuresis” usually refers to the expected abnormal effect of a certain level of blood pressure on sodium excretion. Factors that cause abnormal pressure natriuresis are known. Sympathetic nerve system, genetic factors, and dietary factors may affect an increase in renal perfusion pressure. An increase in renal perfusion pressure increases renal interstitial hydrostatic pressure (RIHP). Increased RIHP affects tubular reabsorption through alterations in tight junctional permeability to sodium in proximal tubules, redistribution of apical sodium transporters, and/or release of renal autacoids. Renal autocoids such as nitric oxide, prostaglandin E2, kinins, and angiotensin II may also regulate pressure natriuresis by acting directly on renal tubule sodium transport. In addition, inflammation and reactive oxygen species may mediate pressure natriuresis. Recently, the use of new drugs associated with pressure natriuretic mechanisms, such as angiotensin receptor neprilysin inhibitor and sodium glucose co-transporter 2 inhibitors, has been consistently demonstrated to reduce mortality and hypertension-related complications. Therefore, the understanding of pressure natriuresis is gaining attention as an antihypertensive strategy. In this review, we provide a basic overview of pressure natriuresis to the target audience of nephrologists. 

Keywords: Blood pressure; Hypertension; Kidney; Pressure natriuresis; Sodium excretion.

Analysis Supports CAC for Personalizing Statin Use

In patients with intermediate risk of atherosclerotic cardiovascular disease along with risk-enhancing factors, coronary artery calcium scoring may help more precisely calculate their need for statin therapy.

Furthermore, when the need for statin treatment isn’t so clear and patients need additional risk assessment, the scoring can provide further information to personalize clinical decision making, according to a cross-sectional study of 1,688 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) published in JAMA Cardiology. In additon to coronary artery calcium (CAC), a low ankle brachial index (ABI) score is a marker for statin therapy, the study found.

The study looked at CAC scoring in the context of ABI and other risk-enhancing factors identified in the 2018 American Heart Association/American College of Cardiology cholesterol management guidelines: a family history of premature atherosclerotic cardiovascular disease (ASCVD), lipid and inflammatory biomarkers, chronic kidney disease, chronic inflammatory conditions, premature menopause or preeclampsia, and South Asian ancestry.

Any number of these factors can indicate the need for statins in people with borderline or intermediate risk. The guidelines also call for selective use of CAC to aid the decision-making process for statin therapy when the risk for developing atherosclerosis isn’t so clear.

 

ARBs Equal ACE Inhibitors for Hypertension, but Better Tolerated

In the largest comparison of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors to date, a study of nearly 2.3 million patients starting the drugs as monotherapy shows no significant differences between the two in the long-term prevention of hypertension-related cardiovascular events.However, side e ffects were notably lower with ARBs.

This is a very large, well-executed observational study that confirms that ARBs appear to have fewer side effects than ACE inhibitors, and no unexpected ARB side effects were detected. “Despite being equally guideline-recommended first-line therapies for hypertension, these results support preferentially starting ARBs rather than ACE inhibitors when initiating treatment for hypertension for physicians and patients considering renin-angiotensin system (RAS) inhibition,” the authors add in the study, published in the journal Hypertension. They note that both drug classes have been on the market a long time, with proven efficacy in hypertension and a wide availability of inexpensive generic forms.

They also stress that their findings only apply to patients with hypertension for whom a RAS inhibitor would be the best choice of therapy.

 

Statins Again Linked to Lower COVID-19 Mortality

Among patients hospitalized for COVID-19, those who had been taking statins had a substantially lower risk of death in a new large observational study. Results showed that use of statins prior to admission was linked to a greater than 40% reduction in mortality and a greater than 25% reduction in risk of developing a severe outcome.

The findings come an analysis of data from the American Heart Association’s COVID-19 Cardiovascular Disease Registry on more than 10,000 patients hospitalized with COVID-19 at 104 hospitals across the United States published in PLoS One.

While several other studies have suggested benefits of statins in COVID-19, this is by far the largest study so far on this topic. This is the most reliable study on statins in COVID-19 to date, with the results adjusted for many confounders, including socioeconomic factors and insurance type, However, it still an observational study and therefore falls short of a randomized study.

After propensity matching for cardiovascular disease, results showed that most of the benefit of statins occurred in patients with known cardiovascular disease. While most patients taking statins will have cardiovascular disease, there are also many patients who take these drugs who don’t have heart disease but do have cardiovascular risk factors, such as those with raised cholesterol, or a family history of cardiovascular disease. For [such patients], the effect of statins was also in the same direction but it was not significant. This doesn’t exclude an effect.

 

Myocarditis Tied to COVID-19 Shots More Common Than Reported?

 While cases of pericarditis or myocarditis temporally linked to COVID-19 vaccination remain rare, they may happen more often than reported, according to a large review of electronic medical records (EMR).

They also appear to represent two “distinct syndromes”. Myocarditis typically occurs soon after vaccination in younger patients and mostly after the second dose, while pericarditis occurs later in older patients, after either the first or second dose. Authors report their analysis in a research letter published in JAMA.

They reviewed the records of 2,000,287 people who received at least one COVID-19 vaccination at 40 hospitals in Washington, Oregon, Montana, and California that are part of the Providence healthcare system and use the same EMR. The median age of the cohort was 57 years and 59% were women.

A little more than three quarters (77%) received more than one dose; most received the mRNA vaccines made by Pfizer (53%) and Moderna (44%); only 3% received the Johnson & Johnson vaccine. The records showed that 20 people had vaccine-related myocarditis (1.0 per 100,000) and 37 had pericarditis (1.8 per 100,000).

A recent report, based on data from the Centers for Disease Control and Prevention (CDC) Vaccine Adverse Events Reporting System (VAERS), suggested an incidence of myocarditis of about 4.8 cases per 1 million following receipt of mRNA COVID-19 vaccine.

 

Aerobic Exercise Reduces BP in Resistant Hypertension

Aerobic exercise may help reduce blood pressure in patients whose hypertension responds poorly to medications, a new study suggests.

A randomized controlled clinical trial showed that patients with resistant hypertension assigned to a moderate-intensity aerobic exercise training program had lower blood pressure (BP) compared with patients who received usual care.

Resistant hypertension persists as a big clinical challenge because the available treatment options to lower blood pressure in this clinical population, namely drugs and renal denervation, show limited success. Aerobic exercise was safe and associated with a significant and clinically relevant reduction in 24-hour, daytime ambulatory, and office blood pressure. The findings were published in JAMA Cardiology. The researchers enrolled 53 patients aged 40 to 75 years with a diagnosis of resistant hypertension in this prospective, single-blinded trial.

Resistant hypertension was defined as having a mean systolic BP of 130 mm Hg or greater on 24-hour ambulatory BP monitoring and/or 135 mm Hg or greater during daytime hours while taking maximally tolerated doses of at least 3 antihypertensive agents, including a diuretic, or to have a controlled BP while taking 4 or more antihypertensive agents.

From March 2017 to December 2019 at two sites in Portugal, 26 patients were randomly assigned to a 12-week aerobic exercise training program involving three 40-minute supervised sessions per week in addition to usual care. Another 27 patients in the control group were allocated to receive usual care only.

24-hour ambulatory systolic blood pressure was reduced by 7.1 mm Hg (95% CI, −12.8 to −1.4; P = .02) in patients in the exercise group compared with the control group. In the exercise group, there were additional reductions of:

  • –5.1 mm Hg of 24-hour ambulatory diastolic blood pressure (95% CI, −7.9 to −2.3; P = .001)
  • –8.4 mm Hg of daytime systolic blood pressure (95% CI, −14.3 to –2.5, P = .006)
  • –5.7 mm Hg of daytime diastolic blood pressure (95% CI, −9.0 to −2.4; P = .001)
  • –10.0 mm Hg of office systolic blood pressure (95% CI, −17.6 to −2.5; P = .01)

Additionally, a significant improvement in cardiorespiratory fitness (5.05 mL/kg per minute of oxygen consumption; 95% CI, 3.5 – 6.6; P < .001) was observed in the exercise group compared with the control group.

Women Still Under-represented in CVD Trials, Despite Requirements

Women, and especially minority women, remain under-represented in most clinical cardiology trials, despite guidelines and legal requirements put forward years ago to ensure broader inclusivity, according to a new report released by the American College of Cardiology (ACC) Cardiovascular Disease in Women Committee.

Women are particularly under-represented in trials of coronary artery disease, heart failure with reduced ejection fraction, and arrhythmia studies involving devices and procedures, the committee found.

Gender-specific data are essential to optimal cardiovascular care and increasing awareness about trials is critical for everyone. Also, having trial information be available to all patients, regardless of where they live, who they are, or where they get care is important. The report was published in the Journal of the American College of Cardiology.

Barriers and Solutions

In the report, the committee outlines barriers to enrolling women in CV clinical trials and offers strategies to help increase participation of women in these trials. One key barrier is low referral rates to cardiologists and specialty programs for more aggressive care, leading to fewer women being treated by specialists who might be recruiting for clinical trials. The committee recommends expanding awareness of ongoing trials to primary care providers and to community and safety-net hospitals, and to offer more locations of trial enrollment if possible.

Another barrier is “ageism,” with older patients disproportionately under-represented in clinical trials overall, further compounding the under-representation of women in CV trials, as heart disease is significantly higher in older-age women. The committee recommends expanding age criteria and limiting exclusion criteria that disproportionately affects the elderly. “It is critical that age and comorbidities be expanded in clinical trial inclusion criteria to reflect real-world patient population.

A lack of awareness, trust, and logistical barriers is another obstacle to getting more women enrolled in CV clinical trials. Research has shown that women are more reluctant than men to consider trial participation.

 

A recently published review article by Perez et al, had discussed the association between hypertension, obesity, and the current COVID-19 pandemic. The article was published in the Current Hypertension Reports in June 2021 and the full article is free to read and to download at the journal website.

Hypertension, Obesity, and COVID-19: a Collision of Pandemics

Annalisa Perez 1, Mihran Naljayan 2, Imran Shuja 2, Andre Florea 2, Efrain Reisin 2

Abstract

To highlight the epidemiology and pathophysiology of hypertension and obesity in COVID-19 infection RECENT FINDINGS: Hypertension and obesity have emerged as significant risk factors for contracting the COVID-19 virus and the subsequent severity of illness. ACE2 receptor expression and dysregulation of the RAAS pathway play important roles in the pathophysiology of these associations, as do the pro-inflammatory state and cytokine dysregulation seen in obesity. Some of these patterns have also been seen historically in other viral illnesses. Understanding the mechanisms behind the associations between COVID-19, hypertension, and obesity is important in developing effective targeted therapies and monitoring vaccine response and efficacy. More research is needed to apply our growing knowledge of the pathophysiology of COVID-19, hypertension, and obesity to prevention and treatment. Interventions focusing on lifestyle modification in managing hypertension and obesity can potentially have a positive impact on containing this pandemic and future viral illness outbreaks.

Keywords

: ACE2 receptor; COVID-19; Hypertension; Obesity; RAAS.

 

 

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