Over one-third of Canadians with hypertension do not achieve recommended blood pressure (BP) targets despite availability of effective treatments. Renal sympathetic nerve denervation (RDN) is a recently approved, minimally invasive treatment for hypertension being offered in multiple Canadian centers. How best to implement this procedure in contemporary Canadian clinical practice remains unclear. Herein, we provide a Canadian hypertension specialist viewpoint on use of RDN in Canada. We review the rationale for, and evidence supporting, the use of RDN and discuss, using two clinical cases, its potential therapeutic role. We note that RDN has effectively lowered BP in multiple, sham-controlled, randomized clinical trials and has a favourable safety profile. Economic modeling estimates that it is cost-effective in the Canadian context. Conversely, the BP lowering effect is relatively modest; no well-established method to pre-identify responders exists; cardiovascular endpoint data supporting use of RDN are lacking; and no clear funding model is currently in place in Canada. Accordingly, we suggest that use of RDN be reserved for willing patients with severely elevated BP despite the use of first-line conventional therapies who have had secondary causes excluded. Examples include patients with resistant hypertension or moderate or severe hypertension and multiple drug intolerance syndrome. In view of its recent approval and known operator-dependency, RDN should be offered solely through programmatic, multidisciplinary collaboration between hypertension specialists and experienced interventionalists using a shared decision-making approach with the patient. Funding deployment should target such programs and sites should carefully monitor their outcomes to confirm comparability to the published literature.

The World Health Organization (WHO) estimates that the number of people living with hypertension (blood pressure (BP) of ≥ 140 mmHg systolic or ≥ 90 mmHg diastolic or on medication) doubled between 1990 and 2019, from 650 million to 1.28 billion. Elevated BP is associated with increased risks of stroke, coronary artery disease (CAD), heart failure (HF), and chronic kidney disease (CKD). Resistant hypertension (RH) is defined as office BP ≥ 140/90 mmHg despite treatment with three classes of antihypertensive agents (including a diuretic) at maximally tolerated doses, or the need for four or more agents regardless of BP level. Device-based antihypertensive therapies primarily target autonomic nervous system through techniques, such as renal denervation, carotid baroreceptor activation, and carotid body ablation. This review outlines the pathophysiological basis of selected interventions, critically evaluates existing clinical evidence, and highlights future directions for their development and integration into clinical practice.

Hypertensive heart disease is a major cause of heart failure (HF), this study evaluate the global burden and trends of HF attributable to hypertensive heart disease from 1990 to 2021. We collected detailed information on prevalence, years lived with disability of HF attributable to hypertensive heart disease from the Global Burden of Disease study 2021 across 204 countries and territories. Numbers, age-standardized rates and average annual percent change of HF attributable to hypertensive heart disease prevalence and years lived with disability were compared by age, sex, and socio-demographic index. In 1990 and 2021, hypertensive heart disease related HF affected more than 4.6 million and 13 million individuals globally, demonstrating an age-standardized prevalence rate of 125.4 [95% uncertainty Interval (UI) 99.0 to 158.0] and 148.3 per 100,000 (95% UI 117.3 to 186.3) and an age-standardized years lived with disability rate of 11.2 (95% UI 7.2 to 15.7) and 13.2 (95% UI 8.4 to 19.1) per 100,000, respectively. Notably, from 1990 to 2021, the global age-standardized prevalence and years lived with disability rates increased consistently, with an average annual percent change of 0.53 (95% CI 0.52 to 0.54) and 0.54 (95% CI 0.53 to 0.55), respectively. The global burden of HF attributable to hypertensive heart disease has risen.

The rate of hypertension hospitalizations is increasing among US adults. Individuals with low socioeconomic position are more likely to have high blood pressure (BP), which may increase their risk of hypertension hospitalization and adverse post-discharge outcomes. We analyzed data from the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study, which enrolled 5,115 adults aged 18 to 30 years from 4 urban US communities in 1985-1986. Hospitalizations were identified by self-report during study exams and annual interviews, with hypertension hospitalizations determined through medical record review, through August 2020. Socioeconomic position included education, family income, having private health insurance, and neighborhood deprivation assessed at the last study visit prior to the hypertension hospitalization. Uncontrolled BP (≥140/90 mmHg) was determined at the first CARDIA study visit after hypertension hospitalization. Overall, 67 CARDIA participants were hospitalized for hypertension. The hazard ratio of hypertension hospitalization among participants who had less than high school versus high school or more education was 3.12 [95%CI: 1.78, 5.48], whose family income was <$25,000 versus ≥$25,000 was 2.43 [95%CI: 1.44, 4.11], who had no private versus private insurance was 2.58 [95%CI: 1.56, 4.28] and those in tertile 3 versus tertile 1 of neighborhood deprivation index (most versus least deprived) was 3.06 [95%CI: 1.23, 7.58]. Among 46 participants who attended a CARDIA study visit following hospital discharge, 23 (50%) had uncontrolled BP. Adults with low socioeconomic position were more likely to be hospitalized for hypertension. Uncontrolled BP was common following hypertension hospitalization.

Vascular aging, often defined in terms of arterial stiffness and impaired arterial hemodynamics, is an important factor associated with hypertension and CVD. Aortic stiffness, a more particular measure of arterial stiffness focusing on central hemodynamics (ie, the aorta), is an independent predictor of hypertension and CVD risk. Higher levels of physical activity are associated with lower arterial stiffness in various White populations, for peripheral and central measures of stiffness, but further investigations into Black populations are warranted. We examined the association between physical activity and aortic stiffness among participants in the Jackson Heart Study (JHS). We analyzed data from JHS participants who completed applanation tonometry assessment as part of an ancillary study (2012-2017). 1,226 Black adults (age 59.0 ± 10.0, 60.4% female) were included for analysis. Associations were assessed using multivariable linear regression models, adjusted for age and sex and then further adjusted for other demographic and CVD-related risk factors. Physical activity was measured via self-report, and aortic stiffness was measured by carotid-femoral pulse wave velocity (cfPWV) using applanation tonometry. Higher total physical activity was associated with lower cfPWV when controlling for risk factors associated with arterial and aortic stiffness (estimated B=-0.96; 95% CI -1.59 to -0.33). When considering American Heart Association physical activity recommendations (ie, ideal activity vs not meeting recommendations), this relationship remained. Higher levels of physical activity were associated with lower levels of aortic stiffness in the Jackson Heart Study.

Multivitamin-multimineral (MVM) supplements have been associated with lower blood pressure (BP) in several small trials. We investigated the effects of a MVM on incident hypertension and BP in a secondary analysis of the COcoa Supplement and Multivitamin Outcomes Study (COSMOS). COSMOS is a 2X2 factorial, double-blinded RCT testing effects of cocoa extract and MVM supplementation among women aged ≥65y and men aged ≥60y. Among 8905 COSMOS participants free from hypertension, effects of MVM supplementation on incident hypertension were investigated. Hypertension diagnosis was ascertained through self-reports. Additionally, in two substudies with BP measurements (N = 529 at clinic by research staff and 994 at home by technician), we evaluated the effects on 2-year BP changes. Incident hypertension was observed in N = 1034 (22.9%) in MVM arm and N = 1039 (23.6%) in placebo arm over a median of 3.4 years (IQR: 3.0, 3.9) of follow-up, with hazard ratio (HR) 0.98 [95% CI: 0.90, 1.06]. Effects differed according to baseline diet quality, with HRs of incident hypertension 0.81 [0.70, 0.95] and 1.14 [1.01, 1.28] among participants with lower and higher Alternate Mediterranean Diet score, respectively (p-interaction = 0.001). There was no effect of MVM on 2-year changes in systolic BP (4.4mmHg in MVM; 4.5mmHg in placebo), while pronounced effects were observed for baseline normal BP (p-interaction = 0.004). MVM supplementation versus placebo did not reduce hypertension incidence or lower BP overall. Exploratory analyses showed greater reduction in hypertension risk and BP changes among those with lower dietary quality and normal BP at baseline, respectively. NCT02422745.

Self-measured blood pressure monitoring (SMBP) is a proposed strategy to improve hypertension control, but few studies compare SMBP with automated office blood pressure (AOBP) measurements over time. Moreover, little is known about reimbursement for these services. We describe a quality improvement initiative in our academic internal medicine practice. Patients received validated home blood pressure (BP) devices and were instructed to check their BP twice daily for seven days each month. Devices transmitted readings seamlessly via a smart phone application that averaged weekly readings. Clinicians reviewed the data and adjusted therapy if indicated. We tracked changes in SMBP, AOBP, antihypertensive medications, and reimbursement. Among 140 patients referred (mean age 57.6 years, 57.1% women, 25.7% Black), 59 completed the program. Over 6 months, the mean self-measured systolic BP decreased by 5.8 mm Hg (95% CI: -8.2 to -3.5) and the mean diastolic BP decreased by 2.8 mm Hg (95% CI: -4.2 to -1.4) and the number with BP < 130/<80 mm Hg increased by 22 percentage points (P = 0.007). However, unattended AOBP showed no change in either systolic (change: 0.1 mm Hg; P = 0.98) or diastolic (change: -0.6 mm Hg; P = 0.64) readings. Reimbursement was variable and ranged from no payment to a maximum payment of $51; when paid, the average payment was $13.81. In this program, SMBP decreased over time while AOBP remained similar. Reimbursement, when received, was modest. Future work should evaluate whether using SMBP as a therapeutic target reduces cardiovascular events.

The Hiroshima Registry for Evaluation and Treatment of Nocturnal and Early Morning Hypertension (Hiroshima NOCTURNE) was a prospective, multicenter study designed to determine whether elevated nighttime blood pressure (BP), assessed using a home BP monitoring (HBPM) device, can be normalized through active antihypertensive therapy in patients already receiving antihypertensive medication. In this subanalysis, we aimed to identify factors associated with failure to normalize nocturnal hypertension. Patients with nocturnal hypertension at baseline who underwent a six-month intervention based on nighttime BP were included. Nocturnal hypertension was defined as a mean nighttime systolic BP of ≥ 120 mmHg. Treatment decisions were left to the discretion of the attending physicians. Among the 90 patients with baseline nocturnal hypertension, 42 (46.7%) failed to achieve normalization (<120 mmHg) after the intervention. In the multivariable analysis, higher baseline nighttime systolic BP (OR 1.07, 95% CI 1.001-1.15, P = 0.046) and baseline diuretic use (OR 3.99, 95% CI 1.17-13.6, P = 0.03) were significantly associated with failure to normalize nocturnal hypertension. Diabetes mellitus tended to be associated with the failure to normalize nocturnal hypertension (OR 3.01, 95% CI 0.93-9.72, P = 0.06). Participants using diuretics at baseline and those with diabetes mellitus were already receiving multiple antihypertensive medications, and additional drug classes were not often prescribed during the intervention. In patients already receiving antihypertensive medication, failure to normalize nocturnal hypertension despite treatment guided by nighttime BP measurements was associated with elevated baseline nighttime BP, diuretic use, and possibly diabetes mellitus. These findings highlight the need for more individualized therapeutic approaches, particularly in patients receiving diuretics or those with diabetes mellitus.

Diagnosing hypertension typically requires repeated blood pressure (BP) readings taken over multiple days, but obtaining accurate BP measurements from patients at home is known to be challenging, at least in part due to failure to accurately report those measurements. Here, we evaluate two low-cost electronic reporting strategies, text messaging and a novel image-based alternative, for acceptability and accuracy. We developed and tested a two-stage optical character recognition (OCR) model to "read" a BP monitor display from patient-provided cellphone photographs. We then conducted a crossover trial to test the accuracy and acceptability of image-based BP reporting with having patients report BP measurements by text messaging. We compared the response rates and values obtained from photo uploads to those from text messages. The majority of the 50 respondents submitted most of the requested data. We received an average of 12/14 texted BP responses and 11.3/14 photo responses from participants. Only 4 participants sent neither text nor photo responses. In addition, our OCR model achieved 98.3% accuracy when "reading" BP values from images of sufficient quality (17.9% were rejected for quality issues), and the average BP reported by subjects did not differ between our text and image-based methods. We were able to successfully "read" BP values from photos of BP monitors sent by participants. Both text messaging and photo uploads of monitor displays appear to be accurate and acceptable approaches for collecting home BP readings.