Aggressive Blood Pressure Control Research Articles

Myocardial Injury After Noncardiac Surgery-Slightly Heavier May Be Better.

Myocardial Injury After Noncardiac Surgery-Slightly Heavier May Be Better.

New-Onset Diabetes after Kidney Transplantation.

New-onset diabetes mellitus after transplantation (NODAT) is a frequent complication in kidney allograft recipients. It may be caused by modifiable and non-modifiable factors. The non-modifiable factors are the same that may lead to the development of type 2 diabetes in the general population, whilst the modifiable factors include peri-operative stress, hepatitis C or cytomegalovirus infection, vitamin D deficiency, hypomagnesemia, and immunosuppressive medications such as glucocorticoids, calcineurin inhibitors (tacrolimus more than cyclosporine), and mTOR inhibitors. The most worrying complication of NODAT are major adverse cardiovascular events which represent a leading cause of morbidity and mortality in transplanted patients. However, NODAT may also result in progressive diabetic kidney disease and is frequently associated with microvascular complications, eventually determining blindness or amputation. Preventive measures for NODAT include a careful assessment of glucose tolerance before transplantation, loss of over-weight, lifestyle modification, reduced caloric intake, and physical exercise. Concomitant measures include aggressive control of systemic blood pressure and lipids levels to reduce the risk of cardiovascular events. Hypomagnesemia and low levels of vitamin D should be corrected. Immunosuppressive strategies limiting the use of diabetogenic drugs are encouraged. Many hypoglycemic drugs are available and may be used in combination with metformin in difficult cases. In patients requiring insulin treatment, the dose and type of insulin should be decided on an individual basis as insulin requirements depend on the patient’s diet, amount of exercise, and renal function.

Cerebral small vessel disease and vascular cognitive impairment: from diagnosis to management.

Purpose of reviewWe present recent developments in the field of small vessel disease (SVD)-related vascular cognitive impairment, including pathological mechanisms, updated diagnostic criteria, cognitive profile, neuroimaging markers and risk factors. We further address available management and therapeutic strategies.Recent findingsVascular and neurodegenerative pathologies often co-occur and share similar risk factors. The updated consensus criteria aim to standardize vascular cognitive impairment (VCI) diagnosis, relying strongly on cognitive profile and MRI findings. Aggressive blood pressure control and multidomain lifestyle interventions are associated with decreased risk of cognitive impairment, but disease-modifying treatments are still lacking. Recent research has led to a better understanding of mechanisms leading to SVD-related cognitive decline, such as blood-brain barrier dysfunction, reduced cerebrovascular reactivity and impaired perivascular clearance.SummarySVD is the leading cause of VCI and is associated with substantial morbidity. Tackling cardiovascular risk factors is currently the most effective approach to prevent cognitive decline in the elderly. Advanced imaging techniques provide tools for early diagnosis and may play an important role as surrogate markers for cognitive endpoints in clinical trials. Designing and testing disease-modifying interventions for VCI remains a key priority in healthcare.

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients with Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure: Post Hoc Analysis of a Randomized Clinical Trial

Current guidelines from the American Heart Association and American Stroke Association call for intensive and aggressive blood pressure control in patients presenting with spontaneous intracerebral hemorrhage (ICH). In patients with systolic blood pressure (SBP) between 150 and 220 mmHg, lowering SBP to 140 mmHg is considered safe and is associated with improved functional outcomes. For patient with systolic blood pressures greater than 220mmHg, it is recommended to use continuous intravenous medications and frequent blood pressure monitoring to aggressively lower blood pressures, though there are no specific goal parameters recommended and inadequate data to evaluate the safety of such intensive blood pressure control.

Abstract 14507: Suboptimal Blood Pressure Control Increases the Risk of Non-alcoholic Fatty Liver Disease

Introduction: Recent blood pressure (BP) guidelines recommend aggressive control of BP to prevent target organ damage, however, no population-level studies have assessed the impact of aggressive BP control on the incidence of Nonalcoholic Fatty Liver Disease (NAFLD). In this study, we investigate the implications of suboptimal BP control for incident NAFLD. Methods: We analyzed data from 6,252 consecutive participants in an employer-mandated routine health evaluation at Hospital Israelita Albert Einstein (São Paulo, Brazil) collected between 2004 to 2016 who were free of NAFLD at baseline. NAFLD was defined as liver ultrasound detected hepatic steatosis among individuals with an alcohol use disorder identification test (AUDIT) score <8. Hypertension was defined as either self-reported history and/or use of BP-lowering medications. Suboptimal BP control was defined per the 2018 ACC/AHA criteria as systolic BP >/= 130mmHg and/or diastolic BP >/= 80 mmHg. Multivariate analysis was conducted adjusting for possible confounders as noted in the figure. Results: Over a median follow-up period of 2.9 years (range: 0.6 - 10.6 years), the incidence of NAFLD was 25.8% among individuals with hypertension (N=473) compared to 15.2% among non-hypertensive individuals (N=5,779; p<0.001). Amongst individuals with known hypertension and suboptimal BP control, the incidence was 29.7% compared to 14.3% among those with optimal BP (adjusted RR 1.80 [95%CI: 1.12 - 2.90]). Similarly, the risk of NAFLD was 18% greater among those without known hypertension but whose BP was suboptimal (adjusted RR: 1.18 [95% CI: 1.05 - 1.33]; figure). Conclusions: Among persons with known hypertension, suboptimal BP is an independent risk of NAFLD. In addition, among those without known hypertension, suboptimal BP is an independent predictor of future NAFLD. Intervention studies are needed to investigate the role of BP control in the prevention of NAFLD.

Intracerebral hemorrhage: update and future directions.

Intracerebral hemorrhage (ICH), defined as bleeding into the brain parenchyma, is a significant public health issue. Although it accounts for only 10 to 15% of strokes, it is associated with the highest morbidity and mortality rates. Despite advances in the field of stroke and neurocritical care, the principles of acute management have fundamentally remained the same over many years. The main treatment strategies include aggressive blood pressure control, early hemostasis, reversal of coagulopathies, clot evacuation through open surgical or minimally invasive surgical techniques, and the management of raised intracranial pressure.

Pocket-Size Mobile Echocardiographic Screening of Thoracic Aortic Aneurysms in Hypertensive Patients

Patients with hypertension may develop a thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients with a point-of-care screening program using pocket-size mobile echocardiographic (PME) devices. We prospectively performed transthoracic aortic ultrasound using a PME device on patients attending our hypertension clinics between June 2016 and July 2018. The echo examinations were performed by a research fellow to obtain aortic diameter measurements including the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta through various standard echo views. Images were stored on the PME and transferred to a desktop computer for measurements and further statistical analysis. During the study period 1529 hypertensive patients (mean age, 62 years [range, 30-85]; 824 men) were recruited. The prevalence of TAA (defined as maximum aortic diameter ≥ 4.5 cm and/or >50% larger than the diameter of the adjacent normal aorta) in our study population was 7.5% (115/1529). Multiple logistic regression analysis identified male gender (odds ratio, 2.120; P < .001) and older age (odds ratio, 1.031; P < .001) as independent factors associated with TAA. Silent TAA is common among hypertensive patients in Hong Kong. We found the PME device to be effective in detecting TAA in a clinic setting. Such an approach may be useful for early detection of TAA among at-risk patients, allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications.

Hemodynamic Safety of Continuous Infusion Labetalol Versus Esmolol Combination Therapies for Type B Aortic Dissections

Background: Medical management for type B aortic dissections (TBADs) require aggressive blood pressure and heart rate control to minimize further dissection extension and to restore perfusion to vital organs. Current guidelines recommend β-blockers (BB) as first-line therapy, however do not differentiate an ideal agent for use. Objective: This study evaluated the hemodynamic safety of continuous infusion labetalol compared to esmolol combination (EC) therapies for TBADs. Methods: This single-center, retrospective analysis identified patients with a TBAD who received high dose continuous intravenous labetalol (HD-CIVL) or EC therapies. Patients who received HD-CIVL or EC therapies for a minimum of 2 hours, during which a minimum of 4 blood-pressure readings were recorded, were included. The primary end point was the incidence of hemodynamic instability with the use of HD-CIVL versus EC therapies. Results: A total of 20 patients receiving HD-CIVL and 22 patients receiving EC therapy were included in the analysis. Ten (50%) of patients receiving HD-CIVL and 7 (32%) of patients receiving EC therapies met the clinical definition of hemodynamic instability (P = .23). Patients experiencing hemodynamic instability were all due to hypotension, with one also being due to bradycardia. Over half the patients in both groups had discontinued therapy ( P = .06) and were administered bolus fluids (P = .27). Only one patient receiving HD-CIVL required vasopressor administration while none in the EC group (P = .48). Conclusion: Our study suggests that HD-CIVL is associated with a nonstatistical significant higher incidence of hemodynamic instability compared to an EC regimen in TBADs. Further studies are warranted in this patient population.

Abstract TP415: Regular Home Blood Pressure Monitoring Reduces the Risk of Stroke Recurrence

Background: High blood pressure (BP) is a well recognized risk factor for ischemic stroke, and aggressive BP control is critical for secondary stroke prevention. However, hypertensive (HTN) outpatients are often found to have uncontrolled BP, in part due to poor compliance with daily at-home BP monitoring and consequent poor medication adherence. Here, we explore the association of patient home BP self-monitoring compliance with stroke recurrence. Method: Ischemic stroke patients with pre-existing HTN were prospectively recruited in accordance with IRB protocol for this observational study. All patients were trained on BP self-monitoring as per standard of care, and were asked to monitor BP at home daily consistently for 2 weeks. BP monitoring compliance, per completion of BP log, was assessed at each follow-up clinical visit by an investigator blinded to patient outcome. Stroke recurrence was followed for 5 years and independently adjudicated by two vascular neurologists. Result: In a total of 219 patients, only 36 patients (16.4%) were compliant in completing the home BP log as instructed. The compliant and non-compliant groups showed no baseline difference and no medication usage difference (p&gt;0.05) (Table 1). Compliance with at-home BP monitoring was associated with well controlled systolic (p&lt;0.001) and diastolic BP (p&lt;0.001). Of note, 30 patients (16.4%) had recurrent strokes in the non-compliant group, while there were no recurrent strokes in the compliant group. BP self-monitoring compliance is associated with reduced incidence of stroke recurrence (p=0.030) and the significance remains robust after adjusting for multiple confounders (p=0.029) (Table 2). Conclusion: Regular home BP monitoring is associated with lower risk of stroke recurrence in HTN stroke patients. Study in expanded patient cohort is ongoing to leverage technology for better home BP monitoring and to create incentives for compliant behavior for better secondary stroke prevention.

Diagnosis and treatment of heart failure with preserved left ventricular ejection fraction.

Nearly six million people in United States have heart failure. Fifty percent of these people have normal left ventricular (LV) systolic heart function but abnormal diastolic function due to increased LV myocardial stiffness. Most commonly, these patients are elderly women with hypertension, ischemic heart disease, atrial fibrillation, obesity, diabetes mellitus, renal disease, or obstructive lung disease. The annual mortality rate of these patients is 8%-12% per year. The diagnosis is based on the history, physical examination, laboratory data, echocardiography, and, when necessary, by cardiac catheterization. Patients with obesity, hypertension, atrial fibrillation, and volume overload require weight reduction, an exercise program, aggressive control of blood pressure and heart rate, and diuretics. Miniature devices inserted into patients for pulmonary artery pressure monitoring provide early warning of increased pulmonary pressure and congestion. If significant coronary heart disease is present, coronary revascularization should be considered.

Renal artery Chronic Total occlusion Angioplasty in a Patient with Bilateral Renal Artery Occlusion and Hypertensive Emergency

Atherosclerotic bilateral renal artery chronic total occlusions (CTOs) as a cause of hypertensive emergency is rare, and other causes such as vasculitis should be ruled out before definitive diagnosis. Successful CTO intervention in such a scenario has only been sparsely reported. A 53-year-old-male smoker with severe resistant hypertension required multiple emergency admissions for flash pulmonary edema and aggressive blood pressure control. He was found to have deranged renal parameters with a serum creatinine of 2.4 mg/dL and an estimated glomerular filtration rate of 25 mL/min. His complete blood picture, metabolic panel, and inflammatory markers were within normal limits. Renal Doppler ultrasonography revealed bilateral severe renal artery stenosis and a contracted left kidney. Renal angiography showed total occlusion of both renal arteries with well-collateralized right kidney. He underwent right renal artery CTO angioplasty with stenting. Left renal artery occlusion was managed conservatively because of the contracted kidney size and poor function. He is doing well for the last 30 months with good hypertension control, well-perfusing and preserved right kidney volume, stable renal function, and significantly fewer medications from baseline. Renal artery stenting is lifesaving in patients with bilateral renal artery occlusion and should be expeditiously performed, particularly in patients with and hypertensive emergency or recurrent unexplained heart failure. Kidney size, function, presence of collateralization, and viable renal parenchymal tissue guide in planning the intervention.

It is Safe to Follow Patients with Medically Treated Type B Aortic Dissections

Introduction - Type B aortic dissection (TABD) is a potentially life threatening disease and early endovascular treatment in uncomplicated cases has been reported. Urgent intervention is necessary in 1/3 of the cases for vascular complications. The promising short-term results of endovascular surgery seem to support the use of stent graft implantation in uncomplicated cases to prevent late aortic complications. Our aim was to analyse the results of late aorta related mortality in medically treated patients and to identify the factors that lead to late aortic interventions. Methods - Consecutive patients presented with acute uncomplicated TBAD in a tertiary care university centre were included in the study. The study period was 10 years (2006-2015). The data were analysed retrospectively. Initial and follow-up CT angiographic images were studied to measure maximal initial and follow-up aortic diameter and the change of the degree of false lumen thrombosis. Statistical methods: univariate analysis and life table calculations. Results - There were 43 patients (74% men), the average age at admission was 62.8 years. The mean follow-up time was 37.2 months. Seven patients (16.28%) had aortic surgery later (4 stent graft implantations, 2 open prosthetic graft implantations and 1 open thoracoabdominal aortic refenestration). Two patients (4.65%) had percutaneous interventions of aortic branches (1 renal artery stent implantation and 1 balloon angioplasty. None of the patients who required late surgery died in 30 days after admission. One patient (2.33%) died during follow up, related to a new dissection (surgery was not performed). CT angiography on admission showed completely patent false lumen in 83.3% of the cases, partial thrombosis was detected in 10% and complete thrombosis in 6.7%.During follow-up of the medically treated patients, the false lumen remained patent in 66.7%, 12.5% had partial thrombosis and 20.8% were thrombosed completely. The patients who required surgery later had patent false lumen in 16.7%, partial thrombosis in 50% and total thrombosis in 33.3%. The average maximum aortic diameter on admission was 41.34 mm (SD: 9.13) with no difference between the cohorts continue to have medical treatment or late surgery (p=0.89). The average increase of aortic diameter was 6.83 mm (SD: 5.31) in the group required surgery later and 5.71 mm (SD: 5.49) in patients without late surgery. The difference was not significant (p=0.16). Conclusion - Based on our low late aorta related mortality in patients treated medically for uncomplicated TABD, we consider the conservative approach and close follow-up (aggressive blood pressure control and serial images) to be a safe strategy in this cohort and we do not recommend early surgery. No death occured following elective late aortic intervention. The changes of the false lumen thrombosis had no relationship to late mortality and aortic intervention.

Hypertension and Coronary Artery Disease in Women: Is Aggressive Blood Pressure Control Appropriate?

Hypertension and Coronary Artery Disease in Women: Is Aggressive Blood Pressure Control Appropriate?

P1822Pocket-size mobile echocardiographic device screening for thoracic aortic aneurysm in asymptomatic hypertensive patients

Abstract Background Patients with hypertension may develop thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients and define the effectiveness of a TAA point-of-care screening program using pocket-size mobile echocardiographic (PME) devices. Methods We prospectively performed transthoracic echocardiography for TAA screening using a PME device on 1529 hypertensive patients (age, 62y [30y to 85y], 824 men) who attended our hypertension specialist clinic between June 2016 and July 2018. Measurement of the dimensions of the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta were obtained through multiple standard echo views. Results The prevalence of TAA (defined as maximum aortic diameter of ≥4.5cm and/or &gt;50% diameter of the adjacent aorta) in our study population was 7.3% (111/1529), with distal ascending aorta as the most frequent location (Figure). Multiple logistic regression analysis identified male gender, older age, and presence of heart valve disease as independent factors associated with TAA (all p&lt;0.05). Figure 1 Conclusions Asymptomatic TAA is common among asymptomatic hypertensive patients. Point-of-care use of PME device is effective in detecting TAA in a clinic setting. Such approach may be useful for early detection of TAA among at-risk patients allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications such as aortic dissection or rupture. Acknowledgement/Funding Health and Medical Research Fund of the Hong Kong Government

NT-PROBNP PREDICTS RECURRENCE AFTER CATHETER ABLATION IN A HYPERTENSIVE POPULATION UNDERGOING AGGRESSIVE BLOOD PRESSURE MANAGEMENT: A SUB-STUDY OF SMAC-AF

Radiofrequency catheter ablation for atrial fibrillation (AF) has developed into a mainstay therapy. The recent Substrate Modification with Aggressive Blood Pressure Control (SMAC-AF) randomized controlled trial did not find that reducing blood pressure prior to ablation reduced recurrence of AF. There has been developing interest in NT-proBNP being a biomarker that could predict ablation success. We investigated the effect of baseline NT-proBNP on recurrence in patients enrolled in SMAC-AF. The randomized nature of the study also allowed us to investigate how this effect differed with aggressive versus standard blood pressure management.

MON-295 DIABETIC KIDNEY DISEASE (DKD) IN INDIA: LESSONS LEARNT FROM A PROSPECTIVE FOLLOW UP STUDY OF DIABETES MELLITUS(DM) PATIENTS OVER 30 YEARS.

Diabetic kidney disease is a major complication in patients with Type 1 and 2 DM. Aggressive control of blood sugar and blood pressure modifies the overall risk of development of DKD. Over the last 3 decades we have developed innovative and inexpensive health care programmes suited to our economic limitations. We present our demographic and biochemical data of a cohort of DM patients and present some of the lessons we have learnt about diabetic kidney disease in this cohort.

Editors' note: Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage

In their single-center retrospective cohort of 119 patients with intracerebral hemorrhage, Dr. Buletko et al. described their observations following an institutional change in blood pressure (BP) protocol from a systolic BP goal of <160 mm Hg to <140 mm Hg. With more aggressive BP control, a higher proportion of patients experienced a neurologic worsening of 4+ points on the NIH Stroke Scale and a higher incidence rate of acute infarcts on MRI. Of note, 96% of patients with systolic BP <120 mm Hg within 72 hours of admission developed acute infarctions. While only patients who underwent diffusion-weighted imaging MRI were included, and time to MRI was no different between the 2 groups, the indications for MRI were not clearly stated and may have contributed to a selection bias among patients who clinically worsened due to new infarcts—artificially inflating the incidence rate of this outcome measure. These and other unmeasured confounders—particularly sepsis and use of certain antihypertensives (e.g., ACE inhibitors), which may increase the risk of acute kidney injury—warrant further investigation. Even so, as Drs. Lattanzi and Silvestrini acknowledge, a more liberal BP threshold may lessen a variety of adverse outcomes among patients with intracerebral hemorrhage. In their single-center retrospective cohort of 119 patients with intracerebral hemorrhage, Dr. Buletko et al. described their observations following an institutional change in blood pressure (BP) protocol from a systolic BP goal of <160 mm Hg to <140 mm Hg. With more aggressive BP control, a higher proportion of patients experienced a neurologic worsening of 4+ points on the NIH Stroke Scale and a higher incidence rate of acute infarcts on MRI.

Abstract 166: Blood Pressure Variability and Cardiovascular Outcomes in Heart Failure with Preserved Ejection Fraction

Background: High blood pressure variability (BPV), independent of mean blood pressure, is associated with increased cardiovascular events in patients with hypertension or chronic kidney disease. Heart failure with preserved ejection fraction (HFpEF) is often managed with aggressive blood pressure control, but the association of BPV with cardiovascular outcomes among patients with HFpEF has not been examined. Methods: We performed a post hoc analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. BPV was assessed for each patient as the standard deviation of all available systolic blood pressure measurements (SD-SBP) during follow up. A cox regression analysis, adjusting for demographic, clinical, and blood pressure medication and measurement characteristics (Figure), was performed to assess the independent association of BPV with all-cause death and a composite of cardiovascular death and heart failure hospitalization. BPV was modeled with a spline function with the median SD-SBP (9.95) chosen as reference, and as quartiles with the highest quartile (Q4) as reference Results: Among 3445 participants at baseline, mean age was 68.6, BMI was 32.1 and 51.5% were female. Over a median follow up of 3.4 years, average SD-SBP was 10.9 mmHg. BPV was associated with the risk of all-cause death [Hazard Ratio (95% CI) vs. Q4: Q1=0.85 (0.65, 1.2) p=0.2, Q2 = 0.75 (0.58, 0.96) p =0.03, Q3 = 0.74 (0.58, 0.93) p=0.01] and composite outcome of cardiovascular death or heart failure hospitalization [Q1 = 0.49 (0.39, 0.63) p &lt; 0.01, Q2 = 0.63 (0.51, 0.77) p&lt;0.01, Q3=0.69 (0.57, 0.83) p&lt;0.01]. The risk of death and the composite outcome appeared to significantly increase as the SD-SBP increased above ~11 mmHg (Figure). Conclusion: In patients with HFpEF, the risk of all cause death and a composite of cardiovascular death and heart failure hospitalization significantly increased, as the SD-SBP increased beyond 11 mmHg. This association was independent of mean SBP. Whether reducing BPV is a potential therapeutic target in HFpEF requires further study.

Over Sized Adult Hearts Can Be Used for Paediatric Transplant Recepients with Good Medium Term Outcomes

Purpose Finding ideal donor hearts perfectly matched for age and weight is a challenge, especially for very sick children. This is a retrospective study evaluating the use of oversized adult hearts for children. Methods Over a 6 year period, 73 children, aged 1 to 17,(median 12) had a heart transplant in our unit. 10 of these patients had a preoperative cardiac arrest, resuscitated with ECMO (ECPR) . ECMO was converted to centrimag in 4 patients. 58 patients received hearts from donors less than 40 years of age,median age 22 (Group A) 15 patients received hearts from donors over 40 years of age, median age 52, recepient age range 8 to 18. (Group B) 35 patients had donor to recipient weight ratio (D:R) less than 2, and 38 had D:R more than 2(maximum D:R of 5) Results There were 7 early deaths and 5 late deaths in the first year after surgery in the entire series.(84 % one year survival) There were no further late deaths in a followup of upto 5 years. The one year survival in both group A and B was similar. 83 vs 80 %.. However 5 patients in group B had evidence of donor coronary artery disease in coronary angiogram done within a year of transplant and 3 have undergone stenting . out of the 39 patients with D:R more than 2,there were 6 early and 2 late deaths(one year survival of 79.5 %). Of the 43 patients with D:R less than 2,there were 2 early and 4 late deaths.(one year survival of 86 %). There were 3 patients who had a delayed chest closure for upto 48 hours after surgery due to size mismatch with no adverse outcomes. 5 patients had a “big heart syndrome with cerebral hyper perfusion and convulsions with hypertension early on in the series. there were 2 early and 2 deaths in this cohort. All these patients were very sick,intermacs 2 and received hearts with excellent ventricular function,with a D: R ratio ranging from 1.47 TO 3.8, median 2.7. with aggressive control of blood pressure and excessive cardiac output, this syndrome is no longer seen. Over sized hearts even with significant ventricular dysfunction seem to function well in smaller recepients. 7 out of 10 patients of ECPR are alive at one year follow up after transplant Conclusion Hearts from oversized adults including those with significant dysfunction can be used safely in children with very good medium term results of 84 % actuarial survival at 5 years. Children receiving hearts from donors over the age of 40,need careful followup for evidence of coronary artery disease.

The Impact of APOL1 on Chronic Kidney Disease and Hypertension.

Essential hypertension is a clinical diagnosis based on the presence of an elevated systemic blood pressure on physical examination without a clear inciting cause. It has multiple etiologies and is not a homogeneous disorder. Hypertension contributes to the development and progression of atherosclerotic cardiovascular diseases, and antihypertensive treatment reduces the risk of fatal and nonfatal myocardial infarction, stroke, and congestive heart failure. Although hypertension is frequently present in nondiabetic individuals with low levels of proteinuria and chronic kidney disease, reducing blood pressures in this population does not reliably slow nephropathy progression. Many of these patients with recent African ancestry have the primary kidney disease "solidified glomerulosclerosis" that is strongly associated with renal-risk variants in the apolipoprotein L1 gene (APOL1). This kidney disease contributes to secondarily elevated blood pressures. The APOL1-associated spectrum of nondiabetic nephropathy also includes proteinuric kidney diseases, idiopathic focal segmental glomerulosclerosis, collapsing glomerulopathy, severe lupus nephritis, and sickle cell nephropathy. This article reviews relationships between mild to moderate essential hypertension and chronic kidney disease with a focus on the role of APOL1 in development of hypertension. Available evidence strongly supports that APOL1 renal-risk variants associate with glomerulosclerosis in African Americans, which then causes secondary hypertension, not with essential hypertension per se.