Blood Pressure Control Research Articles

Alternative Payment Models and Performance in Federally Qualified Health Centers.

Several state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance. To assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs. This retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023. Initial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021. The main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs. A total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (-0.01 pp; 95% CI, -0.21 to 0.19 pp) or stinting on care (-0.02 visits; 95% CI, -0.08 to 0.04 visits). In this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.

Alternative Payment Models and Performance in Federally Qualified Health Centers

ImportanceSeveral state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance.ObjectiveTo assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs.Design, Setting, and ParticipantsThis retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023.ExposureInitial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021.Main Outcomes and MeasuresThe main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs.ResultsA total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (–0.01 pp; 95% CI, –0.21 to 0.19 pp) or stinting on care (–0.02 visits; 95% CI, –0.08 to 0.04 visits).Conclusions and RelevanceIn this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.

Vitamin D and its associations with blood pressure in the Chronic Kidney Disease in Children (CKiD) cohort.

Vitamin D (25OHD) can modulate pathways and mechanisms that regulate blood pressure (BP). Observational studies in children and adults have shown an inverse association between 25OHD and BP. Studies evaluating associations between 25OHD and BP in pediatric chronic kidney disease are limited. We evaluated the associations between 25OHD and BP using data from the Chronic Kidney Disease in Children (CKiD) study. Clinic or ambulatory BP index was defined as participant's BP divided by 95th age-sex-height-specific BP percentile, an index > 1 suggests hypertension. Primary outcomes of interest were changes in systolic and diastolic clinic and ambulatory BP indices over follow-up. Linear mixed-effects models were used to evaluate associations between BP indices and 25OHD. The study cohort consisted of 370 participants who contributed 970 person-visits. A subset of 194 participants with ambulatory BP data contributed 465 person-visits. There was an association between baseline 25OHD levels and clinic systolic BP index such that for every 10ng/ml lower 25OHD, clinic systolic BP index was 1.0% higher (95%CI: 0.2-1.8, p = 0.016) between participants. The association between clinic diastolic BP index with baseline 25OHD was not significant. For within-person changes, longitudinal decreases in 25OHD were not significantly associated with concomitant increases in clinic systolic or diastolic BP index. There were no significant associations between 25OHD levels at baseline or longitudinally with 24-h ABPM indices. Low 25OHD levels were associated with higher clinic systolic BP in children with CKD. Vitamin D supplementation to maintain normal 25OHD levels might be a useful adjunctive treatment in optimizing BP control in these high-risk patients.

Effects of baroreflex activation therapy on cardiac function and morphology.

Arterial hypertension (aHTN) plays a fundamental role in the pathogenesis and prognosis of heart failure with preserved ejection fraction (HFpEF). The risk of heart failure increases with therapy-resistant arterial hypertension (trHTN), defined as inadequate blood pressure (BP) control ≥140/90mmHg despite taking ≥3 antihypertensive medications including a diuretic. This study investigates the effects of the BP lowering baroreflex activation therapy (BAT) on cardiac function and morphology in patients with trHTN with and without HFpEF. Sixty-four consecutive patients who had been diagnosed with trHTN and received BAT implantation between 2012 and 2016 were prospectively observed. Office BP, electrocardiographic and echocardiographic data were collected before and after BAT implantation. Mean patients' age was 59.1years, 46.9% were male, and mean body mass index (BMI) was 33.2kg/m2. The prevalence of diabetes mellitus was 38.8%, atrial fibrillation was 12.2%, and chronic kidney disease (CKD) stage ≥3 was 40.8%. Twenty-eight patients had trHTN with HFpEF, and 21 patients had trHTN without HFpEF. Patients with HFpEF were significantly older (64.7 vs. 51.6years, P<0.0001), had a lower BMI (30.0 vs. 37.2kg/m2, P<0.0001), and suffered more often from CKD-stage ≥3 (64 vs. 20%, P=0.0032). After BAT implantation, mean office BP dropped in patients with and without HFpEF (from 169±5/86±4 to 143±4/77±3mmHg [P=0.0019 for systolic BP and 0.0403 for diastolic BP] and from 170±5/95±4 to 149±6/88±5mmHg [P=0.0019 for systolic BP and 0.0763 for diastolic BP]), while a significant reduction of the intake of calcium-antagonists, α2-agonists and direct vasodilators, as well as a decrease in average dosage of ACE-inhibitors and α2-agonists could be seen. Within the study population, a decrease in heart rate from 74 ± 2 to 67 ± 2 min-1 (P=0.0062) and lengthening of QRS-time from 96±3 to 106±4ms (P=0.0027) and QTc-duration from 422±5 to 432±5ms (P=0.0184) were detectable. The PQ duration was virtually unchanged. In patients without HF, no significant changes of echocardiographic parameters could be seen. In patients with HFpEF, posterior wall diameter decreased significantly from 14.0±0.5 to 12.7±0.3mm (P=0.0125), left ventricular mass (LVM) declined from 278.1±15.8 to 243.9±13.4g (P=0.0203), and e' lateral increased from 8.2±0.4 to 9.0±0.4cm/s (P=0.0471). BAT reduced systolic and diastolic BP and was associated with morphological and functional improvement of HFpEF.

User Acceptability Testing of Mobile Application in Indian Local Languages for Cardiovascular Risk Stratification and Modification among Patients with Type 2 Diabetes

Introduction: Cardiovascular disease is the leading cause of death in patients with type 2 diabetes. Digital health tools like mobile application have fast emerged as a technology capable of closing the gap in cardiovascular disease self- management and revolutionizing the way healthcare is traditionally delivered. One of the causes for low app engagement of Apps in India is perhaps that few of these apps are available in local languages. The goal is to reach as many diabetic patients as possible while avoiding linguistic hurdles.  Methodology: The ‘healthy heart’ mobile app was developed and translated into Hindi and Marathi languages for CVD risk stratification and risk management among Type 2 diabetes mellitus patients. User acceptability testing of the app on its design, presentation, content, and user- friendliness was undertaken. The feedback on utility of the app for CVD risk stratification and modification was assessed. A total 100 multilingual app users profile were noted for CVD Risk Status, Life Style Practices and CVD Risk Factors.  Results: The Healthy Heart multi-lingual app was successfully developed for CVD risk classification and risk management among Type 2 diabetes mellitus patients. The patients had the choice to select the desired language of the app from the versions available in English, Hindi and Marathi. The Mobile App's Home Screen displayed the CVD risk score and category, a health tracker to monitor compliance with WHO recommendations regarding diet, physical activity, addictions, medication adherence, diabetic, and CVD Risk Profile. The majority of respondents rated the App's design, presentation, content, and user- friendliness favorably and emphasized the utility of App for CVD self-management and risk reduction. Characteristics of Type 2 Diabetic patients demonstrated poor compliance for total fruits and vegetable intake, total fat intake and total salt intake, physical activity Guidelines apart from poor control for blood pressure, glycemic control and lipid targets.  Conclusion: The multilingual mobile App for CVD risk stratification, self-management and CVD risk reduction among diabetic patients was successfully developed in Hindi and Marathi language. User acceptability testing results were found to be favorable for the mobile app.

The Tennessee Heart Health Network effectiveness study: A stepped wedge cluster randomized controlled trial to assess the effectiveness of statewide quality improvement cooperative participation on cardiovascular outcomes

BackgroundCardiovascular disease (CVD) is the primary cause of premature morbidity and mortality in the United States and Tennessee ranks among the highest in CVD events. While patient-centered outcomes research (PCOR) evidence-based approaches that reach beyond the traditional doctor-patient visit hold promise to improve CVD care and prevent serious complications, most primary care providers lack time, knowledge, and infrastructure to implement these proven approaches. Statewide primary care quality improvement (QI) collaboratives hold potential to help address primary care needs, however, little is known regarding their effectiveness in improving uptake of PCOR evidence-based population health approaches and improving CVD outcomes. This study describes the design and implementation of a stepped-wedge cluster randomized controlled trial to assess the effectiveness of participation in a statewide quality improvement cooperative (The Tennessee Heart Health Network [TN-HHN]) on cardiovascular outcomes. Methods/designThe TN-HHN Effectiveness Study randomized 77 practices to 4 waves (i.e., clusters), with each wave beginning three months after the start of the prior wave and lasting for 18 months. All practice clusters received one of three Network interventions, and outcomes are measured for each three months both in the control phase and the intervention phase. Primary outcomes include Center for Medicare and Medicaid Services measures for aspirin use, blood pressure control, cholesterol control, and smoking cessation (ABCS). ConclusionsThis trial, upon its conclusion, will allow us to assess the effect of participation in a statewide quality improvement cooperative on cardiovascular outcomes as well as key contributors to successful practice transformation.

Marital Quality-A Neglected Player in the Prevention of Cardiovascular Diseases: A Systematic Review of Longitudinal Studies.

Marital quality (MQ) is a psychosocial factor that has been neglected in cardiovascular prevention guidelines, although its association with cardiovascular diseases has been identified in several studies. Therefore, we aim to investigate how MQ either in positive or negative dimensions affect different cardiovascular risk factors and diseases. We systematically searched different databases in September 2023 for longitudinal studies conducted to assess the contribution of MQ to well-established cardiovascular risk factors and diseases. Two independent researchers screened studies and carried out data extraction and quality assessment of included ones. From 12,175 potential studies screened, 40 were included. The presence of significant heterogeneity in methodology, follow-up, and subsequent effect estimates made it unfeasible to do a meta-analysis. Despite the variation, most studies found a significant association of negative MQ measures with physical inactivity (2/2), high levels of smoking (4/5) and alcohol (3/3) use, increased metabolic syndrome risk (3/3), elevated type 2 diabetes mellitus (T2DM) risk and poor T2DM management (3/6), elevated cardiovascular disease risk and progression (9/11), increased body weight and obesity risk (2/3), elevated blood pressure and hypertension risk (7/8). Positive MQ measures were mainly associated with improvement in blood pressure control (2/2), reduced T2DM risk and its good management (1/1), reduced body weight and obesity risk (2/2), and increased survival in cardiovascular diseases (4/4). Based on current evidence, MQ seems to play a crucial role in developing established cardiovascular risk factors and diseases and is worth considering in preventive strategies.

Exenatide administration time determines the effects on blood pressure dipping in db/db mice via modulation of food intake and sympathetic activity.

Maintaining a normal blood pressure (BP) circadian rhythm is vital for cardiovascular health, but diabetes often disrupts this rhythm. The effect of exenatide, a GLP-1 receptor agonist (GLP-1RA), on BP rhythm in diabetes is uncertain.This study investigates the impact of exenatide administration timing on BP patterns in diabetic db/db mice.Findings indicate that exenatide given at the onset of rest restores normal BP dipping, while at the start of the active phase worsens BP rhythm by modulating food intake and sympathetic activity.Timing GLP-1 RA administration may optimize BP control and provide cardiovascular benefits for type 2 diabetes patients.

Adherence to antihypertensive medication and its associated factors among patients with hypertension attending a tertiary hospital in Kathmandu, Nepal.

Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of premature mortality and morbidity globally. Despite the evidences of the availability of effective treatment for hypertension, its management remains suboptimal. Medication adherence is the most crucial factor for blood pressure control. It is important to identify the factors associated with adherence to antihypertensive treatment for better management. Hence, this study assessed the level of antihypertensive medication adherence and its associated factors among patients with hypertension visiting a tertiary-level hospital in Kathmandu, Nepal. An analytical cross-sectional study was carried out among 308 diagnosed patients with hypertension who were prescribed antihypertensive medication. The Morisky Medication Adherence Scale (MMAS-8) was used to assess medication adherence. Data was collected through face-to-face interviews and analysed using SPSS v26. A bivariate and multivariate logistic regression model was used to assess the factors associated with low medication adherence. More than half (61%) of the study participants had moderate to high levels of medication adherence. Upon bivariate analysis, there was a significant association between presence of side effects, blood pressure status, forgetfulness, high cost, fear of taking medicine lifelong and irregular follow-up with a low level of adherence. Upon multivariate the logistic regression analysis, forgetfulness [Adjusted Odd's Ratio (AOR) 22.5, 95% Confidence Interval(CI) 10.56-47.86], high cost (AOR 3.8, 95%CI 1.25-11.60) and fear of taking medicines lifelong (AOR 6.04, 95%CI 2.96-12.33) were found to be associated factors of low level of adherence. There is an urgency to develop evidence-based strategies to improve the level of adherence to antihypertensive medications among patients with hypertension. Strategies like reminder messaging, setting alarms, expanding the scope of national health insurance and proper counselling to reduce fear could help to improve medication adherence. Hence, the feasibility and effectiveness of such intervention should be explored in future studies.

Not all patients with a headache need a CT scan, but they should be listened to, and also with a stethoscope: a report of a large arteriovenous malformation with a loud cranial bruit

Background: Arteriovenous malformations (AVMs) are abnormal direct connections between arterial and venous systems, without an interposed capillary bed. This permits high-flow arteriovenous shunting, which precipitates structural changes in the afferent and efferent vessels, namely arterial smooth muscle hyperplasia and thinning of venous walls. Patients with intracranial AVMs typically present with a haemorrhage, headache or seizure. Treatment is either via medical management aimed at control of seizures, headache and blood pressure, or interventional via surgical, radiation or radiologically guided embolisation. Case description: We report the case of a woman in her early 40s presenting with a tonic-clonic seizure against a background of a 31-year history of migraine and an 18-month history of tremors in her right arm. The clinical examination was remarkable for an extremely loud cranial bruit and a right homonymous hemianopia. Imaging diagnosed an 8 cm Martin-Spetzler grade V intracranial arteriovenous malformation in her left parietal lobe, which was deemed unsuitable for operative or radiotherapy-based intervention. Conclusion: The patient was managed through observation and relatively good control of her breakthrough seizures was achieved through the addition of brivaracetam to her lamotrigine and carbamazepine-based therapy, six years after her initial presentation.

Cardiovascular Risk Factor Management After Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy (HDP) are associated with significantly increased risk of developing future cardiovascular disease (CVD). Obstetricians play a crucial role in CVD prevention for postpartum women and birthing people with HDP because they are primarily responsible for immediate postpartum management and can assist with care transitions to other health care practitioners for long-term management of CVD risk factors. Standardized calculators can be used to evaluate long-term CVD risk, which can help guide intensity of treatment. Emerging technologies such as remote blood pressure monitoring demonstrate promise for improving outcomes among patients with HDP. After HDP, all patients should be advised of their increased CVD risk. A plan should be made to initiate lifestyle modifications and antihypertensive therapy to achieve optimal blood pressure control with a target of lower than 130/80 mm Hg, assess lipids within 2–3 years of delivery, and evaluate for development of type 2 diabetes. Other CVD risk factors such as nicotine use should similarly be identified and addressed. In this review, we summarize the essential components of managing CVD risk after a pregnancy complicated by HDP, including blood pressure monitoring, risk stratification tools, and evidence-based lifestyle recommendations.

Does clinical practice supported by artificial intelligence improve hypertension care management? A pilot systematic review.

Although artificial intelligence (AI) is considered to be a promising tool, evidence for the effectiveness of AI-supported clinical practice for lowering blood pressure (BP) in the real world is scarce. We conducted a systematic review to elucidate whether AI-supported clinical care improves BP control. We identified two randomized control trials (RCTs) in a literature search. The results revealed no significant difference between AI-supported care and usual care in a random-effects model meta-analysis of RCTs (AI vs. usual care: systolic/diastolic BP difference: -2.13 [95% confidence interval: -4.72 to 0.46] / -1.03 [-2.52 to 0.46]). In this review, we were unable to clarify whether AI-supported clinical practice improved BP control compared with usual care. Further studies will be needed to provide robust evidence for the effectiveness of AI-supported care in clinical settings.

Recent developments in the management of resistant hypertension: focus on endothelin receptor antagonists.

Resistant hypertension is characterized by the inability of guideline-recommended triple combination therapy to control blood pressure(BP) to target. It is associated with a significantly increased risk of adverse outcomes. Despite abundant preclinical evidence supporting thecritical role of the endothelin pathway in resistant hypertension (RH), clinical implementation of endothelin antagonists for the treatment of hypertension was hindered by various factors. Recently, the novel dual endothelin-receptor antagonist aprocitentan was tested in individuals with resistant hypertension in the PRECISION trial and provided compelling evidence supporting both short and longer-term safety and clinically meaningful and sustained BP lowering efficacy.These findings resulted in therecent regulatory approval of aprocitentanby the FDA. Aprocitentan may be a particularly useful antihypertensive option for individuals with advanced age, chronic kidney disease, and albuminuria.

Sex differences in association of joint glycemic, blood pressure and lipid control and two-year risk of falls among older adults with diabetes

AimsTo characterize the risk of falls among males and females by joint glycemic, blood pressure (BP) and cholesterol control among older adults (≥65 years) with diagnosed diabetes in USA. MethodsUsing longitudinal data from the Health and Retirement Study (2006–2019), we studied the association of joint glycemic (HbA1c < 7.5 %), BP (systolic <140 and diastolic <90 mmHg) and cholesterol (total < 200 mg/dL) control with two-year risk of falls. We estimated risk ratios (RR) to describe the associations for joint ABC control and independent biomarker control by sex, using modified Poisson regressions after adjusting for known individual and household risk factors. ResultsThe analytic sample consisted of 4509 observations from 2829 older adults (54.7 % female) with a mean age of 72.2 (SD: 6.6) years and duration of diabetes of 9.9 years. Joint ABC control was not associated with risk of falls among females but was associated with lower risk among males (0.91 [95%CI: 0.81–1.02]). Furthermore, achievement of glycemic control (0.85 [95%CI: 0.73–0.98]) and BP control (0.89 [95%CI: 0.79–1.01]) were associated with lower risk but cholesterol control (1.15 [95%CI: 0.99, 1.34]) was associated with higher risk of falls among males. ConclusionsJoint achievement of glycemic, BP and cholesterol targets may prevent falls among older males. Future studies among people with diabetes should consider biomarker control as a preventive factor for falls.

High plasticity of temperament as a marker of flexible autonomic regulation of the cardiovascular system in urgent adaptive response to cold in young people

The properties of temperament are due to differences in the excitability of brain systems that integrate the behavior of an individual, his emotions and autonomic functions and play an important role in the adaptation of the body to the environment. The mechanisms of mutual influences of individual characteristics of temperament properties and regulation of the cardiovascular system have not been fully elucidated. The aim of this study to assess the relationship between expression of temperament traits and the autonomic regulation of the cardiovascular system in the baseline condition and in response to exposure to cold. The study involved 25 healthy male volunteers aged between 18 and 21 years. Temperament traits were measured using the Structure of Temperament Questionnaire. During the study, heart rate variability (HRV) parameters (5 min), systolic and diastolic blood pressure (SBP and DBP) were recorded at room temperature. In the period from 5 to 10 min of exposure in an UShZ-25N cold chamber (–20°C), HRV were assessed. Immediately after the subjects came out from the cold chamber, blood pressure was measured. Then, 5 min after they left the cold chamber, SBP, DBP, HRV were recorded. The results showed that in young people with different expressions of temperamental properties, no differences were found in the regulation of heart rhythm by the autonomic nervous system in the baseline condition. The high object-related plasticity, i.e. the ease of switching from one type of activity to another, linked with autonomic flexibility and blood pressure control, which restrains a significant increase in blood pressure when exposed to short-term cold, and contributes to the preservation of health.

Updates in inspiratory muscle training for older adults: A systematic review

Systematic reviews support the benefits of inspiratory muscle training (IMT) for exercise performance. Recently, many health benefits from IMT have been reported in older adults. Therefore, this work reviewed the literature focusing on IMT effects beyond physical performance in older adults, such as cardiorespiratory, metabolic, and postural balance outcomes. Searches were conducted with the following terms: ("respiratory muscle training" OR "inspiratory muscle training") OR ("inspiratory muscle strength training") AND ("elderly" OR "older" OR "aging" OR "aging"), and using the databases: MEDLINE (PubMed), SCOPUS and EUROPE PMC. Of the 356 articles found, 13 matched the inclusion criteria after screening. Based on reviewed studies, four to eight weeks of IMT (Mostly from 50 % up to 75 % of MIP, 7 days/week) improve cardiac autonomic control at rest and post-exercise, cerebrovascular response to orthostatic stress, static and dynamic balance, blood pressure control, endothelial function, and oxidative stress in older adults. The benefits of IMT in cardiac autonomic and vascular functions are reversed after training cessation. It thus appears that IMT promotes broad physiological gains for the older population. It is necessary to carry out more randomized clinical trials on the subject to confirm the findings of this research.

Sex‐Dependent Manifestations of Intracranial Aneurysms

Background Intracranial aneurysms (IAs) are more common in women than in men; however, there is still limited knowledge on sex‐dependent differences regarding aneurysm location, multiplicity, rupture risk, risk factors, and histopathology. Methods This cross‐sectional, consecutive cohort study examined whether IAs differ in multiplicity, location, geometry, rupture risk, risk factors, and histology between sexes. Results We included 982 patients (714 women, 268 men) totaling 1484 IAs (1056 unruptured, 397 ruptured). A total of 363 patients (36.97%) had multiple IAs, the proportion of which was significantly higher in women. In women, the internal carotid artery (40.79%) was the most frequent location for IAs, whereas in men most were found along the anterior carotid artery territory (32.86%). Men were significantly more often diagnosed with ruptured aneurysms. Aneurysm geometry did not differ between sexes; however, ruptured aneurysms in men presented with a significantly larger neck diameter than unruptured ones. Regarding risk factors for aneurysm rupture, blood pressure control was more effective in women, whereas the effect of smoking status did not show clear sex‐dependent differences. Histologically, wall‐type classification analysis showed significantly more severe aneurysm wall types in men. Conclusion IA prevalence in women is significantly higher than in men. Women more often present with multiple IAs, whereas men were more often diagnosed with ruptured IAs. Sex‐specific differences in IA location were identified, whereas geometry of IAs did not differ between sexes. IAs in men showed a more severe histological wall type. Further research is needed to unravel the molecular mechanisms underlying these important sex‐dependent manifestations in IAs.

Long-term effectiveness and safety of tolvaptan in autosomal dominant polycystic kidney disease

Background and objectivesEvidence on the long-term use of tolvaptan in autosomal dominant polycystic kidney disease (ADPKD) is limited. The aim was to evaluate the tolvaptan effectiveness and safety in real clinical setting. Material and methodsA single-center observational study (2016–2022) involving ADPKD patients treated with tolvaptan was conducted. Annual change in serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) before and after treatment initiation were evaluated. Change in total kidney volume (TKV), blood pressure (BP) and urinary albuminuria at 12, 24 and 36 months after initiation were also determined. Adverse events (AEs) according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 were analyzed. ResultsA total of 22 patients were included. No significant differences pre- vs post tolvaptan treatment in annual rate of change in eGFR (−3.52ml/min/1.73m2 [−4.98%] vs −3.98ml/min/1.73m2 [−8.48%], p=0.121) and sCr (+0.06mg/dL [4.22%] vs +0.15mg/dL [7.77%], p=0.429) were observed. Tolvaptan improved urinary osmolality at 12 (p=0.019) and 24 months (p=0.008), but not at 36 months (p=0.11). There were no changes in TKV, BP control and urinary albuminuria at 12, 24 or 36 months. A worse response was shown in patients with rapid kidney function decline (p=0.042). A 36.4% of the patients developed grade III/IV AEs. A 22.7% discontinued treatment due to unacceptable toxicity. ConclusionsThis study shows a modest benefit of tolvaptan in ADPKD patients, as well as safety concerns.

Malignant hypertension as a rare cause of thrombotic microangiopathy associated with end-stage renal disease

Malignant hypertension (MH) can precipitate and worsen renal thrombotic microangiopathy. Also, renal thrombotic microangiopathies (TMA) can cause malignant hypertension. Case reports regarding this clinical presentation are limited. A 36-year-old man presented with low urine output and bilateral leg swelling for five days with two episodes of haemoptysis. He was identified as a patient with hypertensive emergency with hypertension mediated organ damage (HMOD) in cardiac and renal functions with thrombotic microangiopathy. Renal biopsy revealed focal acute tubular injury with moderate tubulointerstitial nephritis and hypertensive vascular changes. Multiple anti-hypertensive medications were used for adequate blood pressure control. Despite that, the patient had worsening renal function, and eventually became dependent on haemodialysis. Malignant hypertension has to be considered as one of the aetiologies of TMA as it can lead to end-stage renal disease (ESRD) and poor outcomes. Diagnosis is difficult when both entities are presenting together.

Independent Effects of Blood Pressure on Intraocular Pressure and Retinal Ganglion Cell Degeneration: A Mendelian Randomization Study.

To investigate the causal effect of elevated blood pressure on primary open-angle glaucoma (POAG) and POAG endophenotypes. Two-sample Mendelian randomization (MR) was performed to investigate the causal effect of elevated systolic blood pressure (SBP) (N = 757,601) and diastolic blood pressure (DBP) (N = 757,601) on intraocular pressure (IOP) (N = 139,555), macular retinal nerve fiber layer (mRNFL) thickness (N = 33,129), ganglion cell complex (GCC) thickness (N = 33,129), vertical cup-to-disc ratio (VCDR) (N = 111,724), and POAG liability (Ncases = 16,677, Ncontrols = 199,580). The primary analysis was conducted using the inverse-variance weighted approach. Sensitivity analyses were performed to investigate robustness to horizontal pleiotropy, winner's curse, and collider bias. Multivariable MR was performed to investigate whether any effect of blood pressure on retinal ganglion cell degeneration was mediated through increased IOP. Increased genetically predicted SBP and DBP associated with an increase in IOP (0.17 mm Hg [95% CI = 0.11 to 0.24] per 10 mm Hg higher SBP, P = 5.18 × 10-7, and 0.17 mm Hg [95% CI = 0.05 to 0.28 mm Hg] per 10 mm Hg higher DBP, P = 0.004). Increased genetically predicted SBP associated with a thinner GCC (0.04µm [95% CI = -0.07 to -0.01µm], P = 0.018) and a thinner mRNFL (0.04µm [95% CI = -0.07 to -0.01µm], P = 0.004), an effect that arises independently of IOP according to our mediation analysis. Neither SBP nor DBP associated with VCDR or POAG liability. These findings support a causal effect of elevated blood pressure on retinal ganglion cell degeneration that does not require intermediary changes in IOP. Targeted blood pressure control may help preserve vision by lowering IOP and, independently, by preventing retinal ganglion cell degeneration, including in individuals with a normal IOP.