Systo-diastolic Hypertension Research Articles

Catheter-based renal artery denervation: facts and expectations

Catheter-based renal artery denervation (RAD) is entering a new era. After the disappointing results of SYMPLICITY-HTN 3 trial in year 2014, several technical and methodological advancements led to execution of important SHAM-controlled randomized trials with promising results. Now, the 2023 ESH Guidelines give RAD a class of recommendation II with a Level of Evidence B. Currently, catheter-based RAD has two main areas of application: (a) Hypertensive patients who are still untreated, in whom RAD is a sort of a first-line treatment; (b) Difficult-to-control or true resistant hypertensive patients. Notably, randomized SHAM-controlled trials met their primary end-point in both these conditions. So far, we do not dispose of established predictors of the antihypertensive response to RAD. Some data suggest that younger patients with systo-diastolic hypertension, absence of diffuse atherosclerosis and evidence of sympathetic nervous system overactivity experience a better BP response to the procedure. We reviewed the available data on catheter-based RAD and included an updated meta-analysis of the results of the available SHAM-controlled trials. Overall, the reduction in 24-h systolic blood pressure (BP) after RAD exceeded that after SHAM by 4.58 mmHg (95% CI 3.07–6.10) in untreated patients, and by 3.82 mmHg (95% CI 2.46–5.18) in treated patients, without significant heterogeneity across trials, patient phenotype (untreated versus treated patients) and technique (radiofrequency versus ultrasound). There were no important safety signals related to the procedure. Notably, some data suggest that RAD could be an effective additional approach in patients with atrial fibrillation and other conditions characterized by sympathetic nervous system overactivity.

Is Isolated Diastolic Hypertension an Important Phenotype?

Isolated diastolic hypertension (IDH) is a frequent hypertension phenotype. We review IDH pathophysiology, risk stratification, and therapeutic decisions. Recent guidelines lowering blood pressure cutoff levels have increased IDH prevalence and likely decreased associated cardiovascular risk. Long-term cardiovascular risk and pharmacological intervention in IDH are controversial. Narrow pulse pressure and other physiological and epidemiological characteristics are shared with a systodiastolic hypertension (SDH) subgroup. We propose that IDH be incorporated into a broader category, predominantly diastolic hypertension (PDH), defined by pulse pressure ≤ 45mmHg and includes IDH and SDH with a narrow pulse pressure. IDH-PDH is associated with cardiovascular risk in the long term, especially in young patients. Standardization of the IDH definition and population may contribute to future research to understand genetics, pathophysiology, and eventually therapy in this important subgroup of hypertensive patients.

Association of waist-to-height ratio with hypertension and its subtypes in southern China.

Data regarding the association of the waist-to-height ratio (WHtR) with hypertension (HTN) are conflicting. Moreover, little information is available on the association between WHtR and HTN subtypes. Therefore, we aimed to investigate the associations between WHtR and the prevalence of HTN and its subtypes in a Chinese population. In the cross-sectional analysis, 13,947 adults from the China Hypertension Survey study were analysed. We examined the relationship between WHtR and the prevalence of HTN and its subtypes (isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH) and systodiastolic hypertension (SDH)) using multivariate logistic regression analysis. A generalized additive model (GAM) and smooth curve fitting (penalized spline method) were also used. Overall, the mean WHtR was 0.50. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for HTN, ISH, IDH and SDH for each standard deviation (SD) increase in WHtR were 1.53 (1.45-1.61), 1.36 (1.28-1.44), 1.41 (1.20-1.65) and 1.47 (1.36-1.59), respectively. The fully adjusted smooth curve fitting revealed a linear association between WHtR and HTN, ISH, IDH, and SDH. Moreover, the positive associations between WHtR and HTN and its subtypes were more strong among younger adults (<60 compared with ≥60 years, P values for interaction <0.001). These findings suggested that WHtR was positively associated with HTN and its subtypes, especially among younger adults (<60 years) in southern China.

Office and Ambulatory Arterial Hypertension in Highlanders: HIGHCARE-ANDES Highlanders Study.

Millions of people worldwide live at high altitude, being chronically exposed to hypobaric hypoxia. Hypertension is a major cardiovascular risk factor but data on its prevalence and determinants in highlanders are limited, and systematic studies with ambulatory blood pressure monitoring are not available. Aim of this study was to assess the prevalence of clinic and ambulatory hypertension and the associated factors in a sample of Andean highlanders. Hypertension prevalence and phenotypes were assessed with office and ambulatory blood pressure measurement in a sample of adults living in Cerro de Pasco, Peru (altitude 4340 m). Basic clinical data, blood oxygen saturation, hematocrit, and Qinghai Chronic Mountain Sickness score were obtained. Participants were classified according to the presence of excessive erythrocytosis and chronic mountain sickness diagnosis. Data of 289 participants (143 women, 146 men, mean age 38.3 years) were analyzed. Office hypertension was present in 20 (7%) participants, while ambulatory hypertension was found in 58 (20%) participants. Masked hypertension was common (15%), and white coat hypertension was rare (2%). Among participants with ambulatory hypertension, the most prevalent phenotypes included isolated nocturnal hypertension, isolated diastolic hypertension, and systodiastolic hypertension. Ambulatory hypertension was associated with male gender, age, overweight/obesity, 24-hour heart rate, and excessive erythrocytosis. Prevalence of hypertension among Andean highlanders may be significantly underestimated when based on conventional blood pressure measurements, due to the high prevalence of masked hypertension. In highlanders, ambulatory hypertension may be independently associated with excessive erythrocytosis.

Abstract MP34: Association Between Leg Adiposity And Hypertension Subtype In Young And Middle-aged Adults

Objective: We sought to determine whether leg adiposity was inversely associated with hypertension using the 2011-2016 National Health &amp; Nutrition Examination Surveys. Methods: The study included 5,997 non-pregnant adults aged 20-59 who were not taking antihypertensives and did not have self-reported history of cardiovascular disease. Leg adiposity was defined as the percent of total fat mass present in bilateral lower extremities as per dual-energy x-ray absorptiometry (DXA) scans. Leg adiposity was then categorized into two sex-specific groups (low fat %: &lt;34 for male, &lt;39 for female; high fat %: ≥34 for male, ≥39 for female). The outcome was hypertension subtype. Hypertension was defined as BP &gt;130/80, and subtypes included isolated diastolic hypertension (IDH), isolated systolic hypertension (ISH), and systo-diastolic hypertension (SDH). We estimated relative risk ratios (RRR) using multinomial logistic regression, adjusting for covariates (see Table 1 ) and accounting for the complex survey design. Results: Among the 5,997 participants, 2,945 (49%) were female, the average (SD) age was 37.4 (0.3) years, and 1,465 (24%) had hypertension. Those with higher leg fat had 53%, 39%, and 61% lower unadjusted relative odds of IDH, ISH, and SDH, respectively ( Table 1 ). After adjustment, those with higher leg fat had 31%, 24%, and 34% lower relative odds of IDH, ISH, and SDH, respectively. When treating leg adiposity as a continuous variable, higher leg adiposity reduced relative odds of SDH significantly more than ISH ( Table 1 ). Conclusion: A greater proportional distribution of fat around the legs is inversely, independently associated with all hypertension subtypes.

Association between body mass index and hypertension subtypes in Indian and United States adults

The purpose of this cross-sectional, secondary analysis was to determine the association between BMI & lipids and hypertension subtype in U.S. and Indian adults. Obese BMI was significantly associated with isolated diastolic hypertension (IDH) compared to low/normal BMI (relative risk ratio [95% CI]; U.S.: 4.33 [2.88,6.52]; India: 2.51 [2.41,2.60]). Furthermore, BMI was more strongly associated with IDH than other hypertension subtypes in U.S. and non-obese Indian adults. In obese Indian adults, we observed higher odds of isolated systolic hypertension until the 6th decade, and systo-diastolic hypertension thereafter. Triglyceride levels were associated with IDH in U.S. adults (1.94 [1.43,2.63]).

PP.16.02] ASSOCIATION BETWEEN AMBULATORY BLOOD PRESSURE VALUES AND CENTRAL AORTIC PRESSURE IN LARGE POPULATION OF NORMOTENSIVE AND HYPERTENSIVE SUBJECTS

Objective: Ambulatory blood pressure monitoring (ABPM) and central aortic blood pressure (CBP) are well known predictors of cardiovascular outcome. Our aim was to examine the association of ABPM and CBP data in a large set of normotensive and hypertensive subjects and its relation with pulse wave velocity (PWV). Design and method: Study was done in a single centre and included 2108 subjects (53% female, 85% hypertensives patients, ageing 54+15years, BMI 28+5 Kg/m2) who carried out a 24 h ambulatory BP monitoring (ABPM), measurement of central BP from the aortic wave form (SphygmoCor) and carotid –femoral PWV (Complior). Results: Age, systolic blood pressure (SBP) of 24 h, daytime and nighttime, central BP, augmentation index (Aix) were correlated significantly to each other and all with PWV (R between 0.110–0.367, p < .001). Subjects were divided according to the presence of normal or abnormal values of ABPM and CBP and the correspondent PWV values were determined. Normal ABPM and CBP occurred in 16.5% (G1) and abnormal ABPM and CBP occurred in 58.9% (G4). Abnormal ABPM and normal CBP occurred in 4.1% (G2) and normal ABPM and abnormal CBP in 41.1% (G3). PWV (m/s) significantly increased (ANOVA p < 0.001) from G1 (9.1+2.1), G2 (9.3+2.5), G3 (10.3+2.7) to G4 (11.1+3.0). Sprurious hypertension (isolated systolic, ISH) occurred in 18% of subjects < 50 years. Versus systo-diastolic hypertension (HT), ISH had higher central-peripheral amplification (13+8 v 11+6, p < 0.05) but higher Aix (26+17 vs 22+14%) and PWV (10+3 v 9+2 m/s) than normotensives (both p < 0.05). Conclusions: When abnormal values of ABPM and CBP coexist target organ damage (aortic stiffness) is greater than that occurring when only one is present in the absence of the other. Isolated systolic hypertension in young and middle age associates with higher aortic stiffness and reflected waves suggesting that may not be a benign condition.

Central blood pressure and pulse wave amplification across the spectrum of peripheral blood pressure in overweight and obese youth.

To identify vascular phenotypes across blood pressure (BP) conditions in overweight and obese youths, by assessing office BP (oBP), and central BP (cBP), and pulse pressure (PP) amplification. Whether or not 24-h ambulatory BP monitoring (ABPM) and pulse wave velocity (PWV) add insight to the issue has also been examined. White youths of both sexes with overweight or obesity and of European origin, ranging from 8 to 18 years of age, were included. oBP, cBP, PWV, and 24-h ABPM were measured. oBP conditions and 'white-coat' hypertension were defined as recommend by European Society Hypertension Guidelines in Children and Adolescents. Patients were divided into subgroups of 'normal' or 'high' according to cBP and PP ratio. A total of 593 patients (mean age, 12.2 ± 2.3 years; 275 women) were included in the study. The largest differences between office SBP and central SBP correspond to the isolated systolic hypertension (ISH) group, in which only 25% of patients have high cBP, in contrast to 50% of the systo-diastolic hypertension (SDH) group. Two patterns emerged based on cBP and PP ratio - while the highest cBP was among the SDH, the highest PP amplitude was in the ISH group. Ninety percent of the SDH were confirmed with 24-h ABPM, in contrast to 75% of the ISH, who were white-coat hypertensive. PWV showed a progressive increment across the groups from normotension to SDH. Significant differences were observed only when compared with the normotensive, but not among all other groups. In overweight and obese hypertensive patients, ISH is prevalent, posing a challenge for the clinician of whether these may therefore be diagnosed and managed as hypertensive patients. Until prospective studies can give more knowledge, 24-h ABPM can offer information for making clinical decisions.

Red cell distribution width and end-organ damage in patients with systo-diastolic hypertension

IntroductionBoth end-organ damage and high red cell distribution width (RDW) values are associated with adverse cardiovascular events, inflammatory status, and neurohumoral activation in hypertensive disease and in the general population. In this study, we investigated the relationship between RDW and end-organ damage in hypertensive patients.Material and methodsThe 446 systo-diastolic hypertensive patients included in the study received 24-hour ambulatory blood pressure monitoring. Left ventricular mass index, glomerular filtration rate, and microalbuminuria were measured to identify end-organ damage. High-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels of all patients were also examined.ResultsThe mean age of the participants was 49.96 ±11.04 years. The mean RDW was 13.06 ±1.05%. Red cell distribution width was positively correlated with left ventricular myocardial index (LVMI), urinary albumin, hs-CRP, and NT-proBNP (r = 0.298, p < 0.001; r = 0.228, p < 0.001; r = 0.337, p < 0.001; r = 0.277, p < 0.001, respectively), while RDW was negatively correlated with eGFR (r = –0.153, p < 0.001). Additionally, while there was a positive correlation between RDW and 24-h systolic blood pressure, no correlation was found between RDW and 24-h diastolic blood pressure (r = 0.132, p = 0.006 and r = 0.017, p = 0.725, respectively). Multiple linear regression analysis revealed that RDW levels were independently associated with eGFR, LVMI, and severity of albuminuria (β = 0.126, p = 0.010; β = –0.149, p = 0.002; β = 0.114, p = 0.035).ConclusionsHigh RDW levels in systo-diastolic hypertensive patients were found to be an independent predictor of end-organ damage.

Hypertension subtypes modify metabolic response to thiazide diuretics.

Blood pressure (BP) and metabolic response to thiazide diuretics might be varied in patients with different hypertension subtypes and ethnicities. This study aimed to investigate the response of BP and metabolic profiles to short-term thiazide treatment in an Asian cohort with different hypertension subtypes. Serial ethnic Chinese nondiabetic subjects with hypertension were evaluated. After diet instruction and lifestyle modification for 2 weeks, patients who still had elevated systolic BP (SBP≥140 mmHg) and/or diastolic BP (DBP≥90 mmHg) were given 50 mg of hydrochlorothiazide daily for 2 weeks. The responses of BP and metabolic profiles were evaluated before and after treatment according to the patient's baseline BP subtype - isolated systolic hypertension (ISH), systo-diastolic hypertension (SDH) and isolated diastolic hypertension (IDH). Hydrochlorothiazide treatment significantly reduced the BP in all 92 patients (62 males, aged 45·7 ± 9·6 years), irrespective of their baseline BP subtypes. In patients with SDH (n = 39) or IDH (n = 40), hydrochlorothiazide treatment significantly increased serum adiponectin (P = 0·001 and 0·007, respectively) and reduced asymmetric dimethylarginine levels (P < 0·001, in both groups). Serum cholesterol (P = 0·027) and fasting blood sugar levels (P = 0·044) were significantly improved only in the IDH patients. Furthermore, IDH was independently associated with changes in fasting blood sugar (β = -11·178, P = 0·022) and cholesterol (β = -22·654, P = 0·027). The characteristics of the Asian hypertensive patients with diastolic hypertension can present a favourable metabolic response to the short-term hydrochlorothiazide treatment. The potential positive effect on cardiovascular risk should be validated in long-term studies in this diastolic type of hypertension.

Primary Aldosteronism in a Patient Who Exhibited Heart Failure

Primary aldosteronism (PA) is a common cause of secondary hypertension due to unilateral adrenocortical adenoma (APA) or idiopathic hyperplasia. There is increased awareness of the possible cardiac sequelae of aldosterone excess, including cardiac hypertrophy, fibrosis, and vascular endothelium injury. A 54-year-old woman was referred for rest and nighttime worsening dyspnea and palpitations. One year earlier she was admitted to another hospital with the same symptoms and discharged with a diagnosis of idiopathic dilated cardiomiopathy. At admission, physical examination revealed a body mass index of 21 kg ⁄m and blood pressure (BP) of 210 ⁄105 mm Hg. Chest auscultation revealed mild expiratory wheezes and rales in both lower lobes. Electrocardiography showed signs of left ventricular (LV) overloading and hypertrophy. Laboratory analysis showed severe hypokalemia (1.8 mEq ⁄L; normal range 3.5–5 mEq ⁄L) and metabolic alkalosis (pH 7.51; partial pressure of carbon dioxide 41 mm Hg; partial pressure of oxygen 86 mm Hg; HCO 3 32.6 mmol ⁄L; excess bases 10 mmol ⁄L) (Table I). Chest radiography revealed an enlarged cardiac silhouette, congested pulmonary hilum, and bilateral pleural effusion (Figure 1A). Echocardiography showed an increase in LV end-diastolic diameter (58 mm) and left atrial volume (46 mm) and a signficant decrease in global LV performance (ejection fraction [EF] 30%) (Table II). The 24hour ambulatory BP monitoring (ABPM) revealed severe systo-diastolic hypertension without physiological nocturnal fall (nondipper pattern). Subsequent investigation showed suppressed plasma renin activity (PRA) (0.08 ng ⁄mL ⁄h; normal range 0.2–2.7 ng ⁄mL ⁄h), high plasma aldosterone (PAC 16.17 ng ⁄dL; normal range 7.5–15 ng ⁄dL), and PAC ⁄ PRA ratio (202.17 ng ⁄dL: ng ⁄ml ⁄h; normal value<30 ng ⁄dL: ng ⁄mL ⁄h). Because of suspicion of PA, we performed a captopril test. After 60 minutes of captopril 50 mg, the PAC ⁄PRA ratio was still elevated (529.93 ng ⁄dL: ng ⁄mL ⁄h). Magnetic resonance imaging of the superior abdomen demonstrated a 20-mm nodule in the left adrenal gland (Figure 2). The patient underwent laparoscopy adrenalectomy, and histopathology revealed an APA. Subsequently, her BP was normalized at 140 ⁄90 mm Hg with amlodipine, ramipril, and serum potassium. After 6 months of follow-up, BP was 110 ⁄80 mm Hg, with normal serum potassium. Chest radiography showed resolution of congestive heart pulmonary imaging with a decreased cardiac silhouette (Figure 1B). Repeat echocardiography demonstrated a significant improvement in LV hypertrophy and EF (50%). Recently, the Primary Aldosteronism Prevalence in Italy Study (PAPY) reported a PA prevalence of 11.2% in patients with new-onset hypertension. The potential comorbidity and prevention of excessive cardiovascular events and organ damage led to development of accurate strategies for diagnosis of PA. PA patients display an unfavorable cardiovascular profile, suggesting a role of aldosterone beyond its well-known hypertensive effects. TABLE I. Laboratory Data and Blood Gas Analysis

High Serum Levels of CXC (CXCL10) and CC (CCL2) Chemokines in Untreated Essential Hypertension

Hypertension has been suggested to exert pro-inflammatory actions through increased expression of several mediators, including chemokines. Chemokines are involved in inflammatory and autoimmune disorders, and in the formation of atherosclerotic lesions through promotion of inflammatory cell migration. The aim of this study is to evaluate the influence of high blood pressure on circulating levels of the prototype chemokines C-X-C motif ligand (CXCL)10 and C-C motif ligand (CCL)2 in 140 patients with essential hypertension not affected by thyroid disorders or overt autoimmune or inflammatory diseases, and 140 gender- and age-matched healthy controls. Mean CXCL10 and CCL2 levels were significantly higher in hypertensive patients than in controls. Among hypertensive patients, chemokines levels were higher in those with systo-diastolic hypertension compared to those with isolated systolic hypertension. In a multiple linear regression model using CXCL10 or CCL2 as dependent variables and age, body mass index, glycemia, serum creatinine, high-density-lipoprotein (HDL) and low-density-lipoprotein (LDL) cholesterol, triglycerides, and systolic or diastolic blood pressure values as covariates, only systolic or diastolic blood pressure values were significantly related to CXCL10 or CCL2 levels. In conclusion, this study demonstrates increased circulating levels of the prototype chemokines CXCL10 and CCL2 in patients with hypertension.

Abstract 9736: Identification of Phenotypes at Risk of Transition from Systo-Diastolic Hypertension to Isolated Systolic Hypertension

Background: Isolated Systolic Hypertension (ISH) is the most frequent subtype of uncontrolled hypertension in elderly patients and is associated with high cardiovascular (CV) risk. Little is known about the natural evolution towards this type of hypertension and the CV phenotype associated with its appearance. Aim of the present study was to detect predictors of evolution towards ISH in subjects with initial systo-diastolic hypertension (SDH). Methods: 6,027 individuals with SDH (age 53±11 years, 57% men, systolic blood pressure [SBP] 159±21, diastolic blood pressure [DBP] 99±10), without prevalent CV disease, MDRD-estimated glomerular filtrate ratio (eGFR)&gt;30mL/mmHg/1.73 m2 , and with at least 6 month-follow up were selected from the CampaniaSalute registry. Echocardiography and carotid ultrasound were performed. The diagnosis of ISH was made at the end of follow up according to the ESH/ESC and JNCVII Guidelines (SBP ≥140 mmHg with DBP&lt;90 mmHg). Results: After a mean follow up period of 55±44 months, 19% of the study population exhibited ISH (n=1122). Patients with ISH were older, more often women and more often diabetic, and exhibited higher initial SBP, HDL-cholesterol, left ventricular (LV) mass, relative wall thickness, pulse pressure/stroke index ratio (PP/SVi), more severe carotid atherosclerosis and lower values of eGFR (all p&lt;0.001). These differences were studied using a multivariate proportional hazard model (Cox) including all variables that were found different at the descriptive analysis. Presence of ISH at follow up was independently predicted by older age (p&lt;0.0001; HR=1.20/5 years; CI=1.12-1.28), female gender (p&lt;0.004; HR=1.22; CI=1.06-1.40), baseline higher LV mass index (p=0.04;HR=1.04/5g*m-2.7; CI=1.01-1.05), higher carotid intima-media thickness (p=0.02; HR=1.12/mm; CI=1.02-1.22) and higher PP/SVi (p&lt;0.0001;HR=1.35/Unit); CI=1.23-1.48). Conclusion: Factors influencing the transition from SDH to ISH are older age, female gender and signs of CV target organ damage. Thus, a prompt and aggressive therapy for arterial hypertension before the onset of target organ damage appears desirable to help lowering the prevalence of ISH especially in elderly female patients.

Obesity and Hypertension

The link between obesity and hypertension is well known, but there are still many questions to be answered: Is abdominal adiposity rather than overall obesity more closely associated with high blood pressure? Is obesity an independent cardiovascular risk factor even if not combined with hypertension? Can obesity be metabolically benign? To what extent weight reduction is expected to contribute to the management or the primary prevention of hypertension? Are there compelling indications and/or contraindications to the use of specific classes of antihypertensive drugs for the pharmacological treatment of obesity hypertension? Consequently, the present editorial seeks to answer these questions by briefly reviewing the current state of knowledge of the association of obesity with hypertension. Several tools are used to estimate obesity. The body mass index (BMI), or Quetelet index, is a statistical measurement which compares a person’s weight and height. BMI is body weight in kilograms divided by the height in meters squared, expressed as weight (in kg)/height (m). Overweight is defined as a BMI >25, obesity as a BMI >30, and morbid obesity is a BMI >35. Abdominal obesity is the accumulation of visceral fat resulting in an increase in waist size. It is often referred to as central, visceral, male-type or android obesity vs. female-type or gynoid obesity with a preferential gluteofemoral distribution. Abdominal obesity is diagnosed by a waist circumference >102 cm in men, and >88 cm in women or by a waist-to-hip ratio >0.95 in men and >0.85 in women. As early as in 1980, in the second National Health and Nutrition Examination Survey (NHANES II), it was noted that the prevalence of hypertension was 2.9 times higher in obese than in non-obese adult Americans. The Third National Health and Nutrition Examination Survey (NHANES III) conducted from 1988 to 1994 revealed a similar linear relationship despite a lower prevalence of hypertension. BMI was recently found to be positively associated with blood pressure even in active, American veteran football players. In a cross-sectional analysis of adults enrolled in NHANES 1999-2004, the odds ratio for hypertension for every 5-unit increase in BMI was 1.45 (95% CI 1.39-1.52). Although obesity was associated with hypertension in all age groups and both sexes, the odds for hypertension associated with obesity were relatively higher in younger people. With regard to hypertension subtypes, increasing BMI was a significant predictor of isolated diastolic hypertension or systodiastolic hypertension as opposed to isolated systolic hypertension. Isolated systolic hypertension represented a minority of hypertension cases in obese men, but remained the most prevalent type in obese women. There is substantial evidence that in addition to BMI, both waist circumference and waist-to-hip ratio are correlated with blood pressure, even after adjustment for BMI. The associations of BMI and waist circumference with systolic and diastolic blood pressure and their possible interactions with gender and age were assessed in a cohort of 10,928 non-smoking and never treated for hypertension adults, recruited from all regions of Greece during 1994–1999, within the context of the European From the Center for the Prevention of Cardiovascular Disease, “Hygieias Melathron,” Athens, Greece

Body Mass Index and Hypertension Hemodynamic Subtypes in the Adult US Population

Obesity produces various hemodynamic abnormalities that may impact hypertension subtypes. Similarly, the study of hypertension subtypes provides important information regarding the relative importance of hemodynamic abnormalities contributing to obesity-related hypertension. Cross-sectional analysis of adults enrolled in the Third National Health and Nutrition Examination Survey (NHANES III) (n = 16 545) and NHANES 1999-2004 (n = 12 137). We examined the relationship between body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) and the risk of hypertension and hemodynamic subtypes: isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systodiastolic hypertension (SDH). In NHANES 1999-2004, the odds ratio (OR) for hypertension for every 5-unit increase in BMI was 1.45 (95% confidence interval [CI], 1.39-1.52) (P < .001). However, the magnitude of the relative increase in the odds of hypertension was higher among younger adults. Among patients with hypertension, increasing BMI was a significant predictor of IDH or SDH (OR for IDH or SDH, 1.04; 95% CI, 1.02-1.06) (P < .001), as opposed to ISH. Isolated systolic hypertension represented a minority of hypertension cases in obese men (38.9%; 95% CI, 30.9-47.6) but remained the most prevalent type in obese women (62.1%; 95% CI, 52.4%-71.0%) (P < .001), despite a significant relative decrease in the frequency of ISH with increasing BMI in both sexes. Findings in NHANES III were very similar. Isolated diastolic hypertension and SDH account for most cases of obesity-related hypertension, suggesting that determinants of mean arterial pressure account for the major burden of obesity-related hypertension in US adult men. These findings should be considered in the design of clinical trials and therapeutic strategies for obesity-related hypertension. Further studies should assess determinants of mean arterial pressure in obesity and the role of sex in the pathogenesis of obesity-related hypertension.

The vascular phenotypes in hypertension: Relation with the natural history of hypertension

The different vascular phenotypes found in hypertension comprise different aspects. They may be clinical, diagnostic, structural, mechanical, functional, cellular and extracellular, signaling and molecular, proteomic, and gene expression phenotypes. In this manuscript the emphasis will be on the various structure, mechanics, dysfunction, and cell and signaling changes that can be demonstrated in hypertension, and particularly in human hypertension. The phenotype relates to the natural history of hypertension, increasingly elucidated on the basis of cohort studies. The evolution from pre-hypertension to diastolic, systolic, and systo-diastolic hypertension may have a vascular substratum that could explain, in part, the prevalence of each of these phenotypes. The potential for intervention to prevent the passage from pre-hypertension to hypertension thanks to therapies that modulate the development of vascular remodeling is highlighted.

Natural History of Hypertension Subtypes

The relation between blood pressure (BP) and the risk of cardiovascular disease is direct, graded, and continuous over a wide range, apparently beginning at 115 mm Hg systolic and 75 mm Hg diastolic.1 Despite such a continuous relation, some working definitions, or subtypes, of hypertension have gained wide clinical acceptance. Experimental and clinical data support the notion that the hypertension subtypes defined by isolated or combined elevations of systolic and diastolic BP reflect distinct pathophysiological mechanisms, have different prognostic implications, and may require a different therapeutic approach.2–4 See p 1121 An increase in the stiffness of the aorta and large elastic arteries not accompanied by a rise in arteriolar resistance may lead to isolated systolic hypertension (ISH). In contrast, a predominant rise in arteriolar resistance may lead to combined systo-diastolic hypertension (SDH) if large artery stiffness also increases, or to isolated diastolic hypertension (IDH) if arterial stiffness is normal or low. Thus, IDH might be viewed as a marker of a good elasticity of aorta and large arteries, possibly because of a paucity of atherosclerotic lesions.5 In contrast, because the rigidity of the aorta and large arteries tends to increase with age, systolic BP also tends to increase with age, leading to an elevated frequency of ISH in the elderly.6,7 The decline of diastolic BP with age has been associated with progression of aortic atherosclerosis, defined in one study by the appearance of new calcifications or enlargement of old calcified areas.8 A confounding factor in the assessment of hypertension subtypes is the progressive amplification of the pressure wave during transmission from aorta to peripheral arteries, a phenomenon that is predominant in the young and decreases with aging.2–4 Thus, brachial diastolic BP may overestimate aortic BP, particularly in young subjects. Although ISH is an important …

Epidemiological, pathophysiological and clinical significance of systolic, diastolic and pulse pressure.

Long-term population surveys and studies of untreated hypertensive patients both strongly suggest that over the age of about 45, the height of the systolic blood pressure is a better predictor of cardiovascular outcome than the diastolic pressure. Research into echocardiographic left ventricular size, endothelial function and thromborheology also back up this supposition. In clinical practice, the treatment of isolated systolic hypertension has been shown to be very worthwhile. There remains some uncertainty as to the relative significance of diastolic blood pressure when it is frankly high, as in severe systo-diastolic hypertension. However some clinicians and epidemiologists have questioned whether diastolic pressure is still worth measuring, given the overwhelming importance of the height of the systolic blood pressure at predicting outcome.

The Placebo Effect and White Coat Effect in Isolated Systolic Hypertension and Systo-diastolic hypertension

It is well recognised from many clinical trials that there is a blood pressure lowering effect when placebo is administered to patients with essential hypertension (''placebo effect''). The reduction in blood pressure, however, may also be partly due to loss of the alerting response (''white coat effect'') as a result of familiarisation with the clinical environment. To investigate the hypothesis that there may be a more marked placebo effect and white coat effect in isolated systolic hypertension (ISH) compared with systodiastolic hypertension (SDH), we studied 78 patients with hypertension: 34 had ISH and 44 patients had SDH. The 34 patients with ISH were older (68.7 vs 54.9 years), had a higher SBP (192.2 vs 169.6 mmHg) and lower DBP (85.5 vs 102.0 mmHg) when compared to patients with SDH. Amongst the patients with ISH, there were no significant changes in mean blood pressures pre-placebo (paired t-test, p = NS). In the placebo period, there was a significant reduction in systolic blood pressures at all three points, and a significant reduction in diastolic blood pressures after 2 and 3 months placebo (paired t-test, p < 0.05). There was a mean reduction in mean systolic blood pressure at visit 1 by 5.2%, visit 2 by 5.1% and visit 3 by 4.6%, when compared to mean pre-placebo systolic blood pressures (p < 0.05). The mean reduction in diastolic blood pressure was 5.8% at visit 2 and 3.5% at visit 3, when compared to mean pre-placebo diastolic blood pressure (p < 0.05). At the 4-week visit after receiving placebo, the mean systolic blood pressure decreased by 9.4 mmHg (p = 0.003) and mean diastolic blood pressure by 2.7 mmHg (p = NS) in the patients with ISH. In patients with SDH, there were no statistically significant changes in recorded BP readings following the introduction of placebo. We suggest blood pressures in some patients with ISH may settle with careful follow up and initiation of treatment in these patients could potentially be delayed for at least 3 months, as therapy may not prove necessary.

Aging, hypertension, and renal damage: generalities and results of the Cardiovascular Study in the Elderly.

I N WESTERN SOCIETIES arterial hypertension is a common finding in people over the age of 65. In fact the elderly hypertensive population is made up not only of hypertensive persons who have aged, but also of those who have developed hypertension (mainly systolic) as a consequence of the vascular changes that are characteristic of old age. Ever since the epidemiologic studies conducted in the 60s and the 70s it is known that in the elderly the prevalence of hypertension is very high: 60% for systodiastolic hypertension and 15% to 45% for isolated systolic hypertension. However this particularly high figure may be due to the fact that most studies were based on a single blood pressure (BP) measurement. This may lead to an overestimation of the prevalence of hypertension, as we ourselves have been able to discover with repeated BP measurements over a period of 3 to 5 months of observation.1,2 Other trials have demonstrated a slightly lower prevalence,3,4 but confirm the importance of the phenomenon of hypertension in the elderly, particularly considering that in western countries the number of persons over the age of 65 increases by 4% each year; it has been calculated that by the year 2020 in Italy there will be some 11 million. It is well established that hypertension represents a major risk factor for cardiovascular diseases. This applies particularly to the elderly population where age itself represents a key factor in predicting the risk of atherosclerosis and its complications. Besides, the almost constant association with a deranged cerebral circulation and impaired cardiac and renal function exponentially increases the risk itself.