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CE: Swati; JH-D-17-00975; Total nos of Pages: 3;
JH-D-17-00975
Editor’s Corner
Hypertension: prognostic, diagnostic and
therapeutic aspects
Alberto Zanchetti
A
ll major aspects of hypertension management, prognostic, diagnostic and therapeutic ones are covered
by articles published in the current issue of the
Journal of Hypertension.
A group of 11 articles explores prognostic aspects.
Marron et al. (pp. 000–000) have assessed the hypothesis
that a healthy blood pressure (BP) phenotype they had
developed in cohorts of familial longevity (Long Life Family
Study), characterized by an age-adjusted and sex-adjusted
SBP Z-score between 1.5 and 0.5, is also familial. Among
410 families, only 44 met the criteria for the healthy BP
phenotype. Among the latter families, a higher proportion
of offspring met the American Heart Association definition
of ideal cardiovascular health (10.8 versus 3.8%), driven by
BP, smoking status and BMI. In a sample of the general
population of Didima, Greece, followed-up for 19 years,
Ntineri et al. (pp. 000–000) found home BP predicted total
mortality and cardiovascular disease as reliably as office BP.
However, home SBP variability exhibited superior prognostic ability than office BP variability. Furthermore, Ntineri
et al. report that not only sustained and masked, but also
white-coat hypertension was associated with increased risk
of death and cardiovascular disease events versus normotensive patients. In an editorial commentary, Myers (pp.
000–000) raises the point that the real cardiovascular risk
associated with white-coat hypertension is still controversial, and that a small sample size and a limited number of
end points during follow-up may lead to exaggerated
estimates of cardiovascular risk in patients with whitecoat hypertension.
Three other articles investigating prognostic aspects
focus on comparing BP risk in patients with and without
diabetes mellitus. Gomadam et al. (pp. 000–000) have
analysed data from 17 650 participants from the National
Health And Nutrition Examination Survey III and 1439
participants from the Diabetes Heart Study followed-up
for a mean of 16.2 years and found that the association
between SBP and cardiovascular mortality is nonlinear, but
different in diabetes (U shaped) and nondiabetes, suggesting this may explain why aggressive BP lowering may have
different outcomes in presence or absence of diabetes.
Jiang et al. (pp. 000–000) have investigated the same
problem, though with a cross-sectional approach, in
42 959 patients of the PURE China study, and report both
in patients with and without diabetes risk of stroke and
coronary disease events markedly increased in hypertensive patients compared with individuals with normal BP,
whereas no significant difference in risk was seen between
Journal of Hypertension
high-normal BP and normal BP groups. Always in the
context of the problem of the optimal BP to be achieved
by antihypertensive treatment in patients with diabetes,
Hartaigh et al. (pp. 000–000) have reanalysed data from
the ACCORD trial, in which patients with diabetes were
randomly assigned to achieve intense (<120 mmHg) or
standard (<140 mmHg) BP control, by grouping them
according to whether or not they achieved their respective
goal. They report that, whereas in the standard treatment
arm those who achieved a target less than 140 mmHg had a
substantial reduction in the risk of major cardiovascular
events and all-cause death, no significant risk reduction
occurred in the intense treatment arm for those who
achieved the target SBP less than 120 mmHg as compared
with those who did not. The authors conclude suggesting
that in diabetes, SBP goal should be between 120 and
140 mmHg, but not less than 120 mmHg. This post-hoc
analysis of the ACCORD trial is discussed in an accompanying editorial by Ahmad and Oparil (pp. 000–000), who
remark that a post-hoc analysis of a treatment-to-target
study has obvious limitations, as opposed to a prespecified
analysis of the comparative results of achieving two different BP goals as in the original ACCORD publication.
Other conditions influencing prognosis in hypertension
are discussed by Shi et al. (pp. 000–000) and van der Sande
et al. (pp. 000–000). The former authors report that early
life exposure to the Chinese 1959–1961 famine exacerbated
the association between hypertension and cardiovascular
disease events, especially among women, those living in
urban areas and those with central obesity. Van der Sande
et al. (pp. 000–000) have followed up for about 7 years a
cohort of 6191 hypertensive patients with clinically manifested vascular disease and observed an increased risk of
cardiovascular mortality and all-cause mortality, in presence of controlled and uncontrolled apparent resistant
hypertension.
Predictors of renal function loss have been studied by
two groups: Leiherer et al. (pp. 000–000) report that serum
Journal of Hypertension 2018, 36:000–000
Istituto Auxologico Italiano and Centro Interuniversitario Fisiologia Clinica e Ipertensione, Università degli Studi di Milano, Milano, Italy
Correspondence to Prof Alberto Zanchetti, Istituto Auxologico Italiano IRCCS and
Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università degli Studi di
Milano, Via F. Sforza, 35, 20122 Milano, Italy. Tel: +39 02 50320484;
e-mail: [email protected], [email protected]
J Hypertens 36:000–000 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000001611
www.jhypertension.com
1
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Swati; JH-D-17-00975; Total nos of Pages: 3;
JH-D-17-00975
Zanchetti
uromodulin (UMOD) levels were highest when associated
with a polymorphism in the UMOD coding region and were
significantly associated with estimated glomerular filtration
rate. Prospectively (4-year follow-up), serum uromodulin
concentration was inversely associated with the development of chronic kidney disease (CKD) and significantly
increased a prediction model for CKD. Mallamaci et al. (pp.
000–000) followed up 260 renal transplant patients for over
3.7 years and found daytime and night-time ambulatory
SBP predict the risk of renal function loss over time, nighttime SBP being the strongest predictor. The important
association of night-time hypertension with organ damage
is also underlined in a cross-sectional study by Tadic et al.
(pp. 000–000), who describe a worse right ventricle
mechanics in night-time and day-time/night-time hypertensive patients than in normotensive controls and isolated
daytime hypertensive patients. Finally, another cross-sectional study (Dore et al., pp. 000–000) has investigated the
possible role of intraindividual BP variability in cognitive
decline in community dwelling participants in the MaineSyracuse Longitudinal Study, and report that, in individuals
aged over 60 years, intraindividual BP variability was
inversely correlated with a number of indices of cognitive
function.
Another group of articles in the current issue of the
Journal of Hypertension has diagnostic implications. Jardim
et al. (pp. 000–000) present useful information on reference
values for home BP by height percentiles for age and sex in
a non-European population of adolescents in secondary
cohorts of a Brazilian city (51.3% non-white). Cuspidi et al.
(pp. 000–000) have reviewed and meta-analysed studies
assessing the association of metabolic syndrome with subclinical carotid damage, finding carotid intima–media
thickness is significantly higher in patients with than in
those without the metabolic syndrome. They suggest ultrasound search of subclinical carotid disease may refine
cardiovascular risk stratification and decision-taking strategies in patients with the metabolic syndrome. In another
review in this issue of the Journal, Tsioufis et al. (pp. 000–
000) summarize the evidence supporting a wider use of
renal ultrasound in the diagnostic work-up of patients with
newly diagnosed hypertension, not only to identify causes
of secondary hypertension originating from the kidney, but
also to detect renal injury signalled by increased renal
resistive indices.
Salvi et al. (pp. 000–000) present data on two large
cohorts of patients with the Marfan syndrome (n ¼ 114)
in whom aortic stiffness and central haemodynamics have
been associated with ascending aorta diameters and fibrillin-1 genotype. Pulse wave velocity and central pulse
pressure were significantly higher in Marfan syndrome
patients than in matched controls, although independently
of fibrillin genotype, and were associated with diameters of
ascending aorta. An additional study with diagnostic implications in this issue of the journal was aimed at developing
and validating a scoring system for selection of patients who
should proceed to endocrinologic examinations for primary aldosteronism in newly diagnosed hypertensive
patients. On the basis of a series of 130 consecutive patients,
24 of whom were diagnosed with primary aldosteronism by
an elevated plasma aldosterone concentration-to-plasma
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www.jhypertension.com
renin activity ratio, Yamashita et al. (pp. 000–000) conclude
that a score based on urine pH at least 7.0, female sex and
hypokalemia (PFL score) may be a better parameter than
hypokalemia alone for screening patients with a high
probability of having primary aldosteronism.
A third group of articles in this issue is related with
aspects of hypertension management. Brunström and Carlberg publish a critical review of standardization of relative
risks (RRs) and standard errors according to BP differences
within trials investigating the effects of BP-lowering treatment, showing that standardization of RRs exaggerates
differences between trials and makes meta-analyses highly
sensitive to choice of statistical method. The implications of
standardization are further discussed in an accompanying
editorial by Thomopoulos and Michalopoulou (pp. 000–
000), who agree with the authors that standardization to a
preselected BP reduction is a problematic issue. However,
when selecting to standardize to unmask some clinical
aspects that crude analysis cannot explore, Thomopoulos
and Michalopoulou suggest one should first investigate
whether the projected comparison of the standardized
RRs has a solid clinical justification and whether the outcome to standardize is linearly associated with the extent of
BP reduction.
Two experimental articles have potential therapeutic
implications. Mali et al. (pp. 000–000) provide new evidence in mice that smooth muscle cells stromal interacting
molecule-1 disruption protects the heart from myocardial
infarction through reduction of endoplasmic reticulum
stress, oxidative stress, MAP-kinase, apoptosis and inflammation. Azegami et al. (pp. 000–000) have developed an
intranasal vaccine that simultaneously targets hypertension
and pneumonia, consisting of nanogel incorporating angiotensin II type 1 receptor partial peptide conjugated with
pneumococcal surface protein A. Given intranasally to
spontaneously hypertensive rats, the vaccine attenuated
the development of hypertension and protected the rats
from lethal pneumococcal infection.
Among nonpharmacological interventions, salt reduction is known to be the most cost-effective one. Trieu et al.
(pp. 000–000) report the effect of an 18-month nationwide
salt reduction strategy in Samoa: though there was no
change in mean population salt intake as judged from
two nationally cross-sectional surveys carried out immediately before and after the intervention strategy, there were a
wider awareness of the salt reduction message and some
improvements in salt-related knowledge and behaviours.
Gilardini et al. (pp. 000–000) report that among hypertensive patients with obstructive sleep apnoea, two-thirds have
urinary normetanephrine (uNMT) above the normal limit;
uNMT decreased or normalized, parallel with changes in
the apnoea–hypopnea index under positive airway pressure therapy. Iwashima et al. (pp. 000–000) have investigated the impact of renal function on cardiovascular and
renal outcomes after percutaneous transluminal renal
angioplasty in 139 hypertensive patients with atherosclerotic renal artery stenosis followed up for 5.4 years and
report that impaired renal function and, in particular, a poor
response of estimated glomerular filtration rate to angioplasty are associated with worse outcome. A contribution to
the debated problem of the therapeutic effectiveness of
Volume 35 Number 1 Month 2018
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Swati; JH-D-17-00975; Total nos of Pages: 3;
JH-D-17-00975
Prognostic, diagnostic and therapeutic aspects
catheter renal denervation is provided by Völz et al. (pp.
000–000), who present data from the Swedish Registry for
Renal Denervation showing a sustained reduction in office
and ambulatory BP in patients with resistant hypertension,
associated with a low complication rate. These data are
commented by Mahfoud et al. (pp. 000–000), who mention
the recent positive results of the sham-controlled SPYRALOFF-Medication study [1] in nonmedicated patients, and
show the decrease in BP following renal denervation is
correlated with baseline BP. Nonetheless, the authors conclude renal denervation remains an attractive, but still
elusive potential technique and high-quality research is
needed.
Finally, three articles focus on treatment and control of
hypertension in different parts of the world. Lemogoum
et al. (pp. 000–000) find that hypertension is highly prevalent in Far-North Cameroon, and awareness, treatment
and control rates are low. Agyemang et al. (pp. 000–000)
have investigated prevalence and management of hypertension among relatively homogeneous African migrants
(Ghanaians) living in three European cities, and nonmigrants living in rural and urban Ghana: hypertension
Journal of Hypertension
prevalence, awareness and treatment levels were generally
higher in African migrants to Europe, but BP control level
was lower in Ghanaian migrant men compared with their
nonmigrant peers. Li et al. (pp. 000–000) report data from
the first national spatial analysis of hypertension in China,
showing hypertension prevalence and management are
spatially patterned in China, with demographic, socioeconomic and behavioural factors, weight status, healthcare
use and urbanization accounting for a significant part of the
differences.
ACKNOWLEDGEMENTS
Conflicts of interest
There are no conflicts of interest.
REFERENCE
1. Townsend RR, Mahfoud F, Kandzari DE, Kario K, Pocock S, Weber MA,
et al. Catheter-based renal denervation in patients with uncontrolled
hypertension in the absence of antihypertensive medications (SPYRAL
HTN-OFF MED): a randomised, sham-controlled, proof-of-concept trial.
Lancet Published Online August 28, 2017. doi:10.1016/S0140-6736
(17)32281-X
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Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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