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Investigating multiple aspects of blood pressure control

Zanchetti, Alberto

doi: 10.1097/HJH.0000000000000214

Istituto Auxologico Italiano and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università di Milano, Milan, Italy

Correspondence to Alberto Zanchetti, Centro di Fisiologia Clinica e Ipertensione, Università di Milano, Via F. Sforza, 35, 20122 Milan, Italy. Tel: +39 02 50320484; e-mail:

This issue of the Journal of Hypertension covers various approaches to the study of hypertension, and debates several problems concerning its management. The issue opens with a review by Nikolic et al. (pp. 1159–1169) on the emerging role for metabolomics in gaining mechanistic insight in the field of hypertension.

Three articles address important aspects of prevalence, awareness, treatment and control of hypertension in different parts of the world. Anchala et al. (pp. 1170–1177) provide a systematic review and meta-analysis of data from rural and urban Indians. In their accompanying editorial, Li and Kelly (pp. 1189–1191) remark that this is the first study to present estimates of hypertension according to region and urbanization, thus aiding in the development of intervention programmes in the region. Further information on hypertension in India is needed. Hypertension is a major public health problem in many sub-Saharian countries including Ghana, but data on urban poor communities are limited. Awuah et al. (pp. 1203–1210) provide now some worrisome information, reporting that about one-quarter of the young adult population in low-income communities in Accra have hypertension, with extremely low levels of awareness, treatment and control. On the contrary, new information from Portugal is more encouraging. By a careful comparison of two epidemiological surveys carried out at about 10-year distance, Polonia et al. (pp. 1211–1221) find that in Portugal, proportions of awareness, treatment and control of hypertension have improved considerably during the last decade, despite the fact that salt intake still remains high, being almost double that recommended by the WHO.

Trudel-Fitzgerald et al. (pp. 1222–1228) in a prospective study find that psychological well being, measured by emotional vitality (but not optimism), was associated with a significant reduction of the risk of developing hypertension in the subsequent 10 years. Also, in a prospective follow-up study, Lamy et al. (pp. 1229–1236) have investigated the role of organization work factors on the risk of developing hypertension among hospital nurses. Serum uric acid has been associated with an increased cardiovascular risk, but its role as an independent risk factor is still debated. Bombelli et al. (pp. 1237–1244) bring new evidence from the prospective follow-up of the PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) population study: although serum uric acid is correlated with a number of other cardiovascular risk factors, it was found to independently predict new onset of hypertension and cardiovascular and all-cause mortality.

Ravera et al. (pp. 1245–1254) have assessed the accuracy of a risk calculator including renal function (the INDANA formula – INdividual Data ANalysis of Antihypertensive intervention trials) as compared with that of the traditional Framingham risk score in predicting mortality of hypertensive subjects in two prospective cohorts in primary care, reporting that the INDANA calculator proves to be more accurate. In their commentary, Marchant et al. (pp. 1192–1193) remark that validation of a risk score taking account of renal function impairment is an important step towards personalized and more evidence-based treatment. In another prospective study, Khangura et al. (pp. 1300–1306) have observed that presence of coronary disease in patients with renovascular hypertension is a predictor of worse outcomes after renal revascularization, suggesting diffuse atherosclerosis.

A group of articles deals with obesity and hypertension. In a comprehensive review, Jordan et al. (pp. 1178–1188) summarize and evaluate the cardiovascular risk/benefit profile associated with the use of phentermine and topiramate in the treatment of obesity, and report that their combination is well tolerated and effective in lowering weight in obese patients at low-intermediate cardiovascular risk. C. Agabiti-Rosei et al. (pp. 1264–1274) have investigated the expression of adiponectin and adiponectin receptors in the peri-vascular tissues of obese mice, and found that they are reduced at baseline, but significantly increased after treatment with melatonin, an endogenous hormone with antioxidant and vasculoprotective properties. Alp et al. (pp. 1283–1292) have studied a variety of alterations in cardiac function and structure in obese children, and found that they are similar to those reported in obese adults, suggesting that the cardiac alterations due to obesity start early in life.

Low birth weight and intrauterine growth retardation are known to be associated with cardiovascular disease in adulthood. Kooijman et al. (pp. 1275–1282) have investigated the association of third trimester foetal haemodynamics with cardiovascular outcomes in childhood, but found only weak correlations between foetal cardiac dynamics at 30 gestational weeks with cardiac structural findings at 6 years of age. In a thoughtful editorial commentary, Anna Kistner (pp. 1194–1196) remarks that a continued follow-up of this interesting cohort is indicated, as the possibility cannot be excluded that foetal haemodynamic changes during the latter part of the third trimester might leave a permanent imprint on childhood cardiac function.

Cardiac alterations associated with hypertension have also been explored in a large prospective cohort of hypertensive patients by Courand et al. (pp. 1317–1325), who confirm that electrocardiographic RaVL voltage is associated with an increased risk of cardiovascular and all-cause death.

Two articles explore problems of ageing. Marzak et al. (pp. 1307–1316) have studied ageing in spontaneously hypertensive rats showing that they develop heart failure with preserved ejection fraction associated with left ventricular hypertrophy and cardiac fibrosis. Morgan et al. (pp. 1293–1299) report that arterial telomere uncapping and P53/P21-induced senescence are linked to hypertension independent of telomere length, and telomere uncapping influences hypertension more than mean telomere length.

Finally, a group of articles address topics of therapeutic interest. Lu et al. (pp. 1255–1263) report that a new renin inhibitor, VTP-27999, differs from aliskiren regarding its level of intracellular accumulation and its capacity to interfere with renin signalling via the (pro)renin receptor. Parati et al. (pp. 1326–1333) take advantage of a large ambulatory blood pressure database for testing different indices of 24-h blood pressure variability under monotherapy or combination therapy with telmisartan and amlodipine, and Stergiou et al. (pp. 1197–1200) accompany this article with a critical review of the methods used for assessing blood pressure variability and the effects of various drug classes on variability. Foulquier et al. (pp. 1334–1341) report a posthoc analysis of the Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease (TRANSCEND) trial, exploring whether telmisartan has a differential action in hypertensive and nonhypertensive patients and conclude that myocardial infarction may be further reduced by telmisartan in hypertensive patients. In a commentary of this article, John Chalmers (pp. 1201–1202) highlights not only the well known limitations of posthoc analyses but also those of so many of the best and largest randomized controlled trials: because of cost limitations, trial size and sample size can only address the primary question posed and prevent them to explore very many related questions. Stewart et al. (pp. 1342–1350) examine protocol adherence to structured intensive management in primary care and report that there is considerable potential for structured care management to improve blood pressure in primary care.

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Conflicts of interest

There are no conflicts of interest.

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