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Prediction, diagnosis and treatment of hypertension

Zanchetti, Alberto

doi: 10.1097/HJH.0000000000000939
EDITOR'S CORNER

aIstituto Auxologico Italiano

bCentro Interuniversitario di Fisiologia Clinica e Ipertensione, Università degli Studi di Milano, Milan, Italy

Correspondence to Professor Alberto Zanchetti, Direzione Scientifica, Istituto Auxologico Italiano, Via L. Ariosto, 13, 20145 Milano, Italy. Tel: +39 02 61911 2237; e-mail: alberto.zanchetti@auxologico.it

The articles published in the current issue of the Journal of Hypertension can be grouped according to their research interest and approach, as studies regarding prediction of hypertension development or hypertension-related mortality, studies on assessment of hypertension-associated organ damage, and therapeutic studies.

Bustos et al. (pp. 1062–1067) confirm in a cohort of Chilean individuals born between 1974 and 1978 that birth weight is negatively associated with SBP and DBP. In men of the Kuopio Ischemic Heart Disease cohort, followed up for about 25 years, Kunutsor and Laukkanen (pp. 1055–1061) report that higher serum zinc concentration is positively and independently associated with incident hypertension. Analyzing a cohort of healthy pregnant women of various ethnicities but all living in Norway, Waage et al. (pp. 1151–1159) find that pregnancy may have a more adverse effect on blood pressure trajectories from early pregnancy to postpartum among non-European women compared with Western Europeans, despite their more favourable blood pressure in early pregnancy. On the hypothesis that central blood pressure responses to exercise may provide clinicians with a superior diagnostic and prognostic tool, Lim et al. (pp. 1084–1090) have tested the reliability of oscillometric assessment of central blood pressure responses to submaximal exercise, and report favourable results, at least in their cohort of young healthy men. A related technical article by Pucci et al. (pp. 1091–1098) warns that changes in the upper arm position generate profound changes in augmentation index, and provides further support to the recommendation to keep the upper limb at the heart level during radial waveform assessment.

Redon et al. (pp. 1075–1083) have investigated the attributable risk associated with hypertension for all-cause mortality and cardiovascular hospitalization, in a prospective study of 52 007 individuals with at least one cardiovascular risk factor participating in the Estudio Cardiovascular Valencia (ESCARVAL-RISK) project. They report that hypertension was associated with a substantial amount of avoidable deaths and hospitalizations both in men and women, the population attributable risk of hypertension being higher than those of other major cardiovascular risk factors. Hartog et al. (pp. 1068–1074), analyzing data from a prospective observation cohort of nursing home residents, report that orthostatic hypotension was related to all-cause mortality, but only in the most frail group of this elderly population. Orthostatic hypotension is also the objective of a systematic review and meta-analysis of cross-sectional studies investigating orthostatic hypotension prevalence in individuals with or without hypovitaminosis D. Ometto et al. (pp. 1036–1043) conclude that hypovitaminosis D is associated with a higher prevalence of orthostatic hypotension, but also point out that longitudinal studies and clinical trials are required to confirm these findings.

Signs and mechanisms of hypertension-associated organ damage are investigated in a large group of studies published in this issue. Adji et al. (pp. 1099–1108) report that cardiac magnetic resonance provides noninvasive measures of left ventricular pulsatile load in time and frequency domain, with expected differences between young and older individuals, thus helping interpretation of vascular/ventricular interaction. In the 12 392 hypertensive patients of the Campania Salute Network, Lønnebakken et al. (pp. 1109–1114) have explored the relationship between aortic root dimension and measures of aortic stiffness, and find that small aortic dimension, together with atherosclerotic modifications of the conduit arteries, is associated with increased two-element Windkessel model of arterial stiffness in hypertension, independent of significant effect of confounders. Picone et al. (pp. 1132–1139) report that patients with type 2 diabetes mellitus have a reversed aortic-to-brachial stiffness gradient during rest and exercise, and resting stiffness gradient correlates with estimated glomerular filtration rate independent of aortic pulse wave velocity, suggesting that a reversed aortic-to-brachial stiffness gradient may have a pathophysiological significance. In diabetic patients also, Yannoutsos et al. (pp. 1123–1131) find that aortic stiffness and pulse pressure amplification are not interrelated, and suggest that these markers may provide complementary information for cardiovascular risk. Rosenbaum et al. (pp. 1115–1122) provide a large and detailed study of retinal arteriole remodelling in hypertension, showing that retinal arteriolar remodelling comprises blood pressure and age-driven wall thickening, as well as blood pressure-triggered lumen narrowing in younger individuals. Remodelling reversal, including short-term functional and long-term structural changes, was observed in controlled hypertensive patients. These data are discussed in an accompanying commentary by Rizzoni and Docchio (pp. 1044–1046), who remark that before this approach can be proposed for general use, some conditions should be met, such as its validation against micromyography, demonstration of its prognostic significance in a longitudinal study, and its use in therapeutic intervention trials.

In a large study on black Africans in South Africa, Booysen et al. (pp. 1178–1185) find that glomerular filtration rate estimated by the Chronic Kidney Disease Epidemiological Collaboration equation is better at detecting organ damage than the formula derived from the Modification of Diet in Renal Disease study or the Cockcroft–Gault formula. van Twist et al. (pp. 1160–1169) have investigated a consistent number of patients with fibromuscular dysplasia of the renal arteries and find that renal haemodynamics and responses to renin–angiotensin system modulation were similar in these patients and in patients with essential hypertension.

Lembo et al. (pp. 1201–1207) have studied the impact of pulse pressure on left ventricular global longitudinal strain in normotensive and untreated hypertensive patients, and report that elevated pulse pressure influences left ventricular longitudinal mechanics. Longitudinal strain was also prospectively investigated by Lee et al. (pp. 1195–1200) in hypertensive patients, with the finding that only subepicardial, but not subendocardial, longitudinal strain was an independent predictor of incident cardiovascular events. In their accompanying commentary, Galderisi and Trimarco (pp. 1050–1051) underline the increasing amount of evidence that global longitudinal strain may overhang traditional structural cardiac hallmarks, such as left ventricular mass and hypertrophy in the characterization of the hypertensive heart, and offer a novel “tree” model of left ventricular dysfunction progress in hypertension. Kuznetsova et al. (pp. 1186–1194), analyzing data from the European Project on Genes in Hypertension (EPOGH), propose thresholds for various indexed cardiac parameters, as evaluated by echocardiography. They report that left ventricular mass indexed to height was sensitive in detection of left ventricular hypertrophy associated with obesity and slightly better in prediction of outcome.

A set of articles on therapeutic aspects also deserves attention. Prevention of hypertension development in young individuals with genetic predisposition and increased renal vascular resistance was tested by random allocation to 1-year administration of either candesartan or placebo (Buus et al., pp. 1170–1177). Although candesartan resulted in a reduced vascular resistance, 10 years posttreatment, SBP and DBP values increased to a similar extent in the two groups of patients. In their accompanying editorial commentary, Viazzi et al. (pp. 1047–1049) provide a comprehensive view of the role measurement of the renal resistance index plays in the assessment of organ damage and prediction of renal and cardiovascular outcomes.

Sengul et al. (pp. 1208–1217) compare the results of a recent survey of hypertension prevalence, awareness, treatment, and control among a representative sample of the Turkish population with those of a 2003 survey, and report that some progress has been made in recognizing hypertension, but there is still a large population of untreated or inadequately treated hypertensive patients in Turkey. Petrie et al. (pp. 1140–1150) remark that also in diabetes, blood pressure remains insufficiently controlled, as shown by their analyses of baseline data from the Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) randomized trial; despite prescription of multiple antihypertensive agents, only 51% of the patients were treated to a target blood pressure of less than 140/85 mmHg, and only 26% to a target of less than 130/80 mmHg. Satoh et al. (pp. 1218–1223) have examined the blood pressure-lowering effect and the time to attain the maximal effect of several angiotensin receptor blockers, based on home blood pressure measurements, reporting differences in the maximum effect and the stabilization time between various compounds. These results are discussed by Dolan and O’Brien (pp. 1052–1054) in an accompanying commentary: despite the limitations inherent in the retrospective nature of the study, Dolan and O’Brien remark that Satoh et al.'s data convey some important messages that should be heeded in the management of complex hypertensive patients.

The Systolic Blood Pressure Intervention Trial (SPRINT) investigators (Thomas et al., pp. 1224–1231) report baseline data on antihypertensive medications and sexual function in women, an interesting area scarcely explored so far. They find that among sexually active women in the SPRINT, the prevalence of sexual dysfunction was high, but no class of medication was associated with sexual dysfunction in the multivariable model. Finally, Tully et al. (pp. 1027–1035) publish a systematic review and meta-analysis of prospective observational studies on elderly patients without dementia exposed to diuretic therapy versus other or no antihypertensive therapy. They find that diuretics were associated with reduced dementia risk and Alzheimer's disease risk.

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