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The approach to hypertension

from childhood to old age

Zanchetti, Alberto

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doi: 10.1097/HJH.0000000000001075
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The scope of hypertension research includes blood pressure (BP) regulation at all ages, from childhood to old age, and our readers will be delighted to see that the current issue of the Journal of Hypertension opens with the new 2016 European Society of Hypertension guidelines for the management of high BP in children and adolescents (Lurbe et al., pp. 1887–1920). The 2009 edition of these guidelines, also published in the Journal, had been extremely well received, as witnessed by 337 citations in the international literature, but after 7 years needed an update, which was provided by the Task Force appointed by the European Society of Hypertension and headed by a highly recognized expert, Professor Empar Lurbe. The new guidelines come at a very appropriate time, after the 2013 US Preventive Services Task Force opened a lively debate on the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents, and call our attention on the need of early prevention, particularly of bad habits learned in childhood and endangering health in adulthood.

Readers interested in adolescents BP can also read another epidemiological article in this issue of the journal (Xi et al., pp. 1948–1958) reporting BP and obesity trends from China, Korea, Seychelles, and the United States and showing that, while the prevalence of obesity increased markedly between 1997 and 2012 among adolescents in all four countries, secular BP trends differed in different countries. Finally, an experimental study in the lamb explores the renal effects of preterm birth, a condition known to be linked to the development of hypertension later in life. Sutherland et al. (pp. 1988–1997) found that, in comparison with term controls, preterm lambs had significantly reduced glomerular capillary length, surface area, and total renal filtration surface area.

Also research on hypertension at the other extreme of age is covered in the present issue of the Journal. Sanchez-Martínez et al. (pp. 2045–2052) document the relationship of social support with BP in old people by ambulatory BP monitoring in 1047 community-living elderly individuals in Spain and report that social support is independently associated with lower nocturnal SBP and greater SBP dipping. The influence of socioeconomic status and education on arterial stiffness has been investigated by Trudel et al. (pp. 2038–2044) in 3484 participants in the prospective Whitehall II study: their findings of a greater pulse wave velocity increase over 5 years in participants with lower employment grade, household income, and education suggest that arterial aging could be an important pathophysiological pathway explaining the impact of lower socioeconomic status on cardiovascular disease risk. Jackson et al. (pp. 1959–1966) take issue with previous evidence on the association of depression and anxiety with hypertension: studying a group of women from the Australian Longitudinal Study on Women's Health, they report that the apparent association of depression and hypertension lost significance after adjusting (particularly for obesity), and the association of anxiety and hypertension became nonsignificant after adjusting for depression.

Hörnsten et al. (pp. 2059–2065) have investigated the high BP-dependent risk of stroke in a prospective population-based cohort of people older than 85 years in northern Sweden, and report that SBP at least 160 mmHg and DBP at least 90 mmHg, as well as atrial fibrillation, appear to be risk factors for incident stroke also at this very old age. Very old people (aged 85 and 90 years) were also investigated by Bursztyn et al. (pp. 2053–2058), who find orthostatic hypertension was uncommon at very old age and apparently not associated with higher mortality. Treatment of orthostatic hypotension by droxidopa has been the object of a systematic review and meta-analysis by Strassheim et al. (pp. 1933–1941), who report the drug is effective at reducing dizziness and other symptoms and improving standing SBP by about 4 mmHg. In an accompanying editorial commentary, Jordan et al. (pp. 1942–1944) review the various nonpharmacological and pharmacological procedures used to alleviate severe orthostatic hypotension. They acknowledge available data are limited, but conclude limited data should not lead to therapeutic nihilism.

Another consistent number of studies in this issue of the Journal focus on various aspects of hypertension treatment. Thomopoulos et al. (pp. 1921–1932) continue their series of metaanalyses of BP-lowering treatment trials, investigating treatment discontinuations for adverse events when treatments are based on different classes of antihypertensive agents. They report that reduction of cardiovascular events by all classes of BP-lowering drugs was accompanied by increased treatment discontinuations for adverse events (over discontinuations under placebo), except when angiotensin receptor blockers were used. In trials comparing different drug classes head-to-head, angiotensin receptor blockers were the only class associated with significantly lower risk of adverse events. Discontinuation for adverse events was also found proportional to the overall number of antihypertensive and other cardiovascular drugs received by patients.

Two studies focus on the therapeutic effects of exercise. Ramos et al. (pp. 1977–1987) have done a randomized trial of different volumes of high-intensity interval training on central (aortic) BP in individuals with the metabolic syndrome, and report that three sessions of 4 min of high-intensity exercise per week was sufficient to improve aortic pressure. An experimental study by Herrera et al. (pp. 1967–1976) in rats shows that exercise training attenuated dexamethasone-induced hypertension and improved autonomic balance and skeletal muscle microcirculation.

Another experimental study with potential therapeutic application has been performed by Jíchová et al. (pp. 2008–2025), who have found that early treatment with a new, orally active epoxyeicosatrienoic acid analogue attenuated the development of angiotensin II-dependent malignant hypertension in transgenic rats.

De Cosmo et al. (pp. 2090–2098) summarize experience from the Italian Medical Diabetologists registry on the effects of persistent BP control below recommended values (<140/85 mmHg) on development of diabetic nephropathy, showing diabetic patients who failed to achieve or maintain control over the 4-year study period had an increased risk of either low glomerular filtration rate or albuminuria. Long-term (11 years) changes in albuminuria have been studied by Romundstad et al. (pp. 2081–2089) in 6282 nondiabetic individuals from the Norwegian population-based HUNT cohort. They report that both increasing and decreasing albuminuria were significant and independent predictors of mortality, although the mortality risk of decreasing albuminuria was strongly attenuated when adjusting for comorbidity. These observations are commented by Wiley (pp. 1945–1947) in an accompanying editorial, who remarks Romundstad et al.'s study (pp. 2081–2089) indicates there are numerous opportunities to advance upon traditional cross-sectional or prediction-only study designs using longitudinal assessments to study change and variability in biomarkers and other risk factors.

Remde et al. (pp. 2066–2073) have investigated the effects of specific therapy for primary aldosteronism on the cardiovascular risk markers, copeptin and hsCRP, and found that both were significantly decreased by specific therapy, probably reflecting successful cardiovascular risk reduction, though they did not independently predict cure of primary aldosteronism.

A group of pathophysiological studies include a study by Spradley et al. (pp. 1998–2007) investigating the mechanisms by which obesity increases the risk for hypertensive disorders of pregnancy; a report by Tentori et al. (pp. 2074–2080) that in treatment-naïve essential hypertensive patients aldosterone and endogenous ouabain are linearly related, and patients with higher aldosterone and ouabain levels are salt-sensitive; a study by Huang et al. (pp. 2026–2037) investigating the feasibility of ascending aortic pulse wave velocity measurement using transthoracic echocardiography.

The current issue of the journal also publishes a report from the International Society of Hypertension on a Teaching Seminar recently held in Maputo, Mozambique (pp. 2105–2107) with useful information that adds to that provided by a number of studies on hypertension in Africa that have appeared in the journal in recent years.

Finally, readers of the journal and members of both the European and the International Societies of Hypertension will be interested to read a brief profile of José Luis Rodicio. With his departure, the European Society of Hypertension has lost a Past President, the International Society of Hypertension the host and organizer of its 1992 meeting, the community of hypertension investigators an international protagonist and the initiator of the excellent hypertension research activity all over Spain, all his friends have lost an affectionate companion and an example for life. I would like to express all my sympathy and love for Elena and her children.


Conflicts of interest

There are no conflicts of interest.

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