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Highlights of the February issue

Mancia, Giuseppe

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doi: 10.1097/HJH.0000000000002337
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The February issue of the Journal of Hypertension starts with a systematic review and meta-analysis of the studies that have addressed the effect of gastric bypass versus sleeve gastrectomy on remission of hypertension (Climent et al., pp. 185–194). In 32 articles (6 randomized controlled trials, 18 cohort and eight case--control studies) gastric bypass showed a greater hypertension remission rate than sleeve gastrectomy both at 1 year and at 5 years after the surgical intervention, the increased chance of returning to a normal blood pressure (BP) being 14 and 26%, respectively. This scores in favour of the former more radical approach whenever surgery is regarded as the best therapeutic strategy to deal with an otherwise uncontrollable hypertension. This is followed by an article of Stabouli et al. (pp. 196–200) on the differences between new American and new European hypertension guidelines in children and adolescents. The conclusion is that individual attribution to the various BP categories is characterized by discrepancies that are by no means marginal, this being the case regardless of the children's and adolescents’ body weight, that is, from body weight normality to obesity. The discrepancies extend to the prevalence of conditions characterized by a selective increase of office or out-of-office BP, with a greater prevalence of white-coat hypertension in the American and of masked hypertension in the European guidelines. The impact of these discrepancies for the doctor's decision whether to start antihypertensive treatment will have to await data on whether in white-coat and masked hypertension, treatment is associated with cardiovascular protection, an area on which information is absent also in adult patients. In children and adolescents, the studies will have to be based on improvement of organ damage of documented prognostic significance, rather than on cardiovascular morbid or fatal events. In this context, the observation of Stabouli et al. that the two guidelines predict left ventricular hypertrophy similarly is of specific interest.

The next four papers deal with epidemiology (one paper) and diagnosis (three papers) of hypertension. Cho et al. (pp. 211–217) provide the observation that in 1372 nonhypertensive hospital workers, multiple night-time shifts and short shift intervals are associated with an increase in the risk of developing hypertension, that is, an about 3.3 and 3.7 risk for two to three or at least four consecutive night shifts, respectively. This is in line with the evidence that disturbances of nocturnal sleep duration and quality are accompanied by higher daytime BP values. Stergiou et al. (pp. 218–223) show the results of a retrospective analysis of patients in whom office, ambulatory and home BP were measured. Masked hypertension was detected in 23% of the study population: of those about half (48%) had an elevation of both home and ambulatory BP (dual masked hypertension), whereas the elevation involved only ambulatory or only home BP in 30 and 22% of the patients, respectively. These data extend the results obtained in the PAMELA population prospective study in which office, ambulatory and home BP were measured in each individual. Discrepancies in the ambulatory and home BP-based classifications were by no means rare and their occurrence was prognostically relevant. In white-coat hypertensive individuals, for example, dual out-of-office BP normality was associated with a lower incidence of cardiovascular mortality than one out-of-office BP normality only. Furthermore, in the general PAMELA population, cardiovascular risk showed a tendency to be greater when home and ambulatory BP were both increased compared with when the increase was limited to one of these two pressures. Van daele et al. (pp. 224–234) provide evidence that the pressor response to hand-grip exercise depends not only on the strength of the grip but also on other factors, among which is the muscle mass of the exercising patient. Gotzmann et al. (pp. 235–242) report the results of a large validation study on the accuracy of two new automated oscillometric devices (SphygmoCor XCEL and Mobil-O-Graph NG) for estimation of central BP. Compared with the invasively obtained BP values, these devices slightly underestimated and overestimated central DBP, respectively. Yet, for both devices the correlation between the non-invasive and invasive BP values was high, which, according to the authors, should favour implementation of central BP measurements. However, larger use of central BP measurements also requires evidence that its values add to the prognostic accuracy of peripheral BP measurements, an issue which is still unsettled.

The following articles deal with vascular (four papers) and cardiac (four papers) damage. As far as vascular damage is concerned, Paini et al. (pp. 243–248) provide evidence that in 285 individuals, arterial stiffness (measured by pulse wave velocity) was similarly correlated with unattended and attended office BP values, showing a similar association with this large artery abnormality also when data were analyzed by receiver operator curves. This spreads a message similar to that of a Canadian population study which found cardiovascular outcomes to remain more or less unchanged when unattended BP increased from 120 to 160 mmHg and to only increase when higher values were tested. That is, unattended BP pressure measurements did not seem to be a more sensitive prognostic marker than the classical attended BP measurement approach. Vallée et al. (pp. 249–256) examined the correlation of a number of anthropometric variables other than BMI (waist circumference, waist--hip ratio and waist--height ratio) with arterial stiffness as quantified by pulse wave velocity. The waist--height ratio appeared to have the closest correlation and to be the only variable that improved the prediction of arterial stiffness above that offered by BMI. Cameron et al. (pp. 257–265) show that acute intravenous bevacizumab (a monoclonal antibody that blocks angiogenesis by inhibiting the endothelial growth factor) does not directly cause endothelial--vasomotor or fibrinolytic dysfunction. Studies on the effect of bevacizumab on endothelial function after repeated intravenous administrations will be needed, however, to reliably exclude endothelial damage in conditions requested by the therapeutic use of the drug. This is discussed in the Editorial Commentary of Masi et al. (pp. 201–202). Meyer et al. (pp. 266–273) report that central arterial stiffness (measured by carotid--femoral pulse wave velocity) bears an independent association with retinal vessel caliber in both hypertensive and diabetic patients, suggesting that large and small artery dysfunction progress qualitatively in parallel and that large artery dysfunction reflects the status of cerebral microcirculation. Further considerations are provided by the Editorial Commentary of Rizzoni et al. (pp. 203–205).

Concerning cardiac damage, Vriz et al. (pp. 274–281) describe the echographic alterations of the right ventricle (dimensions, flow patterns and function in mild to moderate hypertensive individuals with preserved left ventricular function). Tadic et al. (pp. 282–288) show that nondipping and reverse dipping have an adverse impact on left ventricular functional and mechanical remodeling, a conclusion reached also by Di Stefano et al. (pp. 289–294) who found a greater left ventricular mass and prevalence of hypertrophy in hypertensive patients with Parkinson's disease and reverse dipping. Lembo et al. (pp. 295–302) report that, in newly diagnosed and never treated hypertensive patients without left ventricular hypertrophy, two-dimensional and speckle-tracking echocardiography can detect a reduction of midwall left ventricular shortening and global longitudinal strain, and thereby document early left ventricular dysfunction. Finally, Kobuch et al. (pp. 303–313) extend their previous observations that in normotensive individuals, the resting blood flow of the brain regions involved with cardiovascular control is inversely related to mean BP values. This time they further report that there is an association between the grey matter volumes of regions involved in cardiovascular control (assessed by nuclear magnetic resonance) and mean BP and muscle sympathetic nerve activity. Whether this means that these structures are involved in the determination of sympathetic tone, BP level and risk of hypertension remains an unanswered question, however Schlaich et al. (pp. 206–207) discuss these possibilities in an Editorial Commentary.

The final six papers address experimental and genetic aspects of hypertension (two papers), secondary hypertension (three papers) and antihypertensive treatment (two papers). Jiang et al. (pp. 314–321) show that, in unrestrained rats, continuous infusion of noradrenaline does not substantially modify mean BP but increases 24-h BP variability. The increase was attenuated by alpha-1-adrenergic receptor blockade, indicating an origin from neuroadrenergic activation. This is in line with the evidence obtained in several animal species and in man that heightened sympathetic cardiovascular influences have a pro-oscillatory BP role. Deng and Menard (pp. 322–331) show that humans and Dahl salt-sensitive rats share three quantitative trait loci involved in BP regulation. Seccia et al. (pp. 332–339) show that in the patients of the PAPPHY study with an atrial fibrillation of an unknown cause, a thorough diagnostic work-up allowed to identify a primary aldosteronism in almost 50% of these cases. Thus, in atrial fibrillation primary aldosteronism may be common and should be actively searched for. This is further supported in the Editorial Commentary of Manolis e Doumas (pp. 208–210). Negro et al. (pp. 340–346) describe a case of an adrenal pheochromocytoma with erythropoietin-secreting cells that did not elevate BP, but caused severe polycythemia, which was improved by adrenalectomy. Li et al. (pp. 347–353) show data that support calculation, via computed tomography, of the right versus the left adrenal gland volume in the diagnosis of primary aldosteronism.

As to the treatment aspects of hypertension. Kayser et al. (pp. 354–361) report the results obtained by use of two beta-blockers (metoprolol or bisoprolol) during the second and third trimester of pregnancy in about 3000 neonates of hypertensive mothers. Compared with infants of normotensive mothers, the rate of neonatal adverse outcomes (low birth weight, prematurity, bradycardia, hypoglycemia and respiratory disorders) was significantly greater. However, the difference was small or absent when data on beta-blockers were compared with those from 225 methyldopa-exposed neonates. Finally, Burger et al. (pp. 362–367) provide a description of how hypertension is managed in the public health section of two South African provinces. Namely, how the outcome of the BP test was communicated, whether lifestyle advice was delivered and how often government guidelines were followed. The results were disappointing, because 39% of the patients received no lifestyle advice and 25% left the facility with no diagnosis and follow-up appointment. These data provide a valuable insight into real life medical practice. It would be desirable to replicate them in other parts of the world.


Conflicts of interest

There are no conflicts of interest.

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