Current Hypertension Reviews - Volume 13, Issue 2, 2017

Background: Hypertensive disorders (preeclampsia, eclampsia, gestational hypertension, and chronic hypertension with superimposed preeclampsia) complicate 3-5% of all pregnancies and are a significant cause of maternal mortality and morbidity. Preeclampsia is a multi-system disorder characterised by new onset hypertension after the 20th week of pregnancy with proteinuria. Proteinuria is defined as 300 mg or more of protein in a 24-hour urine collection or a protein: creatinine ratio of 0.3 mg/dL using a spot urine specimen. Hypertensive disorders have a complex pathophysiology that results from abnormal placen- tation and a maternal response that develops into a clinicalsyndrome for which there is no single test or “cure”. In high income countries, low rates of maternal mortality from hy- pertensive disease in pregnancy illustrate the importance of pregnant women being able to readily access antenatal care. Conclusion: There remains the need to develop evidence-based clinical guidelines for detection, prophylaxis and management worldwide.

Background: Obstructive sleep apnea (OSA) is a major cause of secondary hypertension. Moreover, a considerable proportion of patients with essential hypertension have OSA. OSA also appears to increase the risk for cardiovascular disease and all-cause mortality. Continuous positive airway pressure (CPAP) treatment substantially reduces daytime somnolence and improves quality of life in patients with OSA. However, the effects of CPAP treatment on blood pressure (BP) are questionable. The aim of the present review is to summarize the evidence regarding the association between OSA with hypertension and the effects of CPAP treatment on BP in patients with OSA. The severity of OSA directly correlates with the increase in BP. Moreover, patients with OSA are at increased risk for developing hypertension. However, CPAP treatment does not result in substantial reductions in BP in unselected patients with OSA with moderate adherence to this treatment. Nevertheless, these effects are more pronounced in patients with more severe hypertension, more severe OSA and more importantly, in those who adhere to CPAP treatment. Conclusion: Therefore, it is essential to improve the adherence to CPAP treatment in order to optimally manage this important cause of hypertension.

Background: Renal artery stenosis (RAS) has a high prevalence in older patients, especially in the context of general atherosclerosis. It is frequently associated with resistant hypertension and impaired renal function and their attendant consequences. The issue whether revascularization via percutaneous renal angioplasty and stenting (PRA/S) can benefit these patients remains unsettled. Objective: To present a case series of patients with refractory hypertension and RAS undergoing PRA/S and also to provide an extensive review of the literature on the current status of PRA/S for resistant hypertension. Methods: Data of all consecutive patients undergoing PRA/S by a single operator over 1 year were prospectively collected. These were 9 patients with hypertension refractory to drug therapy who also had other clinical cardiac problems that led to their hospitalization, including flash pulmonary edema and coronary artery disease. They were all receiving ≥3 antihypertensive drugs and renal angiography revealed critical RAS (unilateral in 3 and bilateral in 6). In addition, an extensive literature review of the topic was carried out in PubMed, Scopus and Google Scholar. Results: PRS was successful in all 9 high-risk RAS patients with resistant hypertension (5 men, mean age 71 years) without complications and helped in bringing under control their elevated blood pressure (BP) and in maintaining their renal function over a mean of 21 months. Literature review of this controversial topic indicates that in carefully selected patients, PRA/S may play an important role in controlling BP, alleviating symptoms and perhaps preventing renal failure, albeit without concrete evidence of significantly affecting hard end-points of renal events, major cardiovascular events and death. Randomized controlled studies (RCTs), including a large one (CORAL trial), although heavily criticized, have not provided evidence in favor of revascularization. Although RCTs are rather neutral, a multitude of prospective, observational cohort studies, comparing the outcomes of patients after PRA/S have demonstrated significant improvement in systolic and diastolic BP in about two thirds and improvement and/or stabilization in renal function in 30-40% of patients undergoing PRA/S. Nevertheless, the issue remains unsolved and a subject of future studies for further more definitive settlement. Suggestions have been made to adopt physiological and functional renal lesion assessment that may enhance patient selection, at least for RAS cases of moderate lesion severity. Based on this small case series and on exhaustive literature review, an algorithm for approaching patients with significant RAS is herein proposed. Conclusion: In high-risk RAS patients with truly resistant hypertension, flash pulmonary edema, and/or rapid deterioration of renal function, PRA/S, a procedure with currently high technical success, may constitute the only viable option. Importantly, despite the unfavorable results of RCTs, current guidelines have not yet changed and clinicians should continue to abide by them. They recommend PRA/S as a reasonable option for patients with hemodynamically significant (especially ostial) RAS and uncontrolled, resistant or malignant hypertension, recurrent, unexplained congestive heart failure or pulmonary edema or unstable angina.

Background: An alerting reaction is a physician-induced phenomenon which produces a transient blood pressure rise in the office. Objective: To determine its relationship with target organ damage in treated hypertensives. Method: We used three different indexes for calculating alerting reaction depending on the first, second or third office blood pressure measurement. We correlated these indexes with glomerular filtration rate, left ventricular mass index and pulse wave velocity. Thereafter, for multivariate analysis, we selected the index which better correlated with each target organ damage subtype. Results: We included 174 adults, mean age 67(±13.7) years. 75% of the patients had some degree of blood pressure fall between measurements 1-3. In multivariate linear regression models, after adjusting for classic risk factors, two out of the three systolic alerting reaction indexes showed an independent association with target organ damage. After further adjusting for office blood pressure and white coat effect (calculated with standardized home blood pressure monitoring), left ventricular mass index maintained a statistically significant association. Conclusion: A higher alerting reaction in the office seems to be related to increased target organ damage in treated hypertensives and should not be considered an innocent phenomenon.

Background: Autosomal dominant polycystic kidney disease (ADPKD) commonly results in end-stage renal disease (ESRD), yet a long-term treatment that is well tolerated is still lacking. In a small randomized trial in children and adolescents pravastatin administration for 3 years was associated with reduced renal cyst growth, but no large trial has tested the effect of statins in adults. Methods: We performed a post-hoc analysis of the HALT PKD trials to compare outcomes of participants who never used statins with those who used statin for at least 3 years. Because statins were not randomly allocated, we used propensity score models with inverse probability of treatment weighting to account for imbalances between the groups. For subjects in Study A (preserved renal function, n=438) relevant outcomes were percent change in total kidney and liver volume and the rate of decline in estimated glomerular filtration rate (eGFR); for those in Study B (reduced renal function, n=352) we compared time to the composite endpoint of death, ESRD or 50% decline in eGFR. Follow-up was 5-8 years. Results: There was no difference in any outcome between the 2 groups. However, limitations of this analysis are the small number of statin users in Study A, different statin drugs and doses used, non-randomized allocation and advanced disease stage in Study B. Conclusion: Although this post-hoc analysis of the HALT PKD trials does not demonstrate a benefit of statin therapy, conclusions remain preliminary. A larger randomized trial in young people with ADPKD is necessary to answer the question whether statins can slow renal cyst growth and preserve kidney function.

Background: Ambulatory Arterial Stiffness Index (AASI) has been proposed as an indirect and simpler method to estimate the Arterial Stiffness (AS). AASI, calculated from a set of data collected during a 24-hours ambulatory blood pressure monitoring (ABPM), is defined as 1 minus the regression slope of diastolic on systolic blood pressure (BP) values. For a given increase in diastolic BP, the increase in systolic BP is smaller in a compliant compared to a stiff artery; the stiffer the arterial tree, the closer AASI is to 1. AASI was demonstrated to predict cardiovascular mortality, cerebrovascular events and to be associated with target organ damage. Taking into account the almost complete absence of data regarding the ability of AASI to predict the different degree of AS when hypertensives are divided into four classes of dipping in relation to the extent of the nocturnal reduction of BP (extreme dippers, dippers, mild dippers and reverse dippers) aim to clarify the ability of AASI to estimate the different degree of AS of hypertensive subjects with different nocturnal BP profile and resulting in different extent of organ damage. Materials and Methods: We enrolled 816 subjects (403 men and 413 women) with essential hypertension, referred to the U.O.C of Medicina Interna e Cardioangiologia of the University of Palermo; 173 subjects (71 men and 102 women, mean age 44.4 ± 14.6 years) without a history of hypertension were enrolled as controls. Results: The analysis of data was performed by dividing the population into four categories in relation to the extent of the nocturnal decline of BP: 124 extreme dipper (mean age 54,8 ± 12,4 years, men 46.8 %); 287 dipper (mean age 55,9 ± 14,2 years, men 54,0 %); 271 mild dipper (mean age 61,5 ± 14,7 years, men 52,0 %); 134 reverse dipper (mean age 61,5 ± 14,7 years, men 33.6 %). The mean value of AASI was significantly higher for mild and reverse dippers versus control patients and versus the other categories of dipping. The multiple regression analysis with AASI as the dependent variable confirmed the significant association between AASI and nocturnal dip (p: 0.015). The Multinomial Logistic Regression Analysis, in which AASI values were adjusted for the main confounders (age, sex, Body Mass Index, 24h SBP, 24h DBP) showed that the association between AASI and dipping is maintained only for dipper and extreme dipper hypertensives, missing the significance for mild and reverse subjects. Conclusion: 1) AASI levels are associated with night-to-day BP ratio; 2) Lower levels of AASI are significantly associated to extreme dipper and dipper BP nocturnal profile when compared to healthy controls. 3) After correction for the major confounding factors, the association between AASI and the high-damaged class of hypertensive subjects with lower or no nocturnal fall of BP is lost. Our findings support the hypothesis that AASI is unable to estimate AS of older hypertensive subjects with a high burden of organ and vascular damage and several comorbidities, probably because the nocturnal reduction of BP is the main determinant of AASI, being more powerful than AS itself.

Background: Hypertension is a common health problem concerning a large proportion of population and a leading global risk factor for the burden of cardiovascular disease (CVD). The purpose of this study was to assess the efficacy of the erythrocyte zeta potential as a potential additional indicator for cardiovascular disorder risk so that patients with this can be more rapidly identified and treated. Methods: In the present study, blood samples were collected in 5% dextrose solution from patients suffering from hypertension and healthy volunteers (Not taken any medication). The mobility of individual RBCs was tracked by equipped Zeta meter-ZM4DAQ software using microscopicallyacquired video images, data were recorded 10 times for each sample and average zeta-potential in mv was recorded. Results: We found that mean erythrocytic ZP of control group was found to be 23.41 mv (± 1.87) whereas, erythrocytic ZP for Hypertensive patients was found to be 16.05 (±1.72) mV and Hypertensive patients with Diabetes is much lower from 6.96 mV to 22.76 (+3.88) mV along with structural deformities and increased osmotic fragility of erythrocytes. Conclusion: The data suggest that there are morphological changes in erythrocyte structure, increased osmotic fragility along with significantly lower ZP value as compared to that of healthy volunteers which may be the major cause for progression to the development of cardiovascular disease.

Background: Depression is highly prevalent in End Stage Renal Disease (ESRD) and is the most common psychiatric disorder in this population. Depression is associated with a lack of adherence to hemodialysis (HD) treatment regimens and increased morbidity and mortality. Methods: A descriptive secondary correlational analysis of 118 patients on chronic HD was conducted to determine the prevalence of depression and its relationship to adherence to blood pressure (BP) regimens (fluid adherence, HD and BP medication adherence). Results: Approximately 80% of the sample was found to have moderate depression. Depression was found to be significantly related to BP medication nonadherence at baseline (r = .239, p = .01 and at 12 weeks (r = .20, p = .027). Conclusion: Given the high prevalence of depression and its association with BP medication nonadherence, patients on chronic HD should be routinely assessed for depression and offered validated treatment regimens. Depression is a modifiable risk factor, and interventions that address depression in conjunction with adherence to BP regimens need to be tested in the HD population.