A Chronotherapeutic Approach to Effective Blood Pressure Management

The major randomized trials in hypertension have unequivocally demonstrated the benefits of treatment. None of these trials have sought to address the issue of the potential superiority of 24-hour blood pressure control. However, there is a volume of epidemiologic evidence to suggest that prevention of target organ damage requires the sustained reduction of blood pressure throughout the full 24-hour period between doses. Historically, some antihypertensive drugs have been approved for use at high doses to achieve apparent blood pressure control at the end of the once-daily dosing interval. This approach is flawed; attention is focused on this single time point at the end of the dosing interval, without due regard to the antihypertensive response during the rest of the dosing interval. Subsequently, guidelines formulated by the US Food and Drug Administration suggest that all antihypertensive drugs should consistently achieve a trough:peak ratio decline in blood pressure of at least 50%. Evidence suggests that antihypertensive drugs, such as calcium antagonists and angiotensin II receptor blockers, differ in their ability to provide 24-hour blood pressure control. For example, unlike some other angiotensin II receptor blockers, telmisartan provides consistent reduction of blood pressure during the 24-hour period.     

A Chronotherapeutic Approach to Effective Blood Pressure Management

The major randomized trials in hypertension have unequivocally demonstrated the benefits of treatment. None of these trials have sought to address the issue of the potential superiority of 24-hour blood pressure control. However, there is a volume of epidemiologic evidence to suggest that prevention of target organ damage requires the sustained reduction of blood pressure throughout the full 24-hour period between doses. Historically, some antihypertensive drugs have been approved for use at high doses to achieve apparent blood pressure control at the end of the once-daily dosing interval. This approach is flawed; attention is focused on this single time point at the end of the dosing interval, without due regard to the antihypertensive response during the rest of the dosing interval. Subsequently, guidelines formulated by the US Food and Drug Administration suggest that all antihypertensive drugs should consistently achieve a trough:peak ratio decline in blood pressure of at least 50%. Evidence suggests that antihypertensive drugs, such as calcium antagonists and angiotensin II receptor blockers, differ in their ability to provide 24-hour blood pressure control. For example, unlike some other angiotensin II receptor blockers, telmisartan provides consistent reduction of blood pressure during the 24-hour period.     

Treatment of High Blood Pressure in Germany

The reunification of Germany has made it possible to compare the health care in two independently developed social structures. The prevalence of hypertension was considerably greater in East German men and women, compared with West German men and women, although salt intake was lower in East Germany than in West Germany. Cardiovascular mortality was correspondingly greater. A centralized public health effort was used in East Germany, whereas in West Germany, the activities were decentralized and to a large extent dependent on private philanthropists. In the last two decades, cardiovascular mortality declined in West German men and women, whereas the same was not true for East German men and women. Hypertension incidence, awareness, treatment, and control have improved slightly in Germany, but not enough to explain the improved morbidity figures. Twenty percent of men and women remain unaware of their hypertension, 40% are aware but not treated, and only half are aware and controlled. Complacency is unjustified in Germany and much needs to be done.     

Prevalence of High Blood Pressure in 122,053 Adolescents: A Systematic Review and Meta-Regression

Several studies have reported high prevalence of risk factors for cardiovascular disease in adolescents.To perform: i) systematically review the literature on the prevalence of high blood pressure (HBP) in adolescents; ii) analyze the possible methodological factors associated with HBP; and iii) compare the prevalence between developed and developing countries.We revised 10 electronic databases up to August 11, 2013.Only original articles using international diagnosis of HBP were considered. The pooled prevalence''s of HBP were estimated by random effects. Meta-regression analysis was used to identify the sources of heterogeneity across studies.Fifty-five studies met the inclusion criteria and total of 122,053 adolescents included. The pooled-prevalence of HBP was 11.2%, 13% for boys, and 9.6% for girls (P < 0.01). Method of measurement of BP and year in which the survey was conducted were associated with heterogeneity in the estimates of HBP among boys.The data indicate that HBP is higher among boys than girls, and that the method of measurement plays an important role in the overall heterogeneity of HBP value distributions, particularly in boys.     

A Patient with Acute Kidney Pain and High Blood Pressure

This case presented challenging diagnostic and management issues in a young healthy man who presented with abdominal pain and new-onset hypertension. The differential diagnosis evolved over the course of the clinical presentation. The patient had severe vascular involvement of his renal and basal cerebral arteries that initially was assumed to be due to a vasculitic process or hypercoagulable state. Finally it became apparent that the patient did not have a systemic illness but rather a localized vascular disease most likely due to segmental arterial mediolysis, a rare, under-recognized condition that can potentially be fatal. This condition is often difficult to distinguish from fibromuscular dysplasia. It is important to recognize and correctly diagnose the condition, particularly in the acute phase of the disease, because delay in diagnosis can contribute to morbidity and mortality.     

Prediction of Stable High Blood Pressure in Adolescents

We studied the relative importance of the initial BP and associated factors in adolescents to predict stable high BP. Out of 17.634 children aged 12-13 yrs an upper group the upper 5% of the distribution curves for both SBP and DBP/ a lower group/10% random from the remainder/were yearly fallowed for 4 yrs/boys: 1680, girls: 1643/. About 2/3 of children remained at the same percentile point: < 30% and ≥ 70% of SBP and half of them of DBP distribution. Significant positive tracking correlations were found both for SBP and DBP between the initial BP and follow-up BP readings in the same individual. Stepwise regression analysis showed that the SBP taken at the fourth follow-up can be explained by 29% in boys, 24% in girls on the basis of screening SBP and by 47% in boys, 42% in girls on the basis of SBP measured at the four previous examinations. Using discriminant analysis, 6-9 variables out of 18 studied could correctly allocate adolescents with stable SBP or DBP/< 70% or ≥70% at least 3 examinations/. Our study shows the importance of initial BP and a number of factors associated with stable high BP.     

High Blood Pressure in Children: Clinical and Health Policy Implications

J Clin Hypertens (Greenwich). Hypertension is a global problem, affecting both developed and developing nations. In addition to being a major cause of morbidity and mortality, hypertension places a heavy burden on health care systems, families, and society as a whole. Despite evidence of an increasing prevalence of hypertension among youth, the consequences of early onset are poorly established and often overlooked. Childhood hypertension is often asymptomatic and easily missed, even by health professionals. Target organ damage is detectable in children and adolescents, however, and hypertension continues into adulthood. Additional strategies to improve cardiovascular health among children and adolescents are needed, including methods to achieve healthy lifestyles at home and in school, improved systems for diagnosis, and research on mechanisms and timing of interventions. The burden of hypertension in the young will continue to grow unless it is given the attention it deserves by policy makers, health care providers, schools, parents, and society. This report aims to increase awareness of the problem of hypertension in childhood. Recent reports on prevalence and target organ injury are discussed and health policy initiatives to improve blood pressure control are proposed.     

A High Blood Pressure Predicts Bleeding Complications and a Longer Hospital Stay after Elective Coronary Angiography Using the Femoral Approach

Aim: The aim of this study was to assess risk factors for bleeding complications after elective coronary angiography (CA).
Methods and results: We consecutively included 1,000 patients scheduled for elective diagnostic CA using the femoral approach. A bleeding complication was defined as formation of a hematoma ≥5 cm, severely oozing or pulsating bleeding through the skin, development of a pseudoaneurysm, or a bleeding demanding blood transfusion. We found a bleeding complication in 88 patients. In the multivariate analysis, only female gender and systolic blood pressure were associated with a bleeding complication.
Conclusion: We conclude that systolic blood pressure and female gender are independent predictors of bleeding complications and that a high systolic blood pressure should be reduced before elective CA.     

Working Group Report on High Blood Pressure in Pregnancy

This report updates the 1990 National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy and focuses on classification, pathophysiology, and management of the hypertensive disorders of pregnancy. Using evidence-based medicine and consensus, this report updates contemporary approaches to hypertension control during pregnancy by expanding on recommendations made in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). The recommendations to use K5 for determining diastolic pressure and to eliminate edema as a criterion for diagnosing pre-eclampsia are discussed. In addition, the use of blood pressure increases of 30 mm Hg systolic or 15 mm Hg diastolic as a diagnostic criterion has not been recommended, as available evidence shows that women in this group are not likely to suffer increased adverse outcomes. Management considerations are made between chronic hypertension that is present before pregnancy and those occurring as part of the pregnancy-specific condition preeclampsia, as well as management considerations in women with comorbid conditions. A discussion of the pharmacologic treatment of hypertension in pregnancy includes recommendations for specific agents. The use of low-dose aspirin, calcium, or other dietary supplements in the prevention of pre-eclampsia is described, and expanded sections on counseling women for future pregnancies and recommendations for future research are included. Once again we thank Dr. Ray Gifford, Jr., and his committee for volunteering their time to produce this important report. We hope it helps the busy clinician prevent and manage a very important problem.—Claude Lenfant, MD, Director, National Heart, Lung, and Blood Institute, and Chair, National High Blood Pressure Education Program Coordinating Committee     

High Blood Pressure in Overweight and Obese Youth: Implications for Screening

In the absence of evidence‐based guidelines for high blood pressure screening in asymptomatic youth, a reasonable strategy is to screen those who are at high risk. The present study aimed to identify optimal body mass index (BMI) thresholds as a marker for high‐risk youth to predict hypertension prevalence. In a cross‐sectional study, youth aged 6 to 17 years (n=237,248) enrolled in an integrated prepaid health plan in 2007 to 2009 were classified according to their BMI and hypertension status. In moderately and extremely obese youth, the prevalence of hypertension was 3.8% and 9.2%, respectively, compared with 0.9% in normal weight youth. The adjusted prevalence ratios (95% confidence intervals) of hypertension for normal weight, overweight, moderate obesity, and extreme obesity were 1.00 (Reference), 2.27 (2.08–2.47), 4.43 (4.10–4.79), and 10.76 (9.99–11.59), respectively. The prevalence of hypertension was best predicted by a BMI‐for‐age ≥94th percentile. These results suggest that all obese youth should be screened for hypertension.     

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach

BackgroundAccelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities.ObjectiveTo determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems.DesignQuality improvement study using 1-year cross sections of electronic health record data over 5 years (2013–2017).ParticipantsAdults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative.InterventionsIdentification of a “positive deviant” and dissemination of this system’s best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching).Main MeasuresWe used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics.Key ResultsBP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0–9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5–13.5), Hispanic (10.5%, 95% CI 8.4–12.5), and African American (9.0%, 95% CI 7.7–10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2–19.5; moderate: 5.2%, 95% CI 0.8–9.5; low: 0.2%, 95% CI−3.9 to 4.3).ConclusionsEmploying a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06480-z.     

正常高值血压者血压模式与冠状动脉病变严重程度的关系

目的：探讨正常高值血压者的不同血压模式与冠状动脉病变严重程度的相关性。方法：选择正常高值血压可疑冠状动脉粥样硬化患者218例,均行24小时动态血压监测及冠状动脉造影术。根据动态血压结果,将患者分为杓型、非杓型、反杓型及超杓型血压模式组。冠状动脉病变的狭窄程度用病变血管支数、类型及Gensini积分表示。分析四组血压模式与冠状动脉病变程度的关系。结果:(1).与杓型血压组相比非杓型组、反杓型组、超杓型组24hMSBP、dMSBP、nMSBP均明显增高,且差异有统计学意义（P＜0.05）;（2）.杓型组中单支病变、A型病变发生率最高,多支病变、C型病变发生率最低,其与非杓型、反杓型、超杓型组相比差异均有统计学意义(P<0.05),反杓型组中多支病变、C型病变发生率最高,与杓型、非杓型、超杓型组相比差异有统计学意义(P<0.05);（3）.反杓型、非杓型、超杓型组中Gensini积分均高于杓型组,差异有统计学意义(P<0.05),反杓型组高于非杓型组及超杓型组,差异有统计学意义(P<0.05);（4.）冠状动脉病变的多元线性回归分析结果显示：年龄、nMSBP、反杓型血压模式为冠状动脉病变的独立危险因素。结论：正常高值血压者血压模式与冠状动脉病变程度密切相关。正常高值血压者中反杓型血压模式对冠状动脉病变影响最大。恢复患者正常杓型血压模式对减少靶器官损害有重要意义。