Should antihypertensives be administrated at bedtime?

Ongoing monitoring and targeted treatment are important to ensure the best blood-pressure control and thus prevent cardiovascular risks. In this review, we evaluate the findings of four clinical studies investigating the effects of morning versus bedtime dosing of antihypertensives. In three out of four studies, overwhelming results were found favouring bedtime dosing. The same studies have been criticized for mechanistic implausible results and multiple study biases. No harmful effects were reported in relation to bedtime dosing. Thus, antihypertensives can be taken as it is most convenient for the patient.

The Impact of Education Level on Weight Loss in a Primary Care-Anchored eHealth Lifestyle Coaching Program in Denmark: A Randomized Controlled Trial.

In a randomized controlled trial including 340 people living with obesity, with and without type 2 diabetes, digital coaching has induced significant long-term weight loss compared to the usual methods of care. We investigated whether education level influenced this weight loss and which lifestyle changes supported the digital lifestyle coaching program. The intervention consisted of a 1 h face-to-face motivational interview followed by digital coaching using behavioral change techniques. At 6 months, the weight loss in the intervention group was significantly larger in participants with short education (6.0 vs. 2.2 kg, p < 0.01) (p = 0.006). Participants with long education experienced initially a modest weight loss, but the effect was maintained, leading to the largest weight loss at 24 months (5.06 [-11.98-1.86] kg), even though there were fewer coaching sessions in the maintenance period. In multiple regression analyses, the greater weight loss in the intervention group was associated with short education (ß = 1.81, p = 0.02), improvements in everyday physical activity (ß = 2.60, p = 0.014) and improvements in dietary habits (ß = 3.84, p = 0.013). In conclusion, at 6 months, the effect of the intervention was more pronounced in people with short education through improvements in everyday physical activity and dietary habits. However, participants with long education sustained their weight loss at 24 months.

Effect of exercise on functional capacity and body weight for people with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: Hypertension, type 2 diabetes, and cardiovascular disease affect the activities of daily living at varying degree. While the effects of aerobic exercise on functional capacity are well-documented, the extent of change for different types of exercise in these chronic conditions remains unexplored. Additionally, there is conflicting evidence regarding the role of exercise in reducing body weight. METHODS: We conducted systematic review with meta-analysis and trial sequential analysis and searched various databases from inception to July 2020. We included randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in people with either hypertension, type 2 diabetes, and/or cardiovascular disease irrespective of setting, publication status, year, and language. The outcomes assessed were i) functional capacity assessed through different scales separately i.e., Maximal Oxygen Uptake (VO2max), 6-min walk test (6MWT), 10-m walk test (10MWT), and ii) body weight. RESULTS: We included 950 studies out of which 444 trials randomising 20,098 participants reported on various functional outcomes (355 trials) and body weight (169 trials). The median follow-up was 3 months (Interquartile ranges (IQR): 2.25 to 6). Exercise added to the usual care, improved VO2max (Mean Difference (MD):2.72 ml/kg/min; 95% Confidence Interval (CI) 2.38 to 3.06; p < 0.01; I2 = 96%), 6MWT (MD: 42.5 m; 95%CI 34.95 to 50.06; p < 0.01; I2 = 96%), and 10MWT (MD: 0.06 m/s; 95%CI 0.03 to 0.10; p < 0.01; I2 = 93%). Dynamic aerobic and resistance exercise showed a consistent improvement across various functional outcomes, whereas body-mind therapies (MD: 3.23 ml/kg/min; 95%CI 1.97 to 4.49, p < 0.01) seemed especially beneficial for VO2max and inspiratory muscle training (MD: 59.32 m; 95%CI 33.84 to 84.80; p < 0.01) for 6MWT. Exercise yielded significant reduction in body weight for people with hypertension (MD: -1.45 kg; 95%CI -2.47 to -0.43; p < 0.01), and type 2 diabetes (MD: -1.53 kg; 95%CI -2.19 to -0.87; p < 0.01) but not for cardiovascular disease with most pronounced for combined exercise (MD: -1.73 kg; 95%CI -3.08 to -0.39; p < 0.05). The very low certainty of evidence warrants cautious interpretations of the results. CONCLUSION: Exercise seemed to improve functional capacity for people with hypertension, type 2 diabetes, and/or cardiovascular disease but the effectiveness seems to vary with different forms of exercise. The potentially superior improvement in VO2max and 6MWT by body-mind therapies and inspiratory muscle training calls for further exploration. Additionally, prescribing exercise for the sole purpose of losing weight may be a potential strategy for people with hypertension and type 2 diabetes. The extent of improvement in functional capacity and body weight reduction differed with different exercise regimens hence personalised exercise prescriptions tailored to individual needs may be of importance. PROSPERO REGISTRATION: PROSPERO registration number: CRD42019142313.

N-Terminal Pro-Brain Type Natriuretic Peptide Predicts Cardiovascular Events Independently of Arterial Stiffness, Assessed By Carotid-to-Femoral Pulse Wave Velocity, in Apparently Healthy Subjects.

AIM: This study aimed to evaluate whether N-terminal pro-brain natriuretic peptide (NT-proBNP) and carotid-to-femoral pulse wave velocity (PWV) carried independent prognostic value in predicting cardiovascular events in apparently healthy individuals beyond traditional risk factors. METHODS: A total of 1,872 participants aged 41, 51, 61, or 71 years from the MONItoring of trends and determinants in CArdiovascular disease (MONICA) study were included. Traditional risk factors were assessed, including: smoking status; mean systolic and diastolic blood pressure; body mass index; fasting plasma glucose; serum triglycerides; total, high-density, and low-density lipoprotein cholesterol; NT-proBNP; and PWV. The principal endpoint that was assessed during 16 years of follow-up was a composite of major adverse cardiovascular events (MACE). The secondary endpoints were cardiovascular mortality (CVM), hospitalisation for coronary artery disease (CAD), and a composite of hospitalisation for heart failure (HF) or atrial fibrillation (AF). RESULTS: At baseline, NT-proBNP was associated with PWV (ß=0.14; p<0.001), but not after adjustment for traditional risk factors (ß=-0.01; p=0.67). In models including traditional risk factors and PWV, NT-proBNP was associated with all four outcomes (HRMACE=1.33, 95% CI 1.16-1.52; HRCVM=2.02, 95% CI 1.65-2.48; HRCAD=1.29, 95% CI 1.07-1.55; and HRHF or AF=1.79, 95% CI 1.40-2.28). In the same model, PWV was only associated with CVM (HRCVM=1.20, 95% CI 1.01-1.41). No interactions between NT-proBNP and PWV were found. N-terminal pro-brain natriuretic peptide significantly improved net reclassification (NRI) for MACE (NRI=0.12; p=0.03), CVM (NRI=0.33; p<0.001), and HF or AF (NRI=0.33; p<0.001) beyond traditional risk factors, while PWV did not aid in net reclassification improvement for any endpoint. CONCLUSIONS: In apparently healthy individuals, NT-proBNP and PWV predicted cardiovascular events independently. N-terminal pro-brain natriuretic peptide improved reclassification for the prediction of MACE, CVM, and hospitalisation for HF or AF beyond traditional risk factors, while PWV did not.

A multidisciplinary, shared care clinic using personalized medicine and coordinated care in patients with concomitant type 2 diabetes and cardiovascular disease. Protocol and baseline characteristics.

Background: Concomitant type 2 diabetes (T2DM) and cardiovascular disease (CVD) is frequent with a poor prognosis with high risk of comorbidities. Strict risk factor control reduces the risk for complications - yet many people do not achieve treatment targets. The complexity and fragmentation of the healthcare system may, together with the vulnerability of these patients, be a reason. Objective: The purpose of this paper is to describe the protocol of a non-randomized interventional pilot study testing the feasibility and effect of a multidisciplinary, shared care clinic using personalized medicine and coordinated care in people living with concomitant T2D and CVD. Methods: Participants were included from the Holbaek area in Denmark. People suffered from T2DM and CVD and were dysregulated regarding to HbA1c, cholesterol, micro/macroalbuminuaria or blood pressure. Participants went through a thorough evaluation to identify their needs and resources and received consultations every three months for one year. Results: A total of 63 participants with T2DM and CVD were enrolled in the clinic. The participants had a mean age of 69 years and a BMI of 30.9 kg/m2. Almost 50 % had heart failure, 95 % dyslipidemia and 91 % hypertension. Around 54 % received GLP-1 agonists and 39 % received SGLT-2-inhibitors. Perspectives: To our knowledge, a similar study with a multidisciplinary, shared care, outpatient clinic treating people living with concomitant T2DM and CVD, has not been performed previously. This study will provide information about the feasibility and efficacy of a multidisciplinary clinic based on changes in cardiovascular risk factors and medication.

Blood pressure responses to testosterone therapy are amplified by hematocrit levels in opioid-induced androgen deficiency: a double-blind, randomized, placebo-controlled trial.

Our study aimed to examine the effect of testosterone replacement therapy (TRT) on blood pressure in opioid-treated men with relative hypogonadism, and whether the effect of TRT on blood pressure was modified by body composition, red blood cell levels, or carotid intima media thickness. Men (over 18 years old) receiving opioid treatment and total testosterone less than 12 nmol were randomly assigned to receive either TRT or placebo. Baseline and 6-month measurements included anthropometric measurements, office blood pressure (OBPM), 24-h ambulatory blood pressure, blood samples, and carotid ultrasound. The mean systolic OBPM increased by 6.2 mmHg (0.2-12.1) in the TRT group and decreased by 7.0 mmHg (1.0-15.1) in the placebo group, with a mean difference of 13.2 mmHg (3.4-23.1), P  = 0.01. In the TRT group, a 10 mmHg increase in systolic OBPM was associated with an increase in hematocrit of 0.3% points (0.1-0.5) ( P  = 0.01), whereas no association was observed in the placebo group ( P  = 0.266). Daytime SBP showed a nonsignificant increase of 5.2 mmHg (-1.7, 12.1) ( P  = 0.134) in the TRT group compared to that in the placebo group. However, the impact of TRT on the increase in daytime ambulatory blood pressure was significantly accentuated by baseline values of BMI, hematocrit, and hemoglobin. In conclusion, TRT was associated with higher OBPM compared to placebo, and the increase in blood pressure was linked to higher hematocrit during TRT. Our data suggest that men with opioid-induced androgen deficiency, particularly those with obesity or red blood cell levels in the upper normal range, are more susceptible to increased daytime SBP during TRT.

Improving the accuracy of blood pressure measuring devices in Australia: a modelled return on investment study.

The VALID BP project was initiated to increase the availability of validated blood pressure measuring devices (BPMDs). The goal is to eliminate non validated BPMDs and minimise over- and underdiagnosis of hypertension caused by inaccurate readings. This study was undertaken to assess the potential return on investment in the VALID BP project. The Framework to Assess the Impact of Translational Health Research was applied to the VALID BP project. This paper focuses on the implementation of the cost benefit analysis aspect of this framework to monetise past research investment and model future research costs, implementation costs, and benefits. Analysis was based on reasoned assumptions about potential impacts from availability and use of validated BPMDs (assuming an end goal of 100% validated BPMDs available in Australia by 2028) and improved skills leading to more accurate BP measurement. After 5 years, with 20% attribution of benefits, there is a potential $1.14-$1.30 return for every dollar spent if the proportion of validated BPMDs and staff trained in proper BP measurement technique increased from 20% to 60%. After eight years (2020-2028) and assuming universal validation and training coverage, the returns would be between $2.70 and $3.20 per dollar spent (not including cost of side effects of unnecessary medication or downstream patient impacts from unmanaged hypertension). This modelled economic analysis indicates there will be positive downstream economic benefits if the availability of validated BPMDs is increased. The findings support ongoing efforts toward a universal regulatory framework for BPMDs and can be considered within more detailed future economic analyses.

Effects of adding exercise to usual care on blood pressure in patients with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis.

INTRODUCTION: Exercise is the most recommended lifestyle intervention in managing hypertension, type 2 diabetes, and/or cardiovascular disease; however, evidence in lowering blood pressure is still inconsistent and often underpowered. METHOD: We conducted a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials adding any form of trialist defined exercise to usual care versus usual care and its effect on systolic blood pressure (SBP) or diastolic blood pressure (DBP) in participants with hypertension, type 2 diabetes, or cardiovascular disease searched in different databases from inception to July 2020. Our methodology was based on PRISMA and Cochrane Risk of Bias-version1. Five independent reviewers extracted data and assessed risk of bias in pairs. RESULTS: Two hundred sixty-nine trials randomizing 15 023 participants reported our predefined outcomes. The majority of exercise reported in the review was dynamic aerobic exercise (61%), dynamic resistance (11%), and combined aerobic and resistance exercise (15%). The trials included participants with hypertension (33%), type 2 diabetes (28%), or cardiovascular disease (37%). Meta-analyses and trial sequential analyses reported that adding exercise to usual care reduced SBP [mean difference (MD) MD: -4.1 mmHg; 95% confidence interval (95% CI) -4.99 to -3.14; P  < 0.01; I2  = 95.3%] and DBP (MD: -2.6 mmHg; 95% CI -3.22 to -2.07, P  < 0.01; I2  = 94%). Test of interaction showed that the reduction of SBP and DBP was almost two times higher among trials from low-and middle-income countries (LMICs) as compared to high-income countries (HICs). The exercise induced SBP reduction was also higher among participants with hypertension and type 2 diabetes compared to participants with cardiovascular disease. The very low certainty of evidence warrants a cautious interpretation of the present results. CONCLUSION: Adding any type of exercise to usual care may be a potential complementary strategy for optimal management of blood pressure for patients with hypertension, type 2 diabetes, or cardiovascular disease, especially, in LMICs.PROSPERO registration number CRD42019142313.

The Danish-Norwegian randomized trial on beta-blocker therapy after myocardial infarction: Design, rationale, and baseline characteristics.

AIM: The evidence for beta-blocker therapy after myocardial infarction (MI) is randomized trials conducted more than 30 years ago, and the continued efficacy has been questioned. DESIGN AND METHODS: The ongoing Danish (DANBLOCK) and Norwegian (BETAMI) randomized beta-blocker trials are joined to evaluate the effectiveness and risks of long-term beta-blocker therapy after MI. Patients with normal or mildly reduced left ventricular ejection fraction (LVEF≥40%) will be randomized to open-label treatment with beta-blockers or no such therapy. This event-driven trial will randomize ∼5700 patients and continue until 950 primary endpoints have occurred. As of July 2023, 5228 patients have been randomized. Of the first 4000 patients randomized, median age was 62 years, 79% were men, 48% had a STEMI, and 84% had a normal LVEF. The primary endpoint is a composite of adjudicated recurrent MI, incident heart failure, coronary revascularization, ischemic stroke, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest. The primary safety endpoint includes a composite of recurrent MI, heart failure, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest 30 days after randomization. Secondary endpoints include each of the components of the primary endpoint, patient-reported outcomes, and other clinical outcomes linked to beta-blocker therapy. The primary analysis will be conducted according to the intention-to-treat principle using a Cox proportional hazards regression model. End of follow-up is expected in December 2024. CONCLUSION: The combined BETAMI-DANBLOCK trial will have the potential to affect current clinical practice for beta-blocker therapy in patients with normal or mildly reduced LVEF after MI.

The Prevalence of Polyneuropathy in Type 2 Diabetes Subgroups Based on HOMA2 Indices of ß-Cell Function and Insulin Sensitivity.

OBJECTIVE: Metabolic syndrome components may cumulatively increase the risk of diabetic polyneuropathy (DPN) in type 2 diabetes mellitus (T2DM) patients, driven by insulin resistance and hyperinsulinemia. We investigated the prevalence of DPN in three T2DM subgroups based on indices of ß-cell function and insulin sensitivity. RESEARCH DESIGN AND METHODS: We estimated ß-cell function (HOMA2-B) and insulin sensitivity (HOMA2-S) in 4,388 Danish patients with newly diagnosed T2DM. Patients were categorized into subgroups of hyperinsulinemic (high HOMA2-B, low HOMA2-S), classical (low HOMA2-B, low HOMA2-S), and insulinopenic (low HOMA2-B, high HOMA2-S) T2DM. After a median follow-up of 3 years, patients filled the Michigan Neuropathy Screening Instrument questionnaire (MNSIq) to identify DPN (score ≥ 4). We used Poisson regression to calculate adjusted prevalence ratios (PRs) for DPN, and spline models to examine the association with HOMA2-B and HOMA2-S. RESULTS: A total of 3,397 (77%) patients filled in the MNSIq. The prevalence of DPN was 23% among hyperinsulinemic, 16% among classical, and 14% among insulinopenic patients. After adjusting for demographics, diabetes duration and therapy, lifestyle behaviors, and metabolic syndrome components (waist circumference, triglycerides, HDL cholesterol, hypertension, and HbA1c), the PR of DPN was 1.35 (95% CI 1.15-1.57) for the hyperinsulinemic compared with the classical patients. In spline analyses, we observed a linear relation of higher DPN prevalence with increasing HOMA2-B, independent of both metabolic syndrome components and HOMA2-S. CONCLUSIONS: Hyperinsulinemia marked by high HOMA2-B is likely an important risk factor for DPN beyond metabolic syndrome components and insulin resistance. This should be considered when developing interventions to prevent DPN.

Lenient rate control versus strict rate control for atrial fibrillation: a statistical analysis plan for the Danish Atrial Fibrillation (DanAF) randomized clinical trial.

BACKGROUND: A key decision in the treatment of atrial fibrillation is choosing between a rhythm control strategy or a rate control strategy as the main strategy. When choosing rate control, the optimal heart rate target is uncertain. The Danish Atrial Fibrillation trial is a randomized, multicenter, two-group, superiority trial comparing strict rate control versus lenient rate control in patients with either persistent or permanent atrial fibrillation at inclusion. To prevent bias arising from selective reporting and data-driven analyses, we developed a predefined description of the statistical analysis. METHODS: The primary outcome of this trial is the physical component score of the SF-36 questionnaire. A total of 350 participants will be enrolled based on a minimal important difference of 3 points on the physical component score of the SF-36 questionnaire, a standard deviation of 10 points, a statistical power of 80% (beta of 20%), and an acceptable risk of type I error of 5%. All secondary, exploratory, and echocardiographic outcomes will be hypothesis-generating. The analyses of all outcomes will be based on the intention-to-treat principle. We will analyze continuous outcomes using linear regression adjusting for "site," type of atrial fibrillation at inclusion (persistent/ permanent), left ventricular ejection fraction (≥ 40% or < 40%), and the baseline value of the outcome (all as fixed effects). We define our threshold for statistical significance as a p-value of 0.05 and assessments of clinical significance will be based on the anticipated intervention effects defined in the sample size and power estimations. Thresholds for both statistical and clinical significance will be assessed according to the 5-step procedure proposed by Jakobsen and colleagues. DISCUSSION: This statistical analysis plan will be published prior to enrolment completion and before any data are available and is sought to increase the validity of the DANish Atrial Fibrillation trial. TRIAL REGISTRATION: Clinicaltrials.gov NCT04542785. Registered on Sept 09, 2020.

How Does Occupational Lifting Affect Ambulatory Blood Pressure, Relative Aerobic Workload and Level of Physical Activity?

INTRODUCTION: Occupational physical activity (OPA), including occupational lifting (OL), seems to increase the risk of cardiovascular disease (CVD). Knowledge about the association between OL and risk of CVD is sparse, but repeated OL is assumed to result in prolonged raised blood pressure and heart rate (HR) eventually augmenting the risk of CVD. To disentangle parts of the mechanisms behind the raised 24-hour ambulatory blood pressure measurement (24h-ABPM), by exposure to OL, this study aimed to explore the acute differences in 24h-ABPM, relative aerobic workload (RAW) and OPA across workdays with and without OL, and secondary to assess the feasibility and rater agreement of direct field observations of the frequency and load of occupational lifting. METHODS: This controlled cross-over study investigates associations between moderate to high OL and 24h-ABPM, RAW in per cent of heart rate reserve (%HRR) and level of OPA. This included 2x24h monitoring of 24h-ABPM (Spacelabs 90217), PA (Axivity) and HR (Actiheart), comprising a workday containing OL and a workday without. The frequency and burden of OL were directly observed in field. The data were time synchronized and processed in the Acti4 software. Differences across workdays with and without OL in 24h-ABPM, RAW and OPA were evaluated using repeated 2 × 2 mixed-models among 60 blue-collar workers in Denmark.. Exposure to OL was estimated by direct manual field observation, registering burden and frequency of OL. Interrater reliability tests were performed across 15 participants representing 7 occupational groups. Interclass correlation coefficient (ICC) estimates of total burden lifted and frequency of lifts were calculated, based on a mean-rating (k = 2), absolute-agreement, 2 way mixed-effects model, indicating the raters as fixed effects. RESULTS: OL led to non-significant increases in ABPM during work-time (systolic Δ1.79 mmHg, 95%CI -4.49-8.08, diastolic Δ0.43 mmHg, 95%CI -0.80-1.65), and on 24-hours basis (systolic Δ1.96 mmHg, 95%CI -3.80-7.72, diastolic Δ0.53 mmHg, 95%CI -3.12-4.18), significant increases in RAW during work (Δ7.74 %HRR, 95%CI 3.57-11.91) as well as a raised level of OPA (Δ4156.88 steps, 95%CI 1898.83-6414.93, Δ-0.67 hours of sitting time, 95%CI -1.25-0.10, Δ-0.52 hours of standing time, 95%CI -1.03-0.01, Δ0.48 hours of walking time, 95%CI 0.18-0.78). ICC estimates were 0.998 (95% CI 0.995-0.999) for total burden lifted and 0.992 (95% CI 0.975-0.997) for frequency of lift. DISCUSSION: OL increased both intensity and volume of OPA among blue-collar workers, which supposedly to contributes to an augmented risk of CVD. Although this study finds hazardous acute effects, further investigations are needed to evaluate the long-term effects of OL on ABPM, HR and volume of OPA, also effects of cumulative exposure to OL would be relevant to investigate. CONCLUSION: OL significantly raised the intensity and volume of OPA. Direct field observation of occupational lifting showed an excellent interrater reliability.

Retinal microvascular markers in type 2 diabetes subphenotypes and latent autoimmune diabetes of adults.

PURPOSE: To estimate if newly diagnosed patients with different subphenotypes of type 2 diabetes (T2DM) or latent autoimmune diabetes of adults (LADA) differ with respect to subclinical retinal microvascular structure or diabetic retinopathy (DR). METHODS: This population-based, cross-sectional study of 340 patients (675 eyes) classified patients with recently diagnosed T2DM in different subphenotypes according to beta cell function and insulin sensitivity in to; classical (n = 218), hyperinsulinaemic (n = 86), insulinopenic (n = 20), or LADA (n = 16). Retinal 6-field images were graded according to the International Clinical DR Severity Scale by a retinal expert. Retinal microvascular structures were analysed in eyes by a semiautomatic software. RESULTS: Median age and duration of diabetes were 58.1 (49.9; 65.5) and 0.9 (0.5; 2.4) years, respectively, and 56.8% were male. In a multivariate linear mixed model regression analysis of eyes without DR (n = 570), there was no statistically significant difference in retinal venular or arteriolar width between subtypes and patients with classical T2DM. In addition, eyes from different subphenotypes did not differ according to vessel density, tortuosity or fractal dimension. In a multivariate logistic regression model adjusted for age, sex, HbA1c, diabetes duration, body mass index, mean arterial blood pressure and history of cardiovascular disease, there was a tendency towards persons with hyperinsulinaemic T2DM to be more likely to have DR (OR 1.97, 95% CI 0.95; 4.09) compared to classical T2DM. CONCLUSION: We found no difference in retinal microvascular structure in patients with newly diagnosed subtypes of T2DM. However, DR may be more prevalent in newly diagnosed patients with hyperinsulinaemic T2DM compared to individuals with classical T2DM.

The influence of age and sex on the prognostic importance of traditional cardiovascular risk factors, selected circulating biomarkers and other markers of subclinical cardiovascular damage.

PURPOSE OF REVIEW: There is an increasing need for improved risk stratification to better individualize cardiovascular preventive measures. Although age and sex are strong and easily obtained cardiovascular risk factors (CVRFs), their influence on the prognostic importance of other CVRF, circulating biomarkers and other markers of subclinical cardiovascular damage has not previously been systematically and critically appraised. Therefore, we have revisited the European MORGAM and the Danish MONI10 cohorts. RECENT FINDINGS: Theoretically, the relative risk of many CVRF is expected to be lower in older healthy individuals due to a combination of selection bias by disease, higher absolute risk primarily due to older age, and the fact that the CVRF and markers may primarily influence or reflect early parts of the cardiovascular disease process. This influence of age may vary between sexes, as the cardiovascular disease process is delayed and possibly different in women compared with men. SUMMARY: Adjusted for the remaining Systematic COronary Risk Evaluation (SCORE) CVRF, higher SBP, serum cholesterol, soluble urokinase-type plasminogen activator receptor, left ventricular mass index and atherosclerotic plaques were more closely associated with outcomes in individuals younger than 52 years with some sex-specific differences, whereas higher N-terminal pro-brain natriuretic peptide and urine albumin/creatine ratio were more closely associated with outcomes in subjects aged 61 or 71 years.

Perceptions of pharmacists on the quality of automated blood pressure devices: a national survey.

A recent study found that only 23.8% of blood pressure (BP) devices available for purchase from Australian pharmacies were validated for accuracy. The extent to which pharmacists are aware of this, and other issues related to the accuracy of BP devices, is not known and gathering this information was the aim of this study. An online survey of Australian pharmacists was distributed via the Pharmaceutical Society of Australia between 1 October and 25 November 2020. Questions were focused on the views of pharmacists related to the accuracy of BP devices. Two hundred and ten pharmacists completed the survey. The accuracy of BP devices sold by pharmacists was considered 'quite' or 'extremely important' to most respondents (94%). However, most respondents (90%) were unaware that less than one-quarter of BP devices sold by Australian pharmacies were validated, and this was 'quite' or 'extremely surprising' to many (69%). Many respondents (64%) associated a particular brand of BP device with greater accuracy. There was low awareness on proper ways to identify accurate BP devices, such as checking reputable online databases (43%). BP devices were stocked in respondents' pharmacies based on perceived quality (50%), accuracy (40%), or as determined by the pharmacy chain (36%). In conclusion, providing accurate BP devices to consumers is important to pharmacists, but they were generally unaware that most devices available from pharmacies were not validated for accuracy. Pharmacist education, alongside advocacy for policies including regulations and strategic action, is required to ensure only validated BP devices are sold in Australia.

Effects of adding exercise to usual care in patients with either hypertension, type 2 diabetes or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis.

OBJECTIVE: To assess the beneficial and harmful effects of adding exercise to usual care for people with hypertension, type 2 diabetes mellitus and/or cardiovascular disease. DESIGN: Systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. DATA SOURCES: The CENTRAL, MEDLINE, EMBASE, Science Citation Index Expanded on Web of Science and BIOSIS searched from inception to July 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included all randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in participants with either hypertension, type 2 diabetes or cardiovascular disease irrespective of setting, publication status, year and language. OUTCOME AND MEASURES: The primary outcomes were all-cause mortality, serious adverse events and quality of life. DATA EXTRACTION AND SYNTHESIS: Five independent reviewers extracted data and assessed risk of bias in pairs. Our methodology was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Grading of Recommendations Assessment, Development and Evaluation and Cochrane Risk of Bias-version 1. RESULTS: We included 950 trials, of which 248 trials randomising 21 633 participants reported on our predefined outcomes. All included trials were at high risk of bias. The major types of exercise reported were dynamic aerobic exercise (126/248 trials), dynamic resistance exercise (25/248 trials), and combined aerobic and resistance exercise (58/248 trials). The study participants were included due to cardiovascular diseases (189/248 trials), type 2 diabetes (41/248 trials) or hypertension (16/248 trials). The median intervention period was 3 months (IQR: 2-4 months) and the median follow-up period was 6 months (IQR: 3-8 months) after randomisation. Meta-analyses and trial sequential analyses showed evidence of a beneficial effect of adding exercise to usual care when assessing all-cause mortality (risk ratio (RR) 0.82; 95% CI 0.73 to 0.93; I2=0%, moderate certainty of evidence) and serious adverse events (RR 0.79; 95% CI 0.71 to 0.88; I2=0%, moderate certainty of evidence). We did not find evidence of a difference between trials from different economic regions, type of participants, type of exercise or duration of follow-up. Quality of life was assessed using several different tools, but the results generally showed that exercise improved quality of life, but the effect sizes were below our predefined minimal important difference. CONCLUSIONS: A short duration of any type of exercise seems to reduce the risk of all-cause mortality and serious adverse events in patients with either hypertension, type 2 diabetes or cardiovascular diseases. Exercise seems to have statistically significant effects on quality of life, but the effect sizes seem minimal. PROSPERO REGISTRATION NUMBER: CRD42019142313.

Factors associated with blood pressure control in patients with hypertension and HIV at a large urban HIV clinic in Uganda.

Globally, people living with HIV on antiretroviral therapy have an increased risk of cardiovascular disease. Hypertension is the most important preventable risk factor for cardiovascular disease and is associated with increased morbidity. We conducted an exploratory survey with hypertensive persons living with HIV who received integrated HIV and hypertension care in a large clinic in Uganda between August 2019 and March 2020 to determine factors associated with blood pressure control at six months. Controlled blood pressure was defined as <140/90 mmHg. Multivariable logistic regression was used to determine baseline factors associated with blood pressure control after 6 months of antihypertensive treatment. Of the 1061 participants, 644 (62.6%) were female. The mean age (SD) was 51.1 (9.4) years. Most participants were overweight (n = 411, 38.7%) or obese (n = 276, 25.9%), and 98 (8.9%) had diabetes mellitus. Blood pressure control improved from 14.4% at baseline to 66.1% at 6 months. Comorbid diabetes mellitus (odds ratio (OR) = 0.41, 95% confidence interval (CI) = 0.26-0.64, p < 0.001) and HIV status disclosure (OR = 0.73, 95% CI = 0.55-0.98, p = 0.037) were associated with the absence of controlled blood pressure at 6 months. In conclusion, comorbid diabetes mellitus and the disclosure of an individual's HIV status to a close person were associated with poor blood pressure control among persons living with HIV who had hypertension. Therefore, subpopulations of persons living with HIV with hypertension and comorbid diabetes mellitus may require more thorough assessments and intensive antihypertensive management approaches to achieve blood pressure targets.

Atypical presentation of severe pre-eclampsia with sinus bradycardia and chest pain.

This is a case report of an observation of bradycardia and inverted T-waves anteroseptally on the electrocardiogram along with cardiac symptoms, in a previously healthy 35-year-old woman with post-partum pre-eclampsia. Initially, she had no hypertension or proteinuria, which delayed the time of diagnosis. A possible explanation of bradycardia is a baroreceptor-mediated response to hypertension and hypervolaemia. The changes on the electrocardiogram can be explained by pectus excavatum, an enlarged uterus and endothelial dysfunction. One should always consider peri-partum as well as post-partum pre-eclampsia.

Long-term Weight Loss in a Primary Care-Anchored eHealth Lifestyle Coaching Program: Randomized Controlled Trial.

BACKGROUND: Long-term weight loss in people living with obesity can reduce the risk and progression of noncommunicable diseases. Observational studies suggest that digital coaching can lead to long-term weight loss. OBJECTIVE: We investigated whether an eHealth lifestyle coaching program for people living with obesity with or without type 2 diabetes led to significant, long-term (12-month) weight loss compared to usual care. METHODS: In a randomized controlled trial that took place in 50 municipalities in Denmark, 340 people living with obesity with or without type 2 diabetes were enrolled from April 16, 2018, to April 1, 2019, and randomized via an automated computer algorithm to an intervention (n=200) or a control (n=140) group. Patients were recruited via their general practitioners, the Danish diabetes organization, and social media. The digital coaching intervention consisted of an initial 1-hour face-to-face motivational interview followed by digital coaching using behavioral change techniques enabled by individual live monitoring. The primary outcome was change in body weight from baseline to 12 months. RESULTS: Data were assessed for 200 participants, including 127 from the intervention group and 73 from the control group, who completed 12 months of follow-up. After 12 months, mean body weight and BMI were significantly reduced in both groups but significantly more so in the intervention group than the control group (-4.5 kg, 95% CI -5.6 to -3.4 vs -1.5 kg, 95% CI -2.7 to -0.2, respectively; P<.001; and -1.5 kg/m2, 95% CI -1.9 to -1.2 vs -0.5 kg/m2, 95% CI -0.9 to -0.1, respectively; P<.001). Hemoglobin A1c was significantly reduced in both the intervention (-6.0 mmol/mol, 95% CI -7.7 to -4.3) and control (-4.9 mmol/mol, 95% CI -7.4 to -2.4) groups, without a significant group difference (all P>.46). CONCLUSIONS: Compared to usual care, digital lifestyle coaching can induce significant weight loss for people living with obesity, both with and without type 2 diabetes, after 12 months. TRIAL REGISTRATION: ClinicalTrials.gov NCT03788915; https://clinicaltrials.gov/ct2/show/NCT03788915.