Effect of air pollutants on ambulatory blood pressure.

BACKGROUND AND METHODOLOGY: Air pollutants have a significant impact on public health. The aim of the study was to find out the relationship between ambulatory blood pressure measured by 24-h ambulatory blood pressure monitoring (ABPM) and the atmospheric pollutants that are measured regularly (PM10, PM2.5, NO2 and SO2). An observational study of temporal and geographic measurements of individual patients (case-time series design) was carried out in Primary Care Centres and Hypertension Units in the Barcelona metropolitan area. We included 2888 hypertensive patients≥18 years old, untreated, with a first valid ABPM performed between 2005 and 2014 and with at least one air pollution station within a radius of <3km. RESULTS AND CONCLUSIONS: The mean age was 54.3 (SD 14.6) years. 50.1% were women and 16.9% of the sample were smokers. Mean 24-h blood pressure (BP) was 128.0 (12.7)/77.4 (9.7) mmHg. After adjusting for mean ambient temperature and different risk factors, a significant association was found between ambulatory diastolic BP (DBP) and PM10 concentrations the day before ABPM. For each increase of 10µg/m3 of PM10, an increase of 1.37mmHg 24-h DBP and 1.48mmHg daytime DBP was observed. No relationship was found between PM2.5, NO2 and SO2 and ambulatory BP, nor between any pollutant and clinical BP. The concentration of PM10 the day before the ABPM is significantly associated with an increase in 24-h DBP and daytime DBP.

[2022 Practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension]. / Guía práctica sobre el diagnóstico y tratamiento de la hipertensión arterial en España, 2022. Sociedad Española de Hipertensión - Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA).

Hypertension is the most important risk factor for global disease burden. Detection and management of hypertension are considered as key issues for individual and public health, as adequate control of blood pressure levels markedly reduces morbidity and mortality associated with hypertension. Aims of these practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension include offering simplified schemes for diagnosis and treatment for daily practice, and strategies for public health promotion. The Spanish Society of Hypertension assumes the 2018 European guidelines for management of arterial hypertension developed by the European Society of Cardiology and the European Society of Hypertension, although relevant aspects of the 2017 American College of Cardiology/American Heart Association guidelines and the 2020 International Society of Hypertension guidelines are also commented. Hypertension is defined as a persistent elevation in office systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg, and assessment of out-of-office blood pressure and global cardiovascular risk are considered of key importance for evaluation and management of hypertensive patients. The target for treated blood pressure should be < 130/80 for most patients. The treatment of hypertension involves lifestyle interventions and drug therapy. Most people with hypertension need more than one antihypertensive drug for adequate control, so initial therapy with two drugs, and single pill combinations are recommended for a wide majority of hypertensive patients.

[Position statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)]. / Documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) sobre monitorización ambulatoria de la presión arterial (MAPA) 2019.

Conventional blood pressure (BP) measurement in clinical practice is the most used procedure for the diagnosis and treatment of hypertension (HT), but is subject to considerable inaccuracies due to, on the one hand, the inherent variability of the BP itself and, on the other hand biases arising from the measurement technique and conditions, Some studies have demonstrated the prognosis superiority in the development of cardiovascular disease using ambulatory blood pressure monitoring (ABPM). It can also detect "white coat" hypertension, avoiding over-diagnosis and over-treatment in many cases, as well detecting of masked hypertension, avoiding under-detection and under-treatment. ABPM is recognised in the diagnosis and management of HT in most of international guidelines on hypertension. The present document, taking the recommendations of the European Society of Hypertension as a reference, aims to review the more recent evidence on ABPM, and to serve as guidelines for health professionals in their clinical practice and to encourage ABPM use in the diagnosis and follow-up of hypertensive subjects. Requirements, procedure, and clinical indications for using ABPM are provided. An analysis is also made of the main contributions of ABPM in the diagnosis of "white coat" and masked HT phenotypes, short term BP variability patterns, its use in high risk and resistant hypertension, as well as its the role in special population groups like children, pregnancy and elderly. Finally, some aspects about the current situation of the Spanish ABPM Registry and future perspectives in research and potential ABPM generalisation in clinical practice are also discussed.

Study of arterial stiffness in patients with an acute coronary event and chronic obstructive pulmonary disease confirmed by spirometry. / Estudio de la rigidez arterial en pacientes con un evento coronario agudo y enfermedad pulmonar obstructiva crónica confirmada por espirometría.

BACKGROUND AND OBJECTIVES: Chronic obstructive pulmonary disease (COPD) worsens the prognosis for patients with an acute coronary event (ACE) treated with percutaneous coronary intervention. Objective To assess the effect of COPD on arterial stiffness in patients with an ACE. METHODS: The study included patients with an ACE treated with percutaneous coronary intervention. At 1 month, postbronchodilation spirometry was performed, and arterial stiffness and markers of myocardial damage (troponin T and ProBNP) were measured. RESULTS: We included 68 patients, 33% of whom had COPD (59% undiagnosed). The patients with COPD presented higher arterial stiffness values after adjusting for age and blood pressure readings. The troponin T and ProBNP levels were higher in the patients with COPD. CONCLUSIONS: Arterial stiffness is greater in patients with an ACE if they have concomitant COPD. These findings can help explain the poorer prognosis of patients with both conditions.

[Spanish Society of Hypertension position statement on the 2017 ACC/AHA hypertension guidelines]. / Documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) sobre las guías ACC/AHA 2017 de hipertensión arterial.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently published their guidelines for the prevention, detection, evaluation, and management of hypertension in adults. The most controversial issue is the classification threshold at 130/80mmHg, which will allow a large number of patients to be diagnosed as hypertensive who were previously considered normotensive. Blood pressure (BP) is considered normal (<120mmHg systolic and <80mmHg diastolic), elevated (120-129 and <80mmHg), stage 1 (130-139 or 80-89mmHg), and stage 2 (≥140 or ≥90mmHg). Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. In management, cardiovascular risk would be determinant since those with grade 1 hypertension and an estimated 10-year risk of atherosclerotic cardiovascular disease ≥10%, and those with cardiovascular disease, chronic kidney disease and/or diabetes will require pharmacological treatment, the rest being susceptible to non-pharmacological treatment up to the 140/90mmHg threshold. These recommendations would allow patients with level 1 hypertension and high atherosclerotic cardiovascular disease to benefit from pharmacological therapies and all patients could also benefit from improved non-pharmacological therapies. However, this approach should be cautious because inadequate BP measurement and/or lack of systematic atherosclerotic cardiovascular disease calculation could lead to overestimation in diagnosing hypertension and to overtreatment. Guidelines are recommendations, not impositions, and the management of hypertension should be individualized, based on clinical decisions, preferences of the patients, and an adequate balance between benefits and risks.

[Ambulatory blood pressure monitoring is a useful tool for all patients]. / La monitorización ambulatoria de la presión arterial es un instrumento aconsejable para todos los pacientes.

Clinical blood pressure measurement (BP) is an occasional and imperfect way of estimating this biological variable. Ambulatory blood pressure monitoring (ABPM) is by far the best clinical tool for measuring an individual's blood pressure. Mean values over 24h, through the daytime and at night all make it more possible to predict organic damage and the future development of the disorder. ABPM enables the detection of white-coat hypertension and masked hypertension in both the diagnosis and follow-up of treated patients. Although some of the advantages of ABPM can be reproduced by more automated measurement without the presence of an observer in the clinic or self-measurement at home, there are some other elements of great interest that are unique to ABPM, such as seeing what happens to a patient's BP at night, the night time dipping pattern and short-term variability, all of which relate equally to the patient's prognosis. There is no scientific or clinical justification for denying these advantages, and ABPM should form part of the evaluation and follow-up of practically all hypertensive patients. Rather than continuing unhelpful discussions as to its availability and acceptability, we should concentrate our efforts on ensuring its universal availability and clearly explaining its advantages to both doctors and patients.

Modification over time of pulse wave velocity parallel to changes in aortic BP, as well as in 24-h ambulatory brachial BP.

Arterial stiffness as assessed by carotid-femoral pulse wave velocity (cfPWV) is a marker of preclinical organ damage and a predictor of cardiovascular outcomes, independently of blood pressure (BP). However, limited evidence exists on the association between long-term variation (Δ) on aortic BP (aoBP) and ΔcfPWV. We aimed to evaluate the relationship of ΔBP with ΔcfPWV over time, as assessed by office and 24-h ambulatory peripheral BP, and aoBP. AoBP and cfPWV were evaluated in 209 hypertensive patients with either diabetes or metabolic syndrome by applanation tonometry (Sphygmocor) at baseline(b) and at 12 months of follow-up(fu). Peripheral BP was also determined by using validated oscillometric devices (office(o)-BP) and on an outpatient basis by using a validated (Spacelabs-90207) device (24-h ambulatory BP). ΔcfPWV over time was calculated as follows: ΔcfPWV=[(cfPWVfu-cfPWVb)/cfPWVb] × 100. ΔBP over time resulted from the same formula applied to BP values obtained with the three different measurement techniques. Correlations (Spearman 'Rho') between ΔBP and ΔcfPWV were calculated. Mean age was 62 years, 39% were female and 80% had type 2 diabetes. Baseline office brachial BP (mm Hg) was 143±20/82±12. Follow-up (12 months later) office brachial BP (mm Hg) was 136±20/79±12. ΔcfPWV correlated with ΔoSBP (Rho=0.212; P=0.002), Δ24-h SBP (Rho=0.254; P<0.001), Δdaytime SBP (Rho=0.232; P=0.001), Δnighttime SBP (Rho=0.320; P<0.001) and ΔaoSBP (Rho=0.320; P<0.001). A multiple linear regression analysis included the following independent variables: ΔoSBP, Δ24-h SBP, Δdaytime SBP, Δnighttime SBP and ΔaoSBP. ΔcfPWV was independently associated with Δ24-h SBP (ß-coefficient=0.195; P=0.012) and ΔaoSBP (ß-coefficient= 0.185; P=0.018). We conclude that changes in both 24-h SBP and aoSBP more accurately reflect changes in arterial stiffness than do office BP measurements.

Heart rate and heart rate variability in resistant versus controlled hypertension and in true versus white-coat resistance.

Sympathetic nervous system has an important role in resistant hypertension. Heart rate (HR) is a marker of sympathetic activity, but its association with resistant hypertension has not been assessed. We aimed to evaluate differences in HR values and variability between resistant and controlled patients and between true and white-coat resistant hypertensives (RHs). We compared office and ambulatory HR, nocturnal dip and s.d. in 14,627 RHs versus 11,951 controlled patients (on ⩽ 3 drugs) and in 8730 true (24 h blood pressure (BP) ⩾ 130 and/or 80 mm Hg) versus 4825 white-coat (24-h BP < 130/80 mm Hg) RHs. After adjusting for age, gender, body mass index, diabetes status and beta blocker use, HR values and variability were significantly elevated in resistant versus controlled patients and in true versus white-coat RHs. In logistic regression models, after adjustment for confounders, office HR (odds ratio for each increase in tertile: 1.337; 95% confidence interval: 1.287-1.388; P < 0.001), nocturnal dip (0.958; 0.918-0.999; P = 0.035) and night time s.d. (1.115; 1.057-1.177; P = 0.013) were all significantly associated with the presence of resistant hypertension. Moreover, night time HR (1.160; 1.065-1.265; P < 0.001), nocturnal dip (0.876; 0.830-0.925; P < 0.001) and 24-h s.d. (1.148; 1.092-1.207; P < 0.001) were all significantly associated with true resistant hypertension. In conclusion, both increased HR and variability are associated with resistant hypertension and with true resistance. These suggest the involvement of the sympathetic nervous system in the development of resistance to antihypertensive treatment.

Resistant hypertension: patient characteristics, risk factors, co-morbidities and outcomes.

Among the vast population of hypertensive subjects, between 10 and 15% do not achieve an adequate blood pressure (BP) control despite the use of at least three antihypertensive agents. This group, designated as having resistant hypertension (RH), represents one of the most important clinical challenges in hypertension evaluation and management. Resistant hypertensives are characterized by several clinical particularities, such as a longer history of hypertension, obesity and other accompanying factors, such as diabetes, left ventricular hypertrophy, albuminuria and renal dysfunction. In addition to other diagnostic and therapeutic maneuvers, such as excluding secondary hypertension, ensuring treatment adherence and optimizing therapeutic schemes, ambulatory BP monitoring (ABPM) is crucial in the clinical evaluation of patients with RH. ABPM distinguish between those with out-of-office BP elevation (true resistant hypertensives) and those having white-coat RH (WCRH; normalcy of 24-h BPs), the prevalence of the latter estimated in about one-third of the population with RH. True resistant hypertensives also exhibit more frequently other co-morbidities, more severe target organ damage and a worse cardiovascular prognosis, in comparison to those with WCRH. Some device-based therapies have recently been developed for treatment of RH. This requires a better characterization of a potential candidate population. A better knowledge of the clinical features of resistant hypertensive subjects, the confirmation of elevated BP values out of the doctor's office, and improvements in the search for secondary causes would help to select those candidates for newer therapies, once the pharmacological possibilities have been exhausted.

Resistant hypertension.

UNLABELLED: A 53 year old woman with hypercholesterolemia treated with statins, with no history of cardiovascular disease, was referred to the Hypertension and Vascular Risk Unit for management of hypertension resistant to 4 antihypertensive agents at full doses. The patient had obesity, with a body mass index of 36.3kg/m(2) and office blood pressure 162/102mm Hg. Physical examination showed no data of interest. ANALYSIS: glucose 120mg/dl, glycated Hb: 6.4%, albuminuria 68mg/g, kidney function and study of the renin angiotensin system and other biochemical parameters were normal. Echocardiography: left ventricular mass, 131g/m(2) (normal, <110g/m(2)). True resistant hypertension was confirmed by ambulatory monitoring of blood pressure during 24h (153/89mm Hg). Spironolactone treatment (25mg/day) was added and was well tolerated, with no change in renal function and kaliemia within normal (4.1mmol/l) following the treatment. After 8 weeks, blood pressure was well controlled: office blood pressure 132/86mm Hg and 24h-ambulatory blood pressure: 128/79mm Hg.

[Determination of urinary albumin excretion in arterial hypertension]. / Determinación de la excreción urinaria de albúmina en la hipertensión arterial.

BACKGROUND AND AIM: Urinary albumin excretion (UAE) measurement is recommended in the diagnosis and follow-up of the hypertensive patient. The aim of the study was to evaluate the proportion of hypertensives attended in Primary Care who had an evaluation of UAE in the last year, along with the methodology of the measurement. PATIENTS AND METHODS: A total of 958 investigators consecutively recruited 4786 hypertensives (first five patients who attended). When present, the measurement of UAE during the last year was obtained from clinical records. In those having this measurement, the type of urine collection (24hours, nighttime or morning spot), as well as the value and units of measure (mg/24h, µg/min, mg/g or mg/L) were recorded. RESULTS: Mean age was 66 years. 51% were men and 49% women. UAE was determined in 2301 patients (48.1%). In 329, 24-hour urine was collected, nighttime urine in 122 and in 1850 the collection came from a morning spot sample. However, only 696 patients from the latter group had the value of albumin corrected by the creatinine excretion. Thus, only 24% of hypertensive patients had a valid UAE measurement (mg/24h, µg/min or mg/g). Prevalence of microalbuminuria was 36%. The UAE determination was associated with older age, obesity, diabetes and better blood pressure control rates. CONCLUSION: Only half of hypertensive patients have a UAE measurement and in only 1 out of 4 a validated methodology has been used. It seems necessary a reinforcement of the messages contained in guidelines, as well as its applicability to any particular setting in order to promote a generalized and correct evaluation of UAE in hypertension.

[Prevention of progression and regression of target organ damage. Future strategies]. / Prevención de la progresión y regresión de la lesión orgánica. Estrategias de futuro.

Treatment with renin-angiotensin system blockers (angiotensin converting-enzyme inhibitors and AT1 receptor antagonists) has shown clear benefits in distinct stages of cardiovascular disease (CVD). This treatment lowers blood pressure and prevents the appearance of markers of subclinical disease such as microalbuminuria, reduces cardiovascular and renal episodes in patients with subclinical lesions and prolongs survival in patients with clinical disease or organ dysfunction. Despite this unquestionable benefit, the residual risk in patients receiving these treatments often continues to be highly elevated and consequently strategies to reduce this risk are required. The present article reviews the options that may help to reduce cardiovascular disease. In addition to renin-angiotensin system blockers, these treatments include primary prevention in healthy individuals, stricter therapeutic goals, comprehensive risk control, more complete blocking of the renin-angiotensin system and the use of drugs with synergistic protective mechanisms.

Endothelial dysfunction is associated with increased levels of biomarkers in essential hypertension.

To assess the correlation between endothelial dysfunction and the serum levels of biomarkers of inflammation, remodelling and oxidative stress in essential hypertension, 78 treatment-naïve essential hypertensives (mean age 43 years) underwent measurement of endothelial dysfunction, using the maximal acetylcholine-induced forearm vasodilation and serum levels of adhesion molecules, selectins, chemokines, metalloproteinases, copper, zinc, selenium, vitamins, homocysteine, malondialdehyde, erythrocyte glutathione peroxidase and erythrocyte superoxide dismutase. Mean (+/-s.e.m.) maximal acetylcholine-induced vasodilation was 367+/-20%. Patients with a more impaired acetylcholine-dependent vasodilation (first tertile) had increased levels of e-selectin (P=0.009), p-selectin (P<0.001), monocyte chemotactic protein type 1 (MCP-1; P=0.012) and the tissue inhibitor of metalloproteinases type 1 (TIMP-1; P=0.044), which in turn showed significant inverse correlations with maximal endothelium-dependent vasodilation. Serum levels of selenium (P=0.012), vitamin C (P=0.038), erythrocyte glutathione peroxidase (P<0.001) and superoxide dismutase (P=0.022) activities were reduced in patients with a more impaired endothelium-dependent vasodilation. Recently diagnosed treatment-naïve essential hypertensives showed a relationship between the endothelial dysfunction, serum markers of inflammation and remodelling and levels of antioxidant substances. These could be potentially helpful markers of high risk in hypertensive patients.

Urinary albumin excretion is associated with true resistant hypertension.

Resistant (or refractory) hypertension (RH) is a clinical diagnosis based on blood pressure (BP) office measurements. About one third of subjects with suspected RH have indeed pseudo-resistant hypertension and 24-h ambulatory-blood pressure-monitoring aids to precisely identify them. Our aim was to determine those clinical, laboratory or echocardiographic variables that may be associated with subjects with sustained hypertension (namely true RH). We carried out a cross-sectional analysis of 143 patients consecutively enrolled with the clinical diagnosis of RH. All patients underwent clinical-demographic, laboratory evaluation, 2D-echocardiography and 24-h ambulatory-blood pressure-monitoring. Pseudo-resistant hypertension or white-coat RH was defined if office BP was > or =140 and/or 90 mm Hg and 24-h BP <130/80 mm Hg. One-hundred and three (72%) patients had true RH and 40 (28%) patients had white-coat RH. True RH patients had significantly higher diabetes prevalence and higher office-systolic blood pressure (SBP) levels. Regarding target organ damage, left ventricular mass index (LVMI) and 24-h urinary albumin excretion (UAE) were also higher in true RH after adjustment for possible confounders (P=0.031 and P=0.012, respectively). In a logistic regression analysis, only office-SBP (multivariate OR (95%CI): 1.030 (1.003-1.057), P=0.030) and UAE (multivariate OR (95% CI): 2.376 (1.225-4.608), P=0.010) were independently associated with true RH. We conclude that true resistant hypertension is associated with silent target organ damage, especially UAE. In patients with suspected RH, assessment of 24 h ambulatory BP is the most accurate way to detect a population with high risk for target-organ damage.

Mitigation of calcium channel blocker-related oedema in hypertension by antagonists of the renin-angiotensin system.

This review is aimed at examining calcium channel blocker (CCB)-related oedema and how this can be attenuated through the use of agents that inhibit the renin-angiotensin system. CCBs are effective antihypertensive agents, but their propensity for causing oedema may reduce compliance. A review of the literature has indicated that the absolute incidence of this side effect is difficult to determine because reported rates vary widely, a factor that may stem from differences in the surveillance technique (active vs passive). In a recent trial incorporating active surveillance, 25% of patients who received amlodipine 10 mg per day experienced oedema. CCB-induced oedema is caused by increased capillary hydrostatic pressure that results from preferential dilation of pre-capillary vessels. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) cause post-capillary dilation and normalize hydrostatic pressure, and are thus ideally suited for prevention/reversal of CCB-induced oedema. The efficacy of this strategy was proven using both subjective and objective techniques. ARB/CCB and ACEI/CCB combination therapy is also more effective than CCB monotherapy in controlling blood pressure. These combinations represent an important advance in the management of hypertension.

Control of hypertension in coronary heart disease.

This observational study investigates, for the first time, the actual or out-of-office control of hypertension among coronary heart disease (CHD) patients, by using 24-h ambulatory BP monitoring (ABPM). We used the Spanish Society of Hypertension ABPM Registry, based on a large-scale network of primary-care physicians consecutively recruiting hypertensive patients with conventional clinical indications for ABPM. The average of two office BP measurements was used for analyses. Thereafter, 24-h ABPM was performed, using a SpaceLabs 90207 device. Out-of-office control of hypertension among 2434 treated essential hypertensive patients with clinically documented CHD was much higher (46.4%) than in-office BP control (28.7%). This considerable difference was partly due to the presence of 25.2% of patients with "office resistance", i.e., normal ambulatory BP but with high office BP despite treatment. Although further efforts in controlling BP are needed in CHD patients, physicians should be also comforted by BP results better than previously believed based on office data.

Chronic hypotension in hemodialysis patients: role of functional vascular changes and vasodilator agents.

AIMS: The aim of this study was to evaluate the hemodynamic pattern, vascular compliance, as well as the levels of vasoregulatory hormones and markers of inflammation and oxidative stress in a group of chronic hypotensive (CH) patients undergoing hemodialysis (HD) and to compare them with a group of normotensive HD patients. MATERIAL AND METHODS: 14 normotensive and 10 CH hemodialysis patients were included in the study. Hemodynamic characteristics were evaluated by means of the pulse waveform analysis. Plasma levels of nitrites, interleukin-6 (IL-6), malondialdehyde (MDA), PTH-related peptide (PTHrp), catecholamines, angiotensin II and endothelin were measured. RESULTS: Blood pressure (BP) and peripheral vascular resistances (PVR) were lower in the hypotensive group (p < 0.001 and p = 0.005, respectively), whereas cardiac output was similar in both groups. Large (C1) (p = 0.001) and small (C2) (p = 0.022) artery elasticity indices were higher in hypotensive patients. In the whole group, C1 and C2 inversely correlated with mean BP (MBP). Plasma levels of nitrites (p = 0.011) were higher in hypotensive patients and inversely correlated with MBP (r = -0.516, p = 0.012). Time on HD correlated with plasma nitrites (r = 0.478, p = 0.024) and inversely with MBP (r = -0.598, p = 0.003). CONCLUSIONS: CH in HD patients is characterized by decreased PVR, a preserved cardiac output and greater vascular compliance. CH is associated with longer time on HD and higher plasma levels of nitrites/nitrates, suggesting that an enhanced production of nitric oxide induced by long-term HD, could be involved in CH. These findings suggest that functional vascular changes, likely related to an enhanced production of vasodilator agents, are responsible for CH in HD patients.