Christina Antza

New developments in the pathogenesis of obesity-induced hypertension

Obesity is a disorder that develops from the interaction between genotype and environment involving social, behavioral, cultural, and physiological factors. Obesity increases the risk for type 2 diabetes mellitus, hypertension, cardiovascular disease, cancer, musculoskeletal disorders, chronic kidney and pulmonary disease. Although obesity is clearly associated with an increased prevalence of hypertension, many obese individuals may not develop hypertension. Protecting factors may exist and it is important to understand why obesity is not always related to hypertension. The aim of this review is to highlight the knowledge gap for the association between obesity, hypertension, and potential genetic and racial differences or environmental factors that may protect obese patients against the development of hypertension and other co-morbidities. Specific mutations in the leptin and the melaninocortin receptor genes in animal models of obesity without hypertension, the actions of α-melanocyte stimulating hormone, and SNS activity in obesity-related hypertension may promote recognition of protective and promoting factors for hypertension in obesity. Furthermore, gene-environment interactions may have the potential to modify gene expression and epigenetic mechanisms could also contribute to the heritability of obesity-induced hypertension. Finally, differences in nutrition, gut microbiota, exposure to sun light and exercise may play an important role in the presence or absence of hypertension in obesity.

Comparison Among Recommendations for the Management of Arterial Hypertension Issued by Last US, Canadian, British and European Guidelines

Guidelines for the management of hypertension have been issued by different hypertension societies or organizations. Despite many similarities one can identify major differences in the diagnosis, management and treatment of the hypertensive patients among ESH/ESC, NICE, Canadian and NJC8 guidelines. Differences that can be identified are in the definition of hypertension in the elderly population, the optimal blood pressure targets in different hypertensive populations such as patients with diabetes and chronic kidney disease patients and the choose of the initial and appropriate antihypertensive agent depending on comorbidities of the treated population. Everyday clinical praxis physicians are confused by these differences and these incongruities contribute to doctor and patient inertia to reduce blood pressure levels at an optimal level. Community physicians cannot easily distinguish what recommendations are the best to be used for their patients. The critical view of these differences can also help the guidelines committees to make appropriate changes and finally to agree to a global view of recommendations for the management and treatment of hypertension.

Screening for Malnutrition Among People Accessing Health Services at Greek Public Hospitals: Results From an Observational Multicenter Study.

BACKGROUND Malnutrition is associated with increased hospital stay and subsequently higher healthcare costs. Early detection of malnutrition among people accessing health services at public hospitals is vital to identify and treat malnutrition effectively and in a timewise and cost-effective manner. The aim of this study was to evaluate the nutrition risk of this population. MATERIALS AND METHODS Nutrition screening was performed for 2970 patients (52% male; 55.3 ± 20.1 years old) at 34 hospitals. Nutrition risk was evaluated through 3 nutrition screening tools-Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), and Mini Nutritional Assessment-Screening Form (MNA-SF). RESULTS Malnutrition risk was found: 25.3% with NRS-2002, 22.9% with MUST, and 60.5% with MNA-SF. Nutrition risk among patients accessing health services at public hospitals increases with age (high-risk patients among those ≥80 years old: NRS-2002, 9.8%; MUST, 16.9%; MNA-SF, 43.9%). The highest prevalence of nutrition risk was found at the oncology departments (16.7%, NRS-2002; 23.4%, MUST). According to the NRS-2002 and MUST, surgical patients have a greater risk for malnutrition vs internal medicine patients (adjusted odds ratio [OR] = 1.0, P < .001; adjusted OR = 1.17, P < .001, respectively), whereas according to MNA-SF, surgical patients have 30% lower probability for malnutrition risk against internal medicine patients (adjusted OR = 0.7, P < .001). CONCLUSIONS A high prevalence of malnutrition risk was reported among patients accessing health services at public hospitals. Early detection of malnutrition is vital to allow the allocation of the needed workforce to manage it effectively.

Obesity-Induced Hypertension: New Insights

BACKGROUND New insights on the relationship between weight loss and hypertension and the role of the newly approved anti-obesity drugs on hypertension will be discussed Methods: Weight loss is a major factor to reduce blood pressure when a patient with excess weight is advised from the health care provider to change his lifestyle. A healthy lifestyle with reduction in body weight, reduction in caloric intake, increased fruit and vegetables consumption and reduced salt intake concomitant with an increase in physical exercise can reduce body weight and hypertension in overweight and obese patients, but not all obese are able to reduce their blood pressure and lose weight without treatment and special dietary care. Moreover, most obese people lose weight for a small period and then they regain all the weight that they have lost or even worse, they increase their weight more than before starting a diet. Newly-approved weight loss drugs have variable actions on high blood pressure. Liraglutide and phentermine/topiramate seem to reduce hypertension, while after the bupropion/naltrexone or lorcaserin use trials reported a rise in blood pressure. CONCLUSION Reduction in body weight with treatment is not always associated with reduction in obesity induced hypertension. Weight loss treatments that exhibit sympathomimetic or adrenergic actions should be used with care and for short periods of time.

Early Vascular Aging: A New Target for Hypertension Treatment.

Vascular aging represents a progressive procedure involving biochemical, enzymatic, and cellular changes of the vascular tree. Early vascular aging (EVA), is defined as the inappropriate for age of vascular damage. Increased for age arterial stiffness is a biomarker that should be considered as a cardiovascular (CV) risk factor that can be manipulated. EVA is a new tool for guidance in everyday clinical praxis for patients at increased CV risk or a positive family history of early onset of cardiovascular events, such as stroke or coronary artery disease. Understanding the mechanisms promoting or protecting from EVA, a process that is in close relationship with CV diseases. The role of hypertension treatment against the development of vascular damage is important and different strategies could have a considerable impact on future vascular health.

Combination therapy with lercanidipine and enalapril in the management of the hypertensive patient: an update of the evidence.

Hypertension is an important risk factor for premature death as it increases the probability of stroke, myocardial infarction, and heart failure. Antihypertensive drugs can decrease cardiovascular (CV) morbidity and mortality. The majority of hypertensive patients need more than one antihypertensive agent to attain blood pressure (BP) targets. Monotherapy can effectively reduce BP only in 20%–40% of patients. Multiple mechanisms including increased peripheral vascular resistance, increased cardiac work, and hypervolemia are involved in the pathogenesis of hypertension. Targeting multiple pathways may more potently reduce BP. Increasing the dose of a single agent in many cases does not provide the expected BP-lowering effect because the underlying mechanism of the BP increase is either different or already corrected with the lower dose. Moreover, drugs acting on different pathways may have synergistic effects and thus better control hypertension. It is well known that diuretics enhance the actions of renin–angiotensin aldosterone system and activate it as a feedback to the reduced circulated blood volume. The addition of a renin–angiotensin aldosterone system blocker to a diuretic may more effectively reduce BP because the system is upregulated. Reducing the maximal dose of an agent may also reduce possible side effects if they are dose dependent. The increased prevalence of peripheral edema with higher doses of calcium channel blockers (CCBs) is reduced when renin–angiotensin aldosterone system blockers are added to CCBs through vein dilation. The effectiveness of the combination of enalapril with lercanidipine in reducing BP, the safety profile, and the use of the combination of angiotensin-converting enzyme inhibitors with CCBs in clinical trials with excellent CV hard end point outcomes make this combination a promising therapy in the treatment of hypertension.

PREVALENCE OF BP ELEVATION IN A SCHOOL-BASED POPULATION SCREENING: THE KASTORIA STUDY

Objective: We assessed the prevalence of high blood pressure (BP) in a school based screening study according to the ESH 2016 guideline diagnostic thresholds. Moreover, risk factors for BP elevation in childhood and adolescence, as well as geographic and seasonal risk factors, were investigated for their effect on BP population screening. Design and method: We performed a school-based BP screening study in the municipality of Kastoria in north Greece an area with 50,322 inhabitants. All schools in the municipality were visited during 2013–2016. A trained physician measure BP thrice by a mercury sphygmomanometer according to ESH 2016 guidelines and the last two BPs of this single occasion were averaged for the analysis. Personal history was recorded. Anthropometric measurements were obtained and obesity was defined according to IOFT criteria. Results: 2,832 children and adolescents aged 6–18 years participated in the study. The prevalence of high-normal BP and hypertension in the population was 3.7% and 0.9%, respectively, according to ESH 2016 BP classification. Thirty one % of the population was overweight (22.9%) or obese (9.5%). Among participants with BP elevation, 56.1% of the participants presenting high-normal BP, 55.5% hypertensive and 66.7% isolated systolic hypertensive BP levels were overweight or obese. High BP levels prevalence did not differ by sex, birth weight or gestation week. Prevalence rates were similar in city and surrounding rural areas. Higher prevalence of high normal or hypertensive BP levels was observed during the spring (57.1%) and winter (23.3%) period compared to about 10% at autumn and summer (P < 0.05). Both the highest prevalence of overweight/obesity and elevated BP levels were found in the 6–12 years-old group (62% vs. 38%, P < 0.001 for overweight-obesity, and 27.1% vs. 78.9%, P = 0.05 for high-normal/hypertensive BP levels). The highest prevalence of hypertensive BP levels (27.8%) was observed at 6th grade children. Conclusions: In this European population a low rate of high-normal and hypertensive BP levels was found in single visit following the ESH 2016 guidelines protocol for BP measurement. Overweight and obesity was associated with higher BP levels, but there were also seasonal differences in the prevalence of high BP levels.

PERFORMANCE OF THE AAP 2017 GUIDELINE SIMPLE TABLE ON BP SCHOOL-BASED SCREENING IN A EUROPEAN POPULATION

Objective: We assessed the performance on BP population screening of the simplified AAP 2017 clinical practice guideline based on age and 5th percentile of height, and a similar simplified table based on the 4th Report BP reference tables compared to the ESH 2016 guideline diagnostic thresholds. Design and method: We obtained data from a school-based screening study for the prevalence of high BP in the municipality of Kastoria in north Greece. Blood pressure was measured thrice by a mercury sphygmomanometer according to ESH 2016 guidelines and the last two BPs were averaged for the analysis. Results: The study population included 1,846 children aged 6–12 years and 986 adolescents aged 13–18 years. Compared to the ESH 2016 classification, the AAP 2017 table showed AUC 0.936, sensitivity 95.5%, specificity 91.6%, NPV 99.8%, and PPV 36%, while the 4th report table showed AUC 0.963, sensitivity 99.2%, specificity 93.3%, NPV 100%, and PPV 42.2%. The performance of the 4th report table was similar in both age groups, while the performance of the AAP 2017 table was lower in the adolescent group (AUC 0.884, sensitivity 83.2%, specificity 93.5%, NPV 99.3%, and PPV 32.6%, in adolescents versus AUC 0.953, sensitivity 100%, specificity 90.6%, NPV 100%, and PPV 37.2% in 6–12 years-olds, P < 0.05 for difference in AUC between age groups). Comparing the prevalence of elevated BP by the two simple tables we found agreement by both tables in 96.9% of the subjects (86.7% had normotension and 10.2% had high-normal or hypertensive BP levels), and disagreement in 3.1%. All children classified for further screening by AAP 2017 table were normotensive by ESH 2016 classification. However, 20,8% of the adolescents classified for further screening by 4th report, but not by AAP 2017 table, had BP levels at the high-normal category according to ESH 2016 classification. Conclusions: Simple tables for BP screening based on age present good performance to identify children and adolescents with normal BP levels. However, the table by AAP 2017 guideline may provide high rate of false positive results and fail to classify adolescents eligible for further BP measurements and lifestyle modification.

AMBULATORY VERSUS HOME BLOOD PRESSURE: WHICH CAN PREDICT BETTER EARLY VASCULAR AGEING?

Objective: To identify the blood pressure (BP) measuring method, home, 24 h ABPM and clinic, that can better predict early vascular ageing (EVA) and to create a new predictive model for EVA from BP measurements and other risk factors. Design and method: 282 consecutive subjects (39.7% male) aged 56.8 ± 15.8 years were included in the study. BP was measured at office and out of office with 24h-ABPM on a usual working day and seven days home BP monitoring. Pulse wave velocity (PWV) was measured after 15 min of rest in the supine position. EVA represented carotid-femoral PWV values higher than the expected for age average values. Results: In the univariate analysis, EVA correlated with office systolic BP, average 24 h systolic BP, 24 h diastolic BP, average 24 h and home heart rate, and office heart rate (p < 0.05). The area under the curve for the diagnosis of EVA was 0.620 (90% CI 0.55, 0.69), 0.559 (90% CI 0.48, 0.64) and 0.565 (90% CI 0.49, 0.64), for 24 h, home and clinic systolic BP, respectively. The 24 h systolic and diastolic BP, 24 h heart rate and risk factors such as body mass index, gender, age, creatine clearance, diabetes mellitus, were used to develop a new prediction score with Random Forest algorithm for the prediction of EVA providing a total accuracy 0.82 and high rates of sensitivity and specificity. Conclusions: In conclusion, 24 h systolic BP from ABPM is a better predictor for EVA than home and clinic systolic BP. A new risk assessment tool for EVA was created by 24 h ABPM variables, age, sex, body mass index, diabetes mellitus and creatine clearance.

COMPARATIVE EFFICACY OF ANGIOTENSIN CONVERTING ENZYME INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS II IN ESSENTIAL HYPERTENSION: SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Objective: Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are widely used for the treatment of hypertension. However, data on their comparative efficacy is incomplete. The present systematic review and network meta-analysis investigated the comparative efficacy of these two drug categories in blood pressure reduction, mortality and morbidity of adults with essential hypertension. Design and method: Bibliographic search was performed in Medline (PubMed) and Cochrane Central Register of Controlled Trials (CENTRAL) for placebo- and active-controlled, double-blind randomized trials, which had studied for blood pressure reduction, mortality and/or morbidity. Results: Thirty studies with 7370 participants were included for the blood pressure reduction analysis and eight studies with 25158 participants were included for the mortality/morbidity analysis. The two pharmacological categories did not differ in lowering systolic (WMD: 0.59, 95%CI: −0.21 to 1.38) and diastolic blood pressure (WMD: 0.62, 95%CI: −0,06 to 1.30), all-cause mortality (RR: 0.96, 95%CI 0.80 to 1.14), cardiovascular mortality (RR: 0.87, 95%CI 0.67 to 1.14), fatal and non-fatal myocardial infarction (RR: 1.02, 95%CI 0.75 to 1.37) and stroke (RR: 1.13, 95%CI 0.87 to 1.46). ACEIs found to be superior in the development and/or hospitalization for heart failure (RR: 0.71, 95%CI 0.54 to 0.93). Conclusions: ACEIs and ARBs do not differ in blood pressure reduction, mortality and morbidity in patients with essential hypertension. ACEIs were superior in the development and/or hospitalization for heart failure.