Sex differences in arterial hypertension Gerdts, Eva; Sudano, Isabella; Brouwers, Sofie ...
European heart journal,
12/2022, Volume:
43, Issue:
46
Journal Article
Peer reviewed
Open access
There is strong evidence that sex chromosomes and sex hormones influence blood pressure (BP) regulation, distribution of cardiovascular (CV) risk factors and co-morbidities differentially in females ...and males with essential arterial hypertension. The risk for CV disease increases at a lower BP level in females than in males, suggesting that sex-specific thresholds for diagnosis of hypertension may be reasonable. However, due to paucity of data, in particularly from specifically designed clinical trials, it is not yet known whether hypertension should be differently managed in females and males, including treatment goals and choice and dosages of antihypertensive drugs. Accordingly, this consensus document was conceived to provide a comprehensive overview of current knowledge on sex differences in essential hypertension including BP development over the life course, development of hypertension, pathophysiologic mechanisms regulating BP, interaction of BP with CV risk factors and co-morbidities, hypertension-mediated organ damage in the heart and the arteries, impact on incident CV disease, and differences in the effect of antihypertensive treatment. The consensus document also highlights areas where focused research is needed to advance sex-specific prevention and management of hypertension.
Hypertension is the most common risk factor for atrial fibrillation (AF). The ability to screen for potential AF during blood pressure (BP) measurement may be a valuable tool for early AF detection. ...This study evaluated the frequency of irregular pulse rates suggestive of AF in subjects undergoing ambulatory BP monitoring (ABPM) and compared the characteristics of patients at low risk of presumed AF vs. those at high risk. ABPM recordings were obtained in 4419 subjects aged ≥65 years visiting 304 community pharmacies, with clinically validated automated monitors equipped with an algorithm for detecting possible AF episodes during BP measurement. Subjects with <30% of the readings suggestive of AF were categorized as having a low risk of AF, and those with ≥30% of readings were classified as high risk. A total of 531 subjects (12.0%) were categorized as having a high risk of AF, with the risk increasing with advancing age. Subjects at high risk of AF had lower average systolic BP, higher average diastolic BP and pulse rate (PR), increased BP and PR variabilities, and blunted sleep-associated reductions in BP and PR. In repeated recordings, the reliability of the AF detection algorithm per se was good (kappa 0.476, p = 0.0001; intraclass correlation coefficient 0.56, p = 0.0001). Simultaneous BP measurement and screening for potential AF by ABPM in elderly people in clinical practice may help improve BP control and the detection of subjects at high risk of AF. However, a finding of presumed AF must always be confirmed by an electrocardiogram (ECG).
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Chest pain is one of the most common chief complaints in emergency departments (EDs). Collecting an adequate medical history is challenging but essential in order to use recommended risk scores such ...as the HEART score (based on history, electrocardiogram, age, risk factors, and troponin). Self-reported computerized history taking (CHT) is a novel method to collect structured medical history data directly from the patient through a digital device. CHT is rarely used in clinical practice, and there is a lack of evidence for utility in an acute setting.
This substudy of the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS) aimed to evaluate whether patients with acute chest pain can interact effectively with CHT in the ED.
Prospective cohort study on self-reported medical histories collected from acute chest pain patients using a CHT program on a tablet. Clinically stable patients aged 18 years and older with a chief complaint of chest pain, fluency in Swedish, and a nondiagnostic electrocardiogram or serum markers for acute coronary syndrome were eligible for inclusion. Patients unable to carry out an interview with CHT (eg, inadequate eyesight, confusion or agitation) were excluded. Effectiveness was assessed as the proportion of patients completing the interview and the time required in order to collect a medical history sufficient for cardiovascular risk stratification according to HEART score.
During 2017-2018, 500 participants were consecutively enrolled. The age and sex distribution (mean 54.3, SD 17.0 years; 213/500, 42.6% women) was similar to that of the general chest pain population (mean 57.5, SD 19.2 years; 49.6% women). Common reasons for noninclusion were language issues (182/1000, 18.2%), fatigue (158/1000, 15.8%), and inability to use a tablet (152/1000, 15.2%). Sufficient data to calculate HEART score were collected in 70.4% (352/500) of the patients. Key modules for chief complaint, cardiovascular history, and respiratory history were completed by 408 (81.6%), 339 (67.8%), and 291 (58.2%) of the 500 participants, respectively, while 148 (29.6%) completed the entire interview (in all 14 modules). Factors associated with completeness were age 18-69 years (all key modules: Ps<.001), male sex (cardiovascular: P=.04), active workers (all key modules: Ps<.005), not arriving by ambulance (chief complaint: P=.03; cardiovascular: P=.045), and ongoing chest pain (complete interview: P=.002). The median time to collect HEART score data was 23 (IQR 18-31) minutes and to complete an interview was 64 (IQR 53-77) minutes. The main reasons for discontinuing the interview prior to completion (n=352) were discharge from the ED (101, 28.7%) and tiredness (95, 27.0%).
A majority of patients with acute chest pain can interact effectively with CHT on a tablet in the ED to provide sufficient data for risk stratification with a well-established risk score. The utility was somewhat lower in patients 70 years and older, in patients arriving by ambulance, and in patients without ongoing chest pain. Further studies are warranted to assess whether CHT can contribute to improved management and prognosis in this large patient group.
ClinicalTrials.gov NCT03439449; https://clinicaltrials.gov/ct2/show/NCT03439449.
RR2-10.1136/bmjopen-2019-031871.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
We aimed to study whether inhibition of the renin–angiotensin–aldosterone system has effects on vascular structure and function beyond the effects on blood pressure reduction alone. Patients with ...mild-to-moderate hypertension (
n
= 61, age 54 ± 12 years, 34% women) received the angiotensin converting enzyme inhibitor ramipril 10 mg or the alpha 1-adrenoceptor blocker doxazosin 8 mg double-blind for 12 weeks. Aortic blood pressure, pulse wave velocity, and augmentation index were assessed by applanation tonometry. Endothelial function was studied by forearm post-ischemic flow mediated vasodilatation and by pulse wave analysis with beta 2-adrenoceptor agonist stimulation. Skin microvascular reactivity was assessed by laser Doppler fluxmetry and iontophoresis. Treatment with doxazosin or ramipril reduced aortic and brachial blood pressures (all
P
< 0.001), with greater reductions in aortic than brachial systolic blood pressures (
P
= 0.021) and aortic/brachial pulse pressure ratio (
P
= 0.005). Compared to doxazosin, ramipril reduced carotid-femoral and carotid-radial pulse wave velocity (both
P
< 0.05). Forearm endothelial dependent and independent vasodilatation, assessed by post-ischemic flow mediated vasodilatation and glyceryl trinitrate, and by pulse wave analysis remained unchanged by both doxazosin and ramipril. In addition, skin microvascular endothelial dependent (acetylcholine) and independent vasodilatation (sodium nitroprusside) remained unchanged. In conclusion, ramipril reduced indices of aortic stiffness, suggesting that angiotensin converting enzyme inhibitor therapy may have effects beyond blood pressure reduction. However, treatment did not appear to influence endothelial function. Evidence of endothelial dysfunction and its possible improvement by antihypertensive treatment might require more advanced hypertension.
This study is registered at ClinicalTrials.gov (NCT02901977) and at EudraCT (# 2007-000631-25).
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
BackgroundPublic reporting of performance data has become a common tool in evaluation of healthcare providers. The rating may be misleading if the association between the measured variables and the ...outcome is weak.Methods and resultsNationwide, register-based, cohort study. All Swedish patients hospitalised with an acute coronary syndrome during the time periods 2006–2010 and 2015–2017 were included in the study. Possible associations between cardiovascular morbidity and mortality for these patients and ranking scores for each hospital in a Swedish healthcare quality register for acute coronary syndromes were analysed. We found no association between the ranking score and mortality, and no or weak associations between the ranking score and readmissions.ConclusionsLack of associations between quality measurements and patient outcomes warrants improvement in ranking scores. Cautious use of the ranking results is necessary in comparisons between healthcare providers.
Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart ...disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.
Women with a history of preeclampsia are at increased risk of future cardiovascular disease. Preeclampsia is associated with elevated blood pressure, inflammation and endothelial dysfunction, and ...these findings remain 1 year after delivery. Whether these abnormalities persist long after delivery, and whether they may contribute to future cardiovascular disease, is not well studied. We studied 15 women with a history of preeclampsia and 16 matched controls with an uncomplicated pregnancy 11 years following the index pregnancy; all had also been previously examined at 1 year. We assessed arterial stiffness (pulse wave analysis), 24 h ambulatory blood pressure and endothelial function (forearm flow-mediated dilatation and pulse wave analysis following β receptor agonist provocation), and determined markers of glucose and lipid metabolism, inflammation and vascular function. The preeclampsia group had higher blood pressures and reduced night/day blood pressure ratios, increased body mass index and reduced glucose tolerance, and increased levels of tissue necrosis factor receptor 1 and intracellular adhesion molecule-1, suggesting inflammatory and vascular activation. However, the endothelial impairment observed in the preeclampsia group at 1 year was normalized at 11 years, whereas the control group remained unchanged during follow-up. Our findings of higher blood pressures, impaired glucose tolerance and normalization of endothelial function 11 years after preeclampsia suggest cardiovascular risk factors present already before pregnancy to be more important than permanent endothelial damage for the increased risk of future cardiovascular complications in women with a history of preeclampsia.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Purpose: To describe current antihypertensive treatment in very old hypertensive patients according to sex and comorbidity.
Materials and methods: We used the Stockholm regional healthcare data ...warehouse (Vårdanalysdatabasen) providing information on all healthcare consultations, diagnoses, hospitalizations, dispensed prescription drugs, sex and age in 2.1 million people living in the greater Stockholm region, Sweden. This cross-sectional analysis identified 12,436 individuals with a diagnosis of hypertension, who were 90 years or older.
Results: Mean age was 92.6 ± 2.6 years, 75% were women; and 34% of women and 24% of men had no diagnoses of concomitant diabetes or cardiovascular disease. The number of dispensed drug classes was similar (2.1 ± 1.4) in women and in men. Women more often used angiotensin receptor blockers and beta-blockers, while men more frequently used ACE inhibitors and calcium channel blockers (all p < .05). Compared to men, women with concomitant diabetes or heart failure used less ACE inhibitors or angiotensin receptor blockers (52 vs. 60% and 49 vs. 55%, respectively; all p < .01and adjusted for age and comorbidity), which is contrary to current recommendations.
Conclusion: Our findings suggest that antihypertensive treatment is common also in very old patients. Given the rapidly ageing population and circumstantial evidence in favour of maintaining well-tolerated antihypertensive therapy in very old patients, prospective well-designed outcome studies are warranted.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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