In a retrospective analysis, the authors investigated day‐by‐day blood pressure variability (BPV) and its association with clinical outcomes (critical vs. severe and discharged) in hospitalized ...patients with COVID‐19. The study participants were hospitalized in Tongji Hospital, Guanggu Branch, Wuhan, China, between February 1 and April 1, 2020. BPV was assessed as standard derivation (SD), coefficient of variation (CV), and variability independent of mean (VIM). The 79 participants included 60 (75.9%) severe patients discharged from the hospital after up to 47 days of hospitalization, and 19 (24.1%) critically ill patients transferred to other hospitals for further treatment (n = 13), admitted to ICU (n = 3) or died (n=3). Despite similar use of antihypertensive medication (47.4% vs. 41.7%) and mean levels of systolic/diastolic blood pressure (131.3/75.2 vs. 125.4/77.3 mmHg), critically ill patients, compared with severe and discharged patients, had a significantly (p ≤ .04) greater variability of systolic (SD 14.92 vs. 10.84 mmHg, CV 11.39% vs. 8.56%, and VIM 15.15 vs. 10.75 units) and diastolic blood pressure (SD 9.38 vs. 7.50 mmHg, CV 12.66% vs. 9.80%, and VIM 9.33 vs. 7.50 units). After adjustment for confounding factors, the odds ratios for critical versus severe and discharged patients for systolic BPV were 3.41 (95% confidence interval CI 1.20‐9.66, p = .02), 4.09 (95% CI 1.14‐14.67, p = .03), and 2.81 (95% CI 1.12‐7.05, p = .03) for each 5‐mmHg increment in SD, 5% increment in CV, and 5‐unit increment in VIM, respectively. Similar trends were observed for diastolic BPV indices (p ≤ .08). In conclusion, in patients with COVID‐19, BPV was greater and associated with worse clinical outcomes.
Atrial fibrillation (AF) is underdiagnosed and especially undertreated in China. We aimed to investigate the prevalence of unknown and untreated AF in community residents (greater than or equal to65 ...years old) and to determine whether an education intervention could improve oral anticoagulant (OAC) prescription. We performed a single-time point screening for AF with a handheld single-lead electrocardiography (ECG) in Chinese residents (greater than or equal to65 years old) in 5 community health centers in Shanghai from April to September 2017. Disease education and advice on referral to specialist clinics for OAC treatment were provided to all patients with actionable AF (newly detected or undertreated known AF) at the time of screening, and education was reinforced at 1 month. Follow-up occurred at 12 months. In total, 4,531 participants were screened (response rate 94.7%, mean age 71.6 ± 6.3 years, 44% male). Overall AF prevalence was 4.0% (known AF 3.5% n = 161, new AF 0.5% n = 22). The 183 patients with AF were older (p < 0.001), taller (p = 0.02), and more likely to be male (p = 0.01), and they had a higher prevalence of cardiovascular disease than those without AF (p < 0.001). In total, 85% (155/183) of patients were recommended for OAC treatment by the established guidelines (CHA.sub.2 DS.sub.2 -VASc greater than or equal to 2 for men; greater than or equal to 3 for women). OAC prescription rate for known AF was 20% (28/138), and actionable AF constituted 2.8% of all those screened. At the 12-month follow-up in 103 patients (81% complete), despite disease education and advice on specialist referral, only 17 attended specialist clinics, and 4 were prescribed OAC. Of those not attending specialist clinics, 71 chose instead to attend community health centers or secondary hospital clinics, with none prescribed OAC, and 15 had no review. Of the 17 patients with new AF and a class 1 recommendation for OAC, only 3 attended a specialist clinic, and none were prescribed OAC. Of the 28 AF patients taking OAC at baseline, OAC was no longer taken in 4. Ischemic stroke (n = 2) or death (n = 3) occurred in 5/126 (4%), with none receiving OAC. As screening was performed at a single time point, some paroxysmal AF cases may have been missed; thus, the rate of new AF may be underestimated. We demonstrated a noticeable gap in AF detection and treatment in community-based elderly Chinese: actionable AF constituted a high proportion of those screened. Disease education and advice on specialist referral are insufficient to close the gap. Before more frequent or intensive screening for unknown AF could be recommended in China, greater efforts must be made to increase appropriate OAC therapy in known AF to prevent AF-related stroke.
The authors performed a meta‐analysis to assess the efficacy of non‐atenolol β‐blockers as add‐on to monotherapy or as a component of combination antihypertensive therapy in patients with ...hypertension. The authors searched and identified relevant randomized controlled trials from PubMed until November 2021. Studies comparing blood pressure lowering effects of β‐blockers with diuretics, calcium channel blockers (CCBs), angiotensin‐converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs) were included. The analysis included 20 studies with 5544 participants. β‐blockers add‐on to monotherapy significantly reduced systolic and diastolic blood pressure as compared with non‐β‐blocker monotherapy (weighted mean difference in mm Hg 95% confidence interval: −4.1 −6.0, −2.2 and −3.7 −4.6, −2.8, respectively). These results were consistent across the comparisons with diuretics (systolic pressure, −10.2 −14.2, −6.2; diastolic pressure, −5.4 −8.2, −2.6), CCBs (systolic pressure, −4.1 −7.1, −1.0; diastolic pressure, −2.8 −4.1, −1.5), and ACEIs/ARBs (systolic pressure, −2.9 −4.3, −1.5; diastolic pressure, −4.2 −5.0, −3.4). There was no significant difference in blood pressure lowering effects between combinations with and without a β‐blocker (systolic pressure, −1.3 mm Hg −5.8, 3.2; diastolic pressure, −.3 mm Hg −2.7, 2.1). Metoprolol add‐on or combination therapy had a significantly greater blood pressure reduction than non‐β‐blocker therapy (systolic pressure, −3.6 mm Hg −5.9, −1.3; diastolic pressure, −2.1 mm Hg −3.5, −.7). In conclusion, non‐atenolol β‐blockers are effective in lowering blood pressure as add‐on to monotherapy or as a component of combination antihypertensive therapy. In line with the current hypertension guideline recommendations, β‐blockers can and should be used in combination with other antihypertensive drugs.
Isolated nocturnal hypertension (INH) is a special type of out‐of‐office hypertension. Its determinants and pathophysiology remain unclear. In a nested case‐control study, we intend to investigate ...the host, environmental, and genetic factors in relation to INH. Among 2030 outpatients screened from December 2008 till June 2015, 128 patients with INH were identified, and then 128 normotensives were matched according to sex and age. INH was an elevated nocturnal blood pressure (BP ≥120/70 mmHg) in the presence of a normal daytime BP (< 135/85 mmHg). Host factors included age, sex, body mass index, smoking and drinking, sleep time and duration, heart rate, serum lipids, and serum creatinine. Environmental cues encompassed season, ambient temperature, atmospheric pressure, humidity, and wind speed, and genetic cues 29 single‐nucleotide polymorphisms (SNPs) in 12 clock genes. Daytime and nighttime BPs averaged 124.9/80.7 and 114.5/73.7 mmHg, respectively, in the INH patients and 121.0/76.5 and 101.8/63.3 mmHg in the normotensive controls. Stepwise logistic regression analyses revealed that INH was associated with nighttime heart rate (P = .0018), sleep duration (P = .0499), and relative humidity (P = .0747). The odds ratios (95% CI) for each 10 beats/min faster nighttime heart rate and 10% lower relative humidity were 1.82 (1.25‐2.65) and 0.82 (0.67‐1.00), respectively. Irrespective of the genetic models, no significant association was observed between INH and the SNPs (P ≥ .054). In conclusion, INH was associated with host and environmental factors rather than genetic markers.
Increasing life expectancy in the population means that the prevalence of hypertension in China will increase over the coming decades. Although awareness and control rates have improved, the absolute ...rates remain unacceptably low. Cardiovascular disease (CVD) is the biggest killer in China, and sharp increases in the prevalence of CVD risk factors associated with rapid lifestyle changes will contribute to ongoing morbidity and mortality. This highlights the importance of effectively diagnosing and managing hypertension, where home blood pressure monitoring (HBPM) has an important role. Use of HBPM in China is increasing, particularly now that Asia‐specific guidance is available, and this out‐of‐office BP monitoring tool will become increasingly important over time. To implement these recommendations and guidelines, a Web‐based and WeChat‐linked nationwide BP measurement system is being established in China. Local guidelines state that both HBPM and ambulatory blood pressure monitoring should be implemented where available. In China, hypertension is managed most often using calcium channel blockers, followed by angiotensin receptor blockers or angiotensin‐converting enzyme inhibitors. Key barriers to hypertension control in China are low awareness and control rates.
Advanced glycation end product (AGE) clearance may cause renal tubular injuries, such as changes in sodium reabsorption. We hypothesize that AGEs interact with sodium metabolism to influence blood ...pressure (BP). The study participants were outpatients who were suspected of having hypertension but had not been treated with antihypertensive medication. Clinic and ambulatory blood pressures were measured at baseline (n = 989) and during follow-up (median, 4.4 years, n = 293). Plasma AGE concentrations were measured by enzyme-linked immunosorbent assay. Twenty-four-hour urine was collected for measurements of creatinine, sodium and lithium. In a cross-sectional analysis (n = 989), subjects in the top quintile versus quintiles 1-4 of plasma AGE concentration had significantly (P ≤ 0.004) lower fractional excretion of lithium (18.3% vs. 21.6%) and fractional distal reabsorption rate of sodium (95.0% vs. 95.8%) but similar BP (P ≥ 0.25). However, there was an interaction between plasma AGE concentration and urinary sodium excretion in relation to diastolic BP (P ≤ 0.058). Only in participants with low urinary sodium chloride excretion (≤6 grams/day, n = 189), clinic (84.3 vs. 80.2 mmHg), 24-h (83.9 vs. 80.4 mmHg), daytime (87.8 vs. 84.8 mmHg) and nighttime (75.1 vs. 72.1 mmHg) diastolic BP at baseline were higher (P ≤ 0.05) in the top quintile than in quintiles 1-4 of plasma AGE concentration. In the longitudinal study (n = 383), similar trends were observed, with significant (P ≤ 0.05) differences in the increment in daytime diastolic BP (6.8 vs. -1.7 mmHg) and incidence of ambulatory and treated hypertension (hazard ratio 3.73) during follow-up. In conclusion, AGEs were associated with high BP, probably via enhanced proximal sodium handling and on low dietary sodium intake.
We investigated blood pressure (BP) and heart rate variability and baroreflex sensitivity (BRS) in white-coat, masked and sustained hypertension in untreated patients (n = 645). Normotension and ...white-coat, masked, and sustained hypertension were defined according to the clinic (cutoff 140/90 mmHg) and 24-h ambulatory (130/80 mmHg) BPs. The Finometer device recorded beat-to-beat finger BP and electrocardiograms in the supine and standing positions for the computation of frequency-domain power-spectral BP and heart rate variability indexes and BRS. In multivariate analysis, BP variability indexes in the supine position differed significantly (P < 0.0001) for both low-frequency (LF) and high-frequency (HF) components and the LF/HF ratio, with the lowest LF and HF power and highest LF/HF ratio in white-coat hypertension (n = 28), the highest LF and HF power and lowest LF/HF ratio in sustained hypertension (n = 198), and intermediate values in normotension (n = 189) and masked hypertension (n = 230). These differences diminished in the standing position, being significant (P < 0.0001) only for the LF component variability. The LF/HF ratio in BP in the supine position decreased with advancing age in normotension and sustained hypertension (P ≤ 0.03) but not white-coat or masked hypertension (P ≥ 0.12). For heart rate variability, a significant difference was observed only for the LF component in the supine position (P = 0.0005), which was lowest in white-coat hypertension. BRS in masked and sustained hypertension was significantly (P ≤ 0.0001) lower than that in normotension in both supine and standing positions and decreased with advancing age (P ≤ 0.0001). In conclusion, masked, but not white-coat, hypertension showed similar patterns of, but slightly less severe, changes in BP and heart rate variability and BRS to sustained hypertension.
No previous study has addressed the relative contributions of environmental and genetic cues to the diurnal blood pressure rhythmicity. From 24-hour ambulatory recordings of systolic blood pressure ...obtained in untreated patients (51% women; mean age, 51 years), we computed the night-to-day ratio in 897 and morning surge in 637. Environmental cues included season, mean daily outdoor temperature, atmospheric pressure, humidity and weekday, and the genetic cues 14 single nucleotide polymorphisms in 10 clock genes. Systolic blood pressure averaged (±SD) 126.7±11.9 mm Hg, night-to-day ratio 0.86±0.07, and morning surge 24.8±10.7 mm Hg. In adjusted analyses, night-to-day ratio was 2.4% higher in summer and 1.8% lower in winter (P<0.001) compared with the annual average with a small effect of temperature (P=0.079); morning surge was 1.7 mm Hg lower in summer and 1.1 mm Hg higher in winter (P<0.001). The other environmental cues did not add to the night-to-day ratio or morning surge variance (P≥0.37). Among the 14 genetic variations, only CLOCK rs180260 was significantly associated with morning surge after adjustment for season, temperature, and other host factors and after Bonferroni correction (P=0.044). In CLOCK rs1801260 C allele carriers (n=83), morning surge was 3.7 mm Hg higher than in TT homozygotes (n=554). Of the night-to-day ratio and morning surge variance, season and temperature explained ≈8% and ≈3%, while for genetic cues, these proportions were ≈1% or less. In conclusion, environmental compared with genetic cues are substantially stronger drivers of the diurnal blood pressure rhythmicity.
We investigated the prevalence, awareness, treatment, and control of hypertension in a large opportunistic screening study in China. Our study participants had to be ≥18 years of age and had ideally ...not taken blood pressure (BP) for ≥1 year. BP was measured three times consecutively in the sitting position with a 1‐minute interval, using a validated electronic BP monitor or mercury sphygmomanometer. Trained volunteer investigators administered a questionnaire to collect information on medical history, lifestyle, and use of medications. The 364 000 participants (52.6% women, and mean age 53.4 years) had a mean systolic/diastolic BP of 124.2/76.4 mm Hg. The proportion of hypertension was 24.7%. In all hypertensive subjects (n = 89 925), the awareness, treatment, and control rates of hypertension were 60.1%, 42.5%, and 25.4%, respectively. In multiple stepwise logistic regression analyses, the odds for unawareness vs awareness of hypertension was higher in men and lower with age advancing, current smoking, and the presence of diabetes mellitus, coronary heart disease, and stroke or transient ischemic attack (P < .0001). The odds for uncontrolled vs controlled hypertension was higher with age advancing and current smoking, and lower with the presence of diabetes mellitus and coronary heart disease (P ≤ .03) in 38 207 treated hypertensive patients, and it was also higher with the use of antihypertensive monotherapy (odds ratio 1.13, P = .0003) in 19 523 treated hypertensive patients with specific antihypertensive drugs. Our study identified several factors as barriers to BP control in China, such as male gender, younger age, current smoking, and the under‐use of combination therapy.
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