Physiological studies have long documented the key role played by the autonomic nervous system in modulating cardiovascular functions and in controlling blood pressure values, both at rest and in ...response to environmental stimuli. Experimental and clinical investigations have tested the hypothesis that the origin, progression, and outcome of human hypertension are related to dysfunctional autonomic cardiovascular control and especially to abnormal activation of the sympathetic division. Here, we review the recent literature on the adrenergic and vagal abnormalities that have been reported in essential hypertension, with emphasis on their role as promoters and as amplifiers of the high blood pressure state. We also discuss the possible mechanisms underlying these abnormalities and their importance in the development and progression of the structural and functional cardiovascular damage that characterizes hypertension. Finally, we examine the modifications of sympathetic and vagal cardiovascular influences induced by current nonpharmacological and pharmacological interventions aimed at correcting elevations in blood pressure and restoring the normotensive state.
Blood pressure (BP) control in patients with hypertension is variable worldwide, and in general, it results largely unsatisfactory. Factors responsible for this phenomenon include insufficient ...national cardiovascular healthcare policies for prevention, poor patient compliance with prescribed treatment schedules, and the reluctance of physicians to modify treatment strategies when BP is still elevated, that is, the so-called therapeutic inertia. A further important factor favoring poor BP control is the limited use of combination drug treatment, despite evidence of its superior ability to control BP in patients with difficult-to-treat hypertension. In addition, combination treatment allows to achieve BP control more easily (and more quickly) as compared with monotherapy. This article, after briefly examining the main features of BP control, will review the importance in the treatment of hypertension of the drug combination strategy, based on the recommendations of the 2018 European Society of Cardiology/European Society of Hypertension guidelines. Empahsis will be given to the drug combination treatment as first step of the antihypertensive therapeutic intervention. The potential drawbacks and barriers to combination drug treatment as initial therapeutic strategy will also be briefly discussed.
Several studies reported an association between nonalcoholic fatty liver disease (NAFLD) and the risk of incident hypertension. The objective of this systematic review and meta-analysis was to obtain ...a precise and reliable estimate of the nature and magnitude of this association. We systematically searched Ovid-MEDLINE up to March 2021 for observational studies in which NAFLD was diagnosed in adults using blood-based panels, imaging techniques or liver biopsy and with a follow-up ≥1 year. Measures of association from individual studies were meta-analyzed using random-effects models. Of the 1108 titles initially scrutinized, we included 11 cohort studies with data on 390 348 participants (52% male) and a mean follow-up of 5.7 years. In the overall analysis, NAFLD was associated with a moderately increased risk of incident hypertension (hazard ratio 1.66; 95% confidence interval (CI), 1.38-2.01; test for overall effect z = 5.266; P < 0.001). There was significant heterogeneity among the studies (P < 0.001). Sensitivity analyses showed that estimates were not affected by geographical location, duration of follow-up and adjustment for baseline blood pressure values. On the other hand, the magnitude of the association was lower in studies that adjusted for baseline adiposity compared with those that did not, explaining part of the observed heterogeneity. No significant publication bias was detected by funnel plot analysis and Egger's and Begg's tests. This large meta-analysis indicates that NAFLD is associated with a ~1.6-fold increased risk of developing hypertension. Further studies are needed to investigate the role of NAFLD severity in terms of inflammation and fibrosis on incident hypertension.
Guidelines support use of drug combinations in most hypertensive patients, and recently treatment initiation with two drugs has been also recommended. However, limited evidence is available on ...whether this leads to greater cardiovascular (CV) protection compared to initial monotherapy.
Using the healthcare utilization database of the Lombardy Region (Italy), the 44 534 residents of the region (age 40-80 years) who in 2010 started treatment with one antihypertensive drug (n = 37 078) or a two-drug fixed-dose combination (FDC, n = 7456) were followed for 1 year after treatment initiation to compare the risk of hospitalization for CV disease associated with the two treatment strategies. To limit the confounding associated with non-randomized between-group comparisons, data were also analysed by: (i) matching the two groups by the high-dimensional propensity score (HDPS) and (ii) comparing, in patients experiencing one or more CV events (n = 2212), the CV event incidence during subperiods in which patients were prescribed mono- or FDC therapy (self-controlled case series design). Compared to initial monotherapy, patients on initial FDC therapy showed a reduced 1 year risk of hospitalization for any CV event (-21%, P < 0.01). This was the case also when groups were compared according to the HDPS analysis (-15%, P < 0.05). Finally, in patients experiencing CV events, the event incidence was much less when, during the 1 year follow-up, they were under FDC therapy than under monotherapy (-56%, P < 0.01). The reduced risk of hospitalization was always significant for ischaemic heart disease and new onset atrial fibrillation, and included hospitalization for cerebrovascular disease and heart failure when monotherapy and FDC therapy were compared within patients.
In a real-life setting, a comparison of the incidence of early CV events during antihypertensive monotherapy and FDC shows that the latter strategy leads to a more effective CV protection. This scores in favour of a two-drug FDC strategy as first step in the hypertensive population.
In more severe cases, COVID-19 can lead to acute respiratory distress syndrome (ARDS), multi-organ failure including cardiac injury and toxic shock syndrome with need for intensive care and a ...ventilator support, 1 while at the opposite extreme the signs and symptoms can be those of a mild flu and in many patients the infection is asymptomatic. Since the outbreak of the infection in China, a large number of studies have consistently reported on the cardiovascular (CV) complications of COVID-19 which include acute cardiac injury, cardiac arrhythmias, and diffuse endothelial damage leading to microvascular thrombosis and thromboembolic events. Resistance to the virus may be further reduced by the pathogenetic nature of some of these organ alterations, that is, by the fact the most common cause of risk factor-dependent complications, atherosclerosis, is likely to be co-determined by an inflammatory process that may adversely interact with that of the coronavirus. 1 As far as obesity, a major component of the metabolic syndrome, is concerned, its relationship with the COVID-19 severity may be due to its association with chronic low grade inflammation, higher leptin and lower adiponectin levels, immune response dysregulation, and abnormal pro-inflammatory cytokine production. 2 The association between increased arterial stiffness and the severity and duration of chronic inflammation in a number of systemic inflammatory diseases are well established. 3 The vascular structure and function are altered by edema and inflammatory cells. Furthermore, some other preliminary studies have also reported on the vascular implications of COVID-19 infection. 10,11 In a small, cross-sectional study, Ratchford et al showed that young adults who 3-4 weeks prior to vascular health assessment tested positive on COVID-19, had significantly impaired vascular function as reflected by lower flow-mediated dilation (FMD) of the brachial artery, and increased arterial stiffness derived from carotid-femoral PWV, compared with young healthy adults without prior COVID-19 infection. 10 FMD expressed as percentage change was 2.71 ± 1.21% in the COVID-19 group and 8.81 ± 2.96% (P <.01) in the control group. ...Rodilla et al showed that a pulse pressure of ≥60 mmHg at admission, as a surrogate marker of arterial stiffness, was associated with higher risk of all-cause mortality (adjusted odds ratio 1.27, P =.0001) in hospitalized COVID-19 patients. 11 In addition, in an individual case study involving a 55-year-old man with obesity and no previously known hypertension, we recently showed that several months after recovery from COVID-19, the patient had sustained tachycardia and elevated blood pressure at rest.
The coronavirus disease 2019 (COVID-19) may cause not only an acute respiratory distress syndrome (ARDS) but also multiple organ damage and failure requiring intensive care and leading to death. Male ...sex, advanced age, chronic lung disease, chronic kidney disease and cardiovascular disease, such as hypertension, diabetes and obesity have been identified as risk factors for the COVID-19 severity. Presumably, as these three cardiovascular risk factors are associated with a high prevalence of multiorgan damage. In the present focused clinical review, we will discuss the cardiovascular complications of COVID-19 including acute cardiovascular syndrome (acute cardiac injury/COVID cardiomyopathy, thromboembolic complications and arrhythmias) and post-COVID-19 sequelae. Preliminary data shows that the cause of acute cardiovascular syndrome may be multifactorial and involve direct viral invasion of the heart and vascular system, as well as through the immune and inflammation-mediated systemic cytokine storm. COVID-19 survivors may also show persistently elevated blood pressure and sinus tachycardia at rest. Furthermore, poor diabetic control, persistent renal damage and cerebral sequelae, such as persistent cognitive and neuropsychiatric alterations are also frequently reported. A particular attention should be paid towards cardiovascular protection in COVID-19 patients who develop acute cardiovascular syndromes during hospitalization, and/or permanent/semipermanent sequelae after recovery from COVID-19. These conditions may require careful clinical assessment, treatment and close follow-up to avoid short-term and long-term complications.
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