ARB-based combination therapy for the clinical management of hypertension and hypertension-related comorbidities: a spotlight on their use in COVID-19 patients

Essential hypertension is the most common cardiovascular (CV) risk factor, being primarily involved in the pathogenesis of CV disease and mortality worldwide. Given the high prevalence and growing incidence of this clinical condition in the general population in both high and low-income countries, antihypertensive drug therapies are frequently prescribed in different hypertension-related CV diseases and comorbidities. Among these conditions, evidence are available demonstrating the clinical benefits of lowering blood pressure (BP) levels, particularly in those hypertensive patients at high or very high CV risk profile. Preliminary studies, performed during the Sars-COVID-19 epidemic, raised some concerns on the potential implication of hypertension and antihypertensive medications in the susceptibility of having severe pneumonia, particularly with regard to the use of drugs inhibiting the renin-angiotensin system (RAS), including angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These hypotheses were not confirmed by subsequent studies, which independently and systematically demonstrated no clinical harm of these drugs also in patients with Sars-COVID-19 infection. The aim of this narrative review is to critically discuss the available evidence supporting the use of antihypertensive therapies based RAS blocking agents in hypertensive patients with different CV risk profile and with additional clinical conditions or comorbidities, including Sars-COVID-19 infection, with a particular focus on single-pill combination therapies based on olmesartan medoxomil

Blood Pressure Target Achievement Under Monotheraphy. A Real-Life Appraisal

Introduction: Despite hypertension guidelines suggest that the most effective treatment strategy to improve blood pressure (BP) target achievement is to implement the use of combination treatment, monotherapy is still widely used in the clinical practice of hypertension. Aim: To investigate BP control under monotherapy in the setting of real-life. Methods: We extracted data from a medical database of adult outpatients who were referred to the Hypertension Unit, Sant'Andrea Hospital, Rome (IT), including anthropometric data, CV risk factors and comorbidities, presence or absence of antihypertensive therapy and concomitant medications. Among treated hypertensive patients, we identified only those under single antihypertensive agent (monotherapy). Office BP treatment targets were defined according to 2018 ESC/ESH guidelines as: (a) < 130/80 mmHg in individuals aged 18-65 years; (b) < 140/80 mmHg in those aged > 65 years. Results: From an overall sample of 7797 records we selected 1578 (20.2%) hypertensive outpatients (47.3% female, age 59.5 ± 13.6 years, BMI 26.6 ± 4.4 kg/m2) treated with monotherapies, among whom 30.5% received ACE inhibitors, 37.7% ARBs, 15.8% beta-blockers, 10.6% CCBs, 3.0% diuretics, and 2.0% alpha-blockers. 36.6% of these patients reached the conventional clinic BP goal of < 140/90 mmHg, whilst the 2018 European guidelines BP treatment targets were fulfilled only in 14.0%. In particular, 10.2% patients aged 18-65 years and 20.4% of those aged > 65 years achieved the recommended BP goals. All these proportions results significantly lower than those achieved with dual (18.2%) or triple (22.2%) combination therapy, though higher than those obtained with life-style changes (10.8%). Proportions of patients on monotherapies with normal home and 24-h BP levels were 22.0% and 30.2%, respectively, though only 5.2% and 7.3% of these patients achieved sustained BP control, respectively. Ageing and dyslipidaemia showed significant and independent positive predictive value for the achievement of the recommended BP treatment targets, whereas European SCORE resulted a negative and independent predictor in outpatients treated with monotherapies. Conclusions: Our data showed a persistent use of monotherapy in the clinical practice, though with unsatisfactory BP control, especially in light of the BP treatment targets suggested by the last hypertension guidelines

Hypertension Across the Atlantic. A Sprint or a Marathon?

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Current applications and limitations of European guidelines on blood pressure measurement. implications for clinical practice

Hypertension is the most common cardiovascular (CV) risk factor, strongly and independently associated with an increased risk of major CV outcomes, including myocardial infarction, stroke, congestive heart failure, renal disease and death due to CV causes. Effective control of hypertension is of key importance for reducing the risk of hypertension-related CV complications, as well as for reducing the global burden of CV mortality. However, several studies reported relatively poor rates of control of high blood pressure (BP) in a setting of real-life practice. To improve hypertension management and control, national and international scientific societies proposed several educational and therapeutic interventions, among which the systematic implementation of out-of-office BP measurements represents a key element. Indeed, proper assessment of individual BP profile, including home, clinic and 24-h ambulatory BP levels, may improve awareness of the disease, ensure high level of adherence to prescribed medications in treated hypertensive patients, and thus contribute to ameliorate BP control in treated hypertensive outpatients. In line with these purposes, recent European guidelines have released practical recommendations and clear indications on how, when and how properly measuring BP levels in different clinical settings, with different techniques and different methods. This review aimed at discussing current applications and potential limitations of European guidelines on how to measure BP in office and out-of-office conditions, and their potential implications in the daily clinical management of hypertension

SARS-CoV-2 and Pre-Tamponade Pericardial Effusion. Could Sotos Syndrome Be a Major Risk Factor?

Pericarditis with pericardial effusion in SARS CoV-2 infection is a well-known entity in adults. In children and adolescents, only a few cases have been reported. Here, we present here a case of a 15-year-old girl affected by Sotos syndrome with pre-tamponed pericardial effusion occurred during SARS-CoV-2 infection. A possible relation between SARS-CoV-2 pericarditis and genetic syndromes, as a major risk factor for the development of severe inflammation, has been speculated. We emphasize the importance of active surveillance by echocardiograms when SARS-CoV-2 infection occurs in combination with a genetic condition

Epidemiological Impact and Clinical Consequences of Masked Hypertension. A Narrative Review

Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines

Prevalence and clinical characteristics of isolated systolic hypertension in young: analysis of 24 h ambulatory blood pressure monitoring database

Isolated systolic hypertension (ISHT) is common in elderly patients, whilst its prevalence and clinical impact in young adults are still debated. We aimed to estimate prevalence and clinical characteristics of ISHT and to evaluate out-of-office BP levels and their correlations with office BP in young adults. A single-center, cross-sectional study was conducted at our Hypertension Unit, by including treated and untreated individuals aged 18-50 years, who consecutively underwent home, clinic and 24h ambulatory BP assessment. All BP measurements were performed and BP thresholds were set according to European guidelines: normotension (NT), clinic BP <140/<90mmHg; ISHT, BP ≥140/<90mmHg; isolated diastolic hypertension (IDHT), BP <140/≥90mmHg; systolic-diastolic hypertension (SDHT), BP ≥140/≥90mmHg. European SCORE, vascular and cardiac HMOD were also assessed. From an overall sample of 13,053 records, we selected 2127 young outpatients (44.2% female, age 40.5±7.4 years, BMI 26.7±5.0kg/m2, clinic BP 141.1±16.1/94.1±11.8mmHg, 24h BP 129.0±12.8/82.4±9.8mmHg), among whom 587 (27.6%) had NT, 391 (18.4%) IDHT, 144 (6.8%) ISHT, and 1005 (47.2%) SDHT. Patients with ISHT were predominantly male (61.1%), younger and with higher BMI compared to other groups. They also showed higher home and 24h ambulatory SBP levels than those with NT or IDHT (P<0.001), though similar to those with SDHT. ISHT patients showed significantly higher pulse pressure (PP) levels than other groups, at all BP measurements (P<0.001 for all comparisons), and significantly higher proportion (65.3%) of patients with ISHT had PP >60mmHg. European SCORE resulted significantly higher in patients with ISHT (1.6±2.9%) and SDHT (1.5±2.7%) compared to those with IDHT (0.9±1.5%) or NT (0.8±1.9%) (P=0.017). Though relatively rare, ISHT should be not viewed as a benign condition, being associated with sustained SBP elevation, high European SCORE risk, and vascular HMOD

Adding markers of organ damage to risk score models improves cardiovascular risk assessment: prospective analysis of a large cohort of adult outpatients

Introduction: Global cardiovascular (CV) risk stratification is recommended in all outpatients. Risk score charts, however, do not include markers of organ damage (OD). Aim: To evaluate the potential added value of including different markers of subclinical OD to US Framingham, European SCORE and Italian Cuore risk score calculators. Methods: We prospectively evaluated adult outpatients, who underwent blood pressure (BP) assessment and global CV risk stratification. The following OD markers were considered: 1) cardiac OD: electrocardiographic) or echocardiographic left ventricular (LV) hypertrophy; 2) vascular OD: carotid atherosclerotic plaque; 3) renal OD: reduced estimated glomerular filtration rate or creatinine clearance. Different risk score calculators were applied for comparisons. Results: We included an overall population sample of 1979 outpatients (44.0% female, age 57.2 ± 13.0 years, BMI 26,6 ± 4,4 kg/m2, clinic systolic/diastolic BP 145.4 ± 18.3/85.8 ± 10.7 mm Hg), among whom 117 (5.9%) presented cardiac, 161 (8.1%) vascular, and 117 (5.9%) renal OD. US Framingham, European SCORE and Italian Cuore risk scores were all significantly raised in patients with than in those without OD. A trend toward increase for US Framingham CVD death, European ESC and Italian Cuore scores was observed according to degree of all markers of OD. Among these, reduced ClCr and eGFR showed high sensitivity and specificity to identify high risk individuals. Conclusions: Presence of cardiac, vascular or renal OD is associated with higher risk scores, independently by the types of calculators, age and gender classes. OD detection should be included in CV risk stratification in order to improve diagnostic, prognostic and therapeutic processes

Therapeutic Approach to Hypertension Urgencies and Emergencies During Acute Coronary Syndrome

Uncontrolled hypertension is one of the most common determinant for the persistently high burden of cardiovascular (CV) disease, mostly including coronary artery disease (CAD) and hospital admissions due to acute coronary events. Markedly high blood pressure (BP) levels are also frequently observed during the acute phase of coronary syndromes (both ST-segment and non-ST-segment elevation myocardial infarction and unstable angina). In particular, a sustained raise of BP levels above 180/110 mmHg associated with acute cardiac organ damage, i.e. myocardial ischemia, represents a condition of hypertension emergency and requires rapid hospital admission, prompt pharmacological therapies and non-pharmacological interventions, aimed at restoring coronary flow and preserve vital myocardium. Diagnosis of CAD in hypertensive patients may often be complicated by the concomitant presence of electrocardiographic abnormalities, such as ST-segment depression (at rest or during exercise), which may occur even in the absence of coronary atherosclerosis. Thus, proper identification of CAD may result difficult to perform in the setting of clinical practice, mostly in the presence of left ventricular hypertrophy. In this review, we will briefly discuss diagnostic protocols and pharmacological strategies that can be applied in a setting of hypertension emergency with acute cardiac organ damage in the light of the currently available evidence and recommendations from recent guidelines on hypertension management and control

Prevalence and clinical characteristics of true masked hypertension compared to reverse and isolated nocturnal masked hypertension

Objective: Masked hypertension (MHT) is characterized by normal clinic blood pressure (BP) and above normal 24-hour ambulatory BP levels. Potential clinical impact of this condition is still debated. Aim: To evaluate prevalence, characteristics and clinical outcomes of different forms of MHT. Design and method: We analysed data derived from a large cohort of adult individuals, who consecutively underwent home, clinic and ambulatory BP monitoring at our Hypertension Unit. All BP measurements were performed and BP thresholds were set according to recommendations from European guidelines. Study population was stratified into 3 groups: 1) truly MHT (tMHT): clinic BP  = 130/80 mmHg, non-dipping status; 2) isolated nocturnal MHT (inMHT): clinic BP  = 130/80 mmHg, dipping status; 3) reverse nocturnal MHT (rnMHT): clinic BP  = 130/80 mmHg, reverse dipping status. Results: From an overall sample of 5,634 adult individuals who underwent full BP assessment at our Unit we selected 2,413 (42.8%) untreated adult individuals, among whom 152 (6.3%) had MHT. In this latter group, 64 (42.1) had tMHT, 71 (46.7%) had inMHT, and 15 (9.9%) had rnMHT. No significant differences were found among groups regarding demographic, clinical characteristics and prevalence of risk factors, excluding older age in rnMHT (67.412.9 years; P<0.001) and higher prevalence of diabetes in tMHT (10.9%; P < 0.05) compared to other groups. No significant differences were found among groups for home and clinic BP. Night-time systolic/diastolic BP levels and loads showed a significant trend toward increase from inMHT to tMHT towards rnMHT; whereas systolic/diastolic BP fall showed a significant opposite trend. tMHT was associated to a borderline risk of stroke (OR 0.13; 95% IC 0.013–1.296; P = 0.082) and hospitalization for hypertension (OR 0.413; 95% IC 0.146–1.172; P = 0.097). Conclusions: Further studies are needed with larger population sample and higher number of cardiovascular events to better evaluate the potential prognostic impact of different forms of MHT in the clinical practice. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved