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

Overview of mitral valve replacement versus mitral valve repair due to ischemic papillary muscle rupture: A meta-analysis inspired by a case report

Background: Papillary muscle rupture (PMR) is an infrequent but catastrophic complication after myocardial infarction (MI). Surgical procedure is considered the optimal treatment, despite high risk. However, the gold standard technique is still a major dilemma. Therefore, a meta-analysis was carried out to assess and provide an overview comparing mitral valve replacement (MVR) and mitral valve repair (MVr) for PMR post-MI. Methods: A systematic literature search was performed. Data were extracted and verified using a standardized data extraction form. Meta-analysis was realized mainly using RevMan 5.4 software. Results: From four observational studies 1640 patients were identified; 81% underwent MVR and 19% MVr. Operative mortality results were significantly higher in MVR group than the MVr group. MVR was performed under emergency conditions and patients admitted in cardiogenic shock or who required the use of mechanical cardiac support underwent MVR. MVr had shorter time of hospitalization and similar incidence of postoperative complications than MVR. No significant differences existed between the two procedures regarding cardiopulmonary bypass time. Conclusions: Mitral valve repair appears to be a viable alternative to MVR for post-MI PMR, given that it has lower operative mortality, shorter time of hospitalization and similar incidence of short-term postoperative complications than MVR. However, it needs to be pointed out that MVR was associated with the most critical clinical condition following PMR. There is uncertainty regarding the overall survival and improvement of the quality of life between the procedures. Nevertheless, further completed investigation is required

Correlations between plasma aldosterone levels and ventricular-arterial coupling in adult outpatient with essential hypertension: role of gender

Background: Plasma aldosterone level (PRA) determine an increased risk of cardiovascular events, independent of blood pressure (BP) values. Aim of the study:To evaluate the potential correlations between plasma aldosterone (PA) levels and ventricular-arterial coupling (VAC), a parameter of myocardial efficiency, in adult outpatients with essential hypertension, and to estimate potential impact of gender differences. Results: We included 182 hypertensive outpatients, who has been divided in two groups according to gender (34.6% female; 65% male). We found that PRA resulted significantly and positively correlated with VAC (Pearson r: 0.236; P=0.001), whilst no significance correlations were found between its single components, even if a trend towards augmentation (Pearson r: 0.107; P=0.145) and reduction (Pearson r: -0.63; P=0.391) was found, respectively for arterial and ventricular elastance. PRA correlate positively with BP levels (p<0,001), as well as with LV mass (p=0,004) and VAC (p=0,05) in men, but not in women, Late-wave ratio (E/A) and the early mitral annular velocity (E wave) shown a significant negative correlation with PAC in men (p=0,049 and p=0,018 respectively), but not in women. Conclusion: PA levels, even within the normal range, may affect at early-stage LV efficiency, which was non-invasively evaluated thorughout the echocardiographic measurement of VAC. The discrepancies found in PRA correlations with ecocardiographic parameters according to gender, which may be due to a crosstalk between androgens and the cardiovascular effects of aldosterone, suggest the possible different susceptibility of the ventricle to aldosterone in women and men

Educational interventions may promote better blood pressure control in Russia

Control of hypertension still remains an unresolved clinical problem. Despite marked improvement in both diagnostic opportunities and availability of integrated and well-tolerated antihypertensive drug therapies, several reports have independently and consistently showed a relatively high prevalence of the disease (ranging between 25 and 35%) and persistently low rates of blood pressure control (about 35–45%

Search of multiple markers of organ damage for better cardiovascular risk stratification in hypertension. Role of “SHATS” syndrome in the clinical practice

Essential hypertension is a chronic, asymptomatic disease characterized by sustained and persistent rise in systolic/diastolic blood pressure (BP) levels and increased risk of developing major cardiovascular (CV) complications, including stroke, myocardial infarction, renal disease, congestive heart failure and CV death. Risk of hypertension-related CV complications can be estimated by comprehensive evaluation of individual global CV risk profile, which includes search for CV risk factors and comorbidities, as well as assessment of markers of organ damage (OD)

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

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