Is early and fast blood pressure control important in hypertension management?

Control of blood pressure (BP) in hypertension is recognized as a key measure in the management of cardiovascular (CV) risk and is a cornerstone of preventive strategies. It is not defined, however, whether an initiation of the antihypertensive treatment in the early stages of hypertension (such as prehypertension or high-normal BP), may bring benefits for the long-term prevention of CV events. In addition, it has not been thoroughly addressed the issue whether achievement of a prompt BP reduction in hypertensive patients may contribute to reduce CV damage and events. The aim of this article is to critically examine data from studies exploring these important questions. Our conclusion is that the available evidence, though not very extensive, supports the prevailing benefits associated with early BP control. We also discuss the therapeutic strategies to achieve early control of BP. Finally, we believe that this aspect deserves to be more thoroughly addressed in upcoming international guidelines

Thermally activated vapor bubble nucleation: the Landau-Lifshitz/Van der Waals approach

Vapor bubbles are formed in liquids by two mechanisms: evaporation (temperature above the boiling threshold) and cavitation (pressure below the vapor pressure). The liquid resists in these metastable (overheating and tensile, respectively) states for a long time since bubble nucleation is an activated process that needs to surmount the free energy barrier separating the liquid and the vapor states. The bubble nucleation rate is difficult to assess and, typically, only for extremely small systems treated at atomistic level of detail. In this work a powerful approach, based on a continuum diffuse interface modeling of the two-phase fluid embedded with thermal fluctuations (Fluctuating Hydrodynamics) is exploited to study the nucleation process in homogeneous conditions, evaluating the bubble nucleation rates and following the long term dynamics of the metastable system, up to the bubble coalescence and expansion stages. In comparison with more classical approaches, this methodology allows on the one hand to deal with much larger systems observed for a much longer times than possible with even the most advanced atomistic models. On the other it extends contin- uum formulations to thermally activated processes, impossible to deal with in a purely determinist setting

Dynamics of a vapor nanobubble collapsing near a solid boundary

In the present paper a diffuse interface approach is used to address the collapse of a sub-micron vapor bubble near solid boundaries. This formulation enables an unprecedented description of interfacial flows that naturally takes into account topology modification and phase changes (both vapor/liquid and vapor/supercritical fluid transformations). Results from numerical simulations are exploited to discuss the complex sequence of events associated with the bubble collapse near a wall, encompassing shock-wave emissions in the liquid and reflections from the wall, their successive interaction with the expanding bubble, the ensuing asymmetry of the bubble and the eventual jetting phase

COVID-19 and the Forgotten Majority

No abstract availabl

To whom recommend intensive treatment for hypertension?

Arterial hypertension is the main identifiable cardiovascular risk factor, and although the benefit of blood pressure reduction is universally acknowledged, the scientific community has long been divided over the therapeutic blood pressure targets to be reached, also considering the estimated overall cardiovascular risk and the presence of individual risk factors and associated comorbidities. During the last few years, numerous clinical studies and meta-analyses, in particular, the SPRINT study, have been published, demonstrating the advantages of an intensive antihypertensive treatment, over a target blood pressure value (<140/90 mmHg), in the reduction of major cardiovascular events, myocardial infarction, stroke, heart failure, and all-causes cardiovascular mortality. Stemming from these results the major International Guidelines revisited the therapeutic objectives, recommending blood pressure value <130/80 mmHg for the vast majority of hypertensive patients until the age of 65 and suggesting a reduction of the target also in the elderly. Numerous studies and metaanalyses demonstrated that the reduction of the risk of coronary or cerebral events, and of all-causes cardiovascular mortality, is independent from the baseline value of blood pressure and the individual estimated risk. It has been also demonstrated that an early institution of antihypertensive treatment is associated with a faster realization of the recommended targets, and consequent significant benefits in terms of reduction of the incidence of myocardial infarction, heart failure, and major cardiovascular events, particularly when blood pressure control is achieved during the first 6 months of treatment, and even better during first 3 months. Other studies outlined that combination therapy with two or more drugs, mainly in a single pill configuration, are superior in reaching the recommended therapeutic targets. This is the reason why this strategy is strongly supported by the European Society of Cardiology/ European Society of Hypertension (ESC/ESH) 2018 Guidelines, specifically the use of renin–angiotensin–aldosterone system inhibitors [angiotensin-converting enzyme (ACE) inhibitors and Sartans], in combination with calcium antagonist and/or thiazide diuretics, with the option to add antagonist of mineralcorticoid receptors, when an adequate blood pressure control has not been reached, or other classes of drugs, such as beta-blockers, when specific clinical indications are present, first and foremost ischaemic cardiomyopathy or heart failure. The newly proposed therapeutic goals are particularly important in high-risk patients, such as patients with previous cardiovascular events, diabetes mellitus, renal insufficiency, and patients older than 65 years of age

Atrial fibrillation and ischaemic heart disease. should we use acetylsalicylic acid beside anticoagulants?

Coexistence of atrial fibrillation and ischaemic heart disease is very common and patients affected by these conditions are exposed to both a high ischaemic and haemorrhagic risk. The choice of an appropriate combination of anticoagulant therapy with single or dual antiplatelet treatment is indeed one of the most relevant and contemporary challenges in clinical practice. Several studies and meta-analyses pointed out that 1 year after an acute coronary syndrome or percutaneous revascularization, the use of the sole anticoagulant therapy is not associated with increased risk of major cardiovascular events, whereas there is a substantial reduction of clinical significant bleeding events, as compared to patients treated also with antiplatelet medications. However, there are no clear-cut data regarding the possibility to implement this strategy in each patient, regardless the cardiovascular risk class. Furthermore, for patients requiring a combined anticoagulant and antiplatelet treatment, the available data seem to favour an association of direct anticoagulant and inhibitors of P2Y12, rather than regimens including aspirin. These data are derived mainly from observational studies, with all their limitations. The use of aspirin could be beneficial in patients with significant comorbidities, such as diabetes mellitus, or with severe peripheral atherosclerotic disease, involving the carotids and other large arteries

Aspirin and the Primary Prevention of Cardiovascular Diseases. An Approach Based on Individualized, Integrated Estimation of Risk

While the use of aspirin in the secondary prevention of cardiovascular (CVD) is well established, aspirin in primary prevention is not systematically recommended because the absolute CV event reduction is similar to the absolute excess in major bleedings. Recently, emerging evidence suggests the possibility that the assumption of aspirin, may also be effective in the prevention of cancer. By adding to the CV prevention benefits the potential beneficial effect of aspirin in reducing the incidence of mortality and cancer could tip the balance between risks and benefits of aspirin therapy in the primary prevention in favour of the latter and broaden the indication for treatment with in populations at average risk. While prospective and randomized study are currently investigating the effect of aspirin in prevention of both cancer and CVD, clinical efforts at the individual level to promote the use of aspirin in global (or total) primary prevention could be already based on a balanced evaluation of the benefit/risk ratio

novel blood pressure targets in patients with high normal levels and grade 1 hypertension room for monotherapy

Abstract The 2018 European and 2017 American guidelines recommend to start antihypertensive treatment with combinations of two or more drugs in most hypertensive patients, as a consequence of the suggested more ambitious blood pressure (BP) targets (systolic BP between 130 and 120 mmHg in most patients, diastolic BP between 80 and 70 mmHg). Monotherapy, however, is still suggested as first choice in some specific classes of patients. In this article, we analyze the subgroups of hypertensive patients that should properly started and even maintained on monotherapy, with a focus on subjects with BP in the high-normal range or grade 1 hypertension, young adults with estimated low cardiovascular risk, women during pregnancy or menopause, elderly patients aged >80 years or with frailty parameters. Altogether, these subgroups cover a relatively large proportion of patients with hypertension. Thus, we conclude that, despite the upgrowing role of combination therapy, there is still ample room for the approach with monotherapy in clinical management of hypertension

Sacubitril/Valsartan. Potential Impact of ARNi "Beyond the Wall" of ACE2 on Treatment and Prognosis of Heart Failure Patients With Coronavirus Disease-19

From the beginning of the SARS-CoV-2 pandemia, the type 2 angiotensin-converting enzyme (ACE2), probably the most “unloved and neglected” member of the renin-angiotensin-aldosterone (RAAS) family, has attracted increasing attention since it has been shown as the cell receptor through which the virus enters into the cells (1). The physiological action of ACE2, a membrane protein expressed in the heart, lungs, kidneys, liver, and intestine, consists in degrading angiotensin II (Ang II) to angiotensin (1-7), a heptapeptide with a potent vasodilator function through the Mas receptor able to counterbalance the Ang II effects on vasoconstriction, sodium retention, and fibrosis (1). Previous studies have shown that Ang II type 1 receptor (AT1R) blockers (ARBs), ACE inhibitors (ACEI), and mineralocorticoid receptor antagonists (MRA) may up-regulate the expression of ACE2 both in acute and chronic settings of cardiovascular diseases (CVDs), such as hypertension, heart failure (HF) and myocardial infarction (1). These data have generated concern during the early phases of the pandemia, since it has been speculated that the increase in ACE2 level may have contributed to disease virulence and to adverse outcomes particularly in subjects affected by chronic coexisting conditions, namely hypertension, coronary artery disease, HF, and diabetes, who commonly received treatment with RAAS inhibitors and who were characterized by a worse clinical course (2). On the other hand, it has been observed that the binding between coronavirus and ACE2 leads to ACE2 downregulation, resulting in an unopposed production of Ang II by ACE, contributing to lung damage as a consequence of AT1R mediated inflammation, fibrosis, thrombosis, vasoconstriction, and increased vascular permeability. According to these findings, RAAS inhibitors and, in particular, ARBs may even protect against COVID-19 acute lung injury (1). As a matter of fact, epidemiological studies conducted in large populations of COVID-19 patients demonstrated that ARBs or ACE inhibitors had no association with a severe or fatal course of the diseas