Standard Versus Tight Blood Pressure Control (page 475)
An aggressive approach towards blood pressure (BP) reduction has been tempered by studies, suggesting that an excessive BP lowering may be dangerous, particularly in patients with coronary artery disease (the so called J-shaped curve phenomenon). In the Studio Italiano Sugli Effetti CARDIOvascolari del Controllo della Pressione Arteriosa SIStolica (Cardio-Sis), we randomized 1111 non-diabetic patients with systolic BP ≥150 mm Hg to 2 different systolic BP targets (<140 mm Hg [standard control] or <130 mm Hg [tight control]). In this post hoc analysis, we stratified patients by the absence or presence of established cardiovascular disease at entry. The primary study outcome, ECG left ventricular hypertrophy 2 years after randomization, occurred less frequently in the tight than in the standard control group to a similar extent in the subgroups without and with established cardiovascular disease at entry (P for interaction=0.82). A composite of cardiovascular events and all-cause death (main secondary outcome) also occurred less frequently in the tight than in the standard control group in patients without and with previous cardiovascular disease. Thus, an intensive antihypertensive strategy with systolic BP goal <130 mm Hg reduces left ventricular hypertrophy and improves clinical outcomes to a similar extent in hypertensive patients with and without established cardiovascular disease. These results may remove the fear that a systolic BP target <130 mm Hg would be potentially dangerous in hypertensive patients with established coronary or cerebrovascular disease.
Blood Pressure and Target Organ Damage in Polycystic Ovary Syndrome (page 624)
The polycystic ovary syndrome (PCOS) affects 5% to 10% of premenopausal women worldwide. Besides cutaneous and reproductive abnormalities, these women gather a constellation of cardiovascular risk factors from early ages in relation to their androgen excess and to the frequent association with insulin resistance and obesity. Nonetheless, whether these patients present with abnormalities in the blood pressure regulation is still controversial. To provide answer to this important issue, we compared the office and ambulatory blood pressure monitoring profiles and echocardiographic parameters of a cohort of women with PCOS with those of non-hyperandrogenic women and men. We showed that several blood pressure recordings of the patients with PCOS and weight excess resembled those of men and were increased compared with those of non-hyperandrogenic women. Furthermore, overweight patients with PCOS had frequencies of undiagnosed hypertension mirroring those of men with weight excess. Undiagnosed hypertension in women with PCOS was accompanied by an increase in left ventricular mass, suggesting early target organ damage as well. The main determinants of these disturbances in patients with PCOS were obesity, sympathetic overactivation, and hyperandrogenemia. These findings may have important clinical implications in a highly prevalent condition, such as PCOS, warranting a comprehensive cardiovascular evaluation in these women to identify, treat, and prevent cardiovascular events at the long term.
Refractory Hypertension: Prevalence, Risk Factors (page 451)
Refractory hypertension refers to a phenotype of antihypertensive failure. The initial description of this hypertensive subgroup was based on a retrospective analysis of patients referred to a hypertension specialty clinic. In this prior analysis, refractory hypertension was diagnosed if blood pressure remained uncontrolled after a minimum of 6 months of treatment by a hypertension specialist. Of 308 consecutive patients evaluated for resistant hypertension, 29, or ≈10%, were refractory to treatment, despite treatment with an average of 6 medications, including chlorthalidone and spironolactone. In this issue of Hypertension, the prevalence, risk factors, and comorbidities of patients with refractory hypertension were evaluated in a population-based cohort, the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study (n=30 239). Of the 49% of participants with hypertension, 14.5% had resistant hypertension (blood pressure >140/90 mm Hg on ≥3 classes of antihypertensive agents or <140/90 mm Hg on ≥4 classes), whereas only 78% or 0.5% were refractory to treatment defined as blood pressure >140/90 mm Hg on ≥5 classes of agents, which included a diuretic in all cases. Compared with all hypertensive participants, refractory hypertension was associated with black race, men, living in the stroke belt or buckle, higher body mass index, chronic kidney disease, diabetes mellitus, and history of stoke or coronary artery disease. These findings indicate that refractory hypertension, or antihypertensive failure, is extremely rare.
- © 2014 American Heart Association, Inc.