BACKGROUND: Orthostatic blood pressure (BP) dysregulation measured in-office predicts cardiovascular risk. However, the prevalence of self-measured home orthostatic hypo- and hypertension and their association with markers of atherosclerosis have not yet been described in a large sample of the general population.

METHODS: We performed cross-sectional analyses of home orthostatic BP reactions and pulse wave velocity (PWV), coronary artery calcium score (CACS), and carotid plaques in 4556 Swedish CArdioPulmonary bioImage Study (SCAPIS) participants who had performed home BP measurements and two home-standing BP measurements (Omron M10-IT device). Home orthostatic hypotension (home OH) was defined as a drop in BP after standing of systolic ≥20 mmHg or diastolic ≥10 mmHg, home orthostatic hypertension (home OHT) as an increase in systolic BP after standing of ≥20 mmHg.

RESULTS: Participants with home OH (n = 293, 6.4%) or OHT (n = 139, 3.1%) were more likely than participants with normal home orthostatic BP reactions to have ≥1 carotid plaque (65.5% and 64.7% vs. 55.3%, P < 0.001 and P = 0.027). Participants with home OH had higher PWV (9.2 ± 1.4 vs. 8.9 ± 1.3 m/s, P = 0.005) and were more likely to have CACS ≥ 100 (17.4 vs. 11.6%, P = 0.004). No such associations were observed for home OHT.

CONCLUSIONS: Self-measured home orthostatic hypo- and hypertension were associated with markers of atherosclerosis, and home orthostatic hypotension was also associated with arterial stiffness.

Hypertension is a risk factor for cardiovascular disease, but the evidence for treatment and blood pressure (BP) targets in the elderly is less robust. Orthostatic hypertension is a potential risk factor for cardiovascular mortality and cognitive decline. All 85-years-olds in Linköping municipality, Sweden, were invited to a prospective birth cohort study including questionnaires, cognitive testing and physical examinations, including supine and orthostatic BP measurements. Logistic regression and Cox proportional hazard models were used to assess the impact of baseline supine and orthostatic BP on cognitive decline and all-cause mortality after 5- and 7.2 years respectively. Of 650 invited 85-year-olds, 322 were included. During follow-up, 190 persons died, and 28 persons developed cognitive decline. Neither elevated supine BP nor orthostatic hypertension were associated with cognitive decline. After adjustments, elevated supine BP was not associated with mortality in all participants, but was associated with lower all-cause mortality in participants with previously diagnosed hypertension, HR 0.59 (95% CI 0.41–0.85). Orthostatic hypertension was not associated with all-cause mortality, HR 0.56 (95% CI 0.26–1.22) after multiple adjustments. In 85-year-olds with known hypertension, elevated supine BP was associated with lower all-cause mortality. Orthostatic hypertension was not associated with cognitive decline but trended towards a lower all-cause mortality.

Randomized placebo-controlled cardiovascular outcomes trials of pharmacological blood pressure lowering were performed already inthe1960s, andthescientificevidencesupporting the use of antihypertensive drugs as a cornerstone for cardiovascular protection has grown ever since.1 Today, 4 classes of antihypertensive drugs are considered the most rational drugs of choice because of their proven ability to reduce the incidence of cardiovascular events: inhibitors of the reninangiotensin system (angiotensin converting enzyme inhibitors and angiotensin receptor blockers), calcium channel blockers, thiazides and related diuretics, and beta blockers. Emerging drug classes that appear on the horizon include selective aldosterone synthase inhibitors, dual blockers of endothelin hypertension were randomized to treatment with either the angiotensin receptor blocker olmesartan (20 mgdaily) orto1of2doses(240or480mgdaily)of the novel angiotensin receptor neprilysin inhibitor sacubitril/allisartan. Patients were included based on their systolic office blood pressure, which was required to be 150 to 179 mm Hg at study initiation, following a wash-out period during which participants on prior antihypertensive therapy (approximately 90% of the study cohort) terminated their treatment. After 12 weeks of treatment, the baseline-adjusted changes in office systolic blood pressure (which was the primary outcome) was 23 mmHgwitholmesartan 20 mg daily, 25 mm Hg receptorsAandB,andinjectableblockersofhepatic angiotensinogen mRNA synthesis.2

Aims/hypothesis Previous studies have shown that individuals with similar mean glucose levels (MG) or percentage of time in range (TIR) may have different HbA(1c) values. The aim of this study was to further elucidate how MG and TIR are associated with HbA(1c). Methods Data from the randomised clinical GOLD trial (n=144) and the follow-up SILVER trial (n=98) of adults with type 1 diabetes followed for 2.5 years were analysed. A total of 596 paired HbA(1c)/continuous glucose monitoring measurements were included. Linear mixed-effects models were used to account for intra-individual correlations in repeated-measures data. Results In the GOLD trial, the mean age of the participants (+/- SD) was 44 +/- 13 years, 63 (44%) were female, and the mean HbA(1c) (+/- SD) was 72 +/- 9.8 mmol/mol (8.7 +/- 0.9%). When correlating MG with HbA(1c), MG explained 63% of the variation in HbA(1c) (r=0.79, p&lt;0.001). The variation in HbA(1c) explained by MG increased to 88% (r=0.94, p value for improvement of fit &lt;0.001) when accounting for person-to-person variation in the MG-HbA(1c) relationship. Time below range (TBR; &lt;3.9 mmol/l), time above range (TAR) level 2 (&gt;13.9 mmol/l) and glycaemic variability had little or no effect on the association. For a given MG and TIR, the HbA(1c) of 10% of individuals deviated by &gt;8 mmol/mol (0.8%) from their estimated HbA(1c) based on the overall association between MG and TIR with HbA(1c). TBR and TAR level 2 significantly influenced the association between TIR and HbA(1c). At a given TIR, each 1% increase in TBR was related to a 0.6 mmol/mol lower HbA(1c) (95% CI 0.4, 0.9; p&lt;0.001), and each 2% increase in TAR level 2 was related to a 0.4 mmol/mol higher HbA(1c) (95% CI 0.1, 0.6; p=0.003). However, neither TIR, TBR nor TAR level 2 were significantly associated with HbA(1c) when accounting for MG. Conclusions/interpretation Inter-individual variations exist between MG and HbA(1c), as well as between TIR and HbA(1c), with clinically important deviations in relatively large groups of individuals with type 1 diabetes. These results may provide important information to both healthcare providers and individuals with diabetes in terms of prognosis and when making diabetes management decisions.

Background and aim

Poor dental health status has been linked to increased risk of cardiovascular events in type 2 diabetes (T2D). Less is known about self-perceived dental health and cardiovascular risk. Our aim with this study was to investigate this association.

Methods

Recruitment of T2D patients took place between 2005 and 2008 in Swedish primary care. Teeth satisfaction was assessed by questionnaire at baseline. The major adverse cardiovascular events (MACE) in this study were hospitalization due to myocardial infarction, stroke or cardiovascular death. Cox regression models were used.

Results

Out of 761 participants 601 had complete data. Ninety-two MACEs occurred (median follow-up time: 11.6 years). Those satisfied with their teeth (n = 458) had 61 events (1.2 events per 100 person-years), while those dissatisfied with teeth (n = 143) had 31 events (2.2 events per 100 person-years). Dissatisfaction with teeth was associated with an increased risk of MACE independent of age, sex and levels of CRP (HR 1.85, 95% CI 1.20 – 2.86).

Conclusions

In patients with T2D, dissatisfaction with teeth was associated with increased risk of MACE and may be considered as a marker of risk.

In this community-based cohort of 5861 individuals followed for median 7.2 years, the discriminatory ability of NT-proBNP alone in predicting mortality was similar to that of multiple conventional markers of risk in people without diabetes. In people with diabetes, NT-proBNP alone discriminated risk of mortality better than conventional risk factors.

Hemodynamic responses to exercise in the acute phase after moderate to severe stroke have remained poorly investigated. The aim of this randomized controlled study, in which 52 (32 women) patients with moderate to severe stroke were randomized to three weeks of 20 minutes in-bed cycle exercise 5 days per week or to usual care, was to explore the systolic blood pressure (SBP) response to exercise and to evaluate the impact of the intervention on the resting and post-test systolic and diastolic blood pressures and heart rate, and on the systolic blood pressure response to exercise. We found that resting SBP decreased from baseline to post-intervention in both the intervention group (147.7 +/- 18.1 mmHg to 125.3 +/- 17.1 mmHg, P &lt; .001) and in the control group (147.8 +/- 23.7 mmHg to 131.4 +/- 14.8 mmHg, P &lt; .001) without a significant difference between the groups (interaction P = .308). However, there was a significant difference (interaction P = .010) regarding how. SBP (change in SBP from pre-test to post-test) changed from baseline to post-intervention. In the intervention group, Delta SBP increased from -1.0 +/- 15.0 mmHg to 8.5 +/- 9.4 mmHg, P = .009, whereas in the control group, Delta SBP decreased from 7.1 + 10.9 mmHg to 4.5 + 11.8 mmHg, P = .395. We conclude that patients randomized to in-bed cycle exercise seemed to normalize their blood pressure response to exercise to a larger extent than patients in the control group.

In patients with diabetes and cardiovascular or renal comorbidities, circulating levels of the N-terminal fragment of prohormone B-type natriuretic peptide (NT-proBNP) have similar discriminatory ability as multivariate models for prediction of cardiovascular events or death. We validated this finding in patients with dysglycemia not selected for co-existing cardiorenal diseases. (c) 2021 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Objective: To study risk in white-coat hypertension (WCH) by measurement of coronary artery calcium score (CACS), carotid--femoral pulse-wave velocity (PWV) and carotid plaques. Methods: Cross-sectional population-based cohort with randomized selection of participants from Linkoping, Sweden. An Omron m10-IT oscillometric device was used for clinic and home blood pressures (HBP) in the morning and evening for 1 week. Results: We recruited 5029 middle-aged and mainly defined WCH as SBP at least 140 mmHg and/or DBP at least 90 mmHg with HBP less than 135/85 mmHg. There were 2680 normotensive participants and 648 had WCH after exclusion of treated participants. More women (59.5%) than men (42.8%, P &lt; 0.001) had WCH. We found higher prevalence of CACS greater than 100 compared with less than 100 (12.4 vs. 7.2%, P &lt; 0.001), PWV (11.5 +/- 1.5 vs. 10.4 +/- 1.3 m/s, P &lt; 0.001) and a higher prevalence of one or more carotid plaques (59.5 vs. 48%, P &lt; 0.001) in participants with WCH than in normotension. Participants with WCH also had more dyslipidemia and higher glucose levels. Normotensive women scored lower on nervousness than women with WCH (P = 0.022). After matching of 639 participants with WCH to normotensive participants according to age, gender and systolic HBP the prevalence of a high CACS (12.1 vs. 8.6%, P = 0.003,) PWV (11.0 +/- 0.068 vs. 11.5 +/- 0.068 m/s, estimated marginal means +/- SE, P &lt; 0.001 by ANOVA) but not more carotid plaques (59.5 vs. 55.6%, P = 0.23), remained in the participants with WCH compared with the matched normotensive participants. Conclusion: WCH is particularly common in middle-aged women, and it displays metabolic dysfunction and increased prevalence of arteriosclerotic manifestations in both genders. As markers of increased cardiovascular risk were present also after matching normotensive and WCH participants according to systolic HBP, age and gender, the presence of WCH signals an increased cardiovascular risk burden that is not fully explained by elevated BP levels at home.

Aims: Patients with heart failure and preserved ejection fraction (HFpEF) frequently have difficult-to-control hypertension. We examined the effect of neprilysin inhibition on apparent resistant hypertension in patients with HFpEF in the PARAGON-HF trial, which compared the effect of sacubitril-valsartan with valsartan.

Methods and results: In this post hoc analysis, patients were categorized according to systolic blood pressure at the end of the valsartan run-in (n=4795). Apparent resistant hypertension was defined as systolic blood pressure &gt;= 14 0mmHg (&gt;= 135 mmHg if diabetes) despite treatment with valsartan, a calcium channel blocker, and a diuretic. Apparent mineralocorticoid receptor antagonist (MRA)-resistant hypertension was defined as systolic blood pressure &gt;= 140 mmHg (&gt;= 135 mmHg if diabetes) despite the above treatments and an MRA. The primary outcome in the PARAGON-HF trial was a composite of total hospitalizations for heart failure and death from cardiovascular causes. We examined clinical endpoints and the safety of sacubitril-valsartan according to the hypertension category. We also examined reductions in blood pressure from the end of valsartan run-in to Weeks 4 and 16 after randomization. Overall, 731 patients (15.2%) had apparent resistant hypertension and 135 (2.8%) had apparent MRA-resistant hypertension. The rate of the primary outcome was higher in patients with apparent resistant hypertension [17.3; 95% confidence interval (CI) 15.6-19.1 per 100 person-years] compared to those with a controlled systolic blood pressure (13.4; 12.7-14.3 per 100 person-years), with an adjusted rate ratio of 1.28 (95% CI 1.05-1.57). The reduction in systolic blood pressure at Weeks 4 and 16, respectively, was greater with sacubitril-valsartan vs. valsartan in patients with apparent resistant hypertension [-4.8 (-7.0 to -2.5) and 3.9 (-6.6 to -1.3) mmHg] and apparent MRA-resistant hypertension [-8.8 (-14.0 to -3.5) and -6.3 (-12.5 to -0.1) mmHg]. The proportion of patients with apparent resistant hypertension achieving a controlled systolic blood pressure by Week 16 was 47.9% in the sacubitril-valsartan group and 34.3% in the valsartan group [adjusted odds ratio (OR) 1.78, 95% CI 1.30-2.43]. In patients with apparent MRA-resistant hypertension, the respective proportions were 43.6% vs. 28.4% (adjusted OR 2.63, 95% CI 1.18-5.89).

Conclusion: Sacubitril-valsartan may be useful in treating apparent resistant hypertension in patients with HFpEF, even in those who continue to have an elevated blood pressure despite treatment with at least four antihypertensive drug classes, including an MRA.