hypertension

Importance: Hypertension, defined as office systolic blood pressure (SBP) 130 mm Hg or greater and/or diastolic blood pressure 80 mm Hg or greater, affects 43.9% of women and 49.5% of men in the US. Approximately 19.7% of patients treated for hypertension have apparent resistant hypertension (blood pressure ≥130/80 mm Hg) despite using 3 or more antihypertensive medications, preferably a renin-angiotensin system blocker, a calcium channel blocker, and a thiazide-type diuretic, at maximally tolerated doses.

Observations: Approximately 10% of patients treated for hypertension have true resistant hypertension confirmed with home or 24-hour ambulatory blood pressure monitoring to exclude white-coat hypertension (approximately 37.5% of apparent resistant hypertension) and after excluding medication nonadherence (approximately 50%) and secondary hypertension such as primary aldosteronism (approximately 5%-25%). Conditions associated with resistant hypertension include obesity, diabetes, chronic kidney disease, and sleep apnea. Resistant hypertension is associated with increased risk of cardiovascular death vs controlled blood pressure at 5 years to 10 years (absolute risk increase, 10.3% [95% CI, 8.7%-12.1%]). Lifestyle modifications for resistant hypertension include a low-sodium diet (<1500 mg/d), reducing or avoiding alcohol, 150 min/wk or more of aerobic exercise, and weight loss. Illicit drugs (eg, cocaine) and medications that increase blood pressure (eg, nonsteroid anti-inflammatory drugs, serotonin-norepinephrine reuptake inhibitors) should be avoided. Sleep apnea should be treated when diagnosis is confirmed. Pharmacologic optimization includes use of combination tablets of antihypertensives; intensifying diuretic therapy by using chlorthalidone; and sequential addition of antihypertensive medications using evidence-based algorithms. In a meta-analysis of 20 studies (9 randomized clinical trials [RCTs] and 11 observational studies [331 participants]), use of antihypertensive therapies that combine 2 to 3 medications into a single formulation reduced SBP by -3.99 mm Hg (95% CI, -7.92 to -0.07) vs equivalent doses given separately. For patients with apparent or true resistant hypertension who have an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater and a serum potassium level of 4.5 mmol/L or less, adding spironolactone (25-50 mg/d) compared with placebo lowers office SBP by -13.3 mm Hg (95% CI, -17.89 to -8.72 [4 RCTs]) and 24-hour ambulatory SBP by -8.46 mm Hg (95% CI, -12.54 to -4.38 [2 RCTs]) in a network meta-analysis of 24 RCTs (3485 patients with resistant hypertension). A meta-analysis of 10 RCTs (2478 participants) reported that compared with a sham procedure, catheter-based renal denervation, which disrupts the sympathetic nerves in the renal artery walls, decreased 24-hour ambulatory SBP by -4.4 mm Hg (95% CI, -6.1 to -2.7) and office SBP by -6.6 mm Hg (95% CI, -9.7 to -3.6).

Conclusions and relevance: True resistant hypertension affects 10% of patients treated for hypertension and is diagnosed after excluding white-coat hypertension, medication nonadherence, and secondary hypertension such as primary aldosteronism. First-line treatment includes lifestyle modifications, diuretic therapy with chlorthalidone, and combination tablets of antihypertensives. Spironolactone and renal denervation decrease blood pressure in patients with true resistant hypertension.

Author/s:

Michel Azizi, Wanpen Vongpatanasin, Naomi D. L. Fisher

Management of Orthostatic Hypotension: A Review

Megan George — Thu, 09 Apr 2026 23:15:35 +0000

Date Added:

April 9, 2026

Journal/Publication:

JAMA

Publication Date:

April 6, 2026

URL:

Management of Orthostatic Hypotension: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2026.0284

Keywords

PMID (1):

41941194

MeSH

hypotension

Hypotension, Orthostatic

hypertension

Dizziness

blood pressure

A review and advice about how to help patients with orthostatic hypotension. James W. Mold, MD, MPH

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Importance: Orthostatic hypotension is a common but underrecognized condition that increases with age and is associated with a lower quality of life, falls, and increased mortality. The frequent coexistence of supine hypertension and postprandial hypotension with orthostatic hypotension makes it a challenging condition to manage.

Observations: Testing for orthostatic hypotension should be done in patients with orthostatic symptoms (eg, vision changes and dizziness that occur only when upright and improve when seated or lying down), as well as asymptomatic patients in high-risk groups such as adults with frailty who are older than 70 years, individuals with neurodegenerative or autonomic disorders, and patients with unexplained falls. Patients with orthostatic hypotension should be screened for postprandial hypotension and supine hypertension to inform the treatment approach. Nonpharmacological strategies, such as medication review, increased salt and fluid intake, compression garments, and behavioral modifications, serve as fundamental approaches to treat orthostatic hypotension. Midodrine and droxidopa are the only US Food and Drug Administration-approved medications for orthostatic hypotension, but other medications (eg, fludrocortisone, atomoxetine, pyridostigmine) are used off label as part of an individualized treatment plan. Treatment targets in orthostatic hypotension are focused not on blood pressure measurements but on symptom relief and fall prevention.

Conclusions and relevance: All patients with orthostatic symptoms-along with other select patient groups-should be evaluated for orthostatic hypotension. Nonpharmacological treatments are first line, and medication decisions should be tailored based on clinical presentation and relevant comorbidities.

Author/s:

David Moloney, Ayman Youssef, Luis E. Okamoto

Diagnosis and Management of Resistant Hypertension: A Review

Megan George — Tue, 24 Mar 2026 16:14:03 +0000

Date Added:

March 24, 2026

Journal/Publication:

JAMA

Publication Date:

March 23, 2026

URL:

Diagnosis and Management of Resistant Hypertension: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2026.1221

Keywords

blood pressure

Antihypertensive Agents

Resistant Hypertension

hypertension

Hyperaldosteronism

Anti-Inflammatory Agents

PMID (1):

41870448

MeSH

Blood Pressure Monitoring

Ambulatory

blood pressure

antihypertensive agents

renin-angiotensin system

resistant hypertension

hypertension

White Coat Hypertension

Hyperaldosteronism

Anti-Inflammatory Agents

A review of the evaluation and management of patients with resistant hypertension. James W. Mold, MD, MPH

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Author/s:

Michel Azizi, Wanpen Vongpatanasin, Naomi D L Fisher, Felix Mahfoud, Laurence Amar, Ajay J Kirtane

Management of Hypertension in Adults

Megan George — Tue, 24 Mar 2026 16:08:23 +0000

Date Added:

March 24, 2026

Journal/Publication:

JAMA

Publication Date:

March 23, 2026

URL:

Management of Hypertension in Adults

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2026.1132

Keywords

hypertension

primary aldosteronism

blood pressure

Hypokalemia

PMID (1):

41870440

MeSH

Hypertension, Pulmonary

Guidelines for management of patients with hypertension from the American College of Cardiology and the American Heart Association. James W. Mold, MD, MPH

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Hypertension is the leading modifiable risk factor worldwide for ASCVD, and approximately half of US adults have hypertension.1 Uncontrolled BP contributes to heart failure, stroke, atrial fibrillation, and sudden cardiac death and is associated with development of kidney failure and dementia.2 This guideline was designed to provide clinicians with a risk stratification approach to managing BP. This synopsis highlights key guideline recommendations.

Author/s:

Amber E Johnson, Christopher D Jackson, Jason T Alexander

Hypertension and alcohol: a cross-sectional study comparing PEth with AUDIT and AUDIT-C in primary care

Megan George — Mon, 16 Feb 2026 17:36:14 +0000

Date Added:

February 16, 2026

Journal/Publication:

Family Practice

Publication Date:

February 1, 2026

URL:

Hypertension and alcohol: a cross-sectional study comparing PEth with AUDIT and AUDIT-C in primary care

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1093/fampra/cmaf097

Keywords

alcohol use disorder

cardiovascular disorders

PMID (1):

41511884

MeSH

Alcohol Drinking* / epidemiology

Antihypertensive Agents / therapeutic use

lycerophospholipids* / blood

Hypertension* / drug therapy

Hypertension* / epidemiology

Alcoholism* / diagnosis

primary health care

The results of this study suggest that patients with poorly controlled BP should be further evaluated for alcohol use disorders even if the brief screening questions are negative. James W. Mold, MD, MPH

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Background: This cross-sectional study aimed to describe proportions of patients with indications of alcohol consumption using phosphatidylethanol (PEth), the Alcohol Use Disorders Identification Test (AUDIT), and its consumption-focused version (AUDIT-C), in relation to blood pressure (BP) control, overall and by sex.

Methods: A total of 270 hypertensive primary care patients (ICD-10: I10.9) were stratified into BP control groups: controlled (<140/90 mmHg), uncontrolled (≥140/90 mmHg), and apparent treatment-resistant hypertension (aTRH; ≥140/90 mmHg with ≥3 antihypertensive drugs). A randomized sample from each stratum was invited, baseline data were collected. Alcohol consumption using predefined categories for PEth and AUDIT, and hazardous use (PEth ≥ 0.122 µmol/L; AUDIT ≥ 8; AUDIT-C ≥ 5 for men, ≥4 for women), were analyzed in relation to BP control groups.

Results: Mean age was 67 ± 11 years; 42% were women. PEth indicated high and regular alcohol consumption in 6.4% of controlled, 5.3% of uncontrolled, and 19.2% of aTRH patients (controlled vs. aTRH, P = .027; uncontrolled vs. aTRH, P = .013). AUDIT showed no significant differences in hazardous use between BP groups (P = .865). AUDIT-C identified slightly higher proportions of hazardous use than PEth, across BP groups and sexes. No significant differences were found between BP groups for hazardous use by PEth (P = .339) or AUDIT-C (P = .150).

Conclusions: PEth revealed significantly higher alcohol use in the aTRH group, undetected by AUDIT. AUDIT-C and PEth identified more hazardous use than AUDIT, suggesting their potential to prompt alcohol-related discussions and support evidence-based hypertension care. PEth correlated more strongly with AUDIT-C than with AUDIT.

Clinical trial registration: Retrospectively registered in Clinical Trials, SLSO2022-0143, 2022-12-10.

Keywords: alcohol use disorder; cardiovascular disorders (hypertension/DVT/atherosclerosis); hypertension (high blood pressure); prevention; primary care; screening.

Author/s:

Åsa Thurfjell, Maria Hagströmer, Charlotte Ivarsson, Anders Norrman, Johanna Adami, Lena Lundh, Jan Hasselström

Approach to pelvic venous disorders

Hope Smashey — Wed, 26 Nov 2025 02:00:39 +0000

Date Added:

November 25, 2025

Publisher:

Can Fam Physician

Publication Date:

November 25, 2025

Issue:

Volume:

11-12

Pages:

699-703

URL:

Approach to pelvic venous disorders

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.711112699

Keywords

Vascular Surgical Procedures

hypertension

PMID (1):

41285637

MeSH

Vascular Surgical Procedures

Pelvis

Pelvic Pain

hypertension

A review of relatively common chronic venous abnormalities in the female pelvis that can cause LE varicosities and pelvic pain. James W. Mold, MD, MPH

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Objective: To provide a practical guide to help family physicians recognize, diagnose, and manage patients with pelvic venous disorders (PeVDs), often overlooked as causes of chronic pelvic pain and varicose veins.

Sources of information: This review is based on guidelines from the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, the Society of Interventional Radiology, and the European Society for Vascular Surgery.

Main message: PeVDs are common, though frequently misdiagnosed, causes of chronic pelvic pain and varicose veins predominantly in female patients. These conditions arise from venous reflux or obstruction, which can cause varicose veins and venous hypertension in the renal hilum, pelvis, perineum, and lower extremities. Family physicians should recognize the clinical signs of PeVDs and use appropriate imaging to confirm diagnoses. Interventional treatments, including embolization and stenting, are effective for symptom management and improving patient outcomes.

Conclusion: Early recognition of patients with PeVDs by family physicians is crucial for timely and effective treatment. By using appropriate diagnostic tools and making timely referrals, physicians can substantially improve patients' quality of life.

Author/s:

Andrew D Brown

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

Aubrey Delammermore — Mon, 19 Dec 2022 06:00:00 +0000

Date Added:

December 19, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

December 14, 2022

URL:

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa2212270

Keywords

hypertension

cardiovascular events

heart failure

veterans

infarction

PMID (1):

36516076

MeSH

Hydrochlorothiazide

Sodium Chloride Symporter Inhibitors

Hypokalemia

Angina, Unstable

Chlorthalidone

HCYZ seems to be as effective as chlorthalidone for reducing the risk of major CV events. James W. Mold, MD, MPH

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Background: Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear.

Methods: In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non-cancer-related death. Safety was also assessed.

Results: A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P = 0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001).

Conclusions: In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non-cancer-related deaths than patients who received hydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT02185417.).

Author/s:

Ishani, A., Cushman, W. C., Leatherman, S. M., R. A., Woods, P., Glassman, P. A., Taylor, A. A., Hau, C., Klint, A., Huang, G. D., Brophy, M. T., Fiore, L. D., Ferguson, R. E., Diuretic Comparison Project Writing Group

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Aubrey Delammermore — Thu, 08 Sep 2022 05:00:00 +0000

Date Added:

September 8, 2022

Journal/Publication:

Heart

Publisher:

BMJ Publishing Group

Publication Date:

August 9, 2022

Pages:

1-8

URL:

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1136/heartjnl-2022-321332

Keywords

PMID (1):

35945000

MeSH

Randomized Controlled Trials as Topic

Odds Ratio

body mass index

Salt substitutes, when compared to use of regular salt, reduce BP, CV mortality, and all-cause mortality.

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Objectives The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results.

Methods We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups.

Results There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was −4.61 mm Hg (95% CI −6.07 to −3.14) and of diastolic blood pressure (DBP) was −1.61 mm Hg (95% CI −2.42 to −0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a −1.53 mm Hg (95% CI −3.02 to −0.03, p=0.045) greater reduction in SBP and a −0.95 mm Hg (95% CI −1.78 to −0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94).

Conclusions The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide.

Author/s:

Yin, X., Rodgers, A., Perkovic, A., Huang, L., Li, K., Yu, J., Wu, Y., Wu, J. H. Y., Marklund, M., Huffman, M. D., Miranda, J. J., Di Tanna, G. L., Labarthe, D., Elliott, P., Tian, M., Neal, B.

Screening for Hypertension in Adults

Saige Blanchard — Wed, 05 May 2021 05:00:00 +0000

Date Added:

May 5, 2021

Journal/Publication:

Journal of the American Medical Association

Publisher:

U.S. Preventative Services Task Force

Publication Date:

April 27, 2021

Issue:

Volume:

325

Pages:

1650-1656

URL:

Screening for Hypertension in Adults

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Web Page

DOI (1):

10.1001/jama.2021.4987

Keywords

hypertension

heart failure

myocardial infarction

chronic kidney disease

MeSH

blood pressure

Mass Screening

hypertension

myocardial infarction

No surprise that the USPSTF recommends in-office screening for hypertension. What seems interesting is that they suggest getting confirmatory readings from outside the office before making the diagnosis. James W. Mold, MD, MPH

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IMPORTANCE Hypertension is a prevalent condition that affects approximately 45% of the adult US population and is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor for heart failure, myocardial infarction, stroke, and chronic kidney disease. OBJECTIVE To reaffirm its 2015 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertension in adults, the accuracy of office blood pressure measurement for initial screening, and the accuracy of various confirmatory blood pressure measurement methods. POPULATION Adults 18 years or older without known hypertension. EVIDENCE ASSESSMENT Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that screening for hypertension in adults has substantial net benefit. RECOMMENDATION The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (A recommendation)

Author/s:

U.S. Preventative Services Task Force

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy

Brian Desmarais — Tue, 01 Dec 2020 16:59:44 +0000

Date Added:

December 1, 2020

Journal/Publication:

AHA Journals

Publisher:

American College of Cardiology/American Heart Association

Publication Date:

August 12, 2019

URL:

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

hypertension

MeSH

Cardiomyopathy

Hypertrophic

This is a new guideline from the AHA/ACC on management of patients with hypertrophic cardiomyopathy. James W. Mold, MD, MPH

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Not available.

Author/s:

Joint Committee on Clinical Practice Guidelines

Hormonal Contraception in Women With Hypertension

Brian Desmarais — Tue, 29 Sep 2020 13:19:18 +0000

Date Added:

September 29, 2020

Journal/Publication:

JAMA Insights

Publisher:

JAMA

Publication Date:

September 21, 2020

URL:

Hormonal Contraception in Women With Hypertension

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi:10.1001/jama.2020.11935

Keywords

hypertension

clinical pharmacy and pharmacology

gynecology

Obstetrics and Gynecology

womens health

Advice regarding the use of hormonal contraceptives in women with hypertension. James W. Mold, MD, MPH

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Author/s:

Shufelt, Chrisandra, Levee, Alexis

The Unrecognized Prevalence of Primary Aldosteronism

John Bayhi — Tue, 26 May 2020 21:01:14 +0000

Date Added:

May 26, 2020

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

May 26, 2020

Volume:

Online ahead of print

URL:

The Unrecognized Prevalence of Primary Aldosteronism

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.7326/M20-0065

Keywords

primary aldosteronism

hypertension

cardiovascular disease

PMID (1):

32449886

MeSH

Essential Hypertension

Cross-Sectional Studies

prevalence

cardiovascular diseases

Hyperaldosteronism

hypertension

Hypoakalemia

Blood Pressure Determination

Academic Medical Centers

Potassium

Sodium

This study suggests (confirming what Dr. David Kem at OU has long taught) that primary aldosteronism is much more common than generally thought, occurring in as many as 11% of people with normal BP and 22% of those with hard to control HTN. Usual diagnostic tests aren’t very accurate. We should probably be using spironolactone more often. James W. Mold, MD, MPH

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Background:

Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease.

Objective:

To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure.

Design:

Cross-sectional study.

Setting:

4 U.S. academic medical centers.

Participants:

Participants with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408).

Measurements:

Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 µg/24 h.

Results:

Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 µg/24 h (95% CI, 5.2 to 7.7 µg/24 h) in normotension, 7.3 µg/24 h (CI, 5.6 to 8.9 µg/24 h) in stage 1 hypertension, 9.5 µg/24 h (CI, 8.2 to 10.8 µg/24 h) in stage 2 hypertension, and 14.6 µg/24 h (CI, 12.9 to 16.2 µg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone–renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism.

Limitation:

Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics.

Conclusion:

The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of “essential” hypertension.

Primary Funding Source:

National Institutes of Health.

Author/s:

Brown, JM, Siddiqui, M, Calhoun, DA, Carey, RM, Hopkins, PN, Williams, GH, Vaidya, A

Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial

Brian Desmarais — Thu, 24 Oct 2019 17:04:27 +0000

Date Added:

April 3, 2020

Journal/Publication:

European Heart Journal

Publication Date:

October 22, 2019

URL:

Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1093/eurheartj/ehz754

Keywords

Perhaps once a day antihypertensives should be taken at night rather than in the AM. James W. Mold, MD, MPH

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AIMS:

The Hygia Chronotherapy Trial, conducted within the clinical primary care setting, was designed to test whether bedtime in comparison to usual upon awakening hypertension therapy exerts better cardiovascular disease (CVD) risk reduction.

METHODS AND RESULTS:

In this multicentre, controlled, prospective endpoint trial, 19 084 hypertensive patients (10 614 men/8470 women, 60.5 ± 13.7 years of age) were assigned (1:1) to ingest the entire daily dose of ≥1 hypertension medications at bedtime (n = 9552) or all of them upon awakening (n = 9532). At inclusion and at every scheduled clinic visit (at least annually) throughout follow-up, ambulatory blood pressure (ABP) monitoring was performed for 48 h. During the 6.3-year median patient follow-up, 1752 participants experienced the primary CVD outcome (CVD death, myocardial infarction, coronary revascularization, heart failure, or stroke). Patients of the bedtime, compared with the upon-waking, treatment-time regimen showed significantly lower hazard ratio-adjusted for significant influential characteristics of age, sex, type 2 diabetes, chronic kidney disease, smoking, HDL cholesterol, asleep systolic blood pressure (BP) mean, sleep-time relative systolic BP decline, and previous CVD event-of the primary CVD outcome [0.55 (95% CI 0.50-0.61), P < 0.001] and each of its single components (P < 0.001 in all cases), i.e. CVD death [0.44 (0.34-0.56)], myocardial infarction [0.66 (0.52-0.84)], coronary revascularization [0.60 (0.47-0.75)], heart failure [0.58 (0.49-0.70)], and stroke [0.51 (0.41-0.63)].

CONCLUSION:

Routine ingestion by hypertensive patients of ≥1 prescribed BP-lowering medications at bedtime, as opposed to upon waking, results in improved ABP control (significantly enhanced decrease in asleep BP and increased sleep-time relative BP decline, i.e. BP dipping) and, most importantly, markedly diminished occurrence of major CVD events.

TRIAL REGISTRATION:

ClinicalTrials.gov, number NCT00741585.

Author/s:

Hermida, R.C., Crespo, J.J., Domínguez-Sardiña, M, Otero, A., Moyá, A., Ríos, M.T., Sineiro, E., Castiñeira, M.C., Callejas, P.A., Pousa, L., Salgado, J.L., Durán, C., Sánchez, J.J., Fernández, J.R., Mojón, A., Ayala, D.E., Hygia Project Investigators

Yoga as Antihypertensive Lifestyle Therapy: A Systematic Review and Meta-analysis

Jeffrey Wilson — Mon, 04 Mar 2019 17:52:18 +0000

Date Added:

March 4, 2019

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Elsevier

Publication Date:

March 1, 2019

Issue:

Volume:

Pages:

432-446

URL:

Yoga as Antihypertensive Lifestyle Therapy: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2018.09.023

Keywords

PMID (1):

30792067

MeSH

antihypertensive agents

This meta-analysis suggests that yoga, especially when it includes breathing techniques and meditation/mindfulness, can reduce blood pressure by as much as 11 mmHg systolic and 6 mmHg diastolic.

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OBJECTIVE:

To investigate the efficacy of yoga as antihypertensive lifestyle therapy and identify moderators that account for variability in the blood pressure (BP) response to yoga.

METHODS:

We systematically searched 6 electronic databases from inception through June 4, 2018, for articles published in English language journals on trials of yoga interventions that involved adult participants, reported preintervention and postintervention BP, and had a nonexercise/nondiet control group. Our search yielded 49 qualifying controlled trials (56 interventions). We (1) evaluated the risk of bias and methodological study quality, (2) performed meta-regression analysis following random-effects assumptions, and (3) generated additive models that represented the largest possible clinically relevant BP reductions.

RESULTS:

On average, the 3517 trial participants were middle-aged (49.2±19.5 years), overweight (27.9±3.6 kg/m2) adults with high BP (systolic BP, 129.3±13.3 mm Hg; diastolic BP, 80.7±8.4 mm Hg). Yoga was practiced 4.8±3.4 sessions per week for 59.2±25.0 minutes per session for 13.2±7.5 weeks. On average, yoga elicited moderate reductions in systolic BP (weighted mean effect size, -0.47; 95% CI, -0.62-0.32, -5.0 mm Hg) and diastolic BP (weighted mean effect size, -0.47; 95% CI, -0.61 to -0.32; -3.9 mm Hg) compared with controls (P<.001 for both systolic BP and diastolic BP). Controlling for publication bias and methodological study quality, when yoga was practiced 3 sessions per week among samples with hypertension, yoga interventions that included breathing techniques and meditation/mental relaxation elicited BP reductions of 11/6 mm Hg compared with those that did not (ie, 6/3 mm Hg).

CONCLUSION:

Our results indicate that yoga is a viable antihypertensive lifestyle therapy that produces the greatest BP benefits when breathing techniques and meditation/mental relaxation are included.

Author/s:

Wu, Yin, Johnson, Blair T., Acabchuk, Rebecca L., Chen, Shiqi, Lewis, Holly K., Livingston, Jill, Park, Crystal L., Pescatello, Linda S.

Association Between Use of Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-like Peptide 1 Agonists, and Dipeptidyl Peptidase 4 Inhibitors With All-Cause Mortality in Patients With Type 2 Diabetes

Jeffrey Wilson — Mon, 22 Oct 2018 15:42:39 +0000

Date Added:

November 1, 2018

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

April 17, 2018

Issue:

Volume:

319

Pages:

1580-1591

URL:

Association Between Use of Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-like Peptide 1 Agonists, and Dipeptidyl Peptidase 4 Inhibitors With All-Cause Mortality in Patients With Type 2 Diabetes

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2018.3024

Keywords

SGLT-2 inhibitors

GLP-1 agonists

hypertension

PMID (1):

29677303

MeSH

dipeptidyl-peptidase IV inhibitors

diabetes mellitus, type 2

glucagon-like peptide 1

sodium-glucose transport proteins

While both SGLT-2 inhibitors and GLP-1 agonists reduced both cardiovascular and all-cause mortality compared to controls, their impact was very small (1% or less in both/all cases), probably not enough to be a reason to choose these medications over others, particularly if you are recommending more effective risk reduction strategies like smoking cessation, physical activity, BP reduction, and statins.

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IMPORTANCE:

The comparative clinical efficacy of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors for treatment of type 2 diabetes is unknown.

OBJECTIVE:

To compare the efficacies of SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors on mortality and cardiovascular end points using network meta-analysis.

DATA SOURCES:

MEDLINE, Embase, Cochrane Library Central Register of Controlled Trials, and published meta-analyses from inception through October 11, 2017.

STUDY SELECTION:

Randomized clinical trials enrolling participants with type 2 diabetes and a follow-up of at least 12 weeks were included, for which SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors were compared with either each other or placebo or no treatment.

DATA EXTRACTION AND SYNTHESIS:

Data were screened by 1 investigator and extracted in duplicate by 2 investigators. A Bayesian hierarchical network meta-analysis was performed.

MAIN OUTCOMES AND MEASURES:

The primary outcome: all-cause mortality; secondary outcomes: cardiovascular (CV) mortality, heart failure (HF) events, myocardial infarction (MI), unstable angina, and stroke; safety end points: adverse events and hypoglycemia.

RESULTS:

This network meta-analysis of 236 trials randomizing 176 310 participants found SGLT-2 inhibitors (absolute risk difference [RD], -1.0%; hazard ratio [HR], 0.80 [95% credible interval {CrI}, 0.71 to 0.89]) and GLP-1 agonists (absolute RD, -0.6%; HR, 0.88 [95% CrI, 0.81 to 0.94]) were associated with significantly lower all-cause mortality than the control groups. SGLT-2 inhibitors (absolute RD, -0.9%; HR, 0.78 [95% CrI, 0.68 to 0.90]) and GLP-1 agonists (absolute RD, -0.5%; HR, 0.86 [95% CrI, 0.77 to 0.96]) were associated with lower mortality than were DPP-4 inhibitors. DPP-4 inhibitors were not significantly associated with lower all-cause mortality (absolute RD, 0.1%; HR, 1.02 [95% CrI, 0.94 to 1.11]) than were the control groups. SGLT-2 inhibitors (absolute RD, -0.8%; HR, 0.79 [95% CrI, 0.69 to 0.91]) and GLP-1 agonists (absolute RD, -0.5%; HR, 0.85 [95% CrI, 0.77 to 0.94]) were significantly associated with lower CV mortality than were the control groups. SGLT-2 inhibitors were significantly associated with lower rates of HF events (absolute RD, -1.1%; HR, 0.62 [95% CrI, 0.54 to 0.72]) and MI (absolute RD, -0.6%; HR, 0.86 [95% CrI, 0.77 to 0.97]) than were the control groups. GLP-1 agonists were associated with a higher risk of adverse events leading to trial withdrawal than were SGLT-2 inhibitors (absolute RD, 5.8%; HR, 1.80 [95% CrI, 1.44 to 2.25]) and DPP-4 inhibitors (absolute RD, 3.1%; HR, 1.93 [95% CrI, 1.59 to 2.35]).

CONCLUSIONS AND RELEVANCE:

In this network meta-analysis, the use of SGLT-2 inhibitors or GLP-1 agonists was associated with lower mortality than DPP-4 inhibitors or placebo or no treatment. Use of DPP-4 inhibitors was not associated with lower mortality than placebo or no treatment.

Author/s:

Zheng, Sean L., Roddick, Alistair J., Aghar-Jaffar, Rochan, Shun-Shin, Matthew J., Francis, Darrel, Oliver, Nick, Meeran, Karim