High Blood Pressure & Cardiovascular Prevention

Aspirin Efficacy in Primary Prevention: A Meta-analysis of Randomized Controlled Trials Abstract Introduction The role of aspirin as a means of primary prevention remains controversial. Aim We have conducted a meta-analysis of all randomized controlled trials (RCTs) to evaluate the role of aspirin in primary prevention. Methods Literature search was performed via PubMed, Embase, and the Cochrane Library for all related RCTs. All-cause mortality was the primary endpoint. Secondary endpoints included major adverse cardiovascular events (MACE), myocardial infarction (MI), cardiovascular mortality, cerebrovascular events, and bleeding events. We used a random effects model to report the risk ratios (RRs) with 95% confidence intervals (CIs). Results Our analysis included 17 RCTs (164,862 patients; 83,309 received aspirin and 81,744 received placebo). Our study did not demonstrate any significant reduction in all-cause mortality for patients treated with aspirin when compared with placebo (RR 0.97; 95% CI 0.93–1.01; P = 0.13). Sensitivity analysis performed by excluding healthy elderly (≥ 65) showed significant reductions in all-cause mortality in the aspirin-treated patients (RR 0.94; 95% CI 0.90–0.99; P = 0.01). There were no significant differences between both groups regarding cardiovascular mortality and cerebrovascular events (P > 0.05). However, aspirin-treated patients significantly reduced MACE and MI events (RR 0.89; 95% CI 0.85–0.93; P < 0.001 and RR 0.88; 95% CI 0.78–0.98; P = 0.02, respectively), respectively. However, aspirin was associated with a significantly higher incidence of bleeding, including major bleeding and intracranial bleeding (P < 0.001). Conclusions Aspirin use in primary prevention has resulted in a lower incidence of MACE and MI without significantly effecting cerebrovascular events. However, aspirin was associated with a higher bleeding risk. Use of aspirin as a means of primary prevention should be thoroughly discussed with patients and pursued based on the risk of cardiovascular disease while also considering bleeding risk.

The Effects of Resveratrol Supplementation on Endothelial Function and Blood Pressures Among Patients with Metabolic Syndrome and Related Disorders: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Abstract Introduction There are current trials investigating the effect of resveratrol supplementation on endothelial function and blood pressures among patients with metabolic syndrome (MetS); however, the findings are controversial. Aim This systematic review and meta-analysis of randomized controlled trials (RCTs) were carried out to summarize the effects of resveratrol supplementation on endothelial activation and blood pressures among patients with MetS and related disorders. Methods We searched systematically online databases including: PubMed-Medline, Embase, ISI Web of Science and Cochrane Central Register of Controlled Trials until October, 2018. Two independent authors extracted data and assessed the quality of included articles. Data were pooled using the fixed- or random-effects model and considered as standardized mean difference (SMD) with 95% confidence intervals (95% CI). Results Out of 831 electronic citations, 28 RCTs (with 33 findings reported) were included in the meta-analyses. The findings showed that resveratrol intervention significantly increased flow-mediated dilatation (FMD) levels (SMD 1.77; 95% CI 0.25, 3.29; P = 0.02; I2: 96.5). However, resveratrol supplements did not affect systolic blood pressure (SBP) (SMD − 0.27; 95% CI − 0.57, 0.03; P = 0.07; I2: 88.9) and diastolic blood pressure (DBP) (SMD − 0.21; 95% CI − 0.52, 0.11; P = 0.19; I2: 89.8). Conclusions Resveratrol supplementation significantly increased FMD among patients with MetS and related disorders, but did not affect SBP and DBP. Additional prospective studies are needed to investigate the effect of resveratrol supplementation on endothelial function and blood pressures, using higher-dose of resveratrol with longer durations.

Commentary to “The Possible Role of Nutraceuticals in the Prevention of Cardiovascular Disease”

Morning Surge and Peak Morning Ambulatory Blood Pressure Versus Automated Office Blood Pressure in Predicting Cardiovascular Disease Abstract Introduction Automated office blood pressure (AOBP) has been recently shown to predict equally well to ambulatory blood pressure (ABP), conventional office blood pressure (OBP) and home blood pressure (HBP), cardiovascular (CV) events among hypertensives. Aim To compare AOBP recording and ABP monitoring in order to evaluate morning blood pressure (BP) peak in predicting CV events and deaths in hypertensives. Methods We assessed 236 initially untreated hypertensives, examined between 2009 and 2013. The end points were CV and non-CV death and any CV event including myocardial infarction, evidence of coronary heart disease, heart failure hospitalization, severe arrhythmia, stroke, and symptomatic peripheral artery disease. We fitted proportional hazards models using the different modalities as predictors and evaluated their predictive performance using two metrics: the Akaike’s Information Criterion, and Harrell’s C-index. Results After a mean follow-up of 7 years, 23 subjects (39% women) had at least one CV event. In Cox regression models, systolic conventional OBP, AOBP and peak morning BP were predictive of CV events (p < 0.05). The Akaike Information Criterion showed smaller values for AOBP than peak morning BP, indicating a better performance in predicting CV events (227.2736 and 238.7413, respectively). The C-index was 0.6563 for systolic AOBP and 0.6243 for peak morning BP indicating a better predicting ability for AOBP. Conclusion In initially untreated hypertensives, AOBP appears to be at least equally reliable to 24-h monitoring in the evaluation of morning BP peak in order to detect CV disease whereas the sleep-trough and preawakening morning BP surge did not indicate such an effect.

Is the Oral Microbiome Associated with Blood Pressure in Older Women? Abstract Introduction A possible role of the oral microbiome, specifically oral nitrate reducing flora, in blood pressure (BP) homeostasis, if proven etiologic in nature, could lead to novel mechanism-based therapy to improve hypertension prevention and control. Aim This cross-sectional study characterized and compared the oral microbiome between four study groups based on BP status among 446 postmenopausal women aged 53–82 years. Methods Three study groups were not taking hypertension medication and were separated based on BP, as follows: normal BP (systolic < 120 and diastolic < 80; N = 179), elevated BP/Stage I hypertension (systolic 120–139 or diastolic 80–90; N = 106), Stage II hypertension (systolic > 140 or diastolic > 90; N = 42). The forth group consisted of anyone taking hypertension medications, regardless of BP (N = 119). Subgingival microbiome composition was determined using 16S rRNA sequencing with the Illumina MiSeq platform. Kruskal–Wallis tests were used to compare species-level relative abundance of bacterial operational taxonomic units across the four groups. Results Sixty-five bacterial species demonstrated significant differences in relative abundance in women with elevated BP or using hypertension medication as compared to those with normal BP. After correction for multiple testing, two species, Prevotella oral (species 317) and Streptococcus oralis, remained significant and were lower in abundance among women taking antihypertension medications compared to those with normal BP (corrected P < 0.05). Conclusions These data provide novel description of oral subgingival bacteria grouped according to BP status. Additional larger studies including functional analysis and prospective designs will help further assess the potential role of the oral microbiome in BP regulation and hypertension.

Vascular Aging and Disease of the Large Vessels: Role of Inflammation Abstract Structural and functional arterial properties commonly impair with aging process. These effects on vasculature could act at many levels from microcirculation to large vessels. Above normal aging process classic cardio-vascular risk factors (hypertension, diabetes mellitus, dyslipidemia, etc.) accelerate the physiological process leading to premature structural and functional alterations that has also been termed early vascular aging. Target organ damage evaluation could be clinically important since these alterations precede by many years’ cardiovascular events and so their assessment can predict the onset of more serious and costly events giving the opportunity to prevent CV events by earlier therapeutic intervention. This review will focus on large artery functional properties and particularly on the role of inflammation on the aortic stiffening process.

Vascular Aging and Disease of the Small Vessels Abstract Cardiovascular events are the consequence of vascular damage at both the macro and microcirculatory level. The relationship between large stiffening artery and microvascular disease may be bidirectional, since wave reflection from microvascular sites could increase systolic blood pressure and pulse pressure, while transmission of increased arterial pulsatility to microvessels could represent a mechanism of damage. Hypertension and aging share similar mechanisms of vascular dysfunction. In fact, vascular remodelling, endothelial dysfunction and vascular stiffness are common features in hypertension and aging. Structural and functional changes in small arteries occur during normal and accelerated aging, possibly triggered by hypertension. A cross-talk may be present between large and small artery changes, interacting with pressure wave transmission and reflection, exaggerating cardiac, brain and kidney damage, and finally leading to cardiovascular and renal complications.

Prevention of Cardiovascular Diseases in Children and Adolescents Abstract The atherosclerotic alterations that are the basis of cardiovascular diseases can start already in childhood. For this reason the prevention of cardiovascular diseases should be undertaken very early both in the general population and, in a targeted manner, in subjects at cardiovascular risk. Preventive strategies should include measures to encourage physical activity and correct eating habits and to reduce exposure to pollutants. The main actors responsible for carrying out these preventive interventions are the local and national political authorities. Moreover, particular attention should be paid to the first thousand days of life starting from conception, to prevent unfavorable epigenetic modifications. In addition to initiatives aimed at the general population, interventions should be planned by the medical community to assess the individual risk profile. The current obesity epidemic has in fact made it relatively frequent even among children and adolescents to find some cardiovascular risk factors known in adults such as arterial hypertension, dyslipidemia, glucose metabolism disorders and increased of uric acid values. The purpose of this review is to indicate lines of intervention for cardiovascular prevention in children and adolescents.

Low Density Lipoprotein (LDL) Cholesterol as a Causal Role for Atherosclerotic Disease: Potential Role of PCSK9 Inhibitors Abstract Proprotein convertase subtilisin/kexin type 9 (PCSK9)-related discoveries of the turn of the century have translated into substantial novelty in dyslipidemia treatment in the last 5 years. With chronic preventable atherosclerotic cardiovascular diseases (ASCVD) representing an epidemic of morbidity and mortality worldwide, low-density lipoprotein cholesterol (LDL-c) reduction represents a public health priority. By overcoming two major statin-related issues, namely intolerance and ineffectiveness, PCSK9 inhibitors have offered a safe and effective option in selected clinical settings where LDL-c reduction is required. Herein, we recapitulate recent findings, clinical applications, and ASCVD prevention potential of PCSK9 inhibition, with focus on anti-PCSK9 monoclonal antibodies, evolocumab and alirocumab.

Avoidable Burden of Cardiovascular Diseases in the Eastern Mediterranean Region: Contribution of Selected Risk Factors for Cardiovascular-Related Deaths Abstract Introduction Contribution of risk factors for cardiovascular-related deaths in the Eastern Mediterranean Region Organization (EMRO) is not estimated quantitatively. Aim To determine the avoidable burden of cardiovascular diseases (CVDs) due to hypertension, diabetes, smoking, overweight, and obesity in countries of EMRO of the WHO. Methods The comparative risk assessment methodology was used to calculate the potential impact fraction (PIF) and percentage of the avoidable burden of CVD-related death due to associated risk factors. Population exposure levels for CVDs and corresponding measures of association were extracted from published studies. The attributable burden was calculated by multiplying the Disability-Adjusted Life-Years (DALYs) for CVDs by the estimated impact fraction of risk factors. DALYs of the CVDs in all countries of the EMRO were extracted from the GBD official website in 2016. Results Following reduction of the current prevalence of smoking, obesity, hypertension, diabetes, and overweight to a feasible minimum risk exposure level in Lebanon, about 12.4%, 4.2%, 10.2%, 3.8%, and 5.7% of the burden of CVD-related mortality could be avoidable, respectively. The corresponding values of avoidable burden in selected EMRO countries were 5.1%, 3.5%, 9.4%, 5.9% and 5.3% in Iran and 9.5%, 4.1%, 11%, 8.2% and 5.4% in Egypt. Conclusions Findings suggest that health policy makers of all EMRO countries should take into account the attributable burden of CVD-related mortality due to associated risk factors to effectively develop preventive interventions.