Editorial comments: focus on arterial hypertension and co-morbidities

This edition of the journal is focused on arterial hypertension and related complications. Several and novel aspects are here considered from basic to bedside, with important clinical implication in the current practice. Control rates for hypertension are poor and stagnant.1 Of the many contributing factors, patients’ lack of adherence to medications ranks very high. Available data to quantify adherence are imprecise, coming largely from studies using pill counts and questionnaires, and from refill audits in large prescription databases. We have a fresh source of direct evidence, from rigorous, controlled, randomized trials investigating renal denervation (RDN) in hypertension. One prominent feature of these newer RDN studies in hypertensive patients has been the assessment of medication adherence using highly accurate adherence testing of urine and/or plasma. Accordingly, adherence to hypertension medication in RDN hypertension trials has been discouragingly low during follow-up, even when patients knew testing would be performed. Interestingly, a significant number of patients with hypertension are interested in RDN: non-adherence to medication and side effects from medication have both been significant predictors of patient preference for RDN.2 The goal of this paper is to discuss current perspectives to improve hypertension management using new technologies and methodologies.3 In particular, this work focuses on (i) education programmes for children and adults, (ii) progress in imaging technology for more accurate quantification of adverse consequences of hypertension, (iii) progress in hypertension treatment with lifestyle modifications, antihypertensive agents, and new devices, (iv) tools for addressing poor patient adherence and physician inertia, (v) digital health, telemonitoring, and mobile health approaches, and (vi) healthcare system approaches to CV risk factor management. Non-pharmacological therapies assist in decreasing the daily dose of antihypertensive medication and delaying the transition from prehypertension to hypertension. All the main scientific societies’ hypertension guidelines emphasize lifestyle changes as a core component of treatment for all stages of hypertension. However, it is unclear whether guidelines’ recommendations are consistent. Here, the authors aiming at systematically review hypertension guidelines on their recommendations on non-pharmacological factors, to highlight strength of evidence, similarities, and differences: 10 were included in this systematic review. Most of the suggestions in the guidelines were comparable (reduced salt intake, weight, dietary patterns, increased physical activity and smoking cessation, and limiting alcohol intake). There were some disagreements on what to recommend about new psychological and environmental factors, like stress or air pollution, how much alcohol to drink, how much meat, coffee, tea, and refined sugars to eat.4 The 2021 European Society of Cardiology guideline on cardiovascular disease (CVD) prevention categorizes moderate and severe chronic kidney disease (CKD) as high and very high CVD risk status regardless of other factors like age but does not include estimated glomerular filtration rate (eGFR) and albuminuria in its algorithms, systemic coronary risk estimation 2 (SCORE2) and SCORE2 in older persons (SCORE2-OP), to predict CVD risk.5 Here it has been developed and validated an ‘Add-on’ to incorporate CKD measures into these algorithms: the CKD Add-on (eGFR only) and CKD Add-on (eGFR + ACR) improved C-statistic by 0.006 (95% confidence interval 0.004–0.008) and 0.016 (0.010–0.023), respectively, for SCORE2 and 0.012 (0.009–0.015) and 0.024 (0.014–0.035), respectively, for SCORE2-OP.6 In face of the increased prevalence of CVD in patients with diabetes mellitus (DM), the need for effective preventive intervention is crucial and the use of (lifetime) risk prediction scores play a major role.7 The 2021 European Society of Cardiology CVD prevention guidelines recommend the use of (lifetime) the DIAbetes Lifetime perspective (DIAL) model to aid decisions regarding intensified preventive treatment options in adults with DM. Here the DIAL model has been successfully recalibrated using contemporary and representative registry data (DIAL2) for use in other European countries. The DIAL2 model discriminated well, with C-indices ranging from 0.732 to 0.700 according to different databases.8 Exertional dyspnoea is frequently encountered in patients with DM and could be indicative of altered haemodynamics and pulmonary abnormalities during exercise. People with recently diagnosed DM had abnormal cardiac haemodynamics during graded exercise, as evidenced by a disproportionate increase in peak wedge pressure compared with control patients. These effort cardiac abnormalities may be early indicators of subclinical cardiac dysfunction associated with DM, which may precede the more severe impairment of heart function at rest observed in DM with longer duration. In recent years, it has been demonstrated that cardiac haemodynamic and in particular pulmonary vascular function can be assessed non-invasively by combining exercise echocardiography with cardiopulmonary exercise testing (imaging CPET).9 In this issue of the journal Gojevic and coworkers10 compared the cardiac and pulmonary vascular function between dyspnoeic and non-dyspnoeic patients with Type 2 DM. Imaging CPETs were performed on 50 asymptomatic DM patients and 47 DM patients with unexplained dyspnoea. At peak exercise, the systolic left ventricular reserve was considerably lower in the dyspnoeic group. Additionally, the dyspnoeic group had significantly greater resting and exercise pulmonary arterial pressures (mPAPs). However, in the dyspnoeic group, the mPAP/cardiac output slope negatively predicted exercise capacity. Atrial fibrillation (AF) is the commonest arrhythmia seen in clinical practice: around one in three Europeans is expected to develop AF during their lifetime. The study of its related risk factor has been the object of several recent studies,11,12 but the time trends have been still poorly investigated. Here in a total of 14 818 women and 13 225 men aged 25 years or older without AF enrolled in the Tromsø Study between 1994 and 2008 and followed up for incident AF throughout 2016, AF incidence rates in women decreased from 1.19 to 0.71 per 1000 person-years. In men, AF incidence initially increased from 1.18 to 2.82 per 1000 person-years in 2004, and then declined to 1.94 per 1000 person-years in 2016. Changes in blood pressure, body mass index, physical activity, smoking, and alcohol consumption play a role in the observed time changes.13 Hypertrophic cardiomyopathy (HCM) is a common autosomal dominant cardiac disease (1:500) and a major cause of sudden cardiac death (SCD) in young people. The most serious complication is HCM-related SCD caused by ventricular arrhythmias or death after heart failure or stroke. Depression increases mortality and bad clinical outcomes in coronary heart disease and heart failure patients. Decades of prospective research have linked depression to SCD in the elderly and those with acute myocardial infarction or stable coronary artery disease. Patients with HCM exhibit more psychological discomfort than the general population and worse quality of life and sociability. However, no information is available even on the incidence of mental disorders, including depression and anxiety, in patients with HCM. In this study, Park et al.,14 using nationwide population-based data from the Korean National Health Insurance Service, sought to determine the risk of mental disorders in patients with HCM compared with those without HCM. Overall, 4046 patients with HCM and 12 138 matched individuals were followed up until the first diagnosis of mental disorders or the end of the follow-up. During a median follow-up period of 4.1 years, the incidence rate of the primary outcome was 54.4/1000 person-years in the HCM group and 31.5/1000 person-years in the control group, yielding a hazard ratio of 1.719. In sensitivity analyses, the risk of particular types of mental illnesses, such as single or repeated depressive episodes and anxiety disorders, was higher in HCM patients compared with matched controls.