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1.  Study on Diastolic Dysfunction in Newly Diagnosed Type 2 Diabetes Mellitus and its Correlation with Glycosylated Haemoglobin (HbA1C) 
Introduction
Left ventricular diastolic dysfunction (LVDD) represents the first stage of diabetic cardiomyopathy preceding changes in systolic function, reinforcing the importance of early examination of ventricular function in individuals with diabetes mellitus (DM). This cross-sectional study was conducted to determine the incidence of asymptomatic LVDD in newly diagnosed normotensive cases of type 2 diabetes subjects, and its relation to glycosylated haemoglobin (HbA1C), age at the time of diagnosis, body mass index (BMI) and serum total cholesterol.
Aim and Objective
To study the incidence of left ventricular diastolic dysfunction (LVDD) and its correlation with HbA1C in normotensive, newly diagnosed type 2 diabetic patients.
Materials and Methods
This cross-sectional study was done in western U.P. on 100 patients of newly diagnosed (within 1 month) type 2 DM between patients 30 and 60 years of age, visiting the Medicine and Endocrinology outpatient Department of LLRM Medical College, Meerut. Patients with established type 2 diabetes and already taking antidiabetic treatment, cardiac diseases like valvular heart disease, ischemic and hypertensive heart disease, congestive heart failure, cardiomyopathy, renal failure, chronic pulmonary disease, severe anaemia and haemoglobinopathies were excluded from the study. These patients were informed about the study and informed consent was obtained before proceeding with the investigations. Patients selected were evaluated with relevant investigations like fasting and post prandial blood sugar, HbA1C level, lipid profile and 2D echocardiography to assess LVDD. These selected patients were divided in 2 groups; one with left ventricular diastolic dysfunction (LVDD) and second group of subjects without LVDD. Various parameters like HbA1C, age, body mass index and serum cholesterol were evaluated between these 2 groups. Statistical analysis was performed using Student t-test, Chi-square and Fisher Exact-test.
Results
Out of 100 patients 65 were males and 35 females. Mean age of the population was 50.08 ± 6.32 years. Overall incidence of LVDD was 41%. Grade 1 LVDD was most common. Mean HbA1C level of LVDD group was found higher as compared to those without LVDD.
Conclusion
LVDD is very common at the time of diagnosis of type 2 DM even in normotensive patients independent of confounding effect of hypertension, ischemia and BMI. HbA1C and age, were found to be strong indicators of LVDD in newly diagnosed cases of Type 2 DM.
doi:10.7860/JCDR/2015/13348.6376
PMCID: PMC4576578  PMID: 26435985
BMI; Diabetic cardiomyopathy; Normotensive
2.  Serum lipid profile and its association with hypertension in Bangladesh 
Background
Hypertension and dyslipidemia are major risk factors for cardiovascular disease, accounting for the highest morbidity and mortality among the Bangladeshi population. The objective of this study was to determine the association between serum lipid profiles in hypertensive patients with normotensive control subjects in Bangladesh.
Methods
A cross-sectional study was carried out among 234 participants including 159 hypertensive patients and 75 normotensive controls from January to December 2012 in the National Centre for Control of Rheumatic Fever and Heart Disease in Dhaka, Bangladesh. Data were collected on sociodemographic factors, anthropometric measurements, blood pressure, and lipid profile including total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL), and high density lipoprotein (HDL).
Results
The mean (± standard deviation) systolic blood pressure and diastolic blood pressure of the participants were 137.94±9.58 and 94.42±8.81, respectively, which were higher in the hypertensive patients (P<0.001). The serum levels of TC, TG, and LDL were higher while HDL levels were lower in hypertensive subjects compared to normotensives, which was statistically significant (P<0.001). Age, waist circumference, and body mass index showed significant association with hypertensive patients (P<0.001) but not with normotensives. The logistic regression analysis showed that hypertensive patients had 1.1 times higher TC and TG, 1.2 times higher LDL, and 1.1 times lower HDL than normotensives, which was statistically significant (P<0.05).
Conclusion
Hypertensive patients in Bangladesh have a close association with dyslipidemia and need measurement of blood pressure and lipid profile at regular intervals to prevent cardiovascular disease, stroke, and other comorbidities.
doi:10.2147/VHRM.S61019
PMCID: PMC4086853  PMID: 25061312
Risk factors; cardiovascular diseases; dyslipidemia; blood pressure
3.  The association between obesity and blood pressure in Thai public school children 
BMC Public Health  2014;14:729.
Background
The prevalence of obesity has substantially increased in the past 3 decades in both developed and developing countries and may lead to an increase in high blood pressure (BP) at an early age. This study aimed to determine the prevalence of obesity and its association with blood pressure among primary school children in central Thailand.
Methods
A cross-sectional study was conducted in two public schools in Bangkok in 2012. A total of 693 students (317 boys and 376 girls) aged 8–12 years participated voluntarily. Anthropometric measurements of weight, height, waist circumference (WC) and BP were collected. Fasting venous blood samples were obtained for biochemical analysis of fasting plasma glucose (FPG) and lipid parameters. Child nutritional status was defined by body mass index (BMI) for age based on the 2000 Center for Diseases Control and Prevention growth charts. The cutoff for abdominal obesity was WC at the 75 percentile or greater. Hypertension was defined according to the 2004 Pediatrics US blood pressure reference. Multinomial logistic regression was used to examine the relationship between high BP and obesity after controlling for other covariates.
Results
The prevalence of obese children was 30.6% for boys and 12.8% for girls (mean prevalence 20.9%). Pre-hypertension (Pre-HT) was 5.7% and 2.7% for boys and girls and hypertension (HT) was 4.7% for boys and 3.2% for girls, respectively. Children with pre-HT and HT had significantly higher body weight, height, WC, BMI, SBP, DBP, TG, and TC/HDL-C levels but lower HDL-C levels than those children with normotension. After controlling for age, sex, glucose and lipid parameters, child obesity was significantly associated with pre-HT and HT (odds rations (ORs) = 9.00, 95% CI: 3.20-25.31 for pre-HT and ORs = 10.60, 95% CI: 3.75-30.00 for HT). So also was WC (abdominal obesity) when considered alone (ORs = 6.20, 95% CI: 2.60-14.81 for pre-HT and ORs = 13.73, 95% CI: 4.85-38.83 for HT) (p-value < 0.001).
Conclusions
Obesity among school children was positively associated with higher BP. Prevention of childhood obesity should be strengthened to prevent the risk of early high BP including cardiovascular risk factors.
doi:10.1186/1471-2458-14-729
PMCID: PMC4223408  PMID: 25034700
Child obesity; High blood pressure; School children; Waist circumference
4.  Effects of simvastatin on blood pressure in hypercholesterolemic patients: An open-label study in patients with hypertension or normotension 
Background
Simvastatin has been reported to improve endotheliumdependent vascular relaxation in patients with hypercholesterolemia. The consequent decrease in arterial stiffness might be associated with a decrease in blood pressure (BP).
Objective
The aim of this study was to determine whether simvastatin 20 and 40 mg/d have an effect on systolic and diastolic blood pressure (SBP and DBP, respectively) in patients with hypercholesterolemia, and, if so, whether the effect is dose dependent and/or is related to the changes in the serum lipid profile.
Methods
This 6-month, open-label study was conducted at the Lipid Clinics of the Department of Internal Medicine, University of Milan, Maggiore Hospital IRCCS, and of the Department of Internal Medicine 1, G. Salvini Hospital, Garbagnate Milanese (Milan, Italy). Patients aged 18 to 80 years with primary hypercholesterolemia who were following a low-fat, low-cholesterol diet for >2 months before the study were enrolled. Patients at high risk for cardiovascular disease (CVD), according to the National Cholesterol Education Program Adult Treatment Panel II guidelines, were given simvastatin 20 mg (tablet) QD for 3 months, and those at low risk for CVD continued with diet only for 3 months (controls). Efficacy variables included body weight, SBP, DBP, and serum lipid levels (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high density lipoprotein cholesterol [HDL-C], and triglycerides [TG]). At 3 months, patients in the simvastatin + diet group who reached their therapeutic goal continued to receive simvastatin 20 mg/d for 3 additional months. In simvastatintreated patients who were normotensive at baseline or who became normotensive at 3 months but who did not reach the therapeutic goal, the simvastatin dosage was increased to 40 mg/d. Patients in both groups who remained hypertensive at 3 months were switched to hypotensive therapy. In the diet-only group, patients who were formerly normotensive or who became normotensive at 3 months but who did not reach their therapeutic goal continued with diet only or started lipid-lowering therapy. All other patients in the diet-only group continued to be treated with diet only, for 3 additional months. Efficacy variables were measured again at 6 months. Tolerability of simvastatin was assessed at each visit using patient interview and measurement of serum aminotransferase and creatine phosphokinase levels.
Results
The study population comprised 222 patients (132 women, 90 men; mean [SEM] age, 53.9 [0.95] years [range, 23–76 years]); 115 high-risk patients (57 with untreated stage 1 hypertension) were assigned to the simvastatin + diet group, and 107 low-risk patients (29 with untreated stage 1 hypertension) were assigned to the diet-only group. In the simvastatin group, after 3 months of therapy, mean SBP was decreased by 3.9 (1.49) mm Hg (change, −2.9%), mean DBP decreased by 3.0 (0.87) mm Hg (change, −3.7%), mean TC decreased by 90.6 (3.98) mg/dL (change, −27.0%), mean LDL-C decreased by 88.9 (3.88) mg/dL (change, −35.6%), and mean TG decreased by 26.3 (7.34) mg/dL (change, −15.8%) (all, P < 0.001). Mean HDL-C increased by 3.6 (1.16) mg/dL (change, 6.9%; P < 0.001). The BP-lowering effect was found only in patients with hypertension at baseline (n = 57); in these patients, mean SBP decreased by 7.2 (2.44) mm Hg (change, −4.8%; P < 0.005 vs baseline) and DBP decreased by 4.8 (1.29) mm Hg (change, −5.6%; P < 0.001 vs baseline). Also in the simvastatin group, 26 patients (22.6%) achieved their target SBP/DBP. In patients with normotension at baseline (n = 58), neither SBP nor DBP was changed significantly (changes, −0.8 [1.65] and −1.4 [1.15] mm Hg, respectively [−0.6% and −1.8%, respectively]). The changes in serum lipid levels were similar between hypertensive and normotensive patients in the simvastatin group. Forty-one patients (18 hypertensive and 23 normotensive at baseline) were treated with simvastatin 40 mg/d plus diet between months 3 and 6. At 6 months, no further significant decrease was observed in mean BP. In contrast, the expected dose-dependent response was observed for TC and LDL-C levels. In the diet-only group, no significant changes occurred in BP or serum lipid levels. Changes in BP, TC, LDL-C, TG, and HDL-C were significantly greater in the simvastatin + diet group than in the diet-only group (all, P < 0.001). Body weight did not change significantly in either group.
Conclusions
In this group of patients with hypercholesterolemia, the starting dosage of simvastatin (20 mg/d) was associated with reductions in SBP and DBP within 3 months of treatment in patients with hypertension, and this effect was independent of the lipid-lowering properties of the drug. Although the decrease in BP was modest, it is likely clinically relevant. Further studies on this topic are advisable.
doi:10.1016/S0011-393X(04)80057-2
PMCID: PMC3964554  PMID: 24672080
5.  Pre-hypertension in Uganda: a cross-sectional study 
Background
Persons with a systolic blood pressure (BP) of 120 to < 140 or diastolic BP of 80 to < 90 mm hg are classified as having pre-hypertension. Pre-hypertension is associated with cardiovascular disease (CVD) risk factors, incident CVD and CVD mortality. Understanding determinants of pre-hypertension especially in low income countries is a pre-requisite for improved prevention and control.
Methods
Data were analyzed for 4142 persons aged 18 years and older with BP measured in a community cross sectional survey in Uganda. The prevalence of pre-hypertension was estimated and a number of risk factors e.g. smoking, use of alcohol, overweight, obesity, physical activity, sex, age, marital status, place of residence, and consumption of vegetables and fruits were compared among different groups (normotension, pre-hypertension, and hypertension) using bivariate and multivariable logistic regression.
Results
The age standardized prevalence of normal blood pressure was 37.6%, pre-hypertension 33.9%, hypertension 28.5% and raised blood pressure 62%. There was no difference between the prevalence of hypertension among women compared to men (28.9% versus 27.9%). However, the prevalence of pre-hypertension was higher among men (41.6%) compared to women (29.4%). Compared to people with normal blood pressure, the risk of pre-hypertension was increased by being 40 years and above, smoking, consumption of alcohol, not being married, being male and being overweight or obese. Compared to pre-hypertension, hypertension was more likely if one was more than 40 years, had infrequent or no physical activity, resided in an urban area, and was obese or overweight.
Conclusions
More than one in three of adults in this population had pre-hypertension. Preventive and public health interventions that reduce the prevalence of raised blood pressure need to be implemented.
doi:10.1186/1471-2261-13-101
PMCID: PMC3833647  PMID: 24228945
Cardiovascular diseases; Non communicable diseases; Low income countries; Risk factors; Prevalence
6.  Gender difference in components of metabolic syndrome among patients of type 2 diabetes 
Background and Objectives:
Diabetes mellitus, hypertension, obesity and dyslipidemia are the integral components that constitute metabolic syndrome. It has emerged as cause of substantial mortality with gender difference. To compare the gender characteristics of metabolic syndrome in subjects of type 2 diabetes mellitus.
Methods:
This observational comparative prospective study was conducted in medical ward of BVH Bahawalpur over period of 6 month from January 2014 to June 2014. Sample size of 100 diagnosed cases of type 2 diabetics (comprising equal number of males and females) were collected. As defined by WHO and IDF, variables of metabolic syndrome studied were BMI, hypertension, hyperglycemia and hyperlipidemia. The lipid values were interpreted in normal or high risk category by applying NCEP ATPIII criterion. Fasting sample were collected for sugar and lipid profile. Anthropometric, demographic and biochemical data was tabulated. Continuous and categorical variables were displayed as mean ± standard deviation and percentage respectively. Student ‘t’ test was use to assess the difference for the lipid profile at 5% significance level.
Results:
Female patients were found to be overweight, hypertensive and had uncontrolled hyperglycemia as compared to male subjects. Their systolic blood pressure was 150±25.75 and diastolic was 90±17mm/hg. The mean blood glucose concentration was 246.64±105mg/dl. In age group 35-44 years, the mean triglycerides and cholesterol levels in females were 184.54±42.05 and 192.5±34mg/dl respectively. HDL-C was 33.2±5.19mg/dl. In females with age group of 45-54 years, the mean concentration of triglycerides, total cholesterol and HDL-C were 217.75±77.6mg/dl, 190.95±14.4mg/dl and 31.75±3.8mg/dl respectively, and all were in high risk category when compared to cut off values determined by NCEP/ADA. While in females of age group 55-64 years, the values of TGs, total cholesterol and HDL-C were 204±154.11mg/dl, 200.09± 47.8 mg/dl and 33.4±4.6mg/dl respectively and again all these values were significantly raised.
Conclusion:
Female genders were affected in all respects. They had higher BMI, hypertension, hyperglycemia and hyperlipidemia as compared to male counterparts.
doi:10.12669/pjms.314.6714
PMCID: PMC4590352  PMID: 26430423
Diabetes mellitus; Gender; Metabolic syndrome
7.  High prevalence of undiagnosed diabetes and abnormal glucose tolerance in the Iranian urban population: Tehran Lipid and Glucose Study 
BMC Public Health  2008;8:176.
Background
To estimate the prevalence of diagnosed and undiagnosed diabetes mellitus, impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and combined IFG/IGT in a large urban Iranian population aged ≥ 20 years.
Methods
The study population included 9,489 participants of the Tehran Lipid and Glucose Study with full relevant clinical data. Age-standardized prevalence of diabetes and glucose intolerance categories were reported according to the 2003 American Diabetes Association definitions. Age-adjusted logistic regression models were used to estimate the numbers needed to screen (NNTS) to find one person with undiagnosed diabetes.
Results
The prevalence of diagnosed and undiagnosed diabetes, isolated IFG, isolated IGT, and combined IFG/IGT were 8.1%, 5.1%, 8.7%, 5.4% and 4.0% in men and 10%, 4.7%, 6.3%, 7.6%, and 4.5% in women respectively. Participants with undiagnosed diabetes had higher age, body mass index (BMI), waist circumference, systolic and diastolic blood pressures, triglycerides (all p values <0.001) and lower HDL-cholesterol (only in women, p < 0.01) compared to normoglycemic subjects. Undiagnosed diabetes was associated with family history of diabetes, increased BMI (≥ 25 kg/m2), abdominal obesity, hypertriglyceridemia, hypertension and low HDL-cholesterol levels. Among men, a combination of increased BMI, hypertension, and family history of diabetes led to a NNTS of 1.6 (95% CI: 1.57–1.71) and among women a combination of family history of diabetes and abdominal obesity, yielded a NNTS of 2.2 (95% CI: 2.1–2.4).
Conclusion
In conclusion, about one third of Tehranian adults had disturbed glucose tolerance or diabetes. One- third of total cases with diabetes were undiagnosed. Screening individuals with BMI ≥ 25 kg/m2 (men), hypertension (men), abdominal obesity (women) and family history of diabetes may be more efficient.
doi:10.1186/1471-2458-8-176
PMCID: PMC2413226  PMID: 18501007
8.  Associations between Potentially Modifiable Risk Factors and Alzheimer Disease: A Mendelian Randomization Study 
PLoS Medicine  2015;12(6):e1001841.
Background
Potentially modifiable risk factors including obesity, diabetes, hypertension, and smoking are associated with Alzheimer disease (AD) and represent promising targets for intervention. However, the causality of these associations is unclear. We sought to assess the causal nature of these associations using Mendelian randomization (MR).
Methods and Findings
We used SNPs associated with each risk factor as instrumental variables in MR analyses. We considered type 2 diabetes (T2D, NSNPs = 49), fasting glucose (NSNPs = 36), insulin resistance (NSNPs = 10), body mass index (BMI, NSNPs = 32), total cholesterol (NSNPs = 73), HDL-cholesterol (NSNPs = 71), LDL-cholesterol (NSNPs = 57), triglycerides (NSNPs = 39), systolic blood pressure (SBP, NSNPs = 24), smoking initiation (NSNPs = 1), smoking quantity (NSNPs = 3), university completion (NSNPs = 2), and years of education (NSNPs = 1). We calculated MR estimates of associations between each exposure and AD risk using an inverse-variance weighted approach, with summary statistics of SNP–AD associations from the International Genomics of Alzheimer’s Project, comprising a total of 17,008 individuals with AD and 37,154 cognitively normal elderly controls. We found that genetically predicted higher SBP was associated with lower AD risk (odds ratio [OR] per standard deviation [15.4 mm Hg] of SBP [95% CI]: 0.75 [0.62–0.91]; p = 3.4 × 10−3). Genetically predicted higher SBP was also associated with a higher probability of taking antihypertensive medication (p = 6.7 × 10−8). Genetically predicted smoking quantity was associated with lower AD risk (OR per ten cigarettes per day [95% CI]: 0.67 [0.51–0.89]; p = 6.5 × 10−3), although we were unable to stratify by smoking history; genetically predicted smoking initiation was not associated with AD risk (OR = 0.70 [0.37, 1.33]; p = 0.28). We saw no evidence of causal associations between glycemic traits, T2D, BMI, or educational attainment and risk of AD (all p > 0.1). Potential limitations of this study include the small proportion of intermediate trait variance explained by genetic variants and other implicit limitations of MR analyses.
Conclusions
Inherited lifetime exposure to higher SBP is associated with lower AD risk. These findings suggest that higher blood pressure—or some environmental exposure associated with higher blood pressure, such as use of antihypertensive medications—may reduce AD risk.
Robert A. Scott and colleagues use genetic instruments to identify causal associations between known risk factors and Alzheimer's disease.
Editors' Summary
Background
Worldwide, about 44 million people have dementia, a group of brain degeneration disorders characterized by an irreversible decline in memory, communication, and other “cognitive” functions. Dementia mainly affects older people, and because people are living longer, experts estimate that more than 135 million people will have dementia by 2050. The most common form of dementia, which accounts for 60%–70% of cases, is Alzheimer disease (AD). The earliest sign of AD is often increasing forgetfulness. As the disease progresses, affected individuals gradually lose the ability to look after themselves, they may become anxious or aggressive, and they may have difficulty recognizing friends and relatives. People with late stage disease may lose control of their bladder and of other physical functions. At present, there is no cure for AD, although some of its symptoms can be managed with drugs. Most people with AD are initially cared for at home by relatives and other caregivers, but many affected individuals end their days in a care home or specialist nursing home.
Why Was This Study Done?
Researchers are interested in identifying risk factors for AD, particularly modifiable risk factors, because if such risk factors exist, it might be possible to limit the predicted increase in future AD cases. Epidemiological studies (investigations that examine patterns of disease in populations) have identified several potential risk factors for AD, including hypertension (high blood pressure), obesity, smoking, and dyslipidemia (changes in how the body handles fats). However, epidemiological studies cannot prove that a specific risk factor causes AD. For example, people with hypertension might share another characteristic that causes both hypertension and AD (confounding) or AD might cause hypertension (reverse causation). Information on causality is needed to decide which risk factors to target to help prevent AD. Here, the researchers use “Mendelian randomization” to examine whether differences in several epidemiologically identified risk factors for AD have a causal impact on AD risk. In Mendelian randomization, causal associations are inferred from the effects of genetic variants (which predict levels of modifiable risk factors) on the outcome of interest. Because gene variants are inherited randomly, they are not prone to confounding and are free from reverse causation. So, if hypertension actually causes AD, genetic variants that affect hypertension should be associated with an altered risk of AD.
What Did the Researchers Do and Find?
The researchers identified causal associations between potentially modifiable risk factors and AD risk by analyzing the occurrence of single nucleotide polymorphisms (SNPs, a type of gene variant) known to predict levels of each risk factor, in genetic data from 17,008 individuals with AD and 37,154 cognitively normal elderly controls collected by the International Genomics of Alzheimer’s Project. They report that genetically predicted higher systolic blood pressure (SBP; the pressure exerted on the inside of large blood vessels when the heart is pumping out blood) was associated with lower AD risk (and with a higher probability of taking antihypertensive medication). Predicted smoking quantity was also associated with lower AD risk, but there was no evidence of causal associations between any of the other risk factors investigated and AD risk.
What Do These Findings Mean?
In contrast to some epidemiological studies, these findings suggest that hypertension is associated with lower AD risk. However, because genetically predicted higher SBP was also associated with a higher probability of taking antihypertensive medication, it could be that exposure to such drugs, rather than having hypertension, reduces AD risk. Like all Mendelian randomization studies, the reliability of these findings depends on the validity of several assumptions made by the researchers and on the ability of the SNPs used in the analyses to explain variations in exposure to the various risk factors. Moreover, because all the participants in the International Genomics of Alzheimer’s Project are of European ancestry, these findings may not be valid for other ethnic groups. Given that hypertension is a risk factor for cardiovascular disease, the researchers do not advocate raising blood pressure as a measure to prevent AD (neither do they advocate that people smoke more cigarettes to lower AD risk). Rather, given the strong association between higher SBP gene scores and the probability of exposure to antihypertensive treatment, they suggest that the possibility that antihypertensive drugs might reduce AD risk independently of their effects on blood pressure should be investigated as a priority.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001841.
The UK National Health Service Choices website provides information (including personal stories) about Alzheimer disease
The UK not-for-profit organization Alzheimer’s Society provides information for patients and carers about dementia, including personal experiences of living with Alzheimer disease
The US not-for-profit organization Alzheimer’s Association also provides information for patients and carers about dementia and personal stories about dementia
Alzheimer’s Disease International is the federation of Alzheimer disease associations around the world; it provides links to individual Alzheimer associations, information about dementia, and links to world Alzheimer reports
MedlinePlus provides links to additional resources about Alzheimer disease (in English and Spanish)
Wikipedia has a page on Mendelian randomization (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
A PLOS Medicine Research Article by Proitsi et al. describes a Mendelian randomization study that looked for a causal association between dyslipidemia and Alzheimer disease
doi:10.1371/journal.pmed.1001841
PMCID: PMC4469461  PMID: 26079503
9.  Risk Stratification by Self-Measured Home Blood Pressure across Categories of Conventional Blood Pressure: A Participant-Level Meta-Analysis 
PLoS Medicine  2014;11(1):e1001591.
Jan Staessen and colleagues compare the risk of cardiovascular, cardiac, or cerebrovascular events in patients with elevated office blood pressure vs. self-measured home blood pressure.
Please see later in the article for the Editors' Summary
Background
The Global Burden of Diseases Study 2010 reported that hypertension is worldwide the leading risk factor for cardiovascular disease, causing 9.4 million deaths annually. We examined to what extent self-measurement of home blood pressure (HBP) refines risk stratification across increasing categories of conventional blood pressure (CBP).
Methods and Findings
This meta-analysis included 5,008 individuals randomly recruited from five populations (56.6% women; mean age, 57.1 y). All were not treated with antihypertensive drugs. In multivariable analyses, hazard ratios (HRs) associated with 10-mm Hg increases in systolic HBP were computed across CBP categories, using the following systolic/diastolic CBP thresholds (in mm Hg): optimal, <120/<80; normal, 120–129/80–84; high-normal, 130–139/85–89; mild hypertension, 140–159/90–99; and severe hypertension, ≥160/≥100.
Over 8.3 y, 522 participants died, and 414, 225, and 194 had cardiovascular, cardiac, and cerebrovascular events, respectively. In participants with optimal or normal CBP, HRs for a composite cardiovascular end point associated with a 10-mm Hg higher systolic HBP were 1.28 (1.01–1.62) and 1.22 (1.00–1.49), respectively. At high-normal CBP and in mild hypertension, the HRs were 1.24 (1.03–1.49) and 1.20 (1.06–1.37), respectively, for all cardiovascular events and 1.33 (1.07–1.65) and 1.30 (1.09–1.56), respectively, for stroke. In severe hypertension, the HRs were not significant (p≥0.20). Among people with optimal, normal, and high-normal CBP, 67 (5.0%), 187 (18.4%), and 315 (30.3%), respectively, had masked hypertension (HBP≥130 mm Hg systolic or ≥85 mm Hg diastolic). Compared to true optimal CBP, masked hypertension was associated with a 2.3-fold (1.5–3.5) higher cardiovascular risk. A limitation was few data from low- and middle-income countries.
Conclusions
HBP substantially refines risk stratification at CBP levels assumed to carry no or only mildly increased risk, in particular in the presence of masked hypertension. Randomized trials could help determine the best use of CBP vs. HBP in guiding BP management. Our study identified a novel indication for HBP, which, in view of its low cost and the increased availability of electronic communication, might be globally applicable, even in remote areas or in low-resource settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Globally, hypertension (high blood pressure) is the leading risk factor for cardiovascular disease and is responsible for 9.4 million deaths annually from heart attacks, stroke, and other cardiovascular diseases. Hypertension, which rarely has any symptoms, is diagnosed by measuring blood pressure, the force that blood circulating in the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is pumping out blood (systolic blood pressure) and lowest when the heart is refilling (diastolic blood pressure). European guidelines define optimal blood pressure as a systolic blood pressure of less than 120 millimeters of mercury (mm Hg) and a diastolic blood pressure of less than 80 mm Hg (a blood pressure of less than 120/80 mm Hg). Normal blood pressure, high-normal blood pressure, and mild hypertension are defined as blood pressures in the ranges 120–129/80–84 mm Hg, 130–139/85–89 mm Hg, and 140–159/90–99 mm Hg, respectively. A blood pressure of more than 160 mm Hg systolic or 100 mm Hg diastolic indicates severe hypertension. Many factors affect blood pressure; overweight people and individuals who eat salty or fatty food are at high risk of developing hypertension. Lifestyle changes and/or antihypertensive drugs can be used to control hypertension.
Why Was This Study Done?
The current guidelines for the diagnosis and management of hypertension recommend risk stratification based on conventionally measured blood pressure (CBP, the average of two consecutive measurements made at a clinic). However, self-measured home blood pressure (HBP) more accurately predicts outcomes because multiple HBP readings are taken and because HBP measurement avoids the “white-coat effect”—some individuals have a raised blood pressure in a clinical setting but not at home. Could risk stratification across increasing categories of CBP be refined through the use of self-measured HBP, particularly at CBP levels assumed to be associated with no or only mildly increased risk? Here, the researchers undertake a participant-level meta-analysis (a study that uses statistical approaches to pool results from individual participants in several independent studies) to answer this question.
What Did the Researchers Do and Find?
The researchers included 5,008 individuals recruited from five populations and enrolled in the International Database of Home Blood Pressure in Relation to Cardiovascular Outcome (IDHOCO) in their meta-analysis. CBP readings were available for all the participants, who measured their HBP using an oscillometric device (an electronic device for measuring blood pressure). The researchers used information on fatal and nonfatal cardiovascular, cardiac, and cerebrovascular (stroke) events to calculate the hazard ratios (HRs, indicators of increased risk) associated with a 10-mm Hg increase in systolic HBP across standard CBP categories. In participants with optimal CBP, an increase in systolic HBP of 10-mm Hg increased the risk of any cardiovascular event by nearly 30% (an HR of 1.28). Similar HRs were associated with a 10-mm Hg increase in systolic HBP for all cardiovascular events among people with normal and high-normal CBP and with mild hypertension, but for people with severe hypertension, systolic HBP did not significantly add to the prediction of any end point. Among people with optimal, normal, and high-normal CBP, 5%, 18.4%, and 30.4%, respectively, had a HBP of 130/85 or higher (“masked hypertension,” a higher blood pressure in daily life than in a clinical setting). Finally, compared to individuals with optimal CBP without masked hypertension, individuals with masked hypertension had more than double the risk of cardiovascular disease.
What Do These Findings Mean?
These findings indicate that HBP measurements, particularly in individuals with masked hypertension, refine risk stratification at CBP levels assumed to be associated with no or mildly elevated risk of cardiovascular disease. That is, HBP measurements can improve the prediction of cardiovascular complications or death among individuals with optimal, normal, and high-normal CBP but not among individuals with severe hypertension. Clinical trials are needed to test whether the identification and treatment of masked hypertension leads to a reduction of cardiovascular complications and is cost-effective compared to the current standard of care, which does not include HBP measurements and does not treat people with normal or high-normal CBP. Until then, these findings provide support for including HBP monitoring in primary prevention strategies for cardiovascular disease among individuals at risk for masked hypertension (for example, people with diabetes), and for carrying out HBP monitoring in people with a normal CBP but unexplained signs of hypertensive target organ damage.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001591.
This study is further discussed in a PLOS Medicine Perspective by Mark Caulfield
The US National Heart, Lung, and Blood Institute has patient information about high blood pressure (in English and Spanish) and a guide to lowering high blood pressure that includes personal stories
The American Heart Association provides information on high blood pressure and on cardiovascular diseases (in several languages); it also provides personal stories about dealing with high blood pressure
The UK National Health Service Choices website provides detailed information for patients about hypertension (including a personal story) and about cardiovascular disease
The World Health Organization provides information on cardiovascular disease and controlling blood pressure; its A Global Brief on Hypertension was published on World Health Day 2013
The UK charity Blood Pressure UK provides information about white-coat hypertension and about home blood pressure monitoring
MedlinePlus provides links to further information about high blood pressure, heart disease, and stroke (in English and Spanish)
doi:10.1371/journal.pmed.1001591
PMCID: PMC3897370  PMID: 24465187
10.  The Prevalence and Awareness of Hypertension and the Relationship between Hypertension and Snoring in the Korean Population 
Background:
Hypertension is the most important, and yet modifiable, risk factor for cardiovascular diseases. But in many countries, hypertension remains poorly controlled. Moreover, sleep apnea syndrome has shown that it is correlated with hypertension. The purpose of this study was to investigate the prevalence, awareness and control of hypertension among the Korean people and to evaluate the relationship between hypertension and snoring.
Methods:
A total of 640 subjects living in Ansan, a regional city in Korea, were selected randomly, and trained nursing students investigated their age, sex, medical history, blood pressure, body mass index (BMI) and snoring score. Blood pressures were measured three times with a 10-minute interval and then averaged. The degree of snoring was estimated using a questionnaire. We divided the subjects into hypertensive (BP≥140/90 mmHg) versus normotensive group and snorer versus non-snorer group, and correlated hypertension with snoring.
Results:
Of 640 subjects, 311 were male. The mean age was 39.7 ± 14.6 years (18–77 years), the mean BMI (body mass index) was 22.4 ± 3.0 kg/m2. The mean systolic and diastolic blood pressure was 121 ± 15.7 mmHg and 79.5 ± 11.6 mmHg. The prevalence and awareness of hypertension were 22.2% and 16.9%, respectively, and the prevalence of snoring was 35.2%. With the increment of age, in the male, the prevalence of hypertension and snoring were higher, and the snorer group showed a higher risk of hypertension than the non-snorer group (Odds ratio 2.32, CI=1.56–3.39, p = 0.0001).
Conclusion:
In Korea, the prevalence of hypertension was similar to that in the western countries, but the awareness of hypertension was much lower compared with western countries. The prevalence of hypertension was higher in the snorer group, so more research on the correlation between the two conditions should be advanced in the future.
doi:10.3904/kjim.2001.16.2.62
PMCID: PMC4531715  PMID: 11590903
Hypertension; Prevalence; Awareness; Snoring
11.  Effects of angiotensin II-receptor blockers on soluble cell adhesion molecule levels in uncomplicated systemic hypertension: An observational, controlled pilot study in Taiwanese adults* 
Background:
Controversy exists as to whether individuals with hypertension without risk factors for atherosclerosis (eg, diabetes mellitus, dyslipidemia,
Objective:
The aim of this study was to determine whether (1) levels of solubleCAMs (sCAMs) (soluble E-selectin [sE-selectin], soluble intercellular adhesion molecule-1 [sICAM-1 ], soluble vascular cell adhesion molecule-1 [sVCAM-1 ], and von Willebrand factor [vWF]) are elevated in Taiwanese adults with uncomplicated essential hypertension without other risk factors; (2) CAM levels increase with severity (stage) of hypertension; and (3) monotherapy with the angiotensin II-receptor blocker (ARB) irbesartan modulates CAM expression in a subgroup of these patients.
Methods:
This observational, controlled pilot study was conducted at the Hypertension Clinic, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. Adult patients with uncomplicated essential hypertension without other risk factors (eg, diabetes mellitus, dyslipidemia, obesity) and normotensive controls were eligible. Blood pressure (BP) was determined using 24-hour ambulatory BP monitoring (ABPM) in all participants, and the staging of hypertension was classified based on criteria in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (normotensive, prehypertension, stage I hypertension, and stage II hypertension). The SCAM levels and 24-hour ABPM were measured before and after 8 weeks of open-label irbesartan monotherapy in a subgroup of the patients with hypertension. Patients who had difficulty achieving the target BP values on irbesartan monotherapy were treated with combination therapy (2 or 3 antihypertensive agents); levels of sCAMs were not measured in these patients. Plasma levels of sE-selectin, the sCAMs, and vWF were measured using enzyme-linked immunosorbent assay.
Results:
The study comprised 61 patients with uncomplicated essentialhypertension (33 men and 28 women; mean [SD] age, 51 [12] years) and 17 normotensive controls (11 men, 6 women; mean [SD] age, 52 [ 11 ] years). The mean (SD) dose of irbesartan was 243 (63) mg. Hypertensive patients had significantly higher circulating levels of sICAM-1 compared with normotensive controls (P = 0.009). No significant differences in levels of sVCAM-1, sE-selectin, or vWF were found between hypertensive patients and controls. The mean sICAM-1 level was significantly higher in the prehypertensive patients compared with normotensive controls (P = 0.03). The mean sE-selectin level was significantly higher in the patients with stage I hypertension compared with the prehypertensive group (P = 0.01). The 18 patients given 8 weeks of irbesartan monotherapy showed a significant decrease from baseline in systolic and diastolic BP (both, P = 0.001) and sE-selectin (P= 0.006), but not in sVCAM-1 or sICAM. Forty-three patients did not reach target BP on irbesartan monotherapy and thus were treated with combination therapy.
Conclusions:
Based on the results of this observational, controlled pilotstudy in Taiwanese patients, we suggest that ARB therapy, in addition to reducing BP, has the potential to suppress CAM expression and to improve endothelial dysfunction in hypertension.
doi:10.1016/j.curtheres.2005.06.005
PMCID: PMC3964542  PMID: 24672122
soluble cell adhesion molecule; ambulatory blood pressuremonitoring; systemic hypertension; angiotensin 11-receptor blockers
12.  1999–2009 Trends in Prevalence, Unawareness, Treatment and Control of Hypertension in Geneva, Switzerland 
PLoS ONE  2012;7(6):e39877.
Background
There are no time trends in prevalence, unawareness, treatment, and control of hypertension in Switzerland. The objective of this study was to analyze these trends and to determine the associated factors.
Methods/Findings
Population-based study conducted in the Canton of Geneva, Switzerland, between 1999 and 2009. Blood pressure was measured thrice using a standard protocol. Hypertension was defined as mean systolic or diastolic blood pressure ≥140/90 mmHg or self-reported hypertension or anti-hypertensive medication. Unawareness, untreated and uncontrolled hypertension was determined by questionnaires/blood pressure measurements. Yearly age-standardized prevalences and adjusted associations for the 1999–2003 and 2004–2009 survey periods were reported. The 10-year survey included 9,215 participants aged 35 to 74 years. Hypertension remained stable (34.4%). Hypertension unawareness decreased from 35.9% to 17.7% (P<0.001). The decrease in hypertension unawareness was not paralleled by a concomitant absolute increase in hypertension treatment, which remained low (38.2%). A larger proportion of all hypertensive participants were aware but not treated in 2004–2009 (43.7%) compared to 1999–2003 (33.1%). Uncontrolled hypertension improved from 62.2% to 40.6% between 1999 and 2009 (P = 0.02). In 1999–2003 period, factors associated with hypertension unawareness were current smoking (OR = 1.27, 95%CI, 1.02–1.59), male gender (OR = 1.56, 1.27–1.92), hypercholesterolemia (OR = 1.31, 1.20–1.44), and older age (OR 65–74yrs vs 35–49yrs  = 1.56, 1.21–2.02). In 1999–2003 and 2004–2009, obesity and diabetes were negatively associated with hypertension unawareness, high education was associated with untreated hypertension (OR = 1.45, 1.12–1.88 and 1.42, 1.02–1.99, respectively), and male gender with uncontrolled hypertension (OR = 1.49, 1.03–2.17 and 1.65, 1.08–2.50, respectively). Sedentarity was associated with higher risk of hypertension and uncontrolled hypertension in 1999–2003.
Conclusions
Hypertension prevalence remained stable since 1999 in the canton of Geneva. Although hypertension unawareness substantially decreased, more than half of hypertensive subjects still remained untreated or uncontrolled in 2004–2009. This study identified determinants that should guide interventions aimed at improving hypertension treatment and control.
doi:10.1371/journal.pone.0039877
PMCID: PMC3384604  PMID: 22761919
13.  The prevalence of pre-hypertension and its association to established cardiovascular risk factors in south of Iran 
BMC Research Notes  2012;5:386.
Background
Pre-hypertension is associated with an increased risk of the development of hypertension and subsequent cardiovascular disease and raises mortality risk. The aim of this study was to determine the prevalence of pre-hypertension and to explore the associations between pre-hypertension and established cardiovascular risk factors in a population-based sample of Iranian adults.
Methods
In this cross-sectional study a representative sample of 892 participants aged ≥30 years was selected using a multistage cluster sampling method. After completion of a detailed demographic and medical questionnaire (gender, age, history of diabetes mellitus and hypertension, taking antihypertensive or hypoglycemic agents and history of smoking), all participants were subjected to physical examination, blood lipid profile, blood glucose, anthropometric and smoking assessments, during the years 2009 and 2010. Variables were considered significant at a p-value ≤ 0.05. Statistical analysis was performed using SPSS version 11.5 software.
Results
Pre-hypertension was observed among 300 (33.7%) subjects, 36.4% for men and 31.4% for women (p > 0.05). The pre-hypertensive group had higher levels of blood glucose and triglycerides, higher body mass index and lower percentage of smoking than did the normotensive group. Multivariate logistic regression analysis showed that obesity and overweight were the strongest predictors of pre-hypertension [odds ratio, 2.74: 95% CI (Confidence Interval), 1.62 to 4.62 p < 0.001; odds ratio, 2.56, 95% CI, 1.74 to 3.77, p < 0.001 respectively].
Conclusions
Overweight and obesity are major determinants of the high prevalence rate of pre-hypertension detected in Iranian population. Therefore, primary prevention strategies should concentrate on reducing overweight and obesity if the increased prevalence of pre-hypertension is to be diminished in Iranian adults.
doi:10.1186/1756-0500-5-386
PMCID: PMC3506467  PMID: 22838639
Pre-hypertension; Cardiovascular risk factor; Obesity; BMI
14.  Plasma neuropeptide Y (NPY) and alpha-melanocyte stimulating hormone (a-MSH) levels in patients with or without hypertension and/or obesity: a pilot study 
Aim: Obesity frequently co-exists with hypertension (HTN). Hypothalamus neuropeptides such as neuropeptide Y (NPY) and alpha-melanocyte stimulating hormone (a-MSH) interact with leptin, an anorexic peptide produced mainly by adipose tissue and are involved in the regulation of appetite, energy balance and sympathetic nervous system (SNS) activity, possibly contributing to blood pressure (BP) elevation. We compared plasma NPY and a-MSH levels between patients with or without hypertension and/or obesity and the differences in these neuropeptides between patients with or without pathological heart echo findings, aiming to investigate the possible role of these peptides in obesity induced HTN. Patients and Methods: 160 non-diabetic, treatment-naïve individuals were randomly recruited from our outpatient clinics. Study population was divided into 6 groups, according to body mass index-BMI (OB=obese, OW=overweight, NW=normal weight) and blood pressure. Waist circumference (WC) and heart rate (HR) were also recorded. A heart echo was performed and plasma NPY and a-MSH levels were measured for all participants. Results: Plasma NPY levels and HR were higher in OW and OB hypertensives compared with NW hypertensives. OW and OB hypertensives had also higher NPY concentrations compared with OW and OB normotensives, respectively. However, in NW patients, plasma NPY concentrations did not differ between hypertensives and normotensives. Patients with central obesity (COB) had also higher NPY levels compared with patients without COB, a difference also observed in hypertensives but not in normotensive patients. Furthermore, plasma NPY concentrations were significantly correlated with BMI, WC, HR, systolic and diastolic BP. Patients with left ventricle hypertrophy had higher plasma NPY levels compared with those with normal findings, but this was not seen in hypertensives. The majority of these differences were also observed in male and female patient populations. In contrast, plasma a-MSH levels were similar in all study groups. Conclusions: These results suggest that NPY may be involved in obesity-related HTN, possibly via increased SNS activity. Further investigation is needed to elucidate the role of both NPY and a-MSH in obesity-related HTN.
PMCID: PMC3253505  PMID: 22254185
Neuropeptide Y; alpha-melanocyte stimulating hormone; obesity; hypertension
15.  Study of urban community survey in India: growing trend of high prevalence of hypertension in a developing country 
The prevalence pattern of hypertension in developing countries is different from that in the developed countries. In India, a very large, populous and typical developing country, community surveys have documented that between three and six decades, prevalence of hypertension has increased by about 30 times among urban dwellers and by about 10 times among the rural inhabitants. Various factors might have contributed to this rising trend and among others, consequences of urbanization such as change in life style pattern, diet and stress, increased population and shrinking employment have been implicated. In this paper, we study the prevalence of hypertension in an urban community of India using the JNC VII criteria, with the aim of identifying the risk factors and suggesting intervention strategies. A total of 1609 respondents out of 1662 individuals participated in our cross-sectional survey of validated and structured questionnaire followed by blood pressure measurement. Results showed pre-hypertensive levels of blood pressures among 35.8% of the participants in systolic group (120-139mm of Hg) and 47.7% in diastolic group (80-89 mm of Hg). Systolic hypertension (140 mm of Hg) was present in 40.9% and diastolic hypertension (90 mm of Hg) in 29.3% of the participants. Age and sex-specific prevalence of hypertension showed progressive rise of systolic and diastolic hypertension in women when compared to men. Men showed progressive rise in systolic hypertension beyond fifth decade of life. Bivariate analysis showed significant relationship of hypertension with age, sedentary occupation, body mass index (BMI), diet, ischemic heart disease, and smoking. Multivariate analysis revealed age and BMI as risk factors, and non-vegetarian diet as protective factor with respect to hypertension. Prevalence of prehypertensives was high among younger subjects - particularly students and laborers who need special attention. Role of non-vegetarian diet as a protective factor might have been related to fish-eating behavior of the sample population, who also use mustard oil as cooking medium - both of which have significant level of essential polyunsaturated fatty acids. The observed prevalence of hypertension in this study and other studies suggest the need for a comprehensive national policy to control hypertension in India, and, in other similar developing countries.
PMCID: PMC1145137  PMID: 15968343
Hypertension; eastern India; urban study; JNC-VII criteria; prehypertensives; non-vegetarian diet; developing countries
16.  Effects of Verapamil Slow Release Plus Trandolapril Combination Therapy on Essential Hypertension 
Background: Fixed-dose combination antihypertensive therapy has been recommended for patients with essential hypertension who are unresponsive to monotherapy or as a first-line treatment.
Objective: We investigated the effects of a fixed-dose combination of the phenylalkylamine-type calcium channel blocker verapamil slow release (SR)plus the angiotensin-converting enzyme inhibitor trandolapril on blood pressure (BP), serum lipid profile, urinary albumin excretion (UAE), left ventricular mass (LVM), and LVM index (LVMI), as well as the adverse events associated with this treatment.
Methods: Patients aged 30 to 65 years with mild to moderate essential hypertension were included in the study. All of the patients received capsules containing combination treatment with verapamil SR 180 mg plus trandolapril 2 mg orally, daily for 12 weeks. Mean arterial pressure (MAP), systolic BP (SBP), diastolic BP (DBP), and heart rate (HR) were measured at baseline and at 4, 8, and 12 weeks of treatment. Serum lipid profile, UAE, LVM, LVMI, and body mass index (BMI) were determined at baseline and at the end of the study period. All patients underwent electrocardiography and echocardiography at baseline and week 12. The primary end point of the study was to achieve an SBP/DBP ≤140/≤90 mm Hg (ie, normotensive) during week 12. All adverse events were assessed as mild, moderate, or severe at each visit. According to the response rate at week 12, patients were divided into 2 groups: those who became normotensive (responders) or those who remained hypertensive (SBP/DBP >140/>90 mm Hg; nonresponders).
Results: Forty-one patients (29 women, 12 men; mean [SD] age, 47.7 [7.8] years; mean [SD] BMI, 29.4 [3.5] kg/m2) were enrolled. The median durationof hypertension prior to enrollment was 5 months. Mean MAP, SBP, DBP, UAE, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), LDL-C/highdensity lipoprotein cholesterol (HDL-C) ratio, LVM, LVMI, and BMI decreased significantly after 12 weeks of combination treatment; HR and triglyceride level did not change significantly. Treatment-related adverse events occurred in 31.7% of patients, and none were severe or caused any patient to withdraw from the study. The most common adverse events were cough, constipation, headache, and dryness in the throat. Microalbuminuria, which may be a marker of endothelial dysfunction, was found in 7 (17.1%) patients at baseline and regressed significantly after 12 weeks.
Conclusions: In this study population, the fixed-dose combination of verapamil–trandolapril was an effective and well-tolerated antihypertensive therapy. This combination significantly reduced MAP, BP, TC, LDL-C, LDL-C/HDL-C ratio, UAE, LVM, and LVMI. Also, microalbuminuria decreased after this treatment. Verapamil–trandolapril may be useful in preventing microalbuminuria and left ventricular hypertrophy in patients with essential hypertension.
doi:10.1016/S0011-393X(03)00007-9
PMCID: PMC4053024  PMID: 24944353
essential hypertension; combination therapy; trandolapril; verapamil
17.  Serum lipid profile and correlates in newly presenting Nigerians with arterial hypertension 
Background
Arterial hypertension and dyslipidemia are modifiable cardiovascular risk factors. The multiplicative effect of these risk factors may worsen the atherogenic index of an individual. The objective of this study was to determine the pattern and prevalence of dyslipidemia in newly presenting Nigerians with arterial hypertension, as well as determine some of its correlates.
Methods
This cross-sectional study compared 115 newly presenting, age- and sex-matched individuals with arterial hypertension with 115 normotensive individuals. Fasting lipids, total cholesterol (TC), triglycerides, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and fasting plasma glucose were estimated.
Results
Patients with arterial hypertension had higher body mass index (t=7.64; P=0.000), TC (t=2.95; P=0.006), and HDL-C (t=−5.18; P=0.000). The most common dyslipidemia was low HDL-C, found in both the hypertensive (44.3%) and normotensive (20.9%) patients. The prevalence of dyslipidemia in hypertensives and controls was 64% and 39%, respectively. In hypertensive patients, TC correlated positively to diastolic blood pressure (r=0.218; P=0.0019). Other positive correlates include LDL-C and age (r=0.217; P=0.020) and fasting plasma glucose (r=0.202; P=0.030) and body mass index (r=0.209; P=0.025). Among normotensive controls, TC correlated positively with LDL-C (r=0.63; P=0.000) but correlated negatively with tri glycerides (r=−0.30; P=0.001).
Conclusion
Lipid abnormalities are common in newly presenting Nigerians with arterial hypertension. Screening of these risk factors, promotion of healthy lifestyle, and the institution of therapy is desirable to reduce their multiplicative effects.
doi:10.2147/VHRM.S50690
PMCID: PMC3857265  PMID: 24348044
healthy lifestyle; screening; high-density lipoprotein cholesterol; cardiovascular; atherogenic index
18.  Younger age of escalation of cardiovascular risk factors in Asian Indian subjects 
Background
Cardiovascular risk factors start early, track through the young age and manifest in middle age in most societies. We conducted epidemiological studies to determine prevalence and age-specific trends in cardiovascular risk factors among adolescent and young urban Asian Indians.
Methods
Population based epidemiological studies to identify cardiovascular risk factors were performed in North India in 1999–2002. We evaluated major risk factors-smoking or tobacco use, obesity, truncal obesity, hypertension, dysglycemia and dyslipidemia using pre-specified definitions in 2051 subjects (male 1009, female 1042) aged 15–39 years of age. Age-stratified analyses were performed and significance of trends determined using regression analyses for numerical variables and Χ2 test for trend for categorical variables. Logistic regression was used to identify univariate and multivariate odds ratios (OR) for correlation of age and risk factors.
Results
In males and females respectively, smoking or tobacco use was observed in 200 (11.8%) and 18 (1.4%), overweight or obesity (body mass index, BMI ≥ 25 kg/m2) in 12.4% and 14.3%, high waist-hip ratio, WHR (males > 0.9, females > 0.8) in 15% and 32.3%, hypertension in 5.6% and 3.1%, high LDL cholesterol (≥ 130 mg/dl) in 9.4% and 8.9%, low HDL cholesterol (<40 mg/dl males, <50 mg/dl females) in 16.2% and 49.7%, hypertriglyceridemia (≥ 150 mg/dl) in 9.7% and 6%, diabetes in 1.0% and 0.4% and the metabolic syndrome in 3.4% and 3.6%. Significantly increasing trends with age for indices of obesity (BMI, waist, WHR), glycemia (fasting glucose, metabolic syndrome) and lipids (cholesterol, LDL cholesterol, HDL cholesterol) were observed (p for trend < 0.01). At age 15–19 years the prevalence (%) of risk factors in males and females, respectively, was overweight/obesity in 7.6, 8.8; high WHR 4.9, 14.4; hypertension 2.3, 0.3; high LDL cholesterol 2.4, 3.2; high triglycerides 3.0, 3.2; low HDL cholesterol 8.0, 45.3; high total:HDL ratio 3.7, 4.7, diabetes 0.0 and metabolic syndrome in 0.0, 0.2 percent. At age groups 20–29 years in males and females, ORs were, for smoking 5.3, 1.0; obesity 1.6, 0.8; truncal obesity 4.5, 3.1; hypertension 2.6, 4.8; high LDL cholesterol 6.4, 1.8; high triglycerides 3.7, 0.9; low HDL cholesterol 2.4, 0.8; high total:HDL cholesterol 1.6, 1.0; diabetes 4.0, 1.0; and metabolic syndrome 37.7, 5.7 (p < 0.05 for some). At age 30–39, ORs were- smoking 16.0, 6.3; overweight 7.1, 11.3; truncal obesity 21.1, 17.2; hypertension 13.0, 64.0; high LDL cholesterol 27.4, 19.5; high triglycerides 24.2, 10.0; low HDL cholesterol 15.8, 14.1; high total:HDL cholesterol 37.9, 6.10; diabetes 50.7, 17.4; and metabolic syndrome 168.5, 146.2 (p < 0.01 for all parameters). Multivariate adjustment for BMI, waist size and WHR in men and women aged 30–39 years resulted in attenuation of ORs for hypertension and dyslipidemias.
Conclusion
Low prevalence of multiple cardiovascular risk factors (smoking, hypertension, dyslipidemias, diabetes and metabolic syndrome) in adolescents and rapid escalation of these risk factors by age of 30–39 years is noted in urban Asian Indians. Interventions should focus on these individuals.
doi:10.1186/1471-2261-9-28
PMCID: PMC2713196  PMID: 19575817
19.  Does leptin predict incident hypertension in older adults? 
Clinical endocrinology  2010;73(2):201-205.
Summary
Objective
Leptin is associated with blood pressure (BP) in experimental and cross-sectional studies, but only one previous prospective study of middle-aged men has reported the association between leptin and incident hypertension. We examined the association of leptin levels with incident hypertension in a population-based study of older men and women.
Design
Longitudinal cohort study
Population
Participants were 602 community-dwelling older adults with normal baseline BP levels who attended a research clinic visit between 1984 and 1987 and again 4.4 years later (mean age was 66.2±11.4; 60.6% were men; mean BMI 24.9±3.4 kg/m2).
Measurements
Hypertension was defined as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg and/or antihypertensive drug treatment. Leptin was measured by radioimmunoassay.
Results
After an average 4.4-year follow up (minimum 2 – maximum 7 years), 106 (17.6%) new cases of hypertension were identified. At baseline, participants who developed hypertension were older, and had higher systolic BP and higher total cholesterol compared to participants who remained normotensive. Baseline serum leptin levels were higher in participants who developed hypertension compared to persistent normotensives [median (25th – 75th range)] [8.8(5-16) vs. 7(4-11) ng/mL, P=0.002]. In logistic regression models, leptin (log-transformed) predicted incident hypertension before and after adjustments for baseline age, BMI, systolic BP, total cholesterol, medications, and previous cardiovascular disease (OR 1.75 95%CI 1.17-2.61, P = 0.006). This association persisted after exclusion of 45 obese participants.
Conclusion
Higher leptin levels were independently associated with increased odds of incident hypertension in older adults.
doi:10.1111/j.1365-2265.2010.03781.x
PMCID: PMC2891171  PMID: 20148909
hypertension; leptin; obesity
20.  Impact of Hypertension on the Association of BMI with Risk and Age at Onset of Type 2 Diabetes Mellitus: Age- and Gender-Mediated Modifications 
PLoS ONE  2014;9(4):e95308.
Aims
Given that BMI correlates with risk of Type 2 diabetes mellitus (T2DM), and that hypertension is a common comorbid condition, we hypothesize that hypertension augments significantly the impact of obesity on T2DM onset.
Methods
We obtained data on T2DM in Kuwaiti natives from Kuwait Health Network Registry. We considered 1339 comorbid individuals with onset of hypertension preceding that of T2DM, and 3496 non-hypertensive individuals but with T2DM. Multiple linear regressions, ANOVA tests, and Cox proportional hazards models were used to quantify the impact of hypertension on correlation of BMI with age at onset and risk of T2DM.
Results
Impact of increasing levels of BMI on age at onset ot T2DM is seen augmented in patients diagnosed with hypertension. We find that the slope of the inverse linear relationship between BMI and onset age of T2DM is much steep in hypertensive patients (−0.69, males and −0.39, females) than in non-hypertensive patients (−0.36, males and −0.17, females). The decline in onset age for an unit increase of BMI is two-fold in males than in females. Upon considering BMI as a categorical variable, we find that while the mean onset age of T2DM in hypertensive patients decreases by as much as 5–12 years in every higher BMI categories, significant decrease in non-hypertensive patients exists only when severely obese. Hazard due to hypertension (against the baseline of non-hypertension and normal weight) increases at least two-fold in every obese category. While males have higher hazard due to hypertension in early adulthood, females have higher hazard in late adulthood.
Conclusion
Pre-existing condition of hypertension augments the association of BMI with Type 2 diabetes onset in both males and females. The presented results provide health professionals directives on the extent of weight-loss required to delay onset of Type 2 diabetes in hypertensive versus non-hypertensive patients.
doi:10.1371/journal.pone.0095308
PMCID: PMC3990699  PMID: 24743162
21.  Uric Acid Levels in Normotensive Children of Hypertensive Parents 
This study evaluated uric acid concentrations in normotensive children of parents with hypertension. Eighty normotensive children from families with and without a history of essential hypertension were included. Concentrations of lipid parameters and uric acid were compared. Demographic and anthropometric characteristics were similar in the groups. Systolic and diastolic blood pressure were higher in the normotensive children of parents with hypertension without statistically significant difference (P > 0.05). Uric acid concentrations were higher in the normotensive children of parents with hypertension (4.61 versus 3.57 mg/dL, P < 0.01). Total cholesterol and triglyceride concentrations were similar in the two groups. Systolic and diastolic blood pressure were significantly higher in control children aged >10 years (P < 0.01). Uric acid levels were significantly higher in all children with more pronounced difference after age 10 of years (P < 0.001). Positive correlations were found between the level of serum uric acid and age, body weight, body mass index, and systolic and diastolic blood pressure in the normotensive children of parents. The higher uric acid levels in the normotensive children of hypertensive parents suggest that uric acid may be a predeterminant of hypertension. Monitoring of uric acid levels in these children may allow for prevention or earlier treatment of future hypertension.
doi:10.1155/2015/747082
PMCID: PMC4590931  PMID: 26464873
22.  The prevalence of hypertension, obesity and dyslipidemia in individuals of over 30 years of age belonging to minorities from the pasture area of Xinjiang 
BMC Public Health  2010;10:91.
Background
The prevalence of population-wide hypertension, obesity and dyslipidemia has not been well studied in the pasture area of Xinjiang. The present epidemiological study was performed to determine the prevalence of hypertension, obesity and dyslipidemia in minority populations from the pasture area of Xinjiang and to discuss the potential risk factors for hypertension.
Methods
A population-based, cross-sectional study in the Xinjiang pasture area was performed which included 2251 participants aged over 30 years (90.33% participation rate) of whom 71.26% were Kazaks. Several risk factors were considered: hypertension (defined as systolic or diastolic blood pressure or both of at least 140/90 mmHg measured on one occasion or treatment for hypertension) overweight/obesity (body mass index ≥ 25 kg/m2) alcohol intake, smoking/tobacco use and dyslipidemia. Outcomes were prevalence of hypertension, obesity and dyslipidemia and the associated risk factors of hypertension detected by multivariate logistic regression analysis taking into account various metabolic and lifestyle characteristics.
Results
The prevalence of hypertension, overweight/obesity and dyslipidemia in all participants from the pasture area of Xinjiang was 51.9%, 47.9% and 49.2% respectively. Independently, the prevalence and awareness of hypertension was 52.6% and 15.3% among Kazaks (n = 1604), 54.6% and 14.1% among Uygurs (n = 418), 39.5% and 16.1% among Mongolians (n = 81) and 43.9% and 18.2% among non-Xinjiang-born Han immigrants (n = 148). The prevalence of overweight/obesity in Kazaks, Uygurs, Mongolians and Han immigrants was 46.7%, 48.9%, 62.5% and 50.3%, respectively. The prevalence of dyslipidemia in the four ethnic groups mentioned was 53.5%, 34.8%, 49.3% and 47.3%, respectively. The mean blood pressure in all participants was 136/86 mmHg (pre-hypertensive), the mean BMI was 24.7 kg/m2. Based on multiple logistic regression analysis, the significant risk factors for hypertension were age [1.07(1.06-1.09), P < 0.0001], overweight/obesity [overweight: 1.61(1.22-2.13), p = 0.0007; obesity: 1.95 (1.33-2.87), p = 0.0007], hypercholesterolemia [1.30(1.15-1.47), p < 0.0001] and an alcohol intake of over 30 g/day [2.22(1.43-3.45), p = 0.0004].
Conclusions
The considerably high prevalence of hypertension, overweight/obesity and dyslipidemia among the minority population aged over 30 from the pasture area of Xinjiang calls for effective preventive measures. Age, increased body mass index, hypercholesterolemia and ≥30 g/d alcohol intake can be counted as risk factors for hypertension, but further genetic or environmental clarification would be desirable to explain the unusually high prevalence of the conditions mentioned above.
doi:10.1186/1471-2458-10-91
PMCID: PMC2838812  PMID: 20178648
23.  Hypertension and Its Correlates Among School Adolescents in Delhi 
Background:
Hypertension is fast emerging as a major health problem amongst all school adolescents, particularly in urban areas. Regular screening of the students for this is required for preventing the emergence of complications later in life. Therefore, the present study was undertaken with the objective to determine the prevalence of hypertension amongst urban school adolescents and its correlation with anthropometric measurements.
Methods:
A cross-sectional study was conducted in a school in Central Delhi involving all 315 students of 9th and 11th standard. A preforma was filled by the students and anthropometric measurements along with blood pressure (BP) measurements were taken for each student. Data was analyzed using Epi-info 2005 and SPSS 16.0.
Results:
Out of the total 315 students, 208 (66%) were boys and 107 (34%) were girls and the mean age was 14.31 ± 0.96 years. Overall prevalence of malnutrition was 24% and boys were found to be more obese as compared to girls. There were 5 students (1.6%) who were found to have systolic hypertension while 17 (5.4%) were found to have diastolic hypertension while 4.1% (n = 13) of the participants were systolic pre-hypertensive and 26% (n = 82) were in stage of diastolic pre-hypertension. Body mass index and gender were found to be independent predictor for systolic hypertension.
Conclusions:
Prevalence of hypertension and pre-hypertension was high amongst the school children. BP check-up for children and adolescents is thus recommended to take remedial action on time.
PMCID: PMC3990918  PMID: 24791194
Body mass index; diastolic hypertension; malnutrition; pre-hypertension; systolic hypertension
24.  Obesity and elevated blood pressure among adolescents in Lagos, Nigeria: a cross-sectional study 
BMC Public Health  2012;12:616.
Background
Childhood obesity and associated hypertension are major public health concerns globally. This study aimed to determine the prevalence of obesity and the associated risk of high blood pressure among Nigerian adolescents.
Methods
A cross-sectional school-based study of 885 apparently healthy adolescents was performed. Weight, height and blood pressure (BP) were measured using standard methods. Body mass index (BMI) was calculated and categorized by age, sex and percentile. Obesity and overweight were defined as: ≥ 95th and 85th to < 95th percentiles, respectively, for age, sex and height. Subjects were sub-categorized into age 10–13 years (A) and 14–17 years (B). The odds ratio for pre-hypertensive and hypertensive range BP by age and BMI were generated. Significance was set at P < 0.05.
Results
The prevalence of overweight and obesity were 13.8% and 9.4%, respectively. The prevalence of hypertensive range systolic BP in obese versus normal BMI females was 16% versus 23% (p=0.00) and 12.1% versus 6.4% (p=0.27) in males. The prevalence of hypertensive range diastolic BP in obese versus normal BMI females was 12% versus 1.4% (p=0.00) and 15.2% versus 3.5% (p=0.01) in males. BMI in group B was significantly associated with pre-hypertensive and hypertensive range systolic BP in overweight (P = 0.01, P = 0.002) and obese subjects (P = 0.00, P = 0.00) and with hypertensive range diastolic BP (P = 0.00) only in obese subjects. The only significant association in group A was between obesity and pre-hypertensive range diastolic BP (P = 0.00).
Conclusion
The prevalence of hypertensive range BP among obese Nigerian adolescents was high. Screening for childhood obesity and hypertension, and long-term follow-up of obese adolescents into adulthood are recommended.
doi:10.1186/1471-2458-12-616
PMCID: PMC3490830  PMID: 22867531
Adolescents; Blood pressure; Body mass index; Obesity; Overweight
25.  Joint Associations of Physical Activity and Aerobic Fitness on the Development of Incident Hypertension: Coronary Artery Risk Development in Young Adults (CARDIA) 
Hypertension  2010;56(1):49-55.
Fitness and physical activity are each inversely associated with the development of hypertension. We tested whether fitness and physical activity were independently associated with the 20-year incidence of hypertension in 4618 men and women. Hypertension was determined in participants who had systolic blood pressure (SBP)≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg or who reported antihypertensive medication use. Fitness was estimated based on the duration of a symptom-limited graded exercise treadmill test and physical activity was self-reported. The incidence rate of hypertension was 13.8 per 1000 person-years (n=1022). Both baseline fitness (hazard ratio [HR]=0.63, 95% confidence interval [CI]: 0.56, 0.70 per standard deviation [SD; 2.9 minutes]) and physical activity (HR=0.86, 95% CI: 0.79, 0.84 per SD [297 exercise units]) were inversely associated with incident hypertension when included jointly in a model that also adjusted for age, sex, race, baseline smoking status, SBP, alcohol intake, HDL cholesterol, dietary fiber, dietary sodium, fasting glucose and BMI. The magnitude of association between physical activity and hypertension was strongest among participants in the high fitness (HR= 0.80, 95% CI: 0.68, 0.94) category, whereas the magnitude of association between fitness and hypertension was similar across tertiles of physical activity. The estimated proportion of hypertension cases that could be prevented if participants moved to a higher fitness category (i.e., preventive fraction) was 34% and varied by race and sex group. Fitness and physical activity are each associated with incident hypertension, and low fitness may account for a substantial proportion of hypertension incidence.
doi:10.1161/HYPERTENSIONAHA.109.147603
PMCID: PMC2909350  PMID: 20516395
epidemiology; exercise; ethnicity; risk factors; special populations

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