Background The prevalence of pseudoresistant hypertension (HTN) due to inaccurate BP measurement remains unknown. Methods Triage BP measurements and measurements obtained at the same clinic visit by trained physicians were compared in consecutive adult patients referred for uncontrolled resistant HTN (RHTN). Triage BP measurements were taken by the clinic staff during normal intake procedures. BP measurements were obtained by trained physicians using the BpTRU device. The prevalence of uncontrolled RHTN and differences in BP measurements were compared. Results Of 130 patients with uncontrolled RHTN, 33.1% (n=43) were falsely identified as having uncontrolled RHTN based on triage BP measurements. The median (IQR) of differences in systolic BP between pseudoresistant and true resistant groups were 23 (17 – 33) mm Hg and 13 (6 – 21) mm Hg, respectively (P=0.0001). The median (IQR) of differences in diastolic BP between the two groups were 12 (7 – 18) mm Hg and 8 (4 – 11) mm Hg, respectively (P=0.001). Conclusion Triage BP technique overestimated the prevalence of uncontrolled RHTN in approximately 33% of the patients emphasizing the importance of obtaining accurate BP measurements.

Masked uncontrolled hypertension (MUCH) is defined as controlled automated office BP (AOBP <135/85 mmHg) in clinic in patients receiving antihypertensive medication(s), but uncontrolled BP out-of-clinic by 24-hour ambulatory blood pressure monitoring (ABPM; awake ≥135/85 mmHg).We hypothesized that MUCH patients have greater out-of-clinic sympathetic activity compared to true controlled hypertensives. Patients being treated for hypertension were prospectively recruited after three or more consecutive clinic visits. All patients were evaluated by in-clinic AOBP, plasma catecholamines and spot-urine/plasma metanephrines. In addition, out-of-clinic 24-hr ABPM, 24-hr urinary for catecholamines and metanephrines was done. Out of 237 patients recruited, 169 patients had controlled in-clinic BP of which 156 patients had completed ABPM. Seventy-four were true controlled hypertensives, i.e. controlled by clinic AOBP and by out-of-clinic ABPM. The remaining 82 were controlled by clinic AOBP, but uncontrolled during out-of-clinic ABPM, indicative of MUCH. After exclusion of 4 patients because of inadequate or lack of 24-hr urinary collections, 72 true controlled hypertensive and 80 MUCH patients were analyzed. MUCH patients had significantly higher out-of-clinic BP variability and lower heart rate variability compared to true controlled hypertensives as well as higher levels of out-of-clinic urinary catecholamines and metanephrines levels consistent with higher out-of-clinic sympathetic activity. In contrast, there was no difference in in-clinic plasma catecholamines and spot-urine/plasma levels of metanephrines between the two groups, consistent with similar levels of sympathetic activity while in clinic. MUCH patients have evidence of heightened out-of-clinic sympathetic activity compared to true controlled hypertensives, which may contribute to the development of MUCH.

Background The association of atrial fibrillation (AF) with the severity and control of hypertension (HTN) remains unclear. Methods We analyzed data from the national biracial cohort of REasons for Geographic And Racial Differences in Stroke (REGARDS) study. The AF prevalence ratios were estimated and full multi-variable adjustment included demographics, risk factors, medication adherence, HTN duration and antihypertensive medication classes. Results Of the 30,018 study participants (8.6% with AF), 4,386 had normotension (4.3% with AF), 5,916 had prehypertension (4.3 with AF%), 12,294 had controlled HTN (11.2% with AF), 5,587 had uncontrolled HTN (8.1% with AF), 547 had controlled apparent treatment resistant hypertension (aTRH) (19.2% with AF), and 1288 had uncontrolled aTRH (15.5% with AF). Compared with normotension, the AF prevalence ratios for prehypertension, controlled HTN, uncontrolled HTN, controlled aTRH and uncontrolled aTRH groups in fully adjusted model were 1.01 (95% CI 0.84 – 1.21), 1.42 (1.18 – 1.71), 1.37 (1.14 – 1.65), 1.17 (0.86 – 1.58) and 1.42 (1.10 – 1.84) respectively (p < 0.001). Conclusion The prevalence of AF was similar among persons with HTN regardless of BP level and antihypertensive treatment resistance.

REasons for Geographic and Racial Differences in Stroke (REGARDS) is a longitudinal study supported by the National Institutes of Health to determine the disparities in stroke-related mortality across USA. REGARDS has published a body of work designed to understand the disparities in prevalence, awareness, treatment, and control of coronary heart disease (CHD) and its risk factors in a biracial national cohort. REGARDS has focused on racial and geographical disparities in the quality and access to health care, the influence of lack of medical insurance, and has attempted to contrast current guidelines in lipid lowering for secondary prevention in a nationwide cohort. It has described CHD risk from nontraditional risk factors such as chronic kidney disease, atrial fibrillation, and inflammation (i.e., high-sensitivity C-reactive protein) and has also assessed the role of depression, psychosocial, environmental, and lifestyle factors in CHD risk with emphasis on risk factor modification and ideal lifestyle factors. REGARDS has examined the utility of various methodologies, e.g., the process of medical record adjudication, proxy-based cause of death, and use of claim-based algorithms to determine CHD risk. Some valuable insight into less well-studied concepts such as the reliability of current troponin assays to identify “microsize infarcts,” caregiving stress, and CHD, heart failure, and cognitive decline have also emerged. In this review, we discuss some of the most important findings from REGARDS in the context of the existing literature in an effort to identify gaps and directions for further research.

We assessed the association of mitral annular calcification (MAC) with atherosclerotic risk factors and severity and complexity of coronary artery disease (CAD). Cardiac catheterization reports and electronic medical records from 2010 to 2011 were retrospectively reviewed. A total of 481 patients were divided into 2 groups: MAC present (209) and MAC absent (272). All major cardiovascular risk factors, comorbidities, and coronary lesion characteristics were included. On linear regression analysis, age (P = .001, β 1.12) and female gender (P = .031, β 0.50) were the independent predictors of MAC. Mitral annular calcification was not independently associated with the presence of lesions with >70% stenosis (P = .283), number of obstructive vessels (P = .469), lesions with 50% to 70% stenosis (P = .458), and Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score (P = .479). Mitral annular calcification is probably a benign marker of age-related degenerative changes in the heart independent of the severity and complexity of CAD.

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The association of cardiovascular risk factors and complexity and severity of coronary artery disease with contrast volume (CV) remains unknown. We assessed the predictive factors of CV use during elective and emergent cardiac catheterization (CC). Electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 708 patients were eligible. On multivariable regression analysis, the presence of obstructed coronary arteries was associated with CV (P = .01, β = -14.17), with greater CV used in patients with single or double vessel disease compared to those with triple vessel disease. The presence of lesions with >70% stenosis in major epicardial arteries (P = .019, β = 24.39) and ST-segment elevation myocardial infarction (P = .001, β = 36.14) was associated with increased CV use. Elevated B-type natriuretic peptide (P = .036, β = -17.23) and increase in Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score (P = .024, β = -29.06) were associated with decreased CV use. These aforementioned associations were attenuated after adjusting for percutaneous coronary intervention. Our findings may help predict patient populations who could be exposed to increased CV during CC, thereby possibly increasing their risk of contrast-induced nephropathy.

We sought to determine the association of major cardiovascular risk factors and other comorbidities with the presence or absence of coronary collateral (CC) circulation. All electronic medical records from 2010 to 2011 were retrospectively reviewed. A total of 563 patients were divided into 2 groups: CC present (180) and CC absent (383). Smoking (P = .012, odds ratio [OR] 1.58), hypercholesterolemia (P = .001, OR 2.21), and hypertension (P = .034, OR 1.75) were associated with the presence of CC. Increasing body mass index (BMI, P = .001) and decreasing estimated glomerular filtration rate (eGFR, P = .042) were associated with the absence of CC. On multivariable linear regression analysis, hypercholesterolemia (P = .001, OR 2.28), BMI (P = .012, OR 0.77), and eGFR (P = .001, OR 0.70) were found to be independently associated with CC. Our findings will help predict patient populations more likely to have presence or absence of CC circulation.