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Recent advances in wearable technology through convenient and cuffless systems will enable continuous, noninvasive monitoring of blood pressure (BP), heart rate, and heart rhythm on both longitudinal 24-hour measurement scales and high-frequency beat-to-beat BP variability and synchronous heart rate variability and changes in underlying heart rhythm. Clinically, BP variability is classified into 4 main types on the basis of the duration of monitoring time: very-short-term (beat to beat), short-term (within 24 hours), medium-term (within days), and long-term (over months and years). BP variability is a strong risk factor for cardiovascular diseases, chronic kidney disease, cognitive decline, and mental illness. The diagnostic and therapeutic value of measuring and controlling BP variability may offer critical targets in addition to lowering mean BP in hypertensive populations.

Socioeconomic status is an overlooked risk factor for cardiovascular disease (CVD). Low family income is a measure of socioeconomic status and may portend greater CVD risk. Therefore, we assessed the association of family income with cardiovascular risk factor and disease burden in American adults. This retrospective analysis included data from participants aged ≥ 20 years from the National Health and Nutrition Examination Survey (NHANES) cycles between 2005 and 2018. Family income to poverty ratio (PIR) was calculated by dividing family (or individual) income by poverty guidelines specific to the survey year and used as a measure of socioeconomic status. The association of PIR with the presence of cardiovascular risk factors and CVD as well as cardiac mortality and all-cause mortality was examined. We included 35,932 unweighted participants corresponding to 207,073,472 weighted, nationally representative participants. Participants with lower PIR were often female and more likely to belong to race/ethnic minorities (non-Hispanic Black, Mexican American, other Hispanic). In addition, they were less likely to be married/living with a partner, to attain college graduation or higher, or to have health insurance. In adjusted analyses, the prevalence odds of diabetes mellitus, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), and stroke largely decreased in a step-wise manner from highest (≥ 5) to lowest PIR (< 1). In adjusted analysis, we also noted a mostly dose-dependent association of PIR with the risk of all-cause and cardiac mortality during a mean 5.7 and 5.8 years of follow up, respectively. Our study demonstrates a largely dose-dependent association of PIR with hypertension, diabetes mellitus, CHF, CAD and stroke prevalence as well as incident all-cause mortality and cardiac mortality in a nationally representative sample of American adults. Public policy efforts should be directed to alleviate these disparities to help improve cardiovascular outcomes in vulnerable groups with low family income., (© 2023. The Author(s).)

Purpose of Review: To highlight the indications, procedural considerations, and data supporting the use of stellate ganglion blockade (SGB) for management of refractory ventricular arrhythmias., Recent Findings: In patients with refractory ventricular arrhythmias, unilateral or bilateral SGB can reduce arrhythmia burden and defibrillation events for 24-72 h, allowing time for use of other therapies like catheter ablation, surgical sympathectomy, or heart transplantation. The efficacy of SGB appears to be consistent despite the type (monomorphic vs polymorphic) or etiology (ischemic vs non-ischemic cardiomyopathy) of the ventricular arrhythmia. Ultrasound-guided SGB is safe with low risk for complications, even when performed on anticoagulation. SGB is effective and safe and could be considered for patients with refractory ventricular arrhythmias.

Background: Current guidelines recommend aggressive management of hypertension. Recent evidence suggested potential harm with low blood pressure targets in patients with peripheral artery disease. We investigated the association of a history of hypertension and office systolic blood pressure (SBP) with major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs)., Methods and Results: The EUCLID trial (Examining the Use of Ticagrelor in Peripheral Artery Disease) included 13 885 participants with symptomatic peripheral artery disease; median follow-up was 30 months. Cox proportional hazards regression was used to calculate hazard ratios (HRs) for any MACE, MALE, and MALE including lower extremity revascularization. A clinical history of arterial hypertension was present in 10 857 (78%) participants, and these participants were older and more likely to be female when compared with the 3026 (22%) patients without hypertension. In patients with a history of hypertension, the adjusted hazard ratio for MACE was 0.94, 95% CI, 0.82-1.08; P =0.39, and the adjusted hazard ratio for MALE was 1.08, 95% CI, 0.96-1.23; P =0.21. During follow-up, average SBP was 135 mm Hg (125-145). Every 10 mmHg increase in SBP>125 mmHg was associated with an increased risk of MACE (HR, 1.10 [95% CI, 1.06-1.14]; P <0.001), a marginally increased risk of MALE (HR, 1.07 [95% CI, 1.00-1.15]; P =0.062), and an increased risk of MALE/lower extremity revascularization (HR, 1.08 [95% CI, 1.04-1.11]; P <0.001). Every decrease in 10 mmHg SBP ≤125 mmHg was associated with an increased risk of MACE (HR, 1.19 [95% CI, 1.09-1.31]; P <0.001) but not MALE or MALE/lower extremity revascularization (HR, 1.02 [95% CI, 0.84-1.23], P =0.824; HR, 1.04 [95% CI, 0.95-1.13], P =0.392, respectively)., Conclusions: History of hypertension was not associated with higher hazard for MACE or MALE in patients with peripheral artery disease. In contrast, there was a higher hazard of MACE in patients with out-of-target low and high SBP. High but not low SBP was associated with an increased risk of ischemic limb events. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01732822.

Volume management is an essential component of anti-hypertensive therapy. Different volume phenotypes have been proposed. We sought to study the total blood volume (TBV), plasma volume (PV), and red blood cell volume (RBV) in hypertensive patients. We included patients followed in an outpatient cardiology clinic from 1998 to 2003. Blood volume (BV) parameters were measured using radioisotope iodine-131-labeled albumin dilution technique. Values were expressed as percentage (%) deviation from ideal volumes. A total of 95 patients were included. The intravascular volume distribution as percent deviation from normal volume ranged from - 23 to + 28% for TBV, - 22 to + 36% for PV and - 29 to + 37% for RBV. There was no significant correlation between systolic BP and any of the BV parameters (TBV and SBP, r = - 0.03; PV and SBP, r = - 0.12; RBV and SBP, r = - 0.08). Patients with hypertension have a wide variation in BV parameters. BV does not correlate with SBP.

Purpose of Review: Review the renal nerve anatomy and physiology basics and explore the concept of global vs. selective renal denervation (RDN) to uncover some of the fundamental limitations of non-targeted renal nerve ablation and the potential superiority of selective RDN., Recent Findings: Recent trials testing the efficacy of RDN showed mixed results. Initial investigations targeted global RDN as a therapeutic goal. The repeat observation of heterogeneous response to RDN including non-responders with lack of a BP reduction, or even more unsettling, BP elevations after RDN has raised concern for the detrimental effects of unselective global RDN. Subsequent studies have suggested the presence of a heterogeneous fiber population and the potential utility of renal nerve stimulation to identify sympatho-stimulatory fibers or "hot spots." The recognition that RDN can produce heterogeneous afferent sympathetic effects both change therapeutic goals and revitalize the potential of therapeutic RDN to provide significant clinical benefits. Renal nerve stimulation has emerged as potential tool to identify sympatho-stimulatory fibers, avoid sympatho-inhibitory fibers, and thus guide selective RDN.

Untreated and uncontrolled hypertension (HTN) presents a major public health burden in the USA and worldwide. Despite the known risk for increased cardiovascular (CV) morbidity and mortality, blood pressure remains untreated and uncontrolled at alarming rates of between 20 and 40 % in patients with known HTN. Further, while cumulative evidence indicates that early onset of antihypertensive effect improves CV outcomes, the time to blood pressure (BP) control remains long. The objective of hypertension management cannot be simply to achieve and maintain the goal BP, but to do so quickly to improve short-term and long-term CV outcomes. In this review, we will (1) describe the magnitude of uncontrolled HTN, (2) identify the factors that contribute to uncontrolled BP in patients with the diagnosis of HTN, and (3) explore the rationale for and benefits of aggressive and immediate control of HTN.

Removal of carotid body (CB) improves animal models of hypertension (HTN) and heart failure, via withdrawal of chemoreflex-induced sympathetic activation. Effect of CB tumor (CBT) resection on blood pressure (BP) in subjects with HTN is unknown. A retrospective analysis of 20 subjects with HTN (BP≥140/90 mmHg or anti-hypertensives use) out of 134 with CBT resection. Short-term (30 days from surgery) and long-term (slope of regressions on time over the entire follow-up) changes in BP and heart rate were adjusted for covariates (interval between readings, total follow-up, number of readings and changes in therapy). Age and duration of HTN were 56±4 and 9±5 years. Adjusted short-term decreases in systolic (SBP: -9.9±3.1, p<0.001) and pulse pressures (PP: -7.9±2.7, p<0.002) were significant and correlated with their respective long-term changes (SBP: r=0.47, p=0.047; PP: r=0.54, p=0.019). There was a strong relationship between adjusted short-term changes in SBP and PP (r=0.64, p<0.004). Six (50% of responders or 33% of the total) had short-term falls of SBP ≥10 mmHg and of PP ≥ 5 mmHg. First study to show that unilateral CBT resection is associated with sustained reduction of BP in hypertensive patients. Targeted CB chemoreflex removal could play a role in the therapy of human HTN., (Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Excess blood pressure remains the most important risk factor for cardiovascular and renal disease. Poly pharmacy has been proved safe and effective under clinical trial circumstances; however, the majority of patients fail to sustain pharmaceutical persistence and adherence. The opportunity to offer patients a treatment or device in addition or perhaps instead of drug therapy alone may significantly broaden the options for patients and allow greater success in hypertensive therapy. In this review, we examine the potential of a fixed-volume central arterial-venous anastomosis to reduce blood pressure in hypertensive patients, review possible mechanisms by which the anastomosis may reduce blood pressure, and consider the unique clinical trial opportunities posed by this therapy.

Introduction: The carotid body (CB) has previously been found to be enlarged and hyperactive in various disease states such as heart failure (HF), hypertension (HTN), and respiratory disease. Evaluation of CB size in these disease states using imaging has not been performed. The purpose of this case-control study was to compare CB sizes in patients with HF and HTN with those of controls using CT angiography., Methods: A retrospective review was performed on 323 consecutive patients who had neck computed tomography angiography (CTA) exams in 2011. Following extensive review, 17 HF and HTN patients and 14 controls were identified. Two radiologists blinded to the patient disease status made consensus bilateral carotid body (CB) measurements on the CTA exams using a previously described standardized protocol. CB axial cross-sectional areas were compared between HF and HTN cases and controls using a paired t test., Results: The right CB demonstrated a mean cross-sectional area of 2.79 mm(2) in HF and HTN patients vs. 1.40 mm(2) in controls (p = 0.02). The left CB demonstrated a mean cross-sectional area of 3.13 mm(2) in HF and HTN patients vs. 1.53 mm in controls (p = 0.03)., Conclusion: Our results provide imaging evidence that the carotid bodies are enlarged in patients with HF and HTN. Our case-control series suggests that this enlargement can be detected on neck CTA.

The peripheral chemoreflex is known to be enhanced in individuals with hypertension. In pre-hypertensive (PH) and adult spontaneously hypertensive rats (SHRs) carotid body type I (glomus) cells exhibit hypersensitivity to chemosensory stimuli and elevated sympathoexcitatory responses to peripheral chemoreceptor stimulation. Herein, we eliminated carotid body inputs in both PH-SHRs and SHRs to test the hypothesis that heightened peripheral chemoreceptor activity contributes to both the development and maintenance of hypertension. The carotid sinus nerves were surgically denervated under general anaesthesia in 4- and 12-week-old SHRs. Control groups comprised sham-operated SHRs and aged-matched sham-operated and carotid sinus nerve denervated Wistar rats. Arterial blood pressure was recorded chronically in conscious, freely moving animals. Successful carotid sinus nerve denervation (CSD) was confirmed by testing respiratory responses to hypoxia (10% O(2)) or cardiovascular responses to i.v. injection of sodium cyanide. In the SHR, CSD reduced both the development of hypertension and its maintenance (P<0.05) and was associated with a reduction in sympathetic vasomotor tone (as revealed by frequency domain analysis and reduced arterial pressure responses to administration of hexamethonium; P<0.05 vs. sham-operated SHR) and an improvement in baroreflex sensitivity. No effect on blood pressure was observed in sham-operated SHRs or Wistar rats. In conclusion, carotid sinus nerve inputs from the carotid body are, in part, responsible for elevated sympathetic tone and critical for the genesis of hypertension in the developing SHR and its maintenance in later life.

Heart failure (HF) does not occur in a vacuum and is commonly defined and exacerbated by its co‐morbid conditions. Neurohormonal imbalance and systemic inflammation are some of the key pathomechanisms of HF but also commonly encountered co‐morbidities such as arterial hypertension, diabetes mellitus, cachexia, obesity and sleep‐disordered breathing. A cornerstone of HF management is neurohormonal blockade, which in HF with reduced ejection fraction has been tied to a reduction in morbidity and mortality. Pharmacological treatment effective in patients with HF with reduced ejection fraction did not show substantial effects in HF with preserved ejection fraction. Here, we review novel device‐based therapies using neuromodulation of extra‐cardiac targets to treat cardiometabolic disease. [ABSTRACT FROM AUTHOR]

Background: Prediction of readmission and death after hospitalization for heart failure (HF) is an unmet need. Aim: We evaluated the ability of clinical parameters, NT-proBNP level and noninvasive lung impedance (LI), to predict time to readmission (TTR) and time to death (TTD). Methods and Results: The present study is a post hoc analysis of the IMPEDANCE-HF extended trial comprising 290 patients with LVEF ≤45% and New York Heart Association functional class II–IV, randomized 1:1 to LI-guided or conventional therapy. Of all patients, 206 were admitted 766 times for HF during a follow-up of 57 ± 39 months. The normal LI (NLI), representing the "dry" lung status, was calculated for each patient at study entry. The current degree of pulmonary congestion (PC) compared with its dry status was represented by ΔLIR = ([measured LI/NLI] – 1) × 100%. Twenty-six parameters recorded during HF admission were used to predict TTR and TTD. To determine the parameter which mainly impacted TTR and TTD, variables were standardized, and effect size (ES) was calculated. Multivariate analysis by the Andersen-Gill model demonstrated that ΔLIRadmission (ES = 0.72), ΔLIRdischarge (ES = –3.14), group assignment (ES = 0.2), maximal troponin during HF admission (ES = 0.19), LVEF related to admission (ES = –0.22) and arterial hypertension (ES = 0.12) are independent predictors of TTR (p < 0.01, χ2 = 1,206). Analysis of ES showed that residual PC assessed by ∆LIRdischarge was the most prominent predictor of TTR. One percent improvement in predischarge PC, assessed by ∆LIRdischarge, was associated with a likelihood of TTR increase by 14% (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.13–1.15, p < 0.01) and TTD increase by 8% (HR 1.08, 95% CI 1.07–1.09, p < 0.01). Conclusion: The degree of predischarge PC assessed by ∆LIR is the most dominant predictor of TTR and TTD. [ABSTRACT FROM AUTHOR]

Tricuspid valve disease is an often underrecognized clinical problem that is associated with significant morbidity and mortality. Unfortunately, patients will often present late in their disease course with severe right-sided heart failure, pulmonary hypertension, and life-limiting symptoms that have few durable treatment options. Traditionally, the only treatment for tricuspid valve disease has been medical therapy or surgery; however, there have been increasing interest and success with the use of transcatheter tricuspid valve therapies over the past several years to treat patients with previously limited therapeutic options. The tricuspid valve is complex anatomically, lying adjacent to important anatomic structures such as the right coronary artery and the atrioventricular node, and is the passageway for permanent pacemaker leads into the right ventricle. In addition, the mechanism of tricuspid pathology varies widely between patients, which can be due to primary, secondary, or a combination of causes, meaning that it is not possible for 1 type of device to be suitable for treatment of all cases of tricuspid valve disease. To best visualize the pathology, several modalities of advanced cardiac imaging are often required, including transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, to best visualize the pathology. This detailed imaging provides important information for choosing the ideal transcatheter treatment options for patients with tricuspid valve disease, taking into account the need for the lifetime management of the patient. This review highlights the important background, anatomic considerations, therapeutic options, and future directions with regard to treatment of tricuspid valve disease. [ABSTRACT FROM AUTHOR]

Introduction: Volume management is an essential component of anti-hypertensive therapy. Different volume phenotypes have been proposed. Hypothesis: We sought to study the total blood volume (TBV), red blood cell volume (RBV) and plasma volume (PV) in adult hypertensive patients. Methods: We included patients followed in an outpatient cardiology clinic from 1998-2003. Blood volume (BV) parameters were measured using radioisotope iodine-131 labeled albumin injected over 1 minute with serial blood draws over 12, 18, 24, 30 and 36 minutes extrapolated to time zero (BVA- 100, Daxor, N.Y). Values were expressed as percentage (%) deviation from ideal volumes. The predicted normal BV was determined from patient's height, weight anddeviation from ideal body weight. We correlated seated systolic blood pressure (SBP) with blood volume parameters as well as the association of race and blood volume status. Results: Total of 78 hypertensive patients were included in the analysis. Of them, 55% were Caucasian, 35% were black, 53% were female, 27% had diabetes and 6% had a known history of heart failure. At the time point of the study, 31% were not on anti-hypertensive therapy, 26% were on renin angiotensin inhibitors, 17% on diuretics and 17% on calcium channel blockers. The TBV percent deviation from ideal ranged from -23% to +28%, RBV -29% to +37% and PV -22% to 36% (Figure 1 A-C). There was no significant correlation between SBP and any of the blood volume parameters (Figure 1 D-F). Further, blacks had lower blood volume parameters compared to non-blacks (p<0.001), despite higher SBP (159mmHg, SD +/- 98 vs 142 mmHg, SD+/- 72) (Figure 1 G-I). Conclusions: Patients with hypertension have a wide variation in TBV, RBV and PV. Blood volume does not correlate with SBP and was lower in blacks despite a higher blood pressure. Our findings support the need for more detailed analysis of blood volume type to help guide anti-hypertensive management. [ABSTRACT FROM AUTHOR]