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More than half of US adults have hypertension by 40 years of age and a subsequent increase in atherosclerotic cardiovascular disease risk. Dietary sodium and potassium are intricately linked to the pathophysiology of hypertension. However, blood pressure responses to dietary sodium and potassium, phenomena known as salt and potassium sensitivity of blood pressure, respectively, are heterogenous and normally distributed in the general population. Like blood pressure, salt and potassium sensitivity are complex phenotypes, and previous research has shown that up to 75% of individuals experience a blood pressure change in response to such dietary minerals. Previous research has also implicated both high salt sensitivity and low salt sensitivity (or salt resistance) of blood pressure to an increased risk of hypertension and potentially atherosclerotic cardiovascular disease risk. Given the clinical challenges required to accurately measure the sodium and potassium response phenotypes, genomic characterization of these traits has become of interest for hypertension prevention initiatives on both the individual and population levels. Here, we review advances in human genomics research of blood pressure responses to dietary sodium and potassium by focusing on 3 main areas, including the phenotypic characterization of salt sensitivity and resistance, clinical challenges in diagnosing such phenotypes, and the genomic mechanisms that may help to explain salt and potassium sensitivity and resistance. Through this process, we hope to further underline the value of leveraging genomics and broader multiomics for characterizing the blood pressure response to sodium and potassium to improve precision in lifestyle approaches for primordial and primary atherosclerotic cardiovascular disease prevention. [ABSTRACT FROM AUTHOR]

High blood pressure (BP) is the leading cause of worldwide cardiovascular disease morbidity and mortality. Patients and clinicians dealing with hypertension have benefited from the evidence of event-based randomized controlled clinical trials. One result from those trials has been the development of evidence-based guidelines. The commitment to using evidence from these event-based randomized trials has been a cornerstone in the development of guideline treatment recommendations. However, in some situations, evidence from event-based trials is not available to guideline writers or clinicians for assistance in treatment decision making. Such is the case for the management of many patients with stage 1 hypertension. The purpose of this scientific statement is to provide information complementary to the 2017 Hypertension Clinical Practice Guidelines for the patient with untreated stage 1 hypertension (systolic BP/diastolic BP, 130–139/80–89 mm Hg) with a 10-year risk for atherosclerotic cardiovascular disease <10% who fails to meet the systolic BP/diastolic goal (<130/80 mm Hg) after 6 months of guideline-recommended lifestyle therapy. This statement provides evidence from sources other than event-based randomized controlled clinical trials and offers therapy options for consideration by clinicians. [ABSTRACT FROM AUTHOR]

The purpose of this review is to highlight the most impactful, educational, and frequently downloaded articles published in the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2020. The JCCT reached new records in 2020 for the number of research submissions, published manuscripts, article downloads and social media impressions. The articles in this review were selected by the Editorial Board of the JCCT and are comprised predominately of original research publications in the following categories: Coronavirus disease 2019 (COVID-19), coronary artery disease, coronary physiology, structural heart disease, and technical advances. The Editorial Board would like to thank each of the authors, peer-reviewers and the readers of JCCT for making 2020 one of the most successful years in its history, despite the challenging circumstances of the global COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia. [ABSTRACT FROM AUTHOR]

Background: The Systolic Blood Pressure Intervention Trial (SPRINT) reported that intensive blood pressure (BP) treatment reduced cardiovascular disease and mortality compared to standard BP treatment in hypertension patients. The next important question is how to implement more intensive BP treatment in real-world clinical practice. We designed an effectiveness-implementation hybrid trial to simultaneously test the effectiveness of a multifaceted intervention for intensive BP treatment and its feasibility, fidelity, and sustainability in underserved hypertension patients.Methods: Implementation of Multifaceted Patient-Centered Treatment Strategies for Intensive Blood Pressure Control (IMPACTS) is a cluster randomized trial conducted in 36 Federally Qualified Health Center clinics in Louisiana and Mississippi. Federally Qualified Health Center clinics were randomized to either a multifaceted intervention for intensive BP treatment, including protocol-based treatment using the SPRINT intensive BP management algorithm, dissemination of SPRINT findings, BP audit and feedback, home BP monitoring, and health coaching, or enhanced usual care. Difference in mean systolic BP change from baseline to 18 months is the primary clinical effectiveness outcome, and intervention fidelity, measured by treatment intensification and medication adherence, is the primary implementation outcome. The planned sample size of 1,260 participants (36 clinics with 35 participants each) has 90% power to detect a 5.0-mm Hg difference in systolic BP at a .05 significance level and 80% follow-up rate.Conclusions: IMPACTS will generate critical data on the effectiveness and implementation of a multifaceted intervention for intensive BP treatment in real-world clinical practice and could directly impact the BP-related disease burden in minority and low-income populations in the United States. [ABSTRACT FROM AUTHOR]

BACKGROUND: Aortic valve calcification (AVC), Lp(a) [lipoprotein(a)], and low-density lipoprotein cholesterol (LDL-C) are associated with severe aortic stenosis (AS). We aimed to determine which of these risk factors were most strongly associated with the risk of incident severe AS. METHODS: A total of 6792 participants from the MESA study (Multi-Ethnic Study of Atherosclerosis) had computed tomography-quantified AVC, Lp(a), and LDL-C values at MESA visit 1 (2000–2002). We calculated the absolute event rate of incident adjudicated severe AS per 1000 person-years and performed multivariable adjusted Cox proportional hazards regression. RESULTS: The mean age was 62 years old, and 47% were women. Over a median 16.7-year follow-up, the rate of incident severe AS increased exponentially with higher AVC, regardless of Lp(a) or LDL-C values. Participants with AVC=0 had a very low rate of severe AS even with elevated Lp(a) ≥50 mg/dL (<0.1/1000 person-years) or LDL-C ≥130 mg/dL (0.1/1000 person-years). AVC >0 was strongly associated with severe AS when Lp(a) <50 mg/dL hazard ratio (HR) of 33.8 (95% CI, 16.4–70.0) or ≥50 mg/dL HR of 61.5 (95% CI, 7.7–494.2) and when LDL-C <130 mg/dL HR of 31.1 (95% CI, 14.4–67.1) or ≥130 mg/dL HR of 50.2 (95% CI, 13.2–191.9). CONCLUSIONS: AVC better identifies people at high risk for severe AS compared with Lp(a) or LDL-C, and people with AVC=0 have a very low long-term rate of severe AS regardless of Lp(a) or LDL-C level. These results suggest AVC should be the preferred prognostic risk marker to identify patients at high risk for severe AS, which may help inform participant selection for future trials testing novel strategies to prevent severe AS. [ABSTRACT FROM AUTHOR]

Individuals with coronary artery calcium (CAC) >1000 experience secondary prevention-level risk and thus may optionally be placed on combination lipid-lowering therapy regimens. However, the risk markers in individuals with CAC >1000 that equate to very-high-risk status and corresponding low-density lipoprotein cholesterol (LDL-C) target goals have not yet been studied. Among persons with CAC >1000, we sought to identify risk markers that were associated with atherosclerotic cardiovascular disease (ASCVD) mortality rates approaching that of very-high-risk status in secondary prevention. We studied 2,869 primary prevention patients with CAC >1000 from the CAC Consortium. Multivariable Cox proportional hazards regression assessed the association of risk markers with ASCVD mortality during a median follow-up of 11.8 years. Crude ASCVD mortality rates were compared to those previously reported for patients meeting very-high ASCVD risk, defined by a history of >2 major ASCVD events or a history of 1 major event along with >2 high-risk conditions (1.4 per 100 person-years). The mean age of participants was 66.3 years, 14% were female, 13% were non-white, and 48% were on statin medication at the time of CAC scanning. The median CAC score was 1,572, 65% had left main CAC and 5% had severe left main CAC (>300). Beyond age (HR=2.54, 95% CI: 1.82-3.55, per 10-years older), diabetes (HR=2.06, 95% CI: 1.21-3.51), and severe left main CAC (HR=2.70, 95% CI: 1.46-4.87), there were no other risk markers independently associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), though much higher event rates were observed for persons with diabetes (1.4, 95% CI: 0.8-1.9), severe left main CAC (1.3, 95% CI: 0.6-2.0), and both diabetes and severe left main CAC (7.1, 95% CI: 3.4-10.8) (Central Illustration). Among primary prevention patients with CAC >1000, the presence of diabetes and severe left main CAC are independent prognostic markers of excess risk. There is a spectrum of commensurate secondary prevention level risk for patients with CAC >1000 that corresponds to individualized LDL-C treatment target goals as low as 55 mg/dL, especially for those with diabetes and/or severe left main CAC burden. No [ABSTRACT FROM AUTHOR]

Fragmented investigation has masked the overall picture for causes of cardiovascular disease (CVD). Among the risk factors for CVD, high blood pressure (BP) is associated with the strongest evidence for causation and it has a high prevalence of exposure. Biologically, normal levels of BP are considerably lower than what has typically been characterized as normal in research and clinical practice. We propose that CVD is primarily caused by a right-sided shift in the population distribution of BP. Our view that BP is the predominant risk factor for CVD is based on conceptual postulates that have been tested in observational investigations and clinical trials. Large cohort studies have demonstrated that high BP is an important risk factor for heart failure, atrial fibrillation, chronic kidney disease, heart valve diseases, aortic syndromes, and dementia, in addition to coronary heart disease and stroke. In multivariate modeling, the presumed attributable risk of high BP for stroke and coronary heart disease has increased steadily with progressive use of lower values for normal BP. Meta-analysis of BP-lowering randomized controlled trials has demonstrated a benefit which is almost identical to that predicted from BP risk relationships in cohort studies. Prevention of age-related increases in BP would, in large part, reduce the vascular consequences usually attributed to aging, and together with intensive treatment of established hypertension would eliminate a large proportion of the population burden of BP-related CVD. [ABSTRACT FROM AUTHOR]

The 2017 Hypertension Clinical Practice Guidelines recommend out-of-clinic BP monitoring to screen for white coat and masked hypertension among adults not taking antihypertensive medication and white coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. We estimated the percentage of US adults meeting criteria for out-of-clinic BP monitoring by the American College of Cardiology/American Heart Association guideline using the 2011 to 2014 National Health and Nutrition Examination Survey (n=9623). Among US adults not taking antihypertensive medication, 92.6% (95% CI, 90.7%-94.1%) with systolic/diastolic BP ≥130/80 mm Hg met criteria for out-of-clinic BP monitoring to screen for white coat hypertension and 32.8% (95% CI, 30.4%-35.3%) with systolic/diastolic BP<130/80 mm Hg met criteria to screen for masked hypertension. Criteria for out-of-clinic BP monitoring to screen for white coat hypertension were less often met at an older age and did not differ by race/ethnicity or sex. The proportion meeting criteria for out-of-clinic BP monitoring to screen for masked hypertension was higher at an older age, among men versus women and non-Hispanic blacks and whites versus non-Hispanic Asians or Hispanics. Among US adults taking antihypertensive medication, 12.5% (95% CI, 10.5%-14.9%) with systolic/diastolic BP ≥130/80 mm Hg met criteria to screen for white coat effect and 57.4% (95% CI, 52.7%-62.1%) with systolic/diastolic BP<130/80 mm Hg met criteria to screen for masked uncontrolled hypertension. Criteria for out-of-clinic BP monitoring to screen for white coat effect was more commonly met at an older age and among non-Hispanic blacks than non-Hispanic whites and to screen for masked uncontrolled hypertension in older adults and men. In conclusion, ≈103.8 million US adults (45.8%) met the 2017 Hypertension Clinical Practice Guidelines criteria for out-of-clinic BP monitoring. [ABSTRACT FROM AUTHOR]

As part of the process of developing the 2017 American College of Cardiology/American Heart Associations (ACC/AHA) and American Academy of Pediatrics (AAP) Hypertension guidelines, it was resolved to assure that recommendations for hypertension evaluation and treatment be consistent across the transition from adolescence to adulthood.[1],[2] The ACC/AHA Task Force appointed one of its members (S. Gidding) to be a liaison to the writing groups for both of the guidelines and to assist with the development process. Both guidelines recommend drug treatment initiation for stage 2 hypertension (BP> 140/90 mm Hg in those over 13 years of age), though the pediatric guideline allows for an optional trial of weight reduction in obese children before starting treatment. Whereas it is recommended that all children with a diagnosis of hypertension, receive an echocardiogram at the time of initiation of medication treatment, the adult guideline makes no recommendation regarding echocardiography. When pediatric hypertension patients transition to internal medicine care, their BP stage will be the same, the target BP for treatment will be the same, lifestyle management will be emphasized for stage 1 hypertension, and medication choices will be similar. [Extracted from the article]