Obstructive sleep apnea (OSA) is a risk of hypertension and is associated with cardiovascular disease (CVD) incidence. In Asian countries, the prevalence of OSA is high, as in Western countries. When blood pressure (BP) is evaluated in OSA individuals using ambulatory BP monitoring (ABPM), the BP phenotype often indicates abnormal BP variability, such as increased nighttime BP or abnormal diurnal BP variation, that is, non-dipper pattern, riser pattern, and morning BP surge, and all these conditions have been associated with increased CVD events. Asians have a higher prevalence of increased nighttime BP or morning BP surge than Westerners. Therefore, this review paper focused on OSA and hypertension from an Asian perspective to investigate the importance of the association between OSA and hypertension in the Asian population. Such abnormal BP variability has been shown to be associated with progression of arterial stiffness, and this association could provoke a vicious cycle between abnormal BP phenotypes and arterial stiffness, a phenomenon recognized as systemic hemodynamic atherothrombotic syndrome (SHATS). OSA may be one of the background factors that augment SHATS. An oxygen-triggered nocturnal oscillometric BP measurement device combined with a pulse oximeter for continuous SpO2 monitoring could detect BP variability caused by OSA. In addition to treating the OSA, accurate and reliable detection and treatment of any residual BP elevation and BP variability caused by OSA would be necessary to prevent CVD events. However, more detailed detection of BP variability, such as beat-by-beat BP monitoring, would further help to reduce CV events.
Increased heart rate is a predictor of cardiovascular disease, heart failure, and all-cause mortality. In those with high heart rates, interventions for heart rate reduction have been associated with reductions in coronary events. Asia is a diverse continent, and the prevalences of hypertension and cardiovascular disease differ among its countries. The present analysis of AsiaBP@Home study data investigated differences among resting heart rates (RHRs) in 1443 hypertensive patients from three Asian regions: East Asia (N = 595), Southeast Asia (N = 680), and South Asia (N = 168). This is the first study to investigate self-measured RHR values in different Asian countries/regions using the same validated home BP monitoring device (Omron HEM-7130-AP/HEM-7131-E). Subjects in South Asia had higher RHR values compared with the other two regions, and the regional tendency found in RHR values was different from that found in BP values. Even after adjusting for age, sex, BMI, habitual alcohol consumption, current smoking habit, shift worker, hyperlipidemia, diabetes, chronic kidney disease, history of heart failure, and beta-blocker use, both office and home RHR values in South Asia were the highest among Asia (mean values ± SE of office: East Asia [E] 75.2 ± 1.5 bpm, Southeast Asia [Se] 76.7 ± 1.5 bpm, South Asia [S] 81.9 ± 1.4 bpm; home morning: [E] 69.0 ± 1.2 bpm, [Se] 72.9 ± 1.2 bpm, [S] 74.9 ± 1.1 bpm; home evening: [E] 74.6 ± 1.2 bpm, [Se] 78.3 ± 1.2 bpm, [S] 83.8 ± 1.1 bpm). Given what is known about the impact of RHR on heart disease, our findings suggest the possible benefit of regionally tailored clinical strategies for cardiovascular disease prevention.
Although short and long sleep duration are both risk factors of cardiovascular disease (CVD), the recent meta-analyses have been shown that long sleep duration was closely associated with CVD mortality. While the specific mechanism underlying the association between long sleep duration and CVD remains unclear, long sleep duration was shown to be associated with arterial stiffness and blood pressure variability (BPV) in many Asian populations. This review article will focus on the pathophysiology of long sleep duration, arterial stiffness, BPV and their effects on CVD. To set the stage for this review, we first summarize the current insights for the relationship between long sleep duration and CVD in relation to arterial stiffness and BPV.
Home blood pressure (HBP) has been recognized as a prognostic predictor for cardiovascular events, and integrated into the diagnosis and management of hypertension. With increasing accessibility of oscillometric blood pressure devices, HBP monitoring is easy to perform, more likely to obtain reliable estimation of blood pressures, and feasible to document long-term blood pressure variations, compared to office and ambulatory blood pressures. To obtain reliable HBP estimates, a standardized HBP monitoring protocol is essential. A consensus regarding the optimal duration and frequency of HBP monitoring is yet to be established. Based on the current evidence, the "722" protocol, which stands for two measurements on one occasion, two occasions a day (morning and evening), and over a consecutive of 7 days, is most commonly used in clinical studies and recommended in relevant guidelines and consensus documents. HBP monitoring based on the "722" protocol fulfills the minimal requirement of blood pressure measurements to achieve agreement of blood pressure classifications defined by office blood pressures and to predict cardiovascular risks. In the Taiwan HBP consensus, the frequency of repeating the "722" protocol of HBP monitoring according to different scenarios of hypertension management, from every 2 weeks to 3 months, is recommended. It is reasonable to conclude that the "722" protocol for HBP monitoring is clinically justified and can serve as a basis for standardized HBP monitoring.
Asia has an enormous number of older people and is the primary contributor to the rise in neurodegenerative diseases such as Alzheimer's and Parkinson's disease. The therapy of many neurodegenerative diseases has not yet progressed to the point where it is possible to alter the course of the disease. Mid-life hypertension is an important predictor of later-life cognitive impairment and brain neurodegenerative conditions. These findings highlight the pivotal role of preventing and managing hypertension as a risk factor for neurodegenerative disease. Autonomic dysfunction, neuropsychiatric and sleep disturbances can arise in neurodegenerative diseases, resulting in blood pressure variability (BPV). The BPV itself can worsen the progression of the disease. In older people with neurodegenerative disease and hypertension, it is critical to consider 24-h blood pressure monitoring and personalized blood pressure therapy.
Hypertensive emergency is one of the most challenging conditions to treat in the emergency department (ED). From previous studies, about 1%-3% of hypertensive individuals experienced hypertensive emergencies. Its prevalence varied by country and region throughout Asia. Asian populations have more different biological and cultural backgrounds than Caucasians and even within Asian countries. However, there is a scarcity of research on clinical features, treatment, and outcomes in multinational Asian populations. The authors aimed to review the current evidence about epidemiology, clinical characteristics and outcomes, and practice guidelines in Asia. Five observational studies and nine clinical practice guidelines across Asia were reviewed. The prevalence of hypertensive emergencies ranged from .1% to 1.5%. Stroke was the most common target organ involvement in Asians who presented with hypertensive emergencies. Although most hypertensive emergency patients required hospitalization, the mortality rate was low. Given the current lack of data among Asian countries, a multinational data repository and Asian guidelines on hypertensive emergency management are mandatory.
Arterial hypertension is a major risk factor for cardiovascular disease. The prevalence of primary aldosteronism (PA) ranges from 5% to 10% in the general hypertensive population and is regarded as one of the most common causes of secondary hypertension. There are two major causes of PA: bilateral adrenal hyperplasia and aldosterone-producing adenoma. The diagnosis of PA comprises screening, confirmatory testing, and subtype differentiation. The Endocrine Society Practice Guidelines for the diagnosis and treatment of PA recommends screening of patients at an increased risk of PA. These categories include patients with stage 2 and 3 hypertension, drug-resistant hypertension, hypertensive with spontaneous or diuretic-induced hypokalemia, hypertension with adrenal incidentaloma, hypertensive with a family history of early onset hypertension or cerebrovascular accident at a young age, and all hypertensive first-degree relatives of patients with PA. Recently, several studies have linked PA with obstructive sleep apnea and atrial fibrillation unexplained by structural heart defects and/or other conditions known to cause the arrhythmia, which may be partly responsible for the higher rates of cardiovascular and cerebrovascular accidents in patients with PA. The aim of this review is to discuss which patients should be screened for PA, focusing not only on well-established guidelines but also on additional groups of patients with a potentially higher prevalence of PA, as has been reported in recent research.
There is emerging evidence that α1-blockers can be safely used in the treatment of hypertension. These drugs can be used in almost all hypertensive patients for blood pressure control. However, there are several special indications. Benign prostatic hyperplasia is a compelling indication of α1-blockers, because of the dual treatment effect on both high blood pressure and lower urinary tract symptoms. Many patients with resistant hypertension would require α1-blockers as add-on therapy. Primary aldosteronism screen is a rapidly increasing clinical demand in the management of hypertension, where α1-blockers are useful for blood pressure control in the preparation for the measurement of plasma aldosterone and renin. Nonetheless, α1-blockers have to be used under several considerations. Among the currently available agents, only long-acting α1-blockers, such as doxazosin gastrointestinal therapeutic system 4-8 mg daily and terazosin 2-4 mg daily, should be chosen. Orthostatic hypotension is a concern with the use of α1-blockers especially in the elderly, and requires careful initial bedtime dosing and avoiding overdosing. Fluid retention is potentially also a concern, which may be overcome by combining an α1-blocker with a diuretic.
Morning hypertension is an important clinical target in the management of hypertension for perfect 24-h blood pressure (BP) control. Morning hypertension is generally categorized into two types: "morning surge" type and "sustained nocturnal and morning hypertension" type. The "morning surge" type is characterized by an exaggerated morning blood pressure surge (MBPS), and the "sustained nocturnal and morning hypertension" type with continuous hypertension from nighttime to morning (non-dipper/riser type). They can be detected by home and ambulatory blood pressure measurements (HBPM and ABPM). These two forms of morning hypertension both increase the risk of cardiovascular and renal diseases, but may occur via different pathogenic mechanisms and are associated with different conditions. Morning hypertension should be treated to achieve a morning BP level of
Recent trials have demonstrated the efficacy and safety of percutaneous renal sympathetic denervation (RDN) for blood pressure (BP)-lowering in patients with uncontrolled hypertension. Nevertheless, major challenges exist, such as the wide variation of BP-lowering responses following RDN (from strong response to no response) and lack of feasible and reproducible peri-procedural predictors for patient response. Both animal and human studies have demonstrated different patterns of BP responses following renal nerve stimulation (RNS), possibly related to varied regional proportions of sympathetic and parasympathetic nerve tissues along the renal arteries. Animal studies of RNS have shown that rapid electrical stimulation of the renal arteries caused renal artery vasoconstriction and increased norepinephrine secretion with a concomitant increase in BP, and the responses were attenuated after RDN. Moreover, selective RDN at sites with strong RNS-induced BP increases led to a more efficient BP-lowering effect. In human, when RNS was performed before and after RDN, blunted changes in RNS-induced BP responses were noted after RDN. The systolic BP response induced by RNS before RDN and blunted systolic BP response to RNS after RDN, at the site with maximal RNS-induced systolic BP response before RDN, both correlated with the 24-h ambulatory BP reductions 3-12 months following RDN. In summary, RNS-induced BP changes, before and after RDN, could be used to assess the immediate effect of RDN and predict BP reductions months following RDN. More comprehensive, large-scale and long term trials are needed to verify these findings.
Hypertension is highly prevalent worldwide and is the major risk factor for heart failure (HF). More than half of the patients with HF in Asia suffer from hypertension. According to the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guideline, there are four stages of HF, including at risk for HF (stage A), pre-HF (stage B), symptomatic HF (stage C), and advanced HF (stage D). Given the high prevalence of hypertension as well as HF and the stronger association between hypertension and cardiovascular diseases in Asians compared to the west, measures to prevent and alleviate the progression to clinical HF, especially controlling the blood pressure (BP), are of priority for Asian populations. After reviewing evidence-based studies, we propose a BP target of less than 130/80 mmHg for patients at stages A, B, and C. However, relatively higher BP may represent an opportunity to maximize guideline-directed medical therapy (GDMT), which could potentially result in a better prognosis for patients at stage D. Traditional antihypertensive drugs are the cornerstones for the management of hypertension at stages A and B. Notably, calcium channel blockers (CCBs) are inferior to other drug classes for the preventing of HF, whereas diuretics are superior to others. For patients at stage C, GDMT is essential which also helps the control of BP. In particular, sodium-glucose cotransporter-2 (SGLT2) inhibitors are newer therapies recommended for the treatment of HF and presumably even in hypertension to prevent HF. Regarding patients at stage D, GDMT is also recommended if tolerable and measures should be taken to improve hemodynamics.
The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30 years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices.
Hypertension is an important public health concern. The prevalence keeps increasing, and it is a risk factor for several adverse health outcomes including a decline in cognitive function. Recent data also show that the prevalence of hypertension and age-related dementia is rising in Asian countries, including in the oldest old group. This study aims to discuss possible treatments for high blood pressure in the elderly and propose an optimal target for BP relative to cognitive outcomes. This review discusses several studies on related blood pressure treatments that remain controversial and the consequences if the treatment target is too low or aggressive. Longitudinal, cross-sectional, and RCT studies were included in this review. An optimum systolic blood pressure of 120-130 mm Hg is recommended, especially in nondiabetic hypertensive patients with significant risk factors. In the oldest old group of patients, hypertension might have a protective effect. The use of calcium channel blockers (CCB) and angiotensin receptor blocker (ARB) is independently associated with a decreased risk of dementia in older people. However, personalized care for patients with hypertension, especially for patients who are frail or very old, is encouraged.
Hypertension professionals from Asia have been meeting together for the last decade to discuss how to improve the management of hypertension. Based on these education and research activities, the Hypertension, brain, cardiovascular and renal Outcome Prevention and Evidence in Asia (HOPE Asia) Network was officially established in June 2018 and includes experts from 12 countries/regions across Asia. Among the numerous research and review papers published by members of the HOPE Asia Network since 2017, publications in three key areas provide important guidance on the management of hypertension in Asia. This article highlights key consensus documents, which relate to the Asian characteristics of hypertension, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). Hypertension and hypertension-related diseases are common in Asia, and their characteristics differ from those in other populations. It is essential that these are taken into consideration to provide the best opportunity for achieving "perfect 24-hour blood pressure control", guided by out-of-office (home and ambulatory) blood pressure monitoring. These region-specific consensus documents should contribute to optimizing individual and population-based hypertension management strategies in Asian country. In addition, the HOPE Asia Network model provides a good example of the local interpretation, modification, and dissemination of international best practice to benefit specific populations.
Since noninvasive central blood pressure (BP) measuring devices are readily available, central BP has gained growing attention regarding its clinical application in the management of hypertension. The disagreement between central and peripheral BP has long been recognized. Some previous studies showed that noninvasive central BP may be better than the conventional brachial BP in association with target organ damages and long-term cardiovascular outcomes. Recent studies further suggest that the central BP strategy for confirming a diagnosis of hypertension may be more cost-effective than the conventional strategy, and guidance of hypertension management with central BP may result in less use of medications to achieve BP control. Despite the use of central BP being promising, more randomized controlled studies comparing central BP-guided therapeutic strategies with conventional care for cardiovascular events reduction are required because noninvasive central and brachial BP measures are conveniently available. In this brief review, the rationale supporting the utility of central BP in clinical practice and relating challenges are summarized.
Epidemiologic studies have consistently demonstrated an increased risk of cardiovascular disease during colder temperatures. Hemodynamic changes associated with cold temperature and an increase in thrombogenicity may both account for the increase in cardiovascular risk and mortality. Studies using both in-office and out-of-office BP measurements have consistently shown an elevation in BP during the colder seasons. The large difference in BP between cold and warm months may increase the incidence of hypertension and reduce the hypertension control rate, potentially resulting in increased cardiovascular risk, especially among those at risk of cardiovascular disease. The current trends in global warming and climate change may have a profound impact on the epidemiology of hypertension and cardiovascular disease, as changes in the climate may significantly affect both BP variability and cardiovascular disease, especially in those with high cardiovascular risk and the elderly. Furthermore, climate change could have a significant influence on hypertension in Asia, considering the unique characteristics of hypertensive patients in Asia. As an increase in ambient temperature decreases the mean daytime average and morning surge in BP, but increases the nocturnal BP, it is difficult to predict how environmental changes will affect the epidemiology and prognosis of hypertension in the Asian-Pacific region. However, these seasonal variations in BP could be minimized by adjusting the housing conditions and using anticipation medicine. In this review, we discuss the impact of seasonal variation in the ambient temperature on hypertension and cardiovascular disease and discuss how this may impact the epidemiology of hypertension and cardiovascular disease.
Unlike other international guidelines but in accord with the earlier Japanese Society of Hypertension (JSH) guidelines, the 2019 JSH guidelines ("JSH 2019") continue to emphasize the importance of out-of-office blood pressure (BP) measurements obtained with a home BP device. Another unique characteristic of JSH 2019 is that it sets clinical questions about the management of hypertension that are based on systematic reviews of updated evidence. JSH 2019 states that individuals with office BP
Blood pressure variability (BPV) has been shown to be independently associated with cardiovascular (CV) mortality and morbidity. Patients with type 2 diabetes mellitus (T2DM) have also been shown to have increased BPV. We aimed to compare BPV in hypertensive patients with diabetes with those without diabetes. A total of 1443 hypertensive patients measured their blood pressure (BP) twice in the morning and twice before bed at home for a week. Demographic data, history of T2DM, and anti-hypertensive use were captured. Clinic BP was measured twice in the clinic. Control of BP was defined as clinic systolic BP (SBP) <140 mm Hg and home SBP
The new Chinese hypertension guideline comprehensively covers almost all major aspects in the management of hypertension. In this new guideline, hypertension remains defined as a systolic/diastolic blood pressure of at least 140/90 mm Hg. For risk assessment, a qualitative approach is used similarly as in previous Chinese guidelines according to the blood pressure level and the presence or absence of other risk factors, target organ damage, cardiovascular complications, and comorbid diseases. The therapeutic target is 140/90 mm Hg in general, and if tolerated, especially in high-risk patients, can be more stringent, that is, 130/80 mm Hg. However, a less stringent target, that is, 150/90 mm Hg, is used in the younger (65-79 years, if tolerated, 140/90 mm Hg) and older elderly (≥80 years). Five classes of antihypertensive drugs, including β-blockers, can be used either in initial monotherapy or combination. The guideline also provided information on the management of hypertension in several special groups of patients and in the presence of secondary causes of hypertension. To implement the guideline recommendations, several nationwide hypertension control initiatives are being undertaken with new technology. The new technological platforms hopefully will help improve the management of hypertension and generate scientific evidence for future hypertension guidelines, including a possible Asian hypertension guideline in the near future.
Cardiovascular Disease (CVD) is the leading cause of deaths worldwide, contributing to about 30% of all deaths. Half of the cases of CVD are estimated in Asia, the world's most populous continent. Hypertension, a major modifiable risk factor for CVD, results in more deaths than any other CV risk factors in the Asian regions. The total number of patients with hypertension is likely to grow as the population ages. The proportion of the elderly population aged 65 years or more in Asia is expected to increase from 7.4% in 2015 to 10.9% in 2030. It is important to note that more than half (54%) of the world's population live in Asia. Aside of being the biggest single risk factor for global deaths, hypertension is also an important precursor and most common risk factor of heart failure (HF). An increase in HF prevalence is clearly related to the rapid epidemiological transition caused by changes in lifestyle in Asian countries. However, the availability of data on HF burden and health care delivery is limited in Asia compared with Europe and North America. This reality has driven the working group of Asian experts for example the HOPE Asia Network to concentrate on hypertension as risk factors for CVD, with the mission to improve the management of hypertension resulting in organ protection toward a goal of achieving "ZERO" CV event in Asia. This paper aims to give an overview regarding the heart problems caused by hypertension in Asia, focus on HF.