From the Editor-in-Chief: Issue at a Glance

The current issue of the American Journal of Hypertension for December 2021 begins with a review by G. Grassi on the sympathetic nervous system and its role in hypertension,1 in which the role of sympathetic neural factors in the development and progression of primary hypertension are described on the basis of data collected in the past 10 years. Sympathetic nervous function in primary hypertension and related diseases investigated with microneurography of sympathetic nerve traffic and regional norepinephrine spillover, as well as the sympathetic effects of renal denervation and carotid baroreceptor stimulation and potential involvement of sympathetic nervous system in the “residual risk” of the treated hypertensive patients are discussed. Three commentaries follow, one by Angeli et al.2, another by E. Grossman3, and a third by C. McEniery,4 that will all be discussed with the articles they comment on. The first original paper is a brief communication by Brewster et al.5 Because race is today considered a social construct that can introduce bias and stereotyping leading to inequities in care, the authors investigated whether creatine kinase (CK), that participates in vascular contractility and sodium retention, could serve as a causal parameter of therapy failure better than race/ancestry. They studied a multiethnic population that included 1,405 persons of African, Asian, and European ancestry, and compared the performance of African ancestry vs. resting plasma CK as predictors of treated uncontrolled hypertension. The authors concluded that in contrast to African ancestry, CK could identify hypertensive patients at risk for therapy failure across different ancestry groups, and that prospective studies should establish whether resting plasma CK is clinically useful as an impartial method to predict antihypertensive therapy failure. In a Commentary, Angeli et al.2 indicate that in clinical practice a patient’s diet, family history, biochemical data, comorbidities, social status, immigrant status, access to care, geographic region, and development of target organ damage, etc., are more important than race, and that evaluating only race means that all these are ignored, all of which play a role in the absence of response to treatment. In their Commentary, Angeli et al. suggest in agreement with Brewster et al. that the use of race for therapeutic individualization should be abandoned. Whether CK measurement as a biomarker predictive of therapeutic response in hypertension will demonstrate effectiveness remains to be determined in the view of the authors of the Commentary. The next original article by de Havenon et al.,6 describes a post-hoc analysis of the Atherosclerosis Risk in the Community (ARIC) study in which the authors evaluated long-term blood pressure variability (BPV) using mean systolic BP at visits from 1987 to 1998 and mortality and cardiovascular events from 1998 to 2016. They included 9,578 participants and found that long-term BPV during midlife is an independent predictor of later life mortality but not cardiovascular events. E. Grossman in a Commentary3 on this article concluded that a possible explanation for the association of BPV with increased CV risk is that the need to accommodate to BP fluctuations requires energy through activation of the sympathetic nervous system and the renin–angiotensin system, and that these systems may increase the risk of CV events and mortality. Because low baroreflex sensitivity (BRS) is a risk factor for CV disorders, Man et al.7 investigated determinants of BRS in 901 subjects from the general population. The authors found that age and sex were important factors associated with BRS, and that percentage of body fat was a determinant of a less favorable BRS level than body mass index. The following article by Phillbrick et al.8 examined the performance of a thirty-minute office BP in a diverse urban population that included subjects with diabetes and cardiovascular disease. Compared to the standard procedure, thirty-minute office BP increased the probability for females, Blacks, indigenous, or persons of color to meet BP goals. The next paper in this issue by Nuckols et al.9 investigated the relationship of 24-hour BP with cognitive performance in young women with a recent history of preeclampsia. Women with a history of preeclampsia (hxPE) have, postpartum, increased arterial stiffness and elevated BP. Because aortic stiffness and 24-hour BPV are associated with age-related cognitive decline, the authors investigated 23 women with hxPE and healthy 38 pregnancy controls, 1–3 years postpartum. They assessed cognitive performance and used 24-hour ambulatory BP monitoring to measure BPV and carotid–femoral pulse wave velocity (cfPWV) to determine aortic stiffness. They showed that certain cognitive functions were reduced postpartum in these young women with a recent hxPE, and that this was related to increased 24-hour diastolic BPV. In a Commentary, C.M. McEniery4 brings up the question of whether impairments in cognitive function described by Nuckols et al. arise as a consequence of preeclampsia or whether compared with women with normotensive pregnancies, those who develop preeclampsia have poorer cardiovascular and/or cerebrovascular health prior to pregnancy that affect cognition. The Commentary concludes with the suggestion that mechanistic data of cerebrovascular structure and function prior to pregnancy would be ideal in order understand better the relationship between preeclampsia and cognitive decline described by Nuckols et al. Using central arterial pressure, and aortic velocity and diameter measurements in the outflow tract with echocardiography, Bello et al. determined factors associated with concentric left ventricular hypertrophy (LVH) or remodeling in 709 individuals of African ancestry with volume dependent primary hypertension.10 The authors report that concentric LVH is determined by volume-dependent increases in systemic flow and increased BP equally to eccentric LVH. They conclude that concentric remodeling, however, results from decreases in systolic function beyond LVH. The degree to which psychosocial factors including stress and depression affect the ability to achieve optimal cardiovascular health is unclear, particularly among hypertensive African Americans. Langford et al.11 examined the level to which Life’s Simple 7 (LS7) metrics were achieved in 1,819 African Americans with hypertension participating in the Jackson Heart Study (2000–2004). The combination of high stress and high depressive symptoms was associated with poorer LS7 scores in these subjects. The authors concluded that psychosocial interventions may increase the likelihood of acquiring behaviors that promote optimal cardiovascular health. Because few primary care providers (PCPs) screen for masked hypertension (MHT), Boyd et al.12 investigated the awareness, knowledge, and attitudes toward screening and treatment of masked hypertension in primary care. They found that in 3 medical centers in New York there was limited PCP knowledge about MHT, there were concerns about the accuracy and accessibility of screening tests, PCPs were too busy, and there was felt to be insufficient evidence of benefits of treatment for MHT. Trials demonstrating the latter and education may be needed to increase screening for MHT. In the final article in this issue of the Journal, Miller et al.13 evaluated a quality improvement program to assess the impact of a web-based diet and lifestyle intervention using short animated videos in adults with high BP at a primary care clinic in Saudi Arabia. They enrolled 269 adults with elevated BP who were not on BP medications, and had a high participation rate and a high return rate for reassessment of BP, with an average reduction of systolic BP of 10.5 mm Hg. The authors suggest that such programs are low cost and have great potential for improving follow-up and control of BP, but will require further confirmation with randomized clinical trials.

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