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

The current issue of the American Journal of Hypertension for September 2021 begins with an Editorial1 by one of our Associate Editors, Paul Muntner, with Shakia Hardy, on the Call to Action of the Surgeon General, which advocates for a strong evidence-based framework for patients, clinicians, healthcare systems and society to come together to improve blood pressure control rates, which may actually not be an easy task. Following is a review by Krousel-Wood et al.2 on antihypertensive medication adherence. The authors propose an expanded conceptual framework that incorporates implicit attitudes, time preferences, and structural social determinants of health, as important aspects to consider that could allow understanding variations in adherence to medication. Their model could suggest ways to design, implement and assess interventions that may lead to better medication adherence, and accordingly, to improved outcomes among older patients with hypertension. Two commentaries follow by Escobar et al.3 and by Arredondo et al.4 that will be discussed together with the original studies they refer to. In a short communication, Suvila et al.5 report on correlates of early onset hypertension. They evaluated demographics and lifestyle related to age of onset of hypertension in 3,286 individuals from the Coronary Artery Risk Development in Young Adults (CARDIA) study. They found that individuals who are black, obese, have higher total cholesterol, or have lower HDL-cholesterol level, are at increased risk of developing early-onset hypertension. We know that hypertension in pregnancy is a leading cause of maternal morbidity and mortality in the United States. Kovell et al.6 estimated the adherence to the DASH diet and antihypertensive medication use in women of child-bearing age based on the National Health and Nutrition Examination Surveys from 2001 to 2016. Few women of child-bearing age followed the DASH diet, and many who were hypertensive took antihypertensive medications not recommended during pregnancy. Considering the benefits of adequate BP control during pregnancy, this study underlines the importance of improving the adherence to the DASH diet and prescribing appropriate antihypertensive agents to hypertensive women of child-bearing age. Pulse pressure is a reflection of stiffening of central arteries, and in the following original manuscript in this issue, members of the International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcome Investigators7 evaluated the pulse pressure-related risk over the human life course. From 50 years onwards, pulse pressure-related relative risk decreased, whereas absolute risk increasesd. From the point of view of the lifespan, young adulthood is the time when there may be an opportunity to manage risk factors and prevent target organ damage. The authors add that in the elderly, absolute risk should be managed in order to extend life and enhance quality of life. Patient awareness and clinical inertia, and the obstacles to hypertension control in rural communities in the Dominican Republic, were investigated by Castro-Dominguez et al.8 The authors demonstrate that among rural communities in the Dominican Republic, undiagnosed hypertension is common, especially in younger individuals who are uninsured, or who have limited access to health care. It is rare that treatment is intensified in order to achieve control of BP in primary care. The authors conclude that strategies are needed to address awareness and clinical inertia in order to improve hypertension control. Escobar et al.3 in a Commentary indicates that the study by Castro-Dominguez offers ideas on hypertension management that may provide insight into therapeutic approaches that will help improve blood pressure control in rural areas. Khatib et al.9 investigated race/ethnic differences in atherosclerotic cardiovascular disease (ASCVD) risk factors among patients with hypertension with an analysis of findings from 143 primary care clinics. Disparities in controlling ASCVD risk factors in primary care were found, not fully explained by demographic or clinical characteristics. The authors insist that monitoring changes in disparities is important to ensure equity as interventions to prevent ASCVD in primary care are developed and implemented. Hypertension moved from 15th in 2000 to 11th in 2018 as a leading cause of death in Mississippi. Mendy et al.10 report on temporal trends in hypertension-related mortality among adults in Mississippi by age, sex, and race. The highest magnitude of increase was among those aged 45–64 years, men, Whites and White men compared to other age groups, women, Blacks, and Black men respectively. The authors concluded that interventions to lower blood pressure targeting hypertensive adults are needed. To estimate the prevalence of hypertensive patients in a UK hospital setting, Mahdi et al.11 performed a retrospective cross-sectional observational study of patients admitted to adult wards in four acute hospitals in Oxford, UK, between March 2014 and April 2018. Results. They identified 41,455 eligible admitted patients with a total of 1.7 million blood pressure measurements. They found that large numbers of hospital inpatients have mean in-hospital blood pressures exceeding diagnostic thresholds for hypertension, with no evidence of diagnosis or treatment in the electronic record. Whether screening for in-hospital high blood pressure helps detecting people with undiagnosed hypertension should be assessed. German et al.12 attempted to identify systolic blood pressure trajectories in order to establish whether some are associated with enhanced CVD risk, independently of the baseline blood pressure. They used Cox models in a cohort of participants in the Systolic Blood Pressure Intervention Trial (SPRINT) by incorporating SBP measures during the first 12 months of the trial post-randomization to evaluate the association of SBP trajectories with CVD and all-cause mortality. The authors noted 4 distinct SBP trajectory patterns associated with different cardiovascular outcomes, independent of baseline blood pressure. This may help identify individuals at greater risk, and lead to optimization of antihypertensive therapy to reduce cardiovascular events in the future. Feng et al. assessed the effect of a multicomponent intervention on antihypertensive medication intensification in rural South Asia with a post hoc analysis of a 2-year cluster-randomized controlled trial that incluced 2,645 hypertensives aged ≥40 years from 30 rural communities, 10 each, in Bangladesh, Pakistan, and Sri Lanka.13 They demonstrate that in rural communities in Bangladesh, Pakistan, and Sri Lanka, a multicomponent intervention led to a greater increase in intensification of antihypertensive medication compared with usual care among adults with hypertension. In view of the improved access to health insurance and healthcare services following the Affordable Care Act (ACA) Medicaid expansion, Huguet et al.14 evaluated whether there was a decrease post-ACA in the rate of patients with undiagnosed hypertension and the rate of patients with hypertension without anti-hypertensive medication in community health centers. The authors analyzed electronic health record data from 2012–2017 for 126,699 community health center patients aged 19–64 years with ≥1 visit pre-ACA and ≥1 post-ACA in 14 Medicaid expansion states. They demonstrate that patients who gained health insurance were appropriately diagnosed with hypertension faster and more frequently post-ACA than those with other types of insurance. A Commentary by Arredondo et al.4 on this paper discusses evidence and suggestions for greater health coverage of vulnerable groups. The final original paper in this issue by do Carmo et al.15 investigated the role of mineralocorticoid receptors in obesity using the obese Zucker rat model. There is evidence that obesity-induced hypertension in females, but not males, involves leptin-mediated stimulation of aldosterone secretion and activation of mineralocorticoid receptors. However, the results of this study suggest that there are important sex differences in BP responses to chronic AT1R blockade but no major involvement of MR activation in BP regulation in obese Zucker rats.

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