Editor’s Corner
Hypertension: prognostic, diagnostic and
therapeutic aspects
Alberto Zanchetti
A
ll major aspects of hypertension management, prog-
nostic, diagnostic and therapeutic ones, are covered
by articles published in the current issue of the
Journal of Hypertension.
A group of 11 articles explores prognostic aspects.
Downloaded from http://journals.lww.com/jhypertension by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FJPxKcC74DHjoABLp2xg21OLKNUoFPeEgVHcrd5J1Nc= on 12/12/2018
Marron et al. (pp. 43–53) have assessed the hypothesis
that a healthy blood pressure (BP) phenotype they had
developed in cohorts of familial longevity (Long Life Family
Study), characterized by an age-adjusted and sex-adjusted
SBP Z-score between 1.5 and 0.5, is also familial. Among
410 families, only 44 met the criteria for the healthy BP
phenotype. Among the latter families, a higher proportion of
offspring met the American Heart Association definition of
ideal cardiovascular health (10.8 versus 3.8%), driven by BP,
smoking status and BMI. In a sample of the general popula-
tion of Didima, Greece, followed-up for 19 years, Ntineri
et al. (pp. 69–76) found home BP predicted total mortality
and cardiovascular disease as reliably as office BP. However,
home SBP variability exhibited superior prognostic ability
than office BP variability. Furthermore, Ntineri et al. report
that not only sustained and masked, but also white-coat
hypertension was associated with increased risk of death
and cardiovascular disease events versus normotensive
patients. In an editorial commentary, Myers (pp. 34–36)
raises the point that the real cardiovascular risk associated
with white-coat hypertension is still controversial, and that a
small sample size and a limited number of end points during
follow-up may lead to exaggerated estimates of cardiovas-
cular risk in patients with white-coat hypertension.
Three other articles investigating prognostic aspects
focus on comparing BP risk in patients with and without
diabetes mellitus. Gomadam et al. (pp. 85–92) have ana-
lysed data from 17 650 participants from the National Health
and Nutrition Examination Survey III and 1439 participants
from the Diabetes Heart Study followed-up for a mean of
16.2 years and found that the association between SBP and
cardiovascular mortality is nonlinear, but different in dia-
betes (U shaped) and nondiabetes, suggesting this may
explain why aggressive BP lowering may have different
outcomes in presence or absence of diabetes. Jiang et al.
(pp. 93–100) have investigated the same problem, though
with a cross-sectional approach, in 42 959 patients of the
PURE China study, and report both in patients with and
without diabetes risk of stroke and coronary disease events
markedly increased in hypertensive patients compared
with individuals with normal BP, whereas no significant
difference in risk was seen between high-normal BP and
normal BP groups. Always in the context of the problem of
the optimal BP to be achieved by antihypertensive
Journal of Hypertension
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
treatment in patients with diabetes, Ó Hartaigh et al.
(pp. 101–109) have reanalysed data from the ACCORD trial,
in which patients with diabetes were randomly assigned to
achieve intense (<120 mmHg) or standard (<140 mmHg) BP
control, by grouping them according to whether or not they
achieved their respective goal. They report that, whereas in
the standard treatment arm those who achieved a target less
than 140 mmHg had a substantial reduction in the risk of
major cardiovascular events and all-cause death, no signifi-
cant risk reduction occurred in the intense treatment arm for
those who achieved the target SBP less than 120 mmHg as
compared with those who did not. The authors conclude
suggesting that in diabetes, SBP goal should be between 120
and 140 mmHg, but not less than 120 mmHg. This post-hoc
analysis of the ACCORD trial is discussed in an accompa-
nying editorial by Ahmad and Oparil (pp. 37–40), who
remark that a post-hoc analysis of a treatment-to-target study
has obvious limitations, as opposed to a prespecified analysis
of the comparative results of achieving two different BP goals
as in the original ACCORD publication.
Other conditions influencing prognosis in hypertension
are discussed by Shi et al. (pp. 54–60) and van der Sande
et al. (pp. 143–150). The former authors report that early life
exposure to the Chinese 1959–1961 famine exacerbated the
association between hypertension and cardiovascular dis-
ease events, especially among women, those living in urban
areas and those with central obesity. Van der Sande et al.
(pp. 143–150) have followed up for about 7 years a cohort of
6191 hypertensive patients with clinically manifested vascu-
lar disease and observed an increased risk of cardiovascular
mortality and all-cause mortality, in presence of controlled
and uncontrolled apparent resistant hypertension.
Predictors of renal function loss have been studied by
two groups: Leiherer et al. (pp. 110–118) report that serum
uromodulin (UMOD) levels were highest when associated
with a polymorphism in the UMOD coding region and were
significantly associated with estimated glomerular filtration
rate. Prospectively (4-year follow-up), serum uromodulin
Journal of Hypertension 2018, 36:1–3
Istituto Auxologico Italiano and Centro Interuniversitario Fisiologia Clinica e Iperten-
sione, Università degli Studi di Milano, Milano, Italy
Correspondence to Prof Alberto Zanchetti, Istituto Auxologico Italiano IRCCS and
Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università degli Studi di
Milano, Via F. Sforza, 35, 20122 Milano, Italy. Tel: +39 02 50320484;
e-mail: alberto.zanchetti@unimi.it, alberto.zanchetti@auxologico.it
J Hypertens 36:1– 3 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000001611
www.jhypertension.com 1
Zanchetti
concentration was inversely associated with the develop-
ment of chronic kidney disease (CKD) and significantly
increased a prediction model for CKD. Mallamaci et al.
(pp. 119–125) followed up 260 renal transplant patients for
over 3.7 years and found daytime and night-time ambula-
tory SBP predict the risk of renal function loss over time,
night-time SBP being the strongest predictor. The important
association of night-time hypertension with organ damage
is also underlined in a cross-sectional study by Tadic et al.
(pp. 136–142), who describe a worse right ventricle
mechanics in night-time and day-time/night-time hyperten-
sive patients than in normotensive controls and isolated
daytime hypertensive patients.
Another group of articles in the current issue of the
Journal of Hypertension has diagnostic implications. Jardim
et al. (pp. 61–68) present useful information on reference
values for home BP by height percentiles for age and sex in
a non-European population of adolescents in secondary
cohorts of a Brazilian city (51.3% non-white). Cuspidi
et al. (pp. 23–30) have reviewed and meta-analysed studies
assessing the association of metabolic syndrome with sub-
clinical carotid damage, finding carotid intima–media thick-
ness is significantly higher in patients with than in those
without the metabolic syndrome. They suggest ultrasound
search of subclinical carotid disease may refine cardiovascu-
lar risk stratification and decision-taking strategies in patients
with the metabolic syndrome. In another review in this issue
of the Journal, Tsioufis et al. (pp. 16–22) summarize the
evidence supporting a wider use of renal ultrasound in the
diagnostic work-up of patients with newly diagnosed hyper-
tension, not only to identify causes of secondary hyperten-
sion originating from the kidney, but also to detect renal
injury signalled by increased renal resistive indices.
Salvi et al. (pp. 77–84) present data on two large cohorts
of patients with the Marfan syndrome (n ¼ 114) in whom
aortic stiffness and central haemodynamics have been asso-
ciated with ascending aorta diameters and fibrillin-1 geno-
type. Pulse wave velocity and central pulse pressure were
significantly higher in Marfan syndrome patients than in
matched controls, although independently of fibrillin geno-
type, and were associated with diameters of ascending aorta.
A third group of articles in this issue is related with
aspects of hypertension management. Brunström and
Carlberg publish a critical review of standardization of
relative risks (RRs) and standard errors according to BP
differences within trials investigating the effects of BP-
lowering treatment, showing that standardization of RRs
exaggerates differences between trials and makes meta-
analyses highly sensitive to choice of statistical method.
The implications of standardization are further discussed
in an accompanying editorial by Thomopoulos and
Michalopoulou (pp. 31–33), who agree with the authors
that standardization to a preselected BP reduction is a
problematic issue. However, when selecting to standardize
to unmask some clinical aspects that crude analysis cannot
explore, Thomopoulos and Michalopoulou suggest one
should first investigate whether the projected comparison
of the standardized RRs has a solid clinical justification and
whether the outcome to standardize is linearly associated
with the extent of BP reduction.
2 www.jhypertension.com
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Among nonpharmacological interventions, salt reduc-
tion is known to be the most cost-effective one. Trieu et al.
(pp. 188–198) report the effect of an 18-month nationwide
salt reduction strategy in Samoa: though there was no
change in mean population salt intake as judged from
two nationally cross-sectional surveys carried out immedi-
ately before and after the intervention strategy, there were a
wider awareness of the salt reduction message and some
improvements in salt-related knowledge and behaviours.
Gilardini et al. (pp. 199–204) report that among hyperten-
sive patients with obstructive sleep apnoea, two-thirds have
urinary normetanephrine (uNMT) above the normal limit;
uNMT decreased or normalized, parallel with changes in
the apnoea–hypopnea index under positive airway pres-
sure therapy. Iwashima et al. (pp. 126–135) have investi-
gated the impact of renal function on cardiovascular and
renal outcomes after percutaneous transluminal renal
angioplasty in 139 hypertensive patients with atheroscle-
rotic renal artery stenosis followed up for 5.4 years and
report that impaired renal function and, in particular, a poor
response of estimated glomerular filtration rate to angio-
plasty are associated with worse outcome. A contribution to
the debated problem of the therapeutic effectiveness of
catheter renal denervation is provided by Völz et al.
(pp. 151–158), who present data from the Swedish Registry
for Renal Denervation showing a sustained reduction in
office and ambulatory BP in patients with resistant hyper-
tension, associated with a low complication rate. These data
are commented by Mahfoud et al. (pp. 41–42), who men-
tion the recent positive results of the sham-controlled
SPYRAL-OFF-Medication study [1] in nonmedicated
patients, and show the decrease in BP following renal
denervation is correlated with baseline BP. Nonetheless,
the authors conclude renal denervation remains an attrac-
tive, but still elusive potential technique and high-quality
research is needed.
Finally, three articles focus on treatment and control of
hypertension in different parts of the world. Lemogoum et
al. (pp. 159–168) find that hypertension is highly prevalent
in Far-North Cameroon, and awareness, treatment and
control rates are low. Agyemang et al. (pp. 169–177) have
investigated prevalence and management of hypertension
among relatively homogeneous African migrants (Ghana-
ians) living in three European cities, and nonmigrants living
in rural and urban Ghana: hypertension prevalence, aware-
ness and treatment levels were generally higher in African
migrants to Europe, but BP control level was lower in
Ghanaian migrant men compared with their nonmigrant
peers. Li et al. (pp. 178–187) report data from the first
national spatial analysis of hypertension in China, showing
hypertension prevalence and management are spatially
patterned in China, with demographic, socioeconomic
and behavioural factors, weight status, healthcare use
and urbanization accounting for a significant part of the
differences.
ACKNOWLEDGEMENTS
Conflicts of interest
There are no conflicts of interest.
Volume 36  Number 1  January 2018
 Prognostic, diagnostic and therapeutic aspects

hypertension in the absence of antihypertensive medications (SPYRAL

REFERENCE HTN-OFF MED): a randomised, sham-controlled, proof-of-concept trial.
1. Townsend RR, Mahfoud F, Kandzari DE, Kario K, Pocock S, Weber MA, Lancet Published Online August 28, 2017. doi:10.1016/S0140-6736
et al. Catheter-based renal denervation in patients with uncontrolled (17)32281-X

Journal of Hypertension www.jhypertension.com 3

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.