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High Blood Pressure While Lying Down Linked To Heart Disease Risk
Medical professionals typically measure blood pressure to gather vital information about someone's health. Most often, people are sitting during blood pressure readings.
However, this might not reveal the full picture about a person's cardiovascular health, since some people can have high blood pressure while lying down and normal blood pressure while they are sitting.
Study results shared at the American Heart Association's (AHA) Hypertension Scientific Sessions 2023 suggest that people who only have high blood pressure while lying down are at a similar risk for heart failure, stroke, coronary heart disease, fatal coronary heart disease, and all-cause mortality to people with high blood pressure while both sitting and lying down.
Blood pressure measures the force of blood pressing against the blood vessels that carry blood away from the heart. A blood pressure measurement involves two numbers: the systolic number, which measures when the heart muscles contract, and the diastolic number, which measures when the heart is at rest.
Typically, when someone's blood pressure is normal, the reading is 120/80 millimeters of mercury (mm Hg).
For this study, researchers wanted to see if high blood pressure while lying down, also called supine hypertension, was a risk factor on its own for adverse cardiovascular disease. In other words, would someone who only had high blood pressure lying down still be at risk for poor health outcomes?
Researchers used data from the Atherosclerosis Risk in Communities (ARIC) Study. They ended up including 11,369 participants in their analysis.
They excluded individuals with a history of coronary heart disease, heart failure, or stroke. Researchers defined supine high blood pressure as any reading greater than or equal to 130 mm Hg systolic or any reading greater than or equal to 80 mmH g diastolic while lying down. They defined seated high blood pressure by the same parameters but while sitting rather than lying down.
Among the participants, researchers found that 16% had normal blood pressure while seated but high blood pressure while lying down. They also found that 74% of participants who had high blood pressure while seated also had high blood pressure while lying down.
The average follow-up time was 25–28 years. The investigators found that people with seated and supine high blood pressure were at an increased risk for coronary heart disease, heart failure, stroke, fatal coronary heart disease, and all cause mortality.
The risk was similar for participants who only had high blood pressure while lying down. The researchers also found that the results did not differ based on use of medication for high blood pressure.
Dr. Michael Broukhim, a board certified interventional cardiologist at Providence Saint John's Health Center in Santa Monica, CA, not involved in the research, commented with his thoughts on the study results to Medical News Today:
"High blood pressure is related to an increased risk for cardiovascular disease including coronary artery disease, stroke, kidney disease, heart failure, and premature death. This study demonstrates that measuring seated blood pressures may miss hypertension in a significant proportion of middle-aged adults."
Dr. Cheng-Han Chen, interventional cardiologist and medical director of the Structural Heart Program at MemorialCare Saddleback Medical Center in Laguna Hills, CA, also not involved in the study, further commented that the findings had important implications for blood pressure management strategies.
"This research shows that we may miss the diagnosis of hypertension in many patients if we only measure their blood pressure while sitting, rather than laying down," he told us. "This gives us an important opportunity to better address an important cardiovascular risk factor."
Still, the study cannot establish a causal relationship between any of the factors that the researchers examined. It also appears that more measurements of blood pressure may have provided even more accurate information.
Furthermore, the study has not yet undergone peer review.
Dr. Keith C. Ferdinand, professor of medicine at the Tulane University School of Medicine, not involved in the research, commented to MNT on the study presented at the AHA conference:
"Study abstracts are always interesting. We need confirmation in full peer-reviewed analyses. We would think that supine blood pressure would be a risk because in that particular position the blood pressure is conventionally lower than in a seated position. And it may be a surrogate for someone in whom the blood pressure does not appropriately lower when totally at rest, including the nocturnal period."
This study indicates that it may be helpful to measure blood pressure while people are lying down to obtain a more complete picture of their cardiovascular health. However, there are certain barriers to implementing this in a clinical setting.
Dr. Ferdinand noted that "[c]linicians are presently under great time constraints."
"[They are] often employed by integrated healthcare systems who monitor the numbers of patients that are seen on a regular basis and make assessments of their reimbursement based on a 15-minute conventional visit," he told us.
He explained that "[a]dding the supine blood pressure would be difficult because it not only would complicate the intake […] but would give additional information that the clinician may not have time to appropriately analyze and make a decision."
However, Dr. Broukhim noted that it could be plausible to implement measurements of blood pressure while in the supine position for certain individuals.
"I think it is reasonable to obtain a supine blood pressure in patients presenting to the office if they have a normal seated blood pressure," he commented. "If there is an elevated clinical suspicion of hypertension, an ambulatory systolic blood pressure monitor should be utilized, which will likely demonstrate if supine hypertension is present while the patient is at home."
Dr. Chen similarly noted that: "These findings may play a big role in how we take blood pressure readings in the future. While not entirely feasible in every setting, we should probably adopt supine blood pressure measurements as standard technique whenever possible."
People who are concerned about their blood pressure can talk with their doctor about options for accurate measurement. When blood pressure is high, people can work with their doctor to develop an individualized treatment plan. This may involve taking certain medications, as well as lifestyle changes like quitting smoking and limiting alcohol.
Elevated TyG Index Tied To Increased Risk Of EGFR Decline In Patients With Hypertension
Taiwan: An elevated triglyceride glucose (TyG) index is independently associated with an increased risk of estimated glomerular filtration rate (eGFR) in patients with hypertension, states a study published in The Journal of Clinical Hypertension.
The results indicate that the TyG index could serve as a useful predictor for a decline in renal function among hypertensive patients. Also, the association between the TyG index and renal events suggest that insulin resistance (IR) may be a critical factor in developing hypertensive nephropathy.
Hypertension is a major global health problem affecting about 1.4 billion people worldwide. One of the common complications linked with hypertension is a renal injury that could lead to CKD (chronic kidney disease) and RSRD (end-stage renal disease). Strict BP control has been shown to reduce the risk of renal damage, but it remains uncertain which hypertensive patients are particularly susceptible to this condition, Therefore, identifying novel biomarkers that can predict the development and progression of hypertension-induced renal injury is important.
Insulin resistance has been implicated in kidney damage and progression of nephropathy. Hence IR evaluation may be a valuable tool for assessing the evolution of hypertension-induced renal damage. In this context, the TyG index has emerged as a cost-effective and non-invasive alternative indicator to assess IR. Recent studies have shown that an elevated TyG index is tied to an increased risk of cardiovascular disease, diabetic nephropathy, and arterial stiffness progression. However, there is limited evidence supporting the association between the TyG index and hypertension-induced renal injury.
Thus, there is a need for further need to determine whether the TyG index can serve as a reliable biomarker to evaluate the severity and progression of hypertensive nephropathy. Therefore, Chin-Chou Huang, College of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan, and colleagues aimed to investigate whether the TyG index was correlated with renal function decline in hypertensive patients.
The study included Han Chinese participants with essential hypertension. The TyG index was calculated as ln[fasting triglycerides (mg/dL) * fasting glucose (mg/dL)/2]. The decline in renal function was defined as >25% decline in eGFR. The independent effect of the TyG index on renal events was investigated using the Cox proportional hazard regression model. 548 Han Chinese hypertensive participants with a mean age of 62.1 ± 14.3 years were eligible for enrollment.
The study revealed the following findings:
The study revealed a significant association between an elevated TyG index and an increased risk of eGFR decline of more than 25%.
"The findings suggest that the TyG index could be a useful tool for evaluating future renal events," the researchers wrote. "While there is a need to further investigate the underlying mechanisms linking the TyG index to renal events, our findings support the clinical significance of this index for risk assessment in hypertension patients."
"Future studies should explore the potential use of the TyG index in clinical practice to improve early detection-making and prevention of renal damage," they concluded.
Reference:
Chen, C., Tsai, H., & Huang, C. Triglyceride glucose index and renal function decline in Han Chinese hypertensive patients. The Journal of Clinical Hypertension. Https://doi.Org/10.1111/jch.14720
Lorundrostat Stands A Chance Against Obesity-Related Hypertension
Among selected people with uncontrolled hypertension, blood pressure (BP) could be successfully reduced with a highly selective aldosterone synthase inhibitor, a phase II dose-finding trial found.
In hypertensive patients with suppressed renin -- theoretically the group most likely to benefit from reining in aldosterone production -- reductions of automated office systolic BP reached up to 14.1 mm Hg at 8 weeks in those receiving lorundrostat 50 mg or 100 mg once daily, a significant improvement over the placebo arm's 4-mm Hg reduction, reported Steven Nissen, MD, of Cleveland Clinic, and co-investigators of the small Target-HTN trial.
The subgroup with obesity in particular seemed to derive the greatest BP lowering, they stated in JAMA. The findings were presented at the 2023 Hypertension conference, hosted by the American Heart Association.
Notably, even in people without suppressed renin, 100 mg daily lorundrostat decreased systolic BP by 11.4 mm Hg.
"Lorundrostat was well tolerated, and small expected increases in serum potassium and declines in eGFR suggest a favorable safety profile, particularly with a 50-mg once-daily dose. The trial results support further study of lorundrostat as a treatment for uncontrolled hypertension," the authors concluded.
Lorundrostat is among the new antihypertensives in the pipeline being developed to curb the excess aldosterone synthesis that contributes to high BP.
"This development of this drug is important because no new classes of blood pressure lowering drugs have been introduced for many years," Nissen said in a press release. "Blood pressure is difficult to control in some patients particularly those with obesity and diabetes, so new options will be valuable."
Another selective aldosterone synthase inhibitor, baxdrostat, exhibited mixed results for BP lowering when it progressed to phase II study. Some attribute baxdrostat's failure to beat placebo in the recent HALO trial to hiccups in patient adherence to therapy.
A third agent in this class, dexfadrostat, is in early-phase testing.
Unlike a mineralocorticoid receptor antagonist like spironolactone, the more upstream targeting of aldosterone synthase of these drugs may help classical hyperaldosteronism and obesity-associated hypertension without hormonal adverse effects.
"There is now real potential to provide better-targeted treatment for patients in whom aldosterone excess is known to contribute to their clinical condition and influence their clinical outcome, notably those with difficult-to-control hypertension, obesity, heart failure, chronic kidney disease, and the many with yet-to-be-diagnosed primary aldosteronism," commented Bryan Williams, MD, of University College London, in an accompanying editorial.
Williams wrote that the two safety outcomes "especially relevant" to this new class are blood cortisol and potassium levels.
In Target-HTN, six people had increases in serum potassium above 6.0 mmol/L that corrected with dose reduction or drug discontinuation, while no instances of cortisol insufficiency occurred. "The 50-mg once-daily dose of lorundrostat lowered office BP to a similar degree as the 100-mg once daily dose, but resulted in fewer adverse events, including fewer episodes of hyperkalemia," Nissen's group reported.
Serum aldosterone was in fact reduced by lorundrostat across all doses.
"Consistent with its high selectivity for aldosterone synthase, there was no signal of an effect of lorundrostat on cortisol synthesis," Williams remarked, though he cautioned that "[m]ore significant increases in potassium would be expected in patients with more advanced kidney disease."
"While further studies of this drug are needed, these results are encouraging, particularly among patients with obesity-associated hypertension," said study co-author Luke Laffin, MD, also of Cleveland Clinic, in a statement.
The ongoing ADVANCE-HTN pivotal trial is evaluating lorundrostat as an add-on therapy for 300 people with uncontrolled or resistant hypertension. Another larger phase III trial is being planned for reporting in 2025, drug-maker Mineralys Therapeutics announced.
Target-HTN was a phase II trial conducted at 43 sites in the U.S. Prescreening identified people with systolic automated office BP 130 mm Hg or greater while on at least two antihypertensive medications for at least 4 weeks at maximally tolerated doses
An initial cohort of 163 participants with plasma renin activity (PRA) ≤1.0 ng/mL/h and elevated plasma aldosterone (1.0 ng/dL) was enrolled and randomized to placebo or one of five lorundrostat doses (12.5 mg, 50 mg, or 100 mg once daily, or 12.5 mg or 25 mg twice daily).
Subsequent enrollment included 37 participants with PRA greater than 1.0 ng/mL/h, who were randomized 1:6 to placebo or lorundrostat, 100 mg once daily.
Across the randomized patients, mean age was 65.7 and 60% were women. By race, 36% were Black and 48% Hispanic. Nearly half the participants had a BMI over 30.
Average baseline BP was around 140/80 mm Hg. Three or more antihypertensive medications were already being taken by 42%.
Chief among the limitations of the trial was the small sample size for each tested dose of lorundrostat.
Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow
Disclosures
The study was funded by Mineralys Therapeutics.
Nissen disclosed receiving grants from AbbVie, AstraZeneca, Amgen, Bristol Myers Squibb, Lilly, Esperion Therapeutics, Medtronic, MyoKardia, New Amsterdam Pharmaceuticals, Novartis, and Silence Therapeutics.
Laffin reported institutional services for other Mineralys clinical trials and receipt of personal fees from Medtronic, Lilly, and Crispr Therapeutics; grants from AstraZeneca; and stock options for LucidAct Health and Gordy Health.
Williams reported being the unremunerated chair of the steering committee designing a phase III trial of baxdrostat for AstraZeneca.
Primary Source
JAMA
Source Reference: Laffin LJ, et al "Aldosterone synthase inhibition with lorundrostat for uncontrolled hypertension: The Target-HTN randomized clinical trial" JAMA 2023; DOI: 10.1001/jama.2023.16029.
Secondary Source
JAMA
Source Reference: Williams B "A new dawn for aldosterone as a therapeutic target in hypertension" JAMA 2023; DOI: 10.1001/jama.2023.17087.
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