Obesity represents a pandemic, independent and modifiable cardiovascular risk factor, distinct from other well-known risk factors such as hypertension, hypercholesterolemia, and diabetes mellitus. The impact of this condition on cardiovascular outcomes is remarkably potentiated when obesity is associated with hypertension. These include the development and progression of left ventricular hypertrophy, endothelial dysfunction, sympathetic activation to the heart and peripheral vessels, impaired arterial distensibility, pro-atherogenic vascular alterations and kidney dysfunction and failure. On the clinical ground these alterations favor the development and progression of cardiovascular complications, such as coronary artery disease, chronic heart failure, life-threatening cardiac arrhythmias cerebrovascular disease and sleep apnea syndrome. In conclusion, the present paper will provide a comprehensive in-depth pathophysiological background, clinical consequences and therapeutic implications of the obesity-related hypertensive phenotype.

Although metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed nonalcoholic fatty liver disease, has become the most common chronic liver disorder, its complex pathophysiology has not been fully elucidated up to date. A correlation between elevated sympathetic activation and MASLD has been highlighted in recent preclinical and clinical studies. Furthermore, increased sympathetic activity has been associated with the main mechanisms involved in MASLD, such as lipid accumulation in the liver, insulin resistance, and metabolic dysregulation, while it has been also correlated with the progression of MASLD, leading to liver fibrosis. Preclinical studies demonstrated that therapies which ameliorate the activation of the sympathetic nervous system, such as renal and liver sympathetic denervation, reduce hepatic insulin resistance, decrease hepatic glucose production, and reverse hepatic steatosis in high-fat-diet models. However, data from clinical trials regarding the effect of renal denervation on metabolic parameters are conflicting, since several trials reported a favorable effect, while other trials stated no significant difference, with the profound limitation of the lack of originally designed denervation trials in this setting. Thus, a thorough review of the role of the sympathetic nervous system in the pathophysiology of MASLD, as well as the results of recent sympathetic denervation studies and trials regarding metabolic regulation and MASLD treatment would be of great importance.

New Medicine Service (NMS) components are an important element to improve patient compliance with medical recommendations. NMS provides support to patients prescribed new medicines, helping them to manage long-term conditions. The purpose of this service is to provide patients with advice, guidelines, and educational materials regarding the use of new medicines to increase patient compliance and therapy safety. The NMS has already been introduced in many European countries. This review aims to identify the benefits and potential barriers to implementing the NMS in community pharmacies and to suggest solutions that would increase its effectiveness. Previous studies have primarily shown that the NMS improves patient compliance with therapy, accelerating the expected effects of the therapy. Pharmacist support during implementation of a new drug therapy substantially increases patient safety. As the experience of numerous countries shows, both pharmacists and patients express positive opinions on this service. Therefore, it seems that NMS should be an indispensable part of pharmaceutical patient care in any healthcare system. This article aims to review the implementation of the New Medicine Service (NMS) for community pharmacists in Poland and the provision of a cost-effective approach to improve patient adherence to newly-prescribed medicine for chronic diseases.

Introduction: We previously completed a trial of renal pelvic denervation for treating hypertension that reduced blood pressure by the 2-month primary endpoint. However, information on the durability of effectiveness is a critical requirement for device therapy and we now report data up to 12 months. Methods: This was an open-label, single-arm feasibility study in patients with increased blood pressure despite taking an average of 2.7 medications. The key endpoint reported here was ambulatory blood pressure at 12 months following renal pelvic denervation. Results: In the 17 patients (mean age: 56) studied, there was a reduction from the baseline of 148 + 8.7 mm Hg in the primary endpoint of mean daytime systolic blood pressure at 12 months of 19.1 (26.7, 11.6) mm Hg, p < 0.001, as compared with the 2-month result of 19.4 (24.9, 14.0) mm Hg. The 24-h systolic blood pressure fell by 19.3 (26.7, 11.9), p < 0.001, and nighttime systolic fell by 18.7 (27.5, 9.8), p < 0.001, mm Hg at 12 months. Diastolic pressures also fell significantly from baseline at 12 months. As well, automated office systolic blood pressure was reduced from the baseline of 156.5 ± 12.3 by 24.8 (33.2, 16.8) mm Hg, p < 0.001, at 12 months as compared with 22.4 (31.5, 13.3) at 2 months. All blood pressure changes at 12 months were not different from those at 2 months, thus confirming the durability of the procedure. There were no serious procedural, clinical, or laboratory adverse events related to the intervention. Serum creatinine fell from 1.03 ± 0.22 to 0.82 ± 0.16 mg/dL, and estimated glomerular filtration rate rose from 79.6 ± 17.8 to 96.3 ± 16.4 mL/min/1.73 m2 by 12 months, again sustaining effects seen at 2 months. Conclusion: These findings provide evidence that the significant blood pressure-lowering effects of renal pelvic denervation are durable and safe for at least 1 year and provide the basis for a pivotal randomized blinded trial to further define the safety and effectiveness of this procedure.

Triple Whammy (TW) is a dangerous drug interaction (DI) that can occur when combining angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), with diuretics and non-steroidal anti-inflammatory drugs (NSAIDs). One of the most serious consequences of TW is contributing to pre-renal acute kidney injury (pr-AKI). Due to the fact that the term TW, in context of DI affecting kidneys function is not very widespread, the aim of this article was to gather information on this interaction. Previous knowledge on the mechanism of TW and increasing patient awareness of this interaction is described. In addition, the specific nature of the acute kidney injury (AKI) caused by triple whammy (AKITW) is presented. On the basis of the current state of knowledge, recommendations how to manage the TW DI are also demonstrated.

Magnesium is involved in many essential functions in the body, with a deficiency leading to possible cardiological, metabolic, neurological and rheumatological diseases, among others. The results of studies on the relationships between the occurrence of these diseases and magnesium deficiency helped identify the groups of patients who could benefit from this element. Considering the high frequency of patients using community pharmacy services, pharmacists present a group of medical professionals that can readily diagnose a potential magnesium deficiency in a relatively easy manner and can recommend supplementation in the diet or magnesium deficiency treatment with medicinal products when there are symptoms. For this reason, the objective of this article is to suggest procedures that can be used to identify patients particularly susceptible to magnesium deficiency. The second objective is to create Figures for the management of patients suffering from disorders that, in accordance with current knowledge, are associated with magnesium deficiency. In this context, guidelines were developed to help identify magnesium deficiency in patients with type 2 diabetes, insulin resistance, migraines, fibromyalgia, depression, anxiety states or hypertension. Appropriate supplementation with magnesium and magnesium deficiency treatment in the indicated target groups can largely minimize the symptoms of the diseases and increase patient wellbeing.

The differentiation between ischaemic stroke and haemorrhagic stroke subtype at onset of disease is critical in providing prompt diagnosis and immediate treatment. Although the incidence of haemorrhagic stroke is seven to ten times lower when compared to ischaemic subtypes, severity and associated increased mortality are greater in haemorrhagic stroke. Survival following haemorrhagic stroke is strongly determined by the area of brain bleeding and related tissue damage. Among haemorrhagic stroke, subarachnoid haemorrhage and intracranial haemorrhage are the two major types of haemorrhagic stroke. Although underlying pathophysiology, treatment and prognosis depend on the type of haemorrhage, if not diagnosed and treated promptly, subarachnoid haemorrhage and intracranial haemorrhage result in a loss of cognitive function and subsequent death. While multiple causative factors contribute to this condition, lowering blood pressure and improving adherence to medication can substantially reduce the risk of haemorrhagic stroke.

Renal denervation (RDN), a transcatheter renal sympathetic nerve ablation procedure, is a relatively novel established procedure for the treatment of hypertension, with it being recognized as a third option for hypertension management in the most recent European guidelines, together with pharmacotherapy, for achieving blood pressure targets. Given the relationship between both hypertension and sympathetic overdrive and the development of heart failure (HF), even studies at the dawn of research on RDN explored it as a treatment to overcome diuretic resistance in those patients. As it is now recognized that RDN does not only have organ-specific but also systemic effects, several investigators have aimed to delineate whether renal sympathetic denervation could alter the prognosis, symptoms, and adverse events of HF patients. Data are available in both HF patients with reduced and preserved ejection fraction. As the significance of neuromodulation is gaining grounds in the HF therapeutic arsenal, in this review, we aim to provide a rationale for using RDN in HF and an up-to-date overview of available data in both HF phenotypes, as well as discuss the future of neuromodulatory therapy in HF management.

AbstractClassic and non‐classic cardiovascular (CV) risk factors accumulate in chronic kidney disease (CKD), contributing to vascular remodeling and hemodynamic abnormalities. This study aimed to determine hemodynamic phenotypes based on linear regression of blood pressure (BP) parameters in stage G3‐G4 CKD patients at very high CV risk. 24‐h ambulatory BP monitoring (ABPM), carotid‐femoral pulse wave velocity (PWV) and central BP were obtained from 52 patients (aged 60 ± 11 years, BMI 30 ± 6 kg/m2) with stage G3‐G4 CKD (eGFR 44 ± 12 mL/min./1.73 m2). Linear BP regression coefficients were generated to determine hemodynamic phenotypes using ABPM data. Coexisting hypertension was present in 45 (86%) patients, out of whom 33 (73%) had BP controlled. 24‐h mean systolic/diastolic BP was 128 ± 18/75 ± 12 mm Hg. Twenty‐six patients demonstrated the harmonious (H) and 26 patients diastolic dysfunctional (D) hemodynamic phenotypes. eGFR was not significantly different between both phenotypes. Compared to phenotype H, patients with phenotype D were older (57 ± 11 vs. 63 ± 10 years, p = .04), had higher PWV (8.2 [7.3–10.3] vs. 9.7 [8.3–10.9] m/s, p = .02), ambulatory arterial stiffness index (AASI) (0.31 ± 0.1 vs. 0.40 ± 0.1, p = .02), systolic BP (128 [122–130] vs. 137 [130–150] mm Hg, p = .001) and systolic BP variability (BPV) (11.7 ± 2.3 vs. 15.7 ± 3.4 mm Hg, p < .0001). Our findings suggest that one in two patients with stage G3‐G4 CKD demonstrates an unfavorable D hemodynamic phenotype based on a linear regression model, associated with higher PWV, AASI, systolic BP, and systolic BPV. Further studies are required to assess the clinical utility of hemodynamic phenotypes and whether the D phenotype may predict latent circulatory disorders and outcomes.

Uncontrolled hypertension drives the global burden of increased cardiovascular disease (CVD) morbidity and mortality. Although high blood pressure (BP) is treatable and preventable, only half of the patients with hypertension undergoing treatment have their BP controlled. The failure of polypharmacy to attain adequate BP control may be due to a lack of physiological response, however, medication non-adherence and clinician inertia to increase treatment intensity are critical factors associated with poor hypertension management. The long-time medication titration, lifelong drug therapy, and often multi-drug treatment strategy are frustrating when the BP goal is not achieved, leading to increased CVD risk and a substantial burden on the healthcare system. Growing evidence indicates that neurohumoral activation is critical in initiating and maintaining elevated BP and its adverse consequences. Over the past decades, device-based therapies targeting the mechanisms underlying hypertension pathophysiology have been extensively studied. Among these, robust clinical experience for hypertension management exists for renal denervation (RDN) and baroreflex activation therapy (BAT), carotid body denervation (CBD), central arteriovenous anastomosis, and to a lesser extent, deep brain stimulation. Future studies are warranted to define the role of device-based approaches as an alternative or adjunctive treatment option to treat hypertension.

INTRODUCTION:India is facing a shortage of staff nurses; thus, a better understanding of nurses' workloads is essential for improving and implementing noncommunicable disease (NCD) control strategies. We estimated the proportion of time spent by staff nurses on hypertension and other NCD activities in primary care facilities in 2 states in India.METHODS:We conducted a cross-sectional study in 6 purposively selected primary care facilities in Punjab and Madhya Pradesh during July through September 2021. We used a standardized stopwatch to collect data for time spent on direct hypertension activities (measuring blood pressure, counseling, recording blood pressure measurement, and other NCD-related activities), indirect hypertension activities (data management, patient follow-up calls), and non-NCD activities. We used the Mann-Whitney U test to compare the median time spent on activities between facilities using paper-based records and the Simple mobile device-based app (open-source software).RESULTS:Six staff nurses were observed for 213 person-hours. Nurses spent 111 person-hours (52%; 95% CI, 45%-59%) on direct hypertension activities and 30 person-hours (14%; 95% CI, 10%-19%) on indirect hypertension activities. The time spent on blood pressure measurement (34 minutes) and documentation (35 minutes) was the maximum time on any given day. Facilities that used paper records spent more median time (39 [IQR, 26-62] minutes) for indirect hypertension activities than those using the Simple app (15 [IQR, 11-19] minutes; P < .001).CONCLUSION:Our study found that hypertension activities required more than half of nurses' time in India's primary care facilities. Digital systems can help to reduce the time spent on indirect hypertension activities.

Abstract Background Cardioneuroablation(CNA) is promising and innovative method to cure vagally mediated bradycardia.However, according to current ESC2021 guidelines patients may have indications for permanent pacing. CNA is still referred to patients as an experimental and alternative method,not being recommended in guidelines due to too small amount of evidence.The study sought to validate criteria for permanent pacemaker(PPM) implantation,discontinuation of PPM therapy(PPMT) and risk of PPM implantation after CNA in a large population of patients qualified for electrophysiologic study(EPS),Extracardiac vagal nerve stimulation(ECVS) and CNA. Methods Data were collected from POLish prospective multicentre CardioneuroAblation registry(POLCA) with comprehensive management, interdisciplinary consultations, state-of-art autonomic tests, atropine tests, EPS as well as ECVS. Shared-decision making was used to developed patient-oriented therapy with clear declaration of fulfilling indications for PPMT according to ESC guidelines,(when applicable) and CNA only as alternative and developing technique. Results A total of 195 consecutive adult patients(mean age:55,6+/-14,3 years; min 20,0 Q1 44,96-Q2 58,4 - Q3 67,2; max 82;107(54%)females,) underwent first CNA. Out of them, 17(8,2%) had already PPM. According to current guidelines 100/178(51%) patients had de novo indications for PPM implantation prior to CNA including: SND(n=88,45%), AVB(n=21, 10%), TBS (n=26, 13%), CI-VVS(n=41; 21%),M-VVS(n=1;0,5%), CI-CCS(n=41;21%) or mixed etiologies (n=45;23%). Indications for de novo PMT were present in 32(37%) patients above age 60. During moderate-term (23,7+/-10,3 months), no patient died, and only 10 had syncope (which was diagnosed as orthostatic or vasodepressive). Despite preprocedural positive atropine test and positive ECVS, 6 out of 195 patients (had early and elective PPM implantation due to coexistence of functional and structural bradycardia(n=3) or bradycardia recurrences(n=2) or severe sinus chronotropic incompetence(n=1). There were 7(3,5%) major complications (tamponade (n=2), pericarditis(n=2), pericardial effusion(n=1), femoral aneurysm(n=1), pneumothorax(n=1) of CNA. Only 4 of patients with indications for PPM implantation before CNA still had those indications during follow-up. Out of 6 patients with late PPM implantations after CNA, 1 patient had syncope due to development of AVB. Conclusions About 51%patients referred for CNA had indications for PPM therapy. CNA in subgroup of patients with functional bradycardia is becoming alternative choice to PPMT and allowed to give up PPM implantation at least temporarily in 96%patients without prior PPMT. However some patients require PMT due to failed CNA or reinnervation,but also co-existence or development of complex structural bradyarrhythmias.

The sympathetic nervous system (SNS) is a major regulatory component of the cardiovascular (CV) system affecting short- and long-term blood pressure regulation in the physiological and pathophysiological states. Growing evidence supports the contribution of the sympathetic nervous system activation to the pathogenesis of elevated blood pressure and hypertension-mediated cardiac, vascular, cerebral, and renal organ damage. Hypertension is the leading population-attributable risk factor for the development of heart failure (HF). Increased neurohumoral activation is an important contributing factor to the development of heart failure and a significant predictor of increased mortality. Recognition of sympathetic activation in hypertension and heart failure pathophysiology has led to the development of device-based therapies targeting the mechanisms underlying both conditions. Among interventional therapies, renal denervation (RDN), baroreflex activation therapy, and carotid body denervation have shown clinical benefits in the treatment of hypertension and heart failure.KeywordsHypertensionHeart failureSympathetic nervous systemReflex mechanismsOrgan damageDevice therapy

INTRODUCTION:Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension.METHODS:We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence.RESULTS:We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02).CONCLUSION:Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.