In the whole study group, sclerostin concentration correlated positively with height Z-score, phosphate, and alkaline phosphatase, and negatively with age, peripheral systolic and mean blood pressure, and central systolic and mean blood pressure. In multivariate analysis, systolic blood pressure (SBP) and height expressed as Z-scores were the significant determinants of serum sclerostin in the studied children: height Z-score ), SBP Z-score ). In conclusion, our results suggest a significant association between sclerostin and blood pressure in the pediatric population.Recent studies showed the significance of the canonical Wnt/beta-catenin pathway and its inhibitor—sclerostin, in the formation of arterial damage, cardiovascular morbidity, and mortality. The study aimed to assess serum sclerostin concentration and its relationship with blood pressure, arterial damage, and calcium-phosphate metabolism in children and adolescents with primary hypertension (PH). Serum sclerostin concentration (pmol/L) was evaluated in 60 pediatric patients with PH and 20 healthy children. In the study group, we also assessed calcium-phosphate metabolism, office peripheral and central blood pressure, 24 h ambulatory blood pressure, and parameters of arterial damage. Serum sclerostin did not differ significantly between patients with PH and the control group (36.6 ± 10.6 vs. 41.0 ± 11.9 (pmol/L),  It is estimated that arterial hypertension (AH) affects 3–5% of the pediatric population, and its frequency increases with the age of the children studied . Today, The importance of calcium-phosphate disorders, including vitamin D, in the development of AH and target-organ damage has become the subject of intensive research in recent years . AlthougSOST gene located on 17q12-21 chromosome, produced mainly by osteocytes, but also by chondrocytes, cementocytes, kidneys, liver, and vascular smooth muscle cells. Initially, it was thought that sclerostin belongs to the bone morphogenic protein (BMP) family [Sclerostin is a protein made up of 190 amino acids encoded by the ) family . However) family ,9. In 20The Wnt/beta-catenin system might be the link between the bone and vascular system. Increased Wnt/beta-catenin activity was found in the experimental model of vascular calcification  and scleConsidering the short duration of the disease and a small number of comorbidities, the population of children and adolescents with primary hypertension seems to be an ideal group to study the relationship between sclerostin, blood pressure, and subclinical arterial damage. Our study aims to assess serum sclerostin concentration in pediatric patients with PH and analyze its relationship with peripheral and central blood pressure, parameters of arterial damage, and parameters of calcium-phosphate metabolism.This single-center cross-sectional study included patients with PH treated in 2018–2020 in one tertiary center of pediatric nephrology. The criterion for inclusion in the study was confirmed AH following ESH recommendations ,18,19,20Participants were included in the study consecutively from among the patients after considering inclusion and exclusion criteria to exclude selection bias. In the analyzed period (2018–2020), there were also 31 patients with white coat hypertension and seven patients with masked hypertension who were excluded from further analysis.The authors obtained approval of the local Bioethical Committee before initiating the research . All procedures involving human participants were in accordance with the highest ethical standards of the institutional research committee and were performed according to the Declaration of Helsinki on the treatment of human subjects and its later amendments. Informed consent was obtained from all participants’ representatives and participants (≥16 years) before enrolling in the study.2), antihypertensive medications taken, and duration of hypertension (months). Anthropometric parameters were compared with the standards for the local population and presented in the form of Z-score [In all participants, the following clinical parameters were assessed: sex, age (years), body height (cm), body weight (kg), body mass index (kg/m Z-score . OverweiSerum sclerostin (ELISA enzyme-linked immunosorbent assay) was evaluated in all children studied using a kit from Biomedica Medizinprodukte GmbH, Vienna, Austria (BI-20492 Sclerostin ELISA). Blood samples were drawn on fasting from all the participants and thawed immediately after centrifugation at −84 °C.2) according to the revised 2009 Schwartz formula [All the participants had their calcium-phosphate metabolism evaluated on the basis of: serum concentrations of calcium (mg/dL), phosphate (mg/dL), 25-hydroxyvitamin D–25OHD (ng/mL), parathyroid hormone (pg/mL), and alkaline phosphatase activity (IU/L). In addition, the following biochemical parameters were evaluated: serum concentrations of creatinine (mg/dL), uric acid (mg/dL), total HDL- and LDL-cholesterol (mg/dL), and triglyceride (mg/dL). The estimated glomerular filtration rate (eGFR) was calculated in all patients  according to ESH recommendations and were analyzed using pediatric normative values . All theArterial structure and function tests were performed using following methods: ultrasonographic examination of the common carotid artery —common carotid artery intima media thickness (cIMT) (mm), Z-score , and comt-test for independent groups and non-normally distributed data using the Mann–Whitney U test. The relationship between the two groups of variables was analyzed using Pearson correlation or Spearman rank correlation (depending on the distribution). Percentages in both groups were compared using the chi-square test and Fisher’s exact test. Multivariate analysis was performed using a general linear model. Parameters correlating with each other with r > 0.600 were excluded from the final model to avoid collinearity. The results of the multivariate analysis were presented with beta coefficients, confidence intervals (CI), and p-value. A p-value < 0.05 was considered statistically significant.The results were statistically analyzed using TIBCO Statistica 13.3 software . The numerical data obtained were presented as mean, standard deviation (SD), and interquartile range . The normality of variables was studied using the Shapiro–Wilk test. Normally distributed data were compared with Student Clinical and biochemical parameters in the PH and control groups are presented in p = 0.142) and between patients treated and untreated with antihypertensive agents (34.3 ± 10.6 vs. 38.3 ± 10.4 (pmol/L), p = 0.151).The concentration of sclerostin and parameters of calcium-phosphate metabolism are shown in p = 0.567, aPWV Z-score: r = −0.062, p = 0.584, AIx75HR (%): r = −0.053, p = 0.638, cIMT (mm): r = −0.084, p = 0.459, and cIMT Z-score: r = −0.092, p = 0.417).As there was no significant difference in serum sclerostin between PH and healthy children, both groups were analyzed together. Correlations of serum sclerostin concentration with analyzed clinical and biochemical parameters in 80 studied children are presented in The results of multivariate analysis  are shown in p = 0.058), SBP Z-score , central systolic blood pressure (AoSBP) (mm Hg)) , central pulse pressure (AoPP (mm Hg)) , E-tracking pressure strain elasticity modulus (ET Ep) , and alkaline phosphatase (IU/L) .In a subanalysis of 35 untreated patients with primary hypertension, we found trends towards a negative correlation between serum sclerostin and peripheral systolic blood pressure (SBP) (mm Hg) . However, the authors did not find such a correlation for sclerostin . Gaudio In our cohort of pediatric patients with primary hypertension, we found no significant correlations between serum sclerostin and well-established indices of arterial wall damage . Of note, to increase the precision of our analysis, we analyzed both aortic and local carotid damage. This negative finding can be partially explained by the relatively low severity of arterial lesions in children compared with adult patients. Large multicenter analyses revealed that subclinical arterial damage observed in children and adolescents are mainly adaptations of arterial wall to increased pressure (arteriosclerosis) and do not necessarily indicate the onset of atherosclerosis and calcification of the vascular wall ,27,34. OConversely, our results may indicate a protective effect of Wnt/beta-catenin inhibitors on the level of blood pressure in children. We showed numerous negative correlations between sclerostin and both central and peripheral blood pressure. We confirmed these univariate relationships in multivariate analysis. Additionally, a subanalysis of a small cohort of untreated PH subjects revealed a similar trend.Of note, the relatively low duration of hypertension in our patients excluded advanced arterial lesions. In fact, notwithstanding significantly higher values of indexes of arterial stiffness  in hypertensive than in normotensive patients, this difference might reflect the effect of higher blood pressure values. The absence of a significant relationship between serum sclerostin levels and indexes of arterial stiffness in the whole study population, as opposed to a significant negative correlation between sclerostin levels and systolic blood pressure Z-score at multivariate analysis, supports this interpretation. Thus, the results of this study should certainly be considered preliminary.p = 0.031) was demonstrated in kidney transplant adult patients [Contrary to our results, a positive correlation between serum sclerostin and systolic blood pressure  in the formation of arterial damage. Sclerostin was found to inhibit angiotensin II-induced aortic aneurysm and atherosclerotic plaque formation in mice . In addiIn the analyzed group of patients, we did not find differences between sclerostin concentrations in boys and girls. Other authors found higher serum sclerostin in males in both children  and adulThe same researchers found a positive relationship between sclerostin concentrations and markers of bone turnover: a marker of bone formation—N-terminal collagen propeptide type I (PINP) and a marker of bone resorption—C-terminal collagen telopeptide type I (CTX); however, there was no correlation between sclerostin and parathyroid and 25OHD levels . Our groSome limitations to our research need to be listed. This was a cross-sectional analysis; thus, final conclusions on the nature of the relationship between blood pressure and sclerostin cannot be drawn. Secondly, we did not analyze bone mass, which was found to have a substantial impact on serum sclerostin concentration. Our research did not examine the concentration of Dickkopf-1—another important inhibitor of Wnt/beta-catenin pathway. Additionally, despite the large study sample, analysis in subgroups  may have been subject to error due to small numbers. As many as 25 out of 60 analyzed hypertensive subjects had already been treated with antihypertensive medications, which could have influenced the final results. Antihypertensives might have masked some of the relationships, for example, between sclerostin and target-organ damage. Moreover, the short duration of arterial hypertension in our patients excluded advanced arterial lesions and masked a possible relationship with sclerostin observed in adult studies. Of note, despite many years of our clinical and research experience with the blood pressure monitors used, it should be emphasized that both these devices had been validated only in the adult population so far. The latter may have influenced the results, although it is essential that we tested both control and study groups with the same instruments using the same protocol.Sclerostin, an endogenous inhibitor of Wnt/beta-catenin pathway, was found to be associated with cardiovascular damage in adults. In our research, serum sclerostin was not correlated to non-invasive indices of arterial damage but was inversely associated with systolic blood pressure. These results may suggest a significant association between sclerostin and blood pressure in the pediatric population and are consistent with studies on the cardiovascular safety of sclerostin inhibitors. There is a need for further studies at both experimental and clinical levels on the relationship between cardiovascular and Wnt/beta-catenin systems.


A pressure injury is a common and painful health condition, particularly among people who are elderly or surgical patients. In order to explore how to use the information management system to optimize the pressure injury management process of surgical patients, this work establishes an integrated pressure injury management information platform for surgical patients, which can effectively control the key links in the process and realize the multistep full-process monitoring of surgical patients from admission to discharge. A total of 578 patients before the operation of the information platform were selected as the control group (CG), and after the operation of the information platform, 662 cases became the observation group (OG). Various evaluation metrics are employed to evaluate pressure injury in terms of single-pass rate, high-risk pressure injury, transfer skin condition description matching rate, hospital pressure injury incidence, and incidence of pressure injury in surgical patients at various stages. The results showed that the qualified rate of the pressure injury assessment in the OG was 99.2%, the accuracy rate of high-risk pressure injury screening and reporting was 100.0%, and the matching rate of the transfer skin description was 100.0%, which was higher than that of the CG. The integrated pressure injury management information platform for surgical patients based on the information management system realizes the full, continuous, accurate, and dynamic evaluation and monitoring of patients' skin. Furthermore, it can effectively improve the quality of pressure injury care and facilitate care management. The development of a pressure injury occurs too frequently in the healthcare setting and adversely affects not only the patient, but also family members, hospital staff, and hospital systems. Direct causes of pressure injuries include shear, friction, amount of pressure, loss of sensation, immobility, and combined pathology . IndirecA pressure injury is caused by severe pressure, continuous pressure, or pressure combined with shear force as shown in The prevention of pressure injuries in surgical patients requires effective nursing measures at all stages of the perioperative period. Therefore, the care of pressure injuries in surgical patients is chain-type, interlocking, and continuous and requires the cooperation of multiple departments. The chained process management refers to the activities that take each link as the management object and maintain the effective continuity of each link as the management purpose . To makeThe rest of the paper is ordered as follows: Pressure injury refers to the localized damage that occurs in the skin and/or underlying soft tissues due to intense and persistent pressure or pressure combined with shear force. It usually occurs in bone carina or skin due to medical equipment or other equipment contacts, showing local tissue damage accompanied by pain . IntraopSlowikowski and Funk  showed tIt has been argued consistently that pressure ulcer risk assessment scales need to be developed based on multivariable analyses to identify factors that are independently associated with pressure ulcer development. Several tools have been developed for the formal assessment of risk for pressure ulcers. To evaluate the pressure ulcer, the Braden Pressure Ulcer Risk Scale was developed by Braden and Bergstrom in the United States in 1987 . He et aA third-level A hospital in Shanghai, China, and its intensive care unit (ICU) were selected for trial operation of the system in liver surgery. Likewise, cardiothoracic surgery ICU, neurosurgery ICU, operating room, and resuscitation room were also selected to collect data and evaluate the effect. All patients with hospitalization time greater than 24 h were included in this study, and patients undergoing day surgery were excluded.The system consists of adopting evidence-based nursing methods, raising nursing problems, searching literature, searching scientific basis, evaluating nursing evidence, combined with clinical nursing, and so on, formulating a data management system-based stress injury chain process. The pressure injury management of surgical patients is a care transfer chain, including the entire process “before surgery–during surgery–after surgery.” The transfer of patients involves multiple departments such as the ward, operating room, recovery room, and ICU. Therefore, the management of pressure injury in surgical patients is also a multisectoral process. In the process of multidepartmental information transmission, there may be inconsistencies in records such as evaluation, risk screening, and skin integrity, or due to lack of effective communication between departments, when considering the risk of stress injury, only current factors are considered, and some continuations are ignored such as sexual factors. Due to the different international scales for postadmission-preoperative-postoperative evaluation of patients, most of the current domestic information systems for stress injury only focus on one stage of the patient's hospitalization process or separate the evaluation records of the same patient according to different stages of hospitalization. For nurses in the operating room to understand the evaluation of the preoperative ward, they need to click on different links to inquire. The final form is also isolated. From the preoperative and intraoperative point of view, it is impossible for us to intuitively understand the admission of patients. We use the characteristics of complete information transmission in the information system to conduct a chain combination of the evaluation and records  of the departments involved in the preoperative-intraoperative-postoperative flow chain of surgical patients. The information can be displayed intuitively and accurately on the same interface, so as to realize multiteam cooperation in stress injury management.Evaluation: according to the different predisposing factors of pressure injury after admission and perioperative period of patients in the operating department, an appropriate scale is selected in a targeted manner that also includes the device-induced injury into the scope of the evaluation. By evaluating the predisposing factors of pressure injury and skin condition, patients with a high risk of pressure injury are screened out, as shown in High-risk intervention: based on the evaluation and screening results, evidence-based preventive skin management strategies are adopted for high-risk patients before, during, and after surgery. High-risk patients are included in the third-level monitoring system of the head nurse nursing department after reporting according to the system requirements. Using the information system, the reported status is divided into nine states (three high-risk prediction states and six occurrence states) according to the patient's high-risk situation. The structure model established in the background analyzes and calculates the reporting status and automatically jumps to the reporting status. The management interface realizes a three-level monitoring function, forming a summary of the jurisdiction area according to the identity of the user who login in and sorted and filtered according to requirements, which is convenient for management personnel at all levels to check bottom-up layer-by-layer reporting function and top-down monitoring and guidance function to realize interaction.Handover: patient stress injury management is a continuous process. During cross-departmental handover, the preoperative patient's skin condition, special circumstances, follow-up management suggestions, and precautions must be completely and correctly transmitted to establish a good interdepartmental relationship. This communication helps follow-up departments to accurately grasp the status of patients and take effective measures. In the handover link, the preoperative department and the operating room need to complete the preoperative high-risk factors and early warning of the patient. The postoperative operating room nurse will promptly hand over the patient's high-risk factors during the operation to the resuscitation room and subsequent departments. This can help nurses and managers analyze possible causes of injury and implement process improvements. The content that needs to be handed over is embedded in the nursing form through the information platform, and it can be saved after it is filled in completely. After the system completes the transfer of departments, the handover information is automatically displayed. After the receiving department completes the handover, it is confirmed on the information platform, and the handover process and content are standardized.Nursing: the nursing of pressure injuries in surgical patients is an ongoing process. The nurses in the follow-up department should correctly identify the pressure injury and ensure the continuous decompression of the compressed area; at the same time, within 24 hours after surgery, the surgical nurse should enter the ward and ICU for a return visit to assess the skin condition of the compressed area during the operation. In the event of a stress injury, the operating room should be notified in time, the adverse event should be reported, the cause analysis should be performed, the cause of the injury should be analyzed, and process improvement should be implemented. In the information platform, use of decompression pads, selection of reasonable supports, postoperative decompression methods, incision treatment, and other nursing measures are standardized and set for nurses to check. In the background monitoring, patients with postoperative pressure injury are screened out, and the pressure site during the operation is compared with the site where the pressure ulcer occurs, as one of the bases for confirming the pressure injury related to the operation; the postoperative pressure injury healing time is counted as a reference for the effectiveness of nursing measures. The occurrence of stress injuries is automatically included in the adverse event reporting system.The entire business chain of pressure injury care for surgical patients includes evaluation, high-risk intervention, handover, and nursing care. High-risk patients are screened out by evaluating the patients' pressure injury risk factors, and effective precontrol measures are taken to identify the patients' high-risk factors and follow-up. The management opinions are passed to the next link of the perioperative period, and the follow-up departments conduct predictive management and take personalized nursing measures. These processes are explained as follows.t-test, count data is expressed by frequency and percentage, and comparison between groups is by expressed by χ2 test and Fisher's exact test. The rank data is represented by rank-sum test. The difference was considered statistically significant when P < 0.05 and insignificant otherwise.SPSS 21.0 statistical software was used for data analysis. Measurement data are expressed in the form of mean ± standard deviation, comparison between groups is accomplished with the help of A third-level A hospital in Shanghai, China, was selected for data collection. For the trial operation of the system, patients with liver surgery, cardiothoracic surgery, neurosurgery and their ICUs, operating room, and resuscitation room were selected to evaluate the effect. The cluster sampling method was used to select 1,240 inpatients in the operating department as the research objects. Among them, 578 patients before the operation of the information platform were selected as the control group, and 662 patients after the operation of the information platform were chosen as the observation group. In the observation group, there were 451 males and 211 females with an average age of 52.1 ± 16.8 years. Among the 662 patients, 339 were surgical patients including 188 males and 151 females, with an average age of 50.6 ± 18.4 years and an average operation time of 3.5 ± 1.9 hours. The control group included 386 males and 192 females, with an average age of 50.2 ± 19.2 years. Among the total patients of the control group, 292 were surgical patients with 175 males and 117 females, with an average age of 52.4 ± 18.4 years and an average operation time of 3.6 ± 2.1 hours. There was no statistically significant difference in the general information of the two groups of patients, and they were comparable.The data about the control group was obtained by checking the medical record, and the observation group data was obtained by the information system. The different evaluation metrics for inpatients and surgical patients are discussed as follows.The qualified rate of the pressure injury evaluation sheet for inpatients = the number of qualified cases for the pressure injury evaluation sheet/the total number of cases for the examination evaluation sheet × 100%.The accuracy of screening and reporting high-risk pressure injury hospitalized patients = the actual number of reported cases of high-risk pressure injury hospitalized patients/the number of high-risk pressure injury hospitalized patients that should be reported × 100%.The accuracy of screening and reporting of patients with pressure injury = the actual number of reported cases of patients with pressure injury/the number of cases that should be reported for patients with pressure injury × 100%.The incidence of pressure injury in hospital = the number of new cases of pressure injury in the hospital during the cycle/total number of hospitalized patients in the cycle × 100%.The general evaluation indices for inpatients are computed as follows:The matching rate of the description of the skin condition of the surgical patient's transfer = the number of matching cases with the description of the skin condition of the surgical patient's transfer/the total number of patients undergoing inspection × 100%.Determining that the description of the skin condition of the transfer is consistent, the skin condition described in the skin assessment sheet record of the two departments at the time of the transfer is deemed to be consistent.The incidence of hospital pressure injury in surgical patients = the number of new cases of hospital pressure injury in surgical patients during the cycle/total number of surgical patients in the cycle × 100%.The incidence of stage 1 pressure injury in surgical patients = the number of new cases of stage 1 pressure injury in surgical patients during the cycle/total number of surgical patients in the cycle × 100%.The incidence of stage 2 pressure injury in surgical patients = the number of new cases of stage 2 pressure injury in surgical patients during the cycle/total number of surgical patients in the cycle × 100%.The specific evaluation indices for surgical patients are as follows:P < 0.05). The comparison of the accuracy rate of screening and reporting of high-risk pressure injury for inpatients in the operating department of the two groups is shown in P < 0.05). We compared the matching rate of skin conditions for different patients. The matching rate of the information platform was 91.4% before use and 100% after use, showing that the difference was statistically significant. While comparing the incidence of pressure injury in hospitals between the two groups of surgical patients, we found that the recognition rate of the information platform was 6.5% before use and 3.0% after use. We also compared the incidence of stage 1 pressure injury between the two groups of surgical patients. The incidence of stage 1 pressure injury before the use of the information platform was 5.8% and after the use was 2.7%, which shows that the results are statistically significant (With the increased focus on patient safety and quality of care, understanding how to prevent pressure injury has become a primary interest in acute care hospitals. This study is based on the data management system chain process of the surgical patient pressure injury information platform to achieve the full evaluation of patients from admission to discharge, identify high-risk patients, and timely implement intervention measures, in addition to the continuity of nursing measures through the improvement of handover links. A total of 578 patients were selected as CG, and 662 cases became the OG. The results of the two groups were compared in terms of matching rate, hospital pressure injury incidence, and incidence of pressure injury in surgical patients. The results showed that the proposed information management system can effectively improve the quality of evaluation documents, ensure the accuracy of screening and reporting, guarantee the correctness of skin handover, and reduce the incidence of pressure injuries. It is not only suitable for surgical patients but also widely used in the management of stress injuries for all hospitalized patients. It realizes the whole process and provides continuous, accurate, and dynamic evaluation and monitoring of patients' skin, which has certain application value. This work has important clinical significance for reducing the suffering of patients and improving the quality of life of patients.


Uncontrolled blood pressure (BP) increases the risk of major adverse cardiovascular events. In SPRINT an intensive versus standard BP lowering strategy resulted in a lower rate of cardiovascular events and death. Whether BP reduction only or also the choice of anti‐hypertensive drugs is associated with outcomes remains to be elucidated.We aim to study the association of BP and different anti‐hypertensive drugs with several cardiovascular outcomes.Time‐updated Cox and mixed‐effects models. The primary outcome was a composite of first myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death.p = .006), whereas a DBP <60 mmHg was independently associated with a higher event‐rate . SBP <120 mmHg was associated with lower rate of cardiovascular and all‐cause death on intensive treatment but not on the standard arm (interaction p < .05 for both).A total of 9361 patients were included. The anti‐hypertensive agents most frequently used were ACEi/ARBs, with an almost 20% higher prescription rate in the intensive arm (80% vs. 61%), followed by thiazide‐type diuretics (65% vs. 42%), calcium‐channel blockers (57% vs. 39%), and beta‐blockers (52% vs. 26%). Mineralocorticoid receptor antagonists were rarely used (≤7% of the observations). In multivariate analysis, the use of ACEi/ARBs, especially in combination with thiazides, were independently associated with a lower primary outcome event‐rate (HR [95%CI] 0.75 [0.61–0.92], In SPRINT, an intensive therapy strategy achieving SBP <120 mmHg with a DBP ≥60 mmHg, and using ACEi/ARBs plus thiazides was associated with a lower event‐rate. We hypothesize that both a targeted BP control and the more frequent use of certain medications might have contributed to the observed risk reduction in the intensive treatment arm.22.1ClinicalTrials.gov with the identifier: NCT01206062.SPRINT was sponsored by the NHLBI, with co‐sponsorship by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging. The rationale and protocol for the trial have been previously published and are publicly available.2 calculated with the use of the four‐variable modification of diet in renal disease equationTo participate in SPRINT, patients were required to meet all the following criteria: an age of at least 50 years, a SBP of 130–180 mm Hg, and an increased risk of cardiovascular events . The primary outcome effect was mostly driven by the effect on AHF  and CV death , without a statistically significant effect on MI/ACS or stroke.The primary outcome of the SPRINT trial was a composite of MI, other acute coronary syndromes (ACS), stroke, AHF, or CV death. Compared with a standard systolic BP target of <140 mmHg and intensive strategy with a <120 mmHg, reduced the primary outcome  based on their histogram distribution. Categorical variables are expressed as frequencies and proportions (%). Population description and comparison of patients with “events” versus “no events” was performed using independent samples t‐test for normally distributed continuous variables, Mann–Whitney test for skewed variables, and χ2 test for categorical variables. To select the baseline variables with the strongest outcome association to use in the multivariable adjusted models, we performed a multivariate stepwise (forward) model with the variables with a p value of <.1 from the Table p value <.05 to enter and stay the model. To attain log‐linearity, we categorized continuous variables in concordance with the prespecified categories of age, renal function, and albuminuria.p value of <.1 from the Table 2, urine albumin‐to‐creatinine ratio (UACR) >30 mg/g, prior history of CV disease and the use of three or more anti‐hypertensive (anti‐HT) drugs. This baseline model had a C‐index of 0.71 and was used for adjustment in all time‐updated multivariable models. Time‐updated models were performed using the BP measurements and anti‐HT drugs throughout the follow‐up adjusted on the baseline variables above described. An interaction term between the time‐updated variable and treatment assignment (intensive vs. standard) was tested for all the studied outcomes to assess whether the prognostic associations of BP would vary by treatment allocation. Similar analysis using the average BP throughout the follow‐up (instead of the time‐updated BP) was also performed. The average BP was computed for each studied outcome taking the BP measurements available prior to the outcome of interest. We have categorized the SBP in <120, 120–140, and >140 mmHg and DBP in <60, 60–90, and >90 mmHg based on the functional form  of the variable with regards to its association with the primary outcome and considering clinically relevant and readily applicable cutoffs. The individual anti‐HT drugs were retrieved from free text and grouped into clinically relevant categories: angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARBs), thiazide‐type diuretics, CCBs, beta‐blockers, mineralocorticoid receptor antagonists (MRAs), loop diuretics, central‐acting, and vasodilating drugs. There was only a small proportion of missing data (6.4%) in the adjustment variables that we have inputted using the mean or median of the variable (as appropriate) to avoid loss of statistical power and events. All analyses were performed with the Stata® software .In descriptive analyses, continuous variables are expressed as mean ± standard deviation (SD) or median (percentile33.1Patients who had a primary outcome event (n = 562) were older, more often male, white, and current smokers, had higher baseline SBP and lower DBP, had lower eGFR, lower HDL‐cholesterol, and higher UACR, they used a higher number of anti‐HT agents, statins and aspirin Table . The mea3.22), UACR (>30 mg/g), history of CV disease and use of three or more anti‐HT agents. Female sex was independently associated with a lower event rate (The baseline risk characteristics independently associated with higher primary outcome rate were older age (>75 year), current smoker, CKD , the anti‐HT drugs most frequently used were ACEi/ARBs, with an almost 20% higher prescription rate in the intensive arm (61% vs. 80%), followed by thiazide‐type diuretics, also with a near to 25% higher prescription rate in the intensive arm (42% vs. 65%). In consequence, the combination of ACEi/ARBs plus thiazides was used twice more frequently in the intensive arm (26% vs. 52%). Beta‐blockers and CCBs  were also used more frequently in the intensive arm . Centrally‐acting drugs and vasodilators were less often used, but more frequently in the intensive arm (7% vs. 14%). MRAs were used in low proportion, but with higher proportion in the intensive arm (4% vs. 7%). Loop diuretics were used at nearly similar proportions in both arms (6% vs. 7%). The use of three or more anti‐HT medications was much more frequent in the intensive arm than in the standard one , the use of ACEi/ARBs and thiazide‐type diuretics (or their combination) were associated with a lower primary outcome event rate, whereas DBP <60 mmHg, use of beta‐blockers and loop diuretics were associated with a higher primary outcome event rate . In multp for interaction =.001). A lower SBP was associated with a reduction in primary outcome events in the intensive but not in the standard arm. This differential impact on outcomes was even more marked for other end‐points . A lower DBP (<60 mmHg) was associated with a higher event rate regardless of the treatment arm (Table The association of lower SBP <120 mmHg) with the primary outcome varied according to the treatment group allocation, particularly the average SBP (20 mmHg wp = .076). For HF alone, a DBP <60 mmHg and the use of loop diuretics (in particular) were independently associated with a higher event rate, whereas the use of thiazides and the combination of ACEi/ARBs plus thiazides was independently associated with a lower event rate. For MI, a DBP <60 mmHg was independently associated with higher event rate, whereas the combination of ACEi/ARBs plus thiazides showed a tendency to be associated with a lower event rate (p = .055). For stroke a SBP >140 mmHg and a DBP <60 mmHg tended to be associated with a higher event rate . Loop diuretic use was not associated with an excess of MI nor stroke. For CV death alone, only the use of loop diuretics remained associated with a higher event rate. For all‐cause death, the use of loop diuretics and beta‐blockers remained independently associated with a higher rate; whereas the use of thiazides, ACEi/ARBs or their combination were independently associated with a lower rate  was associated with a lower event rate on the intensive therapy arm but not on the standard therapy arm where it was associated with a higher event rate. For the outcomes of CV death or HF, CV death, and all‐cause death, a statistically significant interaction of SBP‐by‐treatment allocation (intensive vs. standard) was observed . The combination of ACEi/ARBs plus thiazides was independently associated with a lower primary outcome event rate . Moreover, a lower SBP was associated with a lower event rates in the intensive therapy arm but not in the standard therapy where higher event rates were observed. This is a pattern often found in observational studies, likely reflecting a poorer condition of the patient rather than the BP effect itself, and strongly suggests a reverse causation effect.p = .081) despite the inherent loss of statistical power for the study of this outcome alone, suggesting that beta‐blockers were used more often in patients with coronary artery disease and angina pectoris . Thus, similar to loop diuretic use, an indication bias is likely present with beta‐blockers, and the association between beta‐blocker use and worse outcomes may be driven by their use in more severe patients.The use of loop diuretics was infrequent and not much different between the treatment arms (+1.8% in intensive); their association with adverse outcomes (incident HF in particular) suggests that these drugs were used essentially for congestion relief in the setting of HF (instead of BP control) which supports an indication bias. Similar observation could be found for beta‐blockers, that were used more often in the intensive arm (+9.4%) and were associated with a higher risk of primary outcome events (but not CV death) suggesting that these drugs might have been used for treating coronary artery disease, angina, and controlling heart rate in the context of arrhythmia, thus driving the primary outcome associations. Supporting this claim, the association of beta‐blocker use with MI/ACS remained similar as for the primary outcome  and had no impact on outcomes. Given the results of PATHWAY‐2 ,The use of a fixed combination of an ARB (candesartan) plus a thiazide (hydrochlorothiazide) has been tested in the HOPE‐3 (Blood‐Pressure Lowering in Intermediate‐Risk Persons without Cardiovascular Disease) trial,Importantly, the specific treatment choices were made by the treating physician and one cannot ascertain whether ACEi/ARBs are superior to CCBs or other agents from these non‐randomized data. However, the associations reported here are of clinical relevance, because they support the choices made by most clinicians when selecting the anti‐hypertensive treatments to give to their patients.4.1Several limitations should be acknowledged in the present analysis. First, this is a retrospective, non‐randomized and non‐prespecified analysis of a randomized controlled trial, hence the limitations inherent to observational reports are here applied. Importantly, we report associations and causation cannot be inferred from these analyses. Second, the results reported in the present analysis can only be generalized to patients with similar profile to those included in the SPRINT trial, particularly those without diabetes or stroke. Third, we were unable to determine whether the drug dose could influence the studied associations due to a high proportion of missing doses and probable value misassignment. Fourth, the direct and indirect effects of the BP and the anti‐HT treatment cannot be “mediated” due to a direct effect of the anti‐HT treatment on BP and the differential BP impact on outcomes in the intensive versus standard arms. By the associations found, both a lower SBP (if the DBP is kept above 60 mmHg) and the use of ACEi/ARBs/thiazide combination have a favorable outcome impact. Fifth, SPRINT was an open‐label strategy trial, where patients in the intensive arm had more medical visits which might have influenced the trial results in favor of the intensive arm. Lastly, most patients that participated in SPRINT were White, and these findings may not be generalizable to other populations of hypertensive patients.5In SPRINT, an intensive therapy strategy achieving a SBP <120 mmHg with a DBP ≥60 mmHg, and using ACEi/ARBs plus thiazides was associated with a lower event rate. These findings may help guide BP goals and choosing anti‐hypertensive treatments in patients with HT without diabetes.The authors have no conflicts of interest to report regarding the content of this manuscript. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH), the Department of Veterans Affairs, or the U.S. Government.Table S1. Average blood pressure during the follow‐up and its changes from first to the last visit.Table S2. Association of baseline variables with the primary outcomes in univariate and multivariate analyses.Table S3. Time updated univariate analysis for the primary outcome.Table S4. Multivariable outcome associations (for outcomes other than the primary).Table S5. Adjusted association of systolic blood pressure with outcomes on standard and intensive groups, separately.Click here for additional data file.


Sustained control of blood pressure, is dependent on degree of self-management, which includes self-integration, self-regulation, self-monitoring and adherence to regimen. We assessed the pattern of self-management of hypertension among adult hypertensive patients in a developing country.Cross-sectional study design and convenience sampling, was used to recruit adult hypertensive patients, attending Lagos State University Teaching Hospital, Lagos, Nigeria. Interviewer-administered questionnaire was used to obtain data on self-management components. SPSS version 21.0 was used to analyze data, with p-value set at 0.05.One hundred and seven (107) respondents, had mean age of 49.0 ± 12.0 years. Mean value for self-management was 3.15 ± 0.55, comprising self-integration (3.06 ± 0.36), self-regulation (3.32 ± 0.63), self-monitoring (3.29 ± 0.84) and adherence to regimen (3.15 ± 0.55). Most components of self-management, had high levels of mean score. Respondents that were less than 40 years, compared with those that were more than 40 years, had greater mean values for self-integration (3.37 vs 3.05), but significantly lesser values for all other components (p < 0.05).Young hypertensives had poor levels of most components of self-management. There is urgent need for health educational programs on self-management of hypertension among young people in sub-Saharan Africa. Hypertension is a silent killer, and leading cause of morbidity and mortality globallyUnfortunately, there is yet no cure for essential hypertension, which is the most common form of the chronic diseaseKey aspect of patient involvement in self-management of their disease, is the integration of dietary, physical exercise, stress management and other lifestyle changes into their daily livingThere are objective means of assessing these components of self-management of hypertension using structured questionnaire8. Mean scores and levels can be obtained for each component, and compared across timeframes for effective patient management, or between study populations in diverse global settings8. In a survey among hypertensive patients in Bangladesh, moderate levels of each component of self-management was found, with overall mean value of 2.55 ± 0.479. These levels reflect behaviours related to self-management, and may be useful for monitoring and follow-up care of patients. A facility-based cross-sectional study of self-management behaviors among hypertensive patients in Egypt, found 56.7% prevalence of negative behaviors towards hypertensionUnfortunately, there is paucity of research on self-management of hypertension in Nigeria, which has one of the highest burden of cardiovascular diseases in sub-Saharan Africa2, where N is estimated monthly clinic uptake of 125 hypertensive patients, e is error margin of 0.05 and assuming a non-response rate of 10%. Consenting adult hypertensive patients that were at least 20 years old were eligible to participate. Patients that had been diagnosed of hypertension within 12 months were excluded. Also, patients with confirmed diagnosis, as well as those that were being investigated for secondary hypertension were excluded from the study. Patients who were healthcare professionals were excluded from participating.Cross-sectional study design was utilized, and respondents were recruited by convenience sampling from Lagos State University Teaching Hospital (LASUTH), Lagos, Nigeria. Sample comprised attendees of medical out-patient clinic LASUTH, who had been diagnosed of hypertension. Sample size of 106 was calculated using Yamane formulaPretested, interviewer-administered, structured questionnaire, was used to obtain quantitative data, on respondents' socio-demographic variables, the patterns and factors associated with self-management of hypertension. Questionnaire used in this study, was an adaptation of the validated tool used for assessment of self-management of diabetesSPSS was used to enter and analyze data. Frequency distribution of responses to each of the questions was presented in tabular form. Score of 1, 2, 3 and 4, were allocated to ‘never’, ‘rarely’, ‘sometimes’, and ‘always’ Likert scales, respectively. Questions that imply inappropriate practice such as questions 5 and 10 were reverse-scored. Responses to each item was scored, with mean scores obtained for each component, and overall mean score for self-management. Mean scores were categorized into low, moderate, and high levels of self-managementcorresponding to 1.00–2.00, 2.01–3.00, and 3.01–4.00, respectively. Independent t-test and Analysis of Variance (ANOVA), were employed as inferential statistics, to compare mean scores between categorical variables. P-value was set at 0.05. Ethical approval was obtained from the research ethics committee, of Lagos State University Teaching Hospital, Nigeria. Informed and written consent was obtained from respondents before data collection.One hundred and seven (107) respondents gave complete data, with mean age of 49.0 ± 12.0 years ranging from 20 to 69 years. Female: male ratio was 1.2:1, and most respondents (77.6%) were 40 years or older . Eighty-This is one of few studies that assessed pattern of self-management of hypertension in Nigeria, which has one of the highest burden of the chronic disease globally. Unlike the few previous studies in Nigeria, this study assessed each component of self-management among wider age-range of hypertensive patients, including young people who now constitute more than two-thirds of the nation's populationExcept for few notable areas in each component, self-management of hypertension was generally satisfactory in this study. This finding may be due to years of exposure to passive and active health education and counselling in the study area, where patients have been reported to be quite satisfied with care given towards their blood pressure controlMost respondents did not consider hypertension to be part of their lives. In other words, there was high prevalence of non-acceptance of the philosophy of lifelong nature of essential hypertension. This position by respondents, may result from their level of spirituality or belief in possibility of cure for the chronic disease some time sooner or later during their life-course, especially with use of complementary and alternative medicineThis study found poor attitude and practice of salt consumption, among significant proportion of respondents. This practice may potentially reverse gains obtained from beneficial lifestyle modifications. In other words, the high blood pressure effects of excessive salt intake, may neutralize beneficial blood pressure lowering effects of regular exercise, proper dietary habits and stress management. Therefore, excessive salt consumption, may be the singular reason for poor blood pressure control, despite adherence to medications and practice of other lifestyle measuresSelf-integration was found to be significantly better among females compared with males. In other words, female hypertensive patients are better at ensuring practice of preventive measures of proper diet, exercise, and stress management, compared with males. This finding suggests that females may be more conscious of the beneficial effects of these measures, as well as severity of non-compliance, in tune with health belief model of health behaviour. Added benefit of potentially better cosmetic looks from weight loss or maintenance and appropriate diet and other lifestyle modifications, may be more appealing as incentive for females compared with malesDuring collection of data on self-monitoring component, the symptoms suggestive of high and low blood pressure were described to respondents. Most respondents reported recognizing and managing themselves or knowing what to do, when they had these symptoms. However, considering that these symptoms are quite non-specific, the responses may not be considered sufficiently reliable. Yet, while their report of recognition and knowing what to do may appear satisfactory, it may suggest poor control of blood pressure. Well controlled blood pressure, should be devoid of symptoms of high blood pressure. These symptoms may occur due to poor timing of intake of prescribed antihypertensive, as well as potential interaction of the medications with diet, and the influence of other daily activitiesAdditional finding in this study was significantly lower mean values of all components of self-management among respondents that were within 40 years old, compared with those that were older. This suggest poor attitude and practice of preventive measures among younger hypertensive patients. Their potential surprise and stigma due to relatively early diagnosis, belief in its reversibility, and perception of bleak future health status, may all contribute to inconsistencies in initial adoption of preventive measuresThis study has notable limitations. Sample size of 107 hypertensive patents may be quite small and therefore not representative of general population of hypertensive adults in the study setting. Considering that data collection was through interviewer administration of questionnaire, there is possibility of social desirability bias in response to smoking and drinking status. Hence, the true proportion of smokers and drinkers may have been higher than reported in this study. Responses to some questions assessing self-regulation and self-monitoring may also have been under-reported or misunderstood, warranting caution in interpretation of findings, especially for items 12, 27 and 29 (tables 2 and 3). For instance, though trained research assistants provided examples of symptoms suggestive of uncontrolled hypertension and hypotension to enable appropriate response, these symptoms are quite non-specific. Besides non-specificity, there may be differential non-response bias in response, comparing respondents who truly had, and those who did not have these symptoms. Yet, these statements are generally acceptable and validated (though subjective) means of assessing for degree of self-monitoring of chronic cardiometabolic diseasesThis study found high level of self-management of hypertension overall, and for each of the components, except for interaction with professionals, which was within moderate level. Despite this generally satisfactory level of self-management, young people within 40 years, had poor levels of all components of self-management. There is also poor attitude and practice ofalt consumption, which may potentially reverse gains in practice of other preventive measures. These findings have implications for prevention and control of the increasing trend in burden of disease due to hypertension even among young people in developing countries. Other sociodemographic characteristics including gender, level of education and occupation were not associated with self-management and its components.


Chronic kidney disease (CKD) is associated with an increased risk of the progression of coronary artery disease (CAD). However, there are few data on the relationship between CAD severity and the duration of CKD. This study assessed the predictive value of the duration of kidney dysfunction in CKD patients with CAD severity.n = 92; mean age, 68.8 ± 12.8 years) with CKD, severity of CAD was assessed by coronary angiography and quantified by SYNTAX scores, and duration of kidney dysfunction was either assessed by checking historical biochemical parameters of individuals or was based on enquiries.In 145 patients  had a greater prevalence of cardiovascular risk factors including age, gender, history of heart failure and smoking. In CKD patients, SYNTAX scores were positively correlated to duration of CKD and serum uric acid (UA), and negatively correlated to high-density lipoprotein-cholesterol (HDL-C) and ApoA1 levels. Univariate binary logistic regression and multivariate logistic analyses showed that SYNTAX scores correlated significantly with CKD duration, UA, and HDL-C. Receiver-operating characteristic analysis was used to explore a time point when coronary angiography application was economical and effective and yielded a Youden index of 6.5 years.Together, our results demonstrated that the duration of kidney dysfunction was an independent correlate of the severity of CAD in patients with CKD. Our findings suggest that coronary angiography should be considered for CKD patients with renal insufficiency having lasted for more than 6.5 years. Chronic kidney disease (CKD) is reported to accelerate cardiovascular disease (CVD), and CVD is major cause of death in CKD patients . In CKD,via several mechanisms. Along with the classical risk factors of hypertension, dyslipidemia, smoking, diabetes mellitus, and aging [CKD accelerates CAD nd aging , CKD-spend aging . In addind aging .However, it remains unclear how coronary plaques progress over time in CKD patients. The clinical diagnosis of CAD in CKD patients is challenging, as these patients do not demonstrate typical symptoms or electrocardiogram (ECG) changes. Additionally, CKD patients are hesitant to receive coronary angiographies because of potential adverse renal effects of contrast agents. As a result, CKD patients may miss the optimal time for interventional diagnosis and therapy of CAD, resulting in a higher cardiovascular morbidity and mortality.To better understand how renal function influences coronary plaque progression, the present study investigated the relationship between clinical parameters and the severity of coronary lesions. Here, we introduced SYNTAX scores as a quantitative index for coronary artery disease. The SYNTAX score is a comprehensive angiographic scoring system that was initially designed to quantify CAD lesions based on the location, complexity, and functional impact . Further2 for three months or more) admitted to the Rui Jin Hospital in Shanghai, China, between January 2013 and December 2018. GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula [n = 53), chronic glomerulonephritis (n = 34), chronic interstitial nephritis (n = 11), polycystic kidney disease (n = 3), and other/unknown renal diseases (n = 44). The protocol in this study was approved by the institutional ethics committee of Ruijin Hospital (ID: 2020-152), Shanghai, China.The study population comprised 145 patients with CKD (defined as glomerular filtration rate (GFR) < 60 mL/min/1.73 mBody mass index (BMI) was calculated based on the height and weight of each patient. Hypertension was defined as either having a blood pressure ≥ 140/90 mmHg from at least two measurements, or the active use of an antihypertensive treatment. A history of smoking was defined as a patient reporting a history of active smoking within the last six months. Venous blood samples were collected from all patients in the morning after an overnight fast. Biochemical parameters were measured by standard laboratory procedures  and included the following: creatinine (CRE), urea nitrogen (BUN), uric acid (UA), albumin (ALB), white blood cells (WBCs), platelets (PLTs), hemoglobin (Hb), alanine aminotransferase (ALT), aspartate aminotransferase (AST), triglycerides (TGs), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), bilirubin, calcium, phosphate, C-reactive protein (CRP), fasting glucose, and B-type natriuretic peptide (BNP).Two methods were used to assess the duration of kidney dysfunction in each patient. First, the duration of kidney dysfunction was assessed and calculated by checking the historical biochemical parameters of patients. Second, each patient was asked how many years earlier he/she had been diagnosed with kidney dysfunction.a ≥ 50% diameter of stenosis in vessels with a segment length >1.5 mm using the SYNTAX score algorithm available on the SYNTAX website (www.syntaxscore.com) [All patients underwent coronary angiographies through the radial artery using the Judkins technique. Each coronary artery was displayed on at least two different planes. All coronary angiograms were recorded on compact disks in DICOM format and were assessed independently by two experienced interventional cardiologists who were blinded to the study protocol and patient characteristics. In the case of disagreement, the opinion of a senior interventional cardiologist was sought, and the final decision was made by consensus. The SYNTAX score for each patient was calculated based on all coronary lesions with ore.com) ,17.t-tests were used for the comparison of continuous variables while Chi-square tests were used for the comparison of categorical variables. Spearman and Pearson tests were used to evaluate correlations between SYNTAX scores and other variables. Multivariate logistic regression analysis was used for multivariate analysis of independent variables. Receiver-operating characteristic (ROC) analysis was used to determine the cutoff value of CKD duration in the prediction of high SYNTAX scores (≥ 22). A value of p < 0.05 was considered statistically significant.Data were analyzed using SPSS 13.0 . Continuous variables are presented as the mean ± standard deviation (SD), whereas categorical variables are presented as percentages. The total group of patients was dichotomized based on SYNTAX scores  for descriptive and analytical statistics. The missing data of each variable comprised less than 5% of all data, and listwise deletion was applied when data were analyzed. Student’s p = 0.025) and lower HDL-C (p = 0.021) and Apo A1 (p = 0.018). In contrast, there were no significant differences in any other biochemical characteristics between the two groups. Of note, GFR was not a strong predictor of higher SYNTAX scores in the present study and conflicted with a previous study [1 p = 0.0. In contβ = 0.378, p < 0.001), UA , and HDL-C . In unadjusted analysis, CKD duration and SYNTAX scores were positively correlated (The results of univariate binary logistic regression and multivariate logistic analyses to predict the severity of CAD in CKD patients are listed in rrelated . Accordirrelated .Studies show that coronary severity is associated with CKD. To the best of our knowledge, a relationship between the severity of CAD and the duration of CKD has not been reported previously. In this retrospective study, we introduced SYNTAX scores as a quantitative index for coronary artery disease. We showed that SYNTAX scores were significantly associated with CKD duration, UA, and HDL-C. Our results revealed that long-term CKD was a strong predictor of higher SYNTAX scores. ROC was used to explore a time point and yielded a Youden index of 6.5 years. Thus, for patients with a history of renal insufficiency of 6.5 years or longer and clinical symptoms related to CAD, coronary angiography should be considered.CKD is closely related with CVD ,20. It iGiven the high prevalence of CAD in patients with CKD, it is paradoxical that the diagnosis and treatment of CAD in these individuals is low. The universal determination of CAD has only a limited application in patients with CKD. Chest discomfort and ECG abnormalities may not reflect CAD, and CKD patients may have chronic baseline increases in specific cardiac biomarker levels . Thus, mOur present study also showed reduced HDL-C and elevated serum UA levels to be important risk factors for the aggravation of atherosclerosis. HDL-C plays a protective role against developing CAD in several ways. ApoA1 is a primary protein constituent of HDL in plasma. Studies showed that HDL reduced oxidative damage and inflammation, enhanced endothelial function, removed excess cholesterol from macrophages, and exerted protective effects on angiogenesis and glucose homeostasis ,36. UA, Our present study had several limitations. First, the etiology of CKD in each patient was unclear, and few diagnoses were confirmed by renal biopsy. Second, the duration of kidney dysfunction was largely obtained from enquiries, which may have caused data inaccuracy. Third, this was a single-center retrospective case study based on a relatively small number of patients in China. Despite these limitations, our study demonstrated, for the first time, that the duration of kidney dysfunction was associated with atherosclerosis severity in patients with CKD, as determined by coronary angiographies and SYNTAX scores. Taken together, our findings may help to better understand the relationship between CKD and CAD and provide clinical insight for the treatment of CAD in CKD patients. Further research is needed to identify whether angiograms in all patients with CKD of 6.5 years is beneficial in a prospective fashion.


Backgroundγt+Foxp3+ dynamics in acute kidney injury (AKI) and chronic kidney disease (CKD).The role of T-regulatory cells (Tregs) in inflammatory renal disease is not yet established. We attempted to study peripherally circulating T-cells expressing RORAimTo determine the role of T-regulatory cells in AKI and CKD.Research methodology This is a cross-sectional study conducted between January 2019 to January 2021 at a single tertiary care centre in Pune, India. Candidates enrolled in the study were either patients with CKD not on maintenance hemodialysis or newly diagnosed cases of AKI. Kidney transplant recipients, patients with autoimmune diseases like systemic lupus erythematosus (SLE), IgA nephropathy, or those receiving immuno-suppressants were excluded. T-lymphocytes were analyzed using a flow cytometer. Resultsγt:Foxp3 was ≤ 1 in these individuals (control group) while this ratio was significantly altered (MFI RORγt:Foxp3 ≥1) in the AKI/CKD study arm. We examined peripherally circulating T-lymphocytes in acute kidney injury and chronic kidney disease, comparing their activity to healthy volunteers. Biopsy-proven kidney injury patients (29/80) were also included in this study. We found that the ratio of RORγt:Foxp3 was altered in patients with kidney injury (acute and chronic) and was statistically significant compared to controls, indicating that injury may be attributed to T-cell dysfunction. We studied 80 patients with kidney injury, 40 each belonging to the AKI and CKD study groups and 10 healthy volunteers as controls. The rationale behind having a small control group was to merely get an idea of T helper 17 (Th17):Treg ratio and different immune cell-phenotype profiles in healthy volunteers without kidney injury, diabetes, hypertension or any other risk factors. The ratio of RORConclusionOur study provides some evidence of T-cell dysfunction in the pathology of kidney injury in acute and chronic kidney disease via activity of Foxp3 and RORγt. We found that there is evidence of altered Th17/Treg activity in kidney injury, more prevalent in acute than chronic, when compared to healthy volunteers. The kidney is a highly vascular organ, vital for maintaining internal homeostasis via removal of toxins from the blood. Its anatomical structure and function render it vulnerable to a variety of immune, and non-immune mediated injury.Kidney disease is a heterogeneous group of disorders affecting its structure and/or function. Inflammation contributes to a myriad of acute and chronic diseases affecting the kidneys. Duration of more than three months is defined as chronic, while duration of three months or less is termed as acute. There is a complex relationship between acute kidney injury (AKI) and chronic kidney disease (CKD); AKI can lead to CKD, and CKD increases the risk of AKI .The immune system is designed to guard the body against pathogens and other harmful signals. T-regulatory cells (Tregs) play a crucial role in several inflammatory phenomena, including those in the kidney . Tregs pBi-functional Tregs (biTregs) are cells that express both Th17 transcription factor retineic-acid-receptor-related orphan nuclear receptor gamma (RORγt) and Treg-inducing transcription factor Foxp3 . In factIt is thus fascinating to hypothesize that cells expressing both of these transcription factors, Foxp3 and RORγt, play an important role in inflammatory kidney disease. Thus given the clinical implications, it was decided to study peripherally circulating T-cells expressing RORγt+Foxp3+ dynamics in AKI and CKD.Our study was a single-center, cross-sectional study conducted between January 2019 to January 2021. This study was in accordance with the principles of the Declaration of Helsinki and good clinical practice, along with the institutional regulatory guidelines. After seeking approval from the institutional ethical committee of Dr D.Y Patil Vidyapeeth, Pune , patients who presented with acute kidney injury or chronic kidney disease, either to the out-patient department or hospitalised in the ward or critical care unit of Dr D.Y Patil Hospital, Pune, were studied. The study population was divided into three arms, healthy volunteers, AKI and CKD. Patients aged 18-65 years, both male and female were evaluated and categorized according to the aforementioned study arms. AKI and CKD were defined by the AKIN (Acute Kidney Injury Network) criteria  respectiWe excluded kidney transplant recipients, patients with autoimmune kidney disease or those taking steroids or other immunosuppressive agents. HIV, hepatitis B surface antigen (HBsAg) or hepatitis C virus (HCV)-positive candidates were also not included in our study. None of the candidates included in the study had active tuberculosis. Patients with solitary kidney  and with AKI having bilateral kidney size < 8cm in longitudinal axis as seen on sonography were also dropped out.Individuals who did not give written consent to participate in the study were debarred. All candidates underwent ultrasonography of the abdomen, routine blood and urine investigations like hemogram, serum urea, creatinine, HbA1c, dipstick urine routine, microscopy, urine protein creatinine ratio (UPCR). A 3ml sample of blood collected in EDTA bulb was subjected to Ficoll gradient method for making a single cell preparation of peripheral blood mononuclear cells (PBMCs). After extracting T-lymphocytes, they were analysed with a flow cytometer with appropriate instrument setting. Reports from the flow cytometer were received in the format given in Figure Clinical data from the case record proforma which included medical history, physical examination, laboratory and radiological investigations were compiled on MS Office Excel Sheet  and was subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) version 26 . Inter-group comparison of data (two groups) was done using t-test, whereas comparison of more than two groups was done using ANOVA followed by pair-wise comparison using post hoc test. Chi square test was used for comparison of frequencies of categories of variables with groups. For all the statistical tests, p<0.05 was considered to be statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study as 80%. A p<0.01 was interpreted as statistically highly significant whereas p>0.05 was not significant.We studied 80 patients with kidney injury, 40 with acute kidney injury and 40 patients with chronic kidney disease. Ten healthy volunteers were included as controls. The rationale behind having a small size of control group was to gain clarity regarding T-cell activity in health i.e to get an idea of Th17:Treg via RORγt:Foxp3 activity and T-cell phenotypes profile in individuals without diabetes, hypertension, pre-existing kidney injury or any other risk factor or health ailment. The ratio of mean fluorescence intensity (MFI) RORγT:FoxP3 activity was found to be ≤1 in the controls of our study population whereas this ratio was ≥1 in the kidney injury group. This helped us strengthen our hypothesis. A total of 60 men and 20 women with kidney injury were evaluated. The age distribution of the study population is depicted in Figure 27.5% of patients with both acute and chronic kidney injury were in their fourth decade of life, whereas 15% of patients were between 20 - 30 years and 12.5% of patients belonged to the 61-70 years age group. Fifty-two percent of the study population had hypertension. Nineteen of 40 patients with AKI and 28 of 40 patientswith CKD included in the study were hypertensive. Thirty percent of the patients included in the study were diabetics. Figure AKI study armInfections, especially urinary tract infections (UTIs) and sepsis, were the major cause of AKI in our study population (40%), followed by drug induced nephropathy. Fifteen percent of patients in the AKI study arm had kidney injury due to nephrolithiasis with obstructive uropathy. The other causes of AKI in our study were snake bite, dehydration and cardio renal syndrome. Seventy percent of patients with AKI belonged to stage 3 of the AKIN criteria whereas only 15% of patients with AKI belonged to stage 1 and 2 each.CKD study armThirty-two percent of the CKD study arm had diabetic nephropathy as the primary cause of chronic injury followed by chronic glomerulonephritis. Other causes of CKD were long standing obstructive uropathy, non diabetic kidney disease, crescentic glomerulonephritis, cast nephropathy, and CKD of unknown origin.Based on eGFR (CKD-EPI), 2012 KDIGO classification, CKD patients were distributed into five stages, of which the maximum (52.5%) patients belonged to CKD stage IV (G4). 32.5% were found to have CKD-V (G5) and 15% had CKD IIIb (G3b). Incidentally, no patients in the study belonged to CKD stage G1, G2, or G3a.Significance of RORγt and Foxp3 CD4 cells in kidney injuryRORγt is one of the master regulators in the development of Th17 cells. Dellepiane et al. demonstrated that Th17 are the most abundant kidney infiltrating-lymphocytes following AKI in mice. In our study, MFI RORγt values in the AKI study arm when compared to healthy volunteers and CKD patients were found to be statistically significant (p<0.01). Similarly the ratio of RORγt:Foxp3 was also statistically significant for the AKI study arm, as seen in Table Regulatory T cells can co-express RORγt and Foxp3 and are shown to be both pro-inflammatory and immunosuppressive. There is a counterbalance between pathogenic (Th17) T cells that induce autoimmunity and regulatory (Foxp3+) T-cells that inhibit autoimmune tissue injury. MFI Foxp3 was higher in the CKD study arm, making it statistically significant, on comparison, with healthy volunteers and the AKI study arm. There was a statistically non-significant difference (p>0.05%) seen between healthy volunteers, AKI and CKD study arm for CD4% cells. In the post hoc analysis Table  it was fSince 30% of our study population had diabetes, we compared their T-cell activity with non-diabetics. Interestingly the RORγt and Foxp3 activity was statistically insignificant in diabetic patients with kidney injury in our study.Despite the various advances in health care, kidney transplant remains to be the cornerstone for end stage renal disease. With the shortages in donor organs, most of these patients rely on hemodialysis, with a limited success in improving survival. Kidney injury requiring either kidney transplant or hemodialysis add to the global health and financial burden. In the present study, we attempted to test experimental hypothesis   of the rOur study population concentrated on acute and chronic kidney disease, excluding kidney injury secondary to autoimmune diseases like systemic lupus erythematosis, scleroderma or IgA nephropathy and also kidney transplantation recipients or those already receiving immuno-suppressants. Various studies suggest that the immune system is activated after kidney injury. We studied peripherally circulating T-lymphocytes in acute kidney injury and chronic kidney disease , comparing them to healthy volunteers. Blood collection for T-cell analysis was done prior to administering any medications (example - immuno-suppressants) or before subjecting them to renal replacement therapy . To emphasise regarding the frequency of blood sampling, T-cell analysis was done on a one-time blood sample only. Follow-up or post-treatment analysis of T-cells was not done due to financial constraints. Patient care and management were not affected by this study.We found that the mechanism of acute kidney injury may be explained by T-cell dysfunction - Tregs/Th17. The balance between RORγt and Foxp3 may modify the course of disease. Further studies will be needed to analyze whether these molecules can be used as markers for prognostication in treatment course. Likewise, therapies focusing on regulating the function of Tregs and inhibiting pro-inflammatory cytokines may help in reversal of acute kidney injury. AKI remains to be a major risk factor for chronic kidney disease. Similarly multiple acute hits to the kidneys in a patient with pre-existing chronic kidney disease may further decline its function. Hence timely diagnosis and intervention is crucial to reduce the eventual burden of CKD.Studies focusing on specific patterns of AKI would give us a clear understanding of the underlying pathological processes causing injury. In order to attribute kidney injury to T-cell dysfunction, data of 29/80 patients Figure  with kidIn an observational study by Zhu et al. in 2018 , it was LimitationsOur study was limited to a small sample size. During data collection and analysis, we realized, that this study would be of great importance to clinicians if Tregs were also analysed post recovery in AKI. Just like a routine hemogram is a great tool for clinico-pathological correlation, tracking the T-cell profile of an individual in health and disease would be useful to the treating physician. Although we have computed regular follow-up of the patients with kidney injury included in this study, in terms of survival and resolution or progression of renal function, data was insufficient to correlate "one-time" test values of Treg activity (via Foxp3 or Rorγt) to predict patient outcome. Hence whether serial monitoring of Treg activity to assess prognostication of kidney injury would be valuable to know with further follow-up studies.Future work should identify whether clinical application of quantitative or qualitative Tregs in various types of kidney disease would modify the course of disease and play a crucial role in management and reversal of kidney injury in the early stages.Our study favours the hypothesis of the role of T-cell dysfunction in kidney injury (acute and chronic kidney disease) via activity of Foxp3 and RORγt. We found that there is evidence of altered Th17/Treg activity in kidney injury, more prevalent in acute than chronic, when compared to healthy volunteers. We suggest studying urinary cytokines along with simultaneous analysis of T-cells in blood and on kidney biopsy to establish the role of T-cells in kidney injury. Further studies are needed to investigate the trends of T-cell activity with disease severity and progression of kidney injury in the clinical scenario.


Hypertensive patients can freely choose informal medical facilities, such as pharmacies, community health service centres, and cardiology clinics in secondary or tertiary hospitals, as routine places for medical treatment in China currently. The proportions, influencing factors and effects of different health-seeking behaviours on blood pressure (BP) among hypertensive patients in urban communities are not clear. The aim of the study was to investigate health-seeking behaviours and the effects of different health-seeking behaviours on BP among hypertensive patients in urban communities in China.A cross-sectional survey of hypertension was conducted in urban communities in Chengdu. A total of 437 hypertensive patients seeking medical help regularly were sequentially enrolled to complete a the questionnaire on health-seeking behaviours.P = 0.100), respectively. The SBPs were 145.1 ± 18.0, 150.9 ± 19.8, 143.8 ± 17.5 and 136.3 ± 15.1 mm Hg (P = 0.007), respectively, and it was significantly lower in the combined management group than in the other three groups. Compared with patients choosing community health service centre, patients in the combined management group had a significantly lower BP level  adjusting for age, sex, education level, establishment of chronic disease archives, medication adherence and number of antihypertensive drugs.The average age was 67.1 ± 7.5 years old. The control rate of BP was 41.0%, and the systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 144.2 ± 17.9 mm Hg and 75.4 ± 10.4 mm Hg, respectively. Among the hypertensive patients investigated, 62.8% chose community health service centre, 5.2% chose informal medical facilities, 21.5% chose cardiology clinics in secondary or tertiary hospitals, and 10.5% chose both community health service centre and cardiology clinics as the usual places for medical treatment. There were significant differences in education levels, proportions of home BP monitoring, establishment of chronic disease archives in the community, medication adherence and side effects of drugs among the four groups. The control rates of BP were 39.4%, 23.8%, 43.0% and 54.8% (Combined management with both community health service centre and higher-level hospitals can decrease BP. Hypertension is a common cardiovascular risk factor that can cause damage to the heart, brain and kidneys and can give rise to the occurrence of cardiovascular events, such as heart failure, stroke and renal failure. Decreasing blood pressure (BP) to the target can greatly reduce the incidence of cardiovascular events in patients with hypertension , 2. HypeConducting health management in hypertensive patients relying on the community health service centres is an important part of basic public health services in China. Patients with hypertension were advised to establish chronic disease archives and be followed up in the community health service centres according to the guideline . StandarTherefore, we conducted an investigation of the health-seeking behaviours among hypertensive patients in an urban community in Chengdu, a central city in western China, to determine the health-seeking behaviours of hypertensive patients and the influencing factors and to reveal the effects of different health-seeking behaviours on BP.We conducted a cross-sectional survey of hypertension in residents older than 18 years old through door-to-door visits and registration in community activity centres using a random cluster sampling method in 5 randomly selected urban residential communities in Chengdu belonging to the same community health service centre in 2011–2012. As shown in Fig. Basic information included name, age, sex, currently smoking, education level, combined cardiovascular diseases, duration of hypertension, performing home BP monitoring, establishment of chronic disease archives, medication adherence, side effects of drugs, antihypertensive drugs and medical insurance reimbursement. Health-seeking behaviours referred to patients' different choices of medical treatment places. For physical examinations, the patients were asked to sit for at least 5 min, and then 3 consecutive BP readings were recorded from the supported right arm at one-minute intervals using validated OMRON HEM-7200 sphygmomanometers  Co., Ltd, China). The BP was calculated as the average value of the three measurements. The other anthropometric data, including height, weight and waist circumference, were measured as before . Blood t2 (kg/m2). Obesity was defined as BMI ≥ 28 kg/m2 or waist circumference ≥ 90 cm for men and ≥ 85 cm for women [Hypertension was defined as the calculated average systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg or taking antihypertensive drugs . Body maor women , 17. SmoPatients with hypertension were divided into four groups according to the different places that they chose for medical treatment. Group 1 consisted of patients choosing community health service centre as the usual place for medical treatment; group 2 consisted of patients choosing informal medical facilities without physicians in attendance, such as pharmacies, as the usual places for medical treatment; group 3 consisted of patients choosing the cardiology clinics in secondary or tertiary hospitals as the usual places for medical treatment; and group 4, named the combined management group, consisted of patients choosing both community health service centre and higher-level hospitals as the usual places for medical treatment. Descriptive data are presented as the means  and proportions. The F test was used for comparison of the characteristics among the 4 groups, and the LSD test was used for pairwise comparisons between groups. Comparison of categorical variables among 4 groups was evaluated with the Pearson’s χ2 test. The influences of different health-seeking behaviours on the BP control rate and BP level were further analysed using logistic regression analysis and linear regression analysis respectively by taking different groups as categorical variables and group 1 as a reference. The adjusted model was conducted adjusted for age, sex, education level, establishment of chronic disease archives, medication adherence and number of antihypertensive drugs. The SPSS software package  was used to conduct the statistical analysis. Statistical significance was defined as P < 0.05.The average age of the hypertensive patients investigated was 67.1 ± 7.5 years old, 46.5% of whom were male. The average duration of hypertension was 10.1 ± 8.7 years. The total control rate of blood pressure was 41.0%, and the SBP and DBP were 144.2 ± 17.9 mmHg and 75.4 ± 10.4 mm Hg, respectively. Among the participants, 18.3% had a cultural degree of primary school or less, 43.2% had a junior high school education, and 38.5% had a high school level of education or more, and the proportion of smoking was 9.0%. A total of 43.4% of the participants were diagnosed with obesity and 22.0% were diagnosed as having diabetes. 66.3% performed home BP monitoring, 75.5% established chronic disease archives in community health service centre, 85.0% had good medication adherence, 22.5% had side effects of antihypertensive drugs, and 60.8% could receive partial reimbursement.The proportions of different health-seeking behaviours were shown in Table P = 0.100). Table The control rates of BP in the four groups were shown in Fig. P = 0.007). The SBP in the combined management group was significantly lower than that in the other three groups through pairwise comparison. The DBPs in the four groups were 75.9 ± 10.5, 79.0 ± 8.5, 74.3 ± 10.7 and 72.6 ± 9.7 mm Hg, respectively, and the difference was not statistically significant (P = 0.066). Table P = 0.003) and adjusted model  after adjusting for age, sex, education level, establishment of chronic disease archives, medication adherence and number of anti-hypertensive drugs.As shown in Fig. Currently, few studies have reported the medical institution choices of hypertensive patients. Dafeng et al. investigated the health-seeking behaviours of 510 patients with hypertension or diabetes in Wuhan, China, and the results showed that 75.35% of patients chose higher-level hospitals for medical treatment . AnotherHealth-seeking behaviours are defined as any activity undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy . The desA community-based epidemiological survey of hypertension showed that the overall control rate of hypertension was poor, as we mentioned before, at only 5.7% in a population-based screening study , as wellOur study has some limitations. First, the sample size was not sufficiently large to obtain the statistically significant difference of BP control rate among groups, but the significant difference of BP among groups suggested that we can expand the sample size to further clarify the relationship. Second, although we performed the survey using a random cluster sampling method, one-third of the hypertensive patients didn’t go voluntarily to the community health service centre to receive physical examinations and blood tests. We need to recognize the selection bias and avoid generalization when interpreting the results. Third, this study was a cross-sectional community sampling survey for evaluating the influence of different health-seeking behaviours on BP. Since the BP was also affected by many other factors that could not be corrected one by one, it could only provide a reference for studies in the future. It is important to further study the effect of hospital-community combined hypertension management on the BP and to further explore reasonable combined management modes. We have performing a study to evaluate the clinical efficacy and health economics effects of an internet-based patient-primary care physician-cardiologist integrated management model of hypertension in China . We lookIn conclusion, more than half of hypertensive patients we surveyed would like to choose community health service centre while ten percent would like to choose both community health service centre and higher-level hospitals as the usual places for medical treatment in the urban communities in China. The levels of education and the side effects of drugs were related to the patients' health-seeking behaviours. Compared with patients choosing community health service centre, patients in the combined management group had a significantly lower BP after adjusting for age, sex, education level, establishment of chronic disease archives, medication adherence and number of anti-hypertensive drugs. However, how to conduct combined management efficiently requires further study.


Background and aimHypertension possesses significant public health challenges for both developing and developed economies. Therefore, it is crucial to evaluate the awareness of hypertension and health-related quality of life (HRQoL) among patients with hypertension. This study aims to evaluate the knowledge of hypertension and HRQoL among hypertensive patients.Materials and methodsA cross-sectional study using an anonymous questionnaire was conducted over a period of 4 months (November 2020 to February 2021) in Riyadh, Kingdom of Saudi Arabia (KSA). This study included 437 questionnaires submitted by the hypertensive population.ResultsA total of 437 participants were included in this study, with 55.4% being males (n=242). The majority (85.1%) were aware of the normal values of blood pressure. Many participants had no problems with mobility, personal care, usual activities, pain or discomfort, and anxiety or depression. Age groups showed a significant association with mobility and usual activities. The knowledge of hypertension was significantly associated with HRQoL.ConclusionThis study found that majority of the hypertensive patients were aware of the standard values of blood pressure. HRQoL concerning physical functioning and general health is found to be good based on the EuroQol visual analogue scale (EQ VAS) in the hypertensive population who are aware of their condition. This study reported a weak yet significant association between hypertension-related knowledge and HRQoL scores. Several factors can affect the HRQoL of the hypertensive population including gender, education, occupation, and income status. Hypertension (defined as systolic blood pressure above 140 mmHg with a diastolic blood pressure of less than 90 mmHg) is quantitatively the most important modifiable risk factor of cardiovascular and kidney disease, and a leading risk factor for mortality . AccordiHealth-related quality of life (HRQoL) is defined as “an individual’s or a group’s perceived physical and mental health over time” . HRQoL iGiven the high prevalence of hypertension and lack of awareness, the impact on patient’s quality of life is inevitable. There is a growing demand to increase awareness among patients about chronic diseases . SeveralThis cross-sectional study was conducted among hypertensive Saudi patients from November 2020 to February 2021 at the outpatient clinic of the King Saud University Medical City, a tertiary care setting in Riyadh, KSA. This medical city serves a broad range of patients drawn from a large population, several of whom present with complex medical comorbidities.Patients aged 18 years and over, with a confirmed diagnosis (blood pressure reading was taken on two separate occasions that is greater than 140/90 mmHg) of essential hypertension, who have been using antihypertensive agents for the previous three months were included in the study. Patients aged < 18 and > 80 years, having co-morbidities, expatriates from other countries, and pregnant women were excluded.A 21-item self-administered questionnaire for assessing the knowledge of hypertension was distributed among hypertensive patients at the King Saud University Medical City. This questionnaire was adopted from previous studies . The queData for the quality of life was collected using EuroQol five-dimensions - 3-level (EQ-5D-3L), the European quality of life scale . EQ-5D-3In order to elicit a response in 50% of respondents regarding the knowledge of hypertension, with a 95% confidence level and 5% margin of error, a sample size of 377 was estimated. The sample size was calculated by an online sample size calculator. Data analysis was carried out using the SPSS software, version 24 . Numerical data were presented with mean and standard deviation whereas categorical data in frequencies and percentages. Independent samples’ t-test and analysis of variance (ANOVA) were applied for two and more than two means difference, respectively. EQ-5D-3L scores for five dimensions and mean EQ VAS scores were also compared for age and gender. Pearson correlation was used to explore any correlations between knowledge and HRQoL. Correlations were interpreted using the following criteria: 0 to 0.25 = weak correlation, 0.25 to 0.5 = fair correlation, 0.5 to 0.75 = good correlation and > 0.75 = excellent correlation . A P-valA total of 437 questionnaires were returned by the hypertensive patients, and the response rate was 87.4%. The majority of the patients belong to the age group of 48 years and over, with 55.4% being males (n=242). Nearly 47% of the study participants had a bachelor’s degree. Twenty-six percent n=115) had a monthly income of more than 15,000 Saudi riyals. Ninety-seven percent of the study participants resided in urban settings and 3% were from rural areas. Nearly 36% had a duration of hypertension for more than 15 years. There was a significant association in EQ-VAS scores with respect to gender, qualification, occupation, monthly income, and the duration of disease. The mean EQ-VAS score (77.1 ± 17.6) indicated good HRQoL in our study participants  were not aware of the basic definition of hypertension; however, the majority (85.1%) were aware of the normal values of blood pressure Table . More thTable The score of HRQoL based on EQ-VAS score range from 0  to 100   is significantly associated with HRQoL, although a weak correlation. This finding is consistent with that of other studies conducted in hypertensive population in Pakistan ; howeverPrevious studies provide inconsistent findings ranging from weak to strong correlation between the quality of life among hypertensive population and adherence to treatment ,24. The Strengths of our study include patients with a confirmed diagnosis of essential hypertension who have been using antihypertensive agents for the previous three months, the EQ-5D-3L questionnaire which is the European quality of life scale, and exclusion of complications of hypertension that might reduce HRQoL. In addition, we included a large sample of hypertensive patients, and determined individualized factors affecting HRQoL in the hypertensive population. There were some limitations to this study. First, this study was cross-sectional and limited in its capacity to inform about causality. It was conducted at a single tertiary care setting in the KSA, the results cannot be generalized to the entire population. Therefore, these results need to be validated by a multicentre longitudinal study across tertiary care settings in the Kingdom.This study found that majority of the hypertensive patients were aware of the standard values of blood pressure. HRQoL concerning physical functioning and general health found to be good based on EQ VAS in the hypertensive population who are aware of their condition. This study reported a weak yet significant association between hypertension-related knowledge and HRQoL scores. Several factors can affect the HRQoL of the hypertensive population including gender, education, occupation, and income status. The quality of life among hypertensive patients can be improved by conducting educational programs about hypertension at the community level. Future studies can explore the effect of an interdisciplinary education programs on hypertensive patient’s outcomes.