LAUSR

Hypertension remains one of the most common and important cardiovascular risk factors, not only for stroke, but also for myocardial infarction. Coronary plaque rupture is the most common cause of acute coronary syndromes, an event that is triggered by physical forces exerted by the circulating blood. In their Clinical Review ‘Biomechanical stress in coronary atherosclerosis: emerging insights from computational modeling’, Peter Barlis and colleagues from the University of Melbourne in Australia reiterate that early detection of plaques prone to rupture may allow more focused preventative treatment. However, they remind us that current diagnostic methods remain inadequate to detect these lesions. Indeed, established imaging features indicating vulnerability do not confer adequate specificity for symptomatic rupture. Similarly, even though experimental and computational studies have underscored the importance of endothelial shear stress, the ability of shear stress to predict plaque progression remains incremental. In their review, they examine recent advances in image-based computational modelling that have elucidated possible mechanisms of plaque progression and rupture, and potentially novel features of plaques most prone to symptomatic rupture. With further study and clinical validation, these markers and techniques may improve the specificity of future culprit plaque detection. While blood pressure measured at surgery is highly predictive for outcomes, there are patients in which such a measurement does not reflect their true blood pressure. Indeed, masked hypertension, which is present when in-office normotension translates to out-ofoffice hypertension, is present in a surprisingly high percentage of untreated persons and an even higher percentage of patients after beginning antihypertensive medication, as outlined by Staessen et al. from the Universities of Leuven, Maastricht, and California at Irvine in their review ‘Masked hypertension: understanding its complexity’. Not only are those with pre-hypertension more likely to have masked hypertension than those with optimal blood pressure, but also they frequently develop target organ damage prior to transitioning to sustained hypertension. Furthermore, the frequency of masked hypertension is high in individuals of African inheritance and in the presence of increased cardiovascular risk factors and disease states, such as diabetes and chronic renal failure. Nocturnal hypertension and non-dipping may be early markers of masked hypertension. Twenty-four-hour ambulatory blood pressure monitoring, which can detect night-time and 24 h elevated blood pressure remains the gold standard for diagnosing masked hypertension. Almost one-third of treated patients with masked hypertension remain as ‘masked uncontrolled hypertension’, and it becomes important, therefore, to use ambulatory blood pressure monitoring and supplemental home blood pressure measurements for the effective diagnosis and control of hypertension. The sympathetic system, particularly that innervating the kidneys, is an important driver of hypertension. Indeed, surgical sympathectomy not only lowers blood pressure, but also reduces mortality in severe hypertension. Catheter-based renal artery denervation lowers blood pressure in certain patients with uncontrolled hypertension and if enough ablations have been placed. However, the characteristics of patients most likely to benefit from the procedure are not known. Isolated systolic hypertension is characterized by increased vascular stiffness and is the predominant hypertensive phenotype in the elderly. In a first clinical paper ‘Reduced blood pressure-lowering effect of catheter-based renal denervation in patients with isolated systolic hypertension: data from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry’, Felix Mahfoud and colleagues from the Universit€atsklinikum des Saarlandes in Homburg, Germany compared baseline characteristics and systolic blood pressure change at 6 months of patients with isolated systolic hypertension and systolic– diastolic hypertension. To that end, they pooled data from 1103 patients from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. A total of 429 patients had isolated systolic hypertension, and 674 had systolic–diastolic hypertension. Patients with isolated systolic hypertension were significantly older, and had more type 2 diabetes mellitus and a lower estimated glomerular filtration rate. Six months after renal ablation, the systolic blood pressure drop in systolic–diastolic hypertension was 19 mmHg, but it was only 11 mmHg in isolated systolic hypertension. The change in 24-h systolic blood pressure at 6 months was 9 mmHg in patients with systolic–diastolic hypertension, but only 6 mmHg in those with isolated systolic hypertension. Thus, the presence of isolated systolic hypertension at baseline, but not age, was associated with less pronounced blood pressure changes following the procedure. The strongest predictor