Hypertension affects over one billion individuals worldwide and remains the leading modifiable risk factor for cardiovascular disease. While first-line therapies including thiazide-type diuretics, angiotensin converting enzyme inhibitors / angiotensin receptor blockers, and calcium channel blockers can effectively control blood pressure in many patients, 10-20% develop resistant hypertension requiring additional therapeutic approaches. Steroidal mineralocorticoid receptor antagonists (MRAs) have emerged as essential fourth-line agents for resistant hypertension, with spironolactone demonstrating superior efficacy compared to other add-on therapies in the landmark PATHWAY-2 trial. The pathophysiological rationale for MRAs includes natriuretic effects, vasodilatory properties and target organ protection through anti-fibrotic mechanisms. Novel non-steroidal MRAs offer improved selectivity and reduced endocrine side effects compared to traditional agents, potentially expanding the therapeutic window for mineralocorticoid receptor blockade. In this review, we discuss the established role of MRAs in primary and resistant hypertension management and discuss consideration of MRAs in certain hypertension patient populations. We also briefly review patient selection strategies and future directions for this important therapeutic class.

Blood pressure (BP) is involved in the pathogenesis of cerebral small vessel disease (CSVD) and clinical research confirms this strong correlation. Data showing whether daytime or nighttime BP is the most important variable of CSVD are conflicting. Therefore, the purpose of this meta-analysis is to evaluate the impact daytime and nighttime BP in terms of CSVD correlation. Additionally, we evaluated the role of nocturnal BP variation for the same purpose. We systematically searched PubMed and Scopus databases to extract data evaluating the association between different ABPM components (24h, day- and nighttime BP, dipping patterns) and imaging features of CSVD (white matter hypersensitivies, lacunes, cerebral microbleeds). Study quality was evaluated with the Newcastle-Ottawa scale. In the qualitative synthesis, 24 studies with 6822 patients were included. The pooled analysis of 19 studies showed that increased 24h SBP is associated with 41% increased risk of CSVD, and this is consistently observed for both daytime and nighttime SBP. this effect is largely driven by the impact of 24h, day- and night-time SBP on CMBs. Impaired nocturnal BP patterns are strongly associated with CSVD, specifically non-dipping profile with an OR of 2.24 (95% CI: 1.31-3.16) compared to dipping pattern. Reverse dipping was associated with CMBs with an increased OR of 3.02 (95% CI: 1.61, 4.42). Obtaining information on different components of ABPM (24h, day- and night-time BP, dipping profile) may allow identification of patients at higher risk for CSVD including its specific subtypes, specifically CMBs.

Pediatric hypertension is an increasingly recognized public health issue and represents a key target for preventing long-term cardiovascular morbidity and mortality. Adverse childhood experiences-traumatic events related to abuse, neglect, and household dysfunction occurring before age 18-are emerging as significant risk factors for both pediatric and adult hypertension and cardiovascular disease (CVD). While some studies report direct links between childhood adversity and cardiovascular outcomes, others suggest these associations may be mediated by the development of intermediate CVD risk factors such as obesity and mood disorders. Regardless of pathway, evidence indicates that even exposure to a single form of adversity can negatively impact cardiovascular health, with some studies demonstrating threshold and cumulative effects. Early identification of children exposed to adversity may offer a valuable opportunity to guide targeted interventions aimed at the primary prevention of CVD.

Systemic hypertension is a major risk factor for cardiovascular disease and remains challenging to manage despite the widespread use of antihypertensive medications and lifestyle modifications. This review explores the role of gut microbiota in hypertension development and regulation, highlighting key mechanisms such as inflammation, gut-brain axis modulation, and bioactive metabolite production. We also assess the potential of microbiota-targeted therapies for hypertension management. Emerging evidence indicates that microbial dysbiosis, high-salt diets, and gut-derived metabolites such as short-chain fatty acids (SCFAs) and bile acids significantly influence blood pressure regulation. Preclinical and early clinical studies suggest that interventions targeting gut microbiota, including probiotics, prebiotics, synbiotics, fecal microbiota transplantation (FMT), and dietary modifications, may help modulate hypertension. However, variability in gut microbiota composition among individuals and limited human trial data pose challenges to translating these findings into clinical practice. While microbiota-based therapies show promise for hypertension management, further research is needed to establish their efficacy and long-term effects. Large-scale, standardized clinical trials are crucial for understanding the therapeutic potential and limitations of gut microbiota interventions. A deeper understanding of the gut-hypertension axis could lead to novel, personalized treatment strategies for hypertension.

Purpose of ReviewSurvivors of childhood cancer and hematopoietic cell transplant are at risk for developing chronic health conditions, including hypertension. Studies have identified hypertension as an influential risk factor for late kidney dysfunction and cardiovascular disease in childhood cancer survivors. The overall risk of hypertension depends on the specific cancer treatment, from chemotherapy to surgery to radiation. In this report, we aim to review the main causes of hypertension in childhood cancer survivors, with a focus on newer therapies, as well as the current recommendations for screening and management of hypertension in this patient population.Recent FindingsNovel targeted therapies and immunotherapies are being increasingly used in pediatric cancer treatment, with unclear impact on long-term health. Screening guidelines for hypertension in the survivor population have been issued by various childhood cancer cooperative groups based on best available evidence and expert opinion. Newer studies have focused on individual risk prediction, which may help improve the diagnosis and management of hypertension, particularly in higher-risk individuals.SummaryDespite the importance of hypertension as one of the few modifiable risk factors for cardiovascular and renal health, studies have yet to define optimal blood pressure targets, screening parameters, or management strategies in childhood cancer survivors. Additionally, further studies are needed to demonstrate improvement in outcomes following interventions for hypertension specifically in this patient population.

Purpose of ReviewThe role of the lymphatic system in clearing extravasated fluids, lipid transport, and immune surveillance is well established, and lymphatic vasculature can provide a vital role in facilitating crosstalk among various organ systems. Lymphatic vessels rely on intrinsic and local factors to absorb and propel lymph from the interstitium back to the systemic circulation. The biological implications of local influences on lymphatic vessels are underscored by the exquisite sensitivity of these vessels to environmental stimuli. This review is intended to highlight the role of sodium within the local environment in mediating lymphatic and immune cell interactions that contribute to changes in function and disease progression.Recent FindingsWe discuss evidence that accumulation of interstitial sodium modulates lymphatic growth, pumping dynamics, and permeability of renal lymphatics, which involves activation of sodium potassium chloride co-transporter (NKCC1) in lymphatic endothelial cells. These recent findings complement observations that sodium activates immune cells via the epithelial sodium channel (ENaC), leading to the formation and accumulation of lipid oxidation products, isolevuglandins (IsoLGs), in antigen presenting cells, which in turn promotes T cell activation and vasculopathy. In addition, we will underscore the physiologic relevance of altered interplay between immune cells and lymphatics in the sodium avid state that characterizes kidney diseases and consider how sodium accumulation in the interstitial compartment of the kidney modulates the lymphatic network and the interactions between renal lymphatics and activated immune cells.SummaryFinally, this article calls attention to persisting knowledge gaps and stresses the need for additional studies to identify salt-sensing mechanisms, including sodium-activated immune cells and lymphatic endothelial cell interactions, for targeted therapeutic interventions in the setting of renal disease.

Purpose of ReviewIn clinical practice, the diagnosis of hypertension is based on non-invasive upper-arm cuff blood pressure (BP) measurement. Most measurements are performed seated, although evidence indicates that supine BP may provide additional information. This review summarises recent findings on the influence of body posture on BP readings and cardiovascular (CV) risk prediction across office, ambulatory, and home BP monitoring (OBPM, ABPM, HBPM), their clinical implications and future research directions.Recent FindingsIn OBPM, patients with supine-only hypertension demonstrated CV risk comparable to patients with hypertensive BP in both positions, and a higher risk than seated-only hypertensives. Supine hypertension was particularly predictive in individuals under 65 years of age. In ABPM, the strongest predictors of CV events are nocturnal hypertension and abnormal dipping patterns, particularly when patients are truly asleep, whereas supine nocturnal HBPM has been less extensively investigated.SummaryCurrent clinical practice remains primarily based on seated BP measurements. Recent trials have highlighted that supine OBPM may provide additional predictive power in the assessment of CV risk. These findings offer a partial explanation for the residual high predictive value of nocturnal BP values which can be derived from ABPM or specialised HBPM devices that goes beyond the correlation of breathing related sleep disorders Research should focus on homogenising supine risk data into composite risk scores combining seated and supine BP while new outcome studies should consider including supine BP measurement. Future guideline committees should consider recommending the structured clinical application of supine BP, given its demonstrated prognostic benefits.Graphical

Our review explores the epidemiology, physiology, and clinical data surrounding the connection between hyperuricemia and metabolic syndrome, chronic kidney disease, and hypertension. Compelling physiologic mechanisms have been proposed to explain a causal relationship between hyperuricemia and metabolic syndrome, chronic kidney disease, and hypertension but clinical studies have given mixed results in terms of whether intervening with hyperuricemia using urate-lowering therapy has any beneficial effects for patients with these conditions. Despite the large amount of research already put into this topic, more randomized placebo-controlled trials are needed to more firmly establish whether a cause-effect relationship exists and whether lowering uric acid levels in patients with these conditions is beneficial.