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Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2020; 9:CD010315. [PMID: 32905623 PMCID: PMC8094921 DOI: 10.1002/14651858.cd010315.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This is the second update of the review first published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown. OBJECTIVES To determine if lower blood pressure targets (135/85 mmHg or less) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (140 to 160/90 to 100 mmHg or less) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease). SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to November 2019: Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE (from 1946), Embase (from 1974), and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982), along with the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. We applied no language restrictions. SELECTION CRITERIA We included RCTs with more than 50 participants per group that provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (135/85 mmHg or less) compared with standard targets for blood pressure (140 to 160/90 to 100 mmHg or less). Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris. DATA COLLECTION AND ANALYSIS Two review authors independently assessed search results and extracted data using standard methodological procedures expected by Cochrane. We used GRADE to assess the quality of the evidence. MAIN RESULTS We included six RCTs that involved 9484 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). All RCTs provided individual participant data. None of the included studies was blinded to participants or clinicians because of the need to titrate antihypertensives to reach a specific blood pressure goal. However, an independent committee blinded to group allocation assessed clinical events in all trials. Hence, we assessed all trials at high risk of performance bias and low risk of detection bias. Other issues such as early termination of studies and subgroups of participants not predefined were also considered to downgrade the quality evidence. We found there is probably little to no difference in total mortality (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.91 to 1.23; 6 studies, 9484 participants; moderate-quality evidence) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; 6 studies, 9484 participants; moderate-quality evidence). Similarly, we found there may be little to no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; 6 studies, 9484 participants; low-quality evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure) (RR 0.89, 95% CI 0.80 to 1.00; 6 studies, 9484 participants; low-quality evidence). The evidence was very uncertain about withdrawals due to adverse effects. However, studies suggest more participants may withdraw due to adverse effects in the lower target group (RR 8.16, 95% CI 2.06 to 32.28; 2 studies, 690 participants; very low-quality evidence). Systolic and diastolic blood pressure readings were lower in the lower target group (systolic: mean difference (MD) -8.90 mmHg, 95% CI -13.24 to -4.56; 6 studies, 8546 participants; diastolic: MD -4.50 mmHg, 95% CI -6.35 to -2.65; 6 studies, 8546 participants). More drugs were needed in the lower target group (MD 0.56, 95% CI 0.16 to 0.96; 5 studies, 7910 participants), but blood pressure targets were achieved more frequently in the standard target group (RR 1.21, 95% CI 1.17 to 1.24; 6 studies, 8588 participants). AUTHORS' CONCLUSIONS We found there is probably little to no difference in total mortality and cardiovascular mortality between people with hypertension and cardiovascular disease treated to a lower compared to a standard blood pressure target. There may also be little to no difference in serious adverse events or total cardiovascular events. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on withdrawals due to adverse effects, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (135/85 mmHg or less) in people with hypertension and established cardiovascular disease. Several trials are still ongoing, which may provide an important input to this topic in the near future.
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Affiliation(s)
- Luis Carlos Saiz
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | - Javier Gorricho
- Planning, Evaluation and Management Service, General Directorate of Health, Government of Navarre, Pamplona, Spain
| | - Javier Garjón
- Medicines Advice and Information Service, Navarre Health Service, Pamplona, Spain
| | | | - Juan Erviti
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | - Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
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Georgakis MK, Gill D, Webb AJS, Evangelou E, Elliott P, Sudlow CLM, Dehghan A, Malik R, Tzoulaki I, Dichgans M. Genetically determined blood pressure, antihypertensive drug classes, and risk of stroke subtypes. Neurology 2020; 95:e353-e361. [PMID: 32611631 PMCID: PMC7455321 DOI: 10.1212/wnl.0000000000009814] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/05/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We employed Mendelian randomization to explore whether the effects of blood pressure (BP) and BP-lowering through different antihypertensive drug classes on stroke risk vary by stroke etiology. METHODS We selected genetic variants associated with systolic and diastolic BP and BP-lowering variants in genes encoding antihypertensive drug targets from genome-wide association studies (GWAS) on 757,601 individuals. Applying 2-sample Mendelian randomization, we examined associations with any stroke (67,162 cases; 454,450 controls), ischemic stroke and its subtypes (large artery, cardioembolic, small vessel stroke), intracerebral hemorrhage (ICH, deep and lobar), and the related small vessel disease phenotype of white matter hyperintensities (WMH). RESULTS Genetic predisposition to higher systolic and diastolic BP was associated with higher risk of any stroke, ischemic stroke, and ICH. We found associations between genetically determined BP and all ischemic stroke subtypes with a higher risk of large artery and small vessel stroke compared to cardioembolic stroke, as well as associations with deep, but not lobar ICH. Genetic proxies for calcium channel blockers, but not β-blockers, were associated with lower risk of any stroke and ischemic stroke. Proxies for calcium channel blockers showed particularly strong associations with small vessel stroke and the related radiologic phenotype of WMH. CONCLUSIONS This study supports a causal role of hypertension in all major stroke subtypes except lobar ICH. We find differences in the effects of BP and BP-lowering through antihypertensive drug classes between stroke subtypes and identify calcium channel blockade as a promising strategy for preventing manifestations of cerebral small vessel disease.
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Affiliation(s)
- Marios K Georgakis
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Dipender Gill
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Alastair J S Webb
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Evangelos Evangelou
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Paul Elliott
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Cathie L M Sudlow
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Abbas Dehghan
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Rainer Malik
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Ioanna Tzoulaki
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany
| | - Martin Dichgans
- From the Institute for Stroke and Dementia Research (ISD), University Hospital (M.K.G., R.M., M.D.), and Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany; Department of Biostatistics and Epidemiology, School of Public Health (D.G., E.E., C.L.M.S., A.D., I.T.), UK Dementia Research Institute (P.E., A.D.), Health Data Research-UK London (P.E.), and MRC-PHE Centre for Environment, School of Public Health (I.T.), Imperial College London; Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences (A.J.S.W.), University of Oxford, UK; Department of Hygiene and Epidemiology (E.E., I.T.), University of Ioannina Medical School, Greece; National Institute for Health Research Imperial College Biomedical Research Centre (P.E.), London; Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Munich Cluster for Systems Neurology (SyNergy) (M.D.); and German Centre for Neurodegenerative Diseases (DZNE) (M.D.), Munich, Germany.
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Zhang L, Pasha EP, Liu J, Xing CY, Cardim D, Tarumi T, Womack K, Hynan LS, Cullum CM, Zhang R. Steady-state cerebral autoregulation in older adults with amnestic mild cognitive impairment: linear mixed model analysis. J Appl Physiol (1985) 2020; 129:377-385. [PMID: 32614686 DOI: 10.1152/japplphysiol.00193.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We examined whether the efficacy of steady-state cerebral autoregulation (CA) is reduced in older adults with amnestic mild cognitive impairment (aMCI), a prodromal stage of clinical Alzheimer disease (AD). Forty-two patients with aMCI and 24 cognitively normal older adults (NC) of similar age, sex, and education underwent stepwise decreases and increases in mean arterial pressure (MAP) induced by intravenous infusion of sodium nitroprusside and phenylephrine, respectively. Changes in cerebral blood flow (CBF) were measured repeatedly in the internal carotid and vertebral artery. Linear mixed modeling, including random effects of both individual intercept and regression slope, was used to quantify the MAP-CBF relationship accounting for nonindependent, repeated CBF measures. Changes in end-tidal CO2 (EtCO2) associated with changes in MAP were also included in the model to account for their effects on CBF. Marginal mean values of MAP were reduced by 13-14 mmHg during sodium nitroprusside and increased by 20-24 mmHg during phenylephrine infusion in both groups with similar doses of drug infusion. A steeper slope of changes in CBF in response to changes in MAP was observed in aMCI relative to NC, indicating reduced efficacy of CA (MAP × Group, P = 0.040). These findings suggest that cerebrovascular dysfunction may occur early in the development of AD.NEW & NOTEWORTHY Cerebral autoregulation is a fundamental regulatory mechanism to protect brain perfusion against changes in blood pressure that, if impaired, may contribute to the development of Alzheimer's disease. Using a linear mixed model, we demonstrated that the efficacy of cerebral autoregulation, assessed during stepwise changes in arterial pressure, was reduced in individuals with amnestic mild cognitive impairment, a prodromal stage of Alzheimer's disease. These findings support the hypothesis that cerebrovascular dysfunction may be an important underlying pathophysiological mechanism for the development of clinical Alzheimer's disease.
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Affiliation(s)
- Li Zhang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Ultrasound Diagnostics, Tangdu Hospital, Xi'an, China
| | - Evan P Pasha
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jie Liu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chang-Yang Xing
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Ultrasound Diagnostics, Tangdu Hospital, Xi'an, China
| | - Danilo Cardim
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Takashi Tarumi
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kyle Womack
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Linda S Hynan
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - C Munro Cullum
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rong Zhang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
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Cerebral macro- and microcirculatory blood flow dynamics in successfully treated chronic hypertensive patients with and without white mater lesions. Sci Rep 2020; 10:9213. [PMID: 32514031 PMCID: PMC7280202 DOI: 10.1038/s41598-020-66317-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/18/2020] [Indexed: 01/14/2023] Open
Abstract
The mechanisms of high blood pressure (HBP) -related brain pathology progression remain relatively unclear. We investigated whether lowering BP in chronic HBP patients normalizes cerebral perfusion dynamics at resistance vessel and capillary levels. Sixty-seven patients with HBP and 49 age- and sex-matched healthy controls underwent simultaneous recordings of middle cerebral artery blood flow velocity (CBFV), BP, and end-tidal CO2 concentration. Thirty-four controls and 28 patients underwent additional near-infrared spectroscopy recordings (oxygenated [O2Hb] and deoxygenated [HHb] hemoglobin). Degree of microcirculatory white matter lesions was graded by Fazekas scale. Dynamic cerebral autoregulation (dCA) was assessed by transfer function analysis. BP was successfully lowered (patients = 89 ± 15 mm Hg, controls = 87 ± 17), but cerebrovascular resistance was higher in BP patients (p < 0.05). BP-CBFV phase was lower in very low frequency (VLF) (left/right: 48 ± 20°/44 ± 17; controls: 61 ± 20/60 ± 21; p < 0.001) and low frequency (LF) (34 ± 14/35 ± 14; controls: 48 ± 20/44 ± 17; p < 0.05) ranges. Gain was higher in VLF range (in %/ mm Hg 0.56 ± 0.44/0.59 ± 0.49; controls: 0.32 ± 0.29/0.34 ± 0.32; p ≤ 0.005). BP-CBFV phase and gain did not differ across Fazekas groups. Across all patients, the capillary phases and gains (CBFV-[O2Hb], CBFV-[HHb]) were comparable to controls. Successfully treated chronic HBP results in normal brain capillary hemodynamics while the resistance vessel state is disturbed (phase decrease, gain increase).
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Hiremath N, Kate M, Mohimen A, Kesavadas C, Sylaja PN. Risk factors of white matter hyperintensities in South Asian patients with transient ischemic attack and minor stroke. Neuroradiology 2020; 62:1279-1284. [PMID: 32385557 DOI: 10.1007/s00234-020-02429-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Aging and increased burden of cardiovascular risk factors are associated with severity of white matter hyperintensity (WMH). We assessed the burden and risk factor profile of WMHs in South Asian patients with transient ischemic attack (TIA) and minor stroke. METHODS Patients with acute ischemic stroke with the National Institute of Health stroke scale (NIHSS) score ≤ 5 who underwent MRI were included. The severity of WMHs was assessed based on age-related white matter change (ARWMC) scale (0-30). A score of > 8 or more was considered moderate-severe involvement. Logistic regression analysis was performed to assess the association with risk factors. RESULTS A total of 424 patients with a mean ± SD age of 57.4 ± 14.5 years [females, 108 (25.5%)] were analyzed. Fifty-four (12.7%) patients had moderate or severe WMHs (ARWMC score > 8). Age (OR 1.03, 95% CI 1.01-1.06; p = 0.004), hypertension (OR 2.3, 95% CI 1.1-5.1; p = 0.03) and smoking tobacco (OR 2.8, 95% CI 1.4-5.6; p = 0.003) were independently associated with ARWMC score > 8. The median (IQR) regional score in patients with ARWMC score > 8 was maximum in frontal areas 4 (4-6, p < 0.0001) and parietooccipital areas 4.5(4-6, p < 0.0001). The presence of microbleeds (OR 6.3, 95% CI 3.1-12.7; p < 0.0001) was independently associated with ARWMC score > 8. CONCLUSION South Asian patients with TIA and minor stroke are relatively young, and few patients have moderate and severe WMHs. Hypertension and tobacco smoking increases the risk of WMH. Targeting modifiable risk factors may reduce the burden of WMHs and vascular dementia.
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Affiliation(s)
- Nikhil Hiremath
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, 695011, India
| | - Mahesh Kate
- Department of Clinical Neurosciences, Alberta Health Services, Edmonton, Canada
| | - Aneesh Mohimen
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Chandrasekharan Kesavadas
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - P N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, 695011, India.
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Wardlaw J, Bath PMW, Doubal F, Heye A, Sprigg N, Woodhouse LJ, Blair G, Appleton J, Cvoro V, England T, Hassan A, John Werring D, Montgomery A. Protocol: The Lacunar Intervention Trial 2 (LACI-2). A trial of two repurposed licenced drugs to prevent progression of cerebral small vessel disease. Eur Stroke J 2020; 5:297-308. [PMID: 33072884 PMCID: PMC7538764 DOI: 10.1177/2396987320920110] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Small vessel disease causes a quarter of ischaemic strokes (lacunar subtype),
up to 45% of dementia either as vascular or mixed types, cognitive
impairment and physical frailty. However, there is no specific treatment to
prevent progression of small vessel disease. Aim We designed the LACunar Intervention Trial-2 (LACI-2) to test feasibility of
a large trial testing cilostazol and/or isosorbide mononitrate (ISMN) by
demonstrating adequate participant recruitment and retention in follow-up,
drug tolerability, safety and confirm outcome event rates required to power
a phase 3 trial. Methods and design LACI-2 is an investigator-initiated, prospective randomised open label
blinded endpoint (PROBE) trial aiming to recruit 400 patients with prior
lacunar syndrome due to a small subcortical infarct. We randomise
participants to cilostazol v no cilostazol and ISMN or no ISMN, minimising
on key prognostic factors. All patients receive guideline-based best medical
therapy. Patients commence trial drug at low dose, increment to full dose
over 2–4 weeks, continuing on full dose for a year. We follow-up
participants to one year for symptoms, tablet compliance, safety, recurrent
vascular events, cognition and functional outcomes, Trails B and brain MRI.
LACI-2 is registered ISRCTN 14911850, EudraCT 2016–002277-35. Trial outcome: Primary outcome is feasibility of recruitment and
compliance; secondary outcomes include safety (cerebral or systemic
bleeding, falls, death), efficacy (recurrent cerebral and cardiac vascular
events, cognition on TICS, Trails B) and tolerability. Summary LACI-2 will determine feasibility, tolerability and provide outcome rates to
power a large phase 3 trial to prevent progression of cerebral small vessel
disease.
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Affiliation(s)
| | - Philip M W Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | | | - Anna Heye
- The University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | | | | | | | - Vera Cvoro
- The University of Edinburgh, Edinburgh, UK
| | | | - Ahamad Hassan
- University College London Institute of Neurology, London, UK
| | | | - Alan Montgomery
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
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Joutel A. Prospects for Diminishing the Impact of Nonamyloid Small-Vessel Diseases of the Brain. Annu Rev Pharmacol Toxicol 2020; 60:437-456. [PMID: 31425001 DOI: 10.1146/annurev-pharmtox-010818-021712] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Small-vessel diseases (SVDs) of the brain are involved in about one-fourth of ischemic strokes and a vast majority of intracerebral hemorrhages and are responsible for nearly half of dementia cases in the elderly. SVDs are a heavy burden for society, a burden that is expected to increase further in the absence of significant therapeutic advances, given the aging population. Here, we provide a critical appraisal of currently available therapeutic approaches for nonamyloid sporadic SVDs that are largely based on targeting modifiable risk factors. We review what is known about the pathogenic mechanisms of vascular risk factor-related SVDs and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), the most frequent hereditary SVD, and elaborate on two mechanism-based therapeutic approaches worth exploring in sporadic SVD and CADASIL. We conclude by discussing opportunities and challenges that need to be tackled if efforts to achieve significant therapeutic advances for these diseases are to be successful.
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Affiliation(s)
- Anne Joutel
- Institute of Psychiatry and Neurosciences of Paris, INSERM UMR1266, Paris Descartes University, 75014 Paris, France; .,DHU NeuroVasc, Sorbonne Paris Cité, 75010 Paris, France.,Department of Pharmacology, College of Medicine, University of Vermont, Burlington, Vermont 05405, USA
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58
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Smith EE, Markus HS. New Treatment Approaches to Modify the Course of Cerebral Small Vessel Diseases. Stroke 2019; 51:38-46. [PMID: 31752610 DOI: 10.1161/strokeaha.119.024150] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Eric E Smith
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Hugh S Markus
- Department of Clinical Neurosciences, Cambridge University, United Kingdom (H.S.M.)
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Chen X, Huang L, Ye Q, Yang D, Qin R, Luo C, Li M, Zhang B, Xu Y. Disrupted functional and structural connectivity within default mode network contribute to WMH-related cognitive impairment. NEUROIMAGE-CLINICAL 2019; 24:102088. [PMID: 31795048 PMCID: PMC6861557 DOI: 10.1016/j.nicl.2019.102088] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 11/23/2022]
Abstract
Disconnective DMN contribute to impaired cognition
Aims The prevalence of white matter hyperintensities (WMH) rises dramatically with aging. Both the progression of WMH and changing patterns of default mode network (DMN) have been proven to be closely associated with cognitive function. The present study hypothesized that changes in functional connectivity and structural connectivity of DMN contributed to WMH related cognitive impairment. Methods A total of 116 subjects were enrolled from the Cerebral Small Vessel Disease Register in Drum Tower Hospital of Nanjing University, and were distributed across three categories according to Fazekas rating scale: WMH I (n = 57), WMH II (n = 34), and WMH III(n = 25). All participants underwent neuropsychological tests and multimodal MRI scans, including diffusion tensor imaging and resting-state fMRI imaging. The alterations of functional connectivity and structural connectivity within the DMN were further explored. Results Age and hypertension were risk factors for WMH progression. Subjects with a higher WMH burden displayed higher DMN functional connectivity in the medial frontal gyrus, while lower DMN functional connectivity in the thalamus. After adjusting for aging, gender, and education, the increased DMN functional connectivity in the medial frontal gyrus, and the increased mean diffusivity of the white matter tracts between the hippocampus and posterior cingulate cortex were independent indicators of worse performance in memory. Moreover, the decreased DMN functional connectivity in the thalamus and increased mean diffusivity of the white matter tracts between the thalamus and posterior cingulate cortex were independent risk factors for a slower processing speed. Conclusion The changes in functional connectivity and structural connectivity within the DMN attributed to WMH progression were responsible for the development of cognitive impairment.
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Affiliation(s)
- Xin Chen
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Lili Huang
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Qing Ye
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Dan Yang
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Ruomeng Qin
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Caimei Luo
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Mengchun Li
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China
| | - Bing Zhang
- Department of Radiology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China
| | - Yun Xu
- Department of Neurology, Affiliated Drum Tower Hospital, Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, 210008, China; Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing, 210008, China; Nanjing Neuropsychiatry Clinic Medical Center, Nanjing, 210008, China.
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60
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Wardlaw JM, Smith C, Dichgans M. Small vessel disease: mechanisms and clinical implications. Lancet Neurol 2019; 18:684-696. [DOI: 10.1016/s1474-4422(19)30079-1] [Citation(s) in RCA: 500] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 02/06/2023]
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Kulesh AA, Drobakha VE, Shestakov VV. Cerebral small vessel disease: classification, clinical manifestations, diagnosis, and features of treatment. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2019. [DOI: 10.14412/2074-2711-2019-3s-4-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The paper considers the relevance of the problem of cerebral small vessel disease (CSVD) that is an important cause of ischemic and hemorrhagic stroke, associated with the development of cognitive impairment and complications of antithrombotic therapy. It presents briefly the current issues of etiology and pathogenesis of the disease. Sporadic non-amyloid microangiopathy, cerebral amyloid angiopathy, and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) are discussed in detail from the point of view of their clinical presentation, neuroimaging, and features of therapeutic tactics. An algorithm for diagnosing CSVD in patients admitted to hospital for stroke and a differentiated approach to their treatment are proposed. Consideration of the neuroimaging manifestations of CSVD is noted to be necessary for the safe and more effective treatment of patients with cerebrovascular diseases.
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Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. E. Drobakha
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. V. Shestakov
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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Smith PJ, Mabe S, Sherwood A, Babyak MA, Murali Doraiswamy P, Welsh-Bohmer KA, Kraus W, Burke J, Hinderliter A, Blumenthal JA. Association Between Insulin Resistance, Plasma Leptin, and Neurocognition in Vascular Cognitive Impairment. J Alzheimers Dis 2019; 71:921-929. [PMID: 31476159 PMCID: PMC10840083 DOI: 10.3233/jad-190569] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Greater body weight has been associated impairments in neurocognition and greater dementia risk, although the mechanisms linking weight and neurocognition have yet to be adequately delineated. OBJECTIVE To examine metabolic mechanisms underlying the association between obesity and neurocognition. METHODS We conducted a secondary analysis of weight, neurocognition, and the potentially mediating role of metabolic and inflammatory biomarkers among 160 participants from the ENLIGHTEN trial of vascular cognitive impairment, no dementia (CIND). Neurocognition was assessed using a 45-minute assessment battery assessing Executive Function, Verbal and Visual Memory. We considered three metabolic biomarkers: insulin resistance (homeostatic model assessment [HOMA-IR]), plasma leptin, and insulin-like growth factor (IGF-1). Inflammation was assessed using C-reactive protein. Multiple regression analyses were used. RESULTS Participants included 160 sedentary older adults with CIND. Participants tended to be overweight or obese (mean BMI = 32.5 [SD = 4.8]). Women exhibited higher BMI (p = 0.043), CRP (p < 0.001), and leptin (p < 0.001) compared with men. Higher BMI levels were associated with worse performance on measures of Executive Function (β= -0.16, p = 0.024) and Verbal Memory (β= -0.16, p = 0.030), but not Visual Memory (β= 0.05, p = 0.500). Worse metabolic biomarker profiles also were associated with lower Executive Function (β= -0.12, p = 0.050). Mediation analyses suggested leptin was a plausible candidate as a mediator between BMI and Executive Function. CONCLUSIONS In overweight and obese adults with vascular CIND, the association between greater weight and poorer executive function may be mediated by higher leptin resistance.
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Affiliation(s)
- Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Michael A. Babyak
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - P. Murali Doraiswamy
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kathleen A. Welsh-Bohmer
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - William Kraus
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - James Burke
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Kulesh AA, Drobakha VE, Shestakov VV. Sporadic cerebral non-amyloid microangiopathy: pathogenesis, diagnosis, and features of treatment policy. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2018. [DOI: 10.14412/2074-2711-2018-4-13-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. E. Drobakha
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. V. Shestakov
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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Abstract
PURPOSE OF REVIEW Recent US guidelines have changed the definition of hypertension to ≥ 130/80 mmHg and recommended more intense blood pressure (BP) targets. We summarize the evidence for intense BP treatment and discuss risks that must be considered when choosing treatment goals for individual patients. RECENT FINDINGS The SPRINT study reported that treating to a systolic BP target of 120 mmHg reduces cardiovascular outcomes in high-risk individuals, supporting more intensive BP reduction than previously recommended. However, recent observational studies have placed emphasis on the BP J-curve phenomenon, where low BPs are associated with adverse cardiovascular outcomes, suggesting that overly aggressive BP targets may sometimes be harmful. We attempt to reconcile these apparent contradictions for the clinician. We also review other potential dangers of aggressive BP targets, including syncope, renal impairment, polypharmacy, drug interactions, subjective drug side-effects, and non-adherence. We suggest a personalized approach to BP drug management considering individual risks, benefits, and preferences when choosing therapeutic targets, recognizing that a goal of 130/80 mmHg should always be considered. Additionally, we recommend an intense focus on lifestyle changes and medication adherence.
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Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2018; 7:CD010315. [PMID: 30027631 PMCID: PMC6513382 DOI: 10.1002/14651858.cd010315.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND This is the first update of the review published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown. OBJECTIVES To determine if 'lower' blood pressure targets (≤ 135/85 mmHg) are associated with reduction in mortality and morbidity as compared with 'standard' blood pressure targets (≤ 140 to 160/90 to 100 mmHg) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease). SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to February 2018: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982), along with the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. We applied no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) that included more than 50 participants per group and provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (≤ 135/85 mmHg) compared with standard targets for blood pressure (≤ 140 to 160/90 to 100 mmHg).Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris. DATA COLLECTION AND ANALYSIS Two review authors independently assessed search results and extracted data using standard methodological procedures expected by Cochrane. MAIN RESULTS We included six RCTs that involved a total of 9484 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). All RCTs provided individual participant data.We found no change in total mortality (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.91 to 1.23) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; moderate-quality evidence). Similarly, we found no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; low-quality evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure) (RR 0.89, 95% CI 0.80 to 1.00; low-quality evidence). Studies reported more participant withdrawals due to adverse effects in the lower target arm (RR 8.16, 95% CI 2.06 to 32.28; very low-quality evidence). Blood pressures were lower in the lower target group by 8.9/4.5 mmHg. More drugs were needed in the lower target group, but blood pressure targets were achieved more frequently in the standard target group. AUTHORS' CONCLUSIONS We found no evidence of a difference in total mortality, serious adverse events, or total cardiovascular events between people with hypertension and cardiovascular disease treated to a lower or to a standard blood pressure target. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on adverse events, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (≤ 135/85 mmHg) in people with hypertension and established cardiovascular disease. More trials are needed to examine this topic.
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Affiliation(s)
- Luis Carlos Saiz
- Navarre Health ServiceUnit of Innovation and OrganizationPamplonaNavarreSpain
| | - Javier Gorricho
- General Directorate of Health, Government of NavarrePlanning, Evaluation and Management ServicePamplonaNavarraSpain
| | - Javier Garjón
- Navarre Health ServiceDrug Prescribing ServicePlaza de la Paz s/n 4ªPamplonaNavarraSpain31002
| | - Mª Concepción Celaya
- Navarre Health ServiceDrug Prescribing ServicePlaza de la Paz s/n 4ªPamplonaNavarraSpain31002
| | - Juan Erviti
- Navarre Health ServiceUnit of Innovation and OrganizationPamplonaNavarreSpain
| | - Leire Leache
- Navarre Health ServiceUnit of Innovation and OrganizationPamplonaNavarreSpain
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