Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension)

Hypertension Management in the Elderly: What is the Optimal Target Blood Pressure?

Hypertension is a common disease in the elderly associated with significant morbidity and mortality. Due to the complexity of this population, the optimal target of blood pressure (BP) control is still controversial. In this article, we conduct a literature review of trials published in English in the last 10 years which were specifically designed to study the efficacy and safety of various BP targets in patients who are 70 years or older. Using these criteria, we found that the benefits in the positive studies were demonstrated even with a minimal BP control (systolic BP [SBP] <150 mmHg) and continued to be reported for a SBP <120 mmHg. On the other hand, keeping SBP <140 mmHg seemed to be safely achieved in elderly patients. Although the safety of lowering SBP to <120 mmHg is debated, Systolic Blood Pressure Intervention Trial study has shown no increased risk of falls, fractures, or kidney failure in elderly patients with SBP lower than this threshold. While the recent guidelines recommended to keep BP <130/80 mmHg in the elderly, more individualized approach should be considered to achieve this goal in order to avoid undesirable complications. Furthermore, further studies are required to evaluate BP target in very old patients or those with multiple comorbidities.

Antihypertensive Agents in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

This systematic review summarizes the benefits of treating blood pressure (BP) in individuals 65 years and older.

METHODS

We included randomized trials that evaluated BP-lowering medications or BP targets in individuals 65 years and older. Trials were selected and appraised by pairs of independent reviewers.

RESULTS

We included 19 trials (42,134 patients). In individuals 65 years or older, antihypertensive therapy was associated with a reduction in all-cause mortality [relative risk: 0.88 (95% CI: 0.81 to 0.94); high certainty evidence; mean follow-up 31 months], cardiovascular mortality, myocardial infarction, heart failure, stroke, and chronic kidney disease. Individuals 75 years or older had a significant reduction in the risk of all-cause and cardiovascular mortality, stroke, and heart failure. Strict systolic BP targets (<120 mm Hg and <130 mm Hg) were associated with a significant reduction in the risk of all-cause and cardiovascular mortality and heart failure, whereas more liberal systolic targets (<150 mm Hg and <160 mm Hg) were associated with lower risk of heart failure and stroke. Older adults with type 2 diabetes mellitus (DM) had lower risk of chronic kidney disease without a significant reduction in other outcomes. However, there was no significant difference in estimates (i.e., interaction) between those with and without DM.

CONCLUSIONS

Individuals aged 65 years and older or 75 years and older who receive antihypertensive therapy have statistically significant reduction in the risk of all-cause and cardiovascular mortality, heart failure, and stroke. There was no statistically significant difference in estimates between those with and without DM.

Evolution of Blood Pressure Clinical Practice Guidelines: A Personal Perspective

Before the second half of the 20th century, most clinical decision making was based on expert opinion. By the 1960s, experience in actuarial and research cohort studies had provided strong evidence that blood pressure was an important risk factor for cardiovascular disease. The landmark 1967 and 1970 Veterans Administration Cooperative Study trials confirmed the value of antihypertensive drug therapy in preventing stroke, myocardial infarction, and heart failure in adults with high levels of diastolic blood pressure. They also provided an impetus to develop the first blood-pressure-related clinical practice guideline in 1977. In subsequent years, more structured and comprehensive blood-pressure guidelines have evolved to become a major resource in clinical and public health practice. Despite some limitations, these guidelines provide useful evidence-based guidance for diagnosis and management of high blood pressure. The core advice in most of the current comprehensive blood pressure guidelines is more similar than different. Modelling studies suggest that better adherence to guideline recommendations would result in a lower average blood pressure and substantial improvement in public health.

[Arterial hypertension, cognitive disorders and dementia: a view of a cardiologist]

This article presents a review of Russian and foreign literature about the impact of arterial hypertension (AH) on the risk of cognitive impairment and dementia. Large studies have demonstrated the effect of blood pressure (BP) on the risk of vascular dementia and Alzheimer's disease (AD) in elderly and oldest old people as well as a role of antihypertensive therapy. There is evidence of a negative effect of hypertension in middle age on cognitive functions in late-life. Observational studies as a whole have shown the positive effect of antihypertensive therapy on the prevention of cognitive function and dementia. However, there are a number of limitations that dictate the need for further research on this issue. The importance of the interdisciplinary approach to treatment of cognitive impairment by cardiologists and/or therapists, together with neurologists, as well as complex treatment regimens, including correction of risk factors and neuroprotective therapy, is highlighted.

Effect Modification by Age on the Benefit or Harm of Antihypertensive Treatment for Elderly Hypertensives: A Systematic Review and Meta-analysis

BACKGROUND

The influence of age on balance of benefit vs. potential harm of blood pressure (BP)-lowering therapy for elderly hypertensives is unclear. We evaluated the modifying effects of age on BP lowering for various adverse outcomes in hypertensive patients older than 60 years without specified comorbidities.

METHODS

All relevant randomized controlled trials (RCTs) were systematically identified. Coronary heart disease, stroke, heart failure (HF), cardiovascular death, major adverse cardiovascular events (MACE), renal failure (RF), and all-cause death were assessed. Meta-regression analysis was used to explore the relationship between achieved systolic BP (SBP) and the risk of adverse events. Random-effects meta-analysis was used to pool the estimates.

RESULTS

Our study included 18 RCTs (n = 53,993). Meta-regression analysis showed a lower achieved SBP related with a lower risk of stroke and cardiovascular death, but an increased risk of RF. The regression slopes were comparable between populations stratifying by age 75 years. In subgroup analysis, the relative risks of a more aggressive BP lowering strategy were similar between patients aged older or less than 75 years for all outcomes except for RF (P for interaction = 0.02). Compared to treatment with final achieved SBP 140-150 mm Hg, a lower achieved SBP (<140 mm Hg) was significantly associated with decreased risk of stroke (relative risk = 0.68; 95% confidence interval = 0.55-0.85), HF (0.77; 0.60-0.99), cardiovascular death (0.68; 0.52-0.89), and MACE (0.83; 0.69-0.99).

CONCLUSIONS

To treat hypertension in the elderly, age had trivial effect modification on most outcomes, except for renal failure. Close monitoring of renal function may be warranted in the management of elderly hypertension.

Hypertension Management at Older Age: An Update

Hypertension is a risk factor for cardiovascular morbidity and mortality with increasing prevalence with age, whose treatment is associated with benefits over fatal and non-fatal cardiovascular events even later in life. However, there are persistent concerns on the short- and long-term weighted benefits of treating hypertension in the very old, particularly in those with specific clinical features. In fact, a broad range of clinical scenarios can be observed at older ages, spanning from the healthy to the frailest patient, and hypertension clinical trials have traditionally excluded the latter, thus preventing the unconditioned application to these patients of the same recommendations as in younger ages. Persistent issues regarding high blood pressure management in the very old adult are mainly related to treatment threshold and targets, which have been differently addressed by American and European guidelines. Herein, we will examine the challenges related to high blood pressure treatment in healthy and frail older and very old adults. We will discuss the evidence behind current recommendations. Finally, we will recapitulate the recommended treatment options for high blood pressure in these patients in the light of the most recent guidelines.

2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension

: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.

Investigation of one-stage meta-analysis methods for joint longitudinal and time-to-event data through simulation and real data application

Background: Joint modeling of longitudinal and time‐to‐event data is often advantageous over separate longitudinal or time‐to‐event analyses as it can account for study dropout, error in longitudinally measured covariates, and correlation between longitudinal and time‐to‐event outcomes. The current literature on joint modeling focuses mainly on the analysis of single studies with a lack of methods available for the meta‐analysis of joint data from multiple studies.

Methods: We investigate a variety of one‐stage methods for the meta‐analysis of joint longitudinal and time‐to‐event outcome data. These methods are applied to the INDANA dataset to investigate longitudinally measured systolic blood pressure, with each of time to death, time to myocardial infarction, and time to stroke. Results are compared to separate longitudinal or time‐to‐event meta‐analyses. A simulation study is conducted to contrast separate versus joint analyses over a range of scenarios.

Results: The performance of the examined one‐stage joint meta‐analytic models varied. Models that accounted for between study heterogeneity performed better than models that ignored it. Of the examined methods to account for between study heterogeneity, under the examined association structure, fixed effect approaches appeared preferable, whereas methods involving a baseline hazard stratified by study were least time intensive.

Conclusions: One‐stage joint meta‐analytic models that accounted for between study heterogeneity using a mix of fixed effects or a stratified baseline hazard were reliable; however, models examined that included study level random effects in the association structure were less reliable.

Prevalence, management and control of hypertension in older adults on admission to hospital

Introduction

The aim of this study was to explore the prevalence and management of hypertension among older adults on admission to hospital and to assess the choice of antihypertensive pharmacotherapy in light of relevant comorbid conditions using the national treatment guideline.

Materials and methods

A retrospective cross sectional study of 503 patients aged 65 years or older admitted to a large metropolitan teaching hospital in Sydney Australia was conducted. The main outcome measures were prevalence of hypertension, blood pressure (BP) control, antihypertensive medication use and the appropriateness of antihypertensive medications.

Results

Sixty-nine percent (n = 347) of the study population had a documented diagnosis of hypertension and of these, approximately one third were at target BP levels on admission to hospital. Some concerns regarding choice of antihypertensive noted with 51% of those with comorbid diabetes and 30% of those with comorbid heart failure receiving a potentially inappropriate antihypertensive agent.

Conclusions

Despite the use of antihypertensive pharmacotherapy, many older adults do not have optimal BP control and are not reaching target BP levels. New strategies to improve blood pressure control in older populations especially targeting women, those with a past history of myocardial infarction and those on multiple antihypertensive medications are needed.

Chinese expert consensus on the diagnosis and treatment of hypertension in the elderly (2017)

China has stepped into an aging society. The social service development statistical bulletin 2015 published in July 2016 by Ministry of Civil Affairs showed that till the end of 2015, the amount of people ≥60 years of age had already approached to 222 million, which comprised 16.1% of the Chinese population, while the amount of people ≥65 years of age comprised 10.5% of the Chinese population was 143 million.1 Hypertension is an independent risk factor for cardio-cerebral-vascular diseases and is a primary and contributory cause for death and disability in the elderly. A large number of epidemiological and clinical studies have shown that the risk of target organ damage of hypertension such as ischemic heart disease, cardiac insufficiency, stroke, chronic kidney disease, and aortic and peripheral artery diseases significantly increases with aging. Blood pressure control plays a significant role in reducing cardio-cerebral-vascular events and all-cause mortality.2 Compared to younger patients with similar blood pressure elevation, the risks of cardiovascular and cerebrovascular events significantly increase in the elderly. Because of specialties in the pathogenesis and clinical manifestation in older patients with hypertension, physicians should pay more attention to the population characteristics and individual treatments.

Methods of Blood Pressure Assessment Used in Milestone Hypertension Trials

In the present review, we summarized the blood pressure (BP) measurement protocols of contemporary outcome trials in hypertension. In all these trials, clinic BP was used for the diagnosis and therapeutic monitoring of hypertension. In most trials, BP was measured in the sitting position with mercury sphygmomanometers or automated electronic BP monitors by trained observers. BP readings were taken on each occasion at least twice with a 30-to-60-s interval after 5 min of rest. Details regarding the arm side, cuff size, and the timing of BP measurement were infrequently reported. If clinic BP continues being used in future hypertension trials, the measurement should strictly follow current guidelines. The observers must be trained and experienced, and the device should be validated by automated electronic BP monitors. On each occasion, BP readings should be taken 2-3 times. The time interval between successive measurements has to be 30-60 s, and the resting period before the measurement should be at least 5 min in the supine or seated position and 1-3 min standing. BP should usually be measured in the seated position. The higher arm side and an appropriate size cuff should be chosen and noted. BP should be measured at defined trough hours. Automated office BP measurement has recently been used and seems to have less white-coat effect. The out-of-office BP measurement, either ambulatory or home BP monitoring, was only used in a subset of study participants of few hypertension trials. Future trials should consider these novel office or out-of-office BP measurements in guiding the therapy and preventing cardiovascular events.

Pharmacological management of hypertension in the elderly and frail populations

INTRODUCTION

Cardiovascular disease is a leading cause of mortality in the elderly. Hypertension is an important modifiable risk factor that contributes to cardiovascular morbidity and mortality. The prevalence of hypertension is known to increase with age, and hypertension has been associated with an increase in risk for cardiovascular disease in the elderly. There is a wealth of evidence that supports aggressive control of blood pressure to lower cardiovascular risk in the general population. However, there are limited data to guide management of hypertension in the elderly and frail patient subgroups. These subgroups are inadequately treated due to lack of clarity regarding blood pressure thresholds, treatment targets, comorbidities, frailty, drug interactions from polypharmacy, and high cost of care. Areas covered: We review the current evidence behind the definition, goals, and treatments for hypertension in the elderly and frail and outline a strategy that can be used to guide antihypertensive pharmacotherapy in this population. Expert commentary: Lower blood pressure to < 130/80 mm Hg in elderly patients if tolerated and promote use of combination therapy if the blood pressure is > 20/10 mm Hg over the goal blood pressure. Antihypertensive treatment regimens must be tailored to each individual based on their comorbidities, risk for adverse effects, and potential drug interactions ( Figure 1 ).

Blood pressure targets for hypertension in patients with type 2 diabetes

BACKGROUND

Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality.

CONCLUSIONS

We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms.

First-line drugs for hypertension

BACKGROUND

This is the first update of a review published in 2009. Sustained moderate to severe elevations in resting blood pressure leads to a critically important clinical question: What class of drug to use first-line? This review attempted to answer that question.

OBJECTIVES

To quantify the mortality and morbidity effects from different first-line antihypertensive drug classes: thiazides (low-dose and high-dose), beta-blockers, calcium channel blockers, ACE inhibitors, angiotensin II receptor blockers (ARB), and alpha-blockers, compared to placebo or no treatment.Secondary objectives: when different antihypertensive drug classes are used as the first-line drug, to quantify the blood pressure lowering effect and the rate of withdrawal due to adverse drug effects, compared to placebo or no treatment.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

Randomized trials (RCT) of at least one year duration, comparing one of six major drug classes with a placebo or no treatment, in adult patients with blood pressure over 140/90 mmHg at baseline. The majority (over 70%) of the patients in the treatment group were taking the drug class of interest after one year. We included trials with both hypertensive and normotensive patients in this review if the majority (over 70%) of patients had elevated blood pressure, or the trial separately reported outcome data on patients with elevated blood pressure.

DATA COLLECTION AND ANALYSIS

The outcomes assessed were mortality, stroke, coronary heart disease (CHD), total cardiovascular events (CVS), decrease in systolic and diastolic blood pressure, and withdrawals due to adverse drug effects. We used a fixed-effect model to to combine dichotomous outcomes across trials and calculate risk ratio (RR) with 95% confidence interval (CI). We presented blood pressure data as mean difference (MD) with 99% CI.

MAIN RESULTS

The 2017 updated search failed to identify any new trials. The original review identified 24 trials with 28 active treatment arms, including 58,040 patients. We found no RCTs for ARBs or alpha-blockers. These results are mostly applicable to adult patients with moderate to severe primary hypertension. The mean age of participants was 56 years, and mean duration of follow-up was three to five years.High-quality evidence showed that first-line low-dose thiazides reduced mortality (11.0% with control versus 9.8% with treatment; RR 0.89, 95% CI 0.82 to 0.97); total CVS (12.9% with control versus 9.0% with treatment; RR 0.70, 95% CI 0.64 to 0.76), stroke (6.2% with control versus 4.2% with treatment; RR 0.68, 95% CI 0.60 to 0.77), and coronary heart disease (3.9% with control versus 2.8% with treatment; RR 0.72, 95% CI 0.61 to 0.84).Low- to moderate-quality evidence showed that first-line high-dose thiazides reduced stroke (1.9% with control versus 0.9% with treatment; RR 0.47, 95% CI 0.37 to 0.61) and total CVS (5.1% with control versus 3.7% with treatment; RR 0.72, 95% CI 0.63 to 0.82), but did not reduce mortality (3.1% with control versus 2.8% with treatment; RR 0.90, 95% CI 0.76 to 1.05), or coronary heart disease (2.7% with control versus 2.7% with treatment; RR 1.01, 95% CI 0.85 to 1.20).Low- to moderate-quality evidence showed that first-line beta-blockers did not reduce mortality (6.2% with control versus 6.0% with treatment; RR 0.96, 95% CI 0.86 to 1.07) or coronary heart disease (4.4% with control versus 3.9% with treatment; RR 0.90, 95% CI 0.78 to 1.03), but reduced stroke (3.4% with control versus 2.8% with treatment; RR 0.83, 95% CI 0.72 to 0.97) and total CVS (7.6% with control versus 6.8% with treatment; RR 0.89, 95% CI 0.81 to 0.98).Low- to moderate-quality evidence showed that first-line ACE inhibitors reduced mortality (13.6% with control versus 11.3% with treatment; RR 0.83, 95% CI 0.72 to 0.95), stroke (6.0% with control versus 3.9% with treatment; RR 0.65, 95% CI 0.52 to 0.82), coronary heart disease (13.5% with control versus 11.0% with treatment; RR 0.81, 95% CI 0.70 to 0.94), and total CVS (20.1% with control versus 15.3% with treatment; RR 0.76, 95% CI 0.67 to 0.85).Low-quality evidence showed that first-line calcium channel blockers reduced stroke (3.4% with control versus 1.9% with treatment; RR 0.58, 95% CI 0.41 to 0.84) and total CVS (8.0% with control versus 5.7% with treatment; RR 0.71, 95% CI 0.57 to 0.87), but not coronary heart disease (3.1% with control versus 2.4% with treatment; RR 0.77, 95% CI 0.55 to 1.09), or mortality (6.0% with control versus 5.1% with treatment; RR 0.86, 95% CI 0.68 to 1.09).There was low-quality evidence that withdrawals due to adverse effects were increased with first-line low-dose thiazides (5.0% with control versus 11.3% with treatment; RR 2.38, 95% CI 2.06 to 2.75), high-dose thiazides (2.2% with control versus 9.8% with treatment; RR 4.48, 95% CI 3.83 to 5.24), and beta-blockers (3.1% with control versus 14.4% with treatment; RR 4.59, 95% CI 4.11 to 5.13). No data for these outcomes were available for first-line ACE inhibitors or calcium channel blockers. The blood pressure data were not used to assess the effect of the different classes of drugs as the data were heterogeneous, and the number of drugs used in the trials differed.

AUTHORS' CONCLUSIONS

First-line low-dose thiazides reduced all morbidity and mortality outcomes in adult patients with moderate to severe primary hypertension. First-line ACE inhibitors and calcium channel blockers may be similarly effective, but the evidence was of lower quality. First-line high-dose thiazides and first-line beta-blockers were inferior to first-line low-dose thiazides.

Drug treatment of hypertension in older patients with diabetes mellitus

INTRODUCTION

Hypertension is more prevalent in the elderly (age>65 years) diabetic population than in the general population and shows an increasing prevalence with advancing age. Both diabetes mellitus (DM) and hypertension are independent risk factors for cardiovascular (CV) related morbidity and mortality. Optimal BP targets were not identified in elderly patients with DM and hypertension.

AREAS COVERED

In this review article, the authors briefly discuss the pathophysiology of hypertension in elderly diabetics, present evidence with various antihypertensive drug classes supporting the treatment of hypertension to reduce CV events in older diabetics, and then discuss the optimal target BP goals in these patients.

EXPERT OPINION

Clinicians should have a BP goal of less than 130/80 mm in all elderly patients with hypertension and DM, especially in those with high CV-risk. When medications are required for optimal BP control in addition to lifestyle measures, either thiazide diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be considered as initial therapy. Combinations of medications are usually required in these patients because BP control is more difficult to achieve in diabetics than those without DM.

Pros and Cons of Intensive Systolic Blood Pressure Lowering

PURPOSE OF REVIEW

The Systolic Blood Pressure Intervention Trial demonstrated significant decreases in cardiovascular events and total mortality with intensive systolic blood pressure lowering in adults with high cardiovascular risk in the absence of diabetes but benefits were accompanied by increased risk of adverse events.

RECENT FINDINGS

Over 100,000 deaths and 46,000 cases of heart failure may be prevented annually if intensive systolic blood pressure lowering is implemented in 17 million US adults who are age 50 years and older, and have high cardiovascular risk in the absence of diabetes and meet eligibility for the Systolic Blood Pressure Intervention Trial. However, the benefits of intensive SBP lowering will be accompanied by an excess of 43,000 cases of electrolyte abnormalities and 88,000 cases of acute kidney injury. Physicians should consider implementation of intensive systolic blood pressure lowering in appropriate patients who understand the risks and benefits of this intervention.

Considerations for Optimal Blood Pressure Goals in the Elderly Population: A Review of Emergent Evidence

Recent hypertension clinical trials and national guideline updates have created a debate on the most appropriate treatment goals in elderly patients with hypertension. In 2014, recommendations by the Eighth Joint National Committee allowed a more lenient goal for patients 60 years and older compared with previous guidelines. Since then, several large clinical trials and meta-analyses have added more information regarding strict versus lenient treatment goals. Most recently, the American College of Cardiology and American Heart Association Task Force published their highly anticipated hypertension guideline developed in conjunction with nine additional interdisciplinary organizations. This review discusses the culmination of emerging data to provide more insight into the treatment of hypertension in the elderly. A literature search was conducted using PubMed, the Cumulative Index of Nursing and Allied Health, the Cochrane database, and by hand-searching references from relevant articles. The following key terms were used: hypertension, blood pressure, systolic, and elderly. Available literature suggests that it is reasonable to target an office systolic blood pressure of less than 130 mm Hg in elderly patients with hypertension. An individualized approach is reasonable for those who are institutionalized, with high comorbidity burden, or have a short life expectancy. A diastolic blood pressure of less than 60 mm Hg should be avoided due to the potential for an increase in cardiovascular risk. The method of blood pressure measurement is extremely important to consider when determining the blood pressure goal, and proper procedures for accurate blood pressure measurement must be followed. Other factors important to consider may include the patient's comorbidities, frailty, as well as the patient's potential for adverse drug reactions.

Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels: A Systematic Review and Meta-analysis

IMPORTANCE

High blood pressure (BP) is the most important risk factor for death and cardiovascular disease (CVD) worldwide. The optimal cutoff for treatment of high BP is debated.

OBJECTIVE

To assess the association between BP lowering treatment and death and CVD at different BP levels.

DATA SOURCES

Previous systematic reviews were identified from PubMed, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effect. Reference lists of these reviews were searched for randomized clinical trials. Randomized clinical trials published after November 1, 2015, were also searched for in PubMed and the Cochrane Central Register for Controlled Trials during February 2017.

STUDY SELECTION

Randomized clinical trials with at least 1000 patient-years of follow-up, comparing BP-lowering drugs vs placebo or different BP goals were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from original publications. Risk of bias was assessed using the Cochrane Collaborations assessment tool. Relative risks (RRs) were pooled in random-effects meta-analyses with Knapp-Hartung modification. Results are reported according to PRISMA guidelines.

MAIN OUTCOMES AND MEASURES

Prespecified outcomes of interest were all-cause mortality, cardiovascular mortality, major cardiovascular events, coronary heart disease (CHD), stroke, heart failure, and end-stage renal disease.

RESULTS

Seventy-four unique trials, representing 306 273 unique participants (39.9% women and 60.1% men; mean age, 63.6 years) and 1.2 million person-years, were included in the meta-analyses. In primary prevention, the association of BP-lowering treatment with major cardiovascular events was dependent on baseline systolic BP (SBP). In trials with baseline SBP 160 mm Hg or above, treatment was associated with reduced risk for death (RR, 0.93; 95% CI, 0.87-1.00) and a substantial reduction of major cardiovascular events (RR, 0.78; 95% CI, 0.70-0.87). If baseline SBP ranged from 140 to 159 mm Hg, the association of treatment with mortality was similar (RR, 0.87; 95% CI, 0.75-1.00), but the association with major cardiovascular events was less pronounced (RR, 0.88; 95% CI, 0.80-0.96). In trials with baseline SBP below 140 mm Hg, treatment was not associated with mortality (RR, 0.98; 95% CI, 0.90-1.06) and major cardiovascular events (RR, 0.97; 95% CI, 0.90-1.04). In trials including people with previous CHD and mean baseline SBP of 138 mm Hg, treatment was associated with reduced risk for major cardiovascular events (RR, 0.90; 95% CI, 0.84-0.97), but was not associated with survival (RR, 0.98; 95% CI, 0.89-1.07).

CONCLUSIONS AND RELEVANCE

Primary preventive BP lowering is associated with reduced risk for death and CVD if baseline SBP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with CHD.

Frailty, Disability, and Ambulatory Blood Pressure in Older Adults

BACKGROUND AND OBJECTIVE

Frailty and disability are associated with cardiovascular risk factors, including hypertension, in older people; however, little is known about their association with ambulatory blood pressure (BP). Thus, we assessed the relationship of frailty and disability with ambulatory BP in older adults.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 1047 community-living individuals aged ≥60 years in Spain.

MEASUREMENTS

BP was determined with validated devices under standardized conditions during 24 hours. Frailty was defined as having 3 or more of the following criteria: weight loss, low grip strength, low energy, slow gait speed, and low physical activity. Disability was assessed with the Lawton-Brodýs questionnaire on instrumental activities of daily living. Associations with systolic BP (SBP) and dipping (nocturnal SBP decline) were modeled and adjusted for sociodemographic variables, body mass index, lifestyles, antihypertensive drug treatment, comorbidities, 24-hour heart rate, and conventional or ambulatory SBP as appropriate.

RESULTS

Participants' mean age was 71.7 years (50.8% men); 6% were frail and 8.1% had disability. Compared with nonfrail participants, those with frailty had 3.5 mm Hg lower daytime SBP (P = .001), 3.3% less SBP dipping (P = .003), and 3.6 mmHg higher nighttime SBP (P = .016). Compared with participants who are not disabled, those who are disabled had 2.5 mmHg lower daytime SBP (P = .002), 2.5% less SBP dipping (P = .003), and 2.7 mmHg higher nighttime SBP (P = .011).

CONCLUSIONS

In community-dwelling older adults, frailty and disability were independently associated with lower diurnal SBP, blunted nocturnal decline of SBP, and higher nocturnal SBP. These findings may help explain the higher mortality associated with low clinic SBP in frail older subjects observed in epidemiologic studies.

Investigation of 2-stage meta-analysis methods for joint longitudinal and time-to-event data through simulation and real data application

Background

Joint modelling of longitudinal and time‐to‐event data is often preferred over separate longitudinal or time‐to‐event analyses as it can account for study dropout, error in longitudinally measured covariates, and correlation between longitudinal and time‐to‐event outcomes. The joint modelling literature focuses mainly on the analysis of single studies with no methods currently available for the meta‐analysis of joint model estimates from multiple studies.

Methods

We propose a 2‐stage method for meta‐analysis of joint model estimates. These methods are applied to the INDANA dataset to combine joint model estimates of systolic blood pressure with time to death, time to myocardial infarction, and time to stroke. Results are compared to meta‐analyses of separate longitudinal or time‐to‐event models. A simulation study is conducted to contrast separate versus joint analyses over a range of scenarios.

Results

Using the real dataset, similar results were obtained by using the separate and joint analyses. However, the simulation study indicated a benefit of use of joint rather than separate methods in a meta‐analytic setting where association exists between the longitudinal and time‐to‐event outcomes.

Conclusions

Where evidence of association between longitudinal and time‐to‐event outcomes exists, results from joint models over standalone analyses should be pooled in 2‐stage meta‐analyses.

Recent changes in blood pressure levels, hypertension prevalence and treatment rates, and the rate of reaching target blood pressure in the elderly

Antihypertensive treatment has beneficial effects in the elderly. Surveying the situation of blood pressure in the elderly is quite important for planning strategies to manage elderly hypertensives. The aim of the present study was to investigate changes in blood pressure in the elderly over the past 15 years.As part of a physical check-up program between 2001 and 2015, 29,363 elderly participants (≥65 years of age) attended and were enrolled in the present study. The characteristics of the participants in each year were analyzed cross-sectionally and the results were compared over the 15 years. Changes in blood pressure, hypertension prevalence, and treatment rates, and the rate of reaching target blood pressure in the elderly were investigated.The prevalence of hypertension during the study period increased with increasing participant age. However, both the treatment rate and the rate of reaching target blood pressure in treated subjects improved. The blood pressure of treated hypertensive elderly subjects decreased from 146.1/83.0 to 130.6/75.4 mm Hg, and the reduction was most evident after revision of Japanese Society of Hypertension guidelines regarding target blood pressure in elderly hypertensives. Blood pressure in the entire cohort of elderly subjects decreased from 133.8/78.4 mm Hg in 2001 to 127.9/74.6 mm Hg in 2015.Blood pressure in elderly subjects had decreased over the 15-year study period primarily due to reductions in blood pressure in elderly hypertensive patients on medication. Guidelines for the treatment of hypertension have had a beneficial effect on the management of hypertension in the elderly.

Uncontrolled Hypertension Increases with Age in an Older Community-Dwelling Chinese Population in Shanghai

We determined the prevalence of hypertension, medication usage and attainment of blood pressure goals in older (≥65 to <80 years and ≥80 years) urban community-dwelling Chinese subjects. Data were obtained in 3950 subjects (mean age 72.0 years, 1745 male) including 609 subjects aged ≥80 years in the Shanghai Elderly Cardiovascular Health Study (SHECHS). Established cardiovascular disease was present in 7.7% of participants. The prevalence of hypertension was 74.8% overall and it was more than 80% in individuals considered to be in moderate and higher cardiovascular disease risk categories. In hypertensive subjects, 67.1% were on treatment and treatment was more frequent in high and very high cardiovascular risk individuals. Attainment of the systolic blood pressure goal <150 mmHg was 62.9% and was greater in the ≥65 to <80 years group than in the ≥80 years group. The most commonly used antihypertensive treatments were calcium channel blockers (54.2%), followed by angiotensin receptor blockers (43.1%). Diuretics were used in 2.6%. Fixed-dose combination antihypertensive tablets were used in some of the ≥65 to <80 years group (12.4%) and more of the ≥80 years group (18.2%) and 70.9% of the ≥65 to <80 years group and 80.2% of the ≥80 years group were on monotherapy. There were high prevalence and high treatment rates of hypertension, but poor attainment of the systolic blood pressure goal of <150 mmHg, especially in the ≥80 years group of community-dwelling Chinese. Considering that more intensive treatment of hypertension in older subjects may be warranted after recent studies, this might be achieved by more frequent use of combinations of effective therapies and diuretics.

Association Between More Intensive vs Less Intensive Blood Pressure Lowering and Risk of Mortality in Chronic Kidney Disease Stages 3 to 5: A Systematic Review and Meta-analysis

Importance

Trials in patients with hypertension have demonstrated that intensive blood pressure (BP) lowering reduces the risk of cardiovascular disease and all-cause mortality but may increase the risk of chronic kidney disease (CKD) incidence and progression. Whether intensive BP lowering is associated with a mortality benefit in patients with prevalent CKD remains unknown.

Objectives

To conduct a systematic review and meta-analysis of randomized clinical trials (RCTs) to investigate if more intensive compared with less intensive BP control is associated with reduced mortality risk in persons with CKD stages 3 to 5.

Data Sources

Ovid MEDLINE, Cochrane Library, EMBASE, PubMed, Science Citation Index, Google Scholar, and clinicaltrials.gov electronic databases.

Study Selection

All RCTs were included that compared 2 defined BP targets (either active BP treatment vs placebo or no treatment, or intensive vs less intensive BP control) and enrolled adults (≥18 years) with CKD stages 3 to 5 (estimated glomerular filtration rate <60 mL/min/1.73 m2) exclusively or that included a CKD subgroup between January 1, 1950, and June 1, 2016.

Data Extraction and Synthesis

Two of us independently evaluated study quality and extracted characteristics and mortality events among persons with CKD within the intervention phase for each trial. When outcomes within the CKD group had not previously been published, trial investigators were contacted to request data within the CKD subset of their original trials.

Main Outcome and Measure

All-cause mortality during the active treatment phase of each trial.

Results

This study identified 30 RCTs that potentially met the inclusion criteria. The CKD subset mortality data were extracted in 18 trials, among which there were 1293 deaths in 15 924 participants with CKD. The mean (SD) baseline systolic BP (SBP) was 148 (16) mm Hg in both the more intensive and less intensive arms. The mean SBP dropped by 16 mm Hg to 132 mm Hg in the more intensive arm and by 8 mm Hg to 140 mm Hg in the less intensive arm. More intensive vs less intensive BP control resulted in 14.0% lower risk of all-cause mortality (odds ratio, 0.86; 95% CI, 0.76-0.97; P = .01), a finding that was without significant heterogeneity and appeared consistent across multiple subgroups.

Conclusions and Relevance

Randomization to more intensive BP control is associated with lower mortality risk among trial participants with hypertension and CKD. Further studies are required to define absolute BP targets for maximal benefit and minimal harm.

Combination drug treatment in hypertension

Combination treatment of hypertension has been introduced almost 50 years ago, because of the marked blood pressure (BP) elevation of recruited patients in the early randomized controlled trials of BP lowering. However, in all subsequent trials combination treatment was per protocol anticipated irrespectively of the initial randomized treatment to ensure either a desirable BP lowering or a comparable level of BP reduction among arms. Beyond clinical trials, combination treatment is mainly used in the clinical practice to reinforce ongoing single-agent treatment to achieve hypertension control. Renin-angiotensin system inhibiting drugs are the cornerstone of combination treatment of hypertension because they have been repeatedly tested in clinical trials in combination with other agents either from the beginning or during the follow-up. Effective BP lowering following combination treatment depends on the activation of complementary pathophysiological pathways but different agents can stimulate a common mode of action more effectively. The rate of adverse events following combination treatment may be reduced because effects of each agents are reciprocally counterbalanced. Nevertheless, aggressive BP lowering independently of the implemented combination is associated with increase of treatment discontinuations. In the management of resistant hypertension, a fourth-line agent used on top of the failing triple (diuretic-based) combination is effective to control hypertension only in 50% of patients. At present, it is questioned whether combination treatment of hypertension should be used alternatively to monotherapy in newly-diagnosed hypertensive patients without marked BP elevation or at low cardiovascular risk. Selection between free and fixed-dose combination treatment should be individualized depending on clinical criteria.

Effects of blood-pressure-lowering treatment on outcome incidence in hypertension: 10 - Should blood pressure management differ in hypertensive patients with and without diabetes mellitus? Overview and meta-analyses of randomized trials

BACKGROUND

Type 2 diabetes mellitus is associated with an increased risk of hypertension, and cardiovascular and renal disease, and it has been recommended that management of hypertension should be more aggressive in presence than in absence of diabetes mellitus, but the matter is controversial at present.

OBJECTIVES

Meta-analysing all available randomized controlled trials (RCTs) to compare the effects on cardiovascular and renal outcomes of blood pressure BP lowering to different systolic BP (SBP) and diastolic BP (DBP) levels or by different drug classes in patients with and without diabetes mellitus.

METHODS

The database consisted of 72 BP-lowering RCTs (260 210 patients) and 50 head-to-head drug comparison RCTs (247 006). Among these two sets, RCTs or RCT subgroups separately reporting data from patients with and without diabetes mellitus were identified, and stratified by in-treatment achieved SBP and DBP, by drug class compared with placebo, and drug class compared with all other classes. Risk ratios and 95% confidence intervals, and absolute risk reductions of six fatal and non-fatal cardiovascular outcomes, all-cause death, and end-stage renal disease (ESRD) were calculated (random-effects model) separately for diabetes mellitus and no diabetes mellitus, and compared by interaction analysis.

RESULTS

We identified 41 RCTs providing data on 61 772 patients with diabetes mellitus and 40 RCTs providing data on 191 353 patients without diabetes mellitus. For achieved SBP at least 140 mmHg, relative and absolute reductions of most cardiovascular outcomes were significantly greater in diabetes mellitus than no diabetes mellitus, whereas for achieved SBP below 130 mmHg, the difference disappeared or reversed (greater outcome reduction in no diabetes mellitus). Significant ESRD reduction was found only in diabetes mellitus, but it was greatest when achieved SBP was at least 140 mmHg, and no further effect was found at SBP below 140 mmHg. All antihypertensive drug classes reduced cardiovascular risk vs. placebo in diabetes mellitus and no diabetes mellitus, but angiotensin-converting enzyme inhibitors were the only class more effective in diabetes mellitus than in no diabetes mellitus. When compared to other classes, renin-angiotensin system blockers were equally effective in cardiovascular prevention in no diabetes mellitus, but moderately, though significantly, more effective in diabetes mellitus.

CONCLUSION

BP-lowering treatment significantly and importantly reduces cardiovascular risk both in diabetes mellitus and no diabetes mellitus, but evidence for reduced ESRD risk is available only in diabetes. Contrary to past recommendations, in diabetes mellitus there is little or no further benefit in lowering SBP below 130 mmHg, whereas continuing benefit is seen in no diabetes mellitus also at SBP below 130 mmHg. Although all BP-lowering drugs can beneficially be prescribed in hypertensive patients with diabetes mellitus, the current recommendation to initiate or include a renin-angiotensin system blocker is supported by the evidence here presented.

Effects of blood pressure lowering treatment in hypertension: 8. Outcome reductions vs. discontinuations because of adverse drug events - meta-analyses of randomized trials

BACKGROUND

Previous meta-analyses of randomized controlled trials (RCTs) of blood pressure (BP)-lowering treatment provided overwhelming evidence that treatment markedly reduces risk of cardiovascular outcomes in hypertensive patients. However, adverse events associated with BP-lowering treatment have never been surveyed systematically.

OBJECTIVES

Identifying among BP-lowering RCTs those reporting a common and meaningful index of treatment-attributed adverse events, and describing the burden of these adverse events accompanying the benefits of mortality and morbidity reduction induced by treatment.

METHODS

The database consisted of the BP-lowering RCTs (active vs. placebo or less active treatment) we have described (70 RCTs, 255 970 participants, 1 091 964 patient-years). A common index of relevant adverse events was identified as permanent treatment discontinuation attributed to treatment adverse events. Risk ratios and 95% confidence intervals, standardized to a SBP/DBP reduction of 10/5 mmHg, of seven fatal and nonfatal outcomes and of treatment discontinuations for adverse events were calculated (random-effects model). The relationships of outcome reductions and discontinuation excess to SBP and DBP reductions were investigated by meta-regressions.

RESULTS

Forty-four RCTs provided data on treatment discontinuations for adverse events and six more on serious adverse events because of treatment (179 949 patients, 719 796 patient-years). In these 50 RCTs, a significant 24% reduction of major cardiovascular event risk was associated with a significant 89% increase in the risk of discontinuations (33 major cardiovascular effects prevented and 84 excess discontinuations/1000 patients for 5 years). Metaregression analysis indicated that both outcome reductions and treatment discontinuation excess were significantly related to the extent of SBP and DBP reduction, but absolute treatment discontinuation excess disproportionally increased with larger BP reductions than increase in outcome risk reduction. Furthermore, a standard SBP reduction was found associated with a constant relative reduction, but a smaller absolute reduction of cardiovascular events, and a greater relative excess of treatment discontinuations when the achieved SBP was below 130 mmHg rather than in higher ranges.

CONCLUSION

The burden of adverse events associated with BP-lowering treatment should be considered not to deny patients the overwhelming benefits of BP lowering, but whenever the extent of the BP lowering or the BP target to be achieved are discussed.

Threshold and Target for Blood Pressure Lowering in the Elderly

PURPOSE OF REVIEW

Detection of elevated blood pressure values in elderly patients represents a common clinical condition associated with an increased cardiovascular risk. This has been shown to be the case in both systodiastolic and isolated systolic hypertension as well. However, despite the evidence of the benefits of the blood pressure lowering intervention in terms of reduction of cardiovascular morbidity and mortality, at least two issues related to antihypertensive drug treatment in aged individuals are still undefined: (1) the blood pressure threshold at which antihypertensive drug should be initiated and (2) the blood pressure goals of the therapeutic intervention.

RECENT FINDINGS

The present paper will critically review the evidence available so far on these two issues as well as the position of current guidelines and consensus statements. Emphasis will be given to the analysis of the new data of the Systolic Blood Pressure Interventional Trial (SPRINT), which have recently demonstrated the benefits, even in individuals aged more than 75 years, of a tight blood pressure reduction to systolic blood pressure to 120 mmHg or less. The potential limitations of the trial will be also critically addressed and the expectations of ongoing clinical studies investigating the issue in elderly patients properly emphasized. Although of interest, the results of the SPRINT trial encompass a number of limitations which limit their applicability to the general elderly hypertensive population. A prudent approach will be to adopt in clinical practice the less intensive and more conservative targets recommended by current guidelines.

Pharmacotherapy for hypertension in adults aged 18 to 59 years

BACKGROUND

Hypertension is an important risk factor for adverse cardiovascular events including stroke, myocardial infarction, heart failure and renal failure. The main goal of treatment is to reduce these events. Systematic reviews have shown proven benefit of antihypertensive drug therapy in reducing cardiovascular morbidity and mortality but most of the evidence is in people 60 years of age and older. We wanted to know what the effects of therapy are in people 18 to 59 years of age.

OBJECTIVES

To quantify antihypertensive drug effects on all-cause mortality in adults aged 18 to 59 years with mild to moderate primary hypertension. To quantify effects on cardiovascular mortality plus morbidity (including cerebrovascular and coronary heart disease mortality plus morbidity), withdrawal due adverse events and estimate magnitude of systolic blood pressure (SBP) and diastolic blood pressure (DBP) lowering at one year.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to January 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

Randomized trials of at least one year' duration comparing antihypertensive pharmacotherapy with a placebo or no treatment in adults aged 18 to 59 years with mild to moderate primary hypertension defined as SBP 140 mmHg or greater or DBP 90 mmHg or greater at baseline, or both.

DATA COLLECTION AND ANALYSIS

The outcomes assessed were all-cause mortality, total cardiovascular (CVS) mortality plus morbidity, withdrawals due to adverse events, and decrease in SBP and DBP. For dichotomous outcomes, we used risk ratio (RR) with 95% confidence interval (CI) and a fixed-effect model to combine outcomes across trials. For continuous outcomes, we used mean difference (MD) with 95% CI and a random-effects model as there was significant heterogeneity.

MAIN RESULTS

The population in the seven included studies (17,327 participants) were predominantly healthy adults with mild to moderate primary hypertension. The Medical Research Council Trial of Mild Hypertension contributed 14,541 (84%) of total randomized participants, with mean age of 50 years and mean baseline blood pressure of 160/98 mmHg and a mean duration of follow-up of five years. Treatments used in this study were bendrofluazide 10 mg daily or propranolol 80 mg to 240 mg daily with addition of methyldopa if required. The risk of bias in the studies was high or unclear for a number of domains and led us to downgrade the quality of evidence for all outcomes.Based on five studies, antihypertensive drug therapy as compared to placebo or untreated control may have little or no effect on all-cause mortality (2.4% with control vs 2.3% with treatment; low quality evidence; RR 0.94, 95% CI 0.77 to 1.13). Based on 4 studies, the effects on coronary heart disease were uncertain due to low quality evidence (RR 0.99, 95% CI 0.82 to 1.19). Low quality evidence from six studies showed that drug therapy may reduce total cardiovascular mortality and morbidity from 4.1% to 3.2% over five years (RR 0.78, 95% CI 0.67 to 0.91) due to reduction in cerebrovascular mortality and morbidity (1.3% with control vs 0.6% with treatment; RR 0.46, 95% CI 0.34 to 0.64). Very low quality evidence from three studies showed that withdrawals due to adverse events were higher with drug therapy from 0.7% to 3.0% (RR 4.82, 95% CI 1.67 to 13.92). The effects on blood pressure varied between the studies and we are uncertain as to how much of a difference treatment makes on average.

AUTHORS' CONCLUSIONS

Antihypertensive drugs used to treat predominantly healthy adults aged 18 to 59 years with mild to moderate primary hypertension have a small absolute effect to reduce cardiovascular mortality and morbidity primarily due to reduction in cerebrovascular mortality and morbidity. All-cause mortality and coronary heart disease were not reduced. There is lack of good evidence on withdrawal due to adverse events. Future trials in this age group should be at least 10 years in duration and should compare different first-line drug classes and strategies.

Disease drivers of aging

It has long been known that aging, at both the cellular and organismal levels, contributes to the development and progression of the pathology of many chronic diseases. However, much less research has examined the inverse relationship-the contribution of chronic diseases and their treatments to the progression of aging-related phenotypes. Here, we discuss the impact of three chronic diseases (cancer, HIV/AIDS, and diabetes) and their treatments on aging, putative mechanisms by which these effects are mediated, and the open questions and future research directions required to understand the relationships between these diseases and aging.

A sudden death risk score specifically for hypertension: based on 25 648 individual patient data from six randomized controlled trials

OBJECTIVE

To construct a sudden death risk score specifically for hypertension (HYSUD) patients with or without cardiovascular history.

METHODS

Data were collected from six randomized controlled trials of antihypertensive treatments with 8044 women and 17 604 men differing in age ranges and blood pressure eligibility criteria. In total, 345 sudden deaths (1.35%) occurred during a mean follow-up of 5.16 years. Risk factors of sudden death were examined using a multivariable Cox proportional hazards model adjusted on trials. The model was transformed to an integer system, with points added for each factor according to its association with sudden death risk.

RESULTS

Antihypertensive treatment was not associated with a reduction of the sudden death risk and had no interaction with other factors, allowing model development on both treatment and placebo groups. A risk score of sudden death in 5 years was built with seven significant risk factors: age, sex, SBP, serum total cholesterol, cigarette smoking, diabetes, and history of myocardial infarction. In terms of discrimination performance, HYSUD model was adequate with areas under the receiver operating characteristic curve of 77.74% (confidence interval 95%, 74.13-81.35) for the derivation set, of 77.46% (74.09-80.83) for the validation set, and of 79.17% (75.94-82.40) for the whole population.

CONCLUSION

Our work provides a simple risk-scoring system for sudden death prediction in hypertension, using individual data from six randomized controlled trials of antihypertensive treatments. HYSUD score could help assessing a hypertensive individual's risk of sudden death and optimizing preventive therapeutic strategies for these patients.

Stroke in Older Survivors of Ischemic Stroke: Standard Care or Something Different?

Stroke is one of the leading causes of death and disability and it is more likely to occur in those who are older. Because people are living longer, the definition of "old" continues to evolve. Age alone should not influence the healthcare that a patient receives, however, evidence indicates that this does occur, especially in older patients. On the basis of the available evidence, it is time to reconsider whether or not stroke care should differ in older survivors of stroke and if so, why. This is a narrative review of stroke-related health care in those with a recent ischemic stroke. It seeks to answer the following question: Should patients aged ≥80 years who have experienced a recent ischemic stroke receive standard care or something different, and if they should receive something different, what should they receive and why? The review focusses on long-term survival, hyper-acute care, secondary prevention, and rehabilitation. The authors propose a number of recommendations in relation to stroke care in older survivors of a recent ischemic stroke.

Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records

BACKGROUND

Clinical trials show benefit from lowering systolic blood pressure (SBP) in people ≥80 years of age, but nonrandomized epidemiological studies suggest lower SBP may be associated with higher mortality. This study aimed to evaluate associations of SBP with all-cause mortality by frailty category >80 years of age and to evaluate SBP trajectories before death.

METHODS

A population-based cohort study was conducted using electronic health records of 144 403 participants ≥80 years of age registered with family practices in the United Kingdom from 2001 to 2014. Participants were followed for ≤5 years. Clinical records of SBP were analyzed. Frailty status was classified using the e-Frailty Index into the categories of fit, mild, moderate, and severe. All-cause mortality was evaluated by frailty status and mean SBP in Cox proportional-hazards models. SBP trajectories were evaluated using person months as observations, with mean SBP and antihypertensive treatment status estimated for each person month. Fractional polynomial models were used to estimate SBP trajectories over 5 years before death.

RESULTS

During follow-up, 51 808 deaths occurred. Mortality rates increased with frailty level and were greatest at SBP <110 mm Hg. In fit women, mortality was 7.7 per 100 person years at SBP 120 to 139 mm Hg, 15.2 at SBP 110 to 119 mm Hg, and 22.7 at SBP <110 mm Hg. For women with severe frailty, rates were 16.8, 25.2, and 39.6, respectively. SBP trajectories showed an accelerated decline in the last 2 years of life. The relative odds of SBP <120 mm Hg were higher in the last 3 months of life than 5 years previously in both treated (odds ratio, 6.06; 95% confidence interval, 5.40-6.81) and untreated (odds ratio, 6.31; 95% confidence interval, 5.30-7.52) patients. There was no evidence of intensification of antihypertensive therapy in the final 2 years of life.

CONCLUSIONS

A terminal decline of SBP in the final 2 years of life suggests that nonrandomized epidemiological associations of low SBP with higher mortality may be accounted for by reverse causation if participants with lower blood pressure values are closer, on average, to the end of life.

Effects of Sacubitril/Valsartan Versus Olmesartan on Central Hemodynamics in the Elderly With Systolic Hypertension

Effective treatment of systolic hypertension in elderly patients remains a major therapeutic challenge. A multicenter, double-blind, randomized controlled trial with sacubitril/valsartan (LCZ696), a first-in-class angiotensin receptor neprilysin inhibitor, was conducted to determine its effects versus olmesartan (angiotensin receptor blocker) on central aortic pressures, in elderly patients (aged ≥60 years) with systolic hypertension and pulse pressure >60 mm Hg, indicative of arterial stiffness. Patients (n=454; mean age, 67.7 years; mean seated systolic blood pressure, 158.6 mm Hg; mean seated pulse pressure, 69.7 mm Hg) were randomized to receive once-daily sacubitril/valsartan 200 mg or olmesartan 20 mg, force titrated to double the initial doses after 4 weeks, before primary assessment at 12 weeks. The study extended double-blind treatment for 12 to 52 weeks, during which amlodipine (2.5–5 mg) and subsequently hydrochlorothiazide (6.25–25 mg) were added-on for patients not achieving blood pressure target (<140/90). At week 12, sacubitril/valsartan reduced central aortic systolic pressure (primary assessment) greater than olmesartan by −3.7 mm Hg ( P =0.010), further corroborated by secondary assessments at week 12 (central aortic pulse pressure, −2.4 mm Hg, P <0.012; mean 24-hour ambulatory brachial systolic blood pressure and central aortic systolic pressure, −4.1 mm Hg and −3.6 mm Hg, respectively, both P <0.001). Differences in 24-hour ambulatory pressures were pronounced during sleep. After 52 weeks, blood pressure parameters were similar between treatments ( P <0.002); however, more patients required add-on antihypertensive therapy with olmesartan (47%) versus sacubitril/valsartan (32%; P <0.002). Both treatments were equally well tolerated. The PARAMETER study (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Measuring Arterial Stiffness in the Elderly), for the first time, demonstrated superiority of sacubitril/valsartan versus olmesartan in reducing clinic and ambulatory central aortic and brachial pressures in elderly patients with systolic hypertension and stiff arteries.