Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group

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.

Antihypertension drugs in prevention of cognition disorder and dementia: focus on calcium channel blockers and diuretics

Arterial hypertension is associated with elevated risk of cognition decline and vascular dementia development, as the Alzheimer disease development. Therefore, antihypertension therapy might be of preventive value. The review is focused on literary data that witness on, despite controversial, evidence of cerebroprotective action of the range of antihypertension medications. Especially, dihydropyridine calcium antagonists, diuretics and some blockers of renin-angiotensin-aldosterone system. These act not only via blood pressure decrease, but due to additional specific neuroprotective mechanisms. This makes it to consider calcium antagonists and diuretics as a major component of systemic hypertension management, incl. elderly and senile patients, aiming to prevent cognition decline and dementia of various types development.

Nitrendipine, among the calcium channels antagonists, and indapamide among diuretics have acquired the broadest evidence that points on their cerebroprotective properties.

Pharmacological management of hypertension in the elderly and frail populations

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 ).

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.

Risk of stroke and coronary heart disease among various levels of blood pressure in diabetic and nondiabetic Chinese patients

OBJECTIVE

To compare the risk of stroke and coronary heart disease (CHD) among various blood pressure (BP) levels in diabetic and people without diabetes Chinese patients.

METHODS

This cross-sectional study was part of Prospective Urban Rural Epidemiology China study. Patients aged 35 to70 years were recruited from 12 provinces of China between 2005 and 2009. The participants were classified into three groups: hypertension (HTN), high normal BP, and normal BP, and also into SBP and DBP quintiles.

RESULTS

A total of 42 959 patients were analyzed with 38 975 (90.7% of total population) people without diabetes and 3984 (9.3% of total population) diabetic patients. Among diabetic patients, the HTN group was associated with an increased risk of stroke (odds ratio, 3.03; 95% confidence interval, 1.47-6.25) and CHD (odds ratio, 2.21; 95% confidence interval, 1.45-3.38), when compared with normal BP group. Similar results were drawn in nondiabetic patients. However, no significant difference in risk of stroke or CHD was found between high normal BP and normal BP groups in either diabetic or nondiabetic patients. Risk of CHD and stroke increased significantly when SBP was above 125 mmHg or DBP above 72 mmHg in people without diabetes, whereas this trend was attenuated in diabetic patients.

CONCLUSION

HTN was associated with a two-fold increased risk of CHD and a three-fold increased risk of stroke compared with normotension irrespective of diabetes status. For diabetic patients with HTN, a more comprehensive method is essential for assessing cardiovascular risk.

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.

Hypertension: New perspective on its definition and clinical management by bedtime therapy substantially reduces cardiovascular disease risk

Diagnosis of hypertension-elevated blood pressure (BP) associated with increased cardiovascular disease (CVD) risk-and its management for decades have been based primarily on single time-of-day office BP measurements (OBPM) assumed representative of systolic (SBP) and diastolic BP (DBP) during the entire 24-hours span. Around-the-clock ambulatory blood pressure monitoring (ABPM), however, reveals BP undergoes 24-hours patterning characterized in normotensives and uncomplicated hypertensives by striking morning-time rise, 2 daytime peaks-one ~2-3 hours after awakening and the other early evening, small midafternoon nadir and 10-20% decline (BP dipping) in the asleep BP mean relative to the wake-time BP mean. A growing number of outcome trials substantiate correlation between BP and target organ damage, vascular and other risks is greater for the ABPM-derived asleep BP mean, independent and stronger predictor of CVD risk, than daytime OBPM or ABPM-derived awake BP. Additionally, bedtime hypertension chronotherapy, that is, ingestion of ≥1 conventional hypertension medications at bedtime to achieve efficient attenuation of asleep BP, better reduces total CVD events by 61% and major events (CVD death, myocardial infarction, ischaemic and haemorrhagic stroke) by 67%-even in more vulnerable chronic kidney disease, diabetes and resistant hypertension patients-than customary on-awaking therapy that targets wake-time BP. Such findings of around-the-clock ABPM and bedtime hypertension outcome trials, consistently indicating greater importance of asleep BP than daytime OBPM or ambulatory awake BP, call for a new definition of true arterial hypertension plus modern approaches for its diagnosis and management.

Thiazide diuretic-caused hyponatremia in the elderly hypertensive: will a bottle of Nepro a day keep hyponatremia and the doctor away? Study protocol for a proof-of-concept feasibility trial

Background

Hypertension is the most common modifiable risk factor for cardiovascular disease, with an increasing prevalence with age, but with easily available medications to control it. Adverse effects of these medications do limit their use, in particular hyponatremia due to thiazide and thiazide-like diuretics. This is more common in the elderly patients due to a combination of inadequate protein intake and impaired urinary dilution capability, made worse by additional thiazide use. Limiting free water intake and increasing protein intake are often not successful resulting in thiazide avoidance. Daily protein supplement is a potential option in this clinical scenario. We describe the protocol for a feasibility study to explore this option.

Methods

This is a single-arm, prospective, open-label proof-of-concept trial, including elderly patients with thiazide diuretic-induced hyponatremia. Forty patients will be enrolled and receive a bottle of a protein supplement daily, providing 120 mmol of solutes and permitting an extra 163 mL free water loss, for 4 weeks. The main outcome measures will be (1) feasibility for enrollment, (2) safety of the intervention, and (3) potential efficacy of the intervention in improving hyponatremia. Secondary outcome measures will include changes in urine osmolality, body weight, and urea measurements.

Discussion

Thiazide diuretic-induced hyponatremia is an important adverse effect, with significant clinical impact, such as delirium and falls, and limits the use of these potent antihypertensive agents. There are little data on the effect or safety of protein supplementation and also on whether a trial of this is feasible. The results of this proof-of-concept feasibility trial will help plan and execute a larger definitive trial to test protein supplementation as an effective strategy in this condition.

Trial registration

The trial is registered with Clinical trials, registration identifier: NCT02614807.

Effects of a low salt diet on isolated systolic hypertension: A community-based population study

Evidence has shown that long-term sodium reduction can not only reduce blood pressure, but also provide cardiovascular benefits. To date, there is little evidence related to the effects of salt reduction on isolated systolic hypertension (ISH).A total of 126 hypertensive patients were divided into an ISH group (n = 51) and a non-ISH (NISH) group (n = 75). The members of each group were then randomly assigned to low sodium salt (LSSalt) or normal salt (NSalt) diets for 6 months. Their blood pressure was measured every 2 months. Serum plasma renin-angiotensin activity, blood biochemical assays and urinary measurements were determined at the baseline and at the end of the 6 months.At the end of the study, the mean systolic blood pressure (SBP) of the ISH LSSalt group had significantly decreased by 10.18 mm Hg (95% confidence interval (CI): 3.13 to 17.2, P = .006) compared with that of the ISH NSalt group, while the mean SBP only decreased by 5.10 mm Hg (95% CI: -2.02 to 12.2, P = .158) in the NISH LSSalt group compared with that of the NISH NSalt group. The mean diastolic blood pressure (DBP) had no significant differences in the ISH and NISH groups. No obvious renin angiotensin system activation was found after LSSalt intervention. Regarding the urinary excretion of electrolytes and blood biochemical assays, the LSSalt treatment had the same effects on the ISH group as on the NISH group.The present study showed that the SBP of ISH patients was significantly decreased with the LSSalt intervention, while neither the SBP of the NISH patients nor the DBP of either group were similarly decreased, which indicated that ISH patients were more sensitive to salt restriction.

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.

Hypertension and Related Cardiovascular Disease Burden in China

BACKGROUND

With rapid economic development, urbanization, and an aging population, cardiovascular diseases (CVDs) have become the leading cause of death in China.

OBJECTIVES

The aim of this study was to provide a comprehensive review on the prevalence, awareness, treatment, and control of hypertension (HTN) as well as blood pressure (BP)-related morbidity and mortality of CVD in Chinese adults over time.

FINDINGS

The prevalence of HTN in China is high and increasing. Recent estimates are variable but indicate 33.6% (35.3% in men and 32% in women) or 335.8 million (178.6 million men and 157.2 million women) of the Chinese adult population had HTN in 2010, which represents a significant increase from previous surveys. BP-related CVD remains the leading cause of death in Chinese adults, with stroke being the predominant cause of cardiovascular deaths. Of those with HTN, 33.4% (30.4% in men and 36.7% in women) were aware of their condition, 23.9% (20.6% in men and 27.7% in women) were treated, and only 3.9% (3.5% in men and 4.3% in women) were controlled to the currently recommended target of BP <140/90 mm Hg. Awareness and treatment of HTN have improved over time, but HTN control has not. Geographic differences in the prevalence, awareness, treatment, and control of HTN are evident, both in terms of a north-south gradient and urban-rural disparity.

CONCLUSIONS

The prevalence of HTN is high and increasing, while the control rate is low in Chinese adults. Combatting HTN and BP-related morbidity and mortality will require a comprehensive approach at national and local levels. The major challenge moving forward is to develop and implement effective, practical, and sustainable prevention and treatment strategies in China.

Implications of the New National Guidelines for Hypertension

Automated validated devices should be used for measuring blood pressure (BP). A systolic BP between 120 and 129 mm Hg with a diastolic BP < 80 mm Hg should be treated by lifestyle measures. Lifestyle measures plus BP lowering drugs should be used for secondary prevention of recurrent cardiovascular disease (CVD) events in persons with clinical CVD (coronary heart disease, congestive heart failure, and stroke) and an average systolic BP of ≥130 mm Hg or an average diastolic BP ≥ 80 mm Hg. Lifestyle measures plus BP lowering drugs should be used for primary prevention of CVD in persons with an estimated 10-year risk of atherosclerotic CVD ≥ 10% and an average systolic BP ≥130 mm Hg or an average diastolic BP ≥ 80 mm Hg. Lifestyle measures plus BP lowering drugs should be used for primary prevention of CVD in persons with an estimated 10-year risk of atherosclerotic CVD of <10% and an average systolic BP ≥ 140 mm Hg or an average diastolic BP ≥ 90 mm Hg. Initiate antihypertensive drug therapy with 2 first-line drugs from different classes either as separate agents or in a fixed-dose combination in persons with a BP ≥ 140/90 mm Hg or with a BP > 20/10 mm Hg above their BP target. White coat hypertension must be excluded before initiating treatment with antihypertensive drugs in persons with hypertension at low risk for atherosclerotic CVD. Antihypertensive drug treatment for different disorders is discussed.

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.

Treatment of hypertension: The ESH/ESC guidelines recommendations

Effective cardiovascular prevention in the hypertensive setting needs the achievement of a tight blood pressure (BP) control with appropriate lifestyle measures and anti-hypertensive therapy. In fact, the ultimate goal of treatment strategies is the reduction of the excess of cardiovascular mortality and morbidity related to chronically elevated BP. In this chapter we will review the recommendations provided by the latest ESH/ESC guidelines focusing on the non-pharmacological and pharmacological treatment of hypertension. The first part will be focalized on the BP targets to be achieved by the treatment in the general hypertensive population and in specific clinical settings. In the second part, we will also depict the life-style changes with proven anti-hypertensive efficacy. In the third part we will describe the general principles of pharmacological therapy recommended in the general population and in special conditions. Finally we will make a brief comment on the new hypertension guidelines that will be published in 2017.

Managing Hypertension in Patients Aged 75 Years and Older

On the basis of the available data, we would diagnose a normal blood pressure in elderly persons including those 75 years of age and older if the blood pressure was below 120/80 mmHg. We would diagnose hypertension in elderly persons including those aged 75 years and older if the systolic blood pressure was 130 mmHg and higher or if the diastolic blood pressure was 80 mmHg and higher. We would treat these elderly patients with hypertension to a blood pressure goal of less than 130/80 mmHg if the blood pressure was obtained by automated blood pressure monitoring in a quiet room. We would consider treating high-risk persons aged 75 years and older to a blood pressure goal of less than 120/80 mmHg if they were carefully monitored for serious adverse events. If the blood pressure is more than 20/10 mmHg above the goal blood pressure, we would initiate antihypertensive drug therapy with two antihypertensive drugs. The initial drug of choice for the treatment of hypertension in adults aged 75 years and older should be based on co-morbidities, co-incidental indications, tolerability, and cost.

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.

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.

Managing Hypertension in the Elderly: What is Different, What is the Same?

PURPOSE OF REVIEW

The goal is to discuss management of hypertension in the elderly.

RECENT FINDINGS

At 3.14-year follow-up of 2636 persons ≥75 years in the Systolic Blood Pressure Intervention Trial (SPRINT), compared with a systolic blood pressure (SBP) goal of <140 mmHg, a SBP goal of <120 mmHg reduced the primary endpoint of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or cardiovascular death by 34% (p = 0.001), all-cause mortality by 33% (p = 0.009), heart failure by 38% (p = 0.003), and the primary outcome or death by 32% (p < 0.001). Absolute cardiovascular event rates were lower for the intensive treatment group within each frailty stratum. The incidence of serious adverse events was similar in both treatment groups. The SPRINT trial provides very important information on the efficacy and safety of lowering the SBP to <120 mmHg in elderly adults with hypertension.

Bedtime Chronotherapy with Conventional Hypertension Medications to Target Increased Asleep Blood Pressure Results in Markedly Better Chronoprevention of Cardiovascular and Other Risks than Customary On-awakening Therapy

The bases for bedtime hypertension chronotherapy (BHCT) as superior chronoprevention against cardiovascular disease (CVD) are: (1) correlation between blood pressure (BP) and various risks is greater for ambulatory BP monitoring (ABPM) than office BP measurements (OBPM); (2) asleep BP mean is a better predictor of CVD risk than ABPM awake and 24-hour means and OBPM; and (3) targeting of asleep BP by BHCT with one or more conventional medications versus usual on-awakening therapy better reduces major and total CVD events. BHCT offers the most cost-effective chronoprevention against adverse CVD outcomes in regular and vulnerable renal, diabetic, and resistant hypertensive patients.

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.

On-Treatment Blood Pressure and Cardiovascular Outcomes in Older Adults With Isolated Systolic Hypertension

Our aim was to assess optimal on-treatment blood pressure (BP) at which cardiovascular disease (CVD) and all-cause mortality risks are minimized in Japanese older adults with isolated systolic hypertension. We used data from the VALISH study (Valsartan in Elderly Isolated Systolic Hypertension) that recruited older adults (n=3035; mean age, 76 years) with systolic BP (SBP) of ≥160 mm Hg and diastolic BP of <90 mm Hg. Patients were treated by valsartan. Patients were also categorized into 3 groups based on achieved on-treatment SBP of <130 mm Hg (n=317), 130 to <145 mm Hg (n=2025), or ≥145 mm Hg (n=693). The primary outcome was composite CVD (coronary heart disease, stroke, heart failure, cardiovascular deaths, other vascular diseases, and kidney diseases) with secondary outcome being all-cause mortality. Cox proportional hazards models were used to assess the CVD risk for each group. Over a median 3-year follow-up (8022 person-years), 93 CVD events and 52 deaths occurred. Using the on-treatment SBP of 130 to <145 mm Hg as reference stratum, the multivariable-adjusted hazard ratios and 95% confidence intervals of CVD and all-cause mortality risks for those with SBP<130 mm Hg were 2.08 (1.12–3.83) and 2.09 (0.93–4.71) and for those with SBP≥145 mm Hg were 2.29 (1.44–3.62) and 2.51 (1.35–4.66), respectively. On-treatment diastolic BP yielded no relationships with CVD or all-cause mortality risk. In conclusion, among Japanese older adults with isolated systolic hypertension, SBP in the range between 130 and 144 mm Hg was associated with minimal adverse outcomes and a reduction in CVD and all-cause mortality. The BP range will need to be confirmed in randomized controlled trials.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT00151229.

Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention

PURPOSE

Our aim was to update estimates of the health and economic impact of clinical services recommended for the primary prevention of cardiovascular disease (CVD) for the comparative rankings of the National Commission on Prevention Priorities, and to explore differences in outcomes by sex and race/ethnicity.

METHODS

We used a single, integrated, microsimulation model to generate comparable results for 3 services recommended by the US Preventive Services Task Force: aspirin counseling for the primary prevention of CVD and colorectal cancer, screening and treatment for lipid disorders (usually high cholesterol), and screening and treatment for hypertension. Analyses compare lifetime outcomes from the societal perspective for a US-representative birth cohort of 100,000 persons with and without access to each clinical preventive service. Primary outcomes are health impact, measured by the net difference in lifetime quality-adjusted life years (QALYs), and cost-effectiveness, measured in incremental cost per QALY or cost savings per person in 2012 dollars. Results are also presented for population subgroups defined by sex and race/ethnicity.

RESULTS

Health impact is highest for hypertension screening and treatment (15,600 QALYs), but is closely followed by cholesterol screening and treatment (14,300 QALYs). Aspirin counseling has a lower health impact (2,200 QALYs) but is found to be cost saving ($31 saved per person). Cost-effectiveness for cholesterol and hypertension screening and treatment is $33,800 per QALY and $48,500 per QALY, respectively. Findings favor hypertension over cholesterol screening and treatment for women, and opportunities to reduce disease burden across all services are greatest for the non-Hispanic black population.

CONCLUSIONS

All 3 CVD preventive services continue to rank highly among other recommended preventive services for US adults, but individual priorities can be tailored in practice by taking a patient's demographic characteristics and clinical objectives into account.

Effect of Arteriovenous Anastomosis on Blood Pressure Reduction in Patients With Isolated Systolic Hypertension Compared With Combined Hypertension

Background

Options for interventional therapy to lower blood pressure (BP) in patients with treatment‐resistant hypertension include renal denervation and the creation of an arteriovenous anastomosis using the ROX coupler. It has been shown that BP response after renal denervation is greater in patients with combined hypertension (CH) than in patients with isolated systolic hypertension (ISH). We analyzed the effect of ROX coupler implantation in patients with CH as compared with ISH.

Methods and Results

The randomized, controlled, prospective ROX Control Hypertension Study included patients with true treatment‐resistant hypertension (office systolic BP ≥140 mm Hg, average daytime ambulatory BP ≥135/85 mm Hg, and treatment with ≥3 antihypertensive drugs including a diuretic). In a post hoc analysis, we stratified patients with CH (n=31) and ISH (n=11). Baseline office systolic BP (177±18 mm Hg versus 169±17 mm Hg, P=0.163) and 24‐hour ambulatory systolic BP (159±16 mm Hg versus 154±11 mm Hg, P=0.463) did not differ between patients with CH and those with ISH. ROX coupler implementation resulted in a significant reduction in office systolic BP (CH: −29±21 mm Hg versus ISH: −22±31 mm Hg, P=0.445) and 24‐hour ambulatory systolic BP (CH: −14±20 mm Hg versus ISH: −13±15 mm Hg, P=0.672), without significant differences between the two groups. The responder rate (office systolic BP reduction ≥10 mm Hg) after 6 months was not different (CH: 81% versus ISH: 82%, P=0.932).

Conclusions

Our data suggest that creation of an arteriovenous anastomosis using the ROX coupler system leads to a similar reduction of office and 24‐hour ambulatory systolic BP in patients with combined and isolated systolic hypertension.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01642498.

Isolated Systolic Hypertension: An Update After SPRINT

Isolated systolic hypertension is the most common hemodynamic form of hypertension in the elderly. With a rapidly aging population, the prevalence of hypertension, particularly isolated systolic hypertension, is expected to increase substantially. This phenomenon of increasing systolic pressure in the elderly is believed to be secondary to pathophysiological changes of aging as well as modifiable risk factors. Isolated systolic hypertension is associated with substantial mortality and morbidity, particularly of cerebrovascular disease. It is a rapidly growing public health concern and its management continues to remain a challenge to practicing physicians. Recent studies like the Systolic Blood Pressure Intervention Trial (SPRINT) and Heart Outcomes Prevention Evaluation (HOPE)-3 have implications for antihypertensive therapy in general and for the management of isolated systolic hypertension in particular. In this article we will review: 1) epidemiology and pathophysiologic mechanisms, 2) impact of isolated systolic hypertension on cardiovascular outcomes, 3) optimal management strategies, and 4) systolic blood pressure goals in the light of SPRINT and HOPE 3 trials.

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.

Treatment of high blood pressure in elderly and octogenarians: European Society of Hypertension statement on blood pressure targets

The European Society of Hypertension recommend the following main rules for treatment of hypertension in elderly and octogenarians: 1) In elderly hypertensives with SBP ≥ 160 mmHg there is solid evidence to recommend reducing SBP to between 140 mmHg and 150 mmHg. 2) In fit elderly patients less than 80 years old treatment may be considered at SBP ≥ 140 mmHg with a target SBP < 140 mmHg if treatment is well tolerated. 3) In fit individuals older than 80 years with an initial SBP ≥ 160 mmHg it is recommended to reduce SBP to between 150 mmHg and 140 mmHg. 4) In frail elderly patients, it is recommended to base treatment decisions on comorbidity and carefully monitor the effects of treatment. 5) Continuation of well-tolerated antihypertensive treatment should be considered when a treated individual becomes octogenarian. 6) All hypertensive agents are recommended and can be used in the elderly, although diuretics and calcium antagonists may be preferred in isolated systolic hypertension.

Zofenopril or irbesartan plus hydrochlorothiazide in elderly patients with isolated systolic hypertension untreated or uncontrolled by previous treatment: a double-blind, randomized study

OBJECTIVE

To compare zofenopril + hydrochlorothiazide (Z + H) vs. irbesartan + hydrochlorothiazide (I + H) efficacy on daytime SBP in elderly (>65 years) patients with isolated systolic hypertension (ISH), untreated or uncontrolled by a previous monotherapy.

METHODS

After a 1-week run-in, 230 ISH patients (office SBP ≥ 140  mmHg and DBP < 90  mmHg + daytime SBP ≥ 135  mmHg and daytime DBP < 85  mmHg) were randomized double-blind to 18-week treatment with Z + H (30 + 12.5  mg) or I + H (150 + 12.5  mg) once daily, in an international, multicenter study. Z and I doses could be doubled after 6 and 12 weeks, and nitrendipine 20  mg added at 12 weeks in nonnormalized patients.

RESULTS

In the full analysis set (n = 216) baseline-adjusted average (95% confidence interval) daytime SBP reductions after 6 weeks (primary study end point) were similar (P = 0.888) with Z + H [7.7 (10.7, 4.6)  mmHg, n = 107] and I + H [7.9 (10.7, 5.0)  mmHg, n = 109]. Daytime SBP reductions were sustained during the study, and larger (P = 0.028) with low-dose Z + H at study end [16.2 (20.0, 12.5)  mmHg vs. 11.2 (14.4, 7.9)  mmHg I + H]. Daytime SBP normalization (<135 mmHg) rate was similar under Z + H and I + H at 6 and 12 weeks, but more common under Z + H at 18 weeks (68.2 vs. 56.0%, P = 0.031). Both drugs equally reduced SBP in the last 6 h of the dosing interval and homogeneously reduced SBP throughout the 24 h. The proportion of patients reporting drug-related adverse events was low (Z + H: 4.4% vs. I + H: 6.0%; P = 0.574).

CONCLUSION

Elderly patients with ISH respond well to both low and high-dose Z or I combined with H.

Arterial Stiffening in Perspective: Advances in Physical and Physiological Science Over Centuries

Arterial stiffening is not a new issue in medicine or research but was the prime concern of Richard Bright in the early 19th century and of the prominent London physicians and pathologists who tried to unscramble the relationship between kidney, heart, and cerebrovascular disease and hardness of the pulse in the late 19th century. It was of major concern to medical educators including Osler and Mackenzie who were still active in practice 100 years ago. It is all too easy (when dependent on the Internet) to consider arterial stiffness to be a new issue. The terms arterial stiffness, aortic stiffness, or wave reflection do not appear as categories for articles such as this in respectable journals, nor in categories for meetings of specialized physicians. Yet as described in this article, the subject was of interest to clinicians, to investigators such as Harvey in the 17th century, and to physicists who developed laws and principles of elasticity from the study of biological materials including ligaments and arteries. This paper provides a perspective on arterial stiffness from the time of William Harvey and Isaac Newton to the present, with a glance into the future.

Diagnostic and therapeutic problems of isolated systolic hypertension

Prevalence of isolated systolic hypertension increases with age, due to progressive elevation of SBP, and is a major risk factor for cardiovascular morbidity and mortality. Extensive research has shown that lowering SBP improves cardiovascular outcomes in patients with isolated systolic hypertension, yet SBP control rates remain largely inadequate regardless of antihypertensive treatment. Arterial stiffness is a major determinant of elevated SBP resulting from structural changes in the vascular system, mediated by neurohormonal alterations that occur with vascular ageing. Clinical data have demonstrated an independent association between arterial stiffness and cardiovascular outcomes. Therefore, arterial stiffness has the potential to be an important therapeutic target in the management of isolated systolic hypertension. Current antihypertensive treatments have limited effects on arterial stiffness, so the development of new treatments addressing neurohormonal alterations central to vascular ageing is important. Such therapies may represent effective strategies in the future management of SBP.

Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis

BACKGROUND

The benefits of blood pressure lowering treatment for prevention of cardiovascular disease are well established. However, the extent to which these effects differ by baseline blood pressure, presence of comorbidities, or drug class is less clear. We therefore performed a systematic review and meta-analysis to clarify these differences.

METHOD

For this systematic review and meta-analysis, we searched MEDLINE for large-scale blood pressure lowering trials, published between Jan 1, 1966, and July 7, 2015, and we searched the medical literature to identify trials up to Nov 9, 2015. All randomised controlled trials of blood pressure lowering treatment were eligible for inclusion if they included a minimum of 1000 patient-years of follow-up in each study arm. No trials were excluded because of presence of baseline comorbidities, and trials of antihypertensive drugs for indications other than hypertension were eligible. We extracted summary-level data about study characteristics and the outcomes of major cardiovascular disease events, coronary heart disease, stroke, heart failure, renal failure, and all-cause mortality. We used inverse variance weighted fixed-effects meta-analyses to pool the estimates.

RESULTS

We identified 123 studies with 613,815 participants for the tabular meta-analysis. Meta-regression analyses showed relative risk reductions proportional to the magnitude of the blood pressure reductions achieved. Every 10 mm Hg reduction in systolic blood pressure significantly reduced the risk of major cardiovascular disease events (relative risk [RR] 0·80, 95% CI 0·77-0·83), coronary heart disease (0·83, 0·78-0·88), stroke (0·73, 0·68-0·77), and heart failure (0·72, 0·67-0·78), which, in the populations studied, led to a significant 13% reduction in all-cause mortality (0·87, 0·84-0·91). However, the effect on renal failure was not significant (0·95, 0·84-1·07). Similar proportional risk reductions (per 10 mm Hg lower systolic blood pressure) were noted in trials with higher mean baseline systolic blood pressure and trials with lower mean baseline systolic blood pressure (all ptrend>0·05). There was no clear evidence that proportional risk reductions in major cardiovascular disease differed by baseline disease history, except for diabetes and chronic kidney disease, for which smaller, but significant, risk reductions were detected. β blockers were inferior to other drugs for the prevention of major cardiovascular disease events, stroke, and renal failure. Calcium channel blockers were superior to other drugs for the prevention of stroke. For the prevention of heart failure, calcium channel blockers were inferior and diuretics were superior to other drug classes. Risk of bias was judged to be low for 113 trials and unclear for 10 trials. Heterogeneity for outcomes was low to moderate; the I(2) statistic for heterogeneity for major cardiovascular disease events was 41%, for coronary heart disease 25%, for stroke 26%, for heart failure 37%, for renal failure 28%, and for all-cause mortality 35%.

INTERPRETATION

Blood pressure lowering significantly reduces vascular risk across various baseline blood pressure levels and comorbidities. Our results provide strong support for lowering blood pressure to systolic blood pressures less than 130 mm Hg and providing blood pressure lowering treatment to individuals with a history of cardiovascular disease, coronary heart disease, stroke, diabetes, heart failure, and chronic kidney disease.

FUNDING

National Institute for Health Research and Oxford Martin School.