Life course trajectories of systolic blood pressure using longitudinal data from eight UK cohorts

Blood pressure, frailty and dementia

High blood pressure (BP) affects 75% of people aged over 70. Ageing alters BP homeostasis, resulting in postural hypotension and increased BP variability. Co-morbidity and frailty add complexity to understanding BP changes in later life. Longitudinal BP declines are likely driven by accumulating co-morbidity and are accelerated in both frailty and dementia. This narrative review summarises what is known about the association between BP and frailty, the clinical management of BP in frailty and the association between BP, cognitive decline and dementia.

Trajectories of Systolic Blood Pressure in Children: Risk Factors and Cardiometabolic Correlates

OBJECTIVE

To identify systolic blood pressure (SBP) percentile trajectories in children and to describe the early-life risk factors and cardiometabolic correlates of those trajectories.

STUDY DESIGN

Using age-, sex-, and height-specific SBP percentiles based on the American Academy of Pediatrics reference, we examined SBP trajectories using latent class mixed models from ages 3 to 8 years (n = 844) from the Growing Up in Singapore Towards healthy Outcomes-study, a Singaporean mother-offspring cohort study. We analyzed associations between SBP trajectories and early-life risk factors using multinomial logistic regression and differences across trajectories in cardiometabolic outcomes using multiple linear regression.

RESULTS

Children were classified into 1 of 4 SBP percentile trajectories: "low increasing" (15%), "high stable" (47%), "high decreasing" (20%), and "low stable" (18%). Maternal hypertension during early pregnancy was a predictor of the "high stable" and "low increasing" SBP trajectories. Rapid child weight gain in the first 2 years of life was only associated with the "high stable" trajectory. Compared with children in the "low stable" trajectory, children in the "high stable" SBP trajectory had greater body mass index z scores, sum of skinfold thicknesses, waist circumference from ages 3 to 8 years, and abdominal adipose tissue (milliliters) at 4.5 years (adjusted mean difference [95% CI]: superficial and deep subcutaneous abdominal adipose tissue: 115.2 [48.1-182.3] and 85.5 [35.2-135.8]). Their fat mass (kilograms) (1.3 [0.6-2.0]), triglyceride levels (mmol/L) (0.10 [0.02-0.18]), and homeostasis model assessment of insulin resistance (0.28 [0.11 0.46]) at age 6 years were also greater but not their arterial thickness and stiffness.

CONCLUSIONS

Reducing maternal blood pressure during pregnancy and infant weight gain in the first 2 years of life might help to prevent the development of high SBP.

Long-term blood pressure trajectories and associations with age and body mass index among urban women in South Africa

BACKGROUND

Blood pressure (BP) is known to increase inevitably with age. Understanding the different ages at which great gains could be achieved for intervention to prevent and control BP would be of public health importance.

METHODS

Data collected between 2003 and 2014 from 1 969 women aged 22 to 89 years were used in this study. Growth curve models were fitted to describe intra- and inter-individual trajectories. For BP tracking, the intra-class correlation coefficient (ICC) was used to measure dependency of observations from the same individual.

RESULTS

Four patterns were identified: a slow decrease in BP with age before 30 years; a period of gradual increase in midlife up to 60 years; a flattening and slightly declining trend; and another increase in BP in advanced age. These phases persisted but at slightly lower levels after adjustment for body mass index. Three groups of increasing trajectories were identified. The respective number (%) in the low, medium and highly elevated BP groups were 1 386 (70.4%), 482 (24.5%) and 101 (5.1%) for systolic BP; and 1 167 (59.3%), 709 (36.0%) and 93 (4.7%) for diastolic BP. The ICC was strong at 0.71 and 0.79 for systolic and diastolic BP, respectively.

CONCLUSIONS

These results show that BP preventative and control measures early in life would be beneficial for control later in life, and since increase in body mass index may worsen hypertension, it should be prevented early and independently.

Time trends in the relation between blood pressure and dementia in 85-year-olds

OBJECTIVES

Blood pressure has decreased in the general population. We aimed to examine whether this is true also among the very old, and among persons with and without dementia. Further, we aimed to investigate how common undetected and untreated hypertension is in the very old, both among people with and without dementia.

METHOD

Blood pressure was measured in representative population samples of 85-year-olds living in Gothenburg, Sweden, examined 1986-1987 (n = 484) and 2008-2010 (n = 571). Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, edition 3 revised, by the same medical doctor at both examinations.

RESULTS

Both systolic and diastolic blood pressure were lower in 85-year-olds examined 2008-2010 than in those examined 1986-1987, both among those with and without dementia. Participants with dementia had lower systolic blood pressure than those without dementia in both cohorts, and blood pressure levels related to dementia severity. Despite this, hypertension (≥140/90 mmHg) was found in almost half (46.5%) of those with dementia in 2008-2010.

CONCLUSION

Our findings show that time-trends of lower blood pressure in western populations also applies to the very old, and that individuals with dementia continue to have lower blood pressure compared to the rest of the population. The latter finding suggests that the pathophysiological processes in dementia affect blood pressure regulating regions in the brain independent of time trends. Still, hypertension is common in dementia and needs to be detected and treated.

Twenty-Five-Year Changes in Office and Ambulatory Blood Pressure: Results From the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Blood pressure (BP) measured in the office setting increases from early through later adulthood. However, it is unknown to what extent out-of-office BP derived via ambulatory BP monitoring (ABPM) increases over time, and which participant characteristics and risk factors might contribute to these increases.

METHODS

We assessed 25-year change in office- and ABPM-derived BP across sex, race, diabetes mellitus (DM), and body mass index (BMI) subgroups in the Coronary Artery Risk Development in Young Adults study using multivariable-adjusted linear mixed effects models.

RESULTS

We included 288 participants who underwent ABPM at the Year 5 Exam (mean [SD] age, 25.1 [3.7]; 45.8% men) and 455 participants who underwent ABPM at the Year 30 Exam (mean [SD] age, 49.5 [3.7]; 42.0% men). Office, daytime, and nighttime systolic BP (SBP) increased 12.8 (95% confidence interval [CI], 7.6-17.9), 14.7 (95% CI, 9.7-19.8), and 16.6 (95% CI, 11.4-21.8) mm Hg, respectively, over 25 years. Office SBP increased 6.5 (95% CI, 2.3-10.6) mm Hg more among black compared with white participants. Daytime SBP increased 6.3 (95% CI, 0.2-12.4) mm Hg more among participants with a BMI ≥25 vs. <25 kg/m2. Nighttime SBP increased 4.7 (95% CI, 0.5-8.9) mm Hg more among black compared with white participants, and 17.3 (95% CI, 7.2-27.4) mm Hg more among participants with vs. without DM.

CONCLUSIONS

Office- and ABPM-derived BP increased more from early through middle adulthood among black adults and participants with DM and BMI ≥25 kg/m2.

Maintaining Normal Blood Pressure Across the Life Course: The JHS

[Figure: see text].

Longitudinal associations of blood pressure with aortic stiffness and pulsatility: the Atherosclerosis Risk in Communities Study

OBJECTIVE

To characterize the longitudinal relationships between blood pressure measured over 24 years and arterial stiffness in late life measured as pulse wave velocity (PWV).

METHODS

Carotid--femoral (cf) and femoral--ankle (fa) PWV were measured in 4166 adults at the visit 5 Atherosclerosis Risk in Communities study cohort examination (2011-2013). Participants were categorized into tertiles of PWV measurements. Blood pressure measurements were made at baseline (1987-1989), three subsequent triennial examinations, and visit 5.

RESULTS

Partial correlation coefficients between visit 5 cfPWV and SBP ranged from 0.13 for visit 1 SBP to 0.32 for visit 5 SBP. For visit 5 faPWV, correlations were ∼0 for visits 1 to 4 SBP, but was 0.20 for visit 5 SBP. Over 24 years of follow-up, those with higher average SBP were more likely to fall in the middle and upper tertiles of visit 5 cfPWV. Average pulse pressure and mean arterial pressure over 24 years had similar but weaker associations with cfPWV tertiles. DBP had no clear association with cfPWV. Blood pressure measurements were positively associated with faPWV tertiles only cross-sectionally at visit 5.

CONCLUSION

Adult life-course measures of SBP, more so than mean arterial and pulse pressure, were associated with later life central arterial stiffness. By contrast, only contemporaneous measures of blood pressure were associated with peripheral arterial stiffness. Although arterial stiffness was only measured at later life, these results are consistent with the notion that elevated blood pressure over time is involved in the pathogenesis of arterial stiffening.

Blood Pressure Trajectories Across the Life Course

High blood pressure (BP) is a strong modifiable risk factor for cardiovascular disease (CVD). Longitudinal BP patterns themselves may reflect the burden of risk and vascular damage due to prolonged cumulative exposure to high BP levels. Current studies have begun to characterize BP patterns as a trajectory over an individual's lifetime. These BP trajectories take into account the absolute BP levels as well as the slope of BP changes throughout the lifetime thus incorporating longitudinal BP patterns into a single metric. Methodologic issues that need to be considered when examining BP trajectories include individual-level vs. population-level group-based modeling, use of distinct but complementary BP metrics (systolic, diastolic, mean arterial, mid, and pulse pressure), and potential for measurement errors related to varied settings, devices, and number of readings utilized. There appear to be very specific developmental periods during which divergent BP trajectories may emerge, specifically adolescence, the pregnancy period, and older adulthood. Lifetime BP trajectories are impacted by both individual-level and community-level factors and have been associated with incident hypertension, multimorbidity (CVD, renal disease, cognitive impairment), and overall life expectancy. Key unanswered questions remain around the additive predictive value of BP trajectories, intergenerational contributions to BP patterns (in utero BP exposure), and potential genetic drivers of BP patterns. The next phase in understanding BP trajectories needs to focus on how best to incorporate this knowledge into clinical care to reduce the burden of hypertensive-related outcomes and improve health equity.

Age and aging effects on blood pressure: 15 years follow-up of Tehran lipid and glucose study

Age is a known predictor of blood pressure (BP); however, the literature mostly includes cross‐sectional investigations. This prospective cohort study aimed to decompose the cross‐sectional and longitudinal age effects on BP. The secondary data were obtained from the Tehran lipid and glucose study, which comprised six repeated measurements of participants, with median follow‐up of 15.8 (interquartile range of 14.2‐16.9) years. The sample is representative of the metropolitan area of Tehran, Iran, containing 7,460 participants aged 20‐70. The cross‐sectional and longitudinal effects of age (age at baseline and aging, respectively) were fitted in the mixed effects models, taking systolic, diastolic, and pulse BPs as response, adjusting for adiposity, smoking, diabetes, and antihypertensive medication, and stratifying for sex and 10‐year age‐groups. The mean age at baseline was 41.3 (SD = 12.9) years, and 41.7% of the participants were male. Age at baseline and aging were directly associated with BP, aging owned the weaker effect, and the largest distinction were for systolic blood pressure of men aged 40‐49 years (0.75 vs 0.10, p‐value < .001). Moreover, the aging effects on systolic and diastolic BPs were higher in men than women, in the age groups 40‐49 and 30‐39 years (0.35 vs 0.10 and 0.30 vs 0.07, p‐values < .001), respectively. Adjusting for adiposity remarkably declined the impact of aging on BP, among the < 50 years old.

Sex differences in systemic metabolites at four life stages: cohort study with repeated metabolomics

BACKGROUND

Males experience higher rates of coronary heart disease (CHD) than females, but the circulating traits underpinning this difference are poorly understood. We examined sex differences in systemic metabolites measured at four life stages, spanning childhood to middle adulthood.

METHODS

Data were from the Avon Longitudinal Study of Parents and Children (7727 offspring, 49% male; and 6500 parents, 29% male). Proton nuclear magnetic resonance (1H-NMR) spectroscopy from a targeted metabolomics platform was performed on EDTA-plasma or serum samples to quantify 229 systemic metabolites (including lipoprotein-subclass-specific lipids, pre-glycaemic factors, and inflammatory glycoprotein acetyls). Metabolites were measured in the same offspring once in childhood (mean age 8 years), twice in adolescence (16 years and 18 years) and once in early adulthood (25 years), and in their parents once in middle adulthood (50 years). Linear regression models estimated differences in metabolites for males versus females on each occasion (serial cross-sectional associations).

RESULTS

At 8 years, total lipids in very-low-density lipoproteins (VLDL) were lower in males; levels were higher in males at 16 years and higher still by 18 years and 50 years (among parents) for medium-or-larger subclasses. Larger sex differences at older ages were most pronounced for VLDL triglycerides-males had 0.19 standard deviations (SD) (95% CI = 0.12, 0.26) higher at 18 years, 0.50 SD (95% CI = 0.42, 0.57) higher at 25 years, and 0.62 SD (95% CI = 0.55, 0.68) higher at 50 years. Low-density lipoprotein (LDL) cholesterol, apolipoprotein-B, and glycoprotein acetyls were generally lower in males across ages. The direction and magnitude of effects were largely unchanged when adjusting for body mass index measured at the time of metabolite assessment on each occasion.

CONCLUSIONS

Our results suggest that males begin to have higher VLDL triglyceride levels in adolescence, with larger sex differences at older ages. Sex differences in other CHD-relevant metabolites, including LDL cholesterol, show the opposite pattern with age, with higher levels among females. Such life course trends may inform causal analyses with clinical endpoints in specifying traits which underpin higher age-adjusted CHD rates commonly seen among males.

Trans-ethnic meta-analysis identifies new loci associated with longitudinal blood pressure traits

Genome-wide association studies (GWAS) have identified thousands of genetic loci associated with cross-sectional blood pressure (BP) traits; however, GWAS based on longitudinal BP have been underexplored. We performed ethnic-specific and trans-ethnic GWAS meta-analysis using longitudinal and cross-sectional BP data of 33,720 individuals from five cohorts in the US and one in Brazil. In addition to identifying several known loci, we identified thirteen novel loci with nine based on longitudinal and four on cross-sectional BP traits. Most of the novel loci were ethnic- or study-specific, with the majority identified in African Americans (AA). Four of these discoveries showed additional evidence of association in independent datasets, including an intergenic variant (rs4060030, p = 7.3 × 10^–9) with reported regulatory function. We observed a high correlation between the meta-analysis results for baseline and longitudinal average BP (rho = 0.48). BP trajectory results were more correlated with those of average BP (rho = 0.35) than baseline BP(rho = 0.18). Heritability estimates trended higher for longitudinal traits than for cross-sectional traits, providing evidence for different genetic architectures. Furthermore, the longitudinal data identified up to 20% more BP known associations than did cross-sectional data. Our analyses of longitudinal BP data in diverse ethnic groups identified novel BP loci associated with BP trajectory, indicating a need for further longitudinal GWAS on BP and other age-related traits.

Inequality in hospitalization due to non-communicable diseases in Sweden: Age-cohort analysis of the Uppsala Birth Cohort Multigenerational Study

We aimed to investigate cohort differences in age trajectories of hospitalization due to non-communicable conditions, and if these varied by paternal socioeconomic position. We used the Uppsala Birth Cohort Multigenerational Study—including virtually complete information on medical diagnoses.

Our sample constituted 28,448 individuals (103,262 observations). The outcome was five-year prevalence of hospitalization due to major non-communicable conditions in 1989–2008. The exposures were age (19–91), year-of-birth (1915–1929; 1938–1972), gender (man vs woman), and parental socioeconomic position (low, medium, and high). We used multilevel logit models to examine associations between exposures and the hospitalization outcome.

Younger cohorts had a higher prevalence of hospitalization at overlapping ages than those born earlier, with inter-cohort differences emerging from early-adulthood and increasing with age. For instance, at age 40 predicted probability of hospitalization increased across birth-cohorts—from 1.2% (born in 1948-52) to 2.0% (born in 1963-67)—whereas at age 50 it was 2.9% for those born in 1938-42 compared with 4.6% among participants born in 1953-57. Those with medium and low socioeconomic position had 13.0% and 20.0% higher odds of experiencing hospitalization during the observation period, respectively—when age, year-of-birth and gender were accounted for.

We found that no progress was made in reducing the socioeconomic inequalities in hospitalization across cohorts born between 1915 and 1972. Hence, more effective policies and interventions are needed to reduce the overall burden of morbidity—particularly among the most vulnerable.

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What is already known on this subject?

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The evidence on trends in morbidity in Sweden is mainly cross-sectional and focused on individual conditions.

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Rates of various indicators of morbidity (e.g. poor mobility, psychological distress, disability) have increased over time.

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What this study adds.

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Successively younger birth cohorts had a higher prevalence of hospitalization, with differences emerging in early-adulthood.

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Those in medium and low parental socioeconomic position (vs high) had 13% and 20% higher odds of hospitalization.

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No progress was made in reducing the socioeconomic inequalities across cohorts born between 1915 and 1972.

Socioeconomic inequalities in blood pressure: co-ordinated analysis of 147,775 participants from repeated birth cohort and cross-sectional datasets, 1989 to 2016

BACKGROUND

High blood pressure (BP) is a key modifiable determinant of cardiovascular disease and a likely determinant of other adverse health outcomes. While socioeconomic inequalities in BP are well documented, it remains unclear (1) how these inequalities have changed across time, given improvements over time in the detection and treatment of high BP (hypertension); (2) whether BP inequalities are present below and above hypertension treatment thresholds; and (3) whether socioeconomic position (SEP) across life has cumulative effects on BP. We sought to address these gaps using evidence from two complementary sources: birth cohort and repeated cross-sectional datasets.

METHODS

We used three British birth cohort studies-born in 1946, 1958, and 1970-with BP measured at 43-46 years (in 1989, 2003, and 2016), and 21 repeated cross-sectional datasets-the Health Survey for England (HSE), with BP measured among adults aged ≥ 25 years (1994-2016). Adult education attainment was used as an indicator of SEP in both datasets; childhood father's social class was used as an alternative indicator of (early life) SEP in cohorts. Adjusting for the expected average effects of antihypertensive medication use, we used linear regression to quantify SEP differences in mean systolic BP (SBP), and quantile regression to investigate whether inequalities differed across SBP distributions-below and above hypertension treatment thresholds.

RESULTS

In both datasets, lower educational attainment was associated with higher SBP, with similar absolute magnitudes of inequality across the studied period. Differences in SBP by education (Slope Index of Inequality) based on HSE data were 3.0 mmHg (95% CI 1.8, 4.2) in 1994 and 4.3 mmHg (2.3, 6.3) in 2016. Findings were similar for diastolic BP (DBP) and survey-defined hypertension. Inequalities were found across the SBP distribution in both datasets-below and above the hypertension threshold-yet were larger at the upper tail; in HSE, median SBP differences were 2.8 mmHg (1.7, 3.9) yet 5.6 mmHg (4.9, 6.4) at the 90th quantile. Adjustment for antihypertensive medication use had little impact on the magnitude of inequalities; in contrast, associations were largely attenuated after adjustment for body mass index. Finally, cohort data suggested that disadvantage in early and adult life had cumulative independent associations with BP: cohort-pooled differences in SBP were 5.0 mmHg (3.8, 6.1) in a score combining early life social class and own education, yet were 3.4 mmHg (2.4, 4.4) for education alone.

CONCLUSION

Socioeconomic inequalities in BP have persisted from 1989 to 2016 in Britain/England, despite improved detection and treatment of high BP. To achieve future reductions in BP inequalities, policies addressing the wider structural determinants of high BP levels are likely required, particularly those curtailing the obesogenic environment-targeting detection and treatment alone is unlikely to be sufficient.

Early life predictors of development of blood pressure from childhood to adulthood: Evidence from a 30-year longitudinal birth cohort study

BACKGROUND AND AIMS

The early life predictors of changes in the blood pressures of offspring between childhood and young adulthood have not been well defined. Thus, this study aimed to determine the life course association of offspring's blood pressure with prenatal and early infancy lifestyle, and other factors taking advantage of a large community-based, longitudinal study of a birth cohort in Australia - the MUSP study.

METHODS

The systolic and diastolic blood pressure (SBP, DBP) was measured for 3793, 3782, 2628 and 1780 offspring of the Australian longitudinal cohort study at 5, 14, 21 and 30 years of their age, respectively. Individual PP and mean arterial pressure (MAP) was equated, and Generalized Estimating Equations with time (age) and predictor interaction modelling were performed.

RESULTS

Blood pressures of the offspring increased significantly between 5 and 30 years. Early life factors such as pre-pregnancy overweight/obesity, and hypertensive disorder in pregnancy were significantly positively associated, and duration of gestation and pre-pregnancy thinness of the mothers negatively associated with this life course increase in the offspring's blood pressure. Rapid increase in body weight from birth to 5 years had a strong association with increasing blood pressures components throughout their life course.

CONCLUSIONS

Several maternal pre-pregnancy and pregnancy factors along with the early life growth characteristics of offspring are important predictors of increase in blood pressure of the offspring from their childhood to adulthood.

Cross-sectional centiles of blood pressure by age and sex: a four-hospital database retrospective observational analysis

OBJECTIVES

National guidelines for identifying physiological deterioration and sepsis in hospitals depend on thresholds for blood pressure that do not account for age or sex. In populations outside hospital, differences in blood pressure are known to occur with both variables. Whether these differences remain in the hospitalised population is unknown. This database analysis study aims to generate representative centiles to quantify variations in blood pressure by age and sex in hospitalised patients.

DESIGN

Retrospective cross-sectional observational database analysis.

SETTING

Four near-sea-level hospitals between April 2015 and April 2017 PARTICIPANTS: 75 342 adult patients who were admitted to the hospitals and had at least one set of documented vital sign observations within 24 hours before discharge were eligible for inclusion. Patients were excluded if they died in hospital, had no vital signs 24 hours prior to discharge, were readmitted within 7 days of discharge, had missing age or sex or had no blood pressure recorded.

RESULTS

Systolic blood pressure (SBP) for hospitalised patients increases with age for both sexes. Median SBP increases from 122 (CI: 121.1 to 122.1) mm Hg to 132 (CI: 130.9 to 132.2) mm Hg in men, and 114 (CI: 113.1 to 114.4) mm Hg to 135 (CI: 134.5 to 136.2) mm Hg in women, between the ages of 20 and 90 years. Diastolic blood pressure peaked around 50 years for men 76 (CI: 75.5 to 75.9) mm Hg and women 69 (CI: 69.0 to 69.4) mm Hg. The blood pressure criterion for sepsis, systolic <100 mm Hg, was met by 2.3% of younger (20-30 years) men and 3.5% of older men (81-90 years). In comparison, the criterion was met by 9.7% of younger women and 2.6% of older women.

CONCLUSION

We have quantified variations in blood pressure by age and sex in hospitalised patients that have implications for recognition of deterioration. Nearly 10% of younger women met the blood pressure criterion for sepsis at hospital discharge.

The Ankle-Brachial Index Is Associated with Cerebral β-Amyloid Deposition in Cognitively Normal Older Adults

BACKGROUND

Although ankle-brachial index (ABI), an indicator of atherosclerosis or arterial stiffness, has been associated with dementia and Alzheimer's disease (AD), no information is yet available for its contribution to AD pathologies. We investigated the relationship between the ABI and in vivo β-amyloid (Aβ) deposition and AD-specific neurodegeneration in cognitively normal (CN) elderly individuals.

METHODS

A total of 256 CN elderly subjects who participated in the Korean Brain Aging Study for the Early Diagnosis and Prediction of Alzheimer's Disease (KBASE), an ongoing prospective cohort study, were included. All subjects underwent comprehensive clinical and neuropsychological assessments, ABI measurement, apolipoprotein E (APOE) genotyping, [11C]Pittsburgh Compound B (PiB)-positron emission tomography (PET), [18F]-fludeoxyglucose PET, and magnetic resonance imaging.

RESULTS

A significant positive association was found between the ABI and global cerebral Aβ retention measured by PiB-PET, even after controlling for age, sex, and APOE ε4. When three stratified ABI subgroups (ABI < 1.00, 1.00-1.29, and ≥ 1.30) were compared, the highest ABI subgroup (ie, ABI ≥ 1.30) showed significantly higher Aβ deposition than that of the other subgroups. This relationship between Aβ deposition and the ABI was significant only in APOE ε4 carriers, but not in noncarriers. No significant association was observed between the ABI and neurodegeneration in the AD-signature regions.

CONCLUSION

Our findings suggest that a high ABI, possibly related to arterial stiffness, is associated with elevated brain Aβ burden in cognitively healthy elderly individuals, particularly in APOE ε4 carriers.

Depressive Symptoms and Blood Pressure

Abstract. In the present investigation it is hypothesized that depressive symptoms and antidepressant therapy are associated with systolic and diastolic blood pressure. Moreover, in additional analyses, the interaction effects of age, gender, and depressive symptoms are estimated, and discussed in the context of previous findings. Data from the German Health Interview and Examination Survey for Adults (DEGS1) were analyzed ( N = 7,987) by means of multi-response Bayesian hierarchical regression models. Missing data were imputed by the method of chain equations. Independent variables included depressive symptoms, antidepressant medication, gender, age, smoking, physical activity, family history of hypertension, body mass index, and antihypertensive medication. The estimates obtained in the multi-response model revealed that depressive symptoms were negatively associated with arterial blood pressure (−0.09, 99% CI [−0.147; −0.040]). Antidepressant therapy was found to be positively associated with increased blood pressure (1.035, 99% CI [0.333; 1.990]). There were negative interaction effects of depressive symptoms and age among women only (−0.006 99% CI [−0.010; −0.001]). The results agree with previous findings reporting a negative association between depressive symptoms and blood pressure. In addition, regarding the trajectory of blood pressure across the lifespan, interaction effects of depressive symptoms and age were found among females. The results indicate a linear increase in blood pressure with increasing age which, however, tends to flatten and decrease by around age 55 in both males and females. Potential physiological mechanisms may be related to affect regulation taking place at higher levels of cognitive processing and affecting blood pressure regulation, and/or cardiovascular mechanisms related to cerebral blood flow, arterial blood pressure, and depressive symptoms which have not been sufficiently explained so far.

Use of a pooled cohort to impute cardiovascular disease risk factors across the adult life course

BACKGROUND

In designing prevention strategies, it may be useful to understand how early and midlife cardiovascular disease risk factor (CVDRF) exposures affect outcomes that primarily occur in mid to late life. Few single US cohorts have followed participants from early adulthood to late life.

METHODS

We pooled four prospective cohorts that represent segments of the adult life course, and studied 15 001 White and Black adults aged 18 to 95 years at enrollment. We imputed early and midlife exposure to body mass index (BMI), glucose, lipids and blood pressure (BP). CVDRF trajectories were estimated using linear mixed models. Using the best linear unbiased predictions, we obtained person-specific estimates of CVDRF trajectories beginning at age 20 until each participant's end of follow-up. We then calculated for each CVDRF, summary measures of early and midlife exposure as time-weighted averages (TWAs).

RESULTS

In the pooled cohort, 33.7% were Black and 54.8% were female. CVDRF summary measures worsened in midlife compared with early life and varied by sex and race. In particular, systolic and diastolic BP were consistently higher over the adult life course among men, and BMI was higher among Blacks, particularly Black women. Simulation studies suggested acceptable imputation accuracy, especially for the younger cohorts. Correlations of true and imputed CVDRF summary measures ranged from 0.53 to 0.99, and agreement ranged from 67% to 99%.

CONCLUSIONS

These results suggest that imputed CVDRFs may be accurate enough to be useful in assessing the effects of early and midlife exposures on later life outcomes.

Heterogeneity in Trajectories of Systolic Blood Pressure among Young Adults in Qingdao Port Cardiovascular Health Study

Background:

Although increased age is associated with higher systolic blood pressure (SBP) in general, there may be variation across individuals in how SBP changes over time. The goal of this paper is to identify heterogeneity in SBP trajectories among young adults with similar initial values and identify personal characteristics associated with different trajectory patterns. This may have important implications for prevention and prognosis.

Methods:

A cohort of 12,468 individuals aged 18–35 years in the Qingdao Port Cardiovascular Health Study in China was followed yearly during 2000–2011. Individuals were categorized into three strata according to their baseline SBP: ≤110 mmHg, 111–130 mmHg, and >130 mmHg. Within each stratum, group-based trajectory analyses were conducted to identify distinct SBP trajectory patterns, and their association with sociodemographic and baseline health characteristics was assessed by ordinal logistic regression.

Results:

Five distinct groups of individuals exhibiting divergent patterns of increasing, stable or decreasing SBP trends were identified within each stratum. This is a first report to identify a subgroup with decreasing trend in SBP. Individuals with more advanced age, having less than high school education, family history of cardiovascular diseases, greater body mass index, greater waist circumference, and hyperlipidemia at baseline were more likely to experience trajectories of higher SBP within each stratum.

Conclusions:

The diverging trajectories among young adults with similar initial SBP highlight the need for prevention and feasibility of effective blood pressure control, while the identified risk factors may inform targeted interventions.

Sex Differences in Blood Pressure Trajectories Over the Life Course

Importance

If we assume that women and men exhibit variations of the same fundamental vascular physiology, then conventional analyses of subclinical measures would suggest that women catch up to men by midlife in the extent of potentially important vascular disease. Alternatively, under the assumption that vascular physiology may fundamentally differ between women and men, a sex-specific analysis of existing data could offer new insights and augment our understanding of sex differences in cardiovascular diseases.

Objective

To evaluate whether longitudinal patterns of blood pressure (BP) elevation differ between women and men during the life course when considering baseline BP levels as the reference.

Design, Setting, and Participants

We conducted sex-specific analyses of longitudinal BP measures (144 599 observations) collected for a period of 43 years (1971 to 2014) in 4 community-based US cohort studies. The combined total included 32 833 participants (54% female) spanning ages 5 to 98 years. Data were analyzed between May 4, 2019, and August 5, 2019.

Exposures

Age and serially assessed longitudinal BP measures: systolic BP, diastolic BP, mean arterial pressure (MAP), and pulse pressure (PP).

Main Outcomes and Measures

Sex-specific change in each primary BP measure compared with baseline BP levels, derived from multilevel longitudinal models fitted over the age span, and new-onset cardiovascular disease events.

Results

Of the 32 833 participants, 17 733 were women (54%). Women compared with men exhibited a steeper increase in BP that began as early as in the third decade and continued through the life course (likelihood ratio test χ2 = 531 for systolic BP; χ2 = 123 for diastolic BP; χ2 = 325 for MAP; and χ2 = 572 for PP; P for all <.001). After adjustment for multiple cardiovascular disease risk factors, these between-sex differences in all BP trajectories persisted (likelihood ratio test χ2 = 314 for systolic BP; χ2 = 31 for diastolic BP; χ2 = 129 for MAP; and χ2 = 485 for PP; P for all <.001).

Conclusions and Relevance

In contrast with the notion that important vascular disease processes in women lag behind men by 10 to 20 years, sex-specific analyses indicate that BP measures actually progress more rapidly in women than in men, beginning early in life. This early-onset sexual dimorphism may set the stage for later-life cardiovascular diseases that tend to present differently, not simply later, in women compared with men.

Age at period cessation and trajectories of cardiovascular risk factors across mid and later life

Objective

To examine the association between age at period cessation and trajectories of anthropometry, blood pressure, lipids and glycated haemoglobin (HbA1c) from midlife to age 69 years.

Methods

We used data from the UK Medical Research Council National Survey of Health and Development to examine the association between age at period cessation and trajectories of systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI) and waist circumference (WC) from 36 to 69 years and trajectories of triglyceride, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and HbA1c from 53 to 69 years.

Results

We found no evidence that age at period cessation was associated with trajectories of log triglyceride, LDL-C and HDL-C from 53 to 69 years and trajectories of SBP or DBP from 36 to 69 years, regardless of whether period cessation occurred naturally or due to hysterectomy. While we found some evidence of associations of age at period cessation with log BMI, log WC and log HbA1c, patterns were not consistent and differences were small at age 69 years, with confidence intervals that spanned the null value.

Conclusion

How and when women experience period cessation is unlikely to adversely affect conventional cardiovascular risk factors across mid and later life. Women and clinicians concerned about the impact of type and timing of period cessation on conventional cardiovascular intermediates from midlife should be reassured that the impact over the long term is small.

Short- and long-term systolic blood pressure changes have different impacts on major adverse cardiovascular events: Results from a 12.5 years follow-up study

BACKGROUND

Systolic blood pressure increased in middle-aged person contributes significantly to the risk of major adverse cardiovascular events (MACE). Meanwhile, different patterns (short- or long-term change) of SBP increase may result in differential risk and lead to differences in predictive ability.

METHODS

A total of 19,544 and 22,610 participants in the Fuxin Cardiovascular Cohort Study underwent measurement of SBP at 2 examinations for short- and long-term change study population. Cox proportional hazards models were used to relate future clinical outcomes with change in SBP.

RESULTS

During a median follow-up period of 12.5 years, 1064 (772 stroke, 247 myocardial infarction, 528 CVD deaths) and 1316 (958 stroke, 301 myocardial infarction, 660 CVD deaths) MACE were identified during short- and long-terms SBP change, respectively. For SBP increased participants, short-term change in SBP was associated with future MACE (hazard ratio [HR]: 1.241 per 1-SD increase; 95% confidence interval [CI]: 1.146-1.344; P < 0.001), long-term change in SBP (HR: 1.218; 95% CI: 1.123-1.322; P < 0.001). For prehypertension participants, long-term changes conferred a strong impact than short-term. For hypertensive participants, short-term changes conferred a strong impact than long-term.

CONCLUSIONS

Having a SBP rise in short- or long-term both confer an increased risk of MACE and its subgroups. Furthermore, short- and long-term SBP increase patterns adds different additional information beyond one single baseline examination. Change in SBP may be a prognostic surrogate marker and future studies are needed to clarify the possible mechanism for predicting MACE.

Relation of Blood Pressure in Childhood to Self-Reported Hypertension in Adulthood

Blood pressure (BP) tracking (maintaining a BP percentile) across life is not well defined but is important in predicting which children will become hypertensive adults. We computed BP tracking in subjects with BP measured in childhood and adulthood and performed logistic regression to determine the ability of childhood BP to predict adult hypertension (N=5035, 46.7 years, 74.2% white, 17.7% black; 39.6% male). Prevalence of hypertension was 29%. Correlations between systolic BP for child and adolescent were r=0.48; for adolescent and young adult were r=0.40, and for child and young adult were r=0.24 (all P<0.0001). Participants self-reporting adult hypertension were less likely to be white (38.7% black, 27.6% white, 20.9% other; P<0.0001) and female (26.4% females, 32.9% male, P<0.0001). Participants with adult hypertension were more likely to have higher BP and adiposity by age 10 years and abnormal lipids and glucose by age 16 years. There was a graded increase in the frequency of self-reported adult hypertension across the BP change groups, even within the persistently normotensive group (X²<0.0001) from 19% in children with a systolic BP% persistently below the median to 80% for individuals with elevated BP in both childhood and adolescence. Although our precision to predict which individual child is at risk of adult BP-related cardiovascular disease is weak, an increase in systolic BP and body mass index percentile from childhood to adolescence should signal a need for lifestyle intervention to prevent future sustained hypertension-related cardiovascular disease.

Is the association between blood pressure and mortality in older adults different with frailty? A systematic review and meta-analysis

OBJECTIVE

to investigate whether the association between blood pressure and clinical outcomes is different in older adults with and without frailty, using observational studies.

METHODS

MEDLINE, EMBASE and CINAHL were searched from 1st January 2000 to 13th June 2018. PROSPERO CRD42017081635. We included all observational studies reporting clinical outcomes in older adults with an average age over 65 years living in the community with and without treatment that measured blood pressure and frailty using validated methods. Two independent reviewers evaluated study quality and risk of bias using the ROBANS tool. We used generic inverse variance modelling to pool risks of all-cause mortality adjusted for age and sex.

RESULTS

nine observational studies involving 21,906 older adults were included, comparing all-cause mortality over a mean of six years. Fixed effects meta-analysis of six studies demonstrated that in people with frailty, there was no mortality difference associated with systolic blood pressure <140 mm Hg compared to systolic blood pressure >140 mm Hg (HR 1.02, 95% CI 0.90 to 1.16). In the absence of frailty, systolic blood pressure <140 mm Hg was associated with lower risk of death compared to systolic blood pressure >140 mm Hg (HR 0.86, 95% CI 0.77 to 0.96).

CONCLUSIONS

evidence from observational studies demonstrates no mortality difference for older people with frailty whose systolic blood pressure is <140 mm Hg, compared to those with a systolic blood pressure >140 mm Hg. Current evidence fails to capture the complexities of blood pressure measurement, and the association with non-fatal outcomes.

Short-term blood pressure changes have a more strong impact on stroke and its subtypes than long-term blood pressure changes

Background

Elevated blood pressure (BP) is closely related to stroke and its subtypes. However, different time periods changes in BP may result in differential risk of stroke.

Hypothesis

Short‐term blood pressure changes have a more strong impact on stroke and its subtypes than long‐term blood pressure changes.

Methods

We designed the study on the effects of short‐ (2008‐2010) and long‐term (2004‐2010) BP changes on stroke events (2011‐2017), including 22 842 and 28 456 subjects, respectively. The difference in β coefficients between short‐ and long‐term BP changes on the effects of stroke were examined using the Fisher Z test.

Results

During a median 12.5‐year follow‐up period, 1014 and 1505 strokes occurred in short‐ and long‐term groups. In short‐term group, going from prehypertension to hypertension, the risk of stroke events increased (stroke: hazard ratio [HR] = 1.537 [1.248‐1.894], ischemic stroke: 1.456 [1.134‐1.870] and hemorrhagic stroke: 1.630 [1.099‐2.415]); going from hypertension to prehypertension, the risk of stroke events decreased (stroke:0.757 [0.619‐0.927] and hemorrhagic stroke:0.569 [0.388‐0.835]). Similarly, in long‐term group, going from prehypertension to hypertension, individuals had an increased risk of stroke (1.291, 1.062‐1.569) and hemorrhagic stroke (1.818, 1.261‐2.623); going from hypertension to prehypertension, participants had a decreased risk of stroke (0.825, 0.707‐0.963) and hemorrhagic stroke (0.777, 0.575‐0.949). Furthermore, the effects of BP changes during short‐term period on stroke events were greater than that in long‐term period.

Conclusions

Short‐ and long‐terms BP changes were both associated with the risk of stroke events. Furthermore, short‐term BP changes had a stronger impact than did long‐term changes on risk of stroke events.

Isolated systolic hypertension in the young: a position paper endorsed by the European Society of Hypertension

: Whether isolated systolic hypertension in the young (ISHY) implies a worse outcome and needs antihypertensive treatment is still a matter for dispute. ISHY is thought to have different mechanisms than systolic hypertension in the elderly. However, findings from previous studies have provided inconsistent results. From the analysis of the literature, two main lines of research and conceptualization have emerged. Simultaneous assessment of peripheral and central blood pressure led to the identification of a condition called pseudo or spurious hypertension, which was considered an innocent condition. However, an increase in pulse wave velocity has been found by some authors in about 20% of the individuals with ISHY. In addition, obesity and metabolic disturbances have often been documented to be associated with ISHY both in children and young adults. The first aspect to consider whenever evaluating a person with ISHY is the possible presence of white-coat hypertension, which has been frequently found in this condition. In addition, assessment of central blood pressure is useful for identifying ISHY patients whose central blood pressure is normal. ISHY is infrequently mentioned in the guidelines on diagnosis and treatment of hypertension. According to the 2013 European Guidelines on the management of hypertension, people with ISHY should be followed carefully, modifying risk factors by lifestyle changes and avoiding antihypertensive drugs. Only future clinical trials will elucidate if a benefit can be achieved with pharmacological treatment in some subgroups of ISHY patients with associated risk factors and/or high central blood pressure.

Elevated hypertension risk associated with higher dietary acid load: A systematic review and meta-analysis

BACKGROUND & AIMS

The association between dietary acid load and hypertension risk is inconclusive. We conducted a systematic review and meta-analysis to summarize effect of dietary acid load on blood pressure.

METHODS

A comprehensively search was performed in electronic databases including EMBASE, PubMed, Web of Science and Chinese National Knowledge Infrastructure. Summary ORs and their corresponding 95% CIs were computed assuming a randomized model or fixed model.

RESULTS

Ten publications comprising 4 cohort and 6 cross-sectional studies were eligible for meta-analysis. There were 8 studies about potential renal acid load (PRAL) and 4 about net endogenous acid production (NEAP). Essential hypertension was statistically associated with higher PRAL (OR = 1.14, 95% CI = 1.02-1.17). Our findings also demonstrated a positive impact of higher PRAL on elevating both diastolic pressure (WMD = 0.96, 95% CI = 0.67-1.26) and systolic pressure (WMD = 1.57, 95% CI = 1.12-2.03). A 35% increased risk of hypertension associated with higher NEAP was identified (OR = 1.35, 95% CI = 1.03-1.78).

CONCLUSIONS

The current study suggests that dietary acid load might be potential risk factor of hypertension.

How Do Kidneys Adapt to a Deficit or Loss in Nephron Number?

A deficit or loss in the number of nephrons, the functional unit of the kidney, can induce compensatory growth and hyperfunction of remaining nephrons. An increase in single nephron glomerular filtration rate (SNGFR) aims to compensate but may be deleterious in the long term. The increase in SNGFR is determined by the dynamics of nephron loss, total remaining GFR, the body's excretory demand, and the functional capacity to sustain single nephron hyperfunction.

Metabolomic correlates of central adiposity and earlier-life body mass index

BMI is correlated with circulating metabolites, but few studies discuss other adiposity measures, and little is known about metabolomic correlates of BMI from early life. We investigated associations between different adiposity measures, BMI from childhood through adulthood, and metabolites quantified from serum using ¹H NMR spectroscopy in 900 British men and women aged 60-64. We assessed BMI, waist-to-hip ratio (WHR), android-to-gynoid fat ratio (AGR), and BMI from childhood through adulthood. Linear regression with Bonferroni adjustment was performed to assess adiposity and metabolites. Of 233 metabolites, 168; 126; and 133 were associated with BMI, WHR, and AGR at age 60-64, respectively. Associations were strongest for HDL, particularly HDL particle size-e.g., there was 0.08 SD decrease in HDL diameter (95% CI: 0.07-0.10) with each unit increase in BMI. BMI-adjusted AGR or WHR were associated with 31 metabolites where there was no metabolome-wide association with BMI. We identified inverse associations between BMI at age 7 and glucose or glycoprotein at age 60-64 and relatively large LDL cholesteryl ester with postadolescent BMI gains. In summary, we identified metabolomic correlates of central adiposity and earlier-life BMI. These findings support opportunities to leverage metabolomics in early prevention of cardiovascular risk attributable to body fatness.

Fruit, vegetable intake and blood pressure trajectories in older age

Diet rich in fruits and vegetables (F&V) is an established protective factor for hypertension, but the available evidence regarding the impact of F&V consumption on age-related blood pressure change is limited. We examined whether systolic (SBP) and diastolic (DBP) blood pressure trajectories are influenced by F&V intakes in an ageing Russian cohort. Dietary data was available for 8997 men and women in the Health, Alcohol and Psychosocial Factors in Eastern Europe prospective cohort study. Blood pressure measurements were taken at three time-points over 12 years of follow-up, during which time the mean age of the sample changed from 58 to 69 years. The relationships between F&V intake and SBP and DBP were assessed using mixed-effect multilevel models. In the multivariable adjusted models, fruit intake was inversely related to both systolic and diastolic blood pressure at baseline (mean SBP and DBP was 3.5 mmHg and 1.4 mm Hg lower in the highest compared to the lowest intake tertiles, respectively (both p values < 0.001)). However, it was not associated with blood pressure change over time (difference in annual SBP and DBP change was 0.11 mmHg (p value = 0.138) and 0.01 mmHg (p value = 0.894), respectively). We found no significant link between vegetable intake and blood pressure, neither cross-sectionally nor longitudinally. In addition to the association with diet, we observed increasing SBP and mostly steady DBP over age, with deceleration and downward turn after the ages of 55–59 years. On the whole, this analysis found no consistent association between F&V intake and trajectories of blood pressure in older age.

Blood Pressure Trajectories from Childhood to Adolescence in Pediatric Hypertension

It has been known for a long time that elevated blood pressure (BP) in the young may persist and progress into adult hypertension (HTN). Multiple studies have revealed the predicted BP trajectory lines starting from childhood and related them to later cardiovascular (CV) risks in adulthood. As a small baby grows into a tall adult, BP will also naturally increase. Among early-life predictors of adult HTN, birth history, such as prematurity, and low birth weight have been popular subjects in research on pediatric HTN, because body size at birth has been reported to be inversely related to the risk of adulthood HTN. The hypothesis of HTN in prematurely born adolescents has been postulated as a physiological predisposition to postnatal excessive weight gain. Current body weight is a well-known independent predictor of HTN in children, and some studies showed that children demonstrating upward crossing of their weight percentiles while growing into adolescents have significantly increased risk for elevated BP later in life. Recently, reports focused on the adverse effect of excessive catch-up growth in this population are gradually drawing attention. Accordingly, children born prematurely or with intrauterine growth restriction who show rapid changes in their weight percentile should be under surveillance with BP monitoring. Prevention of childhood obesity, along with special care for premature infants or infants small for their gestational age, by providing healthy nutritional guidelines should be cardinal strategies for the prevention of adult HTN and CV risks later in life.

Sex-specific trajectories of measures of cardiovascular health during childhood and adolescence: A prospective cohort study

BACKGROUND AND AIMS

Sex differences in measures of cardiovascular health in adults are well documented. However, the sex-specific aetiology of cardiovascular health across childhood and adolescence is poorly understood.

METHODS

We examined sex differences in trajectories of 11 measures of cardiovascular health from birth to 18 years, in a contemporary birth cohort study in England (N participants per outcomes: 662-13,985, N repeated measures per outcome: 1,831-112,768). Outcomes were measured over varying time spans from birth or mid-childhood to age 18 and with different numbers of repeated measures per outcome. Analyses were performed using fractional polynomial and linear spline multilevel models.

RESULTS

Females had higher mean BMI, height-adjusted fat mass, pulse rate, insulin, triglycerides, and non-high-density lipoprotein cholesterol (HDL-c) and lower mean height-adjusted lean mass from birth or from mid-childhood to age 18. For example, mean non-HDL-c was 0.07 mmol/l (95% confidence interval (CI), 0.04, 0.10) higher in females compared with males at birth. By age 18, this difference persisted and widened to 0.19 mmol/l (95% CI, 0.16, 0.23) higher non-HDL-c in females compared with males. Females had lower levels of glucose from mid-childhood and developed lower systolic blood pressure and higher HDL-c from mid-adolescence onward. For example, females had 0.08 mmol/l (95% CI, 0.05, 0.10) lower mean glucose compared with males at age seven which widened to a difference of 0.22 mmol/l (95% CI, 0.25, 0.19) at age 18.

CONCLUSIONS

Sex differences in measures of cardiovascular health are apparent from birth or mid-childhood and change during early life. These differences may have implications for sex-specific disease risk in future adult populations.

Prospective relation of adolescent citrate excretion and net acid excretion capacity with blood pressure in young adulthood

Experimental data and observational studies in adults suggest that even subtle changes in acid-base balance, indicative of a higher systemic proton load, are related to higher blood pressure (BP) levels and an increased hypertension risk. However, these associations have not been investigated during growth. The kidney is the central organ in regulating excretion of nonvolatile acids, and renal citrate excretion has been shown to be a sensitive, noninvasive marker of changes in systemic acid balance. We thus analyzed the prospective relation of 24-h citrate excretion, as well as net acid excretion capacity (NAEC; a noninvasive indicator of the renal ability to excrete protons), during adolescence (boys: 10-15 yr; girls: 9-14 yr) with BP levels in young adulthood (18-30 yr) in 374 healthy participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. In linear-regression analyses adjusted for age, sex, 24-h urinary excretions of sodium and potassium, as well as further relevant confounders, a 1-mmol/1.73 m²/day higher adolescent citrate excretion was related to 1.2 mmHg lower systolic BP ( P = 0.02) but not to diastolic BP ( P = 0.6). A 10-mEq higher NAEC during adolescence was related to 1.7 mmHg lower systolic BP in young men, but this association was statistically nonsignificant ( P = 0.07) after multivariable adjustment. Additional adjustment for adult body mass index did not alter these findings. To conclude, subtle changes in systemic acid-base balance during adolescence are already indicative for later BP. Potential sex differences in these associations should be investigated in further studies.

Effect of Long-Term Systolic Blood Pressure Trajectory on Kidney Damage in the Diabetic Population: A Prospective Study in a Community-Based Chinese Cohort

Background:

Previous studies have shown that hypertension is an important factor contributing to the occurrence and progression of diabetic kidney damage. However, the relationship between the patterns of blood pressure (BP) trajectory and kidney damage in the diabetic population remains unclear. This prospective study investigated the effect of long-term systolic BP (SBP) trajectory on kidney damage in the diabetic population based on an 8-year follow-up community-based cohort.

Methods:

This study included 4556 diabetic participants among 101,510 participants. BP, estimated glomerular filtration rate (eGFR), and urinary protein were measured every 2 years from 2006 to 2014. SBP trajectory was identified by the censored normal modeling. Five discrete SBP trajectories were identified according to SBP range and the changing pattern over time. Kidney damage was evaluated through eGFR and urinary protein value. A multivariate logistic regression model was used to analyze the influence of different SBP trajectory groups on kidney damage.

Results:

We identified five discrete SBP trajectories: low-stable group (n = 864), moderate-stable group (n = 1980), moderate increasing group (n = 609), elevated decreasing group, (n = 679), and elevated stable group (n = 424). The detection rate of kidney damage in the low-stable group (SBP: 118–124 mmHg) was the lowest among the five groups. The detection rate of each kidney damage index was higher in the elevated stable group (SBP: 159–172 mmHg) compared with the low-stable group. For details, the gap was 4.14 (11.6% vs. 2.8%) in eGFR <60 ml·min⁻¹·1.73 m⁻² and 3.66 (17.2% vs. 4.7%), 3.38 (25.0% vs. 7.4%), and 1.8 (10.6% vs. 5.9%) times in positive urinary protein, eGFR <60 ml·min⁻¹·1.73 m⁻² and/or positive urinary protein, and eGFR decline ≥30%, respectively (P < 0.01).

Conclusion:

An elevated stable SBP trajectory is an independent risk factor for kidney damage in the diabetic population.

Aging and Cardiometabolic Risk in European HEMS Pilots: An Assessment of Occupational Old-Age Limits as a Regulatory Risk Management Strategy

Old-age limits are imposed in some occupations in an effort to ensure public safety. In aviation, the "Age 60 Rule" limits permissible flight operations conducted by pilots aged 60 and over. Using a retrospective cohort design, we assessed this rule's validity by comparing age-related change rates of cardiometabolic incapacitation risk markers in European helicopter emergency medical service (HEMS) pilots near age 60 with those in younger pilots. Specifically, individual clinical, laboratory, and electrocardiogram (ECG)-based risk markers and an overall cardiovascular event risk score were determined from aeromedical examination records of 66 German, Austrian, Polish, and Czech HEMS pilots (average follow-up 8.52 years). Risk marker change rates were assessed using linear mixed models and generalized additive models. Body mass index increases over time were slower in pilots near age 60 compared to younger pilots, and fasting glucose levels increased only in the latter. Whereas the lipid profile remained unchanged in the latter, it improved in the former. An ECG-based arrhythmia risk marker increased in younger pilots, which persisted in the older pilots. Six-month risk of a fatal cardiovascular event (in or out of cockpit) was estimated between 0% and 0.3%. Between 41% and 95% of risk marker variability was due to unexplained time-stable between-person differences. To conclude, the cardiometabolic risk marker profile of HEMS pilots appears to improve over time in pilots near age 60, compared to younger pilots. Given large stable interindividual differences, we recommend individualized risk assessment of HEMS pilots near age 60 instead of general grounding.

Blood Pressure Patterns and Subsequent Coronary Artery Calcification in Women Who Delivered Preterm Births

Women who delivered preterm infants have excess cardiovascular disease, but vascular pathways linking these conditions are not understood. We considered that higher blood pressure over 25 years among women with preterm delivery may be associated with coronary artery calcification (CAC). The CARDIA study (Coronary Artery Risk Development in Young Adults) enrolled 1049 black and white women with births between 1985 and 2010 (n=272 ever preterm [<37 weeks]; n=777 all term births [≥37 weeks]). Latent mixture modeling identified blood pressure trajectories across 20 years, and these were related to CAC at years 20 and 25. Three systolic blood pressure (SBP) patterns were identified: low stable (n=563; 53%), moderate (n=416; 40%), and moderate increasing (n=70; 7%). Women with moderate-increasing SBP were more likely to have delivered preterm compared with those in the low-stable group (40% versus 21%; P<0.0001), and they were more likely to have CAC (38.5% versus 12.2%). The SBP and CAC association varied by preterm birth (P interaction=0.04). Women with preterm delivery and a moderate-increasing SBP had a 2.17-fold higher hazards of CAC (95% confidence interval, 1.14-4.12) compared with women with term births and a lower SBP pattern, adjusted for cardiovascular disease risk factors and other pregnancy features. There was no excess CAC in women with moderate-increasing SBP and term births (adjusted hazard ratio, 1.02; 95% confidence interval, 0.49-2.14). Associations were stronger in women with hypertensive disorders of pregnancy but also detected in those with normotensive preterm deliveries. Women who deliver preterm infants are more likely to follow a high-risk blood pressure pattern throughout the childbearing years that is associated with CAC at midlife.

A holistic approach to healthy ageing: how can people live longer, healthier lives?

BACKGROUND

Although lifespan is increasing, there is no evidence to suggest that older people are experiencing better health in their later years than previous generations. Nutrition, at all stages of life, plays an important role in determining health and wellbeing.

METHODS

A roundtable meeting of UK experts on nutrition and ageing considered key aspects of the diet-ageing relationship and developed a consensus position on the main priorities for research and public health actions that are required to help people live healthier lives as they age.

RESULTS

The group consensus highlighted the requirement for a life course approach, recognising the multifactorial nature of the impact of ageing. Environmental and lifestyle influences at any life stage are modified by genetic factors and early development. The response to the environment at each stage of life can determine the impact of lifestyle later on. There are no key factors that act in isolation to determine patterns of ageing and it is a combination of environmental and social factors that drives healthy or unhealthy ageing. Too little is known about how contemporary dietary patterns and sedentary lifestyles will impact upon healthy ageing in future generations and this is a priority for future research.

CONCLUSIONS

There is good evidence to support change to lifestyle (i.e. diet, nutrition and physical) activity in relation to maintaining or improving body composition, cognitive health and emotional intelligence, immune function and vascular health. Lifestyle change at any stage of life may extend healthy lifespan, although the impact of early changes appears to be greatest.

Maternal prepregnancy BMI or weight and offspring's blood pressure: Systematic review

Emerging evidence suggests that maternal prepregnancy body mass index or weight (MPBW) may be associated with offspring's blood pressure (BP). Therefore, we conducted a systematic review-following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement-to assess and judge the evidence for an association between MPBW with offspring's later BP. Five data bases were searched without limits. Risk of bias was assessed using the "Tool to Assess Risk of Bias in Cohort Studies," and an evidence grade was allocated following the World Cancer Research Fund criteria. Of 2,011 publications retrieved, 16 studies (all cohort studies) were included in the systematic review; thereof, 5 studies (31%) were rated as good-quality studies. Overall, data from 63,959 participants were enclosed. Systolic BP was analysed in 15 (5 good quality), diastolic BP in 12 (3 good quality), and mean arterial pressure in 3 (no good quality) studies. Five good-quality studies of MPBW with offspring's systolic BP as the outcome and 1 good-quality study with offspring's diastolic BP as the outcome observed a significant association. However, after adding offspring's anthropometry variables to the statistical model, the effect attenuated in 4 studies with systolic BP to nonsignificance, the study with diastolic BP remained significant. No good-quality studies were found with respect to offspring's later mean arterial pressure. In conclusion, this systematic review found suggestive, but still limited, evidence for an association between MPBW with offspring's later BP. The available data suggest that the effect might be mainly mediated via offspring's anthropometry.

Sex differences in time trends of blood pressure among Swedish septuagenarians examined three decades apart: a longitudinal population study

OBJECTIVE

The aim of this study was to analyze the influence of birth cohort, sex and age on the trajectories of SBP and DBP in two birth cohorts of 70-year-olds, examined 3 decades apart and followed up at ages 75 and 79-80 years.

METHODS

Two population samples of 70-year-olds from Gothenburg, Sweden, were examined. The first, born in 1901-1902, was examined in 1971-1972 (n = 973). The second, born in 1930, was examined in 2000 (n = 509). Both samples were re-examined at ages 75 and 79-80 years.

RESULTS

We found that SBP and DBP were considerably lower in septuagenarian men and women born 1930 compared with those born 1901-1902, also when adjusting for antihypertensive treatment in different ways. The decline was especially pronounced in women. Blood pressure was higher in women than in men in the 1970s, whereas there were no sex differences in the 2000s. The age-related decline in SBP started earlier and was more accentuated in those born in 1930 than in those born in 1901-1902.

CONCLUSION

Blood pressure decreased, and the age-related decline in SBP started earlier in septuagenarians examined in the 2000s compared with those examined in the 1970s. The decrease was especially pronounced in women and diminished the sex differences. Antihypertensive treatment only partly explained our findings, suggesting that other mostly unknown factors played an important role.

The impact of parity on life course blood pressure trajectories: the HUNT study in Norway

The drop in blood pressure during pregnancy may persist postpartum, but the impact of pregnancy on blood pressure across the life course is not known. In this study we examined blood pressure trajectories for women in the years preceding and following pregnancy and compared life course trajectories of blood pressure for parous and nulliparous women. We linked information on all women who participated in the population-based, longitudinal HUNT Study, Norway with pregnancy information from the Medical Birth Registry of Norway. A total of 23,438 women were included with up to 3 blood pressure measurements per woman. Blood pressure trajectories were compared using a mixed effects linear spline model. Before first pregnancy, women who later gave birth had similar mean blood pressure to women who never gave birth. Women who delivered experienced a drop after their first birth of − 3.32 mmHg (95% CI, − 3.93, − 2.71) and − 1.98 mmHg (95% CI, − 2.43, − 1.53) in systolic and diastolic blood pressure, respectively. Subsequent pregnancies were associated with smaller reductions. These pregnancy-related reductions in blood pressure led to persistent differences in mean blood pressure, and at age 50, parous women still had lower systolic (− 1.93 mmHg; 95% CI, − 3.33, − 0.53) and diastolic (− 1.36 mmHg; 95% CI, − 2.26, − 0.46) blood pressure compared to nulliparous women. The findings suggest that the first pregnancy and, to a lesser extent, successive pregnancies are associated with lasting and clinically relevant reductions in systolic and diastolic blood pressure.

Dietary Acid Load and Potassium Intake Associate with Blood Pressure and Hypertension Prevalence in a Representative Sample of the German Adult Population

Diets rich in fruits and vegetables, like the Dietary Approaches to Stop Hypertension (DASH)-diet, are usually characterized by high potassium intake and reduced dietary acid load, and have been shown to reduce blood pressure (BP). However, the relevance of potential renal acid load (PRAL) for BP has not been compared with the relevance to BP of urinary biomarker (K-urine)- and dietary food frequency questionnaire (K-FFQ)-based estimates of potassium intake in a general adult population sample. For 6788 participants (aged 18–79 years) of the representative German Health-Interview and Examination Survey for Adults (DEGS1), associations of PRAL, K-urine, and K-FFQ with BP and hypertension prevalence were cross-sectionally examined in multivariable linear and logistic regression models. PRAL was significantly associated with higher systolic BP (p = 0.0002) and higher hypertension prevalence (Odds ratio [OR] high vs. low PRAL = 1.45, p = 0.0004) in models adjusted for age, sex, body mass index (BMI), estimated sodium intake, kidney function, relevant medication, and further important covariates. Higher estimates of K-FFQ and K-urine were related to lower systolic BP (p = 0.04 and p < 0.0001) and lower hypertension prevalence (OR = 0.82, p = 0.04 and OR = 0.77, p = 0.02) as well as a lower diastolic BP (p = 0.03 and p = 0.0003). Our results show, for the first time in a comparative analysis of a large representative population sample, significant relationships of BP and hypertension prevalence with questionnaire- and biomarker-based estimates of potassium intake and with an estimate of dietary acid load.

Blood Pressure Trajectories in the 20 Years Before Death

IMPORTANCE

There is mixed evidence that blood pressure (BP) stabilizes or decreases in later life. It is also unclear whether BP trajectories reflect advancing age, proximity to end of life, or selective survival of persons free from hypertension.

OBJECTIVE

To estimate individual patient BP for each of the 20 years before death and identify potential mechanisms that may explain trajectories.

DESIGN, STUDY, AND PARTICIPANTS

We analyzed population-based Clinical Practice Research Datalink primary care and linked hospitalization electronic medical records from the United Kingdom, using retrospective cohort approaches with generalized linear mixed-effects modeling. Participants were all available individuals with BP measures over 20 years, yielding 46 634 participants dying aged at least 60 years, from 2010 to 2014. We also compared BP slopes from 10 to 3 years before death for 20 207 participants who died, plus 20 207 birth-year and sex-matched participants surviving longer than 9 years.

MAIN OUTCOMES AND MEASURES

Clinically recorded individual patient repeated systolic BP (SBP) and diastolic BP (DBP).

RESULTS

In 46 634 participants (51.7% female; mean [SD] age at death, 82.4 [9.0] years), SBPs and DBPs peaked 18 to 14 years before death and then decreased progressively. Mean changes in SBP from peak values ranged from -8.5 mm Hg (95% CI, -9.4 to -7.7) for those dying aged 60 to 69 years to -22.0 mm Hg (95% CI, -22.6 to -21.4) for those dying at 90 years or older; overall, 64.0% of individuals had SBP changes of greater than -10 mm Hg. Decreases in BP appeared linear from 10 to 3 years before death, with steeper decreases in the last 2 years of life. Decreases in SBP from 10 to 3 years before death were present in individuals not treated with antihypertensive medications, but mean yearly changes were steepest in patients with hypertension (-1.58; 95% CI, -1.56 to -1.60 mm Hg vs -0.70; 95% CI, -0.65 to -0.76 mm Hg), dementia (-1.81; 95% CI, -1.77 to -1.87 mm Hg vs -1.41; 95% CI, -1.38 to -1.43 mm Hg), heart failure (-1.66; 95% CI, -1.62 to -1.69 mm Hg vs -1.37; 95% CI, -1.34 to -1.39 mm Hg), and late-life weight loss.

CONCLUSIONS AND RELEVANCE

Mean SBP and DBP decreased for more than a decade before death in patients dying at 60 years and older. These BP decreases are not simply attributable to age, treatment of hypertension, or better survival without hypertension. Late-life BP decreases may have implications for risk estimation, treatment monitoring, and trial design.