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Parekh N, Page A, Ali K, Davies K, Rajkumar C. A practical approach to the pharmacological management of hypertension in older people. Ther Adv Drug Saf 2016; 8:117-132. [PMID: 28439398 DOI: 10.1177/2042098616682721] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Hypertension is the leading cause of cardiovascular (CV) morbidity and mortality in adults over the age of 65. The first part of this paper is an overview, summarizing the current guidelines on the pharmacological management of hypertension in older adults in Europe and the USA, and evidence from key trials that contributed to the guidelines. In the second part of the paper, we will discuss the major challenges of managing hypertension in the context of multimorbidity, including frailty, orthostatic hypotension (OH), falls and cognitive impairment that are associated with ageing. A novel 'BEGIN' algorithm is proposed for use by prescribers prior to initiating antihypertensive therapy to guide safe medication use in older adults. Practical suggestions are highlighted to aid practitioners in making rational decisions to treat and monitor hypertension, and for considering withdrawal of antihypertensive drugs in the complex older person.
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Affiliation(s)
| | - Amy Page
- The University of Western Australia, Crawley, Australia
| | - Khalid Ali
- Brighton and Sussex Medical School, Brighton, UK
| | - Kevin Davies
- Brighton and Sussex Medical School, Brighton, UK
| | - Chakravarthi Rajkumar
- Department of Elderly Medicine, Brighton and Sussex Medical School, Audrey Emerton Building, Eastern Road, Brighton BN2 5BE, UK
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Bozkurt B, Aguilar D, Deswal A, Dunbar SB, Francis GS, Horwich T, Jessup M, Kosiborod M, Pritchett AM, Ramasubbu K, Rosendorff C, Yancy C. Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e535-e578. [DOI: 10.1161/cir.0000000000000450] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pfeffer MA, McMurray JJV. Lessons in Uncertainty and Humility - Clinical Trials Involving Hypertension. N Engl J Med 2016; 375:1756-1766. [PMID: 27806228 DOI: 10.1056/nejmra1510067] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Marc A Pfeffer
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (M.A.P.); and the British Heart Failure Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.)
| | - John J V McMurray
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (M.A.P.); and the British Heart Failure Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.)
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104
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Kjeldsen SE, Stenehjem A, Os I, Van de Borne P, Burnier M, Narkiewicz K, Redon J, Agabiti Rosei E, Mancia G. Treatment of high blood pressure in elderly and octogenarians: European Society of Hypertension statement on blood pressure targets. Blood Press 2016; 25:333-336. [PMID: 27644446 DOI: 10.1080/08037051.2016.1236329] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Sverre E Kjeldsen
- a Departments of Cardiology and Nephrology , Oslo University Hospital , Ullevål.,b Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Aud Stenehjem
- a Departments of Cardiology and Nephrology , Oslo University Hospital , Ullevål
| | - Ingrid Os
- a Departments of Cardiology and Nephrology , Oslo University Hospital , Ullevål.,b Faculty of Medicine , University of Oslo , Oslo , Norway
| | | | - Michel Burnier
- d Service of Nephrology and Hypertension , Centre Hospitalier Universitaire Vaudois , Lausanne , Switzerland
| | - Krzysztof Narkiewicz
- e Department of Hypertension and Diabetology , Medical University of Gdansk , Poland
| | - Josep Redon
- f Department of Internal Medicine , Hospital Clinico, University of Valencia , Valencia , Spain
| | - Enrico Agabiti Rosei
- g Clinica Medica, Department of Clinical and Experimental Sciences , University of Brescia , Brescia , Italy
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105
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Malachias MVB, Ferreira S, Souza WKSB, Ribeiro JM, Miranda RD, Jardim TSV. 7th Brazilian Guideline of Arterial Hypertension: Chapter 11 - Arterial Hypertension in the elderly. Arq Bras Cardiol 2016; 107:64-66. [PMID: 27819390 PMCID: PMC5319468 DOI: 10.5935/abc.20160161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Systolic blood pressure (SBP) is an important predictor of cardiovascular disease (CVD) outcomes. Lowering SBP has been shown to reduce CVD morbidity and mortality, but the optimal SBP target continues to be a topic of intense debate. The Systolic Blood Pressure Intervention Trial (SPRINT) reported a significantly lower risk for CVD outcomes and all-cause mortality by targeting SBP <120 mmHg compared with <140 mmHg in a population of hypertensive persons at high CV risk. In this review, we discuss the strengths, limitations, and generalizability of SPRINT findings to other hypertensive populations that were excluded from the trial, including those with diabetes or prior stroke, <50 years old, and at lower CVD risk. We will focus on the implications of SPRINT findings for appropriate BP targets in high-risk groups of hypertensive persons, including the elderly and those with chronic kidney disease (CKD). We will also address the cost-effectiveness of intensive BP treatment as implemented in SPRINT and the implications of SPRINT for health care policy and future BP guidelines.
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Affiliation(s)
- Hemal Bhatt
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lama Ghazi
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Calhoun
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
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107
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Saito M, Khan F, Stoklosa T, Iannaccone A, Negishi K, Marwick TH. Prognostic Implications of LV Strain Risk Score in Asymptomatic Patients With Hypertensive Heart Disease. JACC Cardiovasc Imaging 2016; 9:911-21. [DOI: 10.1016/j.jcmg.2015.09.027] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/11/2015] [Accepted: 09/29/2015] [Indexed: 11/24/2022]
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Dornbrook-Lavender KA, Pieper JA, Roth MT. Primary Prevention of Coronary Heart Disease in the Elderly. Ann Pharmacother 2016; 37:1654-63. [PMID: 14565805 DOI: 10.1345/aph.1d025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE: To review relevant literature supporting the use of antihypertensive agents, lipid-lowering agents (i.e., statins), and aspirin therapy for the primary prevention of coronary heart disease (CHD) in an elderly patient population (age ≥65 y). DATA SOURCES: A MEDLINE search (1988–January 2003) was conducted. STUDY SELECTION AND DATA EXTRACTION: Primary and tertiary literature involving the uses of antihypertensives, statins, and aspirin therapy in the elderly were reviewed. DATA SYNTHESIS: Mortality due to CHD in the US population has decreased 40–50% over the last 30 years; however, CHD remains the leading cause of morbidity and mortality in elderly persons. As the population continues to age, the number of older adults eligible for primary prevention will rise. The American Heart Association clinical practice guidelines for the primary prevention of CHD were updated in 2002; however, they are based on findings from clinical trials that enrolled predominantly middle-aged white men. The recommendations for elderly individuals are predominantly extrapolated from subgroup analyses of randomized clinical trials or cohort studies. This literature suggests that elderly persons are candidates for primary prevention measures and experience reductions in coronary events when treated with appropriate therapies. CONCLUSIONS: Data suggest that use of antihypertensives, statins, and aspirin therapy in the elderly appears effective to an extent similar to, and often greater than, that observed in younger patients. We believe these agents should be prescribed to all appropriate high-risk elderly patients. Ongoing and future studies will more clearly elucidate the benefits of primary prevention therapy, particularly in persons ≥75 years of age.
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Cao Y, Liu LT, Wu M. Is Chinese herbal medicine effective for elderly isolated systolic hypertension? A systematic review and meta-analysis. Chin J Integr Med 2016; 23:298-305. [PMID: 27225294 DOI: 10.1007/s11655-016-2257-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Indexed: 10/21/2022]
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Patient-Centred Care of Older Adults With Cardiovascular Disease and Multiple Chronic Conditions. Can J Cardiol 2016; 32:1097-107. [PMID: 27378591 DOI: 10.1016/j.cjca.2016.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 12/21/2022] Open
Abstract
Multimorbidity, defined as the presence of 2 or more chronic conditions, is common among older adults with cardiovascular disease. These individuals are at increased risk for poor health outcomes and account for a large proportion of health care utilization. Clinicians are challenged with the heterogeneity of this population, the complexity of the treatment regimen, limited high-quality evidence, and fragmented health care systems. Each treatment recommended by a clinical practice guideline for a single cardiovascular disease might be rational, but the combination of all evidence-based recommendations can be impractical or even harmful to individuals with multimorbidity. These challenges can be overcome with a patient-centred approach that incorporates the individual's preferences, relevant evidence, the overall and condition-specific prognosis, clinical feasibility of treatments, and interactions with other treatments and coexisting chronic conditions. The ultimate goal is to maximize benefits and minimize harms by optimizing adherence to the most essential treatments, while acknowledging trade-offs between treatments for different health conditions. It might be necessary to discontinue therapies that are not essential or potentially harmful to decrease the risk of drug-drug and drug-disease interactions from polypharmacy. A decision to initiate, withhold, or stop a treatment should be on the basis of the time horizon to benefits vs the individual's prognosis. In this review, we illustrate how cardiologists and general practitioners can adopt a patient-centred approach to focus on the aspects of cardiovascular and noncardiovascular health that have the greatest effect on functioning and quality of life in older adults with cardiovascular disease and multimorbidity.
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111
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Marrs JC, Thompson AM. Antihypertensive Therapy in Females: A Clinical Review Across the Lifespan. Pharmacotherapy 2016; 36:638-51. [PMID: 27072935 DOI: 10.1002/phar.1754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hypertension affects one-third of all females in the United States, with the prevalence increasing over a female's lifespan. The approach to treating females with hypertension varies depending on a female's age, race, comorbidities, and whether she is of child-bearing age or pregnant. It is important to factor in the safety and effectiveness of antihypertensive medications across these populations of females. Blood pressure target goals are the same in females as in males regardless of comorbidities or stage of life, with the exception of those females who are pregnant. Recommendations for antihypertensive medication do not differ between females and males based on disease state or stage of life, with the exception of females who are pregnant, breastfeeding, or of child-bearing age. Multiple guidelines recommend avoiding renin-angiotensin system blockers during pregnancy and suggest balancing the risk versus benefit in females of child-bearing age. Further, multiple guidelines provide race-based therapy recommendations for the use of calcium channel blockers and thiazide diuretics in black versus nonblack patients, irrespective of sex. Future research is needed to evaluate whether there are sex differences relative to blood pressure and cardiovascular event-lowering relative to specific antihypertensive medications with a focus on pharmacogenomic differences.
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Affiliation(s)
- Joel C Marrs
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Angela M Thompson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
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112
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Hypertension phenotypes and incident cardiovascular disease and mortality events in a decade follow-up of a Middle East cohort. J Hypertens 2016; 33:1153-61. [PMID: 25699976 DOI: 10.1097/hjh.0000000000000540] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the association of hypertension phenotypes, with the risk of cardiovascular disease (CVD) and mortality. METHODS We examined the risk of hypertension phenotypes, that is, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), systolic-diastolic hypertension (SDH), controlled blood pressure (CBP), and uncontrolled blood pressure (UBP) among 6974 middle-aged and 882 elderly participants. Cox regression analysis was used to estimate the hazard ratio for hypertension phenotypes, considering those with normotension as the reference. RESULTS During more than 10 years of follow-up, in the middle-aged group, 490 CVD events and 152 deaths occurred; corresponding rates for the elderly group were 194 and 183, respectively. In middle-aged patients, ISH, SDH, and UBP increased the risk of CVD, whereas UBP increased the risk of mortality due to CVD and any cause (hazard ratio 5.67 and 2.95, respectively) and IDH increased only the risk of total mortality in the middle-aged group (hazard ratio 2.01; all P values <0.05). In elderly patients, ISH, SDH, and UBP significantly increased the risks of CVD. IDH (hazard ratio 3.20 and 2.01), SDH (hazard ratio 3.80 and 3.23) and CBP (hazard ratio 2.86 and 1.87) increased the risks of CVD and all-cause mortality in this group, respectively (all P values <0.05). CONCLUSION In both middle-aged and elderly population, ISH, SDH, and UBP increase the risk of CVD. Controlling of BP to less than 140/90 mmHg decreases the risk of mortality events among the middle-aged population; however, it is not suitable for the elderly as it was associated with higher risk of mortality.
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Abstract
This protocol was withdrawn in April 2016 as the author team was unable to progress to the final review stage. An editorial decision was taken not to pursue this title. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Rajaa F Faris
- Prince Sultan Cardiac CentreDepartment of CardiologyP.O. Box: 7897RiyadhSaudi Arabia11565
| | - Marcus Flather
- University of East AngliaResearch & Development OfficeLevel 3 EastNorfolk and Norwich University Hospitals NHS Foundation Trust, Colney LaneNorwichUKNR4 7UY
| | - Henry Purcell
- The Royal Brompton Hospital Harefield NHS TrustDepartment of CardiologySydney StreetLondonUKSW3 6LP
| | | | - Andrew JS Coats
- University of East AngliaElizabeth Fry Building University of East AngliaNorwichNorfolkUKNR4 7TJ
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Wang WT, You LK, Chiang CE, Sung SH, Chuang SY, Cheng HM, Chen CH. Comparative Effectiveness of Blood Pressure-lowering Drugs in Patients who have Already Suffered From Stroke: Traditional and Bayesian Network Meta-analysis of Randomized Trials. Medicine (Baltimore) 2016; 95:e3302. [PMID: 27082571 PMCID: PMC4839815 DOI: 10.1097/md.0000000000003302] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hypertension is the most important risk factor for stroke and stroke recurrence. However, the preferred blood pressure (BP)-lowering drug class for patients who have suffered from a stroke has yet to be determined. To investigate the relative effects of BP-lowering therapies [angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blockers (ARB), β blockers, calcium channel blockers (CCBs), diuretics, and combinations of these drugs] in patients with a prior stroke history, we performed a systematic review and meta-analysis using both traditional frequentist and Bayesian random-effects models and meta-regression of randomized controlled trials (RCTs) on the outcomes of recurrent stroke, coronary heart disease (CHD), and any major adverse cardiac and cerebrovascular events (MACCE). Trials were identified from searches of published hypertension guidelines, electronic databases, and previous systematic reviews. Fifteen RCTs composed of 39,329 participants with previous stroke were identified. Compared with the placebo, only ACEI along with diuretics significantly reduced recurrent stroke events [odds ratio (OR) = 0.54, 95% credibility interval (95% CI) 0.33-0.90]. On the basis of the distribution of posterior probabilities, the treatment ranking consistently identified ACEI along with diuretics as the preferred BP-lowering strategy for the reduction of recurrent stroke and CHD (31% and 35%, respectively). For preventing MACCE, diuretics appeared to be the preferred agent for stroke survivors (34%). Moreover, the meta-regression analysis failed to demonstrate a statistical significance between BP reduction and all outcomes (P = 0.1618 for total stroke, 0.4933 for CHD, and 0.2411 for MACCE). Evidence from RCTs supports the use of diuretics-based treatment, especially when combined with ACEI, for the secondary prevention of recurrent stroke and any vascular events in patients who have suffered from stroke.
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Affiliation(s)
- Wei-Ting Wang
- From the Division of Cardiology (W-TW, S-HS), Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Education (L-KY, H-MC, C-HC), Taipei Veterans General Hospital, Taipei, Taiwan; Laboratory of Evidence-based Health care, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan (L-KY, H-MC); Taipei Veterans General Hospital, Taipei, Taiwan; General Clinical Research Center (C-EC), Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health (S-HS, H-MC, C-HC) and Community Medicine Research Center; Department of Medicine (S-HS, H-MC, C-HC), National Yang-Ming University, Taipei, Taiwan; and Division of Preventive Medicine and Health Service (S-YC), Research Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
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116
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Taverny G, Mimouni Y, LeDigarcher A, Chevalier P, Thijs L, Wright JM, Gueyffier F. Antihypertensive pharmacotherapy for prevention of sudden cardiac death in hypertensive individuals. Cochrane Database Syst Rev 2016; 3:CD011745. [PMID: 26961575 PMCID: PMC8665834 DOI: 10.1002/14651858.cd011745.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND High blood pressure is an important public health problem because of associated risks of stroke and cardiovascular events. Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent cardiac events, including myocardial infarction and sudden death (death of unknown cause within one hour of the onset of acute symptoms or within 24 hours of observation of the patient as alive and symptom free). OBJECTIVES To assess the effects of antihypertensive pharmacotherapy in preventing sudden death, non-fatal myocardial infarction and fatal myocardial infarction among hypertensive individuals. SEARCH METHODS We searched the Cochrane Hypertension Specialised Register (all years to January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (2016, Issue 1), Ovid MEDLINE (1946 to January 2016), Ovid EMBASE (1980 to January 2016) and ClinicalTrials.gov (all years to January 2016). SELECTION CRITERIA All randomised trials evaluating any antihypertensive drug treatment for hypertension, defined, when possible, as baseline resting systolic blood pressure of at least 140 mmHg and/or resting diastolic blood pressure of at least 90 mmHg. Comparisons included one or more antihypertensive drugs versus placebo, or versus no treatment. DATA COLLECTION AND ANALYSIS Review authors independently extracted data. Outcomes assessed were sudden death, fatal and non-fatal myocardial infarction and change in blood pressure. MAIN RESULTS We included 15 trials (39,908 participants) that evaluated antihypertensive pharmacotherapy for a mean duration of follow-up of 4.2 years. This review provides moderate-quality evidence to show that antihypertensive drugs do not reduce sudden death (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.81 to 1.15) but do reduce both non-fatal myocardial infarction (RR 0.85, 95% CI 0.74, 0.98; absolute risk reduction (ARR) 0.3% over 4.2 years) and fatal myocardial infarction (RR 0.75, 95% CI 0.62 to 0.90; ARR 0.3% over 4.2 years). Withdrawals due to adverse effects were increased in the drug treatment group to 12.8%, as compared with 6.2% in the no treatment group. AUTHORS' CONCLUSIONS Although antihypertensive drugs reduce the incidence of fatal and non-fatal myocardial infarction, they do not appear to reduce the incidence of sudden death. This suggests that sudden cardiac death may not be caused primarily by acute myocardial infarction. Continued research is needed to determine the causes of sudden cardiac death.
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Affiliation(s)
- Garry Taverny
- Université Claude Bernard Lyon 1UMR5558 ‐ Service de Pharmacologie Clinique et Essais ThérapeutiquesLyonFrance
| | - Yanis Mimouni
- Clinical Investigation Center, Hospices Civils de Lyon CIC1407/INSERM/UCB LyonI/UMR5558EPICIME (Epidémiologie, Pharmacologie, Investigation Clinique et Information médicale, Mère‐Enfant)Groupement Hospitalier Est ‐ Bâtiment "Les Tilleuls", 59 Boulevard PinelBronFrance69677 Bron Cedex
| | | | | | - Lutgarde Thijs
- KU LeuvenDepartment of Cardiovascular SciencesKapucijnenvoer 35, Box 7001LeuvenBelgium3000
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
| | - Francois Gueyffier
- Hopital Cardio‐Vasculaire et Pneumologique Louis PradelUMR5558, CNRS et Université Claude Bernard ‐ Service de Pharmacologie Clinique et Essais ThérapeutiquesLyonFrance
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Effects of blood pressure-lowering treatment. 6. Prevention of heart failure and new-onset heart failure – meta-analyses of randomized trials. J Hypertens 2016; 34:373-84; discussion 384. [DOI: 10.1097/hjh.0000000000000848] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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118
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Parsons C, Murad MH, Andersen S, Mookadam F, Labonte H. The effect of antihypertensive treatment on the incidence of stroke and cognitive decline in the elderly: a meta-analysis. Future Cardiol 2016; 12:237-48. [PMID: 26919226 DOI: 10.2217/fca.15.90] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To evaluate the effectiveness of antihypertensives in reducing neurocognitive outcomes in elderly patients. PATIENTS & METHODS We conducted a systematic literature search of randomized trials in which hypertensive patients with a mean age ≥65 years received antihypertensive or control treatment. Outcomes were stroke, transient ischemic attack, cognitive decline and dementia. We included 14 trials for meta-analysis. RESULTS Compared to placebo, antihypertensive treatment reduced the risk of stroke (RR: 0.67 [95% CI: 0.57-0.79]). Reduced risk was significant for transient ischemic attack, fatal stroke, nonfatal stroke and total stroke. There were insufficient data to compare individual agents. CONCLUSION Antihypertensive treatment is associated with a significant reduction in stroke in elderly individuals. Reductions in dementia and cognitive decline were not significant; however, there was short follow-up. Comparative effectiveness evidence is limited.
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Affiliation(s)
- Christine Parsons
- Deptartment of Internal Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Mohammad Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Stuart Andersen
- Deptartment of Internal Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Farouk Mookadam
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Helene Labonte
- Deptartment of Internal Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
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Brunström M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ 2016; 352:i717. [PMID: 26920333 PMCID: PMC4770818 DOI: 10.1136/bmj.i717] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the effect of antihypertensive treatment on mortality and cardiovascular morbidity in people with diabetes mellitus, at different blood pressure levels. DESIGN Systematic review and meta-analyses of randomised controlled trials. DATA SOURCES CENTRAL, Medline, Embase, and BIOSIS were searched using highly sensitive search strategies. When data required according to the protocol were missing but trials were potentially eligible, we contacted researchers, pharmaceutical companies, and authorities. ELIGIBILITY CRITERIA Randomised controlled trials including 100 or more people with diabetes mellitus, treated for 12 months or more, comparing any antihypertensive agent against placebo, two agents against one, or different blood pressure targets. RESULTS 49 trials, including 73,738 participants, were included in the meta-analyses. Most of the participants had type 2 diabetes. If baseline systolic blood pressure was greater than 150 mm Hg, antihypertensive treatment reduced the risk of all cause mortality (relative risk 0.89, 95% confidence interval 0.80 to 0.99), cardiovascular mortality (0.75, 0.57 to 0.99), myocardial infarction (0.74, 0.63 to 0.87), stroke (0.77, 0.65 to 0.91), and end stage renal disease (0.82, 0.71 to 0.94). If baseline systolic blood pressure was 140-150 mm Hg, additional treatment reduced the risk of all cause mortality (0.87, 0.78 to 0.98), myocardial infarction (0.84, 0.76 to 0.93), and heart failure (0.80, 0.66 to 0.97). If baseline systolic blood pressure was less than 140 mm Hg, however, further treatment increased the risk of cardiovascular mortality (1.15, 1.00 to 1.32), with a tendency towards an increased risk of all cause mortality (1.05, 0.95 to 1.16). Metaregression analyses showed a worse treatment effect with lower baseline systolic blood pressures for cardiovascular mortality (1.15, 1.03 to 1.29 for each 10 mm Hg lower systolic blood pressure) and myocardial infarction (1.12, 1.03 to 1.22 for each 10 mm Hg lower systolic blood pressure). Patterns were similar for attained systolic blood pressure. CONCLUSIONS Antihypertensive treatment reduces the risk of mortality and cardiovascular morbidity in people with diabetes mellitus and a systolic blood pressure more than 140 mm Hg. If systolic blood pressure is less than 140 mm Hg, however, further treatment is associated with an increased risk of cardiovascular death, with no observed benefit.
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Affiliation(s)
- Mattias Brunström
- Department of Public Health and Clinical Medicine, Medicine, Umeå University, SE-901 87 Umeå, Sweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Medicine, Umeå University, SE-901 87 Umeå, Sweden
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Pont L, Alhawassi T. Challenges in the Management of Hypertension in Older Populations. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:167-180. [PMID: 27815929 DOI: 10.1007/5584_2016_149] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The prevalence of hypertension increases with age making it a significant health concern for older persons. Aging involves a range of physiological changes such as increases in arterial stiffness, widening pulse pressure, changes in renin and aldosterone levels, decreases in renal salt excretion, declining in renal function, changes in the autonomic nervous system sensitivity and function and changes to endothelial function all of which may not only affect blood pressure but may also affect individual response to pharmacotherapy used to manage hypertension and prevent end organ damage and other complications associated with poor blood pressure control.Unlike many chronic conditions where there is limited evidence for management in older populations, there is good evidence regarding the management of hypertension in the elderly. The findings from multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults, showing that reduction of blood pressure in older hypertensive populations is associated with reduced mortality and morbidity. Diuretics, agents action on the renin angiotensin system, beta blockers and calcium channel blockers have all been well studied in older populations both in view of the benefits associated with blood pressure lowering and the risks associated with associated adverse events. While all antihypertensive agents will lower blood pressure, when managing hypertension in older persons the choice of agent is dependent not only on the ability to lower blood pressure but also on the potential for harm with older persons. Understanding such potential harms in older populations is essential with older persons experiencing increased sensitivity to many of the adverse effects such as dizziness associated with the use of antihypertensive agents.Despite the wealth of evidence regarding the benefits of managing hypertension in the old and very old, a significant proportion of older individuals with hypertension have suboptimal BP control. While there is good evidence supporting blood pressure lowering in older antihypertensive agents, these have not yet been optimally translated fully into clinical guidelines and clinical practice. There appear to be considerable differences between guidelines in terms of the guidance given to clinicians. Differences in interpretation of the evidence, as well as differences in study design and populations all contribute to differences in the guideline recommendations with respect to older populations, despite the strength of the underlying scientific evidence. Differences around who is considered "old" and what BP targets and management are considered appropriate may lead to confusion among clinicians and further contribute to the evidence-practice lag.
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Affiliation(s)
- Lisa Pont
- Centre for Health System and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia.
| | - Tariq Alhawassi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Cruickshank JM. The Role of Beta-Blockers in the Treatment of Hypertension. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:149-166. [PMID: 27957711 DOI: 10.1007/5584_2016_36] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Two major guide-line committees (JNC-8 and NICE UK) have dropped beta-blockers as first-line therapy in the treatment of hypertension. Also, recent meta-analyses (that do not take age into account) have concluded that beta-blockers are inappropriate first-line agents in the treatment of hypertension. This review seeks to shed some light on the "rights and wrongs" of such actions and conclusions. OBJECTIVES Because the pathophysiology of primary/essential hypertension differs in elderly and younger subjects, the latter being closely linked to obesity and increased sympathetic nerve activity, the author sought to clarify the efficacy of beta-blockers in the younger/middle-aged group in reducing the risk of death, and cardiovascular end-points. EVIDENCE ACQUISITION Four searches were undertaken, utilising PubMed up to 31st Dec 2015. One search was under the terms "hypertension AND obesity AND sympathetic nerve activity". A second was "hypertension AND plasma noradrenaline/norepinephrine AND survival". A third was "beta-blockers or adrenergic beta-antagonists AND hypertension AND age AND stroke or myocardial infarction or death". A fourth was "meta-analysis of beta-blockers AND hypertension AND age AND death, stroke, myocardial infarction" RESULTS: Diastolic (with or without systolic) hypertension, in contrast to isolated systolic hypertension, occurs primarily in younger subjects, and is linked to overweight/obesity and increased sympathetic nerve activity. In younger/middle-aged hypertensive subjects, high plasma norepinephrine levels are linked (independent of blood pressure) to an increased risk of future cardiovascular events and death. High resting heart rates (a surrogate for high sympathetic nerve activity) likewise predict premature all-cause death, coronary heart disease and cardiovascular events in younger hypertensive subjects. In this younger/middle-aged hypertensive group, antihypertensive agents that increase sympathetic nerve activity (diuretics, dihydropyridine calcium blockers, and angiotensin receptor blockers (ARBs)) do not decrease (and may increase) the risk of myocardial infarction, and are therefore inappropriate first-line agents in this age-group. By contrast, in younger/middle-aged hypertensive subjects (less than 60 years old), meta-analysis has shown that beta-blockers are significantly superior to randomised placebo, and at least as effective as randomised comparator agents, in reducing death/stroke/myocardial infarction. In this younger/middle-aged hypertensive group beta-blockers have been shown (vs randomised placebo or diuretics) to reduce the risk of myocardial infarction by 35-50 %, and stroke by 50-55 % (vs placebo), in non-smoker men. Atenolol was at least as effective as ACE-inhibition (captopril) in reducing all 7 cardiovascular endpoints (including stroke which was reduced by 50 %), vs less tight control of blood pressure, in obese hypertensive subjects with type-2 diabetes (UKPDS study); and after 20 years follow-up, atenolol was significantly (23 %) superior to the ACE-inhibitor in reducing the risk of all-cause death (beta-blockers have anti-cancer properties, which maybe relevant). CONCLUSIONS AND RELEVANCE Primary/essential hypertension in younger/middle-age is underpinned by high sympathetic nerve activity. In this age-group high resting heart rates and high plasma norepinephrine levels (independent of blood pressure) are linked to premature cardiovascular events and death. Thus, anti-hypertensive agents that increase sympathetic nerve activity ie diuretics, dihydropyridine calcium blockers, and ARBs, are inappropriate first-line choices in this younger age-group. Beta-blockers perform well vs randomised placebo and other antihypertensive agents regarding reduced risk of death/stroke/myocardial infarction in younger (<60 years) hypertensive subjects, and are a reasonable first-line choice of therapy (certainly in men). These facts should be reflected in the recommendations of guideline committees around the world.
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Affiliation(s)
- John M Cruickshank
- Oxonian Cardiovascular Consultancy, 42 Harefield, Long Melford, Suffolk, CO10 9DE, UK.
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122
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Rich MW. SPRINT for Heart Failure. J Card Fail 2015; 22:97-8. [PMID: 26708353 DOI: 10.1016/j.cardfail.2015.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Michael W Rich
- Washington University School of Medicine, St. Louis, Missouri.
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Abstract
Hypertension is highly prevalent in older age and accounts for a large proportion of cardiovascular (CV) morbidity and mortality worldwide. Isolated systolic hypertension is more common in the elderly than younger adults and associated with poor outcomes such as cerebrovascular disease and acute coronary events. International guidelines are inconsistent in providing recommendations on optimal blood pressure targets in hypertensive elderly patients as a result of the limited evidence in this population. Evidence from clinical trials supports the use of antihypertensive drugs in hypertensive elderly patients due to benefits in reducing CV disease and mortality. However, elderly participants in these trials may not be typical of elderly patients seen in routine clinical practice, and the potential risks associated with use of antihypertensive drugs in the elderly are not as well studied as younger participants. Therefore, the purpose of this review was to provide a comprehensive summary of the benefits and risks of the use of antihypertensive drugs in elderly patients (aged ≥65 years), highlighting landmark clinical trials and observational studies. We will focus on specific outcomes relating to the benefits and risks of these medications in hypertensive elderly patients, such as CV disease, cognitive decline, dementia, orthostatic hypotension, falls, fractures, cancer and diabetes, in order to provide an update of the most relevant and current evidence to help inform clinical decision-making.
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Affiliation(s)
- D A Butt
- Research Institute, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Family and Community Medicine, The Scarborough Hospital, Scarborough, ON, Canada
| | - P J Harvey
- Department of Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada
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Ogliari G, Westendorp RGJ, Muller M, Mari D, Torresani E, Felicetta I, Lucchi T, Rossi PD, Sabayan B, de Craen AJM. Blood pressure and 10-year mortality risk in the Milan Geriatrics 75+ Cohort Study: role of functional and cognitive status. Age Ageing 2015; 44:932-7. [PMID: 26504116 DOI: 10.1093/ageing/afv141] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Optimal blood pressure targets in older adults are controversial. OBJECTIVE to investigate whether the relation of blood pressure with mortality in older adults varies by age, functional and cognitive status. DESIGN longitudinal geriatric outpatient cohort. SETTING Milan Geriatrics 75+ Cohort Study. SUBJECTS One thousand five hundred and eighty-seven outpatients aged 75 years and over. METHODS The relations of systolic (SBP) and diastolic blood pressure (DBP) with mortality risk were analysed using Cox proportional hazards models. Blood pressure, Mini-Mental State Examination (MMSE) and Basic Activities of Daily Living (ADL) were assessed at baseline. All analyses were adjusted for socio-demographic factors, co-morbidities and medications. RESULTS One thousand and forty-six patients died during 10-year follow-up. The relationships of SBP and DBP with mortality risk were U-shaped; SBP of 165 mmHg and DBP of 85 mmHg were associated with the lowest mortality. Patients with SBP < 120 mmHg and patients with SBP 120-139 mmHg had 1.64-fold (95% confidence intervals, CI 1.21-2.23) and 1.32-fold (95% CI 1.10-1.60) higher mortality risk than patients with SBP 160-179 mmHg (P values 0.001 and 0.004, respectively). In patients with SBP below 180 mmHg, higher SBP was associated with lower mortality in patients with impaired ADL and MMSE but not in those with preserved ADL and/or MMSE (P for interaction 0.033). Age did not modify the correlation of SBP with mortality. CONCLUSIONS The correlations of SBP and DBP with mortality were U-shaped. Higher SBP is related to lower mortality in subjects with impaired ADL and MMSE. ADL and MMSE may identify older subjects who benefit from higher blood pressure.
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Affiliation(s)
- Giulia Ogliari
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rudi G J Westendorp
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Majon Muller
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniela Mari
- Clinical Sciences and Community Health, University of Milan, Milan, Italy Geriatric Unit, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Erminio Torresani
- Clinical Chemistry and Microbiology Laboratory, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Felicetta
- Clinical Chemistry and Microbiology Laboratory, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tiziano Lucchi
- Geriatric Unit, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo D Rossi
- Geriatric Unit, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Behnam Sabayan
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anton J M de Craen
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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Alhawassi TM, Krass I, Pont LG. Prevalence, prescribing and barriers to effective management of hypertension in older populations: a narrative review. J Pharm Policy Pract 2015; 8:24. [PMID: 26473036 PMCID: PMC4607150 DOI: 10.1186/s40545-015-0042-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 09/01/2015] [Indexed: 12/24/2022] Open
Abstract
Objectives Hypertension is the leading modifiable cause of mortality worldwide. Unlike many conditions where limited evidence exists for management of older individuals, multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults. Understanding the impact of age on how the prevalence of hypertension and the role of pharmacotherapy in managing hypertension among older persons is a critical element is the provision of optimal health care for older populations. The aim of this study was to explore how the prevalence of hypertension changes with age, the evidence regarding pharmacological management in older adults and to identify known barriers to the optimal management of hypertension in older patients. Methods A review of English language studies published prior to 2013 in Medline, Embase and Google scholar was conducted. Key search terms included hypertension, pharmacotherapy, and aged. Results The prevalence of hypertension was shown to increase with age, however there is good evidence for the use of a number of pharmacological agents to control blood pressure in older populations. System, physician and patient related barriers to optimal blood pressure control were identified. Conclusions Despite good evidence for pharmacological management of hypertension among olderpopulations, under treatment of hypertension is an issue. Concerns regarding adverse effects appearcentral to under treatment of hypertension among older populations.
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Affiliation(s)
- Tariq M Alhawassi
- Faculty of Pharmacy, University of Sydney, Sydney, Australia ; College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ines Krass
- Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | - Lisa G Pont
- Centre for Health Systems and Safety Research, Australian Insititue of Health Innovation, Macquarie University, North Ryde, Australia
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Aparicio LS, Thijs L, Boggia J, Jacobs L, Barochiner J, Odili AN, Alfie J, Asayama K, Cuffaro PE, Nomura K, Ohkubo T, Tsuji I, Stergiou GS, Kikuya M, Imai Y, Waisman GD, Staessen JA. Defining Thresholds for Home Blood Pressure Monitoring in Octogenarians. Hypertension 2015; 66:865-73. [DOI: 10.1161/hypertensionaha.115.05800] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/03/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Lucas S. Aparicio
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Lutgarde Thijs
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - José Boggia
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Lotte Jacobs
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Jessica Barochiner
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Augustine N. Odili
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - José Alfie
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Kei Asayama
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Paula E. Cuffaro
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Kyoko Nomura
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Takayoshi Ohkubo
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Ichiro Tsuji
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - George S. Stergiou
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Masahiro Kikuya
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Yutaka Imai
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Gabriel D. Waisman
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
| | - Jan A. Staessen
- From the Division of Hypertension, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Capital Federal, Argentina (L.S.A., Jessica Barochiner, J.A., P.E.C., G.D.W.); Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (L.T., L.J., A.N.O., J.A.S.); Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República,
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Windham BG, Griswold ME, Lirette S, Kucharska-Newton A, Foraker RE, Rosamond W, Coresh J, Kritchevsky S, Mosley TH. Effects of Age and Functional Status on the Relationship of Systolic Blood Pressure With Mortality in Mid and Late Life: The ARIC Study. J Gerontol A Biol Sci Med Sci 2015; 72:89-94. [PMID: 26409066 DOI: 10.1093/gerona/glv162] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/26/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Impaired functional status attenuates the relationship of systolic blood pressure (SBP) with mortality in older adults but has not been studied in middle-aged populations. METHOD Among 10,264 stroke-free Atherosclerosis Risk in Communities participants (mean age 62.8 [5.7] years; 6,349 [62%] younger [<65 years]; 5,148 [50%] men; 2,664 [26%] Black), function was defined as good function (GF) for those self-reporting no difficulty performing functional tasks and basic or instrumental tasks of daily living; all others were defined as impaired function (IF). SBP categories were normal (<120 mmHg), prehypertension (120-139 mmHg), and hypertension (≥140 mmHg). Mortality risk associated with SBP was estimated using adjusted Cox proportional hazard models with a triple interaction between age, functional status, and SBP. RESULTS Mean follow-up was 12.9 years with 2,863 (28%) deaths. Among younger participants, 3,017 (48%) had IF; 2,279 of 3,915 (58%) older participants had IF. Prehypertension (hazard ratio [HR] = 1.48 [1.03, 2.15] p = .04) and hypertension (HR = 1.97 [1.29, 3.03] p = .002) were associated with mortality in younger GF and older (≥65 years) GF participants (prehypertension HR = 1.21 [1.06, 1.37] p = .005; hypertension HR = 1.47 [1.36, 1.59] p < .001). Among IF participants, prehypertension was not associated with mortality in younger participants (HR = 0.99 [0.85, 1.15] p = .93) and was protective in older participants (HR = 0.87 [0.85, 0.90] p < .001). Hypertension was associated with mortality in younger IF participants (HR = 1.54 [1.30, 1.82] p < .001) but not in older IF participants (HR = 0.99 [0.87, 1.14] p = .93). CONCLUSIONS Compared with younger and well-functioning persons, the additional contribution of blood pressure to mortality is much lower with older age and impaired function, particularly if both are present. Functional status and age could potentially inform optimal blood pressure targets.
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Affiliation(s)
| | - Michael E Griswold
- Center of Biostatistics, University of Mississippi Medical Center, Jackson
| | - Seth Lirette
- Center of Biostatistics, University of Mississippi Medical Center, Jackson
| | - Anna Kucharska-Newton
- Kucharska-Newton: Cardiovascular Disease Program, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Randi E Foraker
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus
| | - Wayne Rosamond
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephen Kritchevsky
- Sticht Center on Aging, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Goeres LM, Williams CD, Eckstrom E, Lee DSH. Pharmacotherapy for hypertension in older adults: a systematic review. Drugs Aging 2015; 31:897-910. [PMID: 25323058 DOI: 10.1007/s40266-014-0219-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypertension increases with increasing age. Optimal treatment of hypertension is important to reduce cardiovascular disease. Recent guidelines for hypertension have made recommendations for older adults but are supported by evidence that includes younger individuals. This systematic review evaluates the benefits and harms of antihypertensive agents in adults aged ≥65 years. METHODS We searched MEDLINE and ClinicalTrials.gov for studies from 1996 to 2014. Eligible studies included participants aged ≥65 years with hypertension. Eligible studies had clearly defined treatment assignments, blood pressure (BP) targets, and evaluated endpoints of cardiovascular morbidity, mortality, and/or harms of antihypertensive medications. We abstracted study characteristics, cardiovascular benefits, and harms. RESULTS Thirty-one articles met the inclusion criteria. Most studies compared different antihypertensive agents and/or placebo groups. These studies consistently demonstrated reduced cardiovascular morbidity and mortality compared with no treatment. Seven studies examined optimal BP targets. Strict control [systolic BP (SBP)<140 mmHg] was not consistently better than mild control (SBP<150 mmHg) for adults aged ≥65 years. Mild SBP control benefitted subjects in all age ranges over 65 years. Few studies assessed and explicitly reported harms. CONCLUSIONS In this review, older adults with hypertension had decreased cardiovascular morbidity and mortality with antihypertensives compared with no treatment. Strict control was not consistently better than mild control in older adults. There was enormous heterogeneity in these studies, and reporting of harms stratified by age is lacking. The current evidence is insufficient to determine the safest, most beneficial hypertension regimen in older adults.
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Affiliation(s)
- Leah M Goeres
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, USA,
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129
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Li Y, Wei FF, Wang S, Cheng YB, Wang JG. Cardiovascular risks associated with diastolic blood pressure and isolated diastolic hypertension. Curr Hypertens Rep 2015; 16:489. [PMID: 25182161 DOI: 10.1007/s11906-014-0489-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
UNLABELLED Hypertension is a major reversible risk factor for cardiovascular complications. According to recent guidelines, hypertension can be subdivided into isolated diastolic, isolated systolic, and systolic and diastolic mixed hypertension using proposed thresholds of various blood pressure components. In the present article, we reviewed the association of cardiovascular outcomes with diastolic blood pressure versus systolic blood pressure and with isolated diastolic hypertension versus systolic and mixed hypertension in observational prospective cohort studies and large-scale individual data-based meta-analysis. Blood pressure was measured either in the clinic or at home or under ambulatory conditions for 24 h in cohort studies. To illustrate the treatment effect of diastolic blood pressure lowering, we also reviewed randomized placebo-controlled outcome trials in diastolic hypertension. CONCLUSIONS The risks conferred by diastolic and systolic blood pressure, irrespective of the methods of blood pressure measurement, are age-dependent. Diastolic blood pressure and isolated diastolic hypertension drive coronary risk in younger subjects, whereas systolic blood pressure is the predominant risk indicator in older people. Reversibility of the risk by diastolic BP lowering treatment in randomized trials confirms that diastolic hypertension is a risk factor that must be treated.
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Affiliation(s)
- Yan Li
- Centre for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluations, Shanghai Key Lab of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China,
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130
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Abstract
Secondary stroke prevention in the elderly in many cases requires the use of drug therapy to maximize risk factor control. However, the elderly (≥65 years) are most likely to receive care that is not evidence-based, because of concerns for adverse events. In this review, we provide evidence to the practitioner in support of the value of blood pressure control with drug therapy to decrease recurrent stroke risk. This review also highlights evidence for the importance of statin therapy in stroke prevention among the elderly. Finally, the appropriate use of antiplatelet therapy and oral anticoagulation is addressed.
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131
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Target blood pressure in elderly hypertensive patients and in patients with diabetes mellitus. J Hypertens 2015; 32:1551-2. [PMID: 24979182 DOI: 10.1097/hjh.0000000000000275] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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132
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Alviar C, Bangalore S, Messerli F. Optimal blood pressure targets in 2014 – Does the guideline recommendation match the evidence base? HIPERTENSION Y RIESGO VASCULAR 2015; 32:71-82. [DOI: 10.1016/j.hipert.2015.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
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133
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Schwartz JB. Primary prevention: do the very elderly require a different approach? Trends Cardiovasc Med 2015; 25:228-39. [PMID: 25560975 PMCID: PMC4374025 DOI: 10.1016/j.tcm.2014.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 01/21/2023]
Abstract
Recent cardiovascular prevention guidelines place a greater emphasis on randomized placebo-controlled trial data as the basis for recommendations. While such trial data are sparse for people over the age of 75 or 80 years, data demonstrate altered risk-benefit relationships in these older patients. Primary prevention strategy decisions should consider estimated life expectancy and overall function as well as cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. Data support treatment of systolic hypertension to reduce stroke, cardiovascular events, and dementia in older patients with at least a 2-year estimated lifespan with modifications in systolic blood pressure goals and a need for greater attention to non-cardiovascular side effects such as falls in the very old. Lowering of elevated cholesterol levels with HMG-CoA reductase inhibitors for primary prevention in people over the age of 75 years requires greater individual considerations, as benefits may not accrue for 3-5 years and there is the potential impact of adverse effects. There is a rationale for lipid-lowering treatment in the more highly functional older patient with cardiovascular (especially stroke) risk higher than side effect risks in the near term and with an estimated lifespan longer than the time to benefit. Aspirin has higher side effect risks and requires a longer time to achieve benefit. Trial data are lacking on exercise interventions, but multi-system benefits have been shown in older patients such that exercise should be part of a preventive regimen. Preventive therapy in the very old means considering not only medical issues of co-morbidities, polypharmacy, and altered risk-benefit relationship of medications but also adjusting goals and approaches across the older agespan in keeping with informed patient preferences.
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Affiliation(s)
- Janice B Schwartz
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Jewish Home of San Francisco, San Francisco, CA; Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA.
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134
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Fisker FY, Grimm D, Wehland M. Third-Generation Beta-Adrenoceptor Antagonists in the Treatment of Hypertension and Heart Failure. Basic Clin Pharmacol Toxicol 2015; 117:5-14. [DOI: 10.1111/bcpt.12396] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/26/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Filip Y. Fisker
- Department of Biomedicine, Pharmacology; Aarhus University; Aarhus Denmark
| | - Daniela Grimm
- Department of Biomedicine, Pharmacology; Aarhus University; Aarhus Denmark
| | - Markus Wehland
- Clinic for Plastic, Aesthetic and Hand Surgery; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
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135
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Abstract
Sixty-eight blood pressure (BP)–lowering randomized controlled trials (defined as randomized controlled trials comparing active treatment with placebo, or less active treatment, achieving a BP difference, performed between 1966 and end 2013 in cohorts with ≥40% hypertensive patients, and exclusive of trials in acute myocardial infarction, heart failure, acute stroke, and dialysis) were identified and meta-analyzed grouping the randomized controlled trials on the basis of clinically relevant questions: (1) does BP lowering reduce all types of cardiovascular outcome? (2) Is prevention of all outcomes proportional to the extent of systolic, diastolic, and pulse BP? (3) Have all classes of BP-lowering drugs been shown capable of reducing all types of cardiovascular outcome? (4) Is BP lowering beneficial when intervention is initiated at any grade (or stage) of hypertension? (5) Do BP-lowering randomized controlled trials provide evidence about systolic BP and diastolic BP targets of treatment? (6) Should BP-lowering treatment be preferentially addressed to patients in higher risk categories promising larger absolute treatment benefits? The results of these meta-analyses provide further support to current hypertension treatment guidelines by showing that BP lowering can significantly reduce major cardiovascular outcomes largely independent of the agents used, significant risk reduction is found at all hypertension grades (stages), and when systolic BP is lowered below a cut off of 140 mm Hg with some further reduction limited to stroke at systolic BP values just <130 mm Hg. Absolute risk reduction progressively increases higher is total cardiovascular risk, but this greater benefit is associated with a progressively higher residual risk, ie, higher treatment failures.
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Affiliation(s)
- Alberto Zanchetti
- From the Istituto Auxologico Italiano, Milan, Italy (A.Z., G.P.); Centro Interuniversitario di Fisiologia Clinica e Ipertensione, University of Milan, Milan, Italy (A.Z.); Department of Cardiology, Helena Venizelou Hospital, Athens, Greece (C.T.); and Department of Health Sciences, University of Milano-Bicocca, Milan, Italy (G.P.)
| | - Costas Thomopoulos
- From the Istituto Auxologico Italiano, Milan, Italy (A.Z., G.P.); Centro Interuniversitario di Fisiologia Clinica e Ipertensione, University of Milan, Milan, Italy (A.Z.); Department of Cardiology, Helena Venizelou Hospital, Athens, Greece (C.T.); and Department of Health Sciences, University of Milano-Bicocca, Milan, Italy (G.P.)
| | - Gianfranco Parati
- From the Istituto Auxologico Italiano, Milan, Italy (A.Z., G.P.); Centro Interuniversitario di Fisiologia Clinica e Ipertensione, University of Milan, Milan, Italy (A.Z.); Department of Cardiology, Helena Venizelou Hospital, Athens, Greece (C.T.); and Department of Health Sciences, University of Milano-Bicocca, Milan, Italy (G.P.)
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136
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137
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Abstract
Hypertension contributes greatly to adverse cardiovascular outcomes; the magnitude of this contribution increases with age. The most recent guideline has proposed raising the goal systolic blood pressure to less than 150 mm Hg among those over age 60; however, this recommendation is not endorsed by other organizations. There are multiple contributors to hypertension in the older individual, including increased vascular stiffness, salt sensitivity, and decreased baroreceptor responsiveness. Therapy in the hypertensive patient over age 60 should be individualized and account for patient's health, functional and cognitive status, comorbidities, frailty, and prognosis.
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Affiliation(s)
- Philip A Kithas
- George E. Wahlen Salt Lake Veterans Administration Medical Center, Geriatrics Division, University of Utah School of Medicine, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Mark A Supiano
- George E. Wahlen Department of Veterans Affairs Health Care System, VA Salt Lake City Geriatric Research, Education, and Clinical Center, Geriatrics Division, University of Utah School of Medicine, Salt Lake City GRECC (182), 500 Foothill Drive, Salt Lake City, UT 84148, USA
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138
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Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension. J Hypertens 2015; 33:195-211. [DOI: 10.1097/hjh.0000000000000447] [Citation(s) in RCA: 194] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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139
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Biderafsh A, Karami M, Faradmal J, Poorolajal J. Estimating the potential impact fraction of hypertension as the main risk factor of stroke: Application of the distribution shift method. J Epidemiol Glob Health 2015; 5:231-7. [PMID: 26231399 PMCID: PMC7320525 DOI: 10.1016/j.jegh.2014.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/21/2014] [Accepted: 11/28/2014] [Indexed: 11/18/2022] Open
Abstract
Few published studies have assessed the impact of quantitative risk factors such as high blood pressure on stroke. The aim of this study was to quantify the potential impact fraction (PIF) of hypertension on stroke in Hamadan Province, western Iran. Avoidable burden of stroke associated with high blood pressure was calculated using distribution shift at different scenarios. Data on the prevalence of high blood pressure among residents of Hamadan province older than 19 years were extracted from non-communicable diseases risk factors surveillance system in 2009. Five mmHg hypothetical reduction in systolic blood pressure above 140 mmHg, leads to 3.5% (PIF=0.035) reduction in the total burden to stroke. This value may reach 7%, if systolic blood pressure decreases 10 mmHg. In addition, 5 mmHg hypothetical reduction in diastolic blood pressure above 82 mmHg, leads to 4.87% reduction in the total burden to stroke. PIF more than 10 mmHg modification on distribution of diastolic blood pressure was estimated as 9.38%. According to these findings, policy makers are advised to implement interventions on hypertension based on the distribution shift method rather than the proportion shift one.
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Affiliation(s)
- Azam Biderafsh
- Department of Biostatistics & Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Manoochehr Karami
- Modeling of Non-Communicable Diseases Research Center, Department of Biostatistics & Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Javad Faradmal
- Modeling of Non-Communicable Diseases Research Center, Department of Biostatistics & Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Jalal Poorolajal
- Modeling of Non-Communicable Diseases Research Center, Department of Biostatistics & Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran
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140
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Effects of blood pressure lowering on outcome incidence in hypertension. 1. Overview, meta-analyses, and meta-regression analyses of randomized trials. J Hypertens 2014; 32:2285-95. [DOI: 10.1097/hjh.0000000000000378] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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141
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Abstract
BACKGROUND Stroke affects 15 million people per year worldwide. Despite recent developments in acute stroke treatment, prevention remains very important. Stroke has a high rate of recurrence; therefore secondary prevention is also important. Many clinical approaches to control risk factors have been proposed. One of these approaches is the prescription of beta-blockers that have effects beyond the reduction of blood pressure, which can reduce the recurrence of stroke. OBJECTIVES To evaluate the efficacy of beta-blockers for preventing stroke recurrence and for reducing death and major vascular events in people with a previous stroke or transient ischaemic attack (TIA), and to determine their safety, particularly with regard to the development of diabetes mellitus. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (May 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library 2014, Issue 5), the Database of Abstracts of Reviews of Effects (DARE) (May 2014), MEDLINE (1966 to May 2014), EMBASE (1980 to May 2014), and Latin American and Caribbean Health Sciences Literature (LILACS) (1982 to May 2014). We also searched ongoing trials registers and reference lists. SELECTION CRITERIA Randomised controlled trials (RCTs) that included participants with previous stroke or TIA due to arterial thrombosis or embolism. The intervention was any beta-blocker versus control, or beta-blocker plus other treatment versus other treatment. DATA COLLECTION AND ANALYSIS Two review authors independently screened the trials identified, appraised quality, and extracted data. MAIN RESULTS We included two RCTs involving 2193 participants in the review. Both studies randomised participants to either beta-blocker (atenolol 5 mg) or placebo and were of a high methodological quality. We noted no statistical differences among the groups in risks of fatal and non-fatal stroke (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.76 to 1.18). For other outcomes analysed (major vascular events, death from all causes, death from cardiovascular causes) , we observed no significant differences between the groups. There were minor blood pressure reductions in the intervention group. Neither of the included studies reported the occurrence of diabetes among their outcomes or assessed quality of life. Adverse events were significantly more frequent in participants taking atenolol than in those given placebo, and were the most common reason given for discontinuing treatment (RR 1.85, 95% CI 1.45 to 2.35). AUTHORS' CONCLUSIONS To date, no available evidence supports the routine use of beta-blockers for secondary prevention after stroke or TIA. More studies with larger samples are needed.
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Affiliation(s)
- Luiz Gustavo De Lima
- Universidade Federal de São PauloBrazilian Cochrane CentreRua Pedro de Toledo 598São PauloSão PauloBrazil04039‐001
| | - Humberto Saconato
- Santa Casa de Campo MourãoDepartment of MedicineBR 158 Saída para Peabiru, 2761Campo MourãoCampo MourãoBrazil87309‐650
| | - Álvaro N Atallah
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeBrazilian Cochrane CentreR. Borges Lagoa, 564 cj 63Vila ClementinoSão PauloSão PauloBrazil04038‐000
| | - Edina MK da Silva
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloSão PauloBrazil04038‐000
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142
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Ambrosius WT, Sink KM, Foy CG, Berlowitz DR, Cheung AK, Cushman WC, Fine LJ, Goff DC, Johnson KC, Killeen AA, Lewis CE, Oparil S, Reboussin DM, Rocco MV, Snyder JK, Williamson JD, Wright JT, Whelton PK. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials 2014; 11:532-46. [PMID: 24902920 PMCID: PMC4156910 DOI: 10.1177/1740774514537404] [Citation(s) in RCA: 391] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND High blood pressure is an important public health concern because it is highly prevalent and a risk factor for adverse health outcomes, including coronary heart disease, stroke, decompensated heart failure, chronic kidney disease, and decline in cognitive function. Observational studies show a progressive increase in risk associated with blood pressure above 115/75 mm Hg. Prior research has shown that reducing elevated systolic blood pressure lowers the risk of subsequent clinical complications from cardiovascular disease. However, the optimal systolic blood pressure to reduce blood pressure-related adverse outcomes is unclear, and the benefit of treating to a level of systolic blood pressure well below 140 mm Hg has not been proven in a large, definitive clinical trial. PURPOSE To describe the design considerations of the Systolic Blood Pressure Intervention Trial (SPRINT) and the baseline characteristics of trial participants. METHODS The Systolic Blood Pressure Intervention Trial is a multicenter, randomized, controlled trial that compares two strategies for treating systolic blood pressure: one targets the standard target of <140 mm Hg, and the other targets a more intensive target of <120 mm Hg. Enrollment focused on volunteers of age ≥50 years (no upper limit) with an average baseline systolic blood pressure ≥130 mm Hg and evidence of cardiovascular disease, chronic kidney disease, 10-year Framingham cardiovascular disease risk score ≥15%, or age ≥75 years. The Systolic Blood Pressure Intervention Trial recruitment also targeted three pre-specified subgroups: participants with chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m(2)), participants with a history of cardiovascular disease, and participants 75 years of age or older. The primary outcome is first the occurrence of a myocardial infarction (MI), acute coronary syndrome, stroke, heart failure, or cardiovascular disease death. Secondary outcomes include all-cause mortality, decline in kidney function or development of end-stage renal disease, incident dementia, decline in cognitive function, and small-vessel cerebral ischemic disease. RESULTS Between 8 November 2010 and 15 March 2013, Systolic Blood Pressure Intervention Trial recruited and randomized 9361 people at 102 clinics, including 3331 women, 2648 with chronic kidney disease, 1877 with a history of cardiovascular disease, 3962 minorities, and 2636 ≥75 years of age. LIMITATIONS Although the overall recruitment target was met, the numbers recruited in the high-risk subgroups were lower than planned. CONCLUSIONS The Systolic Blood Pressure Intervention Trial will provide important information on the risks and benefits of intensive blood pressure treatment targets in a diverse sample of high-risk participants, including those with prior cardiovascular disease, chronic kidney disease, and those aged ≥75 years.
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Affiliation(s)
- Walter T Ambrosius
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kaycee M Sink
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Capri G Foy
- Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Hospital, Bedford, MA, USA
| | - Alfred K Cheung
- Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN, USA
| | - Lawrence J Fine
- Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - David C Goff
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Cora E Lewis
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David M Reboussin
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael V Rocco
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joni K Snyder
- Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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143
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Feldman RD, Hussain Y, Kuyper LM, McAlister FA, Padwal RS, Tobe SW. Intraclass differences among antihypertensive drugs. Annu Rev Pharmacol Toxicol 2014; 55:333-52. [PMID: 25251994 DOI: 10.1146/annurev-pharmtox-010814-124446] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The four major classes of antihypertensive drugs—diuretics, β-blockers, calcium channel blockers, and renin-angiotensin system inhibitors (including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers)—have significant qualitative and quantitative differences in the adverse effects they cause. Structural and chemical differences have been identified within these classes, especially among the calcium channel blockers and, to a lesser extent, among the thiazide/thiazide-like diuretics. However, it has been more difficult to demonstrate that these differences translate into differential effects with respect to either the surrogate endpoint of blood pressure reduction or, more importantly, hypertension-related cardiovascular complications. Based on a hierarchy-of-evidence approach, differences are apparent between hydrochlorothiazide and chlorthalidone based on evidence of moderate quality. Low-quality evidence suggests atenolol is less effective than other β-blockers. However, no significant intraclass differences have been established among the other classes of antihypertensive drugs.
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Affiliation(s)
- R D Feldman
- Departments of Medicine and of Physiology and Pharmacology, Western University, London, Ontario N6A 5B7, Canada;
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144
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Borghi C, Omboni S. Zofenopril plus hydrochlorothiazide combination in the treatment of hypertension: an update. Expert Rev Cardiovasc Ther 2014; 12:1055-65. [DOI: 10.1586/14779072.2014.946405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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145
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Rodriguez CJ, Swett K, Agarwal SK, Folsom AR, Fox ER, Loehr LR, Ni H, Rosamond WD, Chang PP. Systolic blood pressure levels among adults with hypertension and incident cardiovascular events: the atherosclerosis risk in communities study. JAMA Intern Med 2014; 174:1252-61. [PMID: 24935209 PMCID: PMC4573449 DOI: 10.1001/jamainternmed.2014.2482] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Studies document a progressive increase in heart disease risk as systolic blood pressure (SBP) rises above 115 mm Hg, but it is unknown whether an SBP lower than 120 mm Hg among adults with hypertension (HTN) lowers heart failure, stroke, and myocardial infarction risk. OBJECTIVE To examine the risk of incident cardiovascular (CV) events among adults with HTN according to 3 SBP levels: 140 mm Hg or higher; 120 to 139 mm Hg; and a reference level of lower than 120 mm Hg. DESIGN, SETTING, AND PARTICIPANTS A total of 4480 participants with HTN but without prevalent CV disease at baseline (years 1987-1989) from the Atherosclerosis Risk in Communities Study were included. Measurements of SBP were taken at baseline and at 3 triennial visits; SBP was treated as a time-dependent variable and categorized as elevated (≥140 mm Hg), standard (120-139 mm Hg), and low (<120 mm Hg). Multivariable Cox regression models included baseline age, sex, diabetes status, BMI, high cholesterol level, smoking status, and alcohol intake. MAIN OUTCOMES AND MEASURES Incident composite CV events (heart failure, ischemic stroke, myocardial infarction, or death related to coronary heart disease). RESULTS After a median follow-up of 21.8 years, a total of 1622 incident CV events had occurred. Participants with elevated SBP developed incident CV events at a significantly higher rate than those in the low BP group (adjusted hazard ratio [HR], 1.46; 95% CI, 1.26-1.69). However, there was no difference in incident CV event-free survival among those in the standard vs low SBP group (adjusted HR, 1.00; 95% CI, 0.85-1.17). Further adjustment for BP medication use or diastolic BP did not significantly affect the results. CONCLUSIONS AND RELEVANCE Among patients with HTN, having an elevated SBP carries the highest risk for cardiovascular events, but in this categorical analysis, once SBP was below 140 mm Hg, an SBP lower than 120 mm Hg did not appear to lessen the risk of incident CV events.
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Affiliation(s)
- Carlos J Rodriguez
- Department of Medicine and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Katrina Swett
- Department of Medicine and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sunil K Agarwal
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
| | - Ervin R Fox
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Laura R Loehr
- Departments of Medicine and Epidemiology, University of North Carolina at Chapel Hill
| | - Hanyu Ni
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Wayne D Rosamond
- Departments of Medicine and Epidemiology, University of North Carolina at Chapel Hill
| | - Patricia P Chang
- Departments of Medicine and Epidemiology, University of North Carolina at Chapel Hill
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146
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Makridakis S, DiNicolantonio JJ. Hypertension: empirical evidence and implications in 2014. Open Heart 2014; 1:e000048. [PMID: 25332797 PMCID: PMC4195935 DOI: 10.1136/openhrt-2014-000048] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/06/2014] [Accepted: 05/28/2014] [Indexed: 01/13/2023] Open
Abstract
High blood pressure (HBP) or hypertension (HTN) is one of the leading causes of cardiovascular (CV) morbidity and mortality throughout the world. Despite this fact, there is widespread agreement that the treatment of HBP, over the last half century, has been a great achievement. However, after the release of the new Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure-8 (JNC-8) guidelines, there have been heated debates with regard to what are the most evidence-based blood pressure goals. While JNC-8 claims that the goal blood pressure for otherwise healthy patients with mild hypertension (systolic blood pressure ≥140-159 mm Hg and diastolic blood pressure ≥90-99 mm Hg) should be <140/90 mm Hg; a recent Cochrane meta-analysis is in direct conflict with these recommendations. Indeed, a 2012 Cochrane meta-analysis indicated that there is no evidence that treating otherwise healthy mild hypertension patients with antihypertensive therapy will reduce CV events or mortality. Additionally, the Cochrane meta-analysis showed that antihypertensive therapy was associated with a significant increase in withdrawal due to adverse events. Thus, the current evidence in the literature does not support the goals set by the JNC-8 guidelines. In this review we discussed the strengths and limitations of both lines of evidence and why it takes an evidence-based medication to reduce CV events/mortality (eg, how a goal blood pressure is achieved is more important than getting to the goal). As medications inherently cause side effects and come at a cost to the patient, the practice of evidence-based medicine becomes exceedingly important. Although the majority of HTN studies claim great advantages by lowering HBP, this review finds severe conflicts in the findings among the various HTN studies, as well as serious epistemological, methodological and statistical problems that cast doubt to such claims.
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148
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Peters R, Beckett N, McCormack T, Fagard R, Fletcher A, Bulpitt C. Treating hypertension in the very elderly-benefits, risks, and future directions, a focus on the hypertension in the very elderly trial. Eur Heart J 2014; 35:1712-8. [PMID: 24302270 PMCID: PMC5994819 DOI: 10.1093/eurheartj/eht464] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 09/10/2013] [Accepted: 10/17/2013] [Indexed: 11/14/2022] Open
Abstract
Although the number of individuals reaching 80 who are considered to be healthy is increasing, the very elderly are likely to have long-term conditions, to report symptoms and/or be taking at least one regular medication. The impact of antihypertensive treatment has to be taken into account in this context. The treatment regimen in Hypertension in the Very Elderly Trial with a goal blood pressure of <150/80 mmHg has been shown to provide benefits in terms of a reduction in risk of total mortality, stroke, and cardiovascular events with potential benefits and no evidence of increased risk for fracture, dementia, depression, and quality-of-life outcomes. Questions remain as to the level of benefit that would be accrued in the frailer elderly and those at extreme age, for example, over 90.
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Affiliation(s)
- Ruth Peters
- School of Public Health, Imperial College London, London, UK
| | - Nigel Beckett
- Department of Ageing and Health, Guys' and St Thomas' Foundation NHS Trust, Westminster Bridge Road, London SE1 7EH, UK Department of Medicine, Imperial College London, London, UK
| | | | | | - Astrid Fletcher
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
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Peng Y. Expert consensus on blood pressure management of diabetic patients in China. J Diabetes 2014; 6:202-11. [PMID: 24164914 DOI: 10.1111/1753-0407.12103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 10/01/2013] [Accepted: 10/21/2013] [Indexed: 11/29/2022] Open
Abstract
This Expert Consensus proposed by the Chinese Society of Endocrinology (CSE) updates concepts on hypertension management in patients with diabetes. It focuses on clinical outcomes literature published within the past 5 years and currently in press, and incorporates these new observations into modifications of established guidelines. Complications and mortality in diabetic patients are increased when hypertension is present. The present update focuses on questions such as what to do when a diabetic patient has an elevated blood pressure level when therapy is initiated and whether combinations of agents should be used as soon as possible. Although the strategies and principles of treatment remain unchanged, approaches to specific patient-related issues influencing cardiovascular outcomes in people with diabetes have changed. Finally, an updated integrated management of multiple cardiovascular risk factors is provided and is suggested as a starting point to achieve blood pressure goals. In addition to controlling blood pressure, the CSE suggests that individualized strategies are equally important and that attention should be paid to other factors, including safety (which is the most important), feasibility, and health economic evaluation.
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Affiliation(s)
- Yongde Peng
- Department of Endocrinology and Metabolism, Jiaotong University Affliated First People's Hospital, Shanghai, China
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