Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

Hypertension Across a Woman's Life Cycle

PURPOSE OF REVIEW

We reviewed the effects of hypertension and the means to prevent and treat it across the spectrum of a woman's lifespan and identified gaps in sex-specific mechanisms contributing to hypertension in women that need to be addressed.

RECENT FINDINGS

Hypertension continues to be an important public health problem for women across all life stages from adolescence through pregnancy, menopause, and older age. There remain racial, ethnic, and socioeconomic differences in hypertension rates not only overall but also between the sexes. Blood pressure cutoffs during pregnancy have not been updated to reflect the 2017 ACC/AHA changes due to a lack of data. Additionally, the mechanisms behind hypertension development in menopause, including sex hormones and genetic factors, are not well understood. In the setting of increasing inactivity and obesity, along with an aging population, hypertension rates are increasing in women. Screening and management of hypertension throughout a women's lifespan are necessary to reduce the burden of cardiovascular disease, and further research to understand sex-specific hypertension mechanisms is needed.

Early Stage and Established Hypertension in Sub-Saharan Africa: Results From Population Health Surveys in 17 Countries, 2010-2017

BACKGROUND

Multiple studies have reported a high burden of hypertension in sub-Saharan Africa, but none have examined early stage hypertension. We examined contemporary prevalence of diagnosed, treated, and controlled stage I (130-139/80-89 mm Hg) and II (≥140/90 mm Hg) hypertension in the general population of sub-Saharan Africa.

METHODS

We analyzed World Health Organization STEPwise Approach to Noncommunicable Disease Risk Factor Surveillance surveys from 17 sub-Saharan Africa countries including 85 371 respondents representing 85 million individuals from 2010 to 2017. We extracted demographic variables, blood pressure, self-reported hypertension diagnosis/awareness, and treatment status to estimate prevalence of stage I and II hypertension and treatment by country. We examined diagnosis and treatment trends by national sociodemographic index, a marker of development.

RESULTS

Stage I hypertension prevalence (regardless of diagnosis/treatment) was >25% in 13 of 17 countries, highest in Sudan (35.3% [95% CI, 33.7%-37.0%]), and lowest in Eritrea (20.2% [18.8%-21.6%]). Combined stages I and II hypertension prevalence was >50% in 13 countries; <20% were diagnosed in every country. Treatment among those diagnosed ranged from 26% to 63%, and control (<140/90 mm Hg) from 4% to 17%. In 8 of 9 countries reporting on behavioral interventions (eg, salt reduction, weight loss, exercise, and smoking cessation), <60% of diagnosed individuals received counseling. Rates of diagnosis, but not treatment, were positively associated with sociodemographic index (P=0.008), although there was substantial variation between countries even at similar levels of development.

CONCLUSIONS

Hypertension is common in sub-Saharan Africa but rates of diagnosis, treatment, and control markedly low. There is a large population with early stage hypertension that may benefit from behavioral counseling to prevent progression. Our analyses suggest that success in population hypertension care may be achieved independently of socioeconomic development, highlighting a need for policymakers to identify best practices in those countries that outperform similar or more developed countries.

How Do Young and Old Spontaneously Hypertensive Rats Respond to Antihypertensive Therapy? Comparative Studies on the Effects of Combined Captopril and Nifedipine Treatment

Numerous studies on the effects of antihypertensive treatment in young spontaneously hypertensive rats (SHRs) have shown that early-onset therapy may effectively reduce their blood pressure (BP) even to normotensive values. In contrast, only a few studies investigated the effects of treatment started at an advanced age. These studies revealed that antihypertensive effects are lower in adult or even in senescent SHRs compared with young SHRs. Even more, prevention of cardiac sequelae of hypertension such as hypertrophy and fibrosis is less effective when treatment starts late in life. Because, in patients, combination therapies with calcium antagonists are favored, we studied the efficacy of a combination therapy with captopril and nifedipine in young and old SHRs. We directly compared the treatment effects on BP as well as on cardiac hypertrophy and remodeling between these two animal cohorts. With antihypertensive treatment, significantly lower BP values were achieved in young SHRs despite a shorter treatment period compared with old SHRs. Although treatment effects on cardiac hypertrophy were greater in old than in young SHRs, cardiac fibrosis was significantly attenuated only in young but not in old SHRs. The results emphasize the value of antihypertensive therapy and particularly accentuate the importance of an early-onset therapy. With respect to problems such as late diagnosis and poor therapy adherence, these results may have great importance for the treatment of human hypertension.

Combined Neuro-Humoral Modulation and Outcomes in Patients with Chronic Heart Failure and Mildly Reduced or Preserved Ejection Fraction

Pharmacotherapy of chronic heart failure with mildly reduced (HFmrEF) and preserved ejection fraction (HFpEF) remains challenging. We aimed to assess whether combined neuro-humoral modulation (NHM) (renin−angiotensin system inhibitors, betablockers, mineralocorticoid receptor antagonists) was differentially associated with outcome according to phenotype and age groups. Between 1999 and 2018 we recruited in a nationwide cardiology registry 4707 patients (HFmrEF n = 2298, HFpEF n = 2409) from three age groups: <65, 65−79 and 80+ years old. We analyzed clinical characteristics and 1 year all-cause mortality/cardiovascular hospitalization according to none/single, any double, or triple NHM. Prescription rates of no/single and triple NHM were 25.1% and 26.7% for HFmrEF; 36.5% and 17.9% for HFpEF patients, respectively. Older age was associated with higher prescription of no/single NHM in HFmrEF (ptrend = 0.001); the reverse was observed among HFpEF (ptrend = 0.005). Triple NHM increased over time in both phenotypes (all p for trend < 0.0001). Compared to no/single NHM, triple, but not double, NHM was associated with better outcomes in both HFmrEF (HR 0.700, 95%CI 0.505−0.969, p = 0.032) and HFpEF (HR 0.700, 95%CI 0.499−0.983, p = 0.039), with no interaction between NHM treatment and age groups (p = 0.58, p = 0.80, respectively). In a cardiology setting, among HF outpatients with EF > 40%, triple NHM treatment increased over time and was associated with better patient outcomes.

Orthostatic hypotension in elderly: Do you measure orthostatic and clinostatic blood pressure?

In this article we highlighted the blood pressure management in elderly patients with orthostatic hypotension.

Treatment of Hypertension: A Review

IMPORTANCE

Hypertension, defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affects approximately 116 million adults in the US and more than 1 billion adults worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (coronary heart disease, heart failure, and stroke) and death.

OBSERVATIONS

First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption. The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy. The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk. First-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic such as hydrochlorothiazide or chlorthalidone, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker such as enalapril or candesartan, and a calcium channel blocker such as amlodipine and should be titrated according to office and home SBP/DBP levels to achieve in most people an SBP/DBP target (&lt;130/80 mm Hg for adults &lt;65 years and SBP &lt;130 mm Hg in adults ≥65 years). Randomized clinical trials have established the efficacy of BP lowering to reduce the risk of CVD morbidity and mortality. An SBP reduction of 10 mm Hg decreases risk of CVD events by approximately 20% to 30%. Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg.

CONCLUSIONS AND RELEVANCE

Hypertension affects approximately 116 million adults in the US and more than 1 billion adults worldwide and is a leading cause of CVD morbidity and mortality. First-line therapy for hypertension is lifestyle modification, consisting of weight loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, physical activity, and limited alcohol consumption. When drug therapy is required, first-line therapies are thiazide or thiazidelike diuretics, angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, and calcium channel blockers.

Hypertension management in patients with cardiovascular comorbidities

Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.

Cost-Effectiveness of Intensive Versus Standard Blood Pressure Treatment in Older Patients With Hypertension in China

Background:

In the STEP trial (Strategy of Blood Pressure Intervention in older Hypertensive Patients), the risk of cardiovascular events is significantly lower in patients who received intensive systolic blood psressure (BP) treatment than in those who received standard treatment. This study compared the lifetime health benefits and medical costs of intensive BP treatment with those of standard BP treatment.

Methods:

A microsimulation model included 10 000 hypothetical samples of Chinese adults aged 60 to 80 years old with baseline systolic BP higher than 140 mm Hg. Primary outcome was the incremental cost-effectiveness ratio from a payer’s perspective. Secondary outcome was cardiovascular events, including acute coronary syndrome, stroke, acute decompensated heart failure, atrial fibrillation, and death from cardiovascular causes.

Results:

The model simulated that cardiovascular events occurred in 36.88% of the patients in the intensive treatment group, as compared to 41.28% of the patients in the standard treatment group over the lifetime horizon. The mean number of quality-adjusted life-years would be 0.16 higher in patients who received intensive treatment than in those who received standard treatment and would cost Chinese yuan 12 614 (International dollars 3018) more per quality-adjusted life-year gained. Most simulation results indicated that intensive treatment would be cost-effective (82%–95% below the willingness-to-pay threshold of Chinese yuan 72 000 [1× the gross domestic product per capita in China in 2020]). Sensitivity analyses showed that these conclusions were robust.

Conclusions:

In this study, intensive BP treatment prevented cardiovascular events among older patients with hypertension in China and was cost-effective in most scenarios.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03015311

Intensive Versus Standard Blood Pressure Lowering and Days Free of Cardiovascular Events and Serious Adverse Events: a Post Hoc Analysis of Systolic Blood Pressure Intervention Trial

BACKGROUND

Communication of the benefits and harms of blood pressure lowering strategy is crucial for shared decision-making.

OBJECTIVES

To quantify the effect of intensive versus standard systolic blood pressure lowering in terms of the number of event-free days DESIGN: Post hoc analysis of the Systolic Blood Pressure Intervention Trial PARTICIPANTS: A total of 9361 adults 50 years or older without diabetes or stroke who had a systolic blood pressure of 130-180 mmHg and elevated cardiovascular risk INTERVENTIONS: Intensive (systolic blood pressure goal <120 mmHg) versus standard blood pressure lowering (<140 mmHg) MAIN MEASURES: Days free of major adverse cardiovascular events (MACE), serious adverse events (SAE), and monitored adverse events (hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls, or acute kidney injury) over a median follow-up of 3.33 years KEY RESULTS: The intensive treatment group gained 14.7 more MACE-free days over 4 years (difference, 14.7 [95% confidence interval: 5.1, 24.4] days) than the standard treatment group. The benefit of the intensive treatment varied by cognitive function (normal: difference, 40.7 [13.0, 68.4] days; moderate-to-severe impairment: difference, -15.0 [-56.5, 26.4] days; p-for-interaction=0.009) and self-rated health (excellent: difference, -22.7 [-51.5, 6.1] days; poor: difference, 156.1 [31.1, 281.2] days; p-for-interaction=0.001). The mean overall SAE-free days were not significantly different between the treatments (difference, -14.8 [-35.3, 5.7] days). However, the intensive treatment group had 28.5 fewer monitored adverse event-free days than the standard treatment group (difference, -28.5 [-40.3, -16.7] days), with significant variations by frailty status (non-frail: difference, 38.8 [8.4, 69.2] days; frail: difference, -15.5 [-46.6, 15.7] days) and self-rated health (excellent: difference, -12.9 [-45.5, 19.7] days; poor: difference, 180.6 [72.9, 288.4] days; p-for-interaction <0.001).

CONCLUSIONS

Over 4 years, intensive systolic blood pressure lowering provides, on average, 14.7 more MACE-free days than standard treatment, without any difference in SAE-free days. Whether this time-based effect summary improves shared decision-making remains to be elucidated.

TRIAL REGISTRATION

ClinicalTrials.gov Registration: NCT01206062.

Longer-Term All-Cause and Cardiovascular Mortality With Intensive Blood Pressure Control: A Secondary Analysis of a Randomized Clinical Trial

Importance

The Systolic Blood Pressure Intervention Trial (SPRINT) showed that intensive blood pressure control reduced cardiovascular morbidity and mortality. However, the legacy effect of intensive treatment is unknown.

Objective

To evaluate the long-term effects of randomization to intensive treatment with the incidence of cardiovascular and all-cause mortality approximately 4.5 years after the trial ended.

Design, Setting, and Participants

In this secondary analysis of a multicenter randomized clinical trial, randomization began on November 8, 2010, the trial intervention ended on August 20, 2015, and trial close-out visits occurred through July 2016. Patients 50 years and older with hypertension and increased cardiovascular risk but without diabetes or history of stroke were included from 102 clinic sites in the US and Puerto Rico. Analyses were conducted between October 2021 and February 2022.

Interventions

Randomization to systolic blood pressure (SBP) goal of less than 120 mm Hg (intensive treatment group; n = 4678) vs less than 140 mm Hg (standard treatment group; n = 4683).

Main Outcomes and Measures

Extended observational follow-up for mortality via the US National Death Index from 2016 through 2020. In a subset of 2944 trial participants, outpatient SBP from electronic health records during and after the trial were examined.

Results

Among 9361 randomized participants, the mean (SD) age was 67.9 (9.4) years, and 3332 (35.6%) were women. Over a median (IQR) intervention period of 3.3 (2.9-3.9) years, intensive treatment was beneficial for both cardiovascular mortality (hazard ratio [HR], 0.66; 95% CI, 0.49-0.89) and all-cause mortality (HR, 0.83; 95% CI, 0.68-1.01). However, at the median (IQR) total follow-up of 8.8 (8.3-9.3) years, there was no longer evidence of benefit for cardiovascular mortality (HR, 1.02; 95% CI, 0.84-1.24) or all-cause mortality (HR, 1.08; 95% CI, 0.94-1.23). In a subgroup of participants, the estimated mean outpatient SBP among participants randomized to intensive treatment increased from 132.8 mm Hg (95% CI, 132.0-133.7) at 5 years to 140.4 mm Hg (95% CI, 137.8-143.0) at 10 years following randomization.

Conclusions and Relevance

The beneficial effect of intensive treatment on cardiovascular and all-cause mortality did not persist after the trial. Given increasing outpatient SBP levels in participants randomized to intensive treatment following the trial, these results highlight the importance of consistent long-term management of hypertension.

Trial Registration

ClinicalTrials.gov Identifier: NCT01206062.

Individualising intensive systolic blood pressure reduction in hypertension using computational trial phenomaps and machine learning: a post-hoc analysis of randomised clinical trials

BACKGROUND

The cardiovascular benefits of intensive systolic blood pressure control vary across clinical populations tested in large randomised clinical trials. We aimed to evaluate the application of machine learning to clinical trials of patients without and with type 2 diabetes to define the personalised cardiovascular benefit of intensive control of systolic blood pressure.

METHODS

In SPRINT, a trial of intensive (systolic blood pressure <120 mm Hg) versus standard (systolic blood pressure <140 mm Hg) systolic blood pressure control in patients without type 2 diabetes, we defined a phenotypic representation of the study population using 59 baseline variables. We extracted personalised treatment effect estimates for the primary outcome, time-to-first major adverse cardiovascular event (MACE; cardiovascular death, myocardial infarction or acute coronary syndrome, stroke, and acute decompensated heart failure), through iterative Cox regression analyses providing average hazard ratio (HR) estimates weighted for the phenotypic distance of each participant from the index patient of each iteration. Next, we trained an extreme gradient boosting algorithm (known as XGBoost) to predict the personalised effect of intensive systolic blood pressure control using features most consistently linked to increased personalised benefit, before evaluating its performance in the ACCORD BP trial of patients with type 2 diabetes randomly assigned to receive intensive versus standard systolic blood pressure control. We stratified patients based on their predicted treatment effect, and key demographic groups (age, sex, cardiovascular disease, and smoking). We assessed the presence of heterogeneity with an interaction test, and assessed the performance of the algorithm in a simulation analysis of SPRINT in the presence or absence of an artificially introduced heterogeneous treatment effect.

FINDINGS

From SPRINT, we included all 9361 study participants (mean age 67·9 years [SD 9·4], 3332 [35·6%] female) who underwent randomisation to either intensive (n=4678) or standard (n=4683) treatment. The median individualised HR for MACE was 0·63 (IQR 0·53-0·78). An eight-feature tool built for this analysis to predict personalised benefit in SPRINT was externally tested in ACCORD BP (4733 participants (mean age 62·7 years [SD 6·7], 2258 [47·7%] female), wherein it successfully identified individuals with differential benefit from intensive versus standard systolic blood pressure control (adjusted HR for MACE of 0·70 [95% CI 0·55-0·90] in individuals with above-median MACE benefit versus 1·05 [95% CI 0·84-1·32] for below-median predicted benefit; p_interaction=0·0184). Subgroup analysis based on age (<65 years: HR 0·89 [95% CI 0·71-1·12]; ≥65 years: 0·85 [0·67-1·09]), sex (male: 0·89 [0·72-1·10]; female: 0·85 [0·65-1·10]), established cardiovascular disease (no: 0·89 [0·70-1·14]; yes: 0·84 [0·67-1·06]), or active smoking (no: 0·85 [0·71-1·02]; yes: 1·01 [0·64-1·60]) did not identify groups with heterogeneity of treatment effect. In a simulation analysis of SPRINT, the proposed algorithm detected groups with heterogeneous treatment effects in the presence, but not absence, of simulated subgroup differences.

INTERPRETATION

By use of machine learning to define an individual's personalised benefit through phenotypic representations of clinical trials, we created a practical tool for individualising the selection of intensive versus standard systolic blood pressure control in patients without and with type 2 diabetes.

FUNDING

National Heart, Lung, and Blood Institute of the US National Institutes of Health.

Effects of elevated systolic blood pressure on ischemic heart disease: a Burden of Proof study

High systolic blood pressure (SBP) is a major risk factor for ischemic heart disease (IHD), the leading cause of death worldwide. Using data from published observational studies and controlled trials, we estimated the mean SBP-IHD dose-response function and burden of proof risk function (BPRF), and we calculated a risk outcome score (ROS) and corresponding star rating (one to five). We found a very strong, significant harmful effect of SBP on IHD, with a mean risk-relative to that at 100 mm Hg SBP-of 1.39 (95% uncertainty interval including between-study heterogeneity 1.34-1.44) at 120 mm Hg, 1.81 (1.70-1.93) at 130 mm Hg and 4.48 (3.81-5.26) at 165 mm Hg. The conservative BPRF measure indicated that SBP exposure between 107.5 and 165.0 mm Hg raised risk by 101.36% on average, yielding a ROS of 0.70 and star rating of five. Our analysis shows that IHD risk was already increasing at 120 mm Hg SBP, rising steadily up to 165 mm Hg and increasing less steeply above that point. Our study endorses the need to prioritize and strengthen strategies for screening, to raise awareness of the need for timely diagnosis and treatment of hypertension and to increase the resources allocated for understanding primordial prevention of elevated blood pressure.

Provider Perspectives on Patient- and Provider-Facing High Blood Pressure Clinical Decision Support

BACKGROUND

Hypertension, persistent high blood pressures (HBP) leading to chronic physiologic changes, is a common condition that is a major predictor of heart attacks, strokes, and other conditions. Despite strong evidence, care teams and patients are inconsistently adherent to HBP guideline recommendations. Patient-facing clinical decision support (CDS) could help improve recommendation adherence but must also be acceptable to clinicians and patients.

OBJECTIVE

This study aimed to partly address the challenge of developing a patient-facing CDS application, we sought to understand provider variations and rationales related to HBP guideline recommendations and perceptions regarding patient role and use of digital tools.

METHODS

We engaged hypertension experts and primary care respondents to iteratively develop and implement a pilot survey and a final survey which presented five clinical cases that queried clinicians' attitudes related to actions; variations; prioritization; patient input; importance; and barriers for HBP diagnosis, monitoring, and treatment. Analysis of Likert's scale scores was descriptive with content analysis for free-text answers.

RESULTS

Fifteen hypertension experts and 14 providers took the pilot and final version of the surveys, respectively. The majority (>80%) of providers felt the recommendations were important, yet found them difficult to follow-up to 90% of the time. Perceptions of relative amounts of patient input and patient work for effective HBP management ranged from 22 to 100%. Stated reasons for variation included adverse effects of treatment, patient comorbidities, shared decision-making, and health care cost and access issues. Providers were generally positive toward patient use of electronic CDS applications but worried about access to health care, nuance of recommendations, and patient understanding of the tools.

CONCLUSION

At baseline, provider management of HBP is heterogeneous. Providers were accepting of patient-facing CDS but reported preferences for that CDS to capture the complexity and nuance of guideline recommendations.

The role of blood pressure management in stroke prevention: current status and future prospects

INTRODUCTION

Stroke is the second-leading cause of death worldwide and the second-leading cause of disability-adjusted life-years. It is well known that hypertension is a significant risk factor for cardiovascular events, including stroke.

AREAS COVERED

Recent interventional trials have demonstrated the superiority of intensive blood pressure (BP) control for prevention of cardiovascular events compared to standard BP control. Notably, in the Strategy of Blood Pressure Intervention in Elderly Hypertensive Patients (STEP) trial, intensive BP control showed superiority in the prevention of stroke events in elderly hypertensive patients. Novel medications such as angiotensin receptor-neprilysin inhibitors and sodium glucose cotransporter 2 inhibitors have the potential to suppress various CVD events including stroke. Non-pharmacological antihypertensive therapies such as renal denervation have demonstrated BP-lowering effects and may be useful for stroke prevention. Additionally, new methods and systems of BP monitoring including various kinds of nighttime BP measurement devices, wearable devices, and methods using information and communication technology can be used to assess the pathophysiology of BP variability as a risk factor and an event trigger of stroke incidence.

EXPERT OPINION

Novel therapies and new technologies for BP evaluation strongly support the development of individualized anticipatory medicine, which should be useful for the prevention of stroke.

Primary Prevention of Ischemic Stroke

Ischemic stroke is by far the most common type of cerebrovascular event and remains a major cause of death and disability globally. Despite advancements in acute stroke care, primary prevention is still the most cost-effective approach in reducing the burden of ischemic stroke. The two main strategies for primary stroke prevention include population-wide versus high-risk group interventions. Interventions such as increasing access to primary care, regulation of salt and sugar contents in processed foods, public education, and campaigns to control cerebrovascular risk factors are examples of population-wide interventions. High-risk group interventions, on the other hand, focus on recognition of individuals at risk and aim to modify risk factors in a timely and multifaceted manner. This article provides an overview on conventional modifiable risk factors for ischemic stroke and highlights the emerging risk factors and approaches for high-risk group identification and treatment.

Brain Bioenergetics in Chronic Hypertension: Risk Factor for Acute Ischemic Stroke

Chronic hypertension is one of the key modifiable risk factors for acute ischemic stroke, also contributing to determine greater neurological deficits and worse functional outcome when an acute cerebrovascular event would occur. A tight relationship exists between cerebrovascular autoregulation, neuronal activity and brain bioenergetics. In chronic hypertension, progressive adaptations of these processes occur as an attempt to cope with the demanding necessity of brain functions, creating a new steady-state homeostatic condition. However, these adaptive modifications are insufficient to grant an adequate response to possible pathological perturbations of the established fragile hemodynamic and metabolic homeostasis. In this narrative review, we will discuss the main mechanisms by which alterations in brain bioenergetics and mitochondrial function in chronic hypertension could lead to increased risk of acute ischemic stroke, stressing the interconnections between hemodynamic factors (i.e. cerebral autoregulation and neurovascular coupling) and metabolic processes. Both experimental and clinical pieces of evidence will be discussed. Moreover, the potential role of mitochondrial dysfunction in determining, or at least sustaining, the pathogenesis and progression of chronic neurogenic hypertension will be considered. In the perspective of novel therapeutic strategies aiming at improving brain bioenergetics, we propose some determinant factors to consider in future studies focused on the cause-effect relationships between chronic hypertension and brain bioenergetic abnormalities (and vice versa), so to help translational research in this so-far unfilled gap.

Examining the Linear Association Between Blood Pressure Levels and Cardiovascular Diseases in the Absence of Major Risk Factors in China

BACKGROUND

Many studies demonstrate a J-shaped association between blood pressure and cardiovascular diseases (CVDs), but the findings are plagued by confounding from other traditional cardiovascular risk factors (CVRFs). Our aims were to examine the associations of systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels with CVD in individuals without major CVRFs and whether there were thresholds for the association.

METHODS

In the 4C study (China Cardiometabolic Disease and Cancer Cohort), 36 042 CVRF-free participants without CVD, diabetes, dyslipidemia, hypertension, or smoking were identified during 2011 to 2012. Among CVRF-free participants, 17 476 CVRF-preferable individuals with better glycemic (fasting glucose, <110 mg/dL; 2-hour post-load glucose, <140 mg/dL) and lipid profile (total cholesterol, <200 mg/dL; LDL [low-density lipoprotein] cholesterol, <130 mg/dL) were selected. The total person-years of follow-up for CVRF-free subjects and CVRF-preferable subjects were 130 147 and 63 573 person-years, respectively. Information on the development of major CVDs was collected during 2014 to 2016. Cox proportional hazard models were performed to estimate the risks for incident CVD by SBP and DBP groups, respectively.

RESULTS

We found that both baseline SBP and DBP presented significantly linear associations with CVD risks in CVRF-free and CVRF-preferable participants. There is significant increase in the CVD risk among CVRF-free participants with baseline SBP level of 110 to 119 mm Hg (hazard ratio, 1.79 [95% CI, 1.19-2.71]), 120 to 129 mm Hg (hazard ratio, 2.03 [95% CI, 1.36-3.03]), and 130 to 139 mm Hg (hazard ratio, 2.15 [95% CI, 1.40-3.28]) compared with SBP <110 mm Hg. Significant increases were also observed for DBP level of 80 to 89 mm Hg (hazard ratio, 1.43 [95% CI, 1.03-1.97]) compared with DBP <70 mm Hg. Similar results were observed in CVRF-preferable participants.

CONCLUSIONS

SBP and DBP with levels currently considered normal were significantly and linearly associated with incident CVD without thresholds above 110/70 mm Hg among Chinese adults without major CVRFs.

Blood Pressure Intervention and Control in SPRINT

BACKGROUND

The SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated reductions in major cardiovascular disease events and mortality with an intensive systolic blood pressure (SBP) goal intervention. However, a detailed description of the blood pressure intervention, antihypertensive medication usage, blood pressure levels, and rates and predictors of blood pressure control has not been reported previously.

METHODS

Hypertensive participants (n=9361) 50 years and older with elevated cardiovascular disease risk were randomized 1:1 to SBP goal <120 mm Hg or SBP goal <140 mm Hg. Guideline-recommended antihypertensive medications and dosing were provided at no cost. Intensive group participants were started on at least 2 medications, and medications were adjusted monthly until SBP goal was achieved, if feasible. Standard group participants were treated to achieve SBP 135 to 139 mm Hg.

RESULTS

Baseline blood pressure (median±interquartile range) was 138±19/78±16 mm Hg. For intensive group participants, percent at goal rose from 8.9% at baseline to 52.4% at 6 months and average antihypertensive medications rose from 2.2 to 2.7; SBP was <120 mm Hg in 61.6% and <130 mm Hg in 80.0% at their final visit. For the standard group participants, percent at goal rose from 53.0% at baseline to 68.6% at 6 months, while antihypertensive medications fell from 1.9 to 1.8. From 6 to 36 months, median SBP was stable at 119±14 mm Hg for intensive and 136±15 mm Hg for standard participants, with stable numbers of medications. Few predictors of SBP control were found in multiple regression models.

CONCLUSIONS

These results may inform and help replicate the benefits of SPRINT in clinical practice.

REGISTRATION

URL: http://www.

CLINICALTRIALS

gov; Unique identifier: NCT01206062.

Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication

BACKGROUND

Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported.

METHODS

Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls.

RESULTS

Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers.

CONCLUSIONS

Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021

It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.

Open-Angle Glaucomatous Optic Neuropathy Is Related to Dips Rather Than Increases in the Mean Arterial Pressure Over 24-H

BACKGROUND

Mean arterial pressure (MAP) drives ocular perfusion. Excessive 24-h MAP variability relates to glaucoma, however, whether this is due to dips or increases in the blood pressure (BP) is undocumented. We investigated the association of open-angle glaucoma (OAG) in relation to the 5 largest MAP dips/increases over 24-h, henceforth called dips/blips.

METHODS

In the Maracaibo Aging Study (MAS), 93 participants aged ≥40 y (women, 87.1%; mean age, 61.9 y) underwent baseline ophthalmological and 24-h ambulatory BP monitoring assessments. OAG was the presence of optic nerve damage and visual field defects. Statistical methods included logistic regression and the generalized R2 statistic. For replication, 48 OAG cases at the Leuven Glaucoma Clinic were matched with 48 controls recruited from Flemish population.

RESULTS

In the MAS, 26 participants had OAG. OAG compared to non-OAG participants experienced longer and deeper dips (116.5 vs. 102.7 minutes; to 60.3 vs. 66.6 mm Hg; -21.0 vs. -18.0 mm Hg absolute or 0.79 vs. 0.81 relative dip compared to the preceding reading). The adjusted odds ratios associated with dip measures ranged from 2.25 (95% confidence interval [CI], 1.31-4.85; P = 0.009) to 3.39 (95% CI, 1.36-8.46; P = 0.008). On top of covariables and 24-MAP level/variability, the dip measures increased the model performance (P ≤ 0.025). Blips did not associate with OAG. The case-control study replicated the MAS observations.

CONCLUSIONS

Dips rather than increases in the 24-h MAP level were associated with increased risk for OAG. An ophthalmological examination combined with 24-h BP monitoring might be precautious steps required in normotensive and hypertensive patients at risk of OAG.

Control of Blood Pressure and Risk of Cardiovascular Disease and Mortality in Elderly Chinese: A Real-World Prospective Cohort Study

BACKGROUND

The STEP trial (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) showed that older hypertensive patients might benefit from a target systolic blood pressure (SBP) of 110 to <130 mm Hg. We examined whether this target SBP is associated with a decreased risk of cardiovascular disease (CVD) and all-cause mortality among elderly Chinese in real-world settings.

METHODS

This prospective study included 13 383 CVD-free participants aged 60 to 80 years and with SBP within 110 to <150 mm Hg at baseline. Inverse probability of treatment weighting was used to adjust for baseline differences. Weighted Cox proportional hazards models yielded adjusted hazard ratios (HRs) and 95% CIs of CVD and all-cause mortality associated with normalized SBP (110 to <130 mm Hg).

RESULTS

During a median follow-up of 13.01 years, we identified 1727 cases of CVD and 3742 deaths. After inverse probability of treatment weighting, compared with non-normalized SBP, normalized SBP was associated with a decreased risk of CVD (HR, 0.81 [95% CI, 0.76-0.87]) and all-cause mortality (HR, 0.89 [95% CI, 0.85-0.93]). Beneficial effects of longitudinal normalized SBP presented by the updated mean SBP were also observed for CVD (HR, 0.88 [95% CI, 0.78-0.93]) and all-cause mortality (HR, 0.93 [95% CI, 0.88-0.97]). Multiple sensitivity analyses yielded similar results.

CONCLUSIONS

The SBP target of 110 to <130 mm Hg recommended by the STEP trial was associated a lower risk of CVD and all-cause mortality than was SBP of 130 to <150 mm Hg among elderly Chinese in real-world settings.

Silent brain infarcts, peripheral vascular disease and the risk of cardiovascular events in patients with hypertension

BACKGROUND AND AIMS

We aimed to study the relationship between cerebral small vessel disease (cSVD) lesions, as markers of subclinical target organ damage (TOD) in the brain, and incident cardiovascular events (CVE).

METHODS

Data from the ISSYS (Investigating Silent Strokes in hYpertensives Study), which is a longitudinal and observational study conducted in patients with hypertension aged 50-70 years, and stroke-free at the inclusion. At the baseline visit, participants underwent a clinical interview, a brain MRI, urine and blood sampling collection and vascular testing studies. Therefore, we obtained markers of TOD from the brain [white matter hyperintensities, silent brain infarcts (SBI), cerebral microbleeds and enlarged perivascular spaces (EPVS)], from kidney (microalbuminuria, glomerular filtration) and regarding large vessels [ankle-to-brachial index (ABI), carotid-femoral pulse wave velocity]. Survival analyses were used to assess the relationship between these predictors and the incidence of cardiovascular events (CVE).

RESULTS

We followed-up 964 individuals within a median time of 5 years (4.7-5), representing 4377.1 persons-year. We found 73 patients presenting incident CVE, which corresponds to a rate of 8.2%. We found ABI less than 0.9 [hazard ratio, 2.2; 95% confidence interval (CI) 1.17-4.13, P value = 0.014] and SBI (hazard ratio, 2.9; 95% CI 1.47-5.58, P value = 0.002) independently associated with higher risk of incident CVE. The inclusion of both variables in a clinical model resulted in an increased discrimination of individuals with new CVE of 4.72%, according to the integrated discrimination index.

CONCLUSION

Assessment of SBI and ABI less than 0.9 may refine the cardiovascular risk stratification in patients with hypertension.

Impact of Outcome Definitions on Cardiovascular Risk Prediction in a Contemporary Primary Prevention Population

BACKGROUND

Estimation of an individual's cardiovascular disease (CVD) risk may enhance risk discussion and treatment decisions. Yet, common cardiovascular outcomes such as heart failure or coronary revascularization are not included in the estimation of atherosclerotic cardiovascular disease (ASCVD) risk. Our objective was to determine the incidence of ASCVD in a contemporary primary prevention population with more than 10 years of follow-up, and how incidence estimates change when incorporating additional cardiovascular endpoints.

METHODS

We used the population-level CANHEART (Cardiovascular Health in Ambulatory Care Research Team) database of all Ontario residents alive January 1, 2008, aged 30-99 years, and with no prior history of cardiovascular disease. Individuals were followed to December 31, 2019 for incident first and recurrent cardiovascular events. ASCVD outcomes were defined by hospitalizations for myocardial infarction, stroke and circulatory death, while global CVD outcomes also included hospitalizations for unstable angina, transient ischemic attacks, peripheral arterial disease, out-of-hospital cardiac arrests, heart failure and coronary revascularization.

RESULTS

Among 7496 165 individuals free of cardiovascular disease, their mean age was 50 years (SD: 13.9 years) and 52.3% were women. After 11 years of follow-up, the rate of an incident ASCVD event was 3.95 per 1000 person-years while the rate of a global CVD event was almost doubled at 6.67 per 1000 person-years. The most common additional first manifestations of CVD were heart failure which accounted for 12.0% of additional events and coronary revascularization which accounted for 12.7%. When considering first and recurrent events, the rate of ASCVD was 5.20 per 1000 person-years while the rate of all global CVD events was more than double at 10.90 per 1000 person-years. This was mainly due to a higher proportion of recurrent heart failure (13.7%) and coronary revascularization (23.2%) events.

CONCLUSIONS

ASCVD accounts for just over half of all preventable first cardiovascular events and even fewer first and recurrent cardiovascular events in contemporary practice. Estimating broader CVD endpoints may enhance risk-discussions with patients and improve informed decision-making.

Phenotyping the hypertensive heart

Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.

Casting New Light on Statistical Power: An Illuminating Analogy and Strategies to Avoid Underpowered Trials

Current standards for methodological rigor and trial reporting underscore the critical issue of statistical power. Still, the chance of detecting most effects reported in randomized controlled trials in medicine and other disciplines is currently lower than winning a toss of a fair coin. Here we propose that investigators who retain a practical understanding of how statistical power works can proactively avoid the potentially devastating consequences of underpowered trials. We first offer a vivid, carefully constructed analogy that illuminates the underlying relationships among 3 of the 5 essential parameters-namely, statistical power, effect size, and sample size-while holding the remaining 2 parameters constant (type of statistical test and significance level). Second, we extend the analogy to a set of critical scenarios in which investigators commonly miss detecting intervention effects due to insufficient statistical power. Third, we highlight effective pragmatic strategies for the design and conduct of sufficiently powered trials, without increasing sample size.

Genetic Contributors of Efficacy and Adverse Metabolic Effects of Chlorthalidone in African Americans from the Genetics of Hypertension Associated Treatments (GenHAT) Study

Hypertension is a leading risk factor for cardiovascular disease mortality. African Americans (AAs) have the highest prevalence of hypertension in the United States, and to alleviate the burden of hypertension in this population, better control of blood pressure (BP) is needed. Previous studies have shown considerable interpersonal differences in BP response to antihypertensive treatment, suggesting a genetic component. Utilizing data from 4297 AA participants randomized to chlorthalidone from the Genetics of Hypertension Associated Treatments (GenHAT) study, we aimed to identify variants associated with the efficacy of chlorthalidone. An additional aim was to find variants that contributed to changes in fasting glucose (FG) in these individuals. We performed genome-wide association analyses on the change of systolic and diastolic BP (SBP and DBP) over six months and FG levels over 24 months of treatment. We sought replication in the International Consortia of Pharmacogenomics Studies. We identified eight variants statistically associated with BP response and nine variants associated with FG response. One suggestive LINC02211-CDH9 intergenic variant was marginally replicated with the same direction of effect. Given the impact of hypertension in AAs, this study implies that understanding the genetic background for BP control and glucose changes during chlorthalidone treatment may help prevent adverse cardiovascular events in this population.

Impact of multivessel versus single-vessel disease on the association between low diastolic blood pressure and mortality after acute myocardial infarction with revascularization

BACKGROUND

Previous studies demonstrated a J-shaped relationship between low diastolic blood pressure (DBP) and adverse clinical outcomes in patients with acute myocardial infarction (AMI) that was sensitive to revascularization. Hypothesized herein, was that this relationship differs between patients with multivessel disease (MVD) and those with single-vessel disease due to differing degrees of myocardial ischemic burden.

METHODS

Among 9,983 AMI patients from the Korea Acute Myocardial Infarction Registry database who underwent percutaneous coronary intervention and were followed up for a median duration of 3.2 years, average on-treatment DBP was calculated at admission, discharge, and every scheduled visit and divided into these parameters: < 70 mmHg, 70-74 mmHg, 75-79 mmHg, and ≥ 80 mmHg. The relationship between average on-treatment DBP and clinical outcomes including all-cause death, cardiovascular (CV) death, non-CV death, and hospitalization for heart failure was analyzed using the Cox regression models adjusted for clinical covariates.

RESULTS

In patients with MVD, all-cause death (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.06-2.04, p = 0.012) and CV death (HR: 1.59; 95% CI: 1.02-2.46, p = 0.027) were significantly increased in patients with a DBP < 70 mmHg, showing a J-shaped relationship. However, these findings were not significant for single-vessel disease. On a sensitivity analysis excluding subjects with a baseline SBP < 120 mmHg, an increased risk of a low DBP < 70 mmHg remained in MVD.

CONCLUSIONS

The J-shaped relationship between low DBP and adverse clinical outcomes in AMI patients who underwent revascularization persisted in MVD, which has a high ischemic burden. These high-risk patients require cautious treatment.

Actual impact of angiotensin II receptor blocker or calcium channel blocker monotherapy on renal function in real-world patients

OBJECTIVE

This observational retrospective cohort study investigates the effect of antihypertensive therapy with angiotensin II receptor blockers (ARBs) or dihydropyridine calcium channel blockers (dCCBs) monotherapy on renal function using longitudinal real-world health data of a drug-naive, hypertensive population without kidney disease.

METHODS

Using propensity score matching, we selected untreated hypertensive participants (n = 10 151) and dCCB (n = 5078) or ARB (n = 5073) new-users based on annual health check-ups and claims between 2008 and 2020. Participants were divided by the first prescribed drug.

RESULTS

The mean age was 51 years, 79% were men and the mean estimated glomerular filtration rate (eGFR) was 78 ml/min per 1.73 m2. Blood pressure rapidly decreased by approximately 10% in both treatment groups. At the 1-year visit, eGFR levels decreased in the ARB group by nearly 2% but increased in the dCCB group by less than 1%. However, no significant difference was apparent in the annual eGFR change after the 1-year visit. The risk for composite kidney outcome (new-onset proteinuria or eGFR decline ≥30%) was lowest in the ARB group owing to their robust effect on preventing proteinuria: hazard ratio (95% confidence interval) for proteinuria was 0.90 (0.78-1.05) for the dCCB group and 0.54 (0.44-0.65) for the ARB group, compared with that for the untreated group after ending follow-up at the last visit before changing antihypertensive treatment.

CONCLUSION

From the present findings based on the real-world data, ARBs can be recommended for kidney protection even in a primary care setting. Meanwhile, dCCB treatment initially increases eGFR with no adverse effects on proteinuria.

Highlights in ASCVD Primary Prevention for 2021

This review examines key studies published in 2021 that are related to primary prevention of atherosclerotic cardiovascular disease (ASCVD). Major randomized clinical trials (RCTs) concerning traditional risk factors or ASCVD events, meta‐analyses, and key observational studies related to primary prevention of ASCVD were considered. The review includes interventions for weight loss, cardiometabolic and renal disease, blood pressure control, diet, and the occurrence of cardiovascular disease events. A few studies considered both primary and secondary prevention populations. The review is not exhaustive. We did not include studies that focused on heart failure or clinical presentations that may be difficult to classify, such as acute or chronic ischemic cardiovascular disease without myocardial infarction. Our purpose was to highlight recent research that will help the reader stay abreast of the changing field of cardiovascular prevention.

Risk of Mild Cognitive Impairment or Probable Dementia in New Users of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors: A Secondary Analysis of Data From the Systolic Blood Pressure Intervention Trial (SPRINT)

Importance

The cardiovascular and renal outcomes of angiotensin-II receptor blocker (ARB) and angiotensin-converting enzyme inhibitor (ACEI) treatment are well-known; however, few studies have evaluated initiation of these agents and cognitive impairment.

Objective

To emulate a target trial to evaluate the cognitive outcomes of initiating an ARB- vs ACEI-based antihypertensive regimen in individuals at risk for mild cognitive impairment (MCI) and probable dementia (PD).

Design, Setting, and Participants

Active comparator, new-user observational cohort study design using data from the Systolic Blood Pressure Intervention Trial (SPRINT), conducted November 2010 through July 2018. Marginal cause-specific hazard ratios (HRs) and treatment-specific cumulative incidence functions were estimated with inverse probability (IP) weighting to account for confounding. Participants were using neither an ARB nor ACEI at baseline. Data analysis was conducted from April 7, 2021, to April 26, 2022.

Exposures

New users of ARB vs ACEI during the first 12 months of trial follow-up.

Main Outcomes and Measures

Composite of adjudicated amnestic MCI or PD.

Results

Of 9361 participants, 727 and 1313 new users of an ARB or ACEI, respectively, with well-balanced baseline characteristics between medication exposure groups after inverse probability weighting (mean [SD] age, 67 [9.5] years; 1291 ]63%] male; 240 [33%] Black; 89 [12%] Hispanic; 383 [53%] White; and 15 [2%] other race or ethnicity. In the primary analysis, during a median follow-up of 4.9 years, the inverse probability-weighted rate of amnestic MCI or PD was 4.3 vs 4.6 per 100 person-years among participants initiating ARB vs ACEI (HR, 0.93; 95% CI, 0.76-1.13). In subgroup analyses, new users of an ARB vs ACEI had a lower rate of amnestic MCI or PD among those in the standard systolic blood pressure treatment arm (HR, 0.61; 95% CI, 0.41-0.91) but not in the intensive arm (HR, 1.17; 95% CI, 0.90-1.52) (P = .007 for interaction).

Conclusions and Relevance

In this observational cohort study of US adults at high cardiovascular disease risk, there was no difference in the rate of amnestic MCI or PD among new users of an ARB compared with ACEI, although 95% CIs were wide.

Benefits of more intensive versus less intensive blood pressure control. Updated trial sequential analysis

Outcome data from randomized trials which compared different blood pressure (BP) targets grew impressively after publication of recent trials. We conducted a cumulative updated trial sequential analysis of studies which compared a more versus less intensive BP control strategy, for a total of 60,870 randomized patients. The compared BP targets differed across the trials. Outcome measures were stroke, heart failure, myocardial infarction and cardiovascular death. The average duration of follow-up was 3.95 years and achieved systolic BP was 7.69 mmHg lower with the more intensive than the less intensive BP control strategy. The more intensive BP control strategy significantly reduced the risk of stroke (OR 0.79; 95% CI 0.67-0.93), heart failure (OR 0.73; 95% CI 0.55-0.96), myocardial infarction (OR 0.81; 95% CI 0.73-0.91) and cardiovascular death (OR 0.81; 95% CI 0.68-0.98) as compared to the less intensive strategy. In a trial sequential analysis, the more intensive BP control strategy provided conclusive benefits over the less intensive strategy on the risk of stroke, heart failure and myocardial infarction by definitely crossing the efficacy monitoring boundary. For cardiovascular death, the cumulative Z-curve of the sequential analysis touched the efficacy monitoring boundary, but did not cross it. In conclusion, data accrued from randomized trials conclusively demonstrate the superiority of a more intensive over a less intensive BP control strategy for the prevention of stroke, heart failure and myocardial infarction. Results also suggest a significant benefit, albeit not yet conclusive, of a more intensive over a less intensive strategy for prevention of cardiovascular death.

New wrinkles in hypertension management 2022

PURPOSE OF REVIEW

High blood pressure (BP) is the world's leading risk factor for cardiovascular disease (CVD) and death. This review highlights findings during the past 18 months that apply to the management of high BP in adults in the context of the 2017 American College of Cardiology/American Heart Association (AHA) BP guideline.

RECENT FINDINGS

A comprehensive meta-analysis of clinical trials that employed a novel statistical method identified a substantially linear relationship between dietary sodium intake and BP, strongly supporting the AHA daily dietary sodium intake recommendation of less than 1500 mg/day but suggesting that any reduction in sodium intake is likely to be beneficial. Among adults with hypertension, use of a salt substitute (containing reduced sodium and enhanced potassium) led to striking reductions in CVD outcomes. Young adults with stage 1 hypertension and a low 10-year atherosclerotic CVD risk score should be started on a 6-month course of vigorous lifestyle modification; if their BP treatment goal is not achieved, a first-line antihypertensive agent should be added to the lifestyle modification intervention. In patients with stage 4 renal disease, the thiazide-like diuretic chlorthalidone (as add-on therapy) lowered BP markedly compared with placebo. Nonsteroidal mineralocorticoid receptor antagonists (MRAs) represent a new class of MRA that has been shown to lower BP and provide significant CVD protection. In Chinese adults aged 60-80 years at baseline, intensive BP control with a SBP target of 110-129 compared with 130-149 mmHg reduced CVD events with minimal side effects.

SUMMARY

Recent findings have advanced our knowledge of hypertension management, clarifying, amplifying and supporting the 2017 ACC/AHA BP guideline recommendations.

How Much Lowering of Blood Pressure Is Required to Prevent Cardiovascular Disease in Patients With and Without Previous Cardiovascular Disease?

PURPOSE OF REVIEW

To review the recent large-scale randomised evidence on pharmacologic reduction in blood pressure for the primary and secondary prevention of cardiovascular disease.

RECENT FINDINGS

Based on findings of the meta-analysis of individual participant-level data from 48 randomised clinical trials and involving 344,716 participants with mean age of 65 years, the relative reduction in the risk of developing major cardiovascular events was proportional to the magnitude of achieved reduction in blood pressure. For each 5-mmHg reduction in systolic blood pressure, the risk of developing cardiovascular events fell by 10% (hazard ratio [HR] (95% confidence interval [CI], 0.90 [0.88 to 0.92]). When participants were stratified by their history of cardiovascular disease, the HRs (95% CI) in those with and without previous cardiovascular disease were 0.89 (0.86 to 0.92) and 0.91 (0.89 to 0.94), respectively, with no significant heterogeneity in these effects (adjusted P for interaction = 1.0). When these patient groups were further stratified by their baseline systolic blood pressure in increments of 10 mmHg from < 120 to ≥ 170 mmHg, there was no significant heterogeneity in the relative risk reduction across these categories in people with or without previous cardiovascular disease (adjusted P for interaction were 1.00 and 0.28, respectively). Pharmacologic lowering of blood pressure was effective in preventing major cardiovascular disease events both in people with or without previous cardiovascular disease, which was not modified by their baseline blood pressure level. Treatment effects were shown to be proportional to the intensity of blood pressure reduction, but even modest blood pressure reduction, on average, can lead to meaningful gains in the prevention of incident or recurrent cardiovascular disease.

Clinical benefit of systolic blood pressure within the target range among patients with or without diabetes mellitus: a propensity score-matched analysis of two randomized clinical trials

BACKGROUND

Recent guidelines recommended a systolic blood pressure (SBP) target of < 130 mmHg for patients with or without diabetes but without providing a lower bound. Our study aimed to explore whether additional clinical benefits remain at achieved blood pressure (BP) levels below the recommended target.

METHODS

We performed a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) among the non-diabetic population and the Action to Control Cardiovascular Risk in Diabetes BP (ACCORD-BP) trial among diabetic subjects. We used the propensity score method to match patients from the intensive BP group to those from the standard group in each trial. Individuals with different achieved BP levels from the intensive BP group were used as "reference." For each stratum, the trial-specific primary outcome (i.e., composite outcome of myocardial infarction (MI), acute coronary syndrome not resulting in MI, stroke, acute decompensated heart failure (HF), or cardiovascular death for SPRINT; non-fatal MI, non-fatal stroke, or cardiovascular death for ACCORD-BP) was compared by Cox regression.

RESULTS

A non-linear association was observed between the mean achieved BP and incidence of composite cardiovascular events, regardless of treatment allocation. The significant treatment benefit for primary outcome remained at SBP 110-120 mmHg (hazard ratio, 0.59 [95% CI, 0.46, 0.76] for SPRINT; 0.67 [0.52, 0.88] for ACCORD-BP) and SBP 120-130 mmHg for SPRINT (0.47 [0.34, 0.63]) but not for ACCORD-BP (0.93 [0.70, 1.23]). The results were similar for the secondary outcomes including all-cause mortality, cardiovascular mortality, MI, stroke, and HF. Intensive BP treatment benefits existed among patients maintaining a diastolic BP of 60-70 mmHg but were less distinct.

CONCLUSIONS

The treatment benefit persists at as low as SBP 110-120 mmHg irrespective of diabetes status. Achieved very low BP levels appeared to increase cardiovascular events and all-cause mortality.

Longitudinal quantitative assessment of coronary atherosclerosis related to normal systolic blood pressure maintenance in the absence of established cardiovascular disease

BACKGROUND

Atherosclerosis-related adverse events are commonly observed even in conditions with low cardiovascular (CV) risk. Longitudinal data regarding the association of normal systolic blood pressure maintenance (SBP_maintain ) with coronary plaque volume changes (PVC) has been limited in adults without traditional CV disease.

HYPOTHESIS

Normal SBP_maintain is important to attenuate coronary atherosclerosis progression in adults without baseline CV disease.

METHODS

We analyzed 95 adults (56.7 ± 8.5 years; 40.0% men) without baseline CV disease who underwent serial coronary computed tomographic angiography with mean 3.5 years of follow-up. All participants were divided into two groups of normal SBP_maintain (follow-up SBP < 120 mm Hg) and ≥elevated SBP_maintain (follow-up SBP ≥ 120 mm Hg). Annualized PVC was defined as PVC divided by the interscan period.

RESULTS

Compared to participants with normal SBP_maintain , those with ≥elevated SBP_maintain had higher annualized total PVC (mm³ /year) (0.0 [0.0-2.2] vs. 4.1 [0.0-13.0]; p < .001). Baseline total plaque volume (β = .10) and the levels of SBP_maintain (β = .23) and follow-up high-density lipoprotein cholesterol (β = -0.28) were associated with annualized total PVC (all p < .05). The optimal cutoff of SBP_maintain for predicting plaque progression was 118.5 mm Hg (sensitivity: 78.2%, specificity: 62.5%; area under curve: 0.700; 95% confidence interval [CI]: 0.59-0.81; p < .05). SBP_maintain  ≥ 118.5 mm Hg (odds ratio [OR]: 4.03; 95% CI: 1.51-10.75) and baseline total plaque volume (OR: 1.03; 95% CI: 1.01-1.06) independently influenced coronary plaque progression (all p < .05).

CONCLUSION

Normal SBP_maintain is substantial to attenuate coronary atherosclerosis progression in conditions without established CV disease.

Prognostic Impact of Blood Pressure Change Patterns on Patients With Aortic Dissection After Admission

Objectives

Hypertension is a predominant risk factor for aortic dissection (AD), and blood pressure (BP) control plays a vital role in the management of AD. However, the correlation between BP change and the prognosis for AD remains unclear. This study aims to demonstrate the impact of BP change patterns on AD prognosis.

Methods

This retrospective study included AD patients at two institutions (Shanghai Ninth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine and the Vascular Department of the First Affiliated Hospital of Anhui Medical University) between 2004 and 2018. The systolic BP (SBP) change patterns of these patients were analyzed by functional data analysis (FDA). The relationship between BP change patterns and the risk of adverse events (AEs) was assessed using survival analysis.

Results

A total of 458 patients with AD were eligible for analysis. The logistic regression analysis indicated that compared with that in patients with low SBP variation (SBPV), the incidence of AEs in patients with high SBPV was significantly higher (35.84 vs. 20.35%, OR 2.19, P &lt; 0.001). The patients were divided into four categories (accelerating rise, accelerating drop, decelerating rise, and decelerating drop) based on their SBP patterns after FDA fitting. The results of Kaplan–Meier analysis showed that at the 15- and 20-min time points, the incidence of AEs in the decelerating-drop group was significantly lower than that in the accelerating-rise group (OR 0.19, P = 0.031 and OR 0.23, P = 0.050). However, at the 25- and 30-min time points, the difference between these four groups was not significant (OR 0.26, P = 0.08 and OR 0.29, P = 0.10).

Conclusions

This study classified AD patients into four groups according to the SBP change patterns the first 30 min following admission, of which those with accelerating rises in SBP are at the highest risk of AEs, while those with decelerating drops have the best prognosis in the first 24 h after admission. Clinical practitioners may benefit from analyzing patterns of in-hospital SBP.

Association Between Systolic Blood Pressure Variability and Major Adverse Cardiovascular Events in Korean Patients With Chronic Kidney Disease: Findings From KNOW-CKD

Background Whether visit-to-visit systolic blood pressure (SBP) variability can predict major adverse cardiovascular events (MACE) in patients with chronic kidney disease is unclear. Methods and Results We investigated the relationship between SDs of visit-to-visit SBP variability during the first year of enrollment and MACE among 1575 participants from KNOW-CKD (Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease). Participants were categorized into 3 groups according to tertiles of visit-to-visit SBP variability (SD). The study end point was MACE, defined as a composite of nonfatal myocardial infarction, unstable angina, revascularization, nonfatal stroke, hospitalization for heart failure, or cardiac death. During 6748 patient-years of follow-up (median, 4.2 years), MACE occurred in 64 participants (4.1%). Compared with the lowest tertile of visit-to-visit SBP variability (SD), the hazard ratios (HRs) for the middle and the highest tertile were 1.64 (95% CI, 0.80-3.36) and 2.23 (95% CI, 1.12-4.44), respectively, in a multivariable cause-specific hazard model. In addition, the HR associated with each 5-mm Hg increase in visit-to-visit SBP variability (SD) was 1.21 (95% CI, 1.01-1.45). This association was consistent in sensitivity analyses with 2 additional definitions of SBP variability determined by the coefficient of variation and variation independent of the mean. The corresponding HRs for the middle and highest tertiles were 2.11 (95% CI, 1.03-4.35) and 2.28 (95% CI, 1.12-4.63), respectively, in the analysis with the coefficient of variation and 1.76 (95% CI, 0.87-3.57) and 2.04 (95% CI, 1.03-4.03), respectively, with the variation independent of the mean. Conclusions Higher visit-to-visit SBP variability is associated with an increased risk of MACE in patients with chronic kidney disease. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01630486.

Hypotension as a marker or mediator of perioperative organ injury: a narrative review

Perioperative hypotension has been repeatedly associated with organ injury and worse outcome, yet many interventions to reduce morbidity by attempting to avoid or reverse hypotension have floundered. In part, this reflects uncertainty as to what threshold of hypotension is relevant in the perioperative setting. Shifting population-based definitions for hypertension, plus uncertainty regarding individualised norms before surgery, both present major challenges in constructing useful clinical guidelines that may help improve clinical outcomes. Aside from these major pragmatic challenges, a wealth of biological mechanisms that underpin the development of higher blood pressure, particularly with increasing age, suggest that hypotension (however defined) or lower blood pressure per se does not account solely for developing organ injury after major surgery. The mosaic theory of hypertension, first proposed more than 60 yr ago, incorporates multiple, complementary mechanistic pathways through which clinical (macrovascular) attempts to minimise perioperative organ injury may unintentionally subvert protective or adaptive pathways that are fundamental in shaping the integrative host response to injury and inflammation. Consideration of the mosaic framework is critical for a more complete understanding of the perioperative response to acute sterile and infectious inflammation. The largely arbitrary treatment of perioperative blood pressure remains rudimentary in the context of multiple complex adaptive hypertensive endotypes, defined by distinct functional or pathobiological mechanisms, including the regulation of reactive oxygen species, autonomic dysfunction, and inflammation. Developing coherent strategies for the management of perioperative hypotension requires smarter, mechanistically solid interventions delivered by RCTs where observer bias is minimised.

Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years and Older With Hypertension: A Secondary Analysis of Randomized Clinical Trials

Importance

Recent guidelines recommend a systolic blood pressure (BP) goal of less than 150 mm Hg or even 130 mm Hg for adults aged 60 years or older. However, harms from intensive BP treatments occur immediately (eg, syncope, fall), and benefits for cardiovascular event reduction emerge over time. Therefore, harms with low chance of benefit need to be clearer, particularly for those with limited life expectancy.

Objective

To estimate the time needed to potentially derive clinical benefit from intensive BP treatment in patients 60 years and older.

Design, Setting, and Participants

This secondary analysis included individual patient data from published randomized clinical trials with 27 414 patients 60 years or older with hypertension. Patient-level survival data were reconstructed when the original data were not available. Published trials were identified by searching PubMed until October 15, 2021.

Exposures

Intensive BP lowering vs standard BP lowering with the treat-to-target design.

Main Outcomes and Measures

Major adverse cardiovascular event (MACE) defined by each trial, which was broadly similar with all trials including myocardial infarction, stroke, and cardiovascular mortality.

Results

Six trials (original data from 2 trials and reconstructed data from 4 trials) with 27 414 participants (mean age, 70 years; 56.3% were women) were included in the analysis. Intensive BP treatment with a systolic BP target below 140 mm Hg was significantly associated with a 21% reduction in MACE (hazard ratio, 0.79; 95% CI, 0.71-0.88; P < .001). On average, 9.1 (95% CI, 4.0-20.6) months were needed to prevent 1 MACE per 500 patients with the intensive BP treatment (absolute risk reduction [ARR], 0.002). Likewise, 19.1 (95% CI, 10.9-34.2) and 34.4 (95% CI, 22.7-59.8) months were estimated to avoid 1 MACE per 200 (ARR, 0.005) and 100 (ARR, 0.01) patients, respectively.

Conclusions and Relevance

In this analysis, findings suggest that for patients 60 years and older with hypertension, intensive BP treatment may be appropriate for some adults with a life expectancy of greater than 3 years but may not be suitable for those with less than 1 year.

A village doctor-led multifaceted intervention for blood pressure control in rural China: an open, cluster randomised trial

BACKGROUND

The prevalence of uncontrolled hypertension is high and increasing in low-income and middle-income countries. We tested the effectiveness of a multifaceted intervention for blood pressure control in rural China led by village doctors (community health workers on the front line of primary health care).

METHODS

In this open, cluster randomised trial (China Rural Hypertension Control Project), 326 villages that had a regular village doctor and participated in the China New Rural Cooperative Medical Scheme were randomly assigned (1:1) to either village doctor-led multifaceted intervention or enhanced usual care (control), with stratification by provinces, counties, and townships. We recruited individuals aged 40 years or older with an untreated blood pressure of 140/90 mm Hg or higher (≥130/80 mm Hg among those with a history of cardiovascular disease, diabetes, or chronic kidney disease) or a treated blood pressure of 130/80 mm Hg or higher. In the intervention group, trained village doctors initiated and titrated antihypertensive medications according to a standard protocol with supervision from primary care physicians. Village doctors also conducted health coaching on home blood pressure monitoring, lifestyle changes, and medication adherence. The primary outcome (reported here) was the proportion of patients with a blood pressure of less than 130/80 mm Hg at 18 months. The analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03527719, and is ongoing.

FINDINGS

Between May 8 and November 28, 2018, we enrolled 33 995 individuals from 163 intervention and 163 control villages. At 18 months, 8865 (57·0%) of 15 414 patients in the intervention group and 2895 (19·9%) of 14 500 patients in the control group had a blood pressure of less than 130/80 mm Hg, with a group difference of 37·0% (95% CI 34·9 to 39·1%; p<0·0001). Mean systolic blood pressure decreased by -26·3 mm Hg (95% CI -27·1 to -25·4) from baseline to 18 months in the intervention group and by -11·8 mm Hg (-12·6 to -11·0) in the control group, with a group difference of -14·5 mm Hg (95% CI -15·7 to -13·3 mm Hg; p<0·0001). Mean diastolic blood pressure decreased by -14·6 mm Hg (-15·1 to -14·2) from baseline to 18 months in the intervention group and by -7·5 mm Hg (-7·9 to -7·2) in the control group, with a group difference of -7·1 mm Hg (-7·7 to -6·5 mm Hg; p<0·0001). No treatment-related serious adverse events were reported in either group.

INTERPRETATION

Compared with enhanced usual care, village doctor-led intervention resulted in statistically significant improvements in blood pressure control among rural residents in China. This feasible, effective, and sustainable implementation strategy could be scaled up in rural China and other low-income and middle-income countries for hypertension control.

FUNDING

Ministry of Science and Technology of China.

Global Impact of Different Blood Pressure Thresholds in 4 021 690 Participants of the May Measurement Month Initiative

BACKGROUND

Influential guidelines currently define hypertension at different thresholds of blood pressure (BP). The global May Measurement Month initiative provides a unique opportunity to estimate the potential consequences of universal lowering of BP thresholds on the prevalence of hypertension based on a large, real-world, patient-level data set.

METHODS

The average of the second and third of 3 attended BP readings after 5 minutes of rest from 4 021 690 standardized, opportunistic BP screenings in various settings of the 2017 to 2019 May Measurement Month initiatives from 104 countries were analyzed to assess the demographic and phenotypic impact of 3 defined BP thresholds.

RESULTS

The age- and sex-standardized median of the relative increase in rate of hypertension with a change of thresholds from ≥140/≥90 to ≥130/≥80 mm Hg was 72.3% (interquartile range, 59.3%-91.3%) among the participating countries. With a change from ≥140/≥90 to ≥120/≥70 mm Hg, the median range was 162.6% (interquartile range, 132.8%-202.6%). The increase in rate of hypertension was most pronounced in low-income (95.3% and 203.9%) and least pronounced in high-income countries (71.6% and 167.1%).

CONCLUSIONS

The impact of a universal application of lower BP thresholds for the definition of hypertension would have an enormous impact on the prevalence of hypertension globally with large disparities between countries and substantial heterogeneity of demographic and phenotypic patterns, which should be confirmed in dedicated population studies. While focusing on lower BP targets may constitute an opportunity for early intervention, the potential socioeconomic consequences may pose unsurmountable obstacles for most health care systems worldwide.

Effect of Intensive versus Standard BP Control on AKI and Subsequent Cardiovascular Outcomes and Mortality: Findings from the SPRINT EHR Study

Background

Adjudication of inpatient AKI in the Systolic Blood Pressure Intervention Trial (SPRINT) was based on billing codes and admission and discharge notes. The purpose of this study was to evaluate the effect of intensive versus standard BP control on creatinine-based inpatient and outpatient AKI, and whether AKI was associated with cardiovascular disease (CVD) and mortality.

Methods

We linked electronic health record (EHR) data from 47 clinic sites with trial data to enable creatinine-based adjudication of AKI. Cox regression was used to evaluate the effect of intensive BP control on the incidence of AKI, and the relationship between incident AKI and CVD and all-cause mortality.

Results

A total of 3644 participants had linked EHR data. A greater number of inpatient AKI events were identified using EHR data (187 on intensive versus 155 on standard treatment) as compared with serious adverse event (SAE) adjudication in the trial (95 on intensive versus 61 on standard treatment). Intensive treatment increased risk for SPRINT-adjudicated inpatient AKI (HR, 1.51; 95% CI, 1.09 to 2.08) and for creatinine-based outpatient AKI (HR, 1.40; 95% CI, 1.15 to 1.70), but not for creatinine-based inpatient AKI (HR, 1.20; 95% CI, 0.97 to 1.48). Irrespective of the definition (SAE or creatinine based), AKI was associated with increased risk for all-cause mortality, but only creatinine-based inpatient AKI was associated with increased risk for CVD.

Conclusions

Creatinine-based ascertainment of AKI, enabled by EHR data, may be more sensitive and less biased than traditional SAE adjudication. Identifying ways to prevent AKI may reduce mortality further in the setting of intensive BP control.

Updates in hypertension: new trials, targets and ways of measuring blood pressure

PURPOSE OF REVIEW

Several recent trials and observational studies have identified critical areas that can help to improve the management and measurement of blood pressure in patients with hypertension.

RECENT FINDINGS

High-quality trial evidence supports intensive SBP lowering to 110-130 mmHg in older patients, potassium- based salt substitution in patients without chronic kidney disease, and chlorthalidone for the management of hypertension in patients with chronic kidney disease. In addition, population-based studies indicate enormous underdiagnosis of primary aldosteronism as well as greater sustained intensification of antihypertensive therapy in older patients by maximizing medication dosage rather than adding new agents. The prevalence of hypertension is stable worldwide, though is generally improving in high-income countries and worsening in low-income countries. Furthermore, although cuffless blood pressure devices have the potential to improve access to blood pressure measurement, they have not yet demonstrated sufficient accuracy for clinical use.

SUMMARY

Growing evidence supports intensive blood pressure lowering, sodium reduction, targeted antihypertensive treatment and appropriate screening for secondary hypertension to optimize blood pressure control and reduce the risk of target organ damage from hypertension. Future studies are needed to identify ways to improve our ability to implement these findings in routine clinical practice.