National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants

Body Fat Distribution and Systolic Blood Pressure in 10,000 Adults with Whole-Body Imaging: UK Biobank and Oxford BioBank

OBJECTIVE

This study aimed to quantify the associations of regional fat mass and fat-free mass with systolic blood pressure.

METHODS

This analysis combined individual participant data from two large-scale imaging studies: UK Biobank and Oxford BioBank. In both studies, participants were interviewed and measured, and they underwent dual-energy x-ray absorptiometry imaging. Linear regression was used to relate systolic blood pressure to anthropometric measures of adiposity (BMI, waist circumference, and waist to hip ratio) and dual-energy x-ray absorptiometry-derived measures of body composition (visceral android fat, subcutaneous android fat, subcutaneous gynoid fat, and fat-free mass).

RESULTS

Among 10,260 participants (mean age 49; 96% white), systolic blood pressure was positively associated with visceral android fat (3.2 mmHg/SD in men; 2.8 mmHg/SD in women) and fat-free mass (1.92 mmHg/SD in men; 1.64 mmHg/SD in women), but there was no evidence of an association with subcutaneous android or gynoid fat. Associations of systolic blood pressure with BMI were slightly steeper than those with waist circumference or waist to hip ratio; these associations remained unchanged following adjustment for fat-free mass, but adjustment for visceral android fat eliminated associations with waist circumference and waist to hip ratio and more than halved associations with BMI.

CONCLUSIONS

This analysis indicates that visceral fat is the primary etiological component of excess adiposity underlying the development of adiposity-related hypertension.

Cost-effectiveness of risk stratified medication management for reducing premature cardiovascular mortality in Kenya

Background

Cardiovascular disease (CVD) is a major contributor to the burden from non-communicable diseases in Sub-Saharan Africa and hypertension is the leading risk factor for CVD. The objective of this modeling study is to assess the cost-effectiveness of a risk stratified approach to medication management in Kenya in order to achieve adequate blood pressure control to reduce CVD events.

Methods

We developed a microsimulation model to evaluate CVD risk over the lifetime of a cohort of individuals. Risk groups were assigned utilizing modified Framingham study distributions based on individual level risk factors from the Kenya STEPwise survey which collected details on blood pressure, blood glucose, tobacco and alcohol use and cholesterol levels. We stratified individuals into 4 risk groups: very low, low, moderate and high risk. Mortality could occur due to acute CVD events, subsequent future events (for individual who survive the initial event) and other causes. We present cost and DALYs gained due to medication management for men and women 25 to 69 years.

Results

Treating high risk individuals only was generally more cost-effective that treating high and moderate risk individuals. At the anticipated base levels of effectiveness, medication management was only cost-effective under the low cost scenario. The incremental cost per DALY gained with low cost ranged from $1,505 to $3,608, which is well under $4,785 (3 times GPD per capita) threshold for Kenya. Under the low cost scenario, even lower levels of effectiveness of medication management are likely to be cost-effective for high-risk men and women.

Conclusions

In Kenya, our results indicate that the risk stratified approach to treating hypertension may be cost-effective especially for men and women at a high risk for CVD events, but these results are highly sensitive to the cost of medications. Medication management would require significant financial investment and therefore other interventions, including lifestyle changes, should be evaluated especially for those with elevated blood pressure and overall 10-year risk that is less than 20%.

Hypertension in Mozambique: trends between 2005 and 2015

OBJECTIVE

To assess the current prevalence, awareness, treatment and control of arterial hypertension in Mozambican population, including adolescents and young adults, and to appraise their trends over the past decade, for the 25-64 years old population.

METHODS

A cross-sectional study of a representative sample of the population aged 15-64 years (n = 2965) was conducted in 2014-2015, following the Stepwise Approach to Chronic Disease Risk Factor Surveillance. Data from a survey conducted in 2005 using the same methodological approach was used to assess trends in the age group of 25-64 years.

RESULTS

The prevalence of hypertension increased significantly, from 33.1 to 38.9% (P = 0.048), whereas awareness (2005 vs. 2014-2015: 14.8 vs. 14.5%, P = 0.914) and treatment among the aware (2005 vs. 2014-2015: 51.9 vs. 50.1%, P = 0.770) remained similar. Control among the treated increased (from 39.9 to 44.5%, P = 0.587), although not significantly. Mean blood pressure values increased (SBP: from 132.1 to 134.6 mmHg, P = 0.089; DBP: from 78.2 to 82.5 mmHg, P < 0.001). Among participants aged 15-24 years, in 2014-2015 the prevalence of hypertension was 13.1% (95% confidence interval: 9.8-16.4).

CONCLUSION

Our findings show that the prevalence of hypertension in Mozambique is among the highest in developing countries, both in adults and adolescents, portraying an ample margin for reduction of the morbidity and mortality burden because of high blood pressure.

Improved adherence in older patients with hypertension: An observational study of a community-based intervention

AIMS AND OBJECTIVES

This study sought to assess the effect of a community-based intervention influencing adherence status at baseline, 1, 3 and 6 months, and to evaluate the impact that a community-based intervention and socio-economic factors have on adherence.

BACKGROUND

Although high-quality treatment and modern hypertension clinical practice guidelines have been developed worldwide, the outcomes of patients with hypertension in Thailand are not optimal. Implementing a person-centred and integrated health services model to improve hypertension management, such as a community-based intervention, is challenging for healthcare providers in Thailand.

DESIGN

An observational study of a community-based intervention.

METHODS

The study comprised residents in 17 villages in one province of Thailand. A sample of 156 participants was allocated into the intervention and the control groups. Inclusion criteria were people aged 60 years or older diagnosed with hypertension. Exclusion criteria included the latest record of extreme hypertension and having a documented history of cognitive impairment. The intervention group received the 4-week community-based intervention programme. Multiple linear regression was applied to predict the adherence status at each phase. Multiple logistic regression was then implemented to predict influencing factors between the groups.

RESULTS

Patients who received the intervention had significantly lower adherence scores (reflecting a higher level of adherence) at 3 and 6 months after intervention by 1.66 and 1.45 times, respectively, when adjusting for other variables. After 6 months, the intervention was associated with a significant improvement in adherence when adjusting for other variables.

CONCLUSION

This study provides evidence to support the use of community-based interventions as an effective adjunct to hospital-based care of hypertension patients in Thailand.

IMPLICATIONS FOR PRACTICE

Understanding factors between health outcomes and social determinants of health is crucial for informing the development of culturally appropriate interventions.

Factors associated with noncommunicable disease among adults in Mecha district, Ethiopia: A case control study

BACKGROUND

In Ethiopia, the incidence and prevalence of noncommunicable diseases are rising. Within the country, the magnitude of these diseases varies from region to region. However, information about factors associated with noncommunicable disease is limited in the study area. Therefore, the objective of this study was to identify factors associated with noncommunicable disease among adults in Mecha district.

METHODS

Community-based case-control study was carried out among 728 cases and 2907 controls from February1-August 30/2017. The study participants were chosen using a multi-stage sampling technique. Data were collected using structured questionnaire. Fasting blood glucose level was measured in the morning after 8hours of fasting. Statistical Package for Social Science (SPSS) version 20 software was used to enter and analyze data. Crude and adjusted Odds ratios were done for each explanatory variable at 95% confidence level.

RESULTS

The likelihood of developing noncommunicable disease was higher among participants who drank alcohol [AOR = 1.72, 95% CI: (1.3, 2.1)] and coffee [AOR = 4.54, 95% CI: (3.4, 5.9)], did not take vegetables [AOR = 2. 30, 95% CI: (1.6, 3.1)] and fruits [AOR = 2.04, 95% CI: (1.4, 2.9)], took packed oil [AOR = 2.35, 95% CI: (1.7, 3.1)], overweight or obesity [AOR = 2.23, 95% CI: (1.3, 3.8)] and physically inactive [AOR = 1.71, 95% CI: (1.2, 2.4)].

CONCLUSION

Of those assessed, the main factors associated with noncommunicable disease were drinking alcohol and coffee, not taking vegetables and fruits, taking packed oil, being overweight and physically inactive. Thus, the finding suggests changing the dietary habit of the community to increase consumption of fruits and vegetables, use of unsaturated fat for cooking, to avoid consumption of alcohol and to decrease taking coffee, to do physical activity and weight reduction.

Iran in transition

Being the second-largest country in the Middle East, Iran has a long history of civilisation during which several dynasties have been overthrown and established and health-related structures have been reorganised. Iran has had the replacement of traditional practices with modern medical treatments, emergence of multiple pioneer scientists and physicians with great contributions to the advancement of science, environmental and ecological changes in addition to large-scale natural disasters, epidemics of multiple communicable diseases, and the shift towards non-communicable diseases in recent decades. Given the lessons learnt from political instabilities in the past centuries and the approaches undertaken to overcome health challenges at the time, Iran has emerged as it is today. Iran is now a country with a population exceeding 80 million, mainly inhabiting urban regions, and has an increasing burden of non-communicable diseases, including cardiovascular diseases, hypertension, diabetes, malignancies, mental disorders, substance abuse, and road injuries.

Rising rural body-mass index is the main driver of the global obesity epidemic in adults

Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities1,2. This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity3-6. Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.

Latest Concepts in the Endodontic Management of Patients with Cardiovascular Disorders

There are several cardiovascular interventions that need special considerations in the provision of treatments within the scope of endodontics. If these interventions are not carefully identified, diagnosed, and considered in the overall treatment plan for the patient, they may result in fatal conditions. These include hypertension that causes fatal cardiac disorders, such as angina pectoris, ischemic heart diseases, and myocardial infarction, and also cerebrovascular diseases; congestive heart failure; infective endocarditis, valvular diseases, and carrying pacemakers; and the use of antiplatelet and anticoagulant drugs that are commonly prescribed for patients who have experienced heart stroke. The aim of this article is to review the newest recommendations for patients with these disorders who require endodontic treatments.

Perspectives on hypertension's prevalence, treatment and control in a high cardiovascular risk East European country: data from the SEPHAR III survey

OBJECTIVES

To estimate the trend in arterial hypertension's prevalence, awareness, treatment, and control in Romania, starting from the latest national survey Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk in Romania III that has a crucial importance for the development of prevention strategies at national level.

METHODS

A representative sample of 1970 Romanian adults (mean age 48.38 years, age range 18-80 years, 52.5% women, 72.58% response rate), was enrolled. During the two study visits, three blood pressure (BP) measurements were performed at 1-min interval. Hypertension was defined as study SBP at least 140 mmHg and/or study DBP at least 90 mmHg at both study visits or previously diagnosed hypertension, regardless of BP values. BP control was defined as SBP less than 140 mmHg and DBP less than 90 mmHg in hypertensive patients.

RESULTS

General hypertension prevalence is 45.1% (19.1% newly diagnosed hypertension, 80.9% awareness of hypertension), increasing with age, regardless of sex and area of residence. Although the majority (72.2%) of hypertensive patients were treated (51.9% with two or more drugs), only 30.8% of them had controlled BP values. Following the evolution from the last 11 years, it is expected that in 2020 the prevalence of hypertension to be up to 44%, the awareness up to 96.2%, treatment of hypertension up to 83.7%, and BP control up to 36.6%.

CONCLUSION

Hypertension's prevalence in Romania is on the rise despite the increase in awareness, treatment, and control. Possible explanations of this trend might be the increasing incidence of unhealthy lifestyle and diet, including high salt intake, and a general increase in the prevalence of obesity, diabetes mellitus, and dyslipidemia.

Trends in Incidence and Outcomes of Pregnancy-Related Acute Myocardial Infarction (From a Nationwide Inpatient Sample Database)

Acute myocardial infarction (AMI) during pregnancy is rare but fatal complication. Recent incidence of pregnancy related AMI and trends in the related outcomes are unknown. The Nationwide Inpatient Sample database was utilized from years 2005 to 2014. International Classification of Disease-Ninth Revision were used to identify pregnancy related admissions and AMI. Primary outcome was incidence and trend of AMI related to pregnancy and Secondary outcomes were trends in mortality, resource utilization, and predictors of AMI during pregnancy. Simple logistic regression model was used to calculate predictors of AMI during pregnancy. p Values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. A total of 43,437,621 pregnancy related hospitalization and 3,786 cases of AMI (86% ante-partum and 14% postpartum) were noted during study period. The incidence of AMI during the study period was 8.7 per 100,000 pregnancies with an overall increase in incidence during the study period (relative increase of 18.9%, p <0.001). There was a concomitant decrease in mortality (relative decrease of 40.05%, p <0.001), cost of care (relative decrease of 8.70%, p <0.001), and length of stay (relative decrease of 13.53%, p <0.001). Significant predictors of AMI during pregnancy were higher age of pregnancy, black race, co-morbidities such as hypertension, thrombophilia, diabetes milletus, substance abuse, smoking, hyperlipidemia, heart failure, deep venous thrombosis, transfusion, fluid and electrolyte imbalance, and postpartum complications such as hemorrhage, infection, and depression. In conclusion, the incidence of AMI 2005 to 2014 rose with a concomitant decrease in mortality and resource utilization. High-risk patient characteristics were identified which could be utilized for resource allocation to further improve outcomes.

Optimal blood pressure targets for patients with hypertension: a systematic review and meta-analysis

Optimal blood pressure (BP) targets for hypertension have been an important clinical issue but have been elusive. The Systolic Blood Pressure Intervention Trial (SPRINT) showed significant benefits of intensive BP-lowering treatment with a target systolic BP level of < 120 mm Hg on major cardiovascular (CV) events and mortality, whereas there was a modest increase in renal events related to BP-lowering treatment. We searched the PubMed, Cochrane CENTRAL, and ICHUSHI databases for randomized trials that assigned participants to intensive versus usual BP-lowering treatment with different BP targets. The outcomes were major CV events, all-cause death, myocardial infarction, stroke, heart failure, renal events, and adverse events. Nineteen trials that enrolled a total of 55,529 participants with a mean follow-up duration ranging from 1.6 to 12.2 years were included in the present analysis. There was a significant reduction in major CV events, myocardial infarction, and stroke and a trend toward a reduction in heart failure associated with intensive BP-lowering treatment, but no differences in the risks of all-cause death, renal events, or adverse events were observed between the randomized groups. Subgroup analyses indicated that intensive BP-lowering treatment with a target of < 130/80 mm Hg and/or achievement of BP < 130/80 mm Hg were associated with a significant reduction in major CV events compared with the usual group. In conclusion, intensive BP-lowering treatment reduces the risk of CV events. A target BP level of < 130/80 mm Hg appears to be optimal for CV protection in patients with hypertension.

Reduction in sympathetic tone in patients with obstructive sleep apnoea: is fixed CPAP more effective than APAP? A randomised, parallel trial protocol

INTRODUCTION

Obstructive sleep apnoea (OSA) is a prevalent disease associated with cardiovascular events. Hypertension is one of the major intermediary mechanisms leading to long-term cardiovascular adverse events. Intermittent hypoxia and hypercapnia associated with nocturnal respiratory events stimulate chemoreflexes, resulting in sympathetic overactivity and blood pressure (BP) elevation. Continuous positive airway pressure (CPAP) is the primary treatment for OSA and induces a small but significant reduction in BP. The use of auto-adjusting positive airway pressure (APAP) has increased in the last years and studies showed different ranges of BP reduction when comparing both modalities. However, the pathophysiological mechanisms implicated are not fully elucidated. Variations in pressure through the night inherent to APAP may induce persistent respiratory efforts and sleep fragmentation that might impair sympathovagal balance during sleep and result in smaller decreases in BP. Therefore, this double-blind randomised controlled trial aims to compare muscle sympathetic nerve activity (MSNA) assessed by microneurography (reference method for measuring sympathetic activity) after 1 month of APAP versus fixed CPAP in treatment-naive OSA patients. This present manuscript describes the design of our study, no results are presented herein. and is registered under the below reference number.

METHODS AND ANALYSIS

Adult subjects with newly diagnosed OSA (Apnoea-Hypopnoea Index >20/hour) will be randomised for treatment with APAP or fixed CPAP. Measurements of sympathetic activity by MSNA, heart rate variability and catecholamines will be obtained at baseline and after 30 days. The primary composite outcome will be the change in sympathetic tone measured by MSNA in bursts/min and bursts/100 heartbeats. Sample size calculation was performed with bilateral assumption. We will use the Student's t-test to compare changes in sympathetic tone between groups.

ETHICS AND DISSEMINATION

The protocol was approved by The French Regional Ethics Committee. The study started in March 2018 with primary completion expected to March 2019. Dissemination plans of the results include presentations at conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03428516; Pre-results.

Modelling the health co-benefits of sustainable diets in the UK, France, Finland, Italy and Sweden

BACKGROUND/OBJECTIVES

It is not known if diets lower in greenhouse gas (GHG) emissions are also healthier. We evaluated the population health implications of changing to more sustainable diets in the UK, France, Finland, Italy and Sweden.

SUBJECTS/METHODS

We developed a life table model to simulate mortality and morbidity from diet-related diseases over the lifetime of the current population. Populating the model with locally available data for each country, we simulated the impact of country-specific dietary scenarios that had been optimised to meet dietary recommendations and reduce GHG emissions. Outcome measures included a change in disease-specific deaths, life expectancy and disability-adjusted life years (DALYs).

RESULTS

Diets that meet nutritional recommendations lead to substantial improvements in population health, ranging from 0.19 (95% uncertainty interval: 0.18-0.21) DALYs per person in Italy up to 0.89 (0.80-0.98) DALYs per person in Finland. Simultaneously reducing GHG emissions does not reduce the size of this impact, and in some cases produces additional health benefits. If sustainable diets can be maintained throughout adulthood, life expectancy would increase by between 2.3 (1.6-3.2) and 6.8 (5.5-8.5) months by country. However, results are sensitive to assumptions about how quickly changes in diet can influence disease, and future trends in disease.

CONCLUSIONS

Modelling the health impact of diets that are both nutritional and low in GHG emissions shows the potential for significant co-benefits in health and sustainability from dietary changes. Future work is needed to find effective interventions to deliver healthy sustainable diets.

Revealing burden of elevated blood pressure among Polish adolescent participants in a population-based ADOPOLNOR study: prevalence and potent risk factors

New category for elevated blood pressure introduced and described by JNC-7 for adults and adopted by the 2004 Working Group for children and adolescents stands for a pre-sign to hypertension. The ongoing rise in prevalence of high blood pressure in children and adolescents demands their regular screening. The objective of this study was to determine prevalence of elevated BP in Polish adolescents and explain the role of sex, age and body weight status as potent risk factors for this condition. A population-based cross-sectional survey was carried out on a sample of 4,941 students (2,451 boys and 2,490 girls) aged 10–18, participants in the ADOPOLNOR study. Body height and weight were measured and BMI was calculated. Blood pressure was measured twice on each visit on the right arm using a fully calibrated TECH MED TM-Z mercury gauge sphygmomanometer with sets of exchangeable cuffs and a clinical stethoscope. The blood pressure classification was determined using the surveillance method. The depended outcome variable was the elevated BP compared to normal BP for systolic (SBP), diastolic (DBP) and combined SBP and/or DBP. Explanatory variables included demographic characteristics, sex and age, and weight status. Two-way ANCOVA, Chi-square Pearson correlation, and multivariate logistic regression analysis (MLRA) were performed using the STATISTICA 13.1 data analysis software system; p-value <0.05 was considered statistically significant (StatSoft Inc. Tulsa, OK, USA). A clear gender pattern was found in prevalence of elevated BP with girls being more likely than boys to have elevated BP (4.9%, 5.3% and 7.4% for SBP, DBP and combined SBP and/or DBP in girls vs 3.5%, 3.5% and 5.9% in boys). The proportion of both genders with elevated BP gradually increased with age with 4.8% (SBP), 2.8% (DBP) and 5.8% (SBP and/or DBP), and 5.1%, 6.4% and 8.4% in early and late adolescence, respectively. Fifteen percent of obese adolescents had elevated SBP, 14.3% elevated DBP and 17.8% had elevated either SBP and/or DBP combined. At multivariate approach, the adjusted odds ratio for predictors of elevated BP revealed sex, age and weight status for SBP and SBP and/or DPB combined. Age and weight status were predictive for elevated DBP. Weight status (BMI) showed the highest predictive potential of elevated BP for both genders. The likelihood of developing elevated BP increased at least twice with each BMI category increase. Thus, overweight and obese adolescents were twice (overweight) and 4 to 5 times (obese) more likely than their normal weight counterparts in developing elevated BP. The study results confirmed predictive potential of sex, age, and weight status in developing elevated BP in adolescents. The highest odds of the weight status indicate that it is the strongest confounder of elevated BP condition.

[New perspectives on health prevention. Prevalence of hypertension, hypacusis and balance disorders at the Munich Oktoberfest 2016]

BACKGROUND

The prevalence of hypertension, hypacusis and balance disorders will increase due to demographic change and thus represent an increasing public health problem.

OBJECTIVE

To determine the point prevalence of the diseases in focus outside the classical medical setting.

METHOD

At the "Bavarian Central Agriculture Festival", on the margins of the Oktoberfest 2016, visitors were offered a free health check with three health stations (blood pressure measurement, hearing test, balance test). By means of standardized examinations, the prevalence of the diseases was recorded.

RESULTS

1,727 people participated in the blood pressure measurement, 510 in the hearing test and 1,320 in the balance test. At all study sites, an increase in prevalence was observed with increasing age. Overall, the prevalence of hypertensive blood pressure values (> 140/> 90 mmHg) was 23.6%, with a high rate of 30.8% among over-65s. In the hearing test, 41.6% of all participants had a low-grade (20-40 dB) and 15.5% a higher-grade (> 40 dB) hypacusis. A balance value in the normal range was achieved by only 25.2% of the participants.

CONCLUSION

The prevalence of the investigated diseases was very high, especially older men were more often affected by these health problems. Overall, there is a large primary and secondary prevention potential for the prevention and early treatment of the diseases. In order to increase the use, it would be possible in particular to consider expanding access to prevention programs outside of classic medical settings.

Exercise and incidence of myocardial infarction, stroke, hypertension, type 2 diabetes and site-specific cancers: prospective cohort study of 257 854 adults in South Korea

OBJECTIVE

The objective of this study was to examine the longitudinal associations of exercise frequency with the incidence of myocardial infarction, stroke, hypertension, type 2 diabetes and 10 different cancer outcomes.

DESIGN

A prospective cohort study.

SETTING

Physical examination data linked with the entire South Korean population's health insurance system: from 2002 to 2015.

PARTICIPANTS

257 854 South Korean adults who provided up to 7 repeat measures of exercise (defined as exercises causing sweat) and confounders.

PRIMARY OUTCOME MEASURES

Each disease incidence was defined using both fatal and non-fatal health records (a median follow-up period of 13 years).

RESULTS

Compared with no exercise category, the middle categories of exercise frequency (3-4 or 5-6 times/week) showed the lowest risk of myocardial infarction (HR 0.79; 95% CI 0.70 to 0.90), stroke (HR 0.80; 95% CI 0.73 to 0.89), hypertension (HR 0.86; 95% CI 0.85 to 0.88), type 2 diabetes (HR 0.87; 95% CI 0.84 to 0.89), stomach (HR 0.87; 95% CI 0.79 to 0.96), lung (HR 0.80; 95% CI 0.71 to 0.91), liver (HR 0.85; 95% CI 0.75 to 0.98) and head and neck cancers (HR 0.76; 95% CI 0.63 to 0.93; for 1-2 times/week), exhibiting J-shaped associations. There was, in general, little evidence of effect modification by body mass index, smoking, alcohol consumption, family history of disease and sex in these associations.

CONCLUSIONS

Moderate levels of sweat-inducing exercise showed the lowest risk of myocardial infarction, stroke, hypertension, type 2 diabetes, stomach, lung, liver and head and neck cancers. Public health and lifestyle interventions should, therefore, promote moderate levels of sweat-causing exercise as a behavioural prevention strategy for non-communicable diseases in a wider population of East Asians.

Decreases in adiposity reduce the risk of hypertension: Results from a prospective cohort of adolescents

This study aimed to evaluate the effect of age-related changes in body mass index and waist circumference during adolescence on blood pressure levels and incidence of hypertension. Among the 2159 adolescents recruited at 13 years in Porto, Portugal, we evaluated those free of hypertension at baseline and followed-up at 17 years (n = 1377) - EPITeen cohort, 2003-2008. Changes in BMI percentage (BMI%) and waist circumference percentage (WC%) were evaluated continuously as the difference between 13 and 17 years, then categorized in sex-specific quartiles. Hypertension was defined as systolic and/or diastolic blood pressure ≥ 95th sex- age- and height-specific reference percentile. The association between changes in adiposity and incidence of hypertension was computed through generalized linear models with log link function and Poisson distribution [incidence rate ratios (IRR), 95% confidence intervals (95%CI)], adjusting for baseline adiposity, sex, and family history of hypertension. Overall incidence rate of hypertension was 23.8 (95%CI 19.6-28.8) per 1000 person-years. Participants presenting the highest decrease in BMI% from 13 to 17 years (1st quartile) presented lower SBP at 17y, while for those with increasing BMI% (4th quartile) SBP increased. In comparison to stable BMI% (3rd quartile), decreases in BMI% (1st quartile) were associated with 44% lower risk of hypertension at 17y (IRR = 0.56, 95%CI 0.32-0.97). Increases in BMI% (4th quartile) were associated with increased incidence, although without statistical significance (IRR = 1.11, 95%CI 0.66-1.85). Results were similar when considering changes in WC%. Decreases in BMI and WC throughout adolescence in the whole spectrum of adiposity levels presented potential benefit for blood pressure.

Prevalence of high blood pressure and high normal blood pressure among 7- to 17-year-old children and adolescents in developed regions, China from 2014 to 2017: using new national blood pressure reference for Chinese children and adolescents

As the first blood pressure (BP) reference considering influence of height in China, national blood pressure reference for Chinese han children and adolescents aged 7 to 17 years (CCBP) was issued in 2017. The current study aimed to observe the short-term trends in BP and prevalence of high blood pressure (HBP) and high normal blood pressure (HNBP) using this CCBP reference in Suzhou, China. Data of children and adolescents aged 7 to 17 years were collected from 2014 to 2017. Total population of 2014 to 2017 were 617,383, 684,453, 695,302, and 774,605, respectively, and proportions of males were 54.1%, 54.0%, 53.9%, and 53.8%, respectively. P-trend tests were conducted to examine the trends of BP among different age, region, body mass index, and socioeconomic status groups for each gender. Multivariate logistic regression analyses found secular decreases in prevalence of HBP and HNBP, after adjustment for potential confounders. Compared with that in 2014, the odds ratios (95% confidence intervals) for total study population were 0.936 (0.928, 0.944) in 2015, 0.879 (0.872, 0.887) in 2016, and 0.934 (0.926, 0.941) in 2017. In conclusion, prevalence of HBP and HNBP decreased among children and adolescents in developed regions of China from 2014 to 2017, and a slight rise were found in 2017.

Managing hypertension in 2018: which guideline to follow?

Hypertension is a global public health issue and a major cause of morbidity and mortality. Its prevalence is increasing in many Asian countries, with a number of countries with blood pressure above the global average. Although the average systolic blood pressure is decreasing worldwide since the 1980s at the rate of about 1 mm Hg systolic blood pressure per decade, it is increasing in low-income and middle-income countries, especially in the East and South Asian population. Of note, the much larger base Asian population results in a considerably larger absolute number of individuals affected. When compared with Western countries, hypertension among Asian populations has unique features in terms of its onset, clustering of associated cardiovascular risk factors, complications and outcomes. Moreover, only a minority of hypertensive individuals are receiving treatment and achieving control. Projected number of deaths related to hypertension dramatically increased in the last 25 years in some Asian regions with a disproportionately high mortality and morbidity from stroke compared with Western countries. The relation between blood pressure and the risk of stroke is stronger in Asia than in Western regions. Although new Guidelines for hypertension diagnosis and management have been recently released from Europe and North America, the unique features of Asian hypertensive patients raise concerns on the clinical applicability of Western Guidelines to Asian populations. To this purpose, we critically reviewed key elements from the most updated Guidelines. We also discussed their core concepts to verify the impact on hypertension prevention and management in Asian countries.

Doye I, Toure M, Sy MP, Kiviat NB, Sow PS, Gottlieb GS, Hawes SE. Increasing prevalence of hypertension among HIV-positive and negative adults in Senegal, West Africa, 1994-2015

BACKGROUND

Non-communicable diseases, including hypertension (HTN), are increasingly recognized as important causes of morbidity and mortality among people living with HIV (PLHIV) in resource-limited settings. The goals of this study were to determine the prevalence of HTN among PLHIV in Senegal over time and to identify predictors of HTN among HIV-positive versus HIV-negative adults.

METHODS

We conducted a retrospective study using data from individuals enrolled in previous studies in Senegal from 1994-2015. Blood pressure (BP) measurements taken during study visits were used for analysis. HTN was defined as systolic BP≥140 or diastolic BP≥90. We used logistic regression to identify predictors of HTN.

RESULTS

We analyzed data from 2848 adults (1687 HIV-positive, 1161 HIV-negative). Among PLHIV, the prevalence of HTN increased from 11% during 1994-1999 to 22% during 2010-2015. Among HIV-negative individuals, the prevalence of HTN increased from 16% to 32%. Among both groups, the odds of HTN more than doubled from 1994-1999 to 2010-2015 (HIV-positive OR 2·4, 95% CI 1·1-5·0; HIV-negative OR 2·6, 95% CI 1·5-4·6). One quarter of all individuals with HTN had stage 2 HTN. The strongest risk factor for HTN was obesity (HIV-positive OR 3·2, 95% CI 1·7-5·8; p<0·01; HIV-negative OR 7·8, 95% CI 4·5-13·6; p<0·01). Male sex and age ≥50 were also predictive of HTN among both groups. Among HIV-positive subjects, WHO stage 1 or 2 disease was predictive of HTN and among HIV-negative subjects, having no formal education was predictive.

CONCLUSION

Over the past 20 years, the prevalence of HTN has doubled among both HIV-positive and HIV-negative adults in Senegal. Our study indicates that there is an increasing need for the integration of chronic disease management into HIV programs in Senegal. Furthermore, our findings highlight the need for enhanced prevention, recognition, and management of non-communicable diseases, including hypertension and obesity, among both HIV-positive and HIV-negative individuals in Senegal.

A lower blood pressure threshold to define hypertension: the effect on prevalence, control rate, and constituent ratio of systolic and/or diastolic hypertension

OBJECTIVE

To evaluate the impact of the new US hypertension criteria [systolic blood pressure/diastolic blood pressure (SBP/DBP ≥130/80 mmHg)] on hypertension prevalence and the constituent ratio of three hypertension phenotypes.

PARTICIPANTS AND METHODS

This study included 1185 adult participants, who received blood pressure (BP) measurements for 3 days over a 7-day period. At each visit, the BP was measured three times and the average was used as the final value. The criteria of hypertension were if the participant had received treatment with antihypertensive drugs for at least 2 weeks, or SBP/DBP of at least 140/90 mmHg (old criteria) or at least 130/80 mmHg (new criteria) for the untreated participants. The diagnosis of hypertension was made on the basis of first-day BP values (epidemiological method) or the average of the 3-day BP values (clinical method), respectively. The constituent ratios of isolated systolic, isolated diastolic, and systolic-diastolic hypertension were evaluated.

RESULTS

When using the old criteria, the overall epidemiological prevalence of hypertension was 41.1% and the overall clinical prevalence of hypertension was 34.8%. When using the new criteria, these values increased to 64.3 and 57.4%, respectively. Meanwhile, against the old criteria, the new criteria increased the constituent ratio of systolic-diastolic hypertension from 24.4 to 50.5% (P<0.001) for the epidemiological method and from 19.1 to 45.7% (P<0.001) for the clinical method in the newly diagnosed hypertensive patients.

CONCLUSION

The hypertension criteria of at least 130/80 mmHg not only significantly increased the clinical prevalence of hypertension, but significantly altered the constituent ratio of three hypertension phenotypes among the newly diagnosed hypertensive patients.

Relation Between Lead Exposure and Trends in Blood Pressure in Children

Obesity raises blood pressure (BP) in children and adults. Nevertheless, as obesity increased around the globe, population systolic and diastolic blood pressures were flat or fell. Examining children is insightful because pediatric trends are largely unconfounded by antihypertensive therapy. Decomposing BP into arterial types, large artery measures (pulse pressure) increased in concert with obesity while small artery measures (mean arterial pressure, [MAP]) decreased, suggesting small arteries are the locus of the countervailing temporal trends. Pediatric lead exposure decreased as pediatric obesity rose. Over the period of rising obesity, we examined the association between lead exposure and temporal trends in BP. We analyzed anthropometric, BP, and laboratory data on 8-17 year old children from the serial cross-sectional National Health and Nutrition Examination Surveys 1976 through 2008. Multivariable adjusted survey regression was used to examine temporal trends in blood pressure in relation to blood lead concentrations (N = 13,501). As obesity prevalence rose from 5.3% to 24.5%, age-sex adjusted systolic BP was flat (-0.01 [95% confidence interval (CI) -0.06, 0.04] mm Hg/yr, p = 0.8), diastolic BP and MAP decreased (respectively -0.28 [-0.32, -0.24] and -0.19 [CI -0.23, -0.15], both p<0.0001) while pulse pressure increased (0.28 [0.23, 0.32], p<0.001). Accounting for blood lead concentration attenuated the decreasing MAP trend by 67%. In conclusion, the contrary trends in pediatric BP during the rise of pediatric obesity may be substantially attributable to decreasing lead exposure acting on small resistance arteries. These results have implications for globally observed BP trends in youth and adults. Environmental policy altering lead levels may have long-lasting cardiovascular benefits.

Subgroups of lifestyle patterns among hypertension patients: a latent-class analysis

BACKGROUND

Hypertension remains one of the most important preventable risk factors for diseases and death. Identifying clustered patterns of modifiable lifestyle risk factors for hypertension and demographics factors related to these clustered patterns allows for targeting health prevention interventions. Therefore, this study aims to identify latent classes of hypertensive patients' lifestyle risk factors based on the clustering of four modifiable lifestyle risk factors: eating, physical activity patterns, smoking habits, and blood pressure control.

METHODS

A total of 750 patients (Mage = 65.38 years, SDage = 9.2 years) with diagnosed hypertension in urban and rural primary health care centers in Takab (Iran) were recruited randomly from August 2016 to February 2017. Latent class analysis was performed by using proc. LCA in SAS 9.2.

RESULTS

Three classes of lifestyle patterns were identified. About 14.4% of hypertensive patients were categorized in a low-risk class (I), 54.6% in an intermediate-risk class (II), and 31% in a high-risk class (III) of lifestyle. A one-year increase in age significantly increases the risk of membership in classes II and III. Similarly, being widowed or divorced increases the risk of membership in classes II and III. Also, having a higher education level decreases the risk of membership in classes II and III.

CONCLUSIONS

This study contributes to the literature on lifestyle behaviors among older adults and provides evidence that there are considerable differences in lifestyle behaviors between subgroups of older adult patients. The three profiles of hypertensive patients' conditions suggest that because behaviors often occur simultaneously within an individual level, a latent-class approach helps cluster co-occurrence risk behaviors and focuses on interventions targeted to several healthy behaviors among high-risk patients.

Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya

BACKGROUND

Hypertension is the most important risk factor for cardiovascular diseases and the leading cause of death worldwide. Despite growing evidence that the prevalence of hypertension is rising in sub-Saharan Africa, national data on hypertension that can guide programming are missing for many countries. In this study, we estimated the prevalence of hypertension, awareness, treatment, and control. We further examined the factors associated with hypertension and awareness.

METHOD

We used data from the 2015 Kenya STEPs survey, a national cross-sectional household survey targeting randomly selected people aged 18-69 years. Demographic and behavioral characteristics as well as physical measurements were collected using the World Health Organization's STEPs Survey methodology. Descriptive statistics were used to estimate the prevalence, awareness, treatment and control of hypertension. Multiple logistic regression models were used to identify the determinants of hypertension and awareness.

RESULTS

The study surveyed 4485 participants. The overall age-standardized prevalence for hypertension was 24.5% (95% confidence interval (CI) 22.6% to 26.6%). Among individuals with hypertension, only 15.6% (95% CI 12.4% to 18.9%) were aware of their elevated blood pressure. Among those aware only 26.9%; (95% CI 17.1% to 36.4%) were on treatment and 51.7%; (95% CI 33.5% to 69.9%) among those on treatment had achieved blood pressure control. Factors associated with hypertension were older age (p < 0.001), higher body mass index (BMI) (p < 0.001) and harmful use of alcohol (p < 0.001). Similarly, factors associated with awareness were older age (p = 0.013) and being male (p < 0.001).

CONCLUSION

This study provides the first nationally-representative estimates for hypertension in Kenya. Prevalence among adults is high, with unacceptably low levels of awareness, treatment and control. The results also reveal that men are less aware of their hypertension status hence special attention should focus on this group.

Accuracy of blood pressure monitoring devices: a critical need for improvement that could resolve discrepancy in hypertension guidelines

Hypertension is the most significant modifiable risk factor for cardiovascular disease and contributes to the highest global burden of disease. Blood pressure (BP) measurement is among the most important of all medical tests, and it is critical for BP monitoring devices to be accurate. Comprehensive new evidence from meta-analyses clearly shows that many BP monitoring devices (including oscillometric machines and "gold standard" mercury auscultation) do not accurately represent the BP within the arteries at the upper arm (brachial) or central aorta. Particular variability in the accuracy of BP devices compared with intra-arterial BP has been demonstrated in the cuff BP range from prehypertension to grade I hypertension (systolic BP 120-159 to diastolic BP 80-99 mmHg). This is within the BP range that is most common among people worldwide and, thus almost certainly, feeding confusion around optimal hypertension guideline thresholds. At the individual level, inaccurate BP devices have major potential consequences for best practice patient management, where underestimation of true BP is a missed opportunity to lower cardiovascular risk (with therapeutics or lifestyle) and overestimation of true BP could lead to overmedication. Each problem leads to increased cost from preventable cardiovascular events and unnecessary medications. Altogether, there is a critical need to improve the accuracy standards of BP monitoring devices. In the meantime, out-of-office BP (24 h of ambulatory BP and/or home BP monitoring) or automated, unobserved in-office BP monitoring that takes the average of multiple readings using validated devices are the best available options to determine BP control.

Hypertension and physical activity in middle-aged and older adults in China

There are few studies examining the association between levels of physical activity and hypertension in middle-aged and older adults in China. Data were drawn from the Chinese Health and Retirement Longitudinal Study (using four-stage stratified probability-proportional-to-size sampling), involving 7113 individuals aged 45 years and older from 28 provinces of China. Hypertension was defined as a systolic BP ≥ 130 mm Hg, or diastolic BP ≥ 80 mm Hg, or self-reported use of anti-hypertensive medications. The awareness, treatment, and control among hypertensive participants were 53.12%, 43.37%, and 10.03%, respectively. The prevalence of hypertension was 56.12% among all the participants, higher in main city zones (58.68%) than villages (55.52%) and other areas (55.78%, p < 0.0001). Participants who were overweight (BMI ≥ 24: AOR 4.08, 95% CI 3.21-5.20, P < 0.0001; BMI ≥ 28: 10.03, 7.56-13.31, P < 0.0001), and drinking more than once a month (1.28, 1.12-1.46, P < 0.0001) were more likely to have hypertension. The decision tree model was established to analyze the importance of different levels of physical activity on hypertension prevention. Participants who usually participated in moderate-to-vigorous activity for more than 10 minutes (vigorous: 0.82, 0.73-0.91, P = 0.0004; moderate: 0.83, 0.75-0.92, P = 0.0006) were less likely to have hypertension. The results of the decision tree showed that the vigorous physical activity seemed to be more important than moderate and light activity to induce beneficial effects on prevention of hypertension. The strength of our study is in using the decision tree to clearly rank the importance of those key factors affecting hypertension.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Objective

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

Methods

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

Results

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

A comparison of metrics and performance characteristics of different search strategies for article retrieval for a systematic review of the global epidemiology of kidney and urinary diseases

BACKGROUND

Conducting a systematic review requires a comprehensive bibliographic search. Comparing different search strategies is essential for choosing those that cover all useful data sources. Our aim was to develop search strategies for article retrieval for a systematic review of the global epidemiology of kidney and urinary diseases, and evaluate their metrics and performance characteristics that could be useful for other systematic epidemiologic reviews.

METHODS

We described the methodological framework and analysed approaches applied in the previously conducted systematic review intended to obtain published data for global estimates of the kidney and urinary disease burden. We used several search strategies in PubMed and EMBASE, and compared several metrics: number needed to retrieve (NNR), number of extracted data rows, number of covered countries, and when appropriate, sensitivity, specificity, precision, and accuracy.

RESULTS

The initial search obtained 29,460 records from PubMed, and 4247 from EMBASE. After the revision, the full text of 381 and 14 articles respectively was obtained for data extraction (the percentage of useful records is 1.3% for PubMed, 0.3% for EMBASE). For PubMed we developed two search strategies and compared them with a 'gold standard' formed by merging their results: free word search strategy (FreeWoSS) was based on the search for keywords in all fields, and subject headings based search strategy (SuHeSS) used only MeSH-mapped conditions and countries names. SuHeSS excluded almost 15% of useful articles and data rows extracted from them, but had a lower NNR of 40 and higher specificity. FreeWoSS had better sensitivity and was able to cover the vast majority of articles and extracted data rows, but had a higher NNR of 65.

CONCLUSIONS

The sensitive FreeWoSS strategy provides more data for modelling, while the more specific SuHeSS strategy could be used when resources are limited. EMBASE has limited value for our systematic review.

Prevalence and Risk Factors of Hypertension in Two Communes in the Vietnam Northern Mountainous, 2017

Background

The aims were to characterize the prevalence of hypertension (HTN) and explore its associations in the northern mountainous.

Methods

We carried out a cross-sectional study in two communes in Chiem Hoa district, Tuyen Quang province, between June and November 2017. All subjects at the age of 18 years and over currently living in two communes. The usage of the descriptive statistics was to characterize the HTN prevalence. We used the univariate and multivariate models of logistic regression to determine the prevalence and related factors of HTN.

Results

There were 319 people with overall HTN in the total of 675 participants. Among people with HTN, there were 101 ones with isolated systolic hypertension (ISH). The proportion of HTN among the Tay ethnic group was 47.6%. The factors related to HTN included group, body mass index (BMI), low physical fitness, and waist-hip ratio (WHR). These factors as well as the ethnicity were significantly associated with ISH.

Conclusions

Two communes of Chiem Hoa district in Tuyen Quang province had a high prevalence of HTN. Age, BMI, WHR, and physical activity were the risk factors of overall HTN and ISH. In particular, ISH was affected by ethnicity.

Longitudinal Analysis of Long-Term Air Pollution Levels and Blood Pressure: A Cautionary Tale from the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Air pollution exposures are hypothesized to impact blood pressure, yet few longitudinal studies exist, their findings are inconsistent, and different adjustments have been made for potentially distinct confounding by calendar time and age.

OBJECTIVE

We aimed to investigate the associations of long- and short-term [Formula: see text] and [Formula: see text] concentrations with systolic and diastolic blood pressures and incident hypertension while also accounting for potential confounding by age and time.

METHODS

Between 2000 and 2012, Multi-Ethnic Study of Atherosclerosis participants were measured for systolic and diastolic blood pressure at five exams. We estimated annual average and daily [Formula: see text] and [Formula: see text] concentrations for 6,569 participants using spatiotemporal models and measurements, respectively. Associations of exposures with blood pressure corrected for medication were studied using mixed-effects models. Incident hypertension was examined with Cox regression. We adjusted all models for sex, race/ethnicity, socioeconomic status, smoking, physical activity, diet, season, and site. We compared associations from models adjusting for time-varying age with those that adjusted for both time-varying age and calendar time.

RESULTS

We observed decreases in pollution and blood pressures (adjusted for age and medication) over time. Strong, positive associations of long- and short-term exposures with blood pressure were found only in models with adjustment for time-varying age but not adjustment for both time-varying age and calendar time. For example, [Formula: see text] higher annual average [Formula: see text] concentrations were associated with 2.7 (95% CI: 1.5, 4.0) and [Formula: see text] (95% CI: [Formula: see text] 1.0) mmHg in systolic blood pressure with and without additional adjustment for time, respectively. Associations with incident hypertension were similarly weakened by additional adjustment for time. Sensitivity analyses indicated that air pollution did not likely cause the temporal trends in blood pressure.

CONCLUSIONS

In contrast to experimental evidence, we found no associations between long- or short-term exposures to air pollution and blood pressure after accounting for both time-varying age and calendar time. This research suggests that careful consideration of both age and time is needed in longitudinal studies with trending exposures. https://doi.org/10.1289/EHP2966.

Pooling data from different populations: should there be regional differences in cerebral haemodynamics?

BACKGROUND

Though genetic and environmental determinants of systemic haemodynamic have been reported, surprisingly little is known about their influences on cerebral haemodynamics. We assessed the potential geographical effect on cerebral haemodynamics by comparing the individual differences in cerebral blood flow velocity (CBFv), vasomotor tone (critical closing pressure- CrCP), vascular bed resistance (resistance-area product- RAP) and cerebral autoregulation (CA) mechanism on healthy subjects and acute ischaemic stroke (AIS) patients from two countries.

METHODS

Participants were pooled from databases in Leicester, United Kingdom (LEI) and São Paulo, Brazil (SP) research centres. Stroke patients admitted within 48 h of ischaemic stroke onset, as well as age- and sex-matched controls were enrolled. Beat-to-beat blood pressure (BP) and bilateral mean CBFv were recorded during 5 min baseline. CrCP and RAP were calculated. CA was quantified using transfer function analysis (TFA) of spontaneous oscillations in arterial BP and mean CBFv, and the derived autoregulatory index (ARI).

RESULTS

A total of 100 participants (50 LEI and 50 SP) were recruited. No geographical differences were found. Both LEI and SP AIS participants showed lower values of CA compared to controls. Moreover, the affected hemisphere presented lower resting CBFv and higher RAP compared to the unaffected hemisphere in both populations.

CONCLUSIONS

Impairments of cerebral haemodynamics, demonstrated by several key parameters, was observed following AIS compared to controls irrespective of geographical region. These initial results should encourage further research on cerebral haemodynamic research with larger cohorts combining different populations.

Effect of intensive blood pressure lowering on cardiovascular outcomes based on cardiovascular risk: A secondary analysis of the SPRINT trial

BACKGROUND

It is not clear whether risk stratification can help choose the most favourable systolic blood pressure target for primary prevention of cardiovascular events.

DESIGN

A secondary analysis of Systolic Blood Pressure Intervention Trial (SPRINT).

METHODS

To perform a secondary analysis, we obtained the data from SPRINT from the National Heart, Lung, and Blood Institute data repository centre. In SPRINT, an open-label trial, participants without diabetes with systolic blood pressure of ≥130 mmHg were randomly assigned to intensive and standard treatment groups with systolic blood pressure targets of <120 and <140 mmHg, respectively. The primary composite outcome was myocardial infarction and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Here, we have analysed data from participants without cardiovascular disease and chronic kidney disease aged under 75 years categorised based on the baseline 10-year Framingham risk score (<10% (low risk); ≥10% and <15% (intermediate risk); ≥15% (high risk)).

RESULTS

A total of 4298 patients were included in the analysis. With intensive treatment, there was a significant reduction in the primary outcome events in patients at high risk (0.86% per year vs. 1.81% per year; hazard ratio (HR) 0.51; 95% confidence interval (CI) 0.31 to 0.85; P = 0.010), and at intermediate risk (0.60% per year vs. 1.46% per year; HR 0.37; 95% CI 0.17 to 0.82; P = 0.014) but not for those at low risk (0.75% per year vs. 0.57% per year; HR 1.14; 95% CI 0.55 to 2.38; P = 0.714).

CONCLUSIONS

Intensive systolic blood pressure reduction is beneficial for primary prevention of cardiovascular morbidity and mortality in patients without diabetes with more than low cardiac risk (above 10%).

Global Burden of Atherosclerotic Cardiovascular Disease in People Living With HIV: Systematic Review and Meta-Analysis

BACKGROUND

With advances in antiretroviral therapy, most deaths in people with HIV are now attributable to noncommunicable illnesses, especially cardiovascular disease. We determine the association between HIV and cardiovascular disease, and estimate the national, regional, and global burden of cardiovascular disease attributable to HIV.

METHODS

We conducted a systematic review across 5 databases from inception to August 2016 for longitudinal studies of cardiovascular disease in HIV infection. A random-effects meta-analysis across 80 studies was used to derive the pooled rate and risk of cardiovascular disease in people living with HIV. We then estimated the temporal changes in the population-attributable fraction and disability-adjusted life-years (DALYs) from HIV-associated cardiovascular disease from 1990 to 2015 at a regional and global level. National cardiovascular DALYs associated with HIV for 2015 were derived for 154 of the 193 United Nations member states. The main outcome measure was the pooled estimate of the rate and risk of cardiovascular disease in people living with HIV and the national, regional, and global estimates of DALYs from cardiovascular disease associated with HIV.

RESULTS

In 793 635 people living with HIV and a total follow-up of 3.5 million person-years, the crude rate of cardiovascular disease was 61.8 (95% CI, 45.8-83.4) per 10 000 person-years. In comparison with individuals without HIV, the risk ratio for cardiovascular disease was 2.16 (95% CI, 1.68-2.77). Over the past 26 years, the global population-attributable fraction from cardiovascular disease attributable to HIV increased from 0.36% (95% CI, 0.21%-0.56%) to 0.92% (95% CI, 0.55%-1.41%), and DALYs increased from 0.74 (95% CI, 0.44-1.16) to 2.57 (95% CI, 1.53-3.92) million. There was marked regional variation with most DALYs lost in sub-Saharan Africa (0.87 million, 95% CI, 0.43-1.70) and the Asia Pacific (0.39 million, 95% CI, 0.23-0.62) regions. The highest population-attributable fraction and burden were observed in Swaziland, Botswana, and Lesotho.

CONCLUSIONS

People living with HIV are twice as likely to develop cardiovascular disease. The global burden of HIV-associated cardiovascular disease has tripled over the past 2 decades and is now responsible for 2.6 million DALYs per annum with the greatest impact in sub-Saharan Africa and the Asia Pacific regions.

CLINICAL TRIAL REGISTRATION

URL: https://www.crd.york.ac.uk/prospero . Unique identifier: CRD42016048257.

Exploring the relationship of peripheral total bilirubin, red blood cell, and hemoglobin with blood pressure during childhood and adolescence

OBJECTIVE

Total bilirubin is beneficial for protecting cardiovascular diseases in adults. The authors aimed to investigate the association of total bilirubin, red blood cell, and hemoglobin levels with the prevalence of high blood pressure in children and adolescents.

METHODS

A total of 3776 students (aged from 6 to 16 years old) were examined using cluster sampling. Pre-high blood pressure and high blood pressure were respectively defined as the point of 90th and 95th percentiles based on the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Both systolic and diastolic blood pressure were standardized into z-scores.

RESULTS

Peripheral total bilirubin, red blood cell and hemoglobin levels were significantly correlated with age, and also varied with gender. Peripheral total bilirubin was negatively correlated with systolic blood pressure in 6- and 9-year-old boys, whilst positively correlated with diastolic blood pressure in the 12-year-old boys and 13- to 15-year-old girls (p<0.05). Higher levels of red blood cell and hemoglobin were observed in pre-high blood pressure and high blood pressure students when compared with their normotensive peers (p<0.01). The increases in red blood cell and hemoglobin were significantly associated with high blood pressure after adjusting for confounding factors. The ORs (95% CI) of each of the increases were 2.44 (1.52-3.92) and 1.04 (1.03-1.06), respectively. No statistical association between total bilirubin and high blood pressure was observed (p>0.05).

CONCLUSION

Total bilirubin could be weakly correlated with both systolic and diastolic blood pressure, as correlations varied with age and gender in children and adolescents; in turn, the increased levels of red blood cell and hemoglobin are proposed to be positively associated with the prevalence of high blood pressure.

Cardiovascular disease in diabetes type 2: current concepts

Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.

Switching from a high-fat cellulose diet to a high-fat pectin diet reverses certain obesity-related morbidities

Background

Reducing caloric intake is a proven intervention for mitigating and modulating morbidities associated with overnutrition. Caloric restriction is difficult to affect clinically, therefore, dietary interventions that ameliorate the adverse consequences of overnutrition in the presence of a high-calorie diet would be of value.

Methods

Mice were fed an obesogenic diet containing 60% fat + 10% cellulose (HFC), or a control diet containing 10% fat + 10% cellulose (LFC) for 12 wks. Subgroups of mice were then switched from HFC to each of the following diets for an additional 5 wks: 1) 60% fat + 10% pectin (HFP), 2) LFC or 3) 10% fat + 10% pectin (LFP). To test for statistical differences, one-way or two-way ANOVAs were used with or without repeated measurements as needed.

Results

In comparison to HFC, HFP prevented additional weight gain while LFC and LFP triggered weight loss of 22.2 and 25.4%, respectively. Mice continued on HFC experienced a weight increase of 26% during the same 5 wk. interval. After 12 wks, HFC decreased mouse locomotion by 18% when compared to control diet, but a diet switch to LFC or LFP restored mouse movement. Importantly, HFP, LFC, and LFP reduced fasting blood glucose when compared to HFC. Likewise, HFP, LFC and LFP improved glucose tolerance and decreased fatty liver by 37.9, 49.8, 53.6 and 20.2%, 37.2, 43.7%, respectively.

Conclusions

Taken together, the results indicate that the dietary fiber pectin can mitigate some adverse consequences of overnutrition even in the presence of high-fat.

Educational inequalities in midlife risk factors for non-communicable diseases in two Norwegian counties 1974-2002

Background: The absolute educational differences in the mortality of Norwegian women and men increased during 1960-2000 and thereafter levelled off in men, but continued to widen in women. Which of the risk factors for non-communicable diseases (NCDs) might explain these trends? Aim: The aim of this study was to investigate trends in gender-specific, absolute educational differences in established risk factors during 1974-2002. Methods: We used cross-sectional data from 40-45-year-old women and men who participated in one of three health surveys in two counties, from the years 1974-1978, 1985-1988 and 2001-2002. To account for increasing educational attainment through the period we used a regression-based index of inequality (Slope Index of Inequality) to assess the educational gradients over time. Results: From 1974 to 2002, the mean levels of serum total cholesterol and blood pressure decreased and body mass index (BMI) increased in all subgroups by education in both sexes. In men, the educational gradient tended to diminish toward the null for serum total cholesterol and narrowed for systolic blood pressure, but increased for BMI. In women, the educational gradient increased to the double for smoking and increased for triglycerides. Conclusions: In two Norwegian counties, the NCD risk factors showed dynamic patterns during 1974-2002. For blood pressure and serum total cholesterol, the levels showed consistent beneficial changes in all educational subgroups, with a narrowing tendency for educational gradients in men. In women, the educational gradient for smoking increased markedly. Knowledge on midlife trends in the educational gradients of risk factors may help to explain recent and future NCD mortality.

Association between population mean and distribution of deviance in demographic surveys from 65 countries: cross sectional study

OBJECTIVES

To examine whether conditions related to scarcity at the left side of the distribution (anaemia, severe chronic energy deficiency, and underweight) are as strongly related to population means as conditions of excess at the right side of the distribution (overweight and obesity).

DESIGN

Observational study.

SETTING

65 countries, with nationally representative cross sectional data from 1994 to 2014 obtained from the Demographic Health Surveys.

PARTICIPANTS

Non-pregnant women aged 20-49. Sample of 65 countries and n=524 380 for analysis of BMI; sample of 44 countries and n=316 465 for analysis of haemoglobin.

MAIN OUTCOME MEASURES

The association between mean and prevalence of each category. For BMI, prevalence of severe chronic energy deficiency (SCED, BMI <16.0), underweight (BMI <18.5), overweight (BMI >25) and obese (BMI >30.) were measured; for haemoglobin, prevalence of anaemia (haemoglobin <12.0 g/dL) and severe anaemia (haemoglobin <8.0 g/dL) were examined.

RESULTS

There was a strong association between mean BMI and prevalence of overweight (r²=0.98; r=0.99; β=8.3 (8.0 to 8.6)) and obesity (r²=0.93; r=0.97; β=4.2 (3.9 to 4.5)). For left sided conditions, a moderate to strong association was found between mean BMI and prevalence of underweight (r²=0.67; r=-0.82; β=-2.7 (-3.1 to -2.2)), and a weaker association for SCED (r²=0.38; r=-0.61; β=-0.32 (-0.43 to -0.22)). There was a moderate association between mean haemoglobin and prevalence of anaemia (r²=0.46; r=-0.68; β=-10.8 (-14.5 to -7.1)) and a weaker association with severe anaemia (r²=0.30; r=-0.55; β=-0.55 (-0.81 to -0.29)).

CONCLUSIONS

The associations between population means and prevalence of conditions of scarcity such as low BMI and anaemia were substantially weaker than the associations of mean BMI with conditions of excesses such as overweight and obesity.

Prevalence, awareness, treatment and control of hypertension in the adult Polish population - Multi-center National Population Health Examination Surveys - WOBASZ studies

INTRODUCTION

Hypertension is one of the main risk factors of cardiovascular diseases. The first aim of the study was to evaluate the prevalence, awareness and treatment of hypertension as well as treatment effectiveness (blood pressure < 140/90 mm Hg) in a representative sample of the Polish population over the age of 19, examined in the WOBASZ II program. The second aim was to assess the changes in these parameters between 2003-2005 (WOBASZ study) and 2013-2014 in adults aged 20-74.

MATERIAL AND METHODS

Sampling was performed in three stages, stratified according to voivodeship (province), type of commune, and gender. Finally, the study included 6163 persons (3406 women and 2757 men) examined in the years 2013-2014 (aged ≥ 19 years). For comparison the data from 14 755 persons (7783 women and 6452 men aged 20-74 years) examined in the years 2003-2005 were used.

RESULTS

In the years 2013-2014, the age-standardized prevalence of hypertension, awareness, treatment and control was 42.7%, 59.3%, 46.1%, and 23% respectively. In the last decade an increase in the prevalence of hypertension (relative ratio (RR) 1.12; 95% confidence interval (CI): 1.07-1.18), treatment (RR = 1.26; 95% CI: 1.17-1.36) and control (RR = 2.16; 95% CI: 1.9-12.45) was found. In contrast, the awareness decreased nonsignificantly (RR = 0.98; 95% CI: 0.92-1.05).

CONCLUSIONS

The prevalence of hypertension in Poland is high, and increased by about 12% in 10 years. Although the number of treated patients and blood pressure control improved nearly twofold over the last decade, this is still below expectations. Efforts to improve the diagnosis and effective treatment of hypertension in Poland should still be intensified.

Misclassification of blood pressure of Vietnamese adults when only a single measurement is used

A single clinic measurement of blood pressure (BP) may be common in low- and middle-income countries because of limited medical resources. This study aimed to examine the potential misclassification error when only one BP measurement is used. Participants (n = 14,706, 53.5% females) aged 25-64 years were selected by multistage stratified cluster sampling from eight provinces, each representing one of the eight geographical regions of Vietnam. Measurements were made using the World Health Organization STEPS protocols. Data were analyzed using complex survey methods. For systolic BP, 62.7% had a higher first reading whereas 30.0% had a lower first reading, and 27.3% had a reduction of at least 5 mmHg whereas 9.6% had an increase of at least 5 mmHg. Irrespective of direction of change, increased variability in BP was associated with greater age, urban living, greater body size and fatness, reduced physical activity levels, elevated glucose, and raised total cholesterol. These measurement variations would lead to substantial misclassification in diagnosis of hypertension based on a single reading because almost 20% of subjects would receive a different diagnosis based on the mean of two readings.

Subtle changes in diabetic retinas localised in 3D using OCT

PURPOSE

To detect and localise subtle changes in retinas of diabetic patients who clinically have no diabetic retinopathy (DR) or non-proliferative DR (NPDR) as compared to age- and sex- matched controls. Spectral Domain Optical Coherence Tomography (SD-OCT) and software to examine all retinal layers, including deeper layers, were used to quantify foveal avascular zone size and inner and outer retinal layer thicknesses, as well as to detect axial location of prominent lesions.

METHODS

Diabetic subjects, 19 total with 16 having no DR and three having non-proliferative retinopathy, were matched with 19 controls with respect to age and sex. Macular-centred SD-OCT grids of 20 × 15° were taken with the Spectralis. En face or transverse images were generated from the SD-OCT data by automatically segmenting all retinal layers. The transverse images were investigated for foveal avascular zone (FAZ) size, retinal vessel calibre, and structural changes. The size of the FAZ was compared for diabetics vs controls using vendor software and manual marking in Photoshop. Inner retinal layer (IRL_FAZ ) and outer nuclear layer (ONL_FAZ ) thicknesses at the margins of the FAZ were measured using vendor software.

RESULTS

The FAZ area was larger for diabetics (mean ± S.D. = 0.388 ± 0.074 mm² ) than controls (0.243 ± 0.113 mm² ), t₁₈ = 5.27, p < 0.0001, using vendor software. The mean IRL_FAZ was thicker for the diabetics (86.8 ± 14.5 μm) than controls (65.2 ± 16.3 μm), t₁₈ = 4.59, p = 0.00023, despite lack of exudation by clinical exam. There was no significant association between FAZ area and mean IRL_FAZ for the diabetics, r = 0.099, p = 0.69. Vessels not clinically detected were visible in the NFL transverse image of most diabetics, especially for a mild NPDR patient. A prominent lesion found in the en face infra-red image of a mild NPDR subject was localised in the photoreceptor layer by SD-OCT, as well as additional outer retinal changes in other subjects.

CONCLUSIONS

Our results demonstrate changes in inner and outer diabetic retinas not readily detectable by clinical exam. IRL_FAZ had not thinned at the margins of the large FAZs, indicating neural mass did not yet decrease despite potential ischemia.

Trends in age- and sex-specific prevalence and incidence of cardiovascular disease in Western Australia

Background Temporal trends in incidence and mortality of cardiovascular disease (CVD) have been well described, with recent data suggesting declining improvements in those aged under 55 years. However, little is known about the combined impact of incidence and mortality trends on disease prevalence, an important indicator of disease burden and cost. We analysed changes in age-specific and age-standardised temporal trends in prevalence and incidence of CVD subtypes. Methods Annual prevalence and incidence rates of coronary heart disease, cerebrovascular disease and peripheral arterial disease for the Western Australian population for 1995-2010 were calculated using data from the Western Australian Data Linkage System. Joinpoint regression analyses were used to identify joinpoints in trends in age-specific and age-standardised annual prevalence and incidence rates for each CVD subtype. Results Between 1995 and 2010, age- and sex-specific incidence and prevalence of the CVD subtypes generally decreased among middle-aged and older adults, but were stable or increased among younger adults. In < 55 year olds, increases in incidence tended to occur from 2003, while increases in prevalence were from 2007/2008. Declines in age-standardised incidence were greater than those in crude incidence, with changes in population structure having a greater impact among men than women. Conclusions The majority of CVDs occurs in older adults. Our findings of generally worsening trends in prevalence in younger adults across most CVD subtypes were in contrast to generally declining trends in older age groups. These data highlight the importance of monitoring prevalence and incidence, particularly in younger adults.

Management of hypertension in older people

INTRODUCTION

As the population ages, the prevalence of hypertension is increasing. Treatment of hypertension is associated with a reduction in cardiovascular risk. However, the optimal blood pressure targets in older people are not clearly defined due to paucity of randomised clinical trials specific to this age group.

AREAS COVERED

We performed a Medline and Embase search from 1998 to present for articles on the management of hypertension in older people published in English language.

EXPERT COMMENTARY

The recent guidelines have suggested a lower blood pressure target of less than 130/80 mmHg. Due to the heterogeneity of older people, this universal low target may not be applicable to all of them. Targets based on functional level rather than chronological age are more appropriate. Special considerations in older people such as increased prevalence of frailty, falls, dementia, polypharmacy and the predominance of isolated systolic hypertension should also be taken into account. Tighter control, if well tolerated, is suitable for the fit person but relaxed targets are more reasonable in individuals with physical or cognitive decline. Therefore, in older people, targets should be individualised putting quality, rather than quantity, of life at the heart of their care plans.