Pulse pressure predicts mortality in elderly patients

Black Older Adults in the Age of Biomarkers, Physical Functioning, and Genomics: Heterogeneity, Community Engagement, and Bioethics

There are persistent disparities in all-cause mortality between Blacks and Whites in the United States. Black Americans also carry the greatest burden of morbidity from different diseases of aging including heart disease, stroke, hypertension, type 2 diabetes, and certain types of cancer. Health disparities research, and particularly race/ethnic comparison studies of physical health and aging, have consistently positioned Black health in frameworks of disadvantage, suggesting that regardless of the outcome, Black people are in worse states of health and well-being relative to Whites. Yet, extensive evidence suggests that there is significant within-group variability in the aging process among Black older adults. The use of biological, physical performance, and genomic data in survey settings offer new tools and insights to interrogate heterogeneity in Black health. This chapter examines indicators of biological, physical performance, and genetic markers of aging among a national sample of Black Americans ages 54+ years with the aim of addressing two questions about heterogeneity among Black older adults: (a) How do these measures vary by age and gender among Black older adults? (b) Which indicators predict health and mortality among Black older adults? The results indicate that biological, physical performance, and genomic measures of health, generally, have more variation than simple yes or no measures of a disease, condition, or diagnosis among Black older adults, providing counternarratives to the disadvantage frameworks that dominate characterizations of Black health and aging. However, bioethical challenges limit the utility of biomarkers, physical performance, and genomics measures for Black populations.

Association of obesity and pulse pressure with hypertension in an Iranian urban population

Objective:

Nowadays, obesity is an important health problem and pulse pressure (PP) is a good predictor of cardiovascular events. The aim of study was to determine the association of obesity and PP with hypertension (HTN) in individuals aged 30 years or older in the urban population of Jahrom, Iran.

Materials and Methods:

In this study, we used a multistage stratified sampling method to select participants among the urban population aged 30 years or older. Height, weight, and blood pressure were obtained by a trained physician. Obesity was defined according to the World Health Organization classification. Angina was assessed with reliable and validate Rose questionnaire. Data were record by SPSS-16. Categorical and continues variables analyzed by Chi-squared, independent t-test, and one-way ANOVA test. Binary logistic regression analysis method was used for the association of PP and obesity with HTN and Rose angina that adjusted for age, gender, education class, marital status, smoking, total cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein. A P < 0.05 was considered as statistical significance.

Results:

The prevalence of obesity was 18.1% that was greater in women (24.8% vs. 9.9%, P < 0.001). The prevalence of Rose angina and HTN in obese individuals were more than in normal weight individuals (24.8% vs. 16.4%, P = 0.027) and (42.0% vs. 31.1%, P < 0.001), respectively. Furthermore, patients in higher PP groups were older, were more possible to had HTN and had greater diastolic blood pressure (DBP), systolic blood pressure (SBP), and mean arterial pressure (MAP) in compared to individuals in the lower PP group. The individuals with HTN had greater DBP, SBP, MAP, PP, and body mass index (BMI) than individuals without HTN. However, individuals who had Rose angina, only had higher PP and BMI in compared to ones without Rose angina. The obese individuals had 1.97 (1.22–3.17, P = 0.005) fold for HTN risk than individuals with normal weight. In addition, PP weakly increased the risk of HTN about 1.09 fold (1.07–1.10, P < 0.001). However, Rose angina was associated only to overweight status (odds ratio = 1.51, confidence interval 95%: 1.03–2.20), P = 0.035) than individuals in normal weight group.

Conclusion:

Obesity and PP were higher in hypertensive individuals and overweight in individuals with Rose angina. It is time to pay more attention to abnormal BMI.

Influence of Multiple Cardiovascular Risk Factors on Task-Switching in Older Adults: An fMRI Study

Not only are the effects of cardiovascular risk factors such as high blood pressure and low fitness on executive functions and brain activations in older adults scarcely investigated, no fMRI study has investigated the combined effects of multiple risk factors on brain activations in older adults. This fMRI study examined the independent and combined effects of two cardiovascular risk factors, arterial plasticity, and physical fitness, on brain activations during task-switching in older adults. The effects of these two risk factors on age-related differences in activation between older and younger adults were also examined. Independently, low physical fitness and low arterial plasticity were related to reduced suppressions of occipital brain regions. The combined effects of these two risks on occipital regions were greater than the independent effects of either risk factor. Age-related overactivations in frontal cortex were observed in low fitness older adults. Brain-behavior correlation indicates that these frontal overactivations are maladaptive to older adults' task performance. It is possible that the resulting effects of cardiovascular risks on the aging brain, especially the maladaptive overactivations of frontal brain regions by high risk older adults, contribute to often found posterior-anterior shift in aging (PASA) brain activations. Furthermore, observed age-related differences in brain activations during task-switching can be partially attributed to individual differences in cardiovascular risks among older adults.

Impact on Longevity of Genetic Cardiovascular Risk and Lifestyle including Red Meat Consumption

Background

Cardiovascular risk (CVR) underlies aging process and longevity. Previous work points to genetic and environmental factors associated with this risk.

Objectives

The aim of this research is to look for any CVR gene-gene and gene-multifactorial/lifestyle interactions that may impact health and disease and underlie exceptional longevity.

Methods

A case-control study involving 521 both gender individuals, 253 centenarians (100.26 ± 1.98 years), and 268 controls (67.51 ± 3.25 years), low (LCR, n = 107) and high (HCR, n = 161) CVR. Hypertension, diabetes, obesity (BMI, kg·m⁻²), and impaired kidney function were defined according to standard criteria. CVR was calculated using Q risk®. DNA was genotyping (ACE-rs4646994, AGT-rs4762, AGR1-rs5182, GRK4-rs2960306, GRK4-rs1024323, NOS3-rs1799983, and SLC12A3-rs13306673) through iPlex-MassARRAY®, read by MALDI-TOF mass spectrometry, and analyzed by EARTDECODE®.

Results

Antilongevity factors consisted (OR 95% CI, p < 0.05) BMI 1.558 (1.445-1.680), hypertension 2.358 (1.565-3.553), smoking habits 4.528 (2.579-7.949), diabetes 5.553 (2.889-10.675), hypercholesterolemia 1.016 (1.010-1.022), and regular consumption of red meat 22.363 (13.987-35.755). Genetic aspects particularly for HCR individuals ACE II (OR: 3.96 (1.83-8.56), p < 0.0001) and NOS3 TT (OR: 3.11 (1.70-5.70), p < 0.0001) genotypes were also risk associate. Obesity, smoking, hypercholesterolemia, and frequent consumption of red meat have an additive action to hypertension in the longevity process. There was a synergistic interaction between the endothelial NOS3 genotypes and the severity of arterial hypertension. An epistatic interaction between functional genetic variants of GRK4 and angiotensinogen was also observed.

Conclusions

Cardiovascular risk-related genetic and multifactorial or predominantly lifestyle aspects and its interactions might influence the aging process and contribute to exceptional longevity in Portuguese centenarians. Besides lifestyle, the activity of nitrite oxide synthase may be one of the main physiologic regulators of cardiovascular protection in the path of longevity.

Long-Term Peridialytic Blood Pressure Patterns in Patients Treated by Hemodialysis and Hemodiafiltration

Introduction

Online postdilution hemodiafiltration (HDF) is associated with a lower all-cause and cardiovascular mortality than hemodialysis (HD). This may depend on a superior peridialytic (pre- and postdialysis, and the difference between these 2 parameters) hemodynamic profile.

Methods

In this retrospective cohort analysis of individual participant data (IPD) from 3 randomized controlled trials (RCTs) (n = 2011), the effect of HDF and HD on 2-year peridialytic blood pressure (BP) patterns was assessed. Long-term peridialytic systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and pulse pressure (PP), as well as the deltas (post- minus predialytic) were assessed in the total group of patients. Thereafter, these variables were compared between patients on HD and HDF, and in the latter group between quartiles of convection volume.

Results

Mean pre- and postdialysis SBP, DBP, and MAP declined significantly during follow-up (predialytic: SBP −2.16 mm Hg, DBP −2.88 mm Hg, MAP −2.64 mm Hg), PP increased (predialytic 0.96 mm Hg). Peridialytic deltas remained unaltered. Differences between the 2 modalities, or between quartiles of convection volume were not observed. BP changes were independent of various baseline characteristics, including the decline in body weight over time.

Conclusion

We speculate that the combination of a decreasing SBP and an increasing PP may be the clinical sequelae of a worsening cardiovascular system. Because especially HDF with a high convection volume has been associated with a beneficial effect on survival, our study does not support the view that superior peridialytic BP control contributes to this effect.

The association of pulse pressure with metabolic syndrome in Korean elderly: A nationwide population-based study

AIMS

Metabolic syndrome (MetS) is one of the most important issues in elderly people because of its association with ensuing cardiovascular disease (CVD). The components of MetS play a key role in the pathogenesis of arterial thickness and stiffness. Pulse pressure (PP), an easily accessible parameter in a basic health evaluation, has been documented as a marker of arterial stiffness and widespread atherosclerosis. The aim of our study was to assess the association between PP and MetS in Korean elderly people.

METHODS

A nationwide cross-sectional study was conducted to examine the relationship between PP and MetS among 6187 participants (2687 men and 3500 women) aged 60years older Korean people using the Korean National Health and Nutrition Examination Survey. The odds ratios (ORs) and 95% confidence intervals (CIs) for MetS were calculated across PP quartiles using multiple logistic regression analyses.

RESULTS

There was a positive relationship between PP and MetS in a dose-response manner. The prevalence of MetS significantly increased with increasing PP quartile in both men and women (p<0.001). Compared with the lowest PP quartile group, the ORs (95% CIs) for MetS of the highest PP quartile was 2.60 (1.91-3.52) for men and 1.97 (1.48-2.59) for women after adjusting for age, cigarette smoking, alcohol intake, regular exercise and mean arterial blood pressure. These associations remained valid after additionally adjusting for hypertension and diabetes medications.

CONCLUSION

We found a positive relationship between PP and MetS among Korean elderly men and women.

Achieved Blood Pressure and Outcomes in the Secondary Prevention of Small Subcortical Strokes Trial

Studies suggest a J-shaped association between blood pressure and cardiovascular events in the setting of intensive systolic blood pressure control; whether there is a similar association with stroke remains less well established. The Secondary Prevention of Small Subcortical Strokes was a randomized trial to evaluate higher (130-149 mm Hg) versus lower (<130 mm Hg) systolic blood pressure targets in participants with recent lacunar infarcts. We evaluated the association of mean achieved blood pressure, 6 months after randomization, and recurrent stroke, major vascular events, and all-cause mortality. After a mean follow up of 3.7 years, there was a J-shaped association between achieved blood pressure and outcomes; the lowest risk was at ≈124 and 67 mm Hg systolic and diastolic blood pressure, respectively. For example, above a systolic blood pressure of 124 mm Hg, 1 standard deviation higher (11.1 mm Hg) was associated with increased mortality (adjusted hazard ratio: 1.9; 95% confidence interval: 1.4, 2.7), whereas below this level, this relationship was inverted (0.29; 0.10, 0.79), P<0.001 for interaction. Above a diastolic blood pressure of 67 mm Hg, a 1 standard deviation higher (8.2 mm Hg) was associated with an increased risk of stroke (2.2; 1.4, 3.6), whereas below this level, the association was in the opposite direction (0.34; 0.13, 0.89), P=0.02 for interaction. The lowest risk of all events occurred at a nadir of ≈120 to 128 mm Hg systolic blood pressure and 65 to 70 mm Hg diastolic blood pressure. Future studies should evaluate the impact of excessive blood pressure reduction, especially in older populations with preexisting vascular disease.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Association between pulse pressure and risk of hospital admissions for cardiovascular events among people with Type 2 diabetes: a population-based case-control study

AIM

To investigate the association between pulse pressure and risk of hospitalization for cardiovascular events among people with Type 2 diabetes.

METHODS

A population-based case-control study was carried out using data from medical databases. A total of 588 people with Type 2 diabetes from 18 general practices in Cambridgeshire recorded a first hospitalization for a cardiovascular event between 2009 and 2011, and a total of 2920 age-matched, gender-matched and practice-matched control subjects with Type 2 diabetes were selected based on risk-set sampling. Pulse pressure was assessed before admission in 2008-2009. Further dose-response relationships between pulse pressure and risks were explored using spline models.

RESULTS

There was a non-linear relationship between pulse pressure and the risk of hospitalization for a cardiovascular event (P < 0.001 for linearity test). The pulse pressure associated with the lowest risk of hospitalization for a cardiovascular event was 61 (95% CI 57-63) mmHg.

CONCLUSION

In people with Type 2 diabetes, pulse pressure is a good predictor of risk of hospitalization for cardiovascular events. The risk is lowest with a pulse pressure of 57-63 mmHg.

Changes in pulse pressure during hemodialysis treatment and survival in maintenance dialysis patients

BACKGROUND AND OBJECTIVES

Pulse pressure has been shown as a risk factor for mortality in patients on maintenance hemodialysis (MHD). However, the effect of change in pulse pressure during hemodialysis on survival in a large cohort of patients on MHD has not been sufficiently investigated.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study examined the association between time-varying Δ pulse pressure (postdialysis minus predialysis pulse pressure) and mortality in a cohort of 98,577 patients on MHD (July 2001-June 2006) using Cox proportional hazard models with restricted cubic splines.

RESULTS

The average patient age was 62 years old; among the patients, 33% were black and 59% had diabetes. During 134,814 patient-years of at-risk time, 16,054 (16%) patients died, with 6827 (43%) of the deaths caused by cardiovascular causes. In the models including adjustment for either predialysis systolic BP or mean arterial BP, there was a U-shaped association between change in pulse pressure during hemodialysis and all-cause mortality. In the systolic BP plus case mix plus malnutrition-inflammation complex syndrome-adjusted model, large declines in pulse pressure (>-25 mmHg) and increases in pulse pressure >5 mmHg were associated with higher all-cause mortality (reference: ≥-5 to <5 mmHg): hazard ratios (95% confidence intervals [95% CIs]) for change pulse pressures of <-25, ≥-25 to <-15, ≥-15 to <-5, 5 to <15, 15 to <25, and ≥25 mmHg were 1.21 (95% CI, 1.14 to 1.29), 1.03 (95% CI, 0.97 to 1.10), 1.01 (95% CI, 0.96 to 1.06), 1.06 (95% CI, 1.01 to 1.11), 1.17 (95% CI, 1.11 to 1.24), and 1.15 (95% CI, 1.08 to 1.23), respectively. The U-shaped association was observed with cardiovascular death.

CONCLUSIONS

Modest reductions in pulse pressure after hemodialysis are associated with the greatest survival, whereas large declines or rises in pulse pressure are related to higher mortality. Trials determining how to modify pulse pressure response to improve survival in the hemodialysis population are indicated.

Increased total mortality as a function of 24-h pulse pressure dipping

Elevated pulse pressure (PP) as a difference between systolic and diastolic blood pressure is a significant risk factor of cardiovascular (CV) diseases. The goal of our study was to determine the association between PP and major adverse CV events (MACEs), and all-cause and CV mortality in the different age groups of patients with coronary artery disease (CAD) confirmed by angiography. To the PROGNOSIS study, finally there were included 891 subjects with CAD. An analysis of the receiver operating characteristic was used for predicting PP dipping among the age groups of patients. A COX proportional hazards model was used to examine the association between PP and PP dipping and risk of MACE, revascularization, CV and total mortality after adjusting for sex, diabetes, smoking and low-density lipoprotein cholesterol. The median follow-up period was 8.3 years (interquartile range: 5.3-9.0 years). There were 245 (27%) all-cause deaths including 114 (13%) CV deaths during the follow-up period. MACE occurred in 442 (50%) subjects, but coronary artery interventions (percutaneous coronary intervention or coronary artery bypass grafting) were performed in 578 subjects (65%). A Cox proportional regression analysis confirmed the relationship between PP dipping as well as PP dipping thresholds points and risk of MACE and total mortality only in the group of the oldest subjects. In contrast to younger CAD patients, PP dipping is related to MACE, CV and total mortality in very elderly CAD subjects. Nocturnal PP values tend to be higher than diurnal PP values in the oldest CAD individuals. In conclusion, in contrast to younger CAD patients, PP dipping is related to MACE, CV and total mortality in very elderly CAD subjects. Nocturnal PP values tend to be higher than diurnal PP values in the oldest CAD individuals.

Relationship between sum of the four limbs' pulse pressure and brachial-ankle pulse wave velocity and atherosclerosis risk factors in Chinese adults

The aim of the present study was to analyze the relationship between the sum of the four limbs' pulse pressure (Sum-PP) and brachial-ankle pulse wave velocity (baPWV) and atherosclerosis risk factors and evaluate the feasibility of Sum-PP in diagnosing atherosclerosis systemically. For the purpose, a cross-sectional study was conducted on the basis of medical information of 20748 adults who had a health examination in our hospital. Both Sum-PP and baPWV exhibited significant variations among different human populations grouped by gender, smoking, drinking, and age. Interestingly, Sum-PP had similar varying tendency with baPWV in different populations. And further study in different populations showed that Sum-PP was significantly positively related to baPWV. We also investigated the relationship between Sum-PP, baPWV, and cardiovascular risk factors, respectively. We found that both Sum-PP and baPWV had significant positive correlation with atherosclerosis risk factors while both of them were negatively related to HDL-c. In addition, there was a significant close correlation between Sum-PP and baPWV in the whole population (r = 0.4616, P < 0.0001). Thus, Sum-PP is closely related to baPWV and is of important value for clinical diagnosis of atherosclerosis.

Reduced effect of percutaneous renal denervation on blood pressure in patients with isolated systolic hypertension

Renal denervation can reduce blood pressure in certain patients with resistant hypertension. The effect in patients with isolated systolic hypertension (ISH, ≥140/<90 mm Hg) is unknown. This study investigated the effects of renal denervation in 126 patients divided into 63 patients with ISH and 63 patients with combined hypertension (CH, ≥140/≥90 mm Hg) defined as baseline office systolic blood pressure (SBP) ≥140 mm Hg despite treatment with ≥3 antihypertensive agents. Renal denervation significantly reduced office SBP and diastolic blood pressure (DBP) at 3, 6, and 12 months by 17/18/17 and 5/4/4 mm Hg in ISH and by 28/27/30 and 13/16/18 mm Hg in CH, respectively. The reduction in SBP and DBP in ISH was lower compared with patients with CH at all observed time points (P<0.05 for SBP/DBP intergroup comparison). The nonresponder rate (change in office SBP <10 mm Hg) after 6 months was 37% in ISH and 21% in CH (P<0.001). Mean 24-hour ambulatory SBP and DBP after 3, 6, and 12 months were significantly reduced by 10/13/15 and 6/6/9 mm Hg in CH, respectively. In patients with ISH the reduction in systolic ambulatory blood pressure was 4/8/7 mm Hg (P=0.032/P<0.001/P=0.009) and 3/4/2 mm Hg (P=0.08/P<0.001/P=0.130) in diastolic ambulatory blood pressure after 3, 6, and 12 months, respectively. The ambulatory blood pressure reduction was significantly lower after 3 and 12 months in SBP and after 12 months in ambulatory DBP, respectively. In conclusion, renal denervation reduces office and ambulatory blood pressure in patients with ISH. However, this reduction is less pronounced compared with patients with CH.

Prognostic power of lower pulse pressure on long-term all-cause mortality in octogenarians with acute coronary syndrome: a propensity-score-matched cohort study

OBJECTIVE

The impact of lower pulse pressure (PP) on long-term all-cause mortality in the octogenarian patients with acute coronary syndrome (ACS) remains unknown. This study sought to reveal the prognostic power of lower PP in long-term all-cause mortality in the octogenarian ACS patients.

METHODS

The current study included a total of 353 consecutive ACS patients aged at least 80 years during the period of 5-year follow-up. Association between PP and long-term mortality was confirmed by sensitivity analyses such as propensity score matching and multivariate Cox analyses. The matched cohort was developed by one-to-one, nearest-neighbor propensity score matching analyses.

RESULTS

Among patients with ACS, 113 (32.1%) admissions were alive, 240 (67.9%) were dead. There was a U-shaped association of mortality rate with PP, and the mortality rate increased in patients with PP equal to or less than 50  mmHg and greater than 70  mmHg. PP equal to or less than 50  mmHg was a predictor of the mortality rate in the overall cohort [hazard ratio: 1.92, 95% confidence interval (CI): 1.08-3.43, P = 0.027] and in the matched cohort (hazard ratio: 2.67, 95% CI: 1.16-6.14, P = 0.020). Moreover, PP equal to or less than 50  mmHg was independently related to mortality rate in the subgroup with hypertension in the overall cohort (hazard ratio: 2.04, 95% CI: 1.04-4.00, P = 0.039) and in the matched cohort (hazard ratio: 2.63, 95% CI: 1.01-6.83, P = 0.048).

CONCLUSION

This study reveals a U-shaped association of mortality rate with PP in the octogenarians with ACS and demonstrates that PP equal to or less than 50  mmHg has an independent prognostic power in long-term all-cause mortality in the octogenarians with ACS as well as the subgroup with hypertension.

Renal collecting duct NOS1 maintains fluid-electrolyte homeostasis and blood pressure

Nitric oxide is a pronatriuretic and prodiuretic factor. The highest renal NO synthase (NOS) activity is found in the inner medullary collecting duct. The collecting duct (CD) is the site of daily fine-tune regulation of sodium balance, and led us to hypothesize that a CD-specific deletion of NOS1 would result in an impaired ability to excrete a sodium load leading to a salt-sensitive blood pressure phenotype. We bred AQP2-CRE mice with NOS1 floxed mice to produce flox control and CD-specific NOS1 knockout (CDNOS1KO) littermates. CDs from CDNOS1KO mice produced 75% less nitrite, and urinary nitrite+nitrate (NOx) excretion was significantly blunted in the knockout genotype. When challenged with high dietary sodium, CDNOS1KO mice showed significantly reduced urine output, sodium, chloride, and NOx excretion, and increased mean arterial pressure relative to flox control mice. In humans, urinary NOx is a newly identified biomarker for the progression of hypertension. These findings reveal that NOS1 in the CD is critical in the regulation of fluid-electrolyte balance, and this new genetic model of CD NOS1 gene deletion will be a valuable tool to study salt-dependent blood pressure mechanisms.

Mean platelet volume in patients with dipper and non-dipper hypertension

Patients with non-dipper hypertension are known to carry a high risk of cardiovascular complications. In this study, we hypothesized that non-dippers may be associated with platelet dysfunction and it can be determined by mean platelet volume (MPV). A total of 216 outpatients treated with antihypertensive drugs for at least 6 months were enrolled. Dipper and non-dipper patterns were detected and clinical, laboratory and ambulatory blood pressure recording data were matched between non-dipping and dipping groups. MPV was significantly higher in patients in non-dipping than dipping groups (p<0.001). In correlation analyses, MPV was negatively correlated with the rate of systolic and diastolic fall at night (p<0.001, r=-0.46) and (p<0.001, r=-0.43), respectively. Also MPV was correlated with nocturnal pulse pressure (p=0.001, r=0.22). Other variables were similar between non-dipping and dipping groups. The present study showed that MPV is higher in non-dipping than dipping hypertensive patients. Platelet activation or dysfunction probably is an alternative mechanism for increasing cardiovascular events in non-dippers.