The j-point phenomenon in aggressive therapy of hypertension: new insights

Use of advanced statistical techniques to predict all-cause mortality in the Systolic Blood Pressure Intervention Trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) was conducted in patients with hypertension and additional risk for cardiovascular disease who were randomized to the intensive blood pressure group targeting systolic blood pressure (SBP) less than 120 mm Hg and to the standard group where the target was less than 140 mm Hg. Analyses were done in the matched group of participants with the same gender, same age (±2 years) and same SBP (±3 mm Hg) at three months of treatment regardless of initial randomization to intensive or standard group (shaded area in Figure 1).

Methods and results

During 3.26 years of follow-up, intensive group participants had 14.8 mm Hg lower SBP and received on average one more (2.8 vs. 1.8) blood pressure lowering medications. This was associated with lower all-cause mortality in the intensive treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90, p = 0.003). The effect on SBP was achieved at 3 months and remained unchanged thereafter. This paper addresses two questions with respect to all-cause mortality in SPRINT in the matched set. 1) What is the effect of receiving more than one drug on all-cause mortality. Conditional logistic regression for all-cause mortality with respect to number of drugs indicated that during the 3.26 years of follow-up persons who received more than one drug were more likely to die (coefficient = 0.5039, OR = 1.6552, p = 0.0322) than patients who received one drug. 2) Was there a U curve relationship between on treatment SBP and all-cause mortality? A U curve fitting a quadratic equation (parabola) of SBP and all-cause death was observed. This was seen in the patients randomized to the standard target group in unadjusted analyses as well as in analyses adjusted for demographics or all covariates (p < 0.001 for all). The U curves in the combined group and the intensive treatment group were less pronounced.

Conclusion

SPRINT participants who were matched for gender, age, and SBP at 3 months, and received more than one drug had higher all-cause mortality during the 3.26 years of follow-up. Those who were randomized to standard treatment target had a U curve relationship between SBP at three months and all-cause mortality. The U curves in the combined group and the intensive treatment group were less pronounced.

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study

BACKGROUND

There is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE.

METHODS

Multi-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3-6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4h/day) were compared with those with not adherent or those who had not been prescribed CPAP.

RESULTS

Valid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96-2.7; p=0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07-15.1; p=0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2-11.6; p=0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05-1.02; p=0.053).

CONCLUSIONS

In patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events.

Systolic blood pressure target in systemic arterial hypertension: Is lower ever better? Results from a community-based Caucasian cohort

BACKGROUND

Extensive evidence exists about the prognostic role of systolic blood pressure (SBP) reduction ≤140mmHg. Recently, the SPRINT trial successfully tested the strategy of lowering SBP<120mmHg in patients with arterial hypertension (AH).

AIM

To assess whether the SPRINT results are reproducible in a real world community population.

METHODS

Cross-sectional, population-based study analyzing data of 24,537 Caucasian people with AH from the Trieste Observatory of CV disease, 2010 to 2015. We selected and divided 2306 subjects with AH according to the SPRINT trial criteria; similarly, SPRINT clinical outcomes were considered.

RESULTS

Study patients median age was 75±8years, two third male, one third had ischemic heart disease. They were older, with lower body mass index, higher SBP and Framingham CV risk score than the SPRINT patients. Three-hundred-sixty-eight patients (16%) had SBP<120mmHg. During 48 [36-60] months of follow-up, 751 patients (32%) experienced a major adverse cardiac event (MACE). The SBP <120mmHg group had higher incidence of MACE, CV deaths and all-cause death than SBP≥120mmHg group (37% vs 31%; 10% vs 4%; 19% vs 10%, all p<0.05). The condition of SBP<120mmHg was an independent predictor of MACE in multivariate Cox analysis together with older age, male gender, higher Charlson score.

CONCLUSIONS

In our experience, the SBP<120mmHg condition is associated with worse clinical outcomes, suggesting the SPRINT results are not reproducible tout court in Caucasian community populations. These differences should be taken as a warning against aggressive reducing of SBP<120mmHg.

Outcomes of Treated Hypertension at Age 80 and Older: Cohort Analysis of 79,376 Individuals

Objectives

To estimate outcomes according to attained blood pressure (BP) in the oldest adults treated for hypertension in routine family practice.

Design

Cohort analysis of primary care inpatient and death certificate data for individuals with hypertension.

Setting

Primary care practices in England (Clinical Practice Research Datalink).

Participants

Individuals aged 80 and older taking antihypertensive medication and free of dementia, cancer, coronary heart disease, stroke, heart failure, and end‐stage renal failure at baseline.

Measurements

Outcomes were mortality, cardiovascular events, and fragility fractures. Systolic BP (SBP) was grouped in 10‐mmHg increments from less than 125 to 185 mmHg or more (reference 145–154 mmHg).

Results

Myocardial infarction hazards increased linearly with increasing SBP, and stroke hazards increased for SBP of 145 mmHg or greater, although lowest mortality was in individuals with SBP of 135 to 154 mmHg. Mortality of the 13.1% of patients with SBP less than 135 mmHg was higher than that of the reference group (Cox hazard ratio=1.25, 95% confidence interval=1.19–1.31; equating to one extra death per 12.6 participants). This difference in mortality was consistent over short‐ and long‐term follow‐up; adjusting for diastolic BP did not change the risk. Incident heart failure rates were higher in those with SBP less than 125 mmHg than in the reference group.

Conclusion

In routine primary care, SBP less than 135 mmHg was associated with greater mortality in the oldest adults with hypertension and free of selected potentially confounding comorbidities. Although important confounders were accounted for, observational studies cannot exclude residual confounding. More work is needed to establish whether unplanned SBPs less than 135 mmHg in older adults with hypertension may be a useful clinical sign of poor prognosis, perhaps requiring clinical review of overall care.

Nocturnal blood pressure in primary open-angle glaucoma

PURPOSE

To evaluate the nocturnal blood pressure (BP) dipping-pattern in patients with manifest primary open-angle glaucoma (POAG) and to find possible associations with the severity of visual field damage.

METHODS

A number of 314 patients suffering from POAG were consecutively enrolled in this cross-sectional hospital-based study. Each patient had diurnal intraocular pressure (IOP) measurements, 24-hr BP monitoring and computerized perimetry with the Humphrey 30-2 sita Standard program. Inclusion criteria were a mean IOP of less than 15 mmHg with fluctuations of less than 5 mmHg and a visual acuity of at least 20/40. One eye was randomly selected. Based on the night-day BP ratio, a mean arterial nocturnal BP drop of less than 10% was considered as non-dipping, between 10% and 20% as physiological dipping and of more than 20% as over-dipping.

RESULTS

Glaucoma patients with daytime systemic normotension on the average had more visual field loss in the over-dipper group (MD = - 16.6 dB, IQR = -18.9 to -2.7 dB) than glaucoma patients with daytime systemic hypertension, who had less visual field defects in the over-dipper group (MD = -3.9 dB, IQR = -6.2 to -1.9 dB) (p = 0.004). This result was also found taking age, glaucoma duration, visual acuity, gender, systemic and topical medication as covariates into account.

CONCLUSIONS

To judge the nocturnal BP situation of an individual patient, it is important to do this in relation to the daytime BP level. Twenty-four-hour BP evaluation might be important for all patients with POAG, as nocturnal BP could be a modifiable risk factor for glaucoma severity and progression.

The lower the achieved blood pressure goal the better

PURPOSE OF REVIEW

Hypertension is the eminent risk factor for renal and cardiovascular disease (CVD). Its management is a topic of public health priority. As either too high or too low blood pressure (BP) levels can have detrimental effects on health, optimal targets for BP continue to be controversial. The current manuscript will review relevant data published over the last year that add to this topic of controversy.

RECENT FINDINGS

Recent studies confirm increased CVD-related risk with increasing SBP levels more than 140  mmHg among patients with hypertension and CVD as well as those over the age of 60 years. A SBP target less than 140  mmHg conveyed lessened risk of CVD-related events. There is some evidence suggesting that the ideal BP target lies between 120 and 140  mmHg.

SUMMARY

Recent data support a target SBP of less than 140  mmHg among patients with hypertension or CVD, and achievement of this target might benefit those older than 60 years of age as well. Treating to SBPs below 120  mmHg may not result in further benefit. Data from randomized controlled trials specifically addressing the question whether lower BPs are associated with better outcomes are needed to further define ideal BP-target goals.

Misconceptions and facts about treating hypertension

Hypertension is a powerful risk factor strongly linked to adverse cardiovascular outcomes. Because of its high prevalence, health care providers at many levels are involved in treating hypertension. Distinct progress has been made in improving the rates of hypertension awareness and treatment over years, but the overall control of hypertension remains inadequate. Several recent guidelines from different sources have been put forward in an attempt to bridge the gap between existing evidence and clinical practice. Despite this effort, several misconceptions about treating hypertensive cardiovascular disease continue to persist among clinicians. This review highlights some of the misconceptions regarding antihypertensive therapy.

2014 hypertension recommendations from the eighth joint national committee panel members raise concerns for elderly black and female populations

A report from panel members appointed to the Eighth Joint National Committee titled "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults" has garnered much attention due to its major change in recommendations for hypertension treatment for patients ≥60 years of age and for their treatment goal. In response, certain groups have opposed the decision to initiate pharmacologic treatment to lower blood pressure (BP) at systolic BP ≥150 mm Hg and treat to a goal systolic BP of <150 mm Hg in the general population age ≥60 years. This paper contains 3 sections-an introduction followed by the opinions of 2 writing groups-outlining objections to or support of maintaining this proposed strategy in certain at-risk populations, namely African Americans, women, and the elderly. Several authors argue for maintaining current targets, as opposed to adopting the new recommendations, to allow for optimal treatment for older women and African Americans, helping to close sex and race/ethnicity gaps in cardiovascular disease morbidity and mortality.

Increasing complexity: which drug class to choose for treatment of hypertension in the elderly?

Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.

Differences in coronary blood flow in aortic regurgitation and systemic arterial hypertension have implications for diastolic blood pressure targets: a systematic review and meta-analysis

The objective was to evaluate coronary blood flow (CBF) in patients with systemic arterial hypertension (HTN) and to compare it with CBF in patients with aortic regurgitation (AR). A systematic literature search was conducted using the reference terms "coronary blood flow" and either "aortic regurgitation" or "hypertension." The selection criteria included CBF measurement in a concomitant control group, except studies evaluating CBF with aortic-valve replacement surgery. Twenty-two studies met the inclusion criteria. There were 318 persons with HTN, with 185 controls; and 102 persons with AR, with 144 controls. Despite an overall increase in CBF in HTN, CBF per gram of left ventricular mass was significantly (P < 0.0001) reduced. In contrast, CBF per gram of left ventricular mass was significantly (P = 0.004) increased in AR. Aortic regurgitation was associated with a significant (P < 0.0001) increase in CBF during systole and away from diastole, in contrast to persons with HTN. Aortic-valve replacement reversed the increase in systolic CBF. These data suggest that patients with HTN are more vulnerable than patients with AR to lower diastolic blood pressure (DBP), because resting CBF is compromised in HTN. Furthermore, patients with HTN may not compensate for DBP reductions by shifting CBF to systole, such as can occur with the low DBP in AR. Lower DBP in patients with AR cannot be used to justify treating patients with HTN to similar DBP because of the dramatic differences in CBF between the 2 conditions.

Blood pressure j-curve: current concepts

The blood pressure (BP) J-curve debate started in 1979, and we still cannot definitively answer all the questions. However, available studies of antihypertensive treatment provide strong evidence for J-shaped relationships between both diastolic and systolic BP and main outcomes in the general population of hypertensive patients, as well as in high-risk populations, including subjects with coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and elderly patients. However, further studies are still necessary in order to clarify this issue. This is connected to the fact that most available studies were observational, and randomized trials did not have or lost their statistical power and were inconclusive. Perhaps only the Systolic Blood Pressure Intervention Trial (SPRINT) and Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives (ESH-CHL-SHOT) will be able to finally answer all the questions. According to the current state of knowledge, it seems reasonable to suggest lowering BP to values within the 130-139/80-85 mmHg range, possibly close to the lower values in this range, in all hypertensive patients and to be very careful with further BP level reductions, especially in high-risk hypertensive patients.

J Curve in Hypertension

The relationship between blood pressure and cardiovascular disease risk among treated hypertensives is J-shaped: risk is increased at high levels of blood pressure, falls in parallel with blood pressure reduction and increases again when blood pressure falls below a nadir (the point at which blood pressure is too low to maintain perfusion of vital organs). Randomized controlled trials of antihypertensive treatment have identified J-shaped relationships between achieved systolic and diastolic blood pressures and all-cause mortality, as well as fatal and nonfatal cardiovascular events, but not stroke or renal outcomes, in the general population of hypertensives and high-risk prehypertensives, particularly in subgroups such as the elderly and those with coronary artery disease, chronic kidney disease, diabetes, left ventricular hypertrophy, and high cardiovascular risk because of multiple comorbidities and concomitant risk factors. Blood pressure targets <130-140/70-85 mm Hg were not beneficial for any outcome except stroke and chronic kidney disease.