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Pleiss A, Jurivich D, Dahl L, McGrath B, Kin D, McGrath R. The Associations of Pulse Pressure and Mean Arterial Pressure on Physical Function in Older Americans. Geriatrics (Basel) 2023; 8:geriatrics8020040. [PMID: 37102966 PMCID: PMC10137340 DOI: 10.3390/geriatrics8020040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Background: We sought to examine the associations of pulse pressure (PP) and mean arterial pressure (MAP) on physical function in older Americans. Methods: Our analytic sample included 10,478 adults aged ≥65 years from the 2006–2016 Health and Retirement Study. Handgrip strength, gait speed, and standing balance were collected using relatively standard protocols. PP and MAP were calculated from blood pressure measurements. Results: Older Americans with any abnormality in PP had 1.15 (95% confidence interval (CI): 1.05–1.25) greater odds for slowness and 1.14 (CI: 1.05–1.24) greater odds for poorer standing balance. Persons with any abnormality in MAP had 0.90 (CI: 0.82–0.98) decreased odds for weakness and 1.10 (CI: 1.01–1.20) greater odds for poorer standing balance. Those with low PP had 1.19 (CI: 1.03–1.36) greater odds for slow gait speed, while persons with low MAP had 1.50 (CI: 1.09–2.05) greater odds for weakness and 1.45 (CI: 1.03–2.04) greater odds for slowness. Older Americans with high PP had 1.13 (CI: 1.03–1.25) greater odds for slowness and 1.21 (CI: 1.10–1.32) greater odds for poorer balance, whereas those with high MAP had 0.87 (CI: 0.80–0.95) decreased odds for weakness. Conclusions: Cardiovascular dysfunction, as observed by PP and MAP, may help to explain some of our findings.
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Hussain SM, Ernst ME, Barker AL, Margolis KL, Reid CM, Neumann JT, Tonkin AM, Phuong TLT, Beilin LJ, Pham T, Chowdhury EK, Cicuttini FM, Gilmartin-Thomas JFM, Carr PR, McNeil JJ. Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication. Hypertension 2022; 79:2051-2061. [PMID: 35722878 PMCID: PMC9378722 DOI: 10.1161/hypertensionaha.122.19356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported. METHODS Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls. RESULTS Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers. CONCLUSIONS Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.
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Affiliation(s)
- Sultana Monira Hussain
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Victoria 3010 Australia
| | - Michael E. Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy; and, Department of Family Medicine, Carver College of Medicine. The University of Iowa, Iowa City, Iowa. USA
| | - Anna L Barker
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | | | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Johannes T Neumann
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- Department of Cardiology, University Heart & Vascular Center Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andrew M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Thao Le Thi Phuong
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Lawrence J Beilin
- Medical School, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Thao Pham
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Enayet K Chowdhury
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Flavia M Cicuttini
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Julia FM Gilmartin-Thomas
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- College of Health and Biomedicine, and Institute for Health & Sport, Victoria University, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Prudence R Carr
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - John J McNeil
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
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Ascher SB, Scherzer R, Estrella MM, Berry JD, de Lemos JA, Jotwani VK, Garimella PS, Malhotra R, Bullen AL, Katz R, Ambrosius WT, Cheung AK, Chonchol M, Killeen AA, Ix JH, Shlipak MG. Kidney tubule health, mineral metabolism and adverse events in persons with CKD in SPRINT. Nephrol Dial Transplant 2022; 37:1637-1646. [PMID: 34473302 PMCID: PMC9649818 DOI: 10.1093/ndt/gfab255] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Measures of kidney tubule health are risk markers for acute kidney injury (AKI) in persons with chronic kidney disease (CKD) during hypertension treatment, but their associations with other adverse events (AEs) are unknown. METHODS Among 2377 Systolic Blood Pressure Intervention Trial (SPRINT) participants with CKD, we measured at baseline eight urine biomarkers of kidney tubule health and two serum biomarkers of mineral metabolism pathways that act on the kidney tubules. Cox proportional hazards models were used to evaluate biomarker associations with risk of a composite of pre-specified serious AEs (hypotension, syncope, electrolyte abnormalities, AKI, bradycardia and injurious falls) and outpatient AEs (hyperkalemia and hypokalemia). RESULTS At baseline, the mean age was 73 ± 9 years and mean estimated glomerular filtration rate (eGFR) was 46 ± 11 mL/min/1.73 m2. During a median follow-up of 3.8 years, 716 (30%) participants experienced the composite AE. Higher urine interleukin-18, kidney injury molecule-1, neutrophil gelatinase-associated lipocalin (NGAL) and monocyte chemoattractant protein-1 (MCP-1), lower urine uromodulin (UMOD) and higher serum fibroblast growth factor-23 were individually associated with higher risk of the composite AE outcome in multivariable-adjusted models including eGFR and albuminuria. When modeling biomarkers in combination, higher NGAL [hazard ratio (HR) = 1.08 per 2-fold higher biomarker level, 95% confidence interval (CI) 1.03-1.13], higher MCP-1 (HR = 1.11, 95% CI 1.03-1.19) and lower UMOD (HR = 0.91, 95% CI 0.85-0.97) were each associated with higher composite AE risk. Biomarker associations did not vary by intervention arm (P > 0.10 for all interactions). CONCLUSIONS Among persons with CKD, several kidney tubule biomarkers are associated with higher risk of AEs during hypertension treatment, independent of eGFR and albuminuria.
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Affiliation(s)
- Simon B Ascher
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco, CA, USA.,Division of Hospital Medicine, University of California Davis, Sacramento, CA, USA
| | - Rebecca Scherzer
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco, CA, USA
| | - Michelle M Estrella
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco, CA, USA
| | - Jarett D Berry
- Divison of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James A de Lemos
- Divison of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vasantha K Jotwani
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco, CA, USA
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, CA, USA
| | - Rakesh Malhotra
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, CA, USA
| | - Alexander L Bullen
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, CA, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Walter T Ambrosius
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, UT, USA.,Department of Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO, USA
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, CA, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Michael G Shlipak
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco, CA, USA
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4
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Ascher SB, Scherzer R, de Lemos JA, Estrella MM, Jotwani VK, Garimella PS, Bullen AL, Ambrosius WT, Ballantyne CM, Nambi V, Killeen AA, Ix JH, Shlipak MG, Berry JD. Associations of High-Sensitivity Troponin and Natriuretic Peptide Levels With Serious Adverse Events in SPRINT. J Am Heart Assoc 2022; 11:e023314. [PMID: 35243872 PMCID: PMC9075292 DOI: 10.1161/jaha.121.023314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022]
Abstract
Background Assessing the risk of serious adverse events (SAEs) during hypertension treatment is important for understanding the benefit-harm trade-offs of lower blood pressure goals. It is unknown whether high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) provide information about SAEs. Methods and Results In SPRINT (Systolic Blood Pressure Intervention Trial), hs-cTnT and NT-proBNP were measured at baseline in 8828 (94.3%) and 8836 (94.4%) participants, respectively. Multivariable Cox proportional hazards models were used to evaluate hs-cTnT and NT-proBNP associations with a composite of SPRINT's SAEs of interest: hypotension, syncope, bradycardia, acute kidney injury, electrolyte abnormalities, and injurious falls. Elevations in hs-cTnT and NT-proBNP were associated with increased composite SAE risk (hazard ratio [HR] per 2-fold higher hs-cTnT: 1.15; 95% CI, 1.06‒1.25; HR per 2-fold higher NT-proBNP: 1.09; 95% CI, 1.05‒1.14). Compared with both hs-cTnT and NT-proBNP in the lower tertiles, both biomarkers in the highest tertile was associated with increased composite SAE risk (HR, 1.56; 95% CI, 1.32‒1.84). Composite SAE risk was higher in the intensive-treatment group than in the standard-treatment group for participants with both biomarkers in the lower tertiles, but similar between treatment groups for participants with both biomarkers in the highest tertile (P for interaction=0.008). Conclusions Elevations in hs-cTnT and NT-proBNP individually and in combination are associated with higher composite SAE risk in SPRINT. The differential impact of blood pressure treatment on SAE risk across combined biomarker categories may have implications for identifying individuals with more favorable benefit-harm profiles for intensive blood pressure lowering.
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Affiliation(s)
- Simon B. Ascher
- Department of MedicineKidney Health Research CollaborativeSan Francisco Veterans Affairs Health Care System and University of California San FranciscoSan FranciscoCA
- Division of Hospital MedicineUniversity of California DavisSacramentoCA
| | - Rebecca Scherzer
- Department of MedicineKidney Health Research CollaborativeSan Francisco Veterans Affairs Health Care System and University of California San FranciscoSan FranciscoCA
| | - Jame A. de Lemos
- Divison of CardiologyDepartment of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTX
| | - Michelle M. Estrella
- Department of MedicineKidney Health Research CollaborativeSan Francisco Veterans Affairs Health Care System and University of California San FranciscoSan FranciscoCA
| | - Vasantha K. Jotwani
- Department of MedicineKidney Health Research CollaborativeSan Francisco Veterans Affairs Health Care System and University of California San FranciscoSan FranciscoCA
| | - Pranav S. Garimella
- Division of Nephrology‐HypertensionUniversity of California San DiegoSan DiegoCA
| | - Alexander L. Bullen
- Division of Nephrology‐HypertensionUniversity of California San DiegoSan DiegoCA
- Nephrology SectionVeterans Affairs San Diego Healthcare SystemSan DiegoCA
| | - Walter T. Ambrosius
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNC
| | - Christie M. Ballantyne
- Department of Medicine and Center for Cardiometabolic Disease PreventionBaylor College of MedicineHoustonTX
| | - Vijay Nambi
- Department of Medicine and Center for Cardiometabolic Disease PreventionBaylor College of MedicineHoustonTX
- Department of MedicineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTX
| | - Anthony A. Killeen
- Department of Laboratory Medicine and PathologyUniversity of MinnesotaMinneapolisMN
| | - Joachim H. Ix
- Division of Nephrology‐HypertensionUniversity of California San DiegoSan DiegoCA
- Nephrology SectionVeterans Affairs San Diego Healthcare SystemSan DiegoCA
| | - Michael G. Shlipak
- Department of MedicineKidney Health Research CollaborativeSan Francisco Veterans Affairs Health Care System and University of California San FranciscoSan FranciscoCA
| | - Jarett D. Berry
- Divison of CardiologyDepartment of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTX
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5
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Associations of blood pressure with risk of injurious falls in old age vary by functional status: A cohort study. Exp Gerontol 2020; 140:111038. [PMID: 32738383 DOI: 10.1016/j.exger.2020.111038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We aimed to examine to what extent blood pressure (BP) components are associated with injurious falls in older adults, and whether the possible associations differ by functional status (indicated by physical and cognitive impairment at baseline). METHODS This prospective cohort study included 3055 community-living participants of the Swedish National study on Aging and Care in Kungsholmen (aged ≥60 years). At baseline (2001-2004), we measured systolic BP (SBP) and diastolic BP (DBP), mean arterial pressure, pulse pressure (PP), and orthostatic hypotension. Physical function was assessed using tests of balance, chair stands, and walking speed. Cognitive function was assessed with the Mini-Mental State Examination. Injurious falls leading to inpatient or outpatient care during 3 and 10 years of follow-up were identified via patient registers. Data were analyzed using flexible parametric survival models adjusted for potential confounders. RESULTS During the 10-year follow-up period in people without functional impairment, the multi-adjusted hazard ratios (HR) of injurious falls were 1.77 (95% CI 1.02-3.07) for having SBP <130 mmHg, 1.73 (95% CI 1.05-2.83) for having SBP ≥160 mmHg (vs. 130-139), and 1.46 (1.05-2.02) for having higher tertile of PP (vs. lower tertile). During the 3-year follow-up period in people with functional impairment, the multi-adjusted HR of injurious falls was 1.91 (95% CI 1.17-3.13) for having SBP <130 mmHg (vs. 130-139) and 0.74 (0.59-0.94) for having higher tertile of PP (vs. lower tertile). There was no significant association between BP components and injurious falls either in people without functional impairment during the 3-year follow-up period, or in people with functional impairment during the 10-year follow-up period. CONCLUSIONS This large-scale Swedish study provides evidence that the associations between some specific components of BP and risk of injurious falls in older adults vary by functional status. This supports the view that a personalized approach to blood pressure management depending on functional status among older adults might be warranted in clinical settings.
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6
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Abstract
Supplemental Digital Content is available in the text On the basis of the benefits of antihypertensive treatment, progressively intensive treatment is advocated. However, it remains controversial whether intensive blood pressure control might increase the frequency of serious adverse events (SAEs) compared with moderate control. This review assessed the occurrence of SAEs in blood pressure treatment with predefined blood pressure targets. Seven original studies and eight post hoc analyses (derived from two original studies) met the inclusion criteria. Compared with moderate blood pressure treatment, intensive treatment was associated with a significant increase in treatment-related SAEs (Sign-test: P = 0.0002, Wilcoxon signed-rank test: P = 0.001). However, comparability between studies was limited, due to unclear determinations about the treatment-relatedness of adverse events, missing definitions of SAEs and variations in recording methods. Thus, a meta-analysis was not justified. The definitions of serious adverse events and methods of recording and reporting need to be improved and standardized to facilitate the comparison of results.
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7
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Krishnaswami A, Peterson ED, Kim DH, Goyal P, Rich MW. Efficacy and Safety of Intensive Blood Pressure Therapy Using Restricted Mean Survival Time-Insights from the SPRINT Trial. Am J Med 2020; 133:e369-e370. [PMID: 32061731 PMCID: PMC7329585 DOI: 10.1016/j.amjmed.2019.12.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, Calif; Department of Epidemiology and Biostatistics, University of California, San Francisco.
| | - Eric D Peterson
- Duke Clinical Research Institute, and Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Mass
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Michael W Rich
- Division of Cardiology, Washington University, St. Louis, Mo
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8
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Tannenbaum J, Bittner V, Waters DD. When Diastole Lets You Down: Clinical Relevance of a Widened Pulse Pressure. Can J Cardiol 2020; 36:593-595. [PMID: 32007351 DOI: 10.1016/j.cjca.2019.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jordan Tannenbaum
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David D Waters
- Division of Cardiology, Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California, San Francisco, California, USA.
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9
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Affiliation(s)
| | - John B Kostis
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Abel E Moreyra
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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10
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Aronow WS. Hypertension Management in the Very Old. J Am Med Dir Assoc 2019; 20:1057-1059. [PMID: 31133473 DOI: 10.1016/j.jamda.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 03/31/2019] [Accepted: 04/04/2019] [Indexed: 11/16/2022]
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Abstract
Hypertension and dementia are both common disorders whose prevalence increases with age. There are multiple mechanisms by which hypertension affects the brain and alters cognition. These include blood flow dynamics, development of large and small vessel pathology and diverse molecular mechanisms including formation of reactive oxygen species and transcriptional cascades. Blood pressure interacts with Alzheimer disease pathology in numerous and unpredictable ways, affecting both β-amyloid and tau deposition, while also interacting with AD genetic risk factors and other metabolic processes. Treatment of hypertension may prevent cognitive decline and dementia, but methodological issues have limited the ability of randomized clinical trials to show this conclusively. Recent studies have raised hope that hypertension treatment may protect the function and structure of the aging brain from advancing to mild cognitive impairment and dementia.
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Affiliation(s)
- Nasratullah Wahidi
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Alan J Lerner
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
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12
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Ouellet GM, McAvay G, Murphy TE, Tinetti ME. Treatment of Hypertension in Complex Older Adults: How Many Medications Are Needed? Gerontol Geriatr Med 2019; 5:2333721419856436. [PMID: 31245434 PMCID: PMC6580710 DOI: 10.1177/2333721419856436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Many older adults with hypertension receive multiple
antihypertensives. It is unclear whether treatment with several antihypertensive
classes results in greater cardiovascular benefits than fewer antihypertensive
classes. Objectives: We investigated (a) the longitudinal
associations between treatment with ≥ 3 versus 1-2 classes and death and major
adverse cardiovascular events (MACE) and (b) whether these associations varied
by the presence of mobility disability. Methods: We included 6,011
treated hypertensive adults ≥65 from the Medical Expenditure Panel Survey
(MEPS), a nationally representative community sample. Times to MACE and death
were compared between those receiving ≥3 versus 1-2 classes using multivariable
proportional hazards regression. We used inverse probability of treatment
weighting to account for indication and contraindication bias.
Results: There were no significant differences in the risk of
mortality (hazard ratio [HR] = 0.96, p = .769) or MACE (HR =
1.10, p = .574) between the exposure groups, and there were no
significant exposure × mobility disability interactions.
Discussion: We found no benefit of ≥3 versus 1-2
antihypertensive classes in reducing mortality and cardiovascular events in a
representative cohort of older adults, raising concern about the added benefit
of additional antihypertensives in the real world.
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Affiliation(s)
- Gregory M Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gail McAvay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary E Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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13
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Aronow WS. Implications of the New 2017 American College of Cardiology/American Heart Association Guidelines for Hypertension. Minerva Cardioangiol 2019; 67:399-410. [PMID: 31220914 DOI: 10.23736/s0026-4725.19.04965-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Automated validated devices should be used for measuring blood pressure (BP). The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines recommend that a systolic BP between 120-129 mmHg with a diastolic BP less than 80 mmHg should be treated with lifestyle measures. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for secondary prevention of cardiovascular events in persons with clinical cardiovascular disease and an average systolic BP of ≥130 mmHg or an average diastolic BP≥80 mmHg. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease ≥ 10% and an average systolic BP ≥130 mmHg or an average diastolic BP ≥80 mmHg. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease of < 10% and an average systolic BP ≥140 mmHg or an average diastolic BP ≥ 90 mmHg. These guidelines recommend initiating antihypertensive drug therapy with 2 first-line drugs from different classes either as separate agents or in a fixed-dose combination in persons with a BP ≥140/90 mmHg or with a BP > 20/10 mmHg above their BP target. White coat hypertension must be excluded before starting treatment with antihypertensive drugs in persons with hypertension at low risk for atherosclerotic cardiovascular disease. Antihypertensive drug treatment for different disorders is discussed.
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Affiliation(s)
- Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA -
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14
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Pareek M, Vaduganathan M, Biering-Sørensen T, Byrne C, Qamar A, Almarzooq Z, Pandey A, Olsen MH, Bhatt DL. Pulse Pressure, Cardiovascular Events, and Intensive Blood-Pressure Lowering in the Systolic Blood Pressure Intervention Trial (SPRINT). Am J Med 2019; 132:733-739. [PMID: 30659811 DOI: 10.1016/j.amjmed.2019.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/01/2019] [Accepted: 01/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The efficacy and tolerability of intensive blood-pressure lowering may vary by pulse pressure (systolic minus diastolic blood pressure). METHODS SPRINT randomized 9361 high-risk adults without diabetes and who were ≥50 years with systolic blood pressure 130-180 mm Hg to intensive or standard antihypertensive treatment. The primary efficacy end point was the composite of acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. The primary safety end point was composite serious adverse events. We examined the prognostic implications of baseline pulse pressure and the effects of intensive blood-pressure lowering on clinical outcomes across the spectrum of pulse-pressure values using restricted cubic splines. RESULTS Mean baseline pulse pressure was similar between the 2 study groups (intensive treatment 61±14 mm Hg vs standard treatment 62±14 mm Hg; P = 0.59). Except stroke, for which the association with pulse pressure was best defined as linear, pulse pressure displayed a nonlinear U-shaped relationship with the risk of all tested clinical end points (P <0.05), though no association remained significant upon multivariable adjustment (P >0.05). The benefit of intensive blood-pressure management on mortality appeared greatest in patients with a pulse pressure ∼60 mm Hg (P = 0.03 for interaction). Pulse pressure did not modify the effect of intensive blood-pressure lowering for other clinical end points (P >0.05 for interaction). CONCLUSION In a large randomized clinical trial of patients with a high risk of cardiovascular events, risks and benefits of intensive blood-pressure lowering did not appear to be modified by baseline pulse pressure. Selection of appropriate candidates for intensive blood-pressure lowering should not be limited by this parameter.
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Affiliation(s)
- Manan Pareek
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Tor Biering-Sørensen
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Christina Byrne
- Department of Cardiology, The Heart Centre, Rigshospitalet - Copenhagen University Hospital, Denmark
| | - Arman Qamar
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Zaid Almarzooq
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Ambarish Pandey
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Michael Hecht Olsen
- Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass.
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