Hypertension in the elderly

Comparison of bioelectrical body and visceral fat indices with anthropometric measures and optimal cutoffs in relation to hypertension by age and gender among Chinese adults

Background

Few studies have compared bioelectrical body and visceral fat indices with anthropometric measures, or evaluated their optimal cutoffs in relation to hypertension among Asians. We compared the efficiencies of bioelectrical indices (percentage of body fat, PBF; visceral fat area, VFA) with anthropometric measures (body mass index, BMI; waist-hip ratio, WHR) for hypertension and re-evaluated the optimal cutoffs of each index by age and gender.

Methods

We conducted a cross-sectional survey among 8234 adults for health examination. PBF, VFA, BMI, WHR, and data on hypertension and behaviors were collected. Receiver operating characteristic (ROC) curve and areas under curves (AUCs) were used to analyze the efficiencies of the indices for hypertension, optimal cutoffs were estimated using the Youden index.

Results

A total of 8234 individuals aged 21–91 with median age 44 (interquartile range [IQR] 33–56) years were included and 40.56% were men. The overall prevalence of hypertension was 27.47%. The studied indices were all associated with hypertension in all age-specific groups both among men and women except for WHR in 21–29 years old men and PBF in in 21–29 years old women. Among males, there were no statistical differences in powers of four indices for hypertension in all age-specific groups, except for 40–49 years, in which WHR was better than VFA. Among females, no differences were found among the indices in 30–39 and 70–79 years groups, while WHR was the best in 21–29 years group, VFA was better than PBF in 30–39 and 50–59 years groups, BMI was better than PBF and WHR in 60–69 years group. The optimal cutoffs of PBF, VFA, BMI and WHR ranged from 23.9 to 28.7%, 86.4 to 106.9cm², 23.5 to 27.1 kg/m², 0.92 to 0.96 across the age categories in males, and 32.8 to 36.3%, 75.9 to 130.9cm², 21.9 to 26.4 kg/m², 0.84 to 0.95 across the age categories in females, respectively.

Conclusions

The obesity indices’ efficiencies for hypertension varied by age and gender, and their cutoff values varied across the age categories and gender. Specific indices and cutoffs based on person’s age and gender should be used to identify individuals with hypertension.

Sex differences in the time course and mechanisms of vascular and cardiac aging in mice: role of the smooth muscle cell mineralocorticoid receptor

Aging is associated with heart and vascular dysfunction that contributes to cardiovascular disease (CVD) risk. Clinical data support a sexual dimorphism in the time course of aging-associated CVD. However, the mechanisms driving sex differences in cardiovascular aging and whether they can be modeled in mice have not been explored. Mineralocorticoid receptors (MRs) regulate blood pressure, and we previously demonstrated in male mice that MR expression increases in aging mouse vessels and smooth muscle cell-specific MR deletion (SMC-MR-KO) protects from cardiovascular aging. This study characterizes sex differences in murine cardiovascular aging and the associated sex-specific role of SMC-MR. Aortic stiffness, measured by pulse wave velocity, increased from 3 to 12 mo of age in males but not until 18 mo in females. The timing of the rise in aortic stiffening correlated with the timing of increased aortic MR expression, and aortic stiffness did not increase with age in SMC-MR-KO mice of both sexes. Vascular fibrosis increased at 12 mo in males and later at 18 mo in females; however, fibrosis was attenuated by SMC-MR-KO in males only. In resistance vessels, angiotensin type 1 receptor (AT1R)-mediated vasoconstriction also increased at 12 mo in males and 18 mo in females. ANG II-induced vasoconstriction was decreased in SMC-MR-KO specifically in males in association with decreased AT1R expression. Cardiac systolic function declined in males and females by 18 mo of age, which was prevented by SMC-MR-KO specifically in females. Cardiac perivascular fibrosis increased with age in both sexes accompanied by sex-specific changes in the expression levels of MR-regulated profibrotic genes.NEW & NOTEWORTHY These data demonstrate that the delayed and steeper decline in cardiovascular function observed in aging females can be modeled in aging mice. Moreover, the mechanisms driving vascular and cardiac aging phenotypes are distinct between males and females. Mineralocorticoid receptors in smooth muscle cells play a significant role in cardiovascular aging in both sexes; however, they do so by distinct mechanisms. Overall, these findings suggest that sex-specific therapies may be necessary to retard the aging process and improve cardiovascular disease outcomes in the aging population.

A new approach to identifying hypertension-associated genes in the mesenteric artery of spontaneously hypertensive rats and stroke-prone spontaneously hypertensive rats

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Objective:

Hypertension is one of the most prevalent diseases in humans who live a modern lifestyle. Alongside more effective care, clarification of the genetic background of hypertension is urgently required. Gene expression in mesenteric resistance arteries of spontaneously hypertensive rats (SHR), stroke-prone SHR (SHRSP) and two types of renal hypertensive Wistar Kyoto rats (WKY), two kidneys and one clip renal hypertensive rat (2K1C) and one kidney and one clip renal hypertensive rat (1K1C), was compared using DNA microarrays.

Methods:

We used a simultaneous equation and comparative selection method to identify genes associated with hypertension using the Reactome analysis tool and GenBank database.

Results:

The expression of 298 genes was altered between SHR and WKY (44 upregulated and 254 downregulated), while the expression of 290 genes was altered between SHRSP and WKY (83 upregulated and 207 downregulated). For SHRSP versus SHR, the expression of 60 genes was altered (36 upregulated and 24 downregulated). Several genes expressed in SHR and SHRSP were also expressed in the renovascular hypertensive 2K1C and 1K1C rats, indicative of the existence of hyper-renin and/or hypervolemic pathophysiological changes in SHR and SHRSP.

Conclusion:

The overexpression of Kcnq1, Crlf1, Alb and Xirp1 and the inhibition of Galr2, Kcnh1, Ache, Chrm2 and Slc5a7 expression may indicate that a relationship exists between these genes and the cause and/or worsening of hypertension in SHR and SHRSP.

2018 Korean society of hypertension guidelines for the management of hypertension: part III-hypertension in special situations

Treatment of hypertension improves cardiovascular, renal, and cerebrovascular outcomes. However, the benefit of treatment may be different according to the patients' characteristics. Additionally, the target blood pressure or initial drug choice should be customized according to the special conditions of the hypertensive patients. In this part III, we reviewed previous data and presented recommendations for some special populations such as diabetes mellitus, chronic kidney disease, elderly people, and cardio-cerebrovascular disease.

Frailty among institutionalized older people: a cross-sectional study in Natal (Brazil)

OBJECTIVE

Verify the prevalence of frailty and its associated factors in institutionalized older people.

METHODS

Cross-sectional study carried out in 10 nursing homes in Natal (Brazil), between October/2013 and January/2014. All institutionalized older people 60+ that were not hospitalized, in terminal state, coma or under palliative care were included in the study. The dependent variable of the study was the presence/absence of frailty, classified according to the following criteria: severe cognitive decline and/or impossibility of independent walking or being bedridden. The 5 criteria (muscular weakness, unintentional weight loss, low physical activity level, slowness and exhaustion) of Fried et al. were considered for those with preserved cognitive and walking capacity. The chi-square test or Fisher's test and logistic regression were used for bivariate and multiple analysis, respectively. Sociodemographic, institution-related and health-related variables were also included.

RESULTS

Of the 321 participating older people, 80.1% were considered frail, 16.8% pre-frail and 3.1% non-frail. The final model demonstrated association of frailty with age (OR=2.67; 95%CI 1.39-5.14; p=0.003), presence of chronic diseases (OR=10.27; 95%CI 3.42-30.90; p<0.001), systemic arterial hypertension (OR=0.11; 95%CI 0.05-0.27; p<0.001) and institutionalization due to lack of caregiver (OR=2.55; 95%CI 1.36-4.76; p=0.003) adjusted by sex and type of institution.

DISCUSSION

Frailty was highly prevalent in institutionalized older people and its association with multi-factor aspects suggested that action of health services and government representations could aid in the prevention or delay of frailty onset, improving the life quality of older people.

Sex differences in mechanisms of arterial stiffness

Arterial stiffness progressively increases with aging and is an independent predictor of cardiovascular disease (CVD) risk. Evidence supports that there are sex differences in the time course of aging-related arterial stiffness and the associated CVD risk, which increases disproportionately in postmenopausal women. The association between arterial stiffness and mortality is almost twofold higher in women versus men. The differential clinical characteristics of the development of arterial stiffness between men and women indicate the involvement of sex-specific mechanisms. This review summarizes the current literature on sex differences in vascular stiffness induced by aging, obesity, hypertension, and sex-specific risk factors as well as the impact of hormonal status, diet, and exercise on vascular stiffness in males and females. An understanding of the mechanisms driving sex differences in vascular stiffness has the potential to identify novel sex-specific therapies to lessen CVD risk, the leading cause of death in males and females. LINKED ARTICLES: This article is part of a themed section on The Importance of Sex Differences in Pharmacology Research. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.21/issuetoc.

Spirulina maxima Decreases Endothelial Damage and Oxidative Stress Indicators in Patients with Systemic Arterial Hypertension: Results from Exploratory Controlled Clinical Trial

(1) Background: Spirulina (Arthrospira) maxima has shown beneficial effects such as being anti-dyslipidemic, antiviral, antioxidant and antihypertensive. However, there are few and limited clinical studies. (2) Methods: a prospective, randomized, parallel pilot study of 4.5 g administration of Spirulinamaxima or placebo for 12 weeks in 16 patients with systemic arterial hypertension (SAH) undergoing treatment with angiotensin-converting enzyme (ACE) inhibitors was performed to assess the effects on endothelial damage and oxidative stress indicators. The blood levels of sICAM-1, sVCAM-1, endothelin-1, and sE-selectin were quantified; the activities of catalase, superoxide dismutase, glutathione peroxidase, glutathione reductase and concentrations of reduced glutathione, oxidized glutathione, and thiobarbituric acid reactive substances, were also quantified before and after the treatment period. (3) Results: There were statistically significant (p < 0.05) decreases in systolic blood pressure, sVCAM-1, sE-selectin and endothelin-1 levels, and increases in glutathione peroxidase activity and oxidized glutathione levels. (4) Conclusion: The effects found in the present study agree with antihypertensive and antioxidant effects previously reported for Spirulina maxima. However, this is the first report about the effects on indicators of endothelial damage. More research in this field is necessary to gain an insight into the effects of Spirulina on these indicators.

Efficacy and Safety of Sacubitril/Valsartan (LCZ696) Compared With Olmesartan in Elderly Asian Patients (≥65 Years) With Systolic Hypertension

OBJECTIVE

Systolic hypertension is common in elderly patients and remains a challenge to treat effectively. The efficacy and safety of sacubitril/valsartan (LCZ696), a first-in-class angiotensin receptor neprilysin inhibitor, vs. olmesartan was evaluated in elderly Asian patients (≥65 years) with systolic hypertension.

METHODS

In this randomized, double-blind, 14-week study, patients initially received once-daily sacubitril/valsartan 100 mg or olmesartan 10 mg, increased to sacubitril/valsartan 200 mg or olmesartan 20 mg at week 4. At week 10, for patients with blood pressure (BP) >140/90 mm Hg, the doses were up-titrated to sacubitril/valsartan 400 mg or olmesartan 40 mg. The primary assessment was superiority of sacubitril/valsartan vs. olmesartan in reducing office mean sitting (ms) systolic BP (msSBP) from baseline at week 10. Secondary efficacy assessments included changes from baseline in ms diastolic BP (msDBP), ms pulse pressure (msPP), 24-hour mean ambulatory (ma) BP (maBP), and maPP at week 10; msBP and msPP at weeks 4 and 14.

RESULTS

Overall, 588 patients were randomized (mean age, 70.7 years; baseline msBP, 160.3/84.9 mm Hg; msPP, 75.4 mm Hg). At week 10, sacubitril/valsartan provided superior msSBP reductions vs. olmesartan (22.71 vs. 16.11 mm Hg, respectively; P < 0.001); similarly, reductions from baseline in other BP and PP assessments were significantly greater with sacubitril/valsartan. At week 14, despite more patients requiring up-titration in the olmesartan group, msBP and msPP reductions from baseline were significantly greater with sacubitril/valsartan. Both treatments were generally well-tolerated.

CONCLUSION

Sacubitril/valsartan is more effective than olmesartan in reducing BP in elderly Asian patients with systolic hypertension.

Arrhythmogenic Remodeling in Murine Models of Deoxycorticosterone Acetate-Salt-Induced and 5/6-Subtotal Nephrectomy-Salt-Induced Cardiorenal Disease

BACKGROUND

Renal failure is associated with adverse cardiac remodeling and sudden cardiac death. The mechanism leading to enhanced arrhythmogenicity in the cardiorenal syndrome is unclear. The aim of this study was to characterize electrophysiological and tissue alterations correlated with enhanced arrhythmogenicity in two distinct mouse models of renal failure.

METHODS

Thirty-week-old 129Sv mice received a high-salt diet and deoxycorticosterone acetate (DOCA) for 8 weeks, followed by an additional period of high-salt diet for 27 weeks (DOCA-salt aged model). Adult CD-1 mice were submitted to 5/6-subtotal nephrectomy (SNx) and treated for 11 weeks with a high-salt diet (SNx-salt adult model). Vulnerability to arrhythmia as well as conduction velocities (CVs) of the hearts were determined ex vivo with epicardial mapping. Subsequently, the hearts were characterized for connexin 43 (Cx43) and fibrosis.

RESULTS

DOCA-salt and SNx-salt mice developed renal dysfunction characterized by albuminuria. Heart, lung and kidney weights were increased in DOCA-salt mice. Both DOCA-salt and SNx-salt mice were highly susceptible to ventricular arrhythmias. DOCA-salt mice had a significant decrease in both longitudinal and transversal CV in the left ventricle. Histological analysis revealed a significant reduction in Cx43 expression as well as an increase in interstitial fibrosis in both DOCA-salt and SNx-salt mice.

CONCLUSION

DOCA-salt and SNx-salt treatment induced renal dysfunction, which resulted in structural and electrical cardiac remodeling and enhanced arrhythmogenicity. The reduced Cx43 expression and increased fibrosis levels in these hearts are likely candidates for the formation of the arrhythmogenic substrate.

2013 Korean Society of Hypertension guidelines for the management of hypertension: part III-hypertension in special situations

Different treatment strategies are suggested for special situations. Hypertension is common in the elderly and frequently accompanied by or complicates other clinical conditions such as metabolic syndrome, coronary artery disease, heart failure, stroke, diabetes mellitus and chronic kidney disease.

Prevalence and Factors Associated to Hypertension Among Older Adults in Bogotá, Colombia

Objective: To characterize older adults in Bogotá with high blood pressure and identify factors associated to this condition within this population. Method: Using data from the Salud, Bienestar y Envejecimiento (SABE) (Health, Well-being and Aging) Bogotá Study, we analyzed community-dwelling adults 60 years and older with hypertension. We estimated the prevalence and used logistic regression models to identify factors associated to hypertension. Results: The overall prevalence for hypertension was 56.9%. Older age (odds ratio [OR] = 1.46, 95% confidence interval [CI] = [1.07, 1.97]), having health insurance (OR = 4.15, CI = [1.95, 8.85]), cardiovascular diseases (ORs between 1.70 and 3.65), and poor self-rated health (OR = 1.57, CI = [1.20,2.06]) significantly increased the odds of hypertension. Most individuals received pharmacologic treatment (93.5%); however, 28.4% of individuals had uncontrolled hypertension. Discussion: We found a high prevalence of hypertension in our cohort and found that comorbidities and poor self-rated health increase the odds of hypertension. Future studies need to tailor interventions for hypertension management in old age.

Vasodilatory effect of 14,15-epoxyeicosatrienoic acid on mesenteric arteries in hypertensive and aged rats

The objective of this study was to investigate the 14,15-epoxyeicosatrienoic acid (14,15-EET)-induced vasodilatations as well as the underlying signaling pathways in rat mesenteric arteries from young, adult and old normotensive (WKY) and hypertensive rats. Protein expressions for prostaglandin EP(1-4) receptors, large conductance Ca(2+)-activated K(+) (BK(Ca)) channels, and adenylate cyclase (AC) were determined together with 14,15-EET-induced vasodilatations in primary- versus secondary-branches of the mesenteric artery. Responses to 14,15-EET were greater in the smaller secondary- versus primary-branches (and also more sensitive with lower EC50) and were reduced in vessels from old (80 weeks) rats as well as from vessels from the spontaneous hypertensive rats (SHR). Regardless of age or hypertension responses to 14,15-EET were inhibited by the EP2 antagonist AH6809, BK(Ca) channel inhibitor iberiotoxin, or 3',5'-cyclic monophosphate (cAMP)-protein kinase A (PKA) pathway antagonists. These data indicate 14,15-EET-induced vasodilatation is mediated via the activation of EP2 receptors and opening of BK(Ca) channels. The expressions of the EP2 receptor and AC were markedly reduced in vessels from SHR as well as old rats, whereas BK(Ca) expression was reduced in old WKY and SHR, but not adult SHR. Furthermore, expression of the p53 protein, an indicator of cell senescence and apoptosis, was elevated in adult and old SHR as well as in old WKY. In summary, attenuated 14,15-EET-induced vasodilatation in mesenteric arteries from old normotensive WKY as well as adult and old SHR is associated with reduced expression of EP2 receptors and AC.

Hypertension in the elderly: unique challenges and management

Elderly individuals, worldwide, are on the rise, posing new challenges to care providers. Hypertension is highly prevalent in elderly individuals, and multiple challenges face care providers while managing it. In addition to treating hypertension, the physician must treat other modifiable cardiovascular risk factors in patients with or without diabetes mellitus or chronic kidney disease to reduce cardiovascular events and mortality. This review discusses some of the unique characteristics of high blood pressure in the elderly and provides an overview of the challenges facing care providers, as well as the current recommendations for management of hypertension in the elderly.

Olmesartan vs. ramipril in elderly hypertensive patients: review of data from two published randomized, double-blind studies

Hypertension is a frequent condition among individuals over 65 years of age worldwide and is one of the most important risk factors for cardiovascular (CV) disease. Effective drug treatment of elderly hypertensives is usually associated with a marked reduction in CV morbidity and mortality. Among the different classes of antihypertensive agents, angiotensin receptor blockers (ARBs) and ACE-inhibitors are supposed to provide the best efficacy in lowering blood pressure (BP) and protecting target organ damage while featuring a good tolerability profile. However, up to date, few randomized clinical studies have directly compared the activity and safety of ARBs and ACE-inhibitors in elderly hypertensive patients. Aim of this review of published and unpublished pooled data from two recent randomized, double-blind, controlled trials, is to offer a comprehensive head-to-head comparison of the antihypertensive efficacy of the ARB olmesartan medoxomil vs. the ACE-inhibitor ramipril in a large study population including more than 1,400 hypertensive subjects aged 65-89 years with mild-to-moderate essential hypertension. The efficacy of the two drugs was separately evaluated in subgroups of patients classified according to the presence of metabolic syndrome, reduced renal function, CV risk level, gender, class of age, type of arterial hypertension and previous antihypertensive treatments. Olmesartan showed a greater efficacy than ramipril both in terms of clinic BP reduction and rate normalization. Olmesartan appeared significantly superior to ramipril in providing a more homogeneous and long-lasting 24-h BP control and maintaining an effective antihypertensive action in the last 6-h period from drug intake. In subgroups of patients with additional clinical conditions, olmesartan gave comparable, and in some cases greater, BP responses than those achieved with the ACE-inhibitor. The incidence of adverse events was similar for both drugs. Olmesartan may thus represent an effective alternative to ACE-inhibitors among first-line drug treatments for hypertension in older people.

Essential hypertension: an approach to its etiology and neurogenic pathophysiology

Essential hypertension, a rise in blood pressure of undetermined cause, includes 90% of all hypertensive cases and is a highly important public health challenge that remains, however, a major modifiable cause of morbidity and mortality. This review emphasizes that, from an evolutionary point of view, we are adapted to ingest and excrete <1 g of sodium (2.5 g of salt) per day and that essential hypertension develops when the kidneys become unable to excrete the amount of sodium ingested, unless blood pressure is increased. The renal-mean arterial pressure set-point model is briefly described to explain that a shift of the pressure natriuresis relationship toward abnormally high pressure levels is a pathophysiological characteristic of essential hypertension. Evidence indicating that this anomaly in the pressure natriuresis relationship arises from a sympathetic nervous system dysfunction is briefly formulated, and the most widely accepted pathophysiologic proposal to explain the development of this sympathetic dysfunction is described, with commentaries about novel action mechanisms of some drugs currently used in essential hypertension treatment.

Effect of long-term resistance exercise on body composition, blood lipid factors, and vascular compliance in the hypertensive elderly men

Hypertension is designated as either essential (primary) hypertension or secondary hypertension and is defined as a consistently elevated blood pressure exceeding 140/90 mmHg. Hypertension is called "the silent killer" because it often causes no symptoms for many years, even decades, until it finally damages certain critical organs. In various causes of hypertension, obesity is an increasing health problem worldwide, and several epidemiological studies have identified a positive association between obesity and an increased incidence of hypertension. Therefore, in the present study, we investigated the effect of long-term resistance exercise on body composition, blood lipid profile, vascular compliance, and blood pressure in the elderly men. For this study, the In-Body test, blood lipid profile, and analysis of vascular compliance and blood pressure were performing before and after in experiment. The twenty male subjects aged between 68 and 72 yr were recruited from the 'Y' senior towers in Korea. All subjects performed exercises on a weight training machines 40 min once a day for 52 weeks. The exercise intensity for resistance training was 60% of the 10 RM maximal voluntary contraction test. All subjects before performing resistance exercise showed an increase in hypertension following enhanced %fat, blood lipid factors (TC, LDL-C), whereas decreased lean body mass (LBM), vascular compliance. However, 52 weeks of resistance exercise suppressed %fat and LDL-C, whereas improved LBM, vascular compliance, resulting in reducing hypertensive levels in the elderly men. We suggest that resistance exercise can be a valuable tool for the remarkable improvement of hypertension.

Influence of blood pressure profile on frailty phenotype in community-dwelling elders in Brazil - FIBRA study

Frailty is a clinical condition associated with pathological aging and biological vulnerability. In the spectrum of events related to frailty, aging of the cardiocirculatory system and abnormalities in arterial blood pressure (BP) partly explain the changes in tissue perfusion and, potentially, the decrease in physiological reserves. This study investigated the relationship between BP levels, systemic arterial hypertension (SAH) and the frailty phenotype by analyzing frailty criteria in a cross-sectional model into the FIBRA network, a populational sample of community-dwelling elders in Southeastern Brazil. Study participants with ≥65 years were selected by probabilistic sampling of residents in the urban area of the municipality of Campinas (n=900). Considering frailty as a whole and the difference between genders, there was a greater proportion of frail or pre-frail individuals among women than men. Analysis of individual frailty criteria showed that weight loss and fatigue were more common among women (18.3% vs. 12.5%, p=0.034 and 22.5% vs. 11.9%, p<0.001, respectively). Comparison of individuals with or without SAH failed to reveal any differences related to frailty criteria. Nevertheless, averages of diastolic blood pressure (DBP) and mean arterial blood pressure values were lower among elderly individuals with reduced grip strength, physical activity and the frailty classification as a whole (OR 0.986, IC 0.975-0.997) (for every 1 mmHg reduction in MBP values, the likelihood of being frail increased 1.4%). Our findings corroborate the relationship between BP values and frailty in the elderly and contribute to an understanding of the pathophysiological mechanisms of the syndrome.

Public health options for improving cardiovascular health among older Americans

Life expectancy at birth has increased from 74 years in 1980 to 78 years in 2006. Older adults (aged 65 years and older) are living longer with cardiovascular conditions, which are leading causes of death and disability and thus an important public health concern. We describe several major issues, including the impact of comorbidities, the role of cognitive health, prevention and intervention approaches, and opportunities for collaboration to strengthen the public health system. Prevention can be effective at any age, including for older adults. Public health models focusing on policy, systems, and environmental change approaches have the goal of providing social and physical environments and promoting healthy choices.

Combined effects of cognitive impairment and hypertension on total mortality in elderly people: the Kangwha Cohort study

BACKGROUND

Previous studies have shown links between cognitive impairment and hypertension as well as mortality. However, combined effects of these two conditions on mortality have not been fully explored.

OBJECTIVE

To assess the combined effect of cognitive impairment and hypertension on all-cause mortality among the elderly people.

METHODS

We followed a cohort of 2,496 residents in Kangwha County, ranging in age from 64 to 101 years as of March 1994, for all-cause mortality for 11.8 years up to December 31, 2005. We calculated hazard ratios (HR) for all-cause mortality by cognitive status and blood pressure using the Cox proportional hazards model after having controlled for confounding factors.

RESULTS

1,189 people (47.6%) died during the 11.8 years of follow-up. The HR associated with severe cognitive impairment increased from 2.15 (95% CI: 1.30, 3.54) for prehypertension over 2.68 (95% CI: 1.60, 4.48) for stage 1 hypertension to 3.60 (95% CI: 1.99, 6.49) for stage 2 hypertension in women. A mortality risk of 3.67 (95% CI: 2.05, 6.57) was observed among men who had both mild cognitive impairment and stage 2 hypertension.

CONCLUSION

Individuals with coexisting cognitive impairment and hypertension are at an increased risk of all-cause mortality compared with those with cognitive impairment or hypertension alone.

Antihypertensive efficacy and safety of olmesartan medoxomil and ramipril in elderly patients with mild to moderate essential hypertension: the ESPORT study

OBJECTIVE

To compare the efficacy and safety of the angiotensin II antagonist olmesartan medoxomil (O) and the ACE inhibitor ramipril (R) in elderly patients with essential arterial hypertension.

METHODS

After a 2-week placebo wash-out 1102 treated or untreated elderly hypertensive patients aged 65-89 years (office sitting diastolic blood pressure, DBP, 90-109 mmHg and/or office sitting systolic blood pressure, SBP, 140-179 mmHg) were randomized double-blind to 12-week treatment with O 10 mg or R 2.5 mg once-daily. After the first 2 and 6 weeks doses could be doubled in non-normalized [blood pressure (BP) < 140/90 mmHg for nondiabetic and < 130/80 mmHg for diabetic) individuals, up to 40 mg for O and 10 mg for R. Office BPs were assessed at randomization, after 2, 6 and 12 weeks of treatment, whereas 24-h ambulatory BP was recorded at randomization and after 12 weeks.

RESULTS

In the intention-to-treat population (542 patients O and 539 R) after 12 weeks of treatment baseline-adjusted office SBP and DBP reductions were greater (P < 0.01) with O [17.8 (95% confidence interval: 16.8/18.9) and 9.2 (8.6/9.8) mmHg] than with R [15.7 (14.7/16.8) and 7.7 (7.1/8.3) mmHg]. BP normalization rate was also greater under O (52.6 vs. 46.0% R, P < 0.05). In the subgroup of patients with valid ambulatory BP recording (318 O and 312 R) the reduction in 24-h average BP was larger (P < 0.05) with O [SBP: 11.0 (12.2/9.9) and DBP: 6.5 (7.2/5.8) mmHg] than with R [9.0 (10.2/7.9) and 5.4 (6.1/4.7) mmHg]. The larger blood pressure reduction obtained with O was particularly evident in the last 6 h from the dosing interval; a better homogeneity of the 24-h BP control with O was confirmed by higher smoothness indices. The proportion of patients with drug-related adverse events was comparable in the two groups (3.6 O vs. 3.6% R), as well as the number of patients discontinuing study drug because of a side effect (14 O vs. 19 R).

CONCLUSION

In elderly patients with essential arterial hypertension O provides an effective, prolonged and well tolerated BP control, representing a useful option among first-line drug treatments of hypertension in this age group.

Whole rat DNA array survey for candidate genes related to hypertension in kidneys from three spontaneously hypertensive rat substrains at two stages of age and with hypotensive induction caused by hydralazine hydrochloride

Clarification of the genetic nature and more effective care for hypertension are required, given the high incidences of cardiovascular and cerebrovascular mortality. Thus, we surveyed candidate genes for hypertension with rat whole gene DNA microarrays using three novel methods. Gene expression analyses were conducted as follows: Method 1, three types of spontaneously hypertensive rat (SHR) substrains, SHR, stroke-prone SHR (SHRSP) and malignant type of SHRSP (M-SHRSP) were used and compared to normotensive Wistar Kyoto rats; Method 2, the expressed genes between rats of different ages were compared for different blood pressures; and Method 3, genes that were expressed in rats treated with or without an acute hypotensive stimulus, the antihypertensive hydralazine hydrochloride, were compared. This approach identified dozens of genes, including Dusp15, Cyp8b1, Armc 3, Gtpbp4, Mettl2, Mapk14, Prkar2b, frame 12, Anxa13, Ephx2, Myr8 and Pcdh9 by Method 1; Cyp2C and Atp12a by Method 2; and Kcnc3, Vnn1, TC560558 and Gabrq and a number of unknown genes by Methods 2 and 3, as probable candidate genes for hypertension in SHR substrains. Ephx2 was previously reported as a candidate gene in SHRs; however other genes were identified for the first time in this study. Since it was not always possible to completely demonstrate that these genes are responsible for hypertension in SHRs, further research into true candidate genes that participate in the genesis of hypertension in SHR substrains is warranted.

Optimal management of hypertension in elderly patients

Hypertension is a common and important modifiable risk factor for cardiovascular and kidney diseases. The prevalence of hypertension, particularly isolated systolic hypertension, increases with advancing age, and this is partly due to the age-related changes in the arterial tree, leading to an increase in arterial stiffness. Therapeutic lifestyle changes, such as reduced dietary sodium intake, weight loss, regular aerobic activity, and moderation of alcohol consumption, have been shown to benefit elderly patients with hypertension. Lowering blood pressure (BP) using pharmacological agents reduces the risk for cardiovascular morbidity and mortality, with no difference in risk reduction in elderly patients compared to younger hypertensives. Guidelines recommend a BP goal of <140/90 in hypertensive patients regardless of age and <130/80 in patients with concomitant diabetes or kidney disease, and lowering the BP further has not been shown to confer any additional benefit. Moreover, the choice of antihypertensive does not seem to be as important as the degree of BP lowering. Special considerations in the treatment of elderly hypertensive patients include cognitive impairment, dementia, orthostatic hypotension, and polypharmacy.

The metabolic syndrome in older persons

The metabolic syndrome is one of several patterns of risk for atherosclerotic cardiovascular disease. Although the concept of the metabolic syndrome has been known for 2 centuries or more, it is only recently that its individual components have been proposed. Visceral obesity is a central component but other major facets such as hypertension, dyslipidemia, or dysglycemia are often present. These components are well-established cardiovascular risk factors and therefore grouping them under a single entity, namely the metabolic syndrome, has questioned its clinical usefulness and its ability to predict cardiovascular disease. Depending on what criteria are used, the prevalence of this syndrome may be as much as 40% in those aged 60 years and older. Heredity, environmental factors, personal lifestyle habits and behavior, and clinical comorbidities all seem to be associated with the metabolic syndrome. In addition, hypogonadism in men and hypovitaminosis D are age-related issues associated with the metabolic syndrome. In ageing individuals the existence of the metabolic syndrome as a distinct entity is questioned although some studies report an association with diabetes mellitus, physical impairments, and cognitive dysfunction. Further studies that explore these factors over time are needed but for now, treatment remains focused on individual components and not on the syndrome as a whole.