More Versus Less Blood Pressure Lowering: An Update

Intensive blood pressure control for patients aged over 60: A meta-analysis of the SPRINT, STEP, and ACCORD BP randomized controlled trials

OBJECTIVES

To evaluate the effects of intensive treatment to lower blood pressure (BP) on the risk of cardiovascular disease (CVD) among patients aged over 60 years.

STUDY DESIGN

We extracted individual-level data of participants aged over 60 years from the SPRINT study and ACCORD study first, and then conducted a meta-analysis of major adverse cardiovascular events (MACEs) and other adverse events (hypotension and syncope) and renal outcomes across the SPRINT, STEP, ACCORD BP trials, which included 18,806 participants over 60 years of age. Participants were randomized to receive standard BP treatment or intensive BP treatment.

MAIN OUTCOME MEASURES

Hazard ratios (HRs) were used to calculate summary statistics.

RESULTS

In this meta-analysis, intensive treatment did not decrease either the all-cause mortality rate (HR: 0.98; 95 % confidence interval [CI]: 0.76-1.26; p = 0.87) or the cardiovascular mortality rate (HR: 0.77; 95 % CI: 0.54-1.08; p = 0.13). The incidence of MACEs (HR: 0.83; 95 % CI: 0.74-0.94; p = 0.003) and stroke (HR: 0.70; 95 % CI: 0.56-0.88; p = 0.002) was reduced, however. Intensive treatment had no effect on acute coronary syndrome (HR: 0.87; 95 % CI: 0.69-1.10; p = 0.24) or heart failure (HR: 0.70; 95 % CI: 0.40-1.22; p = 0.21). Intensive treatment increased the risk of hypotension (HR: 1.46; 95 % CI: 1.12-1.91; p = 0.006) and syncope (HR: 1.43; 95 % CI: 1.06-1.93; p = 0.02). Intensive treatment did not increase the risk of impaired kidney function among patients with chronic kidney disease (HR: 0.98; 95 % CI: 0.41-2.34; p = 0.96) or without chronic kidney disease (HR: 1.77; 95 % CI: 0.48-6.56; p = 0.40) at baseline.

CONCLUSIONS

Intensive BP goals reduced the incidence of MACEs and increased the risk of other adverse events without significant changes in mortality or renal outcome.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Phyllanthus amarus attenuated derangement in renal-cardiac function, redox status, lipid profile and reduced TNF-α, interleukins-2, 6 and 8 in high salt diet fed rats

High salt diet (HSD) has been implicated in the etiopathogenesis of immune derangement, cardiovascular disorders and, metabolic syndromes. This study investigated the protective effect of ethanol extract of Phyllanthus amarus (EEPA) against high salt diet (HSD) induced biochemical and metabolic derangement in male Wistar rats. The rats were divided into 5 groups of 6 animals each as follows; control group fed with normal rat chow, negative control group, fed HSD only, animals on HSD treated orally with 75 mg/kg, 100 mg/kg, and, 150 mg/kg EEPA once daily. At the end of 8 weeks treatment, lipid profile (TG, TC, LDL, and VLDL), oxidative stress (catalase, reduced glutathione, and malondialdehyde), inflammatory (TNF-a, interleukins 2, 6, and 8), cardiac (lactate dehydrogenase, creatine kinase) and kidney function markers (urea, uric acid, creatinine) were assessed. Serum TG, TC, LDL, and VLDL content were significantly (p < 0.05) elevated in HSD-only fed rats, while HDL was significantly elevated in a concentration-dependent manner in EEPA treated animals. The extract produced a significant (p < 0.05) and dose-dependent increase in the antioxidant enzymes activities and a significant reduction in the malondialdehyde level. A significant (p < 0.05) dose-dependent reduction in serum TNF-alpha, IL-2, 6, and 8 of EEPA treated rats compared with HSD-fed rats was observed. More so, reduction in serum LDH, creatine kinase, creatinine, urea, and uric acid activity of extract-treated animals were noted. EEPA attenuated high salt diet-induced oxidative stress, inflammation, and dyslipidemia in rats.

VEGF-C attenuates renal damage in salt-sensitive hypertension

Salt-sensitive hypertension is a major risk factor for renal impairment leading to chronic kidney disease. High-salt diet leads to hypertonic skin interstitial volume retention enhancing the activation of the tonicity-responsive enhancer-binding protein (TonEBP) within macrophages leading to vascular endothelial growth factor C (VEGF-C) secretion and NOS3 modulation. This promotes skin lymphangiogenesis and blood pressure regulation. Whether VEGF-C administration enhances renal and skin lymphangiogenesis and attenuates renal damage in salt-sensitive hypertension remains to be elucidated. Hypertension was induced in BALB/c mice by a high-salt diet. VEGF-C was administered subcutaneously to high-salt-treated mice as well as control animals. Analyses of kidney injury, inflammation, fibrosis, and biochemical markers were performed in vivo. VEGF-C reduced plasma inflammatory markers in salt-treated mice. In addition, VEGF-C exhibited a renal anti-inflammatory effect with the induction of macrophage M2 phenotype, followed by reductions in interstitial fibrosis. Antioxidant enzymes within the kidney as well as urinary RNA/DNA damage markers were all revelatory of abolished oxidative stress under VEGF-C. Furthermore, VEGF-C decreased the urinary albumin/creatinine ratio and blood pressure as well as glomerular and tubular damages. These improvements were associated with enhanced TonEBP, NOS3, and lymphangiogenesis within the kidney and skin. Our data show that VEGF-C administration plays a major role in preserving renal histology and reducing blood pressure. VEGF-C might constitute an interesting potential therapeutic target for improving renal remodeling in salt-sensitive hypertension.

Lessons learned from Systolic Blood Pressure Intervention Trial

PURPOSE OF REVIEW

The optimal blood pressure (BP) goal during treatment of hypertension has been controversial. In this report, recent articles that elaborate on this issue are reviewed.

RECENT FINDINGS

Results from the Systolic Blood Pressure Intervention Trial (SPRINT) have suggested substantial benefits from more intensive BP lowering than is recommended in current US BP management guidelines.

SUMMARY

Increasing evidence suggests that intensive BP lowering provides a cost-effective means to improve health in many adults with high BP. SPRINT provides the most convincing confirmation, but experience in other trials, alone and in pooled analyses augments and broadens the evidence base to patient groups who were not included in SPRINT. Implementation trials to document feasibility and effectiveness of SPRINT-like interventions in routine practice, including in resource-constrained settings, are warranted.