Association of systolic blood pressure levels with cardiovascular events and all-cause mortality among older adults taking antihypertensive medication

Association of socioeconomic status with prognosis in hypertensive patients over age 65: a cohort study in the community setting

OBJECTIVE

To examine whether socioeconomic status is associated with prognosis after the diagnosis of hypertension (HTN), in a population older than 65 years, in the community setting.

DESIGN

Retrospective cohort study.

SETTING

All the primary care centres of the Community of Madrid (n=392).

PARTICIPANTS

All patients (>65 years) with a new diagnosis of HTN in 2007-08, without previous kidney or cardiovascular (K/CV) events (n=21 754).Patient records from primary care electronic health records and Spanish mortality database were analysed from January 2007 through December 2018. Sociodemographic data such as age, gender, Area Deprivation Index (MEDEA-Mortalidad en áreas pequeñas Españolas y Desigualdades Socioeconómicas y Ambientales-Index in quintiles), and characteristics, such as smoking, type 2 diabetes mellitus and hypercholesterolaemia, were collected at the time of enrolment.

PRIMARY AND SECONDARY OUTCOME MEASURES

The occurrence of K/CV events (including mortality from these causes) and total mortality were evaluated using Cox regression.

RESULTS

Patients had a mean age of 73.5 (SD 6.5) years, and 63.5% were women. The median follow-up was 128.7 months (IQR: 110.6-136.7 months). There were 10 648 first K/CV events, including 1508 deaths from these causes and 4273 deaths from other causes. Adjusted for age, gender, smoking, diabetes and hypercholesterolaemia, when comparing the third, fourth and last quintiles (less affluent) of the Deprivation Index with respect to the first quintile, the hazard of K/CV events increased by 14.8% (95% CI: 3.3 to 27.6%), 16.0% (95% CI: 6.4 to 26.4%) and 19.1% (95% CI: 8.9 to 30.2%), respectively. The MEDEA Index was not associated with differences in adjusted total mortality.

CONCLUSION

Living in a low socioeconomic status area is associated with an increase in kidney or cardiovascular events in hypertensive patients diagnosed after age 65 years, which will result in a significant increase in disease burden even if not related to an increase in total mortality.

Optimal Systolic Blood Pressure for the Prevention of All-Cause and Cardiovascular Disease Mortality in Older Adults With Hypertension: Nationwide Population-Based Cohort Study

BACKGROUND

Target systolic blood pressure (SBP) levels for older adults with hypertension vary across countries, leading to challenges in determining the appropriate SBP level.

OBJECTIVE

This study aims to identify the optimal SBP level for minimizing all-cause and cardiovascular disease (CVD) mortality in older Korean adults with hypertension.

METHODS

This retrospective cohort study used data from the National Health Insurance Service database. We included older adults aged 65 years or older who were newly diagnosed with hypertension and underwent a National Health Insurance Service health checkup in 2003-2004. We excluded patients who had a history of hypertension or CVD, were not prescribed medication for hypertension, had missing blood pressure or any other covariate values, and had fewer than 2 health checkups during the follow-up period until 2020. We categorized the average SBP levels into 6 categories in 10 mm Hg increments, from <120 mm Hg to ≥160 mm Hg; 130-139 mm Hg was the reference range. Cox proportional hazards models were used to examine the relationship between SBP and all-cause and CVD mortalities, and subgroup analysis was conducted by age group (65-74 years and 75 years or older).

RESULTS

A total of 68,901 older adults newly diagnosed with hypertension were included in this study. During the follow-up period, 32,588 (47.3%) participants had all-cause mortality and 4273 (6.2%) had CVD mortality. Compared to older adults with SBP within the range of 130-139 mm Hg, individuals who fell into the other SBP categories, excluding those with SBP 120-129 mm Hg, showed significantly higher all-cause and CVD mortality. Subgroup analysis showed that older adults aged 65-74 years had higher all-cause and CVD mortality rates according to SBP categories than those aged 75 years or older.

CONCLUSIONS

The SBP levels within the range of 120-139 mm Hg were associated with the lowest all-cause and CVD mortality rates among older Korean adults with hypertension. It is recommended to reduce SBP to <140 mm Hg, with 120 mm Hg as the minimum value for SBP, for older Korean adults with hypertension. Additionally, stricter SBP management is required for adults aged 65-74 years.

Effect of 10-year cumulative blood pressure exposure on atherosclerotic cardiovascular disease of different age groups: kailuan cohort study

Background

The level at which cumulative blood pressure (BP) can increase the risk of ASCVD in different age groups remains unclear. This study aimed to investigate the association of 10-year cumulative BP levels with the long-term risk of ASCVD of different age groups.

Methods

Cumulative BP exposure was assessed using the time-weighted average (TWA) BP divided into four BP groups. The participants were also divided into four groups according to their baseline age (<50, 50-59, 60-69, or ≥70 years). The association between TWA BP and the risk of ASCVD was assessed by age group using multivariate Cox models. The China-PAR prediction model was used to assess the ability of TWA BP to predict ASCVD.

Results

In the group aged <50 years, the hazard ratios and 95% confidence intervals for the risk of ASCVD were 2.66 (1.04-6.80), 3.38 (1.54-7.43), and 3.13 (1.36-7.24) for the elevated BP, stage 1 hypertension, and stage 2 hypertension groups, respectively, when compared with the normal BP group. There was a significant difference in the risk of ASCVD between the age groups, with participants aged <50 years having the highest risk, followed by those aged 50-59, 60-69, and ≥70 years.

Conclusions

The risk of ASCVD with high cumulative BP exposure was age-dependent, with a gradual decrease in risk with increasing age.

Impact of hypertension diagnosis on morbidity and mortality: a retrospective cohort study in primary care

BACKGROUND

Hypertension is responsible for a huge burden of disease. The aim of this study was to evaluate the impact of newly diagnosed hypertension on the occurrence of kidney or cardiovascular events (K/CVEs) and on mortality among community dwellers.

METHODS

Retrospective cohort study, conducted from January, 2007, to December, 2018. All patients (age > 18) newly diagnosed with hypertension and no previous K/CVEs in 2007 and 2008, in the primary care centers of Madrid (Spain) (n = 71,770), were enrolled. The control group (n = 72,946) included patients without hypertension, matched by center, sex and age. The occurrence of kidney or CV events, including mortality from these causes and total mortality were evaluated using Cox regression and multistate models. Data were collected from three sources: personal data from administrative records, clinical data from medical records, and mortality data from regional and national databases.

RESULTS

The median follow-up was 138.61 months (IQR: 124.68-143.97 months). There were 32,896 K/CVEs (including 3,669 deaths from these causes) and 12,999 deaths from other causes. Adjusted for sex, smoking, diabetes and socioeconomic status, K/CVEs HR was 4.36 (95% CI: 3.80-5.00) for diagnoses before 45 years of age, 2.45(95% CI: 2.28- 2.63) for diagnosis between 45 to 54 years, and HR decreased to 1.86 (95% CI: 1.64-210) for diagnoses over age 85. Total mortality risk was only higher for hypertension diagnosed before 55 years of age (HR: 2.47, 95% CI: 1.90-3.19 for ages 18 to 44; and HR: 1.14, 95% CI: 1.02-1.28 for ages 45 to 54).

CONCLUSION

The diagnosis of hypertension in the community environment, in patients without evidence of previous kidney or CV disease, is associated with a large increase in the risk of K/CVEs, but especially in individuals diagnosed before the age of 55. This diagnosis is only associated with an increase in kidney or cardiovascular mortality or overall mortality when it occurs before age 55.

Impacto del control de la tensión arterial sobre la morbimortalidad en pacientes hipertensos mayores de 65 años en el ámbito comunitario

Objetivo: evaluar el impacto del control de la tensión arterial (TA) sobre la morbimortalidad en > 65 años, sin patología cardiovascular previa, en el ámbito comunitario. Métodos: estudio de cohortes retrospectivas. Se incluyeron todos los pacientes (≥ 65 años) con diagnóstico de hipertensión arterial (HTA) (01/01/2007-31/12/2008), sin eventos cardiovasculares previos de los centros de salud de la Comunidad de Madrid, con al menos dos registros de TA el primer año de seguimiento (n = 17.150). Se evaluaron la aparición de eventos cardiovasculares (incluida mortalidad cardiovascular) y la mortalidad total, mediante regresión de Cox. Resultados: la mediana de seguimiento para mortalidad fue de 90,48 meses (rango intercuartil [RIC]: 53,19-130,30 meses). Se produjeron 8.641 eventos cardiovasculares y 1.026 muertes por cualquier causa. Ajustado por género, grado de hipertensión, tabaquismo, diabetes e hipercolesterolemia, el buen control (TA < 140/90 mmHg) no se asociaba con una disminución de eventos cardiovasculares, pero sí con una disminución de mortalidad del 14,41% (hazard ratio [HR] 0,8559; intervalo de confianza [IC] 95%: 0,7776-0,9421%) entre 75 y 84 años. Cuando se utilizan las cifras de 130/80 mmHg para definir el buen control, este se asociaba con un exceso de mortalidad del 43,58% (IC 95%: 19,60-72,36%) entre 65 y 74 años y del 61,22% (IC 95%: 22,99-111,35%) en sujetos de 85 y más años. Conclusión: el control de la TA en sujetos >65 años se asocia con una disminución ligera de la mortalidad entre 75 y 84 años. Cifras de control más estrictas se relacionan con mayor ocurrencia de evento cardiovascular y de mortalidad, especialmente en el grupo de mayor edad. Palabras clave: hipertensión, indicadores de morbimortalidad, Atención Primaria de Salud, salud de la persona anciana.

Control of Blood Pressure and Risk of Cardiovascular Disease and Mortality in Elderly Chinese: A Real-World Prospective Cohort Study

BACKGROUND

The STEP trial (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) showed that older hypertensive patients might benefit from a target systolic blood pressure (SBP) of 110 to <130 mm Hg. We examined whether this target SBP is associated with a decreased risk of cardiovascular disease (CVD) and all-cause mortality among elderly Chinese in real-world settings.

METHODS

This prospective study included 13 383 CVD-free participants aged 60 to 80 years and with SBP within 110 to <150 mm Hg at baseline. Inverse probability of treatment weighting was used to adjust for baseline differences. Weighted Cox proportional hazards models yielded adjusted hazard ratios (HRs) and 95% CIs of CVD and all-cause mortality associated with normalized SBP (110 to <130 mm Hg).

RESULTS

During a median follow-up of 13.01 years, we identified 1727 cases of CVD and 3742 deaths. After inverse probability of treatment weighting, compared with non-normalized SBP, normalized SBP was associated with a decreased risk of CVD (HR, 0.81 [95% CI, 0.76-0.87]) and all-cause mortality (HR, 0.89 [95% CI, 0.85-0.93]). Beneficial effects of longitudinal normalized SBP presented by the updated mean SBP were also observed for CVD (HR, 0.88 [95% CI, 0.78-0.93]) and all-cause mortality (HR, 0.93 [95% CI, 0.88-0.97]). Multiple sensitivity analyses yielded similar results.

CONCLUSIONS

The SBP target of 110 to <130 mm Hg recommended by the STEP trial was associated a lower risk of CVD and all-cause mortality than was SBP of 130 to <150 mm Hg among elderly Chinese in real-world settings.

Validity and reliability of a short self-efficacy instrument for hypertension treatment adherence among adults with uncontrolled hypertension

OBJECTIVE

To establish the reliability and validity of a self-report measure designed to assess self-efficacy for hypertension treatment adherence.

METHODS

This investigation was embedded within a six-month randomized clinical trial (RCT), which demonstrated that a tailored, stage-matched intervention was more effective at improving hypertension control than usual care among individuals (n = 533) with repeated uncontrolled hypertension. The instrument used to assess self-efficacy for hypertension treatment adherence (SE-HTA) comprised three subscales that assessed diet self-efficacy (DSE), exercise self-efficacy (ESE), and medication self-efficacy (MSE). To determine SE-HTA validity and reliability, we assessed internal consistency using Cronbach's α coefficients, conducted exploratory factor analysis, and evaluated convergent and discriminant validity, as well as test-retest reliability using Spearman's ρ correlation coefficients.

RESULTS

Cronbach's α (internal consistency) values for DSE, ESE, and MSE were 0.81, 0.82 and 0.74. Factor analysis and the scree plot demonstrated three distinct factors, which correspond to the three subscales contained in the SE-HTA instrument. SE-HTA possessed good convergent and discriminant validity, and moderate test-retest reliability.

CONCLUSION

The SE-HTA instrument containing diet, exercise, and medication adherence subscales is valid and reliable in adults with uncontrolled hypertension.

PRACTICE IMPLICATIONS

This SE-HTA instrument measures self-efficacy and could help facilitate behavior change in hypertension.

Associations of falls and severe falls with blood pressure and frailty among Chinese community-dwelling oldest olds: The Chinese Longitudinal Health and Longevity Study

INTRODUCTION

Falls are a leading cause of death among Chinese oldest olds. However, studies on Chinese community-dwelling older adults are lacking. We aimed to identify the associations of falls and severe falls with blood pressure and frailty among Chinese community-dwelling oldest olds.

METHODS

Cross-sectional analyses were conducted with 6,595 community-dwelling oldest olds (aged ≥80 years) from 22 Chinese provinces from the Chinese Longitudinal Health and Longevity Study (CLHLS). Systolic BP (SBP) and diastolic BP (DBP) were measured twice at participants' homes, and a 38-item frailty index was used to assess the frailty status of participants. Falls and severe falls were confirmed through face-to-face interviews. Multivariate logistic regression was used to investigate the associations of BP and frailty with falls and severe falls.

RESULTS

The mean participant age was 91.0 years, and 56.1% were female. In total, 24.2% participants had a history of fall and 8.3% had a history of severe falls. The multivariate-adjusted odds ratio (OR) for falls among the oldest old with SBP ≥140 mm Hg compared to those with an SBP of 120-129 mm Hg was 1.20 (95% confidence interval [CI], 1.01-1.44). The adjusted OR for falls among frail participants compared to robust participants was 1.39 (95% CI, 1.02-1.89). DBP and pre-frailty were not associated with falls after multivariate adjustment. SBP, DBP, and frailty status were not associated with severe falls after multivariate adjustment.

CONCLUSIONS

SBP and frailty but not DBP and pre-frailty are associated with increased odds of falls among Chinese community-dwelling oldest olds.

Association of optimal blood pressure with mortality in patients taking antihypertensive medications

We investigated the relationship between blood pressure (BP) and mortality in patients taking antihypertensive medications in the Korean using data from the 2007-2015 Korean National Health and Nutrition Examination Surveys. A total of 6601 patients aged 30-74 years were included. Systolic BP (SBP) and diastolic BP (DBP) were both divided into four groups as follows: SBP < 120, 120 ≤ SBP ≤ 129 130 ≤ SBP ≤ 139, and SBP ≥ 140; DBP < 70, 70 ≤ DBP ≤ 79, 80 ≤ DBP ≤ 89, and DBP ≥ 90. The survival rates and hazard ratios were evaluated using Kaplan-Meier curves and multivariable Cox regression analyses. To evaluate the predictability of all-cause mortality according to SBP and/or DBP, we calculated Harrell's concordance-index. The lowest DBP group had a high risk of mortality regardless of the SBP status. The group with DBP < 70 mm Hg and SBP ≥ 140 mm Hg showed the highest mortality. The discriminatory ability calculated using Harrell's C-indexes was greater for the combination of SBP and DBP compared to DBP or SBP alone. These results suggest that it is more effective to simultaneously evaluate the effect of SBP and DBP to predict mortality; clinicians should manage DBP < 70 mm Hg when treating hypertensive patients.

Managing Hypertension in the elderly: What's new?

Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world. Hypertension is a major risk factor for cardiovascular events and mortality in the elderly. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling persons aged 65 years and older with an average systolic blood pressure of 130 ​mm Hg or higher or a diastolic blood pressure of 80 ​mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 ​mm Hg For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment. Randomized clinical trials need to be performed in frail elderly patients with hypertension living in nursing homes. Elderly frail persons with prevalent and frequent falls, marked cognitive impairment, and multiple comorbidities requiring multiple antihypertensive drugs also need to be included in randomized clinical trials. Data on patients older than 85 years treated for hypertension are also sparse. These patients need clinical trial data. Finally, the effect of different antihypertensive drugs on clinical outcomes including serious adverse events needs to be investigated in elderly frail patients with hypertension and different comorbidities.

Managing the elderly patient with hypertension: current strategies, challenges, and considerations

Introduction: Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world.Areas covered: An extensive literature review of articles and clinical trials on PUBMED on the topic of hypertension in the elderly from 1976 through January 2020 was conducted. This review article discusses clinical trials on treatment of hypertension in the elderly, the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, the 2018 European Society of Cardiology/European Society of Hypertension guidelines, and the treatment of hypertension and of resistant hypertension in the elderly.Expert opinion: The 2017 ACC/AHA hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mm Hg. For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment.

Epidemiology of hypertensive heart disease in Poland: findings from the Global Burden of Disease Study 2016

INTRODUCTION

Hypertension may cause target organ damage leading to hypertensive heart disease (HHD). The burden caused by HHD in Poland has not been studied systematically. The purpose of this study was to describe the burden of HHD in Poland in terms of prevalence, mortality, disability-adjusted life years lost (DALY) and key risk factors.

MATERIAL AND METHODS

Data were obtained from the Global Burden of Diseases, Injuries and Risk Factors (GBD) Study database. The GBD uses a wide range of data sources and complex statistical methods to estimate disease burden for all countries by age, sex, and year. HHD was defined by ICD-9 codes 402-402.91 and ICD-10 codes I11-I11.9. From the GBD 2016 estimates, we extracted data for Poland between 1990 and 2016.

RESULTS

Hypertensive heart disease is the fourth most important cause of cardio- and cerebrovascular death, after ischemic heart disease, stroke and cardiomyopathy. In 2016, there were about 180 000 people diagnosed with HHD in Poland and close to 5000 HHD-related deaths. HHD prevalence increased from 0.29% in 1990 to 0.47% in 2016 and was higher in women, while mortality increased from 11.2 to 12.7 per 100 000, largely due to population aging. Age-standardized death and DALY rates declined between 1990 and 2016 and were lower than in Central Europe but higher than in Western Europe.

CONCLUSIONS

Our data suggest a need for national initiatives to improve the diagnosis and treatment of hypertension, slow the progression of HHD, and reduce the related risks and premature deaths.

Ambulatory blood-pressure monitoring, antihypertensive therapy and the risk of fall injuries in elderly hypertensive patients

Background

Fall injuries are common among the elderly. The aim of this study was to investigate whether blood-pressure patterns, as measured by 24-h ambulatory blood pressure monitoring (ABPM), or intensification of antihypertensive therapy following the 24-h ABPM, may be associated with fall injuries in hypertensive elderly patients.

Methods

In a retrospective study, community-based elderly patients (age ≥ 70 years) who were referred to 24-h ABPM were evaluated for fall injuries within one-year post-ABPM. We compared the clinical characteristics, 24-h ABPM patterns and the intensification of hypertensive therapy following 24-h ABPM, between patients with and without a fall injury.

Results

Overall 1032 hypertensive elderly patients were evaluated. Fifty-five (5.3%) had a fall injury episode in the year following ABPM. Patients with a fall injury were significantly older, and with higher rates of previous falls. Lower 24-h diastolic blood-pressure (67.3 ± 7.6 vs. 70.7 ± 8.8 mmHg; P < 0.005) and increased pulse-pressure (74.7 ± 14.3 vs. 68.3 ± 13.7 mmHg; P < 0.005), were found in the patients with a fall injury, compared to those without a fall injury. After adjustment for age, gender, diabetes mellitus and previous falls, lower diastolic blood-pressure and increased pulse-pressure were independent predictors of fall injury. Intensification of antihypertensive treatment following the 24-h ABPM was not associated with an increased rate of fall injury.

Conclusions

Low diastolic blood-pressure and increased pulse-pressure in 24-h ABPM were associated with an increased risk of fall injury in elderly hypertensive patients. Intensification of antihypertensive treatment following 24-h ABPM was not associated with an increased risk of fall injury.

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.

Renal sympathetic denervation lowers arterial pressure in canines with obesity-induced hypertension by regulating GAD65 and AT1R expression in rostral ventrolateral medulla

To explore the roles of glutamate acid decarboxylase 65 (GAD65) and angiotensin II type 1 receptor (AT₁R) in the action of renal sympathetic denervation (RSD) on obesity-induced hypertension in canines. Thirty-two beagles were randomly divided into a hypertensive model (n = 22) and control (n = 10) groups. A hypertensive canine model was established by feeding a high-fat diet. Twenty hypertensive beagles were randomized equally to a sham-surgery and RSD-treated group receiving catheter-based radiofrequency RSD. Compared with the control group, the sham-surgery group exhibited significant increases in blood pressure, serum angiotensin II level, rostral ventrolateral medulla (RVLM) glutamate level, and AT₁R mRNA and protein expression and decreases in γ-amino acid butyric acid (γ-GABA) level and GAD65 mRNA and protein expression in the RVLM (all P < 0.05). Treatment with RSD significantly attenuated the above abnormal alterations (all P < 0.05). Linear correlation analysis revealed that angiotensin II level was positively correlated with glutamate level (r = 0.804) and inversely correlated with γ-GABA level (r = -0.765). GAD65 protein expression was positively correlated with γ-GABA level (r = 0.782). Catheter-based radiofrequency RSD can decrease blood pressure in obesity-induced hypertensive canines. The antihypertensive mechanism might be linked to upregulation of GAD65 and downregulation of AT₁R in the RVLM.

Serum lipid profile, sleep-disordered breathing and blood pressure in the elderly: a 10-year follow-up of the PROOF-SYNAPSE cohort

OBJECTIVES

Dyslipidemia, sleep-disordered breathing (SDB) and hypertension are comorbid factors evidenced in adults, but poorly studied in old people. This study aimed to examine the long-term evolution of the serum lipid profile, and its relationships with SDB and blood pressure (BP) in the elderly.

METHODS

A ten-year follow-up of the prospective Prognostic Indicator of Cardiovascular and Cerebrovascular Events (PROOF) and the Autonomic Nervous System Activity, Aging and Sleep Apnea/Hypopnea (SYNAPSE) cohort, which initially included 1011 elderly subjects from the general population, and who were untreated by continuous positive airway pressure (CPAP). Serum lipid profile, respiratory polygraphy for SDB and ambulatory blood pressure monitoring were performed.

RESULTS

A total of 266 subjects (male/female 150/116; age 66.2 ± 0.8 years) were reassessed after 9.6 ± 0.7 years (age 75.8 ± 1.2 years). The prevalence of high-risk dyslipidemia decreased from 61.3 to 44.4%, and hypertension from 57.9 to 27.4%. The nocturnal oxygen desaturation index increased (mean + 2.3 ± 6.7 events/hour; p < 0.001), while the mean SaO₂ and minimal SaO₂ decreased. These variations (Δ) of oxygen desaturation worsened whether or not elderly subjects took anti-hypertensive and lipid-lowering treatments, and were not associated with serum lipid variations. The decrease in diurnal diastolic BP was independently associated with aging, and with the lowering of the waist/hip ratio (ΔW/H) and low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, while the decrease in diurnal systolic BP only depended on aging and ΔW/H.

CONCLUSIONS

The results suggested that the observed worsening of nocturnal oxygen desaturation after 10 years in the elderly was independent of the change in circulating lipids, and not influenced by lipid-lowering treatments. However, the variation in blood pressure remained associated with aging, waist/hip and LDL-C/HDL-C ratios.

TRIAL REGISTRY

NCT00759304 and NCT00766584 at clinicaltrials.gov.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Design and implementation of a combined observational and interventional study: Trends of prevalence, awareness, treatment and control hypertension and the effect of expanded chronic care model on control, treatment and self-care

BACKGROUND

Lack of information about hypertension leads to failure in detection, treatment and reduced estimation of this disease effects. So, a comprehensive study, named trends of prevalence, awareness, treatment and control hypertension among the adults in Isfahan, Iran (2001-2016) and evaluation of the effect of expanded chronic care model (ECCM) on control, treatment and self-care, has been designed. This study explains the aspects of design and methods of its implementation.

METHODS

This study was conducted in four stages in 2014-2016. In the 1st stage, valid questionnaires were made to assess knowledge, attitude and practice, and self-care. In the 2nd stage, the status of prevalence, awareness, treatment and control and hypertension risk factors was assessed. In the 3rd stage, a two-group clinical trial was conducted to evaluate the effectiveness of ECCM on hypertensive patients and their families. In the 4th stage, the results of hypertension prevalence and its risk factors in adults in 2016 were compared with two other studies undertaken in 2001 and 2007.

RESULTS

To develop the questionnaire, face and content validity, internal and external reliability, and construct validity were examined. Prevalence, awareness, treatment and control of hypertension and risk factors among 2107 adult individuals were determined in Isfahan. In a clinical trial, 216 hypertensive patients were randomly assigned into intervention and control groups. Finally, a sample size of 8073 people was used to determine and compare the 15-year-old trend of hypertension and its affecting factors.

CONCLUSION

It is obvious that the final findings of this study will play a key role in health and research policy and provide a suitable model for implementing appropriate interventional measures at the provincial and national levels.

Blood Pressure, Antihypertensive Polypharmacy, Frailty, and Risk for Serious Fall Injuries Among Older Treated Adults With Hypertension

Antihypertensive medication and low systolic blood pressure (BP) and diastolic BP have been associated with an increased falls risk in some studies. Many older adults have indicators of frailty, which may increase their risk for falls. We contrasted the association of systolic BP, diastolic BP, number of antihypertensive medication classes taken, and indicators of frailty with risk for serious fall injuries among 5236 REGARDS study (Reasons for Geographic and Racial Difference in Stroke) participants ≥65 years taking antihypertensive medication at baseline with Medicare fee-for-service coverage. Systolic BP and diastolic BP were measured, and antihypertensive medication classes being taken assessed through a pill bottle review during a study visit. Indicators of frailty included low body mass index, cognitive impairment, depressive symptoms, exhaustion, impaired mobility, and history of falls. Serious fall injuries were defined as fall-related fractures, brain injuries, or joint dislocations using Medicare claims through December 31, 2014. Over a median of 6.4 years, 802 (15.3%) participants had a serious fall injury. The multivariable-adjusted hazard ratio for a serious fall injury among participants with 1, 2, or ≥3 indicators of frailty versus no frailty indicators was 1.18 (95% confidence interval, 0.99-1.40), 1.49 (95% confidence interval, 1.19-1.87), and 2.04 (95% confidence interval, 1.56-2.67), respectively. Systolic BP, diastolic BP, and number of antihypertensive medication classes being taken at baseline were not associated with risk for serious fall injuries after multivariable adjustment. In conclusion, indicators of frailty, but not BP or number of antihypertensive medication classes, were associated with increased risk for serious fall injuries among older adults taking antihypertensive medication.

Eplerenone for hypertension

BACKGROUND

Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension.

OBJECTIVES

To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all-cause mortality, cardiovascular events (fatal or non-fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure.

SEARCH METHODS

We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions.

SELECTION CRITERIA

We selected randomized placebo-controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5.

MAIN RESULTS

A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta-analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI -11.08 to -7.34; I² = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI -5.03 to -3.33; I² = 0%) (moderate quality evidence).There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment.

AUTHORS' CONCLUSIONS

Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients.

Predictive Value of Cumulative Blood Pressure for All-Cause Mortality and Cardiovascular Events

The predictive value of cumulative blood pressure (BP) on all-cause mortality and cardiovascular and cerebrovascular events (CCE) has hardly been studied. In this prospective cohort study including 52,385 participants from the Kailuan Group who attended three medical examinations and without CCE, the impact of cumulative systolic BP (cumSBP) and cumulative diastolic BP (cumDBP) on all-cause mortality and CCEs was investigated. For the study population, the mean (standard deviation) age was 48.82 (11.77) years of which 40,141 (76.6%) were male. The follow-up for all-cause mortality and CCEs was 3.96 (0.48) and 2.98 (0.41) years, respectively. Multivariate Cox proportional hazards regression analysis showed that for every 10 mm Hg·year increase in cumSBP and 5 mm Hg·year increase in cumDBP, the hazard ratio for all-cause mortality were 1.013 (1.006, 1.021) and 1.012 (1.006, 1.018); for CCEs, 1.018 (1.010, 1.027) and 1.017 (1.010, 1.024); for stroke, 1.021 (1.011, 1.031) and 1.018 (1.010, 1.026); and for MI, 1.013 (0.996, 1.030) and 1.015 (1.000, 1.029). Using natural spline function analysis, cumSBP and cumDBP showed a J-curve relationship with CCEs; and a U-curve relationship with stroke (ischemic stroke and hemorrhagic stroke). Therefore, increases in cumSBP and cumDBP were predictive for all-cause mortality, CCEs, and stroke.

Measures of Kidney Disease and the Risk of Venous Thromboembolism in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study

BACKGROUND

Kidney disease has been associated with venous thromboembolism (VTE) risk, but results conflict and there is little information regarding blacks.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

30,239 black and white adults 45 years or older enrolled in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study 2003 to 2007.

PREDICTORS

Estimated glomerular filtration rate (eGFR) using the combined creatinine-cystatin C (eGFR_cr-cys) equation and urinary albumin-creatinine ratio (ACR).

OUTCOMES

The primary outcome was adjudicated VTE, and secondary outcomes were provoked and unprovoked VTE, separately. Mortality was a competing-risk event.

RESULTS

During 4.6 years of follow-up, 239 incident VTE events occurred over 124,624 person-years. Cause-specific HRs of VTE were calculated using proportional hazards regression adjusted for age, sex, race, region of residence, and body mass index. Adjusted VTE HRs for eGFR_cr-cys of 60 to <90, 45 to <60, and <45 versus ≥90mL/min/1.73m² were 1.28 (95% CI, 0.94-1.76), 1.30 (95% CI, 0.77-2.18), and 2.13 (95% CI, 1.21-3.76). Adjusted VTE HRs for ACR of 10 to <30, 30 to <300, and ≥300 versus <10mg/g were 1.14 (95% CI, 0.84-1.56), 1.15 (95% CI, 0.79-1.69), and 0.64 (95% CI, 0.25-1.62). Associations were similar for provoked and unprovoked VTE.

LIMITATIONS

Single measurement of eGFR and ACR may have led to misclassification. Smaller numbers of events may have limited power.

CONCLUSIONS

There was an independent association of low eGFR (<45 vs ≥90mL/min/1.73m²) with VTE risk, but no association of ACR and VTE.

Geographic Distributions in Hypertension Diagnosis, Measurement, Prevalence, Awareness, Treatment and Control Rates among Middle-aged and Older Adults in China

Hypertension is of public health importance in China, but information on geographic distribution on hypertension by map visualization is limited for middle-aged and older adults. Regional geographic variations remain unexplained. Our study is to present geographic distributions at the provincial level and identify provinces and municipalities with high hypertension diagnosis, measurement and prevalence rates and/or low awareness, treatment, control rates among aged 45+ adults in China. We used data collected from the China Health and Retirement Longitudinal Study (n = 13,583) of Chinese people aged 45 years or older. We used weighted rates for our analysis. The rates by provinces and municipalities were compared using map visualization, and explore the main factors of the disparity using ordinal logistic regression. Higher hypertension prevalence rates (56.3%) but lower hypertension awareness, treatment and control rates (37.3%, 21.1% and 14.9%, respectively) were observed in Guizhou. Shanghai and Beijing had the highest hypertension prevalence, awareness and treatment rates (65.0%, 87.8% and 80.0% for Shanghai, 57.5%, 88.6% and 77.5% for Beijing, respectively). Remarkable variations were observed among surveyed provinces and municipalities. Several Chinese regions show particularly higher prevalence rates and/or lack of hypertension awareness and poor control.

What Should Be the Target Blood Pressure in Elderly Patients With Diabetes?

Hypertension is very common in elderly subjects with type 2 diabetes. The coexistence of hypertension and diabetes can be devastating to the cardiovascular system, and in these patients, tight blood pressure (BP) control is particularly beneficial. Little information is available regarding the target BP levels in elderly hypertensive patients with type 2 diabetes, and therefore extrapolation from data in the general population should be done. However, it is difficult to extrapolate from the general population to these frail individuals, who usually have isolated systolic hypertension, comorbidities, organ damage, cardiovascular disease, and renal failure and have a high rate of orthostatic and postprandial hypotension. On the basis of the available evidence, we provide arguments supporting the individualized approach in these patients. Target BP should be based on concomitant diseases, orthostatic BP changes, and the general condition of the patients. It is recommended to lower BP in the elderly patient with diabetes to <140-150/90 mmHg, providing the patient is in good condition. In patients with isolated systolic hypertension, the same target is reasonable providing the diastolic BP is >60 mmHg. In patients with coronary artery disease and in patients with orthostatic hypotension, excessive BP lowering should be avoided. In elderly hypertensive patients with diabetes, BP levels should be monitored closely in the sitting and the standing position, and the treatment should be tailored to prevent excessive fall in BP.

Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients

Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites. We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by Vascular Profiler-1000 device. In the continuous study, ICAS was significantly associated with age, male, average brachial SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, subjects with the top quartile of inter-arm DBP difference (≥4 mmHg) showed significantly higher risk of ICAS (OR = 2.109; 95% CI, 1.24–3.587). And the participants with the top quartile of inter-arm SBP difference (≥6 mmHg) showed significantly higher risk of ECAS (OR = 2.288; 95% CI, 1.309–3.998). In conclusion, we reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study.

Evidence-based assessment of lipoprotein(a) as a risk biomarker for cardiovascular diseases - Some answers and still many questions

The present article is aimed at outlining the current state of knowledge regarding the clinical value of lipoprotein(a) (Lp(a)) as a marker of cardiovascular disease (CVD) risk by summarizing the results of recent clinical studies, meta-analyses and systematic reviews. The literature supports the predictive value of Lp(a) on CVD outcomes, although the effect size is modest. Lp(a) would also appear to have an effect on cerebrovascular outcomes, however the effect appears even smaller than that for CVD outcomes. Consideration of apolipoprotein(a) (apo(a)) isoforms and LPA genetics in relation to the simple assessment of Lp(a) concentration may enhance clinical practice in vascular medicine. We also describe recent advances in Lp(a) research (including therapies) and highlight areas where further research is needed such as the measurement of Lp(a) and its involvement in additional pathophysiological processes.

Systolic blood pressure and cardiovascular mortality in middle-aged and elderly adults - The Singapore Chinese Health Study

BACKGROUND

While elevated systolic blood pressure (SBP) is related to cardiovascular disease (CVD) mortality, it is unclear if the optimal SBP level may differ by age or the presence of underlying CVD.

OBJECTIVE

We investigated the association between SBP categories and CVD mortality among middle-aged and elderly adults with and without CVD history.

METHODS

We used data from 30,692 participants of the population-based Singapore Chinese Health Study who had blood pressures measured using a standard protocol at ages 48-85years between 1994 and 2005. Information on lifestyle factors were collected at recruitment (1993-1998) and during follow-up interviews (1999 and 2004). Mortality was identified via nationwide registry linkage up to 31 December 2014.

RESULTS

SBP 120-139mmHg category was associated with lowest risk of CVD mortality in both age-groups of <60 and 60+years, as well as in those with and without underlying coronary heart disease or stroke. Overall, compared to this category, CVD risk was non-significantly increased in lower SBP categories and significantly increased in the higher SBP categories. The risk estimates associated with elevated SBP were higher among those <60years compared to their older counterparts, but less distinct between those with and without underlying CVD.

CONCLUSION

SBP 120-139mmHg was associated with the lowest risk of CVD mortality in middle aged and elderly adults, regardless of underlying CVD. Although risks in both adult groups were similar, there is a greater risk associated with higher SBP among those aged below 60years, highlighting a greater urgency of treatment in this younger group.

Cardiovascular diseases in patients 65 years and younger with non-cardiogenic stroke

INTRODUCTION

Approximately 10-15% of patients with stroke are under 65 years of age. The aim of the study was to determine types of stroke In people below 65. We analysed the incidence and types of associated cardiovascular diseases in patients with non-cardiogenic stroke.

MATERIAL AND METHODS

In this prospective study patients (aged ≤ 65) with stroke underwent physical examination, computed tomography of the head, blood tests, electrocardiogram, echocardiography, and transcranial and carotid artery ultrasound. Classification of stroke was performed according to the ASCOD scale. Analysis considered the incidence of heart diseases in patients with non-cardiogenic stroke and the incidence of heart diseases recognised as a cause of cerebral embolism in patients with cardiogenic stroke.

RESULTS

The study included 611 patients with stroke at the age of 27-65 (mean: 57.2 ±6.7; M/F 380/231). Stroke of heterogeneous aetiology was observed in 321 patients, cardiogenic stroke in 78, and stroke caused by small vessel and carotid artery disease in 73 and 72 patients, respectively. The most common heart diseases in non-cardiogenic stroke patients included persistent foramen ovale, coronary heart disease and past myocardial infarction. The most common causes of cardiogenic embolism were cardiomyopathy, atrial fibrillation and interatrial septal defect.

CONCLUSIONS

Aetiologically heterogeneous stroke and cardiogenic stroke are the most commonly observed among young stroke patients. Cardiomyopathy and atrial fibrillation are the most common sources of cerebral embolism in young patients with cardiogenic stroke. Nearly 1/5 of patients with a non-cardiogenic stroke have congenital or acquired structural changes in the heart.

Recognition and Management of Hypertension in Older Persons: Focus on African Americans

Hypertension is the most commonly diagnosed condition in persons aged 60 and older and is the single most important risk factor for cardiovascular disease (ischemic heart disease, heart failure, and stroke), kidney disease, and dementia. More than half of individuals with hypertension in the United States are aged 60 and older. Hypertension disproportionately affects African Americans, with all age groups, including elderly adults, having a higher burden of hypertension-related complications than other U.S.

POPULATIONS

Multiple clinical trials have demonstrated the beneficial effects of blood pressure (BP) reduction on cardiovascular morbidity and mortality, with most of the evidence in individuals aged 60 and older. Several guidelines have recently been published on the specific management of hypertension in individuals aged 60 and older, including in high-risk groups such as African Americans. Most recommend careful evaluation, thiazide diuretics and calcium-channel blockers for initial drug therapy in most African Americans, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in those with chronic kidney disease or heart failure. Among the areas of controversy is the recommended target BP in African Americans aged 60 and older. A recent U.S. guideline recommended raising the systolic BP target from less than 140 mmHg to less than 150 mmHg in this population. This article will review the evidence and current guideline recommendations for hypertension treatment in older African Americans, including the rationale for continuing to recommend a SBP target of less than 140 mmHg in this population.

Improved Cardiovascular Disease Outcomes in Older Adults

Longevity is increasing and the population of older adults is growing. The biology of aging is conducive to cardiovascular disease (CVD), such that prevalence of coronary artery disease, heart failure, valvular heart disease, arrhythmia and other disorders are increasing as more adults survive into old age.  Furthermore, CVD in older adults is distinctive, with management issues predictably complicated by multimorbidity, polypharmacy, frailty and other complexities of care that increase management risks (e.g., bleeding, falls, and rehospitalization) and uncertainty of outcomes.  In this review, state-of-the-art advances in heart failure, acute coronary syndromes, transcatheter aortic valve replacement, atrial fibrillation, amyloidosis, and CVD prevention are discussed.  Conceptual benefits of treatments are considered in relation to the challenges and ambiguities inherent in their application to older patients.

High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults

Although hypertension is common among older adults, the optimal blood pressure (BP) for survival in older adults remains unclear. We attempt to use a large cohort to assess the relationship between BP and mortality and to gain insight into what level of BP is required for optimal survival in older adults.A total of 77,389 community-dwelling adults, aged ≥65 years, were followed between 2006 and 2010. Mortality was determined using matching cohort identifications with national death files. Cox proportional hazards regression models were used to evaluate the relationship of BP with all-cause, cardiovascular disease (CVD), and expanded-CVD mortalities.The mortality risks of the stage 2-3 hypertension group were substantial (all-cause mortality: hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.10-1.37; CVDs mortality: HR: 1.31; 95% CI: 1.05-1.64; expanded-CVDs mortality: HR: 1.40; 95% CI: 1.15-1.71). The cardiovascular and expanded-cardiovascular mortality risks were lowest when systolic blood pressures were 120 to 129 mm Hg, and increased significantly when systolic blood pressures (SBPs) were ≥160 mm Hg or diastolic BPs were ≥90 mm Hg. A J-curve phenomenon for SBP on CVD and expanded-CVD mortality was observed. The impacts of stage 2-3 hypertension on mortality risks were significantly increased among women. The mortality risks of hypertension were not attenuated with older age.This study provides insight for identifying the optimal BP for survival in older adults, and extends the knowledge of the impacts of hypertension on mortality risks among women and the older adults.

Relationship of Blood Pressure With Mortality and Cardiovascular Events Among Hypertensive Patients aged ≥ 60 years in Rural Areas of China: A Strobe-Compliant Study

The Eighth Joint National Committee (JNC-8) panel recently recommended a systolic blood pressure (BP) threshold of ≥ 150 mmHg for the initiation of drug therapy and a therapeutic target of <150/90 mmHg in patients ≥ 60 years of age. However, results from some post-hoc analysis of randomized controlled trials and observational studies did not support these recommendations. In the prospective cohort study, 5006 eligible hypertensive patients aged ≥ 60 years from rural areas of China were enrolled for the present analysis. The association between the average follow-up BP and outcomes (all-cause and cardiovascular death, incident coronary heart disease [CHD], and stroke), followed by a median of 4.8 years, were evaluated using Cox proportional hazards models adjusting for other potential confounders. The relationship between BP (systolic or diastolic) showed an increased or J-shaped curve association with adverse outcomes. Compared with the reference group of BP <140/90 mmHg, the risk of all-cause death (hazard ratio [HR]: 2.698; 95% confidence interval [CI]: 1.989-3.659), cardiovascular death (HR: 2.702; 95% CI: 1.855-3.935), incident CHD (HR: 3.263; 95% CI: 2.063-5.161), and stroke (HR: 2.334; 95% CI: 1.559-3.945) was still significantly increased in the group with BP of 140-149/<90 mmHg. Older hypertensive patients with BP of 140-149/<90 mmHg were at higher risk of developing adverse outcomes, implying that lenient BP control of 140-149/<90 mmHg, based on the JNC-8 guidelines, may not be appropriate for hypertensive patients aged ≥ 60 years in rural areas of China.

Baseline characteristics of African Americans in the Systolic Blood Pressure Intervention Trial

The Systolic Blood Pressure Intervention Trial (SPRINT) will compare treatment to a systolic blood pressure goal of <120 mm Hg to treatment to the currently recommended goal of <140 mm Hg for effects on incident cardiovascular, renal, and neurologic outcomes including cognitive decline. The objectives of this analysis are to compare baseline characteristics of African American (AA) and non-AA SPRINT participants and explore factors associated with uncontrolled blood pressure (BP) by race. SPRINT enrolled 9361 hypertensive participants aged older than 50 years. This cross-sectional analysis examines sociodemographics, baseline characteristics, and study measures among AAs compared with non-AAs. AAs made up 31% of participants. AAs (compared with non-AAs) were younger and less frequently male, had less education, and were more likely uninsured or covered by Medicaid. In addition, AAs scored lower on the cognitive screening test when compared with non-AAs. Multivariate logistic regression analysis found BP control rates to <140/90 mm Hg were higher for AAs who were male, had higher number of chronic diseases, were on diuretic treatment, and had better medication adherence. SPRINT is well poised to examine the effects of systolic blood pressure targets on clinical outcomes as well as predictors influencing BP control in AAs.

Blood Pressure Goals and Targets in the Elderly

OPINION STATEMENT

The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document on hypertension in the elderly recommends that the blood pressure be reduced to less than 140/90 mmHg in adults aged 60-79 years and the systolic blood pressure to 140 to 145 mmHg if tolerated in adults aged 80 years and older. I strongly support these guidelines based on clinical trial data, especially from the Systolic Hypertension in the Elderly trial and from the Hypertension in the Very Elderly trial (HYVET). Other guidelines supporting reducing the blood pressure to less than 140/90 mmHg in adults aged 60 to 79 years of age include the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines, the minority report from the 2013 Eighth Joint National Committee (JNC 8) guidelines, the 2013 Canadian Hypertension Education Program guidelines, the 2011 UK guidelines, the 2014 American Society of Hypertension (ASH)/International Society of Hypertension (ISH) guidelines, and the 2015 AHA/ACC/ASH scientific statement on treatment of hypertension in patients with coronary artery disease. I support these guidelines. In adults aged 80 years and older, a blood pressure below 150/90 mm Hg has been recommended by these guidelines, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease. I support these guidelines. The 2013 JNC 8 guidelines recommend reducing the blood pressure to less than 140/90 mmHg in adults aged 60 years and older with diabetes mellitus or chronic kidney disease but to less than 150/90 mmHg in adults aged 60 years and older without diabetes mellitus or chronic kidney disease. I strongly disagree with this recommendation and am very much concerned that the higher systolic blood pressure goal recommended by JNC 8 guidelines in adults aged 60 years and older without diabetes mellitus or chronic kidney disease will lead to an increase in cardiovascular events and mortality in these adults.

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.

Coronary heart disease risk factors and outcomes in the twenty-first century: findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

REasons for Geographic and Racial Differences in Stroke (REGARDS) is a longitudinal study supported by the National Institutes of Health to determine the disparities in stroke-related mortality across USA. REGARDS has published a body of work designed to understand the disparities in prevalence, awareness, treatment, and control of coronary heart disease (CHD) and its risk factors in a biracial national cohort. REGARDS has focused on racial and geographical disparities in the quality and access to health care, the influence of lack of medical insurance, and has attempted to contrast current guidelines in lipid lowering for secondary prevention in a nationwide cohort. It has described CHD risk from nontraditional risk factors such as chronic kidney disease, atrial fibrillation, and inflammation (i.e., high-sensitivity C-reactive protein) and has also assessed the role of depression, psychosocial, environmental, and lifestyle factors in CHD risk with emphasis on risk factor modification and ideal lifestyle factors. REGARDS has examined the utility of various methodologies, e.g., the process of medical record adjudication, proxy-based cause of death, and use of claim-based algorithms to determine CHD risk. Some valuable insight into less well-studied concepts such as the reliability of current troponin assays to identify "microsize infarcts," caregiving stress, and CHD, heart failure, and cognitive decline have also emerged. In this review, we discuss some of the most important findings from REGARDS in the context of the existing literature in an effort to identify gaps and directions for further research.

Lipids, blood pressure and kidney update 2014

This paper is an effort to review all the most important studies and guidelines in the topics of lipid, blood pressure and kidney published in 2014. Irrespective of advances, the options for improving simultaneous hypercholesterolemia and hypertension management (as well as its complication - chronic kidney disease) remain a problem. Recommending hypolidemic, hypotensive and kidney disease drugs to obtain therapy targets in cardiovascular, diabetic, elderly and kidney disease (=high risk) patients might strengthen risk factor control, improve compliance and the therapy efficacy, and in the consequence reduce the risk of cardiovascular events and mortality rate. That is why the authors have decided to summary and discuss the recent scientific achievements in the field of lipid, blood pressure and kidney.