Pulse Pressure and Risk for Cardiovascular Events in Patients With Atherothrombosis

Relationships between ankle blood pressure indices and major adverse cardiovascular events in people with and without type 2 diabetes

BACKGROUND

The relationship between ankle blood pressure (BP) and cardiovascular disease remains unclear. We examined the relationships between known and new ankle BP indices and major cardiovascular outcomes in people with and without type 2 diabetes.

METHODS

We used data from 3 large trials with measurements of ankle systolic BP (SBP), ankle-brachial index (ABI, ankle SBP divided by arm SBP), and ankle-pulse pressure difference (APPD, ankle SBP minus arm pulse pressure). The primary outcome was a composite of cardiovascular mortality, myocardial infarction, hospitalization for heart failure, or stroke. Secondary outcomes included death from cardiovascular causes, total (fatal and non-fatal) myocardial infarction, hospitalization for heart failure, and total stroke.

RESULTS

Among 42,929 participants (age 65.6 years, females 31.3%, type 2 diabetes 50.1%, 53 countries), the primary outcome occurred in 7230 (16.8%) participants during 5 years of follow-up (19.4% in people with diabetes, 14.3% in those without diabetes). The incidence of the outcome increased with lower ankle BP indices. Compared with people whose ankle BP indices were in the highest fourth, multivariable-adjusted hazard ratios (HRs, 95% CI) of the outcome for each lower fourth were 1.05 (0.98-1.12), 1.17 (1.08-1.25), and 1.54 (1.54-1.65) for ankle SBP; HR 1.06 (0.99-1.14), 1.26 (1.17-1.35), and 1.48 (1.38-1.58) for ABI; and HR 1.02 (0.95-1.10), 1.15 (1.07-1.23), and 1.48 (1.38-1.58) for APPD. The largest effect size was noted for ankle SBP (HRs 1.05 [0.90-1.21], 1.21 [1.05-1.40], and 1.93 [1.68-2.22]), and APPD (HRs 1.08 [0.93-1.26], 1.30 [1.12-1.50], and 1.97 [1.72-2.25]) with respect to hospitalization for heart failure, while only a marginal association was observed for stroke. The relationships were similar in people with and without diabetes (all p for interaction > 0.05).

CONCLUSIONS

Inverse and independent associations were observed between ankle BP and cardiovascular events, similarly in people with and without type 2 diabetes. The largest associations were observed for heart failure and the smallest for stroke. Including ankle BP indices in routine clinical assessments may help to identify people at highest risk of cardiovascular outcomes.

Particulate matter, polycyclic aromatic hydrocarbons and metals, platelet parameters and blood pressure alteration: Multi-pollutants study among population

Epidemiological findings have determined the linkage of fine particulate matter (PM2.5) and the morbidity of hypertension. However, the mode of action and specific contribution of PM2.5 component in the blood pressure elevation remain unclear. Platelets are critical for vascular homeostasis and thrombosis, which may be involved in the increase of blood pressure. Among 240 high-PM2.5 exposed, 318 low-PM2.5 exposed workers in a coking plant and 210 workers in the oxygen plant and cold-rolling mill enrolled in present study, both internal and external exposure characteristics were obtained, and we performed linear regression, adaptive elastic net regression, quantile g-computation and mediation analyses to analyze the relationship between urine metabolites of polycyclic aromatic hydrocarbons (PAHs) and metals fractions with platelets indices and blood pressure indicators. We found that PM2.5 exposure leads to increased systolic blood pressure (SBP) and pulse pressure (PP). Specifically, for every 10 μg/m3 increase in PM2.5, there was a 0.09 mmHg rise in PP. Additionally, one IQR increase in urinary 1-hydroxypyrene (1.06 μmol/mol creatinine) was associated with a 3.43 % elevation in PP. Similarly, an IQR increment of urine cobalt (2.31 μmol/mol creatinine) was associated with a separate 1.77 % and 4.71 % elevation of SBP and PP. Notably, platelet-to-lymphocyte ratio (PLR) played a mediating role in the elevation of SBP and PP induced by cobalt. Our multi-pollutants results showed that PAHs and cobalt were deleterious contributors to the elevated blood pressure. These findings deepen our understanding of the cardiovascular effects associated with PM2.5 constituents, highlighting the importance of increased vigilance in monitoring and controlling the harmful components in PM2.5.

Association between pulse pressure and carotid plaques in old adults with uncontrolled hypertension: results from a community-based screening in Hangzhou, China

BACKGROUND

There is a broad pulse pressure (PP) and a high prevalence of carotid plaques in old adults. Previous studies have indicated that PP is strongly associated with carotid plaque formation. This study aimed to explore this association in old adults with uncontrolled hypertension.

METHODS

1371 hypertensive patients aged ≥ 60 years with uncontrolled hypertension were enrolled in a community-based screening in Hangzhou, China. Carotid plaques were assessed using ultrasonography. Logistic regression models were used to estimate the association between PP and carotid plaques by odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Carotid plaques were detected in 639 (46.6%) of subjects. Multiple plaques were found in 408 (63.8%) and soft plaques in 218 (34.1%). Elevated PP was associated with a high prevalence of carotid plaques. After adjusting for traditional risk factors, compared to patients within the lowest tertile of PP, those within the highest tertiles had an increased risk of carotid plaques (OR 2.061, CI 1.547-2.745). For each 1-SD increase, the risk increased by 40.1% (OR 1.401, CI 1.237-1.587). There was a nonlinear association between PP and carotid plaques (P nonlinearity = 0.039). The risk increased rapidly after the predicted PP level reached around 60 mmHg. The associations were stronger among participants with multiple and soft plaques.

CONCLUSIONS

Our findings suggested that PP was independently associated with carotid plaques in old adults with uncontrolled hypertension who have an increased risk of atherosclerosis.

Systolic blood pressure status modifies the associations between the triglyceride-glucose index and incident cardiovascular disease: a national cohort study in China

BACKGROUND

The triglyceride-glucose (TyG) index and blood pressure (BP) are correlated and serve as risk factors for cardiovascular disease (CVD). The potential impact of BP status on the association between the TyG index and CVD risk remains uncertain. This study aims to investigate the relationships between the TyG index and incident CVD in Chinese middle-aged and elderly adults, considering variations in BP status among participants.

METHODS

6558 participants (mean age: 58.3 (± 8.7) years; 46.0% were men) without prevalent CVD were recruited from the China Health and Retirement Longitudinal Study. Participants were divided into three groups according to their systolic blood pressure (SBP) levels (< 120mmHg, 120 ∼ 129mmHg, ≥ 130mmHg). The TyG index was computed as ln[triglyceride (mg/dl) * fasting blood glucose (mg/dl)/2]. The primary outcome was CVD (heart disease and stroke), and the secondary outcomes were individual CVD components. Cox regression models and restricted cubic splines were performed to investigate the associations between continuous and categorical TyG with CVD.

RESULTS

1599 cases of CVD were captured during 58,333 person-years of follow-up. Per 1-SD higher TyG index was associated with a 19% (HR: 1.19; 95% CI: 1.12, 1.27) higher risk for incident CVD, and the participants with the highest quartile of TyG index had a 54% (HR: 1.54; 95% CI: 1.29, 1.84) higher risk of CVD compared to those in the lowest quartile. SBP significantly modifies the association between the TyG index and CVD, with higher HRs for CVD observed in those with optimal and normal SBP. SBP partially mediated the associations between the TyG index with CVD. The results were generally consistent among participants with varying pulse pressure statuses rather than diastolic BP statuses.

CONCLUSIONS

The associations between the TyG index and CVD were modified by BP status, with greater HRs for CVD observed among those who had SBP < 130mmHg. SBP can partially mediate the association between the TyG index with CVD, highlighting the importance of early screening for the TyG index to identify at risk of hypertension and CVD.

John J, Van Iterson EH, Laffin LJ. Association of pulse pressure with death, myocardial infarction, and stroke among cardiovascular outcome trial participants

Background

Prior evidence demonstrates that pulse pressure (PP), a surrogate marker of arterial stiffness, is an independent risk factor for mortality and major adverse cardiovascular (CV) events.

Objectives

The study aimed to identify the association of PP with death, myocardial infarction, and stroke among participants enrolled in large CV outcome clinical trials and determine if this association was impacted by pre-existing CV disease, or specific CV risk factors.

Methods

A total of 65,382 individuals, ages 19 to 98 years, that were enrolled in one of five CV outcome trials were analyzed. Baseline demographics, history, blood pressures, and medications were collected. Univariate and multivariable analyses were conducted to explore temporal patterns, risks, and adjusted survival rates.

Results

Mean baseline PP was 52 ± 12 mmHg. For every 10 mmHg increase in PP, there was an increased risk of death, stroke, or myocardial infarction (hazard ratio (HR) 1.11, 95 % CI 1.08 to 1.14, p < 0.001). Similarly, a PP ≥ 60 mmHg demonstrated an HR of 1.27 (95 % CI 1.19 to 1.36, p < 0.001) compared with PP < 60 mmHg. A similar association existed for all subgroups analyzed except for participants with a history of stroke where increasing PP did not increase risk (HR 1.02, 95 % CI 0.95 to 1.10, p = 0.53). PP was a better predictor of adverse outcomes when compared to both systolic and diastolic blood pressures using the AIC and C-index.

Conclusions

Among participants enrolled in CV outcome trials, baseline PP is associated with increased risk of death, myocardial infarction, and stroke for those with pre-existing CV disease and risk factors with the exception of a prior history of stroke.

High pulse pressure predicts primary arteriovenous fistula failure within 1 year

BACKGROUND

The arteriovenous fistula is the preferred access route for hemodialysis, although its high primary failure rate remains a clinical challenge. Multiple studies have attempted to determine the risk factors for primary arteriovenous fistula failure; however, none have identified pulse pressure as a potential predictive marker. High pulse pressure is a surrogate poor arterial compliance endpoint and leads to inferior cardiovascular outcomes. Our aim was to determine whether elevated pulse pressure indicates poor arteriovenous fistula maturation.

METHODS

We retrospectively reviewed 274 patients who underwent an arteriovenous fistula index operation between September 1, 2018 and May 31, 2019. Demographic, clinical data, and operative parameters were collected and analyzed. The maximum follow-up period was 365 days. Arteriovenous fistula failure was defined as the inability to achieve functional use during the follow-up period. We identified risk factors for arteriovenous fistula failure by performing a multivariate logistic regression analysis using backward elimination procedures.

RESULTS

A total of 274 patients were included in the study. The patients' average age was 61.3 ± 14.0 years, approximately half of the patients (n = 161, 58.8%) were male, and the majority had hypertension. At the end of the follow-up period, 68 (24.8%) had arteriovenous fistula failure. The proportion of patients with pulse pressure values of >60 mmHg was significantly higher in the failure group than in the maturation group (66.0% vs 80.9%; p = 0.021). A PP value of >60 mmHg (odds ratio = 2.25; 95% confidence interval = 1.14-4.42; p = 0.019) and coronary artery disease or myocardial infarction (odds ratio = 1.97; 95% confidence interval = 1.01-3.84; p = 0.045) were found to be independent risk factors for primary arteriovenous fistula failure.

CONCLUSIONS

High pulse pressure is an independent risk factor for primary arteriovenous fistula failure.

Non-alcoholic fatty liver disease mediates the effect of obesity on arterial hypertension

BACKGROUND

It has been consistently shown that obesity contributes directly to arterial hypertension and cardiovascular disease (CVD), independently of other risk factors. Likewise, non-alcoholic fatty liver disease (NAFLD) is acknowledged as a contributor and a risk enhancer for CVD.

OBJECTIVES

We tested the hypothesis of a causal role of NAFLD in the effect of obesity on arterial hypertension.

METHODS

Using causal mediation analysis, we quantified the magnitude of the body mass index (BMI) effect on arterial hypertension and CV-traits mediated by NAFLD. First, we analysed data from 1348 young adults in the Bogalusa Heart Study (BHS), a cohort aimed at assessing the natural history of CVD. Then, we used data from 3359 participants of the National Health and Nutrition Examination Survey (2017-2018 cycle, NHANES) to replicate the findings.

RESULTS

We found that roughly 92% of the effects of BMI on arterial hypertension in the BHS and 51% in the NHANES population are mediated by NAFLD. In addition, indirect effects of BMI on systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) through NAFLD explained up to 91%, 93%, and 100% of the total effect, respectively, in the BHS. In the NHANES survey, indirect effects of BMI through NAFLD on CV traits explain a significant proportion of the total effects (SBP = 60.4%, HR = 100%, and pulse pressure = 88%).

CONCLUSION

NAFLD mediates a substantial proportion of the effect of obesity on the presence of hypertension and CV-parameters independently of relevant covariates. This conclusion has implications for clinical management.

Blood pressure, arterial stiffness, and cardiovascular risk profiles in 8-12-year-old children following preeclampsia (FINNCARE-study)

OBJECTIVES

The aim was to study if children following preeclampsia (PE) develop alterations in blood pressure (BP) and arterial stiffness already early in life, and how this is associated with gestational, perinatal and child cardiovascular risk profiles.

METHODS

One hundred eighty-two PE (46 early-onset with diagnosis before 34 gestational weeks, and 136 late-onset) and 85 non-PE children were assessed 8-12 years from delivery. Office and 24-h ambulatory BP, body composition, anthropometrics, lipids, glucose, inflammatory markers, and tonometry-derived pulse wave velocity (PWV) and central BPs were assessed.

RESULTS

Office BP, central BPs, 24-h systolic BP (SBP) and pulse pressure (PP) were higher in PE compared with non-PE. Early-onset PE children had the highest SBP, SBP-loads, and PP. SBP nondipping during night-time was common among PE. The higher child 24-h mean SBP among PE was explained by maternal SBP at first antenatal visit and prematurity (birth weight or gestational weeks), but child 24-h mean PP remained related with PE and child adiposity after adjustments. Central and peripheral PWVs were elevated in late-onset PE subgroup only and attributed to child age and anthropometrics, child and maternal office SBP at follow-up, but relations with maternal antenatal SBPs and prematurity were not found. There were no differences in body anthropometrics, composition, or blood parameters.

CONCLUSIONS

PE children develop an adverse BP profile and arterial stiffness early in life. PE-related BP is related with maternal gestational BP and prematurity, whereas arterial stiffness is determined by child characteristics at follow-up. The alterations in BP are pronounced in early-onset PE.Clinical Trial Registration information: https://clinicaltrials.gov/ct2/show/NCT04676295ClinicalTrials.gov Identifier: NCT04676295.

Detection of the Relationship between the Multi-Dimensional Data Sets of Serially Measured Blood Pressure and the Future Risk of Death in Healthy Elderly Japanese Population

AIMS

Whether the multi-dimensional data of serially measured blood pressure contains information for predicting the future risk of death in elderly individuals in nursing homes is unclear.

METHODS

Of the elderly individuals staying in a nursing home, 19,740 and 40,055 individuals with serially measured blood pressure from day 1 to 365 (for AI-long) and 1 to 90 (for AI-short) along with the death information at day 366 to 730 and 91-365 were included. The neural network-based artificial intelligence (AI) was applied to find the relationship between BP time-series and the future risks of death in both populations.

RESULTS

AI-long found a significant relationship between the serially measured BP from day 1 to day 365 days and the risk of death occurring 366-730 days with c-statistics of 0.57 (95% CI: 0.51-0.63). AI-short also found a significant relationship between the serially measured BP from day 1 to day 90 and the rate of death occurring 91-365 days with c-statistics of 0.58 (95%CI: 0.52-0.63).

CONCLUSION

Our results suggest that neural network-based AI could find the hidden subtle relationship between multi-dimensional data of serially measured BP and the future risk of death in apparently healthy elderly Japanese individuals under nursing care.

Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury

BACKGROUND

Pulse pressure is a dynamic marker of cardiovascular function and is often impaired in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Pulsatile blood flow also serves as a regulator of vascular endothelium, and continuous-flow mechanical circulatory support can lead to endothelial dysfunction. We explored the impact of early low pulse pressure on occurrence of acute brain injury (ABI) in VA-ECMO.

METHODS

We conducted a retrospective analysis of adults with VA-ECMO at a tertiary care center between July 2016 and January 2021. Patients underwent standardized multimodal neuromonitoring throughout ECMO support. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressures were recorded every 15 min. Low pulse pressure was defined as a median pulse pressure < 20 mm Hg in the first 12 h of ECMO. Multivariable logistic regression was performed to investigate the association between pulse pressure and ABI.

RESULTS

We analyzed 5138 blood pressure measurements from 123 (median age 63; 63% male) VA-ECMO patients (54% peripheral; 46% central cannulation), of whom 41 (33%) experienced ABI. Individual ABIs were as follows: ischemic stroke (n = 18, 15%), hypoxic ischemic brain injury (n = 14, 11%), seizure (n = 8, 7%), intracranial hemorrhage (n = 7, 6%), cerebral edema (n = 7, 6%), and brain death (n = 2, 2%). Fifty-eight (47%) patients had low pulse pressure. In a multivariable model adjusting for preselected covariates, including cannulation strategy (central vs. peripheral), lactate on ECMO day 1, and left ventricle venting strategy, low pulse pressure was independently associated with ABI (adjusted odds ratio 2.57, 95% confidence interval 1.05-6.24). In a model with the same covariates, every 10-mm Hg decrease in pulse pressure was associated with 31% increased odds of ABI (95% confidence interval 1.01-1.68). In a sensitivity analysis model adjusting for systolic pressure, pulse pressure remained significantly associated with ABI.

CONCLUSIONS

Early low pulse pressure (< 20 mm Hg) was associated with ABI in VA-ECMO patients. Low pulse pressure may serve as a marker of ABI risk, which necessitates close neuromonitoring for early detection.

The Associations of Pulse Pressure and Mean Arterial Pressure on Physical Function in Older Americans

Background: We sought to examine the associations of pulse pressure (PP) and mean arterial pressure (MAP) on physical function in older Americans. Methods: Our analytic sample included 10,478 adults aged ≥65 years from the 2006–2016 Health and Retirement Study. Handgrip strength, gait speed, and standing balance were collected using relatively standard protocols. PP and MAP were calculated from blood pressure measurements. Results: Older Americans with any abnormality in PP had 1.15 (95% confidence interval (CI): 1.05–1.25) greater odds for slowness and 1.14 (CI: 1.05–1.24) greater odds for poorer standing balance. Persons with any abnormality in MAP had 0.90 (CI: 0.82–0.98) decreased odds for weakness and 1.10 (CI: 1.01–1.20) greater odds for poorer standing balance. Those with low PP had 1.19 (CI: 1.03–1.36) greater odds for slow gait speed, while persons with low MAP had 1.50 (CI: 1.09–2.05) greater odds for weakness and 1.45 (CI: 1.03–2.04) greater odds for slowness. Older Americans with high PP had 1.13 (CI: 1.03–1.25) greater odds for slowness and 1.21 (CI: 1.10–1.32) greater odds for poorer balance, whereas those with high MAP had 0.87 (CI: 0.80–0.95) decreased odds for weakness. Conclusions: Cardiovascular dysfunction, as observed by PP and MAP, may help to explain some of our findings.

Hemodynamic profiles of arterial hypertension with ambulatory blood pressure monitoring

Blood pressure (BP) measurements obtained during a twenty-four-hour ambulatory blood pressure monitoring (24 h ABPM) have not been reliably applied to extract arterial hemodynamics. We aimed to describe the hemodynamic profiles of different hypertension (HT) subtypes derived from a new method for total arterial compliance (C_t) estimation in a large group of individuals undergoing 24 h ABPM. A cross-sectional study was conducted, which included patients with suspected HT. Cardiac output, C_t, and total peripheral resistance (TPR) were derived through a two-element Windkessel model without having a pressure waveform. Arterial hemodynamics were analyzed according to HT subtypes in 7434 individuals (5523 untreated HT and 1950 normotensive controls [N]). The individuals mean age was 46.2 ± 13.0 years; 54.8% were male, and 22.1% were obese. In isolated diastolic hypertension (IDH), the cardiac index (CI) was greater than that in normotensive (N) controls (CI: IDH vs. N mean difference 0.10 L/m/m²; CI 95% 0.08 to 0.12; p value <0.001), with no significant clinical difference in C_t. Isolated systolic hypertension (ISH) and divergent systolic-diastolic hypertension (D-SDH) had lower C_t values than nondivergent HT subtype (C_t: divergent vs. nondivergent mean difference -0.20 mL/mmHg; CI 95% -0.21 to -0.19 mL/mmHg; p value <0.001). Additionally, D-SDH displayed the highest TPR (TPR: D-SDH vs. N mean difference 169.8 dyn*s/cm^-5; CI 95% 149.3 to 190.3 dyn*s/cm^-5; p value <0.001). A new method is provided for the simultaneous assessment of arterial hemodynamics with 24 h ABPM as a single diagnostic tool, which allows a comprehensive assessment of arterial function for hypertension subtypes. Main hemodynamic findings in arterial HT subtypes with regard to C_t and TPR. The 24 h ABPM profile reflects the state of C_t and TPR. Younger individuals with IDH present with a normal C_t and frequently increased CO. Patients with ND-SDH maintain an adequate C_t with a higher TPR, while subjects with D-SDH present with a reduced C_t, high PP and high TPR. Finally, the ISH subtype occurs in older individuals with significantly reduced C_t, high PP and a variable TPR proportional to the degree of arterial stiffness and MAP values. There was an observed increase in PP with age in relation to the changes in C_t (see also text). SBP: systolic blood pressure; DBP: diastolic blood pressure; MAP: mean arterial pressure; PP: pulse pressure; N: normotension; HT: hypertension; IDH: isolated diastolic hypertension; ND-SDH: nondivergent systole-diastolic hypertension; D-SDH: divergent systolic-diastolic hypertension; ISH: isolated systolic hypertension; C_t: total arterial compliance; TPR: total peripheral resistance; CO: cardiac output; 24 h ABPM: 24 h ambulatory blood pressure monitoring.

The optimal pulse pressures for healthy adults with different ages and sexes correlate with cardiovascular health metrics

Background

Pulse pressure (PP) may play a role in the development of cardiovascular disease, and the optimal PP for different ages and sexes is unknown. In a prospective cohort, we studied subjects with favorable cardiovascular health (CVH), proposed the mean PP as the optimal PP values, and demonstrated its relationship with healthy lifestyles.

Methods and results

Between 1996 and 2016, a total of 162,636 participants (aged 20 years or above; mean age 34.9 years; 26.4% male subjects; meeting criteria for favorable health) were recruited for a medical examination program. PP in male subjects was 45.6 ± 9.4 mmHg and increased after the age of 50 years. PP in female subjects was 41.8 ± 9.5 mmHg and increased after the age of 40 years, exceeding that of male subjects after the age of 50 years. Except for female subjects with a PP of 40-70 mmHg, PP increase correlates with both systolic blood pressure (BP) increase and diastolic BP decrease. Individuals with mean PP values are more likely to meet health metrics, including body mass index (BMI) <25 kg/m² (chi-squared = 9.35, p<0.01 in male subjects; chi-squared = 208.79, p < 0.001 in female subjects) and BP <120/80 mmHg (chi-squared =1,300, p < 0.001 in male subjects; chi-squared =11,000, p < 0.001 in female subjects). We propose a health score (Hscore) based on the sum of five metrics (BP, BMI, being physically active, non-smoking, and healthy diet), which significantly correlates with the optimal PP.

Conclusion

The mean PP (within ±1 standard deviation) could be proposed as the optimal PP in the adult population with favorable CVH. The relationship between health metrics and the optimal PP based on age and sex was further demonstrated to validate the Hscore.

Pulse pressure and all-cause mortality in ischaemic heart failure patients: a prospective cohort study

BACKGROUND

Whether the association between pulse pressure (PP) and mortality varies with systolic blood pressure (SBP) in ischaemic heart failure (HF) with left ventricular systolic dysfunction (LVSD) is unknown.

OBJECTIVE

To evaluate the association between PP and all-cause mortality in ischaemic HF patients with SBP status at admission.

PATIENTS AND METHODS

This prospective cohort study included 1581 ischaemic HF patients with LVSD. A total of 23.3% (n = 368) and 22.2% (n = 351) of the participants had SBP <110 mmHg and SBP >140 mmHg, respectively, with more than 80% of participants being male. Restricted cubic spline was performed to determine whether a nonlinear relationship existed between PP and all-cause mortality risk. A multivariable Cox proportional hazards model was used to assess the association between PP and all-cause mortality.

RESULTS

After a median of follow-up of 3.0 years, 257 events (16.4%) were observed in the cohort. There was a J-shaped relationship between PP and all-cause mortality (P value for nonlinearity = 0.020), with a risk nadir of approximately 46-49 mmHg. All-cause mortality risk varied with SBP status. Higher PP was associated with worse prognosis when the SBP was ≥110 mmHg, whereas the relationship did not reach statistical significance when the SBP was <110 mmHg.

CONCLUSION

A J-shaped relationship between PP and all-cause mortality was observed in ischaemic HF patients with LVSD, and higher PP was associated with worse prognosis only in those with SBP ≥110 mmHg. Further studies are needed to corroborate these findings.KEY MESSAGESA J-shaped relationship between pulse pressure and all-cause mortality was observed in ischaemic heart failure patients with left ventricular systolic dysfunction, with a risk nadir of approximately 46-49 mmHg.All-cause mortality risk varied with systolic blood pressure status, and higher pulse pressure was associated with worse prognosis when systolic blood pressure was above 110 mmHg.

Gender-specific differences in central blood pressure and optimal target blood pressure based on the prediction of cardiovascular events

Background

Hypertension (HBP) is a common disease among both men and women. Central blood pressure (CBP) is a method of evaluating aorta pressure that can assess the intrinsic BP of an individual patient that more closely correlates with cardiovascular disease (CVD) outcomes than peripheral BP parameters. We evaluated gender-specific differences in CBP and optimal target BP based on a composite outcome of CVD, heart failure (HF), and hypertensive complications in patients with HBP.

Method

Patients were enrolled from June 2011 to December 2015 and were followed through December 2019. CBP was measured using radial tonometry. The primary endpoint was a composite outcome.

Result

The median follow-up period for enrolled patients was 6.5 years. Out of a total of 2,115 patients with an average age of 57.9 ± 13.6 years, 266 patients (12.6%) had events of primary end points during the follow-up period. There was no difference in the lowest BP level between men and women in the incidence of CVD. Among the women (49.6%), 78.1% were postmenopausal. In a multivariable Cox proportional hazards model, CBP and systolic BP showed an increase in risk of 10 and 11%, respectively, with every 10 mmHg increase, and there was a similar trend of 12 and 13%, respectively, in postmenopausal women. However, PP showed an increase in risk of about 2% every 10 mmHg increase, but a tendency to increase risk by 19% in postmenopausal women.

Conclusion

This study demonstrated that postmenopausal women will continue to show increased risk for CVD at BP higher than the optimal level. Conversely, there was no increase in CV risk due to menopause at BP values below the optimal level. Therefore, well-controlled BP is more important in postmenopausal women.

Systematic review and meta-analysis of the intervention effect of curcumin on rodent models of myocardial infarction

Objective: This study aimed to evaluate the intervention effect of curcumin in myocardial infarction rodent models. Methods: A systematic retrieval of relevant studies on curcumin intervention in rats or mice myocardial infarction models was conducted, and the data were extracted. The outcome indicators included biochemical blood indicators, such as creatine kinase (CK), creatine kinase isoenzyme (CK-MB), malondialdehyde (MDA), lactate dehydrogenase (LDH) and superoxide dismutase (SOD), as well as cardiac tissue structure indicators, such as left ventricular weight to body weight ratio (LVW/BW), apoptosis index, left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic diameter (LVESD), and myocardial infarction area, and hemodynamic indexes, such as systolic blood pressure (SBP), diastolic blood pressure (DBP), left ventricular end-diastolic pressure (LVEDP), left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), maximum rate of left ventricular pressure rise (+dp/dtmax), and maximum rate of left ventricular pressure decline (-dp/dtmax). These results were then analyzed by meta-analysis. Studies were evaluated for methodological quality using the syrcle's bias risk tool. Results: A total of 24 studies were included in the meta-analysis. The quality assessment of included studies revealed that the evidence was low quality and none of studies was judged as having a low risk of bias across all domains. The results revealed that curcumin could reduce CK-MB, CK, LDH, and MDA levels. They also revealed that it could lower SBP, DBP, LVEDP, LVW/BW, apoptosis index, LVEDD, LVESD, and myocardial infarction area and increase LVEF, LVFS, +dp/dtmax, and-dp/dtmax. However, it had no significant impact on the heart rate and the levels of SOD in the models. Conclusion: Curcumin alleviates myocardial injury and oxidative stress in myocardial infarction rodent models in terms of blood biochemistry indicators, improves the diastolic and systolic capacity of the ventricle in terms of hemodynamic indexes, and reduces the necrosis and apoptosis of cardiomyocytes in terms of tissue structure. The methodological quality of the studies was low and additional research is warranted.

Association of cumulative blood pressure with cardiovascular mortality in Chinese older people: A longitudinal prospective study

OBJECTIVE

Long-term cumulative blood pressure (BP) was associated with cardiovascular mortality in middle-aged to older people. Whether cumulative BP was associated with cardiovascular mortality is uncertain in Chinese older people.

DESIGN

Data were obtained from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), a nationwide, ongoing, prospective cohort study of community-dwelling Chinese older people.

SETTING, AND PARTICIPANTS

A total of 3361 older participants from the CLHLS study were included (men: 46.68 %, age: ≥65 years, median age: 78.00 years [IQR: 71.0-86.00 years]).

METHODS

Cumulative BP, including systolic BP (SBP), diastolic BP (DBP) and pulse pressure (PP), was determined by the area under the curve based on three measurements of BP (waves 2008, 2011, and 2014). The outcome was cardiovascular mortality, which was followed from wave 2014 to wave 2018.

RESULTS

During a median follow-up period of 3.98 years, 211 cardiovascular death were recorded. The higher cumulative SBP and PP tended to be positively linearly associated with an elevated risk of cardiovascular mortality. For each SD increment, the adjusted HRs of mortality risk was 1.28 (95 % CI: 1.11-1.47; p = 0.001) and 1.24 (95 % CI, 1.09-1.43; p = 0.002) for cumulative SBP and PP, respectively. While there was no association between cumulative DBP and cardiovascular mortality. In addition, multiple sensitivity analyses suggested robustness of the results.

CONCLUSIONS/IMPLICATIONS

Our results indicate that cumulative SBP and PP were associated with cardiovascular mortality in Chinese older people; however, there was no such association between cumulative DBP and mortality. Therefore, control of long-term SBP and PP may be required in those people.

Associations of blood pressure components with risks of cardiovascular events and all-cause death in a Chinese population: A Prospective Study

The associations of blood pressure components with cardiovascular risks and death remain unclear, and the definition of wide pulse pressure (PP) is still controversial. Using data from 1257 participants without a history of cardiovascular disease, who were followed for 4.84 years, we performed multivariable Cox regression analyses to assess how systolic blood pressure (SBP), diastolic blood pressure (DBP), and PP contribute to risks of cardiovascular events and all‐cause death. Among all participants, SBP and PP were significantly associated with the risks of cardiovascular events and all‐cause death (all p < .05). DBP was not significantly associated with the risk of all‐cause death; rather, it was only associated with a marginally significant 1% increased risk for cardiovascular events (p = 0.051). In participants aged < 65 years, DBP was significantly associated with a 3% increased risk for cardiovascular events (hazard ratio [HR]: 1.03, 95% confidence interval [95% CI]: 1.01–1.06). The association between PP and cardiovascular events appeared to be J‐shaped in comparison to participants with the lowest‐risk PP (50–60 mmHg), with adjusted HRs of 1.71 (95% CI: 1.03–2.85), 1.63 (95% CI: 1.00–2.68), and 2.13 (95% CI: 1.32–3.43) in the <50, 60.0–72.5, and ≥72.5 mmHg subgroups, respectively. The optimal cutoff points of a wide PP for predicting the risks of cardiovascular events and all‐cause death were 70.25 and 76.25 mmHg, respectively. SBP and PP had a greater effect on cardiovascular risk, whereas DBP independently influenced cardiovascular events in middle‐aged participants. Considerable PP alterations should be avoided in antihypertensive treatment.

The prognostic role of intra-aortic pulse pressure measured before percutaneous coronary intervention in patients with chronic coronary syndrome: a single-center, retrospective, observational cohort study

BACKGROUND

The relationship between pulse pressure and prognosis in patients with chronic coronary syndrome (CCS) is contradictory. In the present study, we aimed to examine the relationship between intra-aortic pulse pressure (IAPP) and major adverse cardiovascular events (MACE) in patients with CCS undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 139 CCS patients who underwent elective PCI with regular one-year follow-up, were stratified into two subgroups according to IAPP. The primary outcomes included the occurrence of MACE, defined as cardiovascular death, acute myocardial infarction with ST-segment elevation (STEMI), acute myocardial infarction without ST-segment elevation (NSTEMI), target vessel revascularization (TVR), and stroke.

RESULTS

The mean age of the patients was 57.6 ± 10.4 years, 32% of whom were female. The mean IAPP, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were 54.0 ± 17.6 mmHg, 129.7 ± 20 mmHg, and 75.8 ± 11.8 mmHg, respectively. SBP, IAPP, and left ventricular ejection fraction (LVEF) were significantly higher in the high IAPP group (p < .001, p < .001, p = .001, respectively). The MACE rate was significantly higher in the low IAPP group than in the high IAPP group (30.4% vs. 8.6%, p = 0,001). The LVEF (OR = 0.93, CI:0.88-0.99, p = .025) and IAPP (OR = 0.89, CI:0.83-0.95, p = .001) were found to be independent predictors of MACE. The IAPP value of 39.5 mmHg was identified as an effective cutoff point for prediction of MACE-free survival rates (AUC:0.853, CI:0.768-0.937).

CONCLUSION

Invasively measured IAPP has prognostic information about cardiovascular outcomes in patients with CCS. The risk of MACE is significantly greater in CCS patients with low IAPP compared with those who have high IAPP values.

Proximal Region of Carotid Atherosclerotic Plaque Shows More Intraplaque Hemorrhage: The Plaque at Risk Study

BACKGROUND AND PURPOSE

Intraplaque hemorrhage contributes to lipid core enlargement and plaque progression, leading to plaque destabilization and stroke. The mechanisms that contribute to the development of intraplaque hemorrhage are not completely understood. A higher incidence of intraplaque hemorrhage and thin/ruptured fibrous cap (upstream of the maximum stenosis in patients with severe [≥70%] carotid stenosis) has been reported. We aimed to noninvasively study the distribution of intraplaque hemorrhage and a thin/ruptured fibrous cap in patients with mild-to-moderate carotid stenosis.

MATERIALS AND METHODS

Eighty-eight symptomatic patients with stroke (<70% carotid stenosis included in the Plaque at Risk study) demonstrated intraplaque hemorrhage on MR imaging in the carotid artery plaque ipsilateral to the side of TIA/stroke. The intraplaque hemorrhage area percentage was calculated. A thin/ruptured fibrous cap was scored by comparing pre- and postcontrast black-blood TSE images. Differences in mean intraplaque hemorrhage percentages between the proximal and distal regions were compared using a paired-samples t test. The McNemar test was used to reveal differences in proportions of a thin/ruptured fibrous cap.

RESULTS

We found significantly larger areas of intraplaque hemorrhage in the proximal part of the plaque at 2, 4, and 6 mm from the maximal luminal narrowing, respectively: 14.4% versus 9.6% (P = .04), 14.7% versus 5.4% (P < .001), and 11.1% versus 2.2% (P = .001). Additionally, we found an increased proximal prevalence of a thin/ruptured fibrous cap on MR imaging at 2, 4, 6, and 8 mm from the MR imaging section with the maximal luminal narrowing, respectively: 33.7% versus 18.1%, P = .007; 36.1% versus 7.2%, P < .001; 33.7% versus 2.4%, P = .001; and 30.1% versus 3.6%, P = .022.

CONCLUSIONS

We demonstrated that intraplaque hemorrhage and a thin/ruptured fibrous cap are more prevalent on the proximal side of the plaque compared with the distal side in patients with mild-to-moderate carotid stenosis.

Evaluating Impact of Pulse Pressure on Indexes of Myocardial Work by Speckle-Tracking Echocardiography in Normotensive, Prehypertensive and Newly Diagnosed Hypertensive Patients

Background

The impact of pulse pressure (PP) on indexes of myocardial work (MWIs). This study aims to explore the potential association of high PP with myocardial work (MW).

Hypothesis

PP had an association with four indexes of MW in a mixed population of normotensive, prehypertensive and newly diagnosed hypertensive individuals.

Methods

The study was a single-center, cross-sectional, observational study. A total of 204 participants (66 normotensive, 35 prehypertensive and 103 newly diagnosed hypertensive individuals) were evaluated by speckle-tracking echocardiography (STE) and blood pressure measurement. According to the PP tertiles, the participants were divided into three groups: Group I (<44 mmHg, n=67), Group II (44–52 mmHg, n=68) and Group III (≥52 mmHg, n=69).

Results

In Group II and Group III, the proportion of males was higher than that in Group I (median 46 vs 30 (P=0.002)). With increasing PP, the three indexes of MW, namely, GWI, GCW and GWW, increased, and the differences among the three groups were statistically significant (P<0.001). PP was positively related to GWI, GCW and GWW and negatively correlated with GWE. After adjusting for E/e’, LVMI, LAVI and GLS, PP was still significantly correlated with the four MW indexes (both P<0.001).

Conclusion

PP had a strong association with four indexes of MW in a mixed population of normotensive, prehypertensive and newly diagnosed hypertensive individuals. The evaluation of PP and MWIs might be valuable for identifying very early diastolic impairment of the heart.

Clinical Significance of Mean and Pulse Pressure in Patients With Heart Failure With Preserved Ejection Fraction

It remains debated whether pulse pressure is associated with left ventricular traits and adverse outcomes over and beyond mean arterial pressure (MAP) in patients with heart failure (HF) with preserved ejection fraction. We investigated these associations in 3428 patients with HF with preserved ejection fraction (51.5% women; mean age, 68.6 years) enrolled in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist). We computed association sizes and hazards ratios with 1-SD increase in MAP and pulse pressure. In multivariable-adjusted analyses, association sizes (P≤0.039) for MAP were 0.016 cm and 0.014 cm for septal and posterior wall thickness, -0.15 for E/A ratio, -0.66 for E/e', and -0.64% for ejection fraction, independent of pulse pressure. With adjustment additionally applied for MAP, E/A ratio and longitudinal strain increased with higher pulse pressure with association sizes amounting to 0.067 (P=0.026) and 0.40% (P=0.023). In multivariable-adjusted analyses of both placebo and spironolactone groups, lower MAP and higher pulse pressure predicted the primary composite end point (P≤0.028) and hospitalized HF (P≤0.002), whereas MAP was also significantly associated with total mortality (P≤0.007). Sensitivity analyses stratified by sex, median age, and region generated confirmatory results with exception for the association of adverse outcomes with pulse pressure in patients with age ≥69 years. In conclusion, the clinical application of MAP and pulse pressure may refine risk estimates in patients with HF with preserved ejection fraction. This finding may help further investigation for the development of HF with preserved ejection fraction preventive strategies targeting pulsatility and blood pressure control.

Insertion/deletion polymorphism at angiotensin-converting enzyme gene in PTSD individuals and their reciprocal effects on blood pressure

OBJECTIVES

The aim of the present study was to investigate relationships between insertion/deletion (I/D) polymorphism at angiotensin-converting enzyme gene (ACE) and post-traumatic stress disorder (PTSD), as well as their interactions on blood pressure.

METHODS

Variants of ACE I/D were identified by polymerase chain reaction method and verified by DNA sequencing. PTSD symptoms were assessed by the PTSD Checklist-Civilian Version (PCL-C) based on DSM-IV-TR criteria among high school students at 6 months after the 2008 Wenchuan earthquake.

RESULTS

Female subjects were found to have higher prevalence of PTSD and PCL-C scores than male counterparts in the II homozygotes (p = .038 for PTSD and p = .003 for PCL-C scores) and the ID heterozygotes (p = .000 for PTSD and p = .000 for PCL-C scores), but not in the DD homozygotes. Male subjects with the ID (p = .046) or the DD genotype (p = .039) had lower pulse pressure (PP) than the male II homozygotes, while the female II homozygotes had lower diastolic blood pressure (DBP) than the female DD homozygotes (p = .036). ACE I/D, PTSD, or PCL-C scores, as well as gender and BMI, were found to be the predictors of PP.

CONCLUSIONS

These results indicate that there are interactions of ACE I/D and PTSD, together with gender and BMI, on PP. This finding may be the additional explanation for the heterogeneous relationships between PTSD and blood pressure, and suggest psychiatry care and different medication strategies for patients with comorbidities of PTSD and hypertension and with different genotypes of ACE I/D.

Association between pulse pressure, systolic blood pressure and the risk of rapid decline of kidney function among general population without hypertension: results from the China health and retirement longitudinal study (CHARLS)

BACKGROUND

Association between blood pressure (BP) and kidney function among the middle and old aged general population without hypertension remains unclear.

METHODS

Participants aged ≥ 45 years, with complete data in 2011 and 2015 interviews of the China Health and Retirement Longitudinal Study(CHARLS), and without pre-existing hypertension were included. Systolic BP (SBP) was categorized as low (< 120 mmHg), medium (120-129 mmHg), and high (120-139 mmHg). Diastolic BP (DBP) was categorized as low (< 60 mmHg), medium (60-74 mmHg), and high (75-89 mmHg). Pulse pressure (PP) was categorized as normal (< 60 mmHg) and high (≥ 60 mmHg). The outcome was defined as rapid decline of estimated glomerular filtration rate(eGFR, decline ≥ 4 ml/min/1.73 m2/year). BP combination was designed according to the category of SBP and PP. The association between BP components, types of BP combination, and the risk of rapid decline of eGFR was analyzed using multivariate logistic regression models, respectively. Age-stratified analyses were conducted.

RESULTS

Of 4,534 participants included, 695(15.3%) individuals were recognized as having rapid decline of eGFR. High PP[odds ratio(OR) = 1.34, 95%confidence interval(CI) 1.02-1.75], low SBP (OR = 1.28, 95%CI 1.03-1.59), and high SBP (OR = 1.32, 95% CI 1.02-1.71) were significantly associated with the risk of eGFR decline. Low SBP were associated with 65% increment of the risk of eGFR decline among participants aged < 55 years. The combination of high SBP and high PP (OR = 1.79, 95% CI 1.27-2.54) and the combination of low SBP and high PP (OR = 3.07, 95% CI 1.24-7.58) were associated with the increased risk of eGFR decline among the middle and old aged general population.

CONCLUSION

Single and combination of high PP and high SBP could be the risk indicators of eGFR decline among the middle and old aged general population.

The U-shape relationship between pulse pressure level on inpatient admission and long-term mortality in acute coronary syndrome patients undergoing percutaneous coronary intervention

The association between pulse pressure and long-term mortality was investigated among acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI). The study population included 5055 ACS patients in the Department of Cardiology of Beijing Friendship Hospital who were enrolled from January 2013 to July 2019. The median duration of follow-up was 24 months. Multivariate Cox regression was used to analyze the relationships between PP on inpatient admission and mortalities. Non-linear associations were studied by restricted cubic splines. Considering the heart function, the analyses were performed in the whole cohort and the LVEF > = 0.5 cohort separately. Subgroup analyses were performed according to the different diagnosis (the myocardial infarction subgroup and the unstable angina pectoris subgroup). When PP was used as categorical variable, the high PP group (≥61 mm Hg) significantly increased the risk of death compared with the intermediate PP group (50-60 mm Hg) in the both cohorts. When PP was used as continuous variable, a U-shape relationship were found between PP and mortalities in the whole cohort (p (for nonlinearity) = .005 and .003, respectively), with reference PP level of 55 mm Hg. However, this U-shape relationship disappeared in the LVEF > 0.5 cohort (p (for nonlinearity) = .111 and .117, respectively). The similar results were obtained in MI subgroup. From this study, the U-shape relationships between PP level and all-cause and cardiac mortalities were found in ACS patients who underwent PCI. The U-shape relationships disappeared in the LVEF > 0.5 cohort. The reference PP level was 55 mm Hg.

Association between pulse pressure and progression of chronic kidney disease

The aim of this study was to investigate the association between pulse pressure (PP) and chronic kidney disease (CKD) progression among the general population in Japan. We conducted a population-based cohort study of the residents of Iki Island, Nagasaki, Japan, from 2008 to 2018. We identified 1042 participants who had CKD (estimated glomerular filtration rate(eGFR) < 60 mL/min/1.73 m2 or the presence of proteinuria) at baseline. Cox's proportional hazard model was used to evaluate the association between PP and progression of CKD. During a 4.66-year mean follow-up, there were 241 cases of CKD progression (incident rate: 49.8 per 1000 person-years). A significant increase existed in CKD progression per 10 mmHg of PP elevation, even when adjusted for confounding factors [adjusted hazard ratio 1.17 (1.06-1.29) p < 0.001]. Similar results were obtained even after dividing PP into quartiles [Q2: 1.14 (0.74-1.76), Q3: 1.35 (0.88-2.06), Q4: 1.87 (1.23-2.83) p = 0.003 for trend]. This trend did not change significantly irrespective of baseline systolic or diastolic blood pressures. PP remained a potential predictive marker, especially for eGFR decline. In conclusion, we found a significant association between PP and CKD progression. PP might be a potential predictive marker for CKD progression.

Low-intensity pulsed ultrasound prevents angiotensin II-induced aortic smooth muscle cell phenotypic switch via hampering miR-17-5p and enhancing PPAR-γ

Vascular events can trigger a pathological phenotypic switch in vascular smooth muscle cells (VSMCs), decreasing and disrupting the plasticity and diversity of vascular networks. The development of novel therapeutic approaches is necessary to prevent these changes. We aimed to investigate the effects and associated mechanisms of low-intensity pulsed ultrasound (LIPUS) irradiation on the angiotensin II (AngII)-induced phenotypic switch in VSMCs. In vivo, AngII was infused subcutaneously for 4 weeks to stimulate vascular remodeling in mice, and LIPUS irradiation was applied for 20 min every 2 days for 4 weeks. In vitro, cultured rat aortic VSMCs (RAVSMCs) were pretreated once with LIPUS irradiation for 20 min before 48-h AngII stimulation. Our results showed that LIPUS irradiation prevents AngII-induced vascular remodeling of the whole wall artery without discriminating between adventitia and media in vivo and RAVSMC phenotypic switching in vitro. LIPUS irradiation downregulated miR-17-5p expression and upregulated peroxisome proliferator-activated receptor gamma (PPAR-γ) expression. The PPAR-γ activator rosiglitazone could mimic the favorable effects of LIPUS irradiation on AngII-treated RAVSMCs. In contrast, GW9662 could impede the LIPUS-mediated downregulation of RAVSMC proliferation and inflammation under AngII stimulation conditions in vivo and in vitro. Also, the miR-17-5p agomir has the same effects as GW9662 in vitro. Besides, the inhibitory effects of GW9662 against the anti-remodeling effects of LIPUS irradiation in AngII-induced RAVSMCs could be blocked by pretreatment with the miR-17-5p antagomir. Overall, LIPUS irradiation prevents AngII-induced RAVSMCs phenotypic switching through hampering miR-17-5p and enhancing PPAR-γ, suggesting a new approach for the treatment of vascular disorders.

Nighttime ambulatory pulse pressure predicts cardiovascular and all-cause mortality among middle-aged participants in the 21-year follow-up

Office pulse pressure (PP) is a predictor for cardiovascular (CV) events and mortality. Our aim was to evaluate ambulatory PP as a long‐term risk factor in a random cohort of middle‐aged participants. The Opera study took place in years 1991–1993, with a 24‐h ambulatory blood pressure measurement (ABPM) performed to 900 participants. The end‐points were non‐fatal and fatal CV events, and deaths of all‐causes. Follow‐up period, until the first event or until the end of the year 2014, was 21.1 years (mean). Of 900 participants, 22.6% died (29.6% of men/15.6% of women, p<.001). A CV event was experienced by 208 participants (23.1%), 68.3% of them were male (p<.001). High nighttime ambulatory PP predicted independently CV mortality (hazard ratio [HR] 2.60; 95% confidence interval [CI 95%] 1.08–6.31, p=.034) and all‐cause mortality in the whole population (HR 1.72; Cl 95% 1.06–2.78, p=.028). In males, both 24‐h PP and nighttime PP associated with CV mortality and all‐cause mortality (24‐h PP HR for CV mortality 2.98; CI 95% 1.11–8.04, p=.031 and all‐cause mortality HR 2.40; CI 95% 1.32–4.37, p=.004). Accordingly, nighttime PP; HR for CV mortality 3.13; CI 95% 1.14–8.56, p=.026, and for all‐cause mortality HR 2.26; CI 95% 1.29–3.96, p=.004. Cox regression analyses were adjusted by sex, CV risk factors, and appropriate ambulatory mean systolic BP. In our study, high ambulatory nighttime PP was detected as a long‐term risk factor for CV and all‐cause mortality in middle‐aged individuals.

Blood Pressure Determinants of Cerebral White Matter Hyperintensities and Microstructural Injury: UK Biobank Cohort Study

Supplemental Digital Content is available in the text.

Small vessel disease and related stroke and dementia risks are linked to aging and hypertension, but it is unclear whether the pulsatile or steady blood pressure (BP) component is more important for the development of macrostructural hyperintensities and microstructural white matter damage. This was a cross-sectional analysis of the UK Biobank cohort study of community-based adults from 22 UK centers. Linear associations were determined between neuroimaging markers (white matter hyperintensity [WMH] volume and diffusion imaging indices) and mean arterial pressure and pulse pressure (PP), both unadjusted and adjusted for age, sex, cardiovascular risk factors, antihypertensive medication, BP source, and assessment center. In 37 041 participants aged 45 to 82 years (53% female), univariable analyses demonstrated that increases in both BP components were associated with greater WMH volume and white matter injury on diffusion indices, with a larger effect for PP (standardized effect size for WMH: mean arterial BP: 0.182 [95% CIs, 0.170–0.193]; PP: 0.285 [95% CIs, 0.274–0.296]). In multivariable analyses, associations with mean arterial pressure remained similar, but associations with PP diminished, reflecting covariance with age and risk factors (standardized effect size for WMH: mean arterial BP: 0.106 [95% CIs, 0.095–0.117]; PP: 0.011 [95% CIs, −0.001 to 0.023]). The synergistic interaction between PP and age increased the effect of age on WMH and diffusion indices. Both macrostructural and microstructural white matter injury had similar associations with the pulsatile and steady components of hypertension, although PP accentuated the relationship between age and white matter damage.

Intensive blood pressure lowering in different age categories: insights from the Systolic Blood Pressure Intervention Trial

AIMS

The 2018 ESC/ESH guidelines for hypertension recommend differential management of patients who are <65, 65-79, and ≥80 years of age. However, it is unclear whether intensive blood pressure lowering is well-tolerated and modifies risk uniformly across the age spectrum.

METHODS AND RESULTS

SPRINT randomized 9361 high-risk adults without diabetes and age ≥50 years with systolic blood pressure 130-180 mmHg to either intensive or standard antihypertensive treatment. The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. The primary safety endpoint was composite serious adverse events. We assessed whether age modified the efficacy and safety of intensive vs. standard blood pressure lowering using Cox proportional-hazards regression and restricted cubic splines. In all, 3805 (41%), 4390 (47%), and 1166 (12%) were <65, 65-79, and ≥80 years. Mean age was similar between the two study groups (intensive group 67.9 ± 9.4 years vs. standard group 67.9 ± 9.5 years; P = 0.94). Median follow-up was 3.3 years. In multivariable models, age was linearly associated with the risk of stroke (P < 0.001) and non-linearly associated with the risk of primary efficacy events, death from cardiovascular causes, death from any cause, heart failure, and serious adverse events (P < 0.001). The safety and efficacy of intensive blood pressure lowering were not modified by age, whether tested continuously or categorically (P > 0.05).

CONCLUSION

In SPRINT, the benefits and risks of intensive blood pressure lowering did not differ according to the age categories proposed by the ESC/ESH guidelines for hypertension.

TRIAL REGISTRATION

SPRINT (Systolic Blood Pressure Intervention Trial); ClinicalTrials.gov Identifier: NCT01206062, https://clinicaltrials.gov/ct2/show/NCT01206062.

Grapefruit juice enhances the systolic blood pressure-lowering effects of dietary nitrate-containing beetroot juice

AIMS

Dietary nitrate from sources such as beetroot juice lowers blood pressure (BP) via the nitrate-nitrite-nitric oxide (NO) pathway. However, NO and nitrite are inactivated via reoxidation to nitrate, potentially limiting their activity. Cytochrome P450-3A4 inhibition with troleandomycin prevents nitrite re-oxidation to nitrate in rodent liver. Grapefruit juice contains the CYP3A4 inhibitor furanocoumarin. We therefore hypothesized that grapefruit juice would enhance BP-lowering with beetroot juice by maintaining circulating [nitrite].

METHODS

We performed a randomized, placebo-controlled, 7-hour crossover study in 11 healthy volunteers, attending on 3 occasions, receiving: a 70-mL shot of active beetroot juice (Beet-It) and either (i) 250 mL grapefruit juice (Active Beet+GFJ), or (ii) 250 mL water (Buxton, Active Beet+H2 O); or (iii) Placebo Beet+GFJ.

RESULTS

The addition of grapefruit juice to active beetroot juice lowered systolic BP (SBP): Active Beet+GFJ vs Active Beet+H2 O (P = .02), and pulse pressure, PP (P = .0003). Peak mean differences in SBP and PP were seen at T = 5 hours: -3.3 mmHg (95% confidence interval [CI] -6.43 to -0.15) and at T = 2.5 hours: -4.2 mmHg (95% CI -0.3 to -8.2), respectively. Contrary to the hypothesis, plasma [nitrite] was lower with Active Beet+GFJ vs Active Beet+H2 O (P = .006), as was salivary nitrite production (P = .002) and saliva volume (-0.34 mL/min [95% CI -0.05 to -0.68]). The taste score of Beet+GFJ was 1.4/10 points higher than Beet+H2 O (P = .03).

CONCLUSION

Grapefruit juice enhanced beetroot juice's effect on lowering SBP and PP despite decreasing plasma [nitrite]. Besides suggesting more complex mechanisms, there is potential for maximising the clinical benefit of dietary nitrate and targeting isolated systolic hypertension.

Association Between Blood Pressure Variability and Short-Term Outcome After Intra-arterial Thrombectomy in Acute Stroke Patients With Large-Vessel Occlusion

The optimal range of blood pressure variability (BPV) for acute stroke patients with large-vessel occlusion (LVO) remains unclear. This study investigated the association between BPV from admission through the first 24 h after intra-arterial thrombectomy (IAT) and short-term outcome in LVO patients. We retrospectively analyzed 257 consecutive patients with LVO stroke who were treated with IAT. BP values were recorded at 2-h intervals from admission through the first 24 h after IAT. BPV, as reflected by pulse pressure variability (PPV), was determined based on standard deviation (SD), coefficient of variation (CV), successive variation (SV), and the difference between maximum and minimum blood pressure (ΔBP; systolic BP minus diastolic BP). The association between BPV and clinical outcome (Modified Rankin Scale score at 90 days) was analyzed by multivariate logistic regression analysis. Of the 257 included patients, 70 had a good outcome at 3 months. PPV from admission through the first 24 h after IAT was independently associated in a graded manner with poor outcome [multivariable-adjusted odds ratios (95% confidence interval) for the highest of PPV were 43.0 (8.7–212.8) for SD, 40.3 (9.8–165.0) for CV, 55.0 (11.2–271.2) for SV, and 40.1 (8.0–201.9) for ΔBP]. The area under the receiver operating characteristic curve (95% confidence interval) of the PPV parameters were 0.924 (0.882–0.965) for SD, 0.886 (0.835–0.938) for CV, 0.932 (0.891–0.973) for SV, and 0.892 (0.845–0.939) for ΔBP, and the Youden index values were 0.740, 0.633, 0.759, and 0.756, respectively. In summary, BPV from admission through the first 24 h after IAT was independently associated with poor outcome at 3 months in patients with LVO, with greater variability corresponding to a stronger association. Thus, PPV may be a clinically useful predictor of functional prognosis in LVO patients treated with IAT.

Linear and Nonlinear Mendelian Randomization Analyses of the Association Between Diastolic Blood Pressure and Cardiovascular Events: The J-Curve Revisited

BACKGROUND

Recent clinical guidelines support intensive blood pressure treatment targets. However, observational data suggest that excessive diastolic blood pressure (DBP) lowering might increase the risk of myocardial infarction (MI), reflecting a J- or U-shaped relationship.

METHODS

We analyzed 47 407 participants from 5 cohorts (median age, 60 years). First, to corroborate previous observational analyses, we used traditional statistical methods to test the shape of association between DBP and cardiovascular disease (CVD). Second, we created polygenic risk scores of DBP and systolic blood pressure and generated linear Mendelian randomization (MR) estimates for the effect of DBP on CVD. Third, using novel nonlinear MR approaches, we evaluated for nonlinearity in the genetic relationship between DBP and CVD events. Comprehensive MR interrogation of DBP required us to also model systolic blood pressure, given that the 2 are strongly correlated.

RESULTS

Traditional observational analysis of our cohorts suggested a J-shaped association between DBP and MI. By contrast, linear MR analyses demonstrated an adverse effect of increasing DBP increments on CVD outcomes, including MI (MI hazard ratio, 1.07 per unit mm Hg increase in DBP; P<0.001). Furthermore, nonlinear MR analyses found no evidence for a J-shaped relationship; instead confirming that MI risk decreases consistently per unit decrease in DBP, even among individuals with low values of baseline DBP.

CONCLUSIONS

In this analysis of the genetic effect of DBP, we found no evidence for a nonlinear J- or U-shaped relationship between DBP and adverse CVD outcomes; including MI.

Sequential nephron blockade with combined diuretics improves diastolic function in patients with resistant hypertension

AIMS

Hypertension is a major contributor to cardiac diastolic dysfunction. Different therapeutics strategies have been proposed to control blood pressure (BP), but their independent impact on cardiac function remains undetermined. In patients with resistant hypertension, we compared the changes in cardiac parameters between two strategies based on sequential nephron blockade (NBD) with a combination of diuretics or sequential renin-angiotensin system blockade (RASB).

METHODS AND RESULTS

After a 4-week period where all patients received Irbesartan 300 mg/day + hydrochlorothiazide 12.5 mg/day + amlodipine 5 mg/day, 140 resistant hypertension patients (54.8 ± 11.1 years, 76% men, mean duration with hypertension: 13.1 ± 10.5 years, no previous history of heart failure or current symptoms of congestive heart failure) were randomized 1:1 to the NBD regimen or to the RASB regimen at week 0 (W0, baseline). Treatment intensity was increased at week 4, 8, or 10 if home BP was ≥135/85 mmHg, by sequentially adding 25 mg spironolactone, 20-40 mg furosemide, and 5 mg amiloride (NBD group) or 5-10 mg ramipril and 5-10 mg bisoprolol (RASB group). No other antihypertensive drug was allowed during the study. BP, BNP levels, and echocardiographic parameters were assessed at weeks 0 and 12. The baseline characteristics, laboratory parameters, and plasma hormones (BNP, renin, and aldosterone) and cardiac echocardiographic parameters did not significantly differ between the NBD and the RASB groups. Over 12 weeks, BNP levels significantly decreased in NBD but increased in RASB (mean [CI 95%] change in log-transformed BNP levels: -43% [-67%; -23%] vs. +55% [46%; 62%] in NBD vs. RASB, respectively, P < 0.0001). Similarly, the proportion of patients presenting ≥2 echocardiographic criteria of diastolic dysfunction decreased between baseline and W12 from 31% to 3% in NBD but increased from 19% to 32% in RASB (P = 0.0048). As compared with RASB, NBD induced greater decrease in ambulatory systolic BP (P < 0.0001), pulse pressure (P < 0.0001), and systemic vascular resistance (P < 0.005). In multivariable linear regression analyses, NBD treatment was significantly associated with decreased BNP levels (adjusted ß: -46.41 ± 6.99, P < 0.0001) independent of age, gender, renal function, and changes in BPs or heart rate.

CONCLUSIONS

In patients with resistant hypertension, nephron blockade with a combination of diuretics significantly improves cardiac markers of diastolic dysfunction independently of BP lowering.

Salt and potassium intake among adult Ghanaians: WHO-SAGE Ghana Wave 3

Though Ghana has high hypertension prevalence, the country lacks current national salt consumption data required to build and enhance advocacy for salt reduction. We explored the characteristics of a randomly selected sub sample that had valid urine collection, along with matched survey, anthropometric and BP data (n = 839, mean age = 60y), from the World Health Organization's Study on global AGEing and adult health (WHO-SAGE), Ghana Wave 3, n = 3053). We also investigated the relationship between salt intake and blood pressure (BP) among the cohort. BP was measured in triplicate and 24 h urine was collected for the determination of urinary sodium (Na), potassium (K), creatinine (Cr) and iodine levels. Hypertension prevalence was 44.3%. Median salt intake was 8.3 g/day, higher in women compared to men (8.6, interquartile range (IQR) 7.5 g/day vs 7.5, IQR 7.4 g/day, p <  0.01), younger participants (18-49 y) compared to older ones (50+ y) (9.7, IQR 7.9 g/day vs 8.1, IQR 7.1 g/day, p <  0.01) and those with higher Body Mass Index (BMI) (> 30 kg/m2) compared to a healthy BMI (18.5-24.9 kg/m2) (10.04, IQR 5.1 g/day vs 6.2, IQR 5.6 g/day, p <  0.01). More than three quarters (77%, n = 647) of participants had salt intakes above the WHO maximum recommendation of 5 g/d, and nearly two thirds (65%, n = 548) had daily K intakes below the recommended level of 90 mmol. Dietary sodium to potassium (Na: K) ratios above 2 mmol/mmol were positively associated with increasing BP with age. Population-based interventions to reduce salt intake and increase K consumption are needed.

Genetically Predicted Blood Pressure Across the Lifespan: Differential Effects of Mean and Pulse Pressure on Stroke Risk

Hypertension is the leading risk factor for stroke. Yet, it remains unknown whether blood pressure pulsatility (pulse pressure [PP]) causally affects stroke risk independently of the steady pressure component (mean arterial pressure [MAP]). It is further unknown how the effects of MAP and PP on stroke risk vary with age and stroke cause. Using data from UK Biobank (N=408 228; 38-71 years), we selected genetic variants as instruments for MAP and PP at age ≤55 and >55 years and across age deciles. We applied multivariable Mendelian randomization analyses to explore associations with ischemic stroke, intracerebral hemorrhage, and their subtypes. Higher genetically predicted MAP was associated with higher risk of ischemic stroke and intracerebral hemorrhage across the examined age spectrum. Independent of MAP, higher genetically predicted PP only at age >55 years was further associated with higher risk of ischemic stroke (odds ratio per-SD-increment, 1.23 [95% CI, 1.13-1.34]). Among subtypes, the effect of genetically predicted MAP on large artery stroke was attenuated, whereas the effect of genetically predicted PP was augmented with increasing age. Genetically predicted MAP, but not PP, was associated with small vessel stroke and deep intracerebral hemorrhage homogeneously across age deciles. Neither genetically predicted MAP nor PP were associated with lobar intracerebral hemorrhage. Beyond an effect of high MAP at any age on ischemic and hemorrhagic stroke, our results support an independent causal effect of high PP at older ages on large artery stroke. This finding warrants further investigation for the development of stroke preventive strategies targeting pulsatility in later life.

Short-term outcome after ischemic stroke and 24-h blood pressure variability: association and predictors

To examine the association between blood pressure (BP) variability measured within 24 h after admission for acute ischemic stroke and functional outcome 30 days after stroke onset and to find outcome predictors. A total of 174 patients were included in this retrospective study. Supine BP was measured every 4 h during the first 24 h after admission. The functional outcome was assessed using the modified Rankin Scale. BP parameters including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and pulse pressure (PP) were examined. A set of six variability indices was calculated, including standard deviation (SD), successive variation (SV), difference between maximum and minimum value (DMM), and maximal successive change (MSC). Patients with high SBP or PP variability measures were significantly more likely to develop an unfavorable outcome. All PP variability indices displayed the highest correlations with the outcome. This association was confirmed in logistic regression analysis, both in univariable model and a model adjusted to the baseline National Institute of Health Stroke Scale score and mean BP (the OR for an unfavorable outcome following a 10-mmHg increase in SD, SV, MSC, and DMM parameters was in the interval 1.4-2.7, p < 0.05). Following receiver operating characteristic analysis, the PP parameters yielded area under the curve (AUC) values between 0.654 and 0.666, p < 0.005. Thus, in the acute phase of ischemic stroke, the SD and MSC indices of PP variability during the first 24 h after admission were robustly associated with patients' 30-day outcomes and served as predictors of unfavorable outcomes with thresholds of 14 and 26 mmHg, respectively.

Effects of hesperidin in orange juice on blood and pulse pressures in mildly hypertensive individuals: a randomized controlled trial (Citrus study)

Purpose

To assess the sustained and acute effects, as well as the influence of sustained consumption on the acute effects, of orange juice (OJ) with a natural hesperidin content and hesperidin-enriched OJ (EOJ) on blood (BP) and pulse (PP) pressures in pre- and stage-1 hypertensive individuals.

Methods

In a randomized, parallel, double-blind, placebo-controlled trial, participants (n = 159) received 500 mL/day of control drink, OJ, or EOJ for 12 weeks. Two dose–response studies were performed at baseline and after 12 weeks.

Results

A single EOJ dose (500 mL) reduced systolic BP (SBP) and PP, with greater changes after sustained treatment where a decrease in diastolic BP (DBP) also occurred (P < 0.05). SBP and PP decreased in a dose-dependent manner relative to the hesperidin content of the beverages throughout the 12 weeks (P < 0.05). OJ and EOJ decreased homocysteine levels at 12 weeks versus the control drink (P < 0.05). After 12 weeks of EOJ consumption, four genes related to hypertension (PTX3, NLRP3, NPSR1 and NAMPT) were differentially expressed in peripheral blood mononuclear cells (P < 0.05).

Conclusion

Hesperidin in OJ reduces SBP and PP after sustained consumption, and after a single dose, the chronic consumption of EOJ enhances its postprandial effect. Decreases in systemic and transcriptomic biomarkers were concomitant with BP and PP changes. EOJ could be a useful co-adjuvant tool for BP and PP management in pre- and stage-1 hypertensive individuals.

Electronic supplementary material

The online version of this article (10.1007/s00394-020-02279-0) contains supplementary material, which is available to authorized users.

Brachial pulse pressure in acute heart failure. Results of the Heart Failure Registry

Aims

To investigate the still uncertain independent prognostic impact of pulse pressure (PP) in acute heart failure (HF), in particular across the left ventricular ejection fraction (EF) phenotypes, and the potential contribution of PP in outlining the individual phenotypes.

Methods and results

We prospectively evaluated 1‐year death and rehospitalization in 4314 patients admitted for acute HF grouped by EF and stratified by their PP level on admission. In HF with reduced (< 40%) EF (HFrEF), the highest quartiles of PP had the lowest unadjusted [hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.61–0.98] and adjusted (HR 0.64 0.50–0.82) risk of 1 year all cause death compared to the lowest quartile. Its prognostic impact was partially mediated by systolic blood pressure (SBP). In HF with preserved (≥ 50%) EF (HFpEF), the intermediate quartile of PP showed the lowest 1 year all cause mortality in unadjusted (HR 0.598, CI 0.416–0.858) and adjusted (HR 0.55, 95% CI 0.388‐0.801) models with no relationship with SBP. In a receiver operating characteristic analysis, a combination of PP > 60 mmHg and SBP > 140 mmHg was associated to a preserved EF with a high performance value. No prognostic significance of PP was found in the HF with mid‐range EF subgroup.

Conclusions

In acute HFrEF, there is an almost linear inverse relation between mortality and PP, partly mediated by SBP. In HFpEF, a J‐shaped relationship between mortality and PP was present with a better prognosis at the nadir. A combination of PP > 60 mmHg with SBP > 140 mmHg may be clinically helpful as marker of a preserved left ventricular EF.

Association between blood pressure variability, cardiovascular disease and mortality in type 2 diabetes: A systematic review and meta-analysis

AIM

To investigate the associations of blood pressure variability (BPV), expressed as long-term (visit-to-visit) and short-term (ambulatory blood pressure monitoring [ABPM] and home blood pressure monitoring [HBPM]) and all-cause mortality, major adverse cardiovascular events (MACEs), extended MACEs, microvascular complications (MiCs) and hypertension-mediated organ damage (HMOD) in adult patients with type 2 diabetes.

MATERIALS AND METHODS

PubMed, Medline, Embase, Cinahl, Web of Science, ClinicalTrials.gov and grey literature databases were searched for studies including patients with type 2 diabetes, at least one variable of BPV (visit-to-visit, HBPM, ABPM) and evaluation of the incidence of at least one of the following outcomes: all-cause mortality, MACEs, extended MACEs and/or MiCs and/or HMOD. The extracted information was analyzed using random effects meta-analysis and meta-regression.

RESULTS

Data from a total of 377 305 patients were analyzed. Systolic blood pressure (SBP) variability was associated with a significantly increased risk of all-cause mortality (HR 1.12, 95% CI 1.04-1.21), MACEs (HR 1.01, 95% CI 1.04-1.17), extended MACEs (HR 1.07, 95% CI 1.03-1.11) and MiCs (HR 1. 12, 95% CI 1.01-1.24), while diastolic blood pressure was not. Associations were mainly driven from studies on long-term SBP variability. Qualitative analysis showed that BPV was associated with the presence of HMOD expressed as carotid intima-media thickness, pulse wave velocity and left ventricular hypertrophy. Results were independent of mean blood pressure, glycaemic control and serum creatinine levels.

CONCLUSIONS

Our results suggest that BPV might provide additional information rather than mean blood pressure on the risk of cardiovascular disease in patients with type 2 diabetes.

Prognostic Significance of Pulse Pressure Variability During Mechanical Thrombectomy in Acute Ischemic Stroke Patients

Background Studies on the role of blood pressure ( BP ) variability specifically during mechanical thrombectomy ( MT ) are sparse and limited. Moreover, pulse pressure ( PP ) has not been considered as a potent hemodynamic parameter to describe BP variability during MT . We assessed the impact of PP variability on functional outcome in acute ischemic stroke patients with large vessel occlusion during MT . Methods and Results Acute ischemic stroke patients presenting with large vessel occlusion from January 2012 to June 2016 were included. BP data during MT were prospectively collected in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Logistic regression models were used to assess the association between PP coefficients of variation and functional outcome at 3 months (modified Rankin Scale). Among the 343 included patients, PP variability was significantly associated with worse 3-month modified Rankin Scale in univariable (odds ratio [OR] =1.56, 95% confidence interval [CI]: 1.24-1.96 per 1-unit increase, P=0.0002) and multivariable ordinal logistic regression (adjusted OR =1.40, 95% CI : 1.09-1.79, P=0.008). PP variability was also associated with unfavorable outcome (modified Rankin Scale 3-6) in univariable ( OR =1.53, 95% CI : 1.17-2.01, P=0.002) and multivariable analysis (adjusted OR =1.42, 95% CI : 1.02-1.98, P=0.04). There was an association between PP variability and 3-month all-cause mortality in univariable analysis ( OR = 1.37, 95% CI : 1.01-1.85 per 1-unit increase of the coefficient of variation of the PP , P=0.04), which did not remain significant after adjustment for potential confounders. Conclusions PP variability during MT is an independent predictor of worse clinical outcome in acute ischemic stroke patients. These findings support the need for a close monitoring of BP variability during MT . Whether pharmacological interventions aiming at reducing BP variability during MT could impact functional outcome needs to be determined.

Association of Pulse Pressure With Clinical Outcomes in Patients Under Different Antiplatelet Strategies After Percutaneous Coronary Intervention: Analysis of GLOBAL LEADERS

BACKGROUND

We evaluated the association of pulse pressure (PP) and different antiplatelet regimes with clinical and safety outcomes in an all-comers percutaneous coronary intervention (PCI) population.

METHODS

In this analysis of GLOBAL LEADERS (n = 15,936) we compared the experimental therapy of 23 months of ticagrelor after 1 month of dual-antiplatelet therapy (DAPT) vs standard DAPT for 12 months followed by aspirin monotherapy in subjects who underwent PCI and were divided into 2 groups according to the median PP (60 mm Hg). The primary end point (all-cause death or new Q-wave myocardial infarction) and the composite end points: patient-oriented composite end points (POCE), Bleeding Academic Research Consortium (BARC) 3 or 5, and net adverse clinical events (NACE) were evaluated.

RESULTS

At 2 years, subjects in the high-PP group (n = 7971) had similar rates of the primary end point (4.3% vs 3.9%; P = 0.058), POCE (14.9% vs 12.7%; P = 0.051), and BARC 3 or 5 (2.5% vs 1.7%; P = 0.355) and higher rates of NACE (16.4% vs 13.7%; P = 0.037) compared with the low-PP group (n = 7965). Among patients with PP < 60 mm Hg, the primary end point (3.4% vs 4.4%, adjusted hazard ratio [aHR] 0.77, 95% confidence interval [CI] 0.61-0.96), POCE (11.8% vs 13.5%, aHR 0.86, 95% CI 0.76-0.98), NACE (12.8% vs 14.7%, aHR 0.85, 95% CI 0.76-0.96), and BARC 3 or 5 (1.4% vs 2.1%, aHR 0.69, 95% CI 0.49-0.97) were lower with ticagrelor monotherapy compared with DAPT. The only significant interaction was for BARC 3 or 5 (P = 0.008).

CONCLUSIONS

After contemporary PCI, subjects with high PP levels experienced high rates of NACE at 2 years. In those with low PP, ticagrelor monotherapy led to a lower risk of bleeding events compared with standard DAPT.

Association between blood pressure components and the presence of carotid plaque among adults aged 45 years and older: a population-based cross-sectional study in rural China

OBJECTIVE

Pulse pressure is strongly associated with the early development of large-vessel atherosclerotic disease. However, the relationship between pulse pressure and carotid plaque in China is unknown. Thus, we investigated the associations of pulse pressure and mean arterial pressure with the presence of carotid plaques in a low-income population in rural China.

PARTICIPANTS AND METHODS

Residents, aged ≥45 years, without histories of stroke or cardiovascular disease were enrolled. Participant demographics, previous medical histories, and lifestyle information were collected; anthropometric measures, serum profiles, and B-mode ultrasonographic investigations were also performed.

RESULTS

The mean age of participants (n = 3789) was 59.9 years overall (men 61.1 years; women, 59.1 years). The mean SBP (146.42 mmHg) and DBP (86.81 mmHg), pulse pressures (59.61 mmHg), and mean arterial pressures (106.68 mmHg) were high in this population. The odds ratio (95% confidence interval) for the association of pulse pressure with the presence of carotid plaques was 1.028 (1.023-1.033), in the univariate analysis. After gradual adjustment for demographic features, risk factors, and serum profile measurements, this positive association remained statistically significant (all, P < 0.001). However, there was no significant relationship between mean arterial pressure and the presence of carotid plaques.

CONCLUSION

These findings suggest that an elevated pulse pressure is an independent risk factor for the presence of carotid plaque. These results suggest that enhanced monitoring of blood pressure components, among low-income residents, is crucial for decreasing the risk of stroke and other cardiovascular disease in China.

Diastolic Blood Pressure J-Curve Phenomenon in a Tertiary-Care Hypertension Clinic

Supplemental Digital Content is available in the text.

Concerns exist regarding the potential increased cardiovascular risk from lowering diastolic blood pressure (DBP) in hypertensive patients. We analyzed 30-year follow-up data of 10 355 hypertensive patients attending the Glasgow Blood Pressure Clinic. The association between blood pressure during the first 5 years of treatment and cause-specific hospital admissions or mortality was analyzed using multivariable adjusted Cox proportional hazard models. The primary outcome was a composite of cardiovascular admissions and deaths. DBP showed a U-shaped association (nadir, 92 mm Hg) for the primary cardiovascular outcome hazard and a reverse J-shaped association with all-cause mortality (nadir, 86 mm Hg) and noncardiovascular mortality (nadir, 92 mm Hg). The hazard ratio for the primary cardiovascular outcome after adjustment for systolic blood pressure was 1.38 (95% CI, 1.18–1.62) for DBP <80 compared with DBP of 80 to 89.9 mm Hg (referrant), and the subdistribution hazard ratio after accounting for competing risk was 1.33 (1.17–1.51) compared with DBP ≥80 mm Hg. Cause-specific nonfatal outcome analyses showed a reverse J-shaped relationship for myocardial infarction, ischemic heart disease, and heart failure admissions but a U-shaped relationship for stroke admissions. Age-stratified analyses showed DBP had no independent effect on stroke admissions among the older patient subgroup (≥60 years of age), but the younger subgroup showed a clear U-shaped relationship. Intensive blood pressure reduction may lead to unintended consequences of higher healthcare utilization because of increased cardiovascular morbidity, and this merits future prospective studies. Low on-treatment DBP is associated with increased risk of noncardiovascular mortality, the reasons for which are unclear.