Level of Blood Pressure Control and Cardiovascular Events: SPRINT Criteria Versus the 2014 Hypertension Recommendations

Asthma and increased risk of myocardial infarction and mortality among hypertensive Korean patients

This study aimed to evaluate the effects of asthma on cardiovascular disease incidence in patients with hypertension. A total of 639,784 patients with hypertension from the Korea National Health Insurance Service database were included, of whom 62,517 had history of asthma after propensity score matching. The risks of all-cause mortality, myocardial infarction (MI), stroke, and end-stage renal disease (ESRD) were assessed according to the presence of asthma, long-acting β2-agonist (LABA) inhaler usage, and/or systemic corticosteroid usage for up to 11 years. In addition, whether these risks were modified by average blood pressure (BP) levels during the follow-up period was examined. Asthma was associated with an increased risk of all-cause mortality (hazard ratio [HR], 1.203; 95% confidence interval [CI], 1.165-1.241) and MI (HR, 1.244; 95% CI, 1.182-1.310) but not the risk of stroke or ESRD. LABA inhaler usage was associated with a higher risk of all-cause mortality and MI, and systemic corticosteroids usage showed a higher risk of ESRD as well as all-cause mortality and MI among hypertensive patients with asthma. Compared to patients without asthma, there was a graded increase in the risk of all-cause mortality and MI in those with asthma without LABA inhaler/systemic corticosteroid usage and in those with asthma with LABA inhaler/systemic corticosteroid usage. These associations were not significantly modified by BP levels. This nationwide population-based study supports that asthma may be a clinical factor that increases the risk of poor outcomes in patients with hypertension.

Achievements of primary prevention targets in individuals with high risk of cardiovascular disease: an 8-year follow-up of the Tromsø study

Aims

To study change over 8 years in cardiovascular risk, achievement of national guideline-based treatment targets of lipids, blood pressure (BP) and smoking in primary prevention of cardiovascular disease (CVD), medication use, and characteristics associated with target achievement among individuals with high CVD risk in a general population.

Methods and results

We followed 2524 women and men aged 40-79 years with high risk of CVD attending the population-based Tromsø study in 2007-08 (Tromsø6) to their participation in the next survey in 2015-16 (Tromsø7). We used descriptive statistics and regression models to study change in CVD risk and medication use, and characteristics associated with treatment target achievement. In total, 71.4% reported use of BP- and/or lipid-lowering medication at second screening. Overall, CVD risk decreased during follow-up, with a larger decrease among medication users compared with non-users. Treatment target achievement was 31.0% for total cholesterol <5 mmol/L, 27.3% for LDL cholesterol <3 mmol/L, 43.4% for BP <140/90 (<135/85 if diabetes) mmHg, and 85.4% for non-smoking. A total of 9.8% reached all treatment targets combined. Baseline risk factor levels and current medication use had the strongest associations with treatment target achievement.

Conclusion

We found an overall improvement in CVD risk factors among high-risk individuals over 8 years. However, guideline-based treatment target achievement was relatively low for all risk factors except smoking. Medication use was the strongest characteristic associated with achieving treatment targets. This study has demonstrated that primary prevention of CVD continues to remain a major challenge.

Cost-effectiveness analysis of intensive blood pressure control in Korea

This study was a cost-effectiveness analysis of intensive blood pressure (BP) control among hypertensive patients in Korea. We constructed a Markov model comparing intensive versus standard BP control treatment and calculated the incremental cost-effectiveness ratio. The study population consisted of hypertensive patients over 50 years old with systolic blood pressures (SBPs) exceeding 140 mmHg and at high risk of cardiovascular disease. Treatment alternatives included lowering the SBP below 120 mmHg (intensive) and 140 mmHg (standard) for target BP. We assumed five scenarios with different medication adherence. The effectiveness variable was quality-adjusted life years (QALYs), and costs included medical costs related to hypertension (HT), complications, and nonmedical costs. In addition, we performed a sensitivity analysis to confirm the robustness of the results of this study. Scenario 5, with 100% medication adherence, showed the lowest incremental cost-effectiveness ratio (ICER) of $1,373 USD, followed by scenario 1 (first 15 years: 62.5%, 16-30 years: 65.2%, after 30 years: 59.5%), scenario 2 (first five years: 62.5% decrease by 5% every five years), and scenario 3 (first 10 years: 62.5% decrease by 10% every 10 years). The ICERs in all scenarios were lower than the willingness to pay (WTP) threshold of $9,492-$32,907 USD in Korea. Tornado analysis showed that the ICERs were changed greatly according to stroke incidence. Intensive treatment of HT prevents cardiovascular disease (CVD); therefore, intensive treatment is more cost-effective than standard treatment despite the consumption of more health resources. ICERs are considerably changed according to medication adherence, confirming the importance of patient adherence to treatment.

Protective effect of controlled blood pressure on risk of dementia in low-risk, grade 1 hypertension

OBJECTIVE

High blood pressure (BP) increases the risk of dementia; however, few studies have reported on the risk of dementia in patients with low-risk, early-grade hypertension. We investigated the protective effect of controlled BP on risk of dementia in treated, low-risk, grade 1 hypertensive patients from the entire National Health Insurance Service National Health Examinee cohort.

METHODS

We selected grade 1 hypertension (140-159/90-99 mmHg) patients with low risk, diagnosed in 2005-2006. All patients (N = 128 665) were classified into controlled (average BP < 140/90 mmHg during the follow-up) and uncontrolled (average BP ≥ 140/90 mmHg) BP groups and followed up until 2015. The risk of dementia was estimated using Cox proportional hazard model after adjustments for propensity score.

RESULTS

Average BP was 131/81 mmHg in the controlled group (N = 49 408) and 144/87 mmHg in the uncontrolled group (N = 99 257). Overall dementia incidence rates in controlled and uncontrolled groups were 4.9 and 8.1 per 1000 person-year, respectively. The controlled group showed lower risk of overall dementia, Alzheimer's disease, and vascular dementia than the uncontrolled group. The controlled group had a low risk of vascular dementia at all ages, especially in the younger group (age <60). The optimal BP level associated with the lowest risk of dementia was 130 to less than 140 mmHg for SBP and 70 to less than 80 mmHg for DBP.

CONCLUSION

We concluded that among even low-risk and grade 1 hypertension patients, controlled BP significantly reduced the risk of dementia, including Alzheimer's disease and vascular dementia.

Risk of fatal and nonfatal coronary heart disease and stroke events among adult patients with hypertension: basic Markov model inputs for evaluating cost-effectiveness of hypertension treatment: systematic review of cohort studies

Objectives

Hypertension is a risk factor for a number of vascular and cardiac complications. A Markov like simulation based on cardiovascular disease (CVD) policy model is being used for evaluating cost-effectiveness of hypertension treatment. Stroke, angina, myocardial infarction (MI), cardiac arrest and all-cause mortality were only included CVD outcome variables in the model. Therefore this systematic review was conducted to evaluate completeness of CVD policy model for evaluation of cost-effectiveness across different regions.

Key findings

Fourteen cohort studies involving a total of 1 674 773 hypertensive adult population and 499 226 adults with treatment resistant hypertension were included in this systematic review. Hypertension is clearly associated with coronary heart disease (CHD) and stroke mortality, unstable angina, stable angina, MI, heart failure (HF), sudden cardiac death, transient ischemic attack, ischemic stroke, sub-arachnoid hemorrhage, intracranial hemorrhage, peripheral arterial disease (PAD), and abdominal aortic aneurism (AAA). Lifetime risk of developing HF is higher among hypertensives across all ages, with slight variation among regions. Treatment resistant hypertension is associated with higher relative risk of developing major CVD events and mortality when compared with the non-resistant hypertension.

Summary

The CVD policy model can be used in most of the regions for evaluation of cost-effectiveness of hypertension treatment. However, hypertension is highly associated with HF in Latin America, Eastern Europe, and Sub-Saharan Africa. Therefore, it is important to consider HF in CVD policy model for evaluating cost-effectiveness of hypertension treatment in these regions. We do not suggest the inclusion of PAD and AAA in CVD policy model for evaluating cost-effectiveness of hypertension treatment due to lack of sufficient evidence. Researchers should consider the effect of treatment resistant hypertension either through including in the basic model or during setting the model assumptions.

Circadian Regulation of Blood Pressure: of Mice and Men

PURPOSE OF REVIEW

Blood pressure (BP) exhibits strong diurnal variations that have been shown to be important for normal physiology and health. In this review, we highlight recent advances in both basic and clinic research on how the circadian clock affects these BP rhythms.

RECENT FINDINGS

Tissue-specific and inducible knockout rodent models have provided novel ways to dissect how circadian clocks regulate BP rhythms and demonstrated that loss of these rhythms is associated with the development of disease. The use of circadian-specific research protocols has translated findings from rodent models to humans, providing insight into circadian control of BP, as well as how sleep, activity, and other factors influence diurnal BP rhythms. Circadian mechanisms play an important role in the regulation of diurnal BP rhythms. Future research needs to extend these findings to clinical populations and determine the extent to which circadian factors may play a role in the development of novel treatment approaches to the management of hypertension.

Fixed and Low-Dose Combinations of Blood Pressure-Lowering Agents: For the Many or the Few?

Despite the widespread availability of several effective classes of drugs, systemic arterial hypertension remains poorly controlled in the majority of patients worldwide. In this article, we discuss the different modalities and effects of combination therapy and possible future research questions. Treatment with a single antihypertensive agent can effectively reduce blood pressure in only a limited number of patients, while most require therapy with two or more agents to achieve target levels. As initial therapy, American and European guidelines suggest a combination of two antihypertensive drugs and the use of a third antihypertensive drug when hypertension is still uncontrolled. Initial combination therapy is recommended in high-risk patients for an immediate blood pressure response, improved tolerability and possibly increased patient adherence. In addition to the potential benefits of combining different drug classes with synergistic pharmacological and physiological actions, this approach is useful for increasing the patient compliance with treatment, in particular if provided at fixed doses in a single pill. The minimisation of side effects is critical for the long-term treatment of a largely asymptomatic condition such as systemic hypertension. Low-dose combinations of different drugs from classes with complementary actions may provide the best ratio of lower side effects and improved tolerability with a significant blood pressure reduction, particularly in high-risk patients. This approach could be aided by a multidisciplinary lifestyle intervention on risk factors.

Impact of Modifiable Bleeding Risk Factors on Major Bleeding in Patients With Atrial Fibrillation Anticoagulated With Rivaroxaban

Background Reducing major bleeding events is a challenge when managing anticoagulation in patients with atrial fibrillation. This study evaluated the impact of modifiable and nonmodifiable bleeding risk factors in patients with atrial fibrillation receiving rivaroxaban and estimated the impact of risk factor modification on major bleeding events. Methods and Results Modifiable and nonmodifiable risk factors associated with major bleeding events were identified from the XANTUS (Xarelto for Prevention of Stroke in Patients With Atrial Fibrillation) prospective registry data set (6784 rivaroxaban-treated patients). Parameters showing univariate association with bleeding were used to construct a multivariable model identifying independent risk factors. Modeling was used to estimate attributed weights to risk factors. Heavy alcohol use (hazard ratio [HR]=2.37; 95% CI 1.24-4.53); uncontrolled hypertension (HR after parameter-wise shrinkage=1.79; 95% CI 1.05-3.05); and concomitant treatment with antiplatelets, nonsteroidal anti-inflammatory drugs, or paracetamol (HR=1.80; 95% CI 1.24-2.61) were identified as modifiable, independent bleeding risk factors. Increasing age (HR=1.25 [per 5-year increment]; 95% CI 1.12-1.38); heart failure (HR=1.97; 95% CI 1.36-2.86); and vascular disease (HR=1.91; 95% CI 1.32-2.77) were identified as nonmodifiable bleeding risk factors. Overall, 128 (1.9%) patients experienced major bleeding events; of these, 11% had no identified bleeding risk factors, 50% had nonmodifiable bleeding risk factors only, and 39% had modifiable bleeding risk factors (with or without nonmodifiable risk factors). The presence of 1 modifiable bleeding risk factor doubled the risk of major bleeding. Conclusions Elimination of modifiable bleeding risk factors is a potentially effective strategy to reduce bleeding risk in atrial fibrillation patients receiving rivaroxaban. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01606995.

The protective effect of klotho against contrast-associated acute kidney injury via the antioxidative effect

As oxidative stress is one major factor behind contrast-associated acute kidney injury (CA-AKI), we investigated the protective effect of klotho against CA-AKI via the antioxidative effect. In in vitro experiments, cells (NRK-52E) were divided into the following three groups: control, iopamidol, or iopamidol + recombinant klotho (rKL) groups. Moreover, cell viability was measured with the Cell Counting Kit-8 assay, and oxidative stress was examined with 2',7'-dichlorodihydrofluorescein diacetate fluorescence intensity. RT-PCR and Western blot analysis were performed to assess propidium iodide klotho expression, and Bax-to-Bcl-2 and apoptosis ratios were evaluated with annexin V/Hoechst 33342 staining. Furthermore, we knocked down the klotho gene using siRNA to verify the endogenous effect of klotho. In our in vivo experiments, oxidative stress was evaluated with the thiobarbituric acid-reactive substance assay, and apoptosis was evaluated with the Bax-to-Bcl-2 ratio and cleaved caspase-3 immunohistochemistry. Additionally, cell and tissue morphology were investigated with transmission electron microscopy. In both in vitro and in vivo experiments, mRNA and protein expression of klotho significantly decreased in CA-AKI mice compared with control mice, whereas oxidative stress and apoptosis markers were significantly increased in CA-AKI mice. However, rKL supplementation mitigated the elevated apoptotic markers and oxidative stress in the CA-AKI mouse model and improved cell viability. In contrast, oxidative stress and apoptotic markers were more aggravated when the klotho gene was knocked down. Moreover, we found more cytoplasmic vacuoles in the CA-AKI mouse model using transmission electron microscopy but fewer cytoplasmic vacuoles in rKL-supplemented cells. The present study shows that klotho in proximal tubular cells can protect against CA-AKI via an antioxidative effect.

Blood pressure level associated with lowest cardiovascular event in hypertensive diabetic patients

BACKGROUND

The ACCORD BP trial failed to show the benefit of strict blood pressure (BP) control on cardiovascular events in diabetics with high cardiovascular risk. However, this result cannot be generalized to all diabetics. We investigated whether lower mean BP in diabetic people with hypertension is associated with better prognosis.

METHODS

Participants from the Korea National Health Insurance Service Health Examinee Cohort who were diagnosed with diabetes and hypertension between 2003 and 2006 were included in the analysis (N = 7926). Mortality and cardiovascular events were compared among three groups according to mean SBP (<130, 130-<140, ≥140 mmHg) and mean DBP (<80, 80-<90, ≥ 90 mmHg) recorded during follow-up health examinations for up to 11 years.

RESULTS

Significant reductions in the risk of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and end-stage renal disease were observed in patients with a mean SBP of 130 mmHg to less than 140 mmHg, as compared with patients with a mean SBP of at least 140 mmHg. The additional clinical benefit of a mean SBP of less than 130 mmHg was unclear. Lower risk of all-cause death, cardiovascular mortality, and nonfatal strokes was observed in patients with a mean DBP of 80 mmHg to less than 90 mmHg. A mean DBP of less than 80 mmHg was associated with further reduction in all-cause mortality, cardiovascular mortality, ischaemic stroke, and total stroke.

CONCLUSION

A mean BP of less than 140/80 mmHg was associated with further reduction in the risk of all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular events in diabetic hypertensive patients.

The relationship of all-cause mortality to average on-treatment systolic blood pressure is significantly related to baseline systolic blood pressure: implications for interpretation of the Systolic Blood Pressure Intervention Trial study

BACKGROUND

The SPRINT study demonstrated that targeting systolic blood pressure (SBP) less than 120 mmHg was associated with lower cardiovascular event and mortality rates. In the LIFE study, however, a lower achieved SBP was associated with increased mortality. Mean baseline SBP in SPRINT was 140 mmHg and a third of the population had a baseline SBP 132 mmHg or less, raising the question of whether the lower baseline SBP in SPRINT could in part account for these differences.

METHODS

All-cause mortality during 4.8 ± 0.9 years follow-up was examined in relation to tertiles of achieved on-treatment average SBP in patients with baseline SBP of 25th percentile or less versus greater than 25th percentile value of 164 mmHg in 7998 nondiabetic hypertensive patients with ECG left ventricular hypertrophy randomly assigned to losartan-based or atenolol-based treatment. Average on-treatment SBP less than 142 mmHg (lowest tertile) and average SBP 142 mmHg to less than 152 mmHg (middle tertile) were compared with average SBP at least 152 mmHg (highest tertile and reference group).

RESULTS

In the overall population, there was a significant interaction between baseline SBP 164 mmHg or less and average on-treatment SBP less than 142 mmHg in Cox analysis (χ = 15.48, P < 0.001). Among patients with baseline SBP greater than 164 mmHg, in multivariate Cox analyses adjusting for other potential predictors of mortality and a propensity score for having baseline SBP 164 mmHg or less and compared with average on-treatment SBP at least 152 mmHg, average on-treatment SBP less than 142 mmHg was associated with 32% higher mortality (hazard ratio 1.32, 95% CI 1.01-1.65), whereas average SBP of 142 mmHg to less than 152 mmHg was associated with 24% lower mortality (hazard ratio 0.76, 95% CI 0.59-0.98). In contrast, among patients with baseline SBP 164 mmHg or less, both average on-treatment SBP less than 142 mmHg (hazard ratio 0.60, 95% CI 0.36-0.99) and average SBP of 142 mmHg to less than 152 mmHg (hazard ratio 0.51, 95% CI 0.30-0.89) were associated with significantly lower mortality compared with average SBP of at least 152 mmHg.

CONCLUSION

Achievement of an average SBP less than 142 mmHg was associated with reduced mortality in patients with baseline SBP 164 mmHg or less but with increased mortality in those with higher baseline SBP in LIFE. These findings suggest that the lower mortality associated with a lower targeted SBP in SPRINT may not be applicable to patients with considerably higher baseline SBP than SPRINT patients. Further study is necessary to better understand these findings.

CLINICAL TRIALS REGISTRATION

http://clinicaltrials.gov/ct/show/NCT00338260?order=1.

Clinical Benefit of Treatment of Stage-1, Low-Risk Hypertension

Evidence about the benefits of treating uncomplicated, low-risk, stage-1 hypertension is lacking. The study aimed to investigate the association between mean blood pressure (BP) and clinical outcomes, and to determine optimal BPs in treated, low-risk, stage-1 hypertension. From the National Health Insurance Service Health Examination Database, patients with stage-1 hypertension between 2005 and 2006 were selected. They had a systolic BP of 140 to 159 mm Hg or diastolic BP of 90 to 99 mm Hg. Patients were grouped as controlled (mean BP <140/90 mm Hg; n=99 301) and uncontrolled (mean BP ≥140/90 mm Hg; n=49 460) according to their mean BP recorded during the follow-up health examination. All-cause mortality and cardiovascular outcomes were examined. Mean BPs in the controlled and uncontrolled groups were 131.1/80.9 and 144.6/86.8 mm Hg, respectively. Controlled BP was associated with significantly lower risks of all-cause mortality, all stroke, hemorrhagic stroke, ischemic stroke, and end-stage renal disease. Subgroup analysis demonstrated benefits of controlled BP in hypertensive patients aged <50 years for all-cause mortality, all stroke, hemorrhagic stroke, ischemic stroke, and end-stage renal disease, with no significant interaction according to age. The BP associated with the lowest risk of all-cause mortality was 120 to <130 mm Hg (systolic BP) and 70 to <80 mm Hg (diastolic BP). There was an increased risk of myocardial infarction in patients with mean systolic BP <120 mm Hg and diastolic BP <80 mm Hg. BP <140/90 mm Hg was associated with a significant reduction in the risk of mortality, stroke, and end-stage renal disease, with the lowest mortality risk at BP ranges of 120 to <130 and 70 to <80 mm Hg.

Value of electrocardiographic left ventricular hypertrophy as a predictor of poor blood pressure control: Evidence from the China stroke primary prevention trial

Recent studies have shown that hypertension is poorly controlled in many populations worldwide. Electrocardiographic left ventricular hypertrophy is a common manifestation of preclinical cardiovascular disease that strongly predicts cardiovascular disease morbidity and mortality. However, little information is available regarding the role of left ventricular hypertrophy in blood pressure (BP) control. We aimed to assess the relationship between electrocardiographic left ventricular hypertrophy and BP control in the China Stroke Primary Prevention Trial. The study population included 17,312 hypertensive patients who were selected from a group of 20,702 adults who had participated in the China Stroke Primary Prevention Trial and had undergone electrocardiography at baseline visit. Multivariate analysis identified left ventricular hypertrophy as a predictor of unsatisfactory BP control. The results revealed that 8.1% of hypertensive adults exhibit left ventricular hypertrophy and that the disease is more prevalent in males (12.8%) than in females. Multivariate regression analysis showed that the electrocardiographic left ventricular hypertrophy group had a significantly higher rate of unsatisfactory BP control [odds ratio (OR) 1.42, 95% confidence interval (95% CI) 1.26-1.61, P < .001) than the nonleft ventricular hypertrophy group.Notable differences in BP control were also observed among males (OR 1.37, 95% CI 1.17-1.60, P < .001) and females (OR 1.45, 95% CI 1.18-1.77, P < .001) and especially among patients with comorbid diabetes (OR 2.32, 95% CI 1.31-4.12, P = .004). In conclusion, the results of this study indicate that electrocardiographic left ventricular hypertrophy appears to be an independent predictive factor for poor BP control, especially in females and patients with comorbid diabetes.

Association of blood pressure components with mortality and cardiovascular events in prehypertensive individuals: a nationwide population-based cohort study

BACKGROUND

The effects of each blood pressure index [systolic and diastolic blood pressure (SBP, DBP), pulse pressure (PP), mean arterial pressure (MAP)] on the occurrence of mortality and cardiovascular (CV) events have not yet been investigated in prehypertensive populations.

METHODS

A total of 30,258 prehypertensive Korean participants underwent periodic health examination between 2003 and 2004 were enrolled, and the associations of BP components with mortality and CV events were investigated. Moreover, based on the DBP [80 ≤ DBP <90 mmHg (N = 21,323) and DBP <80 mmHg (N = 8,935)], the effects of BP components were also evaluated.

RESULTS

Multivariate Cox analyses in prehypertensive group revealed that the hazard ratios (HRs) were 1.121 and 1.130 per 10 mmHg increase in SBP and PP for mortality, respectively. Additionally, 10 mmHg increase of SBP (HR:1.090) was still significantly, but increase of PP (HR:1.060) was marginally associated with higher incidence of CV events. However, there were no significant associations with increase in DBP or MAP on adverse clinical outcomes in prehypertensive group. In the prehypertensive subjects with DBP <80 mmHg, CV events more frequently occurred by 38.8% and 28.5% per 10 mmHg increase in SBP and PP, respectively.

CONCLUSIONS

Prehypertensive subjects might need to be cautioned when they have high SBP or PP with low DBP even in healthy populations. Key message Prehypertensive subjects should be cautioned when they have high-systolic blood pressure or pulse pressure with low-diastolic blood pressure, even without previous hypertension, diabetes mellitus or chronic kidney disease.

The role of noninvasive cardiovascular testing, applied clinical nutrition and nutritional supplements in the prevention and treatment of coronary heart disease

Numerous clinical trials suggest that we have reached a limit in our ability to decrease the incidence of coronary heart disease (CHD) and cardiovascular disease (CVD) utilizing the traditional diagnostic evaluation, prevention and treatment strategies for the top five cardiovascular risk factors of hypertension, diabetes mellitus, dyslipidemia, obesity and smoking. About 80% of heart disease (heart attacks, angina, coronary heart disease and congestive heart failure) can be prevented by optimal nutrition, optimal exercise, optimal weight and body composition, mild alcohol intake and avoiding smoking. Statistics show that approximately 50% of patients continue to have CHD or myocardial infarction (MI) despite presently defined 'normal' levels of the five risk factors listed above. This is often referred to as the 'CHD gap'. Novel and more accurate definitions and evaluations of these top five risk factors are required, such as 24 h ambulatory blood pressure (ABM) results, advanced lipid profiles, redefined fasting and 2 h dysglycemia parameters, a focus on visceral obesity and body composition and the effects of adipokines on cardiovascular risk. There are numerous traumatic insults from the environment that damage the cardiovascular system but there are only three finite vascular endothelial responses, which are inflammation, oxidative stress and immune vascular dysfunction. In addition, the concept of translational cardiovascular medicine is mandatory in order to correlate the myriad of CHD risk factors to the presence or absence of functional or structural damage to the vascular system, preclinical and clinical CHD. This can be accomplished by utilizing advanced and updated CV risk scoring systems, new and redefined CV risk factors and biomarkers, micronutrient testing, cardiovascular genetics, nutrigenomics, metabolomics, genetic expression testing and noninvasive cardiovascular testing.

Relation Between Blood Pressure and Clinical Outcome in Hypertensive Subjects With Previous Stroke

Background

This study investigated whether a mean blood pressure (BP) of <130/80 mm Hg is associated with further reduction in cardiovascular outcomes in treated hypertensive subjects with previous stroke.

Methods and Results

Subjects from the Korea National Health Insurance Service health examinee cohort diagnosed as having stroke and hypertension from January 1st, 2003 and December 31st, 2006 (N=2320) were grouped according to mean systolic (<130, 130–<140, and ≥140 mm Hg) and diastolic (<80, 80–<90, and ≥90 mm Hg) BP recorded during follow‐up health examinations. All‐cause and cardiovascular mortality over 11 years were compared. Compared with subjects with a systolic BP of ≥140 mm Hg (N=736), subjects with a systolic BP of 130 to <140 mm Hg (N=793) had a significantly lower risk of all‐cause death (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.47–0.79; P<0.001), cardiovascular mortality (HR, 0.39; 95% CI, 0.25–0.61; P<0.001), and fatal ischemic stroke (HR, 0.25; 95% CI, 0.10–0.63; P=0.003). Systolic BP of <130 mm Hg (N=791) was associated with lower risk of nonfatal hemorrhagic stroke. Subjects with a diastolic BP of 80 to <90 mm Hg (N=1100) had significantly lower risk of all‐cause death (HR, 0.60, 95% CI, 0.45–0.80; P<0.001) and cardiovascular mortality (HR, 0.45; 95% CI, 0.30–0.70; P<0.001) than those with a diastolic BP of ≥90 mm Hg (N=342). Diastolic BP of <80 mm Hg (N=878) was associated with reduced risk of nonfatal hemorrhagic stroke and further lowering of all‐cause mortality and cardiovascular mortality.

Conclusions

BP of <130/80 mm Hg was associated with improved outcomes in hypertensive subjects with previous stroke.

Relation of Chronic Obstructive Pulmonary Disease to Cardiovascular Disease in the General Population

Chronic obstructive pulmonary disease (COPD) is a major health problem that contributes to substantial morbidity and mortality globally. This study investigated the relation between COPD and the risk of cardiovascular disease in the general population. We evaluated the cardiovascular effect of COPD using Korean National Health Insurance Service data from 2002 to 2013. We compared selected cardiovascular disease risk factors depending on pulmonary function using the Korean Health and Nutritional Examination Survey (KNHANES, n = 24,429) data. COPD was diagnosed in 11,771 patients (2.4%) in the National Health Insurance Service cohort. During the follow-up period (45.5 ± 14.9 months), subjects with COPD had lower cumulative survival rate for all-cause mortality, cardiovascular mortality, and sudden cardiac death (SCD, all p values <0.001). COPD was associated with an increased risk of all-cause mortality even after adjustment for potential confounding variables (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.33 to 1.55, p <0.001). However, COPD did not significantly increase the risk of cardiovascular mortality (HR 1.02, 95% CI 0.84 to 1.22, p = 0.876) and SCD (HR 1.07, 95% CI 0.79 to 1.44, p = 0.664) when adjusted for potential confounding variables. Analysis of the KNHANES cohort showed that systolic blood pressure, current smoking status, and Framingham risk score increased progressively with a decrease in pulmonary function (all p <0.001). In conclusion, COPD was associated with all-cause mortality, but not with cardiovascular mortality and SCD, whereas poor pulmonary function was associated with a heightened cardiovascular risk.

Modifiable Risk Factors for Incident Heart Failure in Atrial Fibrillation

OBJECTIVES

This study sought to identify modifiable risk factors and estimate the impact of risk factor modification on heart failure (HF) risk in women with new-onset atrial fibrillation (AF).

BACKGROUND

Incident HF is the most common nonfatal event in patients with AF, although strategies for HF prevention are lacking.

METHODS

We assessed 34,736 participants in the Women's Health Study who were free of prevalent cardiovascular disease at baseline. Cox models with time-varying assessment of risk factors after AF diagnosis were used to identify significant modifiable risk factors for incident HF.

RESULTS

Over a median follow-up of 20.6 years, 1,495 women developed AF without prevalent HF. In multivariable models, new-onset AF was associated with an increased risk of HF (hazard ratio [HR]: 9.03; 95% confidence interval [CI]: 7.52 to 10.85). Once women with AF developed HF, all-cause (HR: 1.83; 95% CI: 1.37 to 2.45) and cardiovascular mortality (HR: 2.87; 95% CI: 1.70 to 4.85) increased. In time-updated, multivariable models accounting for changes in risk factors after AF diagnosis, systolic blood pressure >120 mm Hg, body mass index ≥30 kg/m², current tobacco use, and diabetes mellitus were each associated with incident HF. The combination of these 4 modifiable risk factors accounted for an estimated 62% (95% CI: 23% to 83%) of the population-attributable risk of HF. Compared with women with 3 or 4 risk factors, those who maintained or achieved optimal risk factor control had a progressive decreased risk of HF (HR for 2 risk factors: 0.60; 95% CI: 0.37 to 0.95; 1 risk factor: 0.40; 95% CI: 0.25 to 0.63; and 0 risk factors: 0.14; 95% CI: 0.07 to 0.29).

CONCLUSIONS

In women with new-onset AF, modifiable risk factors including obesity, hypertension, smoking, and diabetes accounted for the majority of the population risk of HF. Optimal levels of modifiable risk factors were associated with decreased HF risk. Prospective assessment of risk factor modification at the time of AF diagnosis may warrant future investigation.