1
|
Wamil M, Nazarzadeh M, Rahimi K. Blood pressure management in type 2 diabetes: a review of recent evidence. Heart 2024:heartjnl-2024-323998. [PMID: 39103202 DOI: 10.1136/heartjnl-2024-323998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/12/2024] [Indexed: 08/07/2024] Open
Abstract
The frequent concurrence of elevated blood pressure (BP) and type 2 diabetes markedly elevates the risk of cardiovascular disease and mortality. In this review, we discuss the evidence supporting the role of BP-lowering therapies in preventing cardiovascular events in people with type 2 diabetes and the most appropriate BP treatment target in these individuals. We outline possible reasons for the heterogeneous effect of BP lowering in patients with and without diabetes and consider several pathophysiological mechanisms that could potentially explain such differences. The review introduces a mediation model, delineating the intricate interplay between hypertension and diabetes and their joint contribution to cardiovascular and renal pathologies. Finally, we outline the role of lifestyle changes and other pharmacological options in attenuating cardiometabolic risks in patients with type 2 diabetes. We propose a comprehensive, patient-centred management strategy, integrating various antihypertensive therapeutic approaches and providing clinicians with a systematic framework for better decision-making.
Collapse
Affiliation(s)
- Malgorzata Wamil
- Deep Medicine, Nuffield Department of Reproductive and Women's Health, University of Oxford, Oxford, UK
- Cardiology Department, Great Western Hospital NHS Trust, Swindon, UK
- Cardiology Department, Mayo Clinic Healthcare in London, London, UK
| | - Milad Nazarzadeh
- Deep Medicine, Nuffield Department of Reproductive and Women's Health, University of Oxford, Oxford, UK
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Reproductive and Women's Health, University of Oxford, Oxford, UK
| |
Collapse
|
2
|
McCarthy CP, Jackson R, McEvoy JW, Rahimi K. From Treating Hypertension to Lowering Cardiovascular Disease Risk. Hypertension 2024; 81:1655-1658. [PMID: 38887943 DOI: 10.1161/hypertensionaha.124.21722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Affiliation(s)
- Cian P McCarthy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston (C.P.M.)
| | - Rod Jackson
- Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand (R.J.)
| | - John W McEvoy
- Cardiology Department, University of Galway School of Medicine and National Institute for Prevention and Cardiovascular Health, Ireland (J.W.M.)
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Reproductive and Women's Health, University of Oxford, United Kingdom (K.R.)
| |
Collapse
|
3
|
Iglseder B, Mutzenbach JS. [Prevention of ischemic stroke in old age]. Z Gerontol Geriatr 2024; 57:402-410. [PMID: 39105805 PMCID: PMC11315753 DOI: 10.1007/s00391-024-02336-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 06/19/2024] [Indexed: 08/07/2024]
Abstract
Stroke is one of the main causes of permanent disability and death and the risk increases with age. Primary and secondary prevention therefore have a high priority. The treatment of risk factors, such as high blood pressure, diabetes mellitus and hyperlipidemia is just as important as anticoagulation in atrial fibrillation, in addition to optimization of lifestyle and diet. Platelet function inhibitors play a role in the prophylaxis of recurrence, carotid surgery and stenting are used in selected patients. There is little study evidence for old people, individualized treatment planning takes functional status and comorbidities into account.
Collapse
Affiliation(s)
- Bernhard Iglseder
- Universitätsklinik für Geriatrie der PMU, Uniklinikum Salzburg - Campus Christian-Doppler-Klinik, Ignaz-Harrer-Straße 79, 5020, Salzburg, Österreich.
| | - J Sebastian Mutzenbach
- Universitätsklinik für Neurologie, neurologische Intensivmedizin und Neurorehabilitation, Uniklinikum Salzburg - Campus Christian-Doppler-Klinik, Salzburg, Österreich
| |
Collapse
|
4
|
Pozarickij A, Gan W, Lin K, Clarke R, Fairhurst-Hunter Z, Koido M, Kanai M, Okada Y, Kamatani Y, Bennett D, Du H, Chen Y, Yang L, Avery D, Guo Y, Yu M, Yu C, Schmidt Valle D, Lv J, Chen J, Peto R, Collins R, Li L, Chen Z, Millwood IY, Walters RG. Causal relevance of different blood pressure traits on risk of cardiovascular diseases: GWAS and Mendelian randomisation in 100,000 Chinese adults. Nat Commun 2024; 15:6265. [PMID: 39048560 PMCID: PMC11269703 DOI: 10.1038/s41467-024-50297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/04/2024] [Indexed: 07/27/2024] Open
Abstract
Elevated blood pressure (BP) is major risk factor for cardiovascular diseases (CVD). Genome-wide association studies (GWAS) conducted predominantly in populations of European ancestry have identified >2,000 BP-associated loci, but other ancestries have been less well-studied. We conducted GWAS of systolic, diastolic, pulse, and mean arterial BP in 100,453 Chinese adults. We identified 128 non-overlapping loci associated with one or more BP traits, including 74 newly-reported associations. Despite strong genetic correlations between populations, we identified appreciably higher heritability and larger variant effect sizes in Chinese compared with European or Japanese ancestry populations. Using instruments derived from these GWAS, multivariable Mendelian randomisation demonstrated that BP traits contribute differently to the causal associations of BP with CVD. In particular, only pulse pressure was independently causally associated with carotid plaque. These findings reinforce the need for studies in diverse populations to understand the genetic determinants of BP traits and their roles in disease risk.
Collapse
Affiliation(s)
- Alfred Pozarickij
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Wei Gan
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Human Genetics Centre of Excellence, Novo Nordisk Research Centre Oxford, Innovation Building, Old Road Campus, Oxford, UK
| | - Kuang Lin
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zammy Fairhurst-Hunter
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Masaru Koido
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Masahiro Kanai
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Yukinori Okada
- Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, 565-0871, Japan
- Department of Genome Informatics, Graduate School of Medicine, University of Tokyo, Tokyo, 113-0033, Japan
- Laboratory for Systems Genetics, RIKEN Center for Integrative Medical Sciences, Kanagawa, 230- 0045, Japan
- Laboratory of Statistical Immunology, Immunology Frontier Research Center (WPI-IFReC), Osaka University, Suita, 565-0871, Japan
| | - Yoichiro Kamatani
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Derrick Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Huaidong Du
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yiping Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ling Yang
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Daniel Avery
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yu Guo
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, 100037, Beijing, China
| | - Min Yu
- Zhejiang CDC, Zhejiang, China
| | - Canqing Yu
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Xueyuan Road, Haidian District, 100191, Beijing, China
- Peking University Center for Public Health and Epidemic Preparedness and Response, 100191, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, 100191, Beijing, China
| | - Dan Schmidt Valle
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jun Lv
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Xueyuan Road, Haidian District, 100191, Beijing, China
- Peking University Center for Public Health and Epidemic Preparedness and Response, 100191, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, 100191, Beijing, China
| | - Junshi Chen
- China National Center For Food Safety Risk Assessment, Beijing, China
| | - Richard Peto
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Liming Li
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Xueyuan Road, Haidian District, 100191, Beijing, China.
- Peking University Center for Public Health and Epidemic Preparedness and Response, 100191, Beijing, China.
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, 100191, Beijing, China.
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iona Y Millwood
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robin G Walters
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| |
Collapse
|
5
|
Luo X, Liu W, Sun N, Bo P, Chen Y, Han Q, Li N, Lu X, Mou J, Sun G, Zhang Y. The prevalence of monotherapy and combination therapy in hypertension in China from 2019 to 2021: A nationwide population-based cross-sectional study. J Clin Hypertens (Greenwich) 2024. [PMID: 39012241 DOI: 10.1111/jch.14870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/13/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
There are no nationwide surveys on antihypertensive drugs in China. In order to assess the current status of antihypertensive drug therapy in patients with hypertension and analyzed factors that may affect combination therapy, using convenience sampling, we recruited 305,624 patients with hypertension from the Chinese Cardiovascular Association Database-Hypertension Center between January 2019 and December 2021. Chi-squared test was performed to analyze the administered antihypertensive drug types and their combinations in different hospital settings. Logistic regression was used to assess the factors influencing combination therapy. We found around 33.1% of the participants had stage 2 and above hypertension, of which 67.9% were treated with combination therapy. In community or general hospitals, the most common monotherapy was calcium channel blockers (CCB), angiotensin-converting enzyme inhibitor/angiotensin II receptor inhibitor (ACEI/ARB) and diuretic were the main single-pill combinations (SPCs), and ACEI/ARB and CCB were the main free combination. From 2019 to 2021, the rates of combination therapy increased (58.8%-64.1%) with SPCs from 25.9% to 31.0% and free combination from 31.9% to 32.6%. Patients aged < 60 years, with stage 2 and above hypertension, with an education level of high school and above, visiting general hospitals, living in the eastern region of China, with hypertension risk factors and comorbidities, and without anxiety or depression were more likely to receive combination therapy (all P < .05). The combination therapy use rate increased yearly and the rate of SPCs rose obviously. Individual, hospital, and regional differences in patients with hypertension influenced combination therapy.
Collapse
Affiliation(s)
- Xiaoyang Luo
- Cardiovascular Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
- Cardiovascular Department, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Wei Liu
- Cardiovascular Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Ningling Sun
- Cardiovascular Department, Peking University People's Hospital, Beijing, China
| | - Peili Bo
- Cardiovascular Department, Qilu Hospital of Shandong University, Jinan, China
| | - Yuanyuan Chen
- Cardiovascular Department, Peking University People's Hospital, Beijing, China
| | - Qinghua Han
- Cardiovascular Department, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Nanfang Li
- Cardiovascular Department, Xinjiang Uigur Municipal People's Hospital, Urumqi, China
| | - Xinzheng Lu
- Cardiovascular Department, Jiangsu Province Hospital, Nanjing, China
| | - Jianjun Mou
- Cardiovascular Department, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Gang Sun
- Cardiovascular Department, The Second Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Yuqing Zhang
- Cardiovascular Department, Fu Wai Hospital, Center for Cardiovascular Diseases, Beijing, China
| |
Collapse
|
6
|
Nejad SH, Azzam O, Schlaich MP. Recent developments in the management of resistant hypertension: focus on endothelin receptor antagonists. Future Cardiol 2024:1-11. [PMID: 38953510 DOI: 10.1080/14796678.2024.2367390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 06/10/2024] [Indexed: 07/04/2024] Open
Abstract
Resistant hypertension is characterized by the inability of guideline-recommended triple combination therapy to control blood pressure (BP) to target. It is associated with a significantly increased risk of adverse outcomes. Despite abundant preclinical evidence supporting the critical role of the endothelin pathway in resistant hypertension (RH), clinical implementation of endothelin antagonists for the treatment of hypertension was hindered by various factors. Recently, the novel dual endothelin-receptor antagonist aprocitentan was tested in individuals with resistant hypertension in the PRECISION trial and provided compelling evidence supporting both short and longer-term safety and clinically meaningful and sustained BP lowering efficacy. These findings resulted in the recent regulatory approval of aprocitentan by the FDA. Aprocitentan may be a particularly useful antihypertensive option for individuals with advanced age, chronic kidney disease, and albuminuria.
Collapse
Affiliation(s)
- Sayeh Heidari Nejad
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit & RPH Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Omar Azzam
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit & RPH Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit & RPH Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Australia
| |
Collapse
|
7
|
Sun G, Wang C, Ye N, Shi C, Ouyang N, Qiao L, Li G, Zhang L, Yu Y, Li Z, Zhou Y, Chen Z, Zhang S, Zhang P, Geng D, Miao W, Liu S, Sun Y. Impact of baseline cardiovascular risk on the outcomes of intensive blood pressure intervention: a post hoc analysis of the China rural hypertension control project. BMC Med 2024; 22:258. [PMID: 38902731 PMCID: PMC11188272 DOI: 10.1186/s12916-024-03494-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND The 2018/2023 ESC/ESH Guidelines underlined a gap how baseline cardiovascular disease (CVD) risk predicted blood pressure (BP) lowering benefits. Further, 2017 ACC/AHA Guideline and 2021 WHO Guideline recommended implementation studies about intensive BP control. Now, to bridge these guideline gaps, we conducted a post hoc analysis to validate whether the baseline CVD risk influences the effectiveness of the intensive BP control strategy, which was designed by China Rural Hypertension Control Project (CRHCP). METHODS This is a post hoc analysis of CRHCP, among which participants were enrolled except those having CVD history, over 80 years old, or missing data. Subjects were stratified into quartiles by baseline estimated CVD risk and then grouped into intervention and usual care group according to original assignment in CRHCP. Participants in the intervention group received an integrated, multi-faceted treatment strategy, executed by trained non-physician community health-care providers, aiming to achieve a BP target of < 130/80 mmHg. Cox proportional-hazards models were used to estimate the hazard ratios of outcomes for intervention in each quartile, while interaction effect between intervention and estimated CVD risk quartiles was additionally assessed. The primary outcome comprised myocardial infarction, stroke, hospitalization for heart failure, or CVD deaths. RESULTS Significant lower rates of primary outcomes for intervention group compared with usual care for each estimated CVD risk quartile were reported. The hazard ratios (95% confidence interval) in the four quartiles (from Q1 to Q4) were 0.59 (0.40, 0.87), 0.54 (0.40, 0.72), 0.72 (0.57, 0.91) and 0.65 (0.53, 0.80), respectively (all Ps < 0.01). There's no significant difference of hazard ratios by intervention across risk quartiles (P for interaction = 0.370). Only the relative risk of hypotension, not symptomatic hypotension, was elevated in the intervention group among upper three quartiles. CONCLUSIONS Intensive BP lowering strategy designed by CRHCP group was effective and safe in preventing cardiovascular events independent of baseline CVD risk. TRIAL REGISTRATION The trial is registered with ClinicalTrials.gov, NCT03527719.
Collapse
Affiliation(s)
- Guozhe Sun
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Chang Wang
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Ning Ye
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Chuning Shi
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Nanxiang Ouyang
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Lixia Qiao
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Guangxiao Li
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Linlin Zhang
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Yao Yu
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Zhi Li
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Ying Zhou
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Zihan Chen
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Shu Zhang
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Pengyu Zhang
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Danxi Geng
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Wei Miao
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Songyue Liu
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Yingxian Sun
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China.
| |
Collapse
|
8
|
Burke JF, Copeland LL, Sussman JB, Hayward RA, Gross AL, Briceño EM, Whitney R, Giordani BJ, Elkind MSV, Manly JJ, Gottesman RF, Gaskin DJ, Sidney S, Yaffe K, Sacco RL, Heckbert SR, Hughes TM, Galecki AT, Levine DA. Development and validation of the Michigan Chronic Disease Simulation Model (MICROSIM). PLoS One 2024; 19:e0300005. [PMID: 38753617 PMCID: PMC11098406 DOI: 10.1371/journal.pone.0300005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/19/2024] [Indexed: 05/18/2024] Open
Abstract
Strategies to prevent or delay Alzheimer's disease and related dementias (AD/ADRD) are urgently needed, and blood pressure (BP) management is a promising strategy. Yet the effects of different BP control strategies across the life course on AD/ADRD are unknown. Randomized trials may be infeasible due to prolonged follow-up and large sample sizes. Simulation analysis is a practical approach to estimating these effects using the best available existing data. However, existing simulation frameworks cannot estimate the effects of BP control on both dementia and cardiovascular disease. This manuscript describes the design principles, implementation details, and population-level validation of a novel population-health microsimulation framework, the MIchigan ChROnic Disease SIMulation (MICROSIM), for The Effect of Lower Blood Pressure over the Life Course on Late-life Cognition in Blacks, Hispanics, and Whites (BP-COG) study of the effect of BP levels over the life course on dementia and cardiovascular disease. MICROSIM is an agent-based Monte Carlo simulation designed using computer programming best practices. MICROSIM estimates annual vascular risk factor levels and transition probabilities in all-cause dementia, stroke, myocardial infarction, and mortality in a nationally representative sample of US adults 18+ using the National Health and Nutrition Examination Survey (NHANES). MICROSIM models changes in risk factors over time, cognition and dementia using changes from a pooled dataset of individual participant data from 6 US prospective cardiovascular cohort studies. Cardiovascular risks were estimated using a widely used risk model and BP treatment effects were derived from meta-analyses of randomized trials. MICROSIM is an extensible, open-source framework designed to estimate the population-level impact of different BP management strategies and reproduces US population-level estimates of BP and other vascular risk factors levels, their change over time, and incident all-cause dementia, stroke, myocardial infarction, and mortality.
Collapse
Affiliation(s)
- James F. Burke
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | | | - Jeremy B. Sussman
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, United States of America
- Ann Arbor Veteran’s Affairs Hospital, Center for Clinical Management and Research, Ann Arbor, MI, United States of America
| | - Rodney A. Hayward
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, United States of America
- Ann Arbor Veteran’s Affairs Hospital, Center for Clinical Management and Research, Ann Arbor, MI, United States of America
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School Public Health, Baltimore, MD, United States of America
| | - Emily M. Briceño
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Department of Physical Medicine and Rehabilitation, U-M, Ann Arbor, MI, United States of America
| | - Rachael Whitney
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
| | - Bruno J. Giordani
- Department of Psychiatry & Michigan Alzheimer’s Disease Center, U-M, Ann Arbor, MI, United States of America
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Jennifer J. Manly
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University, New York, NY, United States of America
| | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke (NINDS), Bethesda, MD, United States of America
| | - Darrell J. Gaskin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Stephen Sidney
- Kaiser Permanente Northern California Division of Research, Oakland, CA, United States of America
| | - Kristine Yaffe
- Departments of Psychiatry, Neurology and Epidemiology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Ralph L. Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Timothy M. Hughes
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Andrzej T. Galecki
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Department of Biostatistics, U-M, Ann Arbor, MI, United States of America
| | - Deborah A. Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, United States of America
| |
Collapse
|
9
|
Feigin VL, Martins SC, Brainin M, Norrving B, Kamenova S, Giniyat A, Kondybayeva A, Aldyngurov DK, Bapayeva M, Zhanuzakov M, Hankey GJ. Twenty years on from the introduction of the high risk strategy for stroke and cardiovascular disease prevention: a systematic scoping review. Eur J Neurol 2024; 31:e16157. [PMID: 38009814 PMCID: PMC11235671 DOI: 10.1111/ene.16157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE Early this century, the high risk strategy of primary stroke and cardiovascular disease (CVD) prevention for individuals shifted away from identifying (and treating, as appropriate) all at-risk individuals towards identifying and treating individuals who exceed arbitrary thresholds of absolute CVD risk. The public health impact of this strategy is uncertain. METHODS In our systematic scoping review, the electronic databases (Scopus, MEDLINE, Embase, Google Scholar, Cochrane Library) were searched to identify and appraise publications related to primary CVD/stroke prevention strategies and their effectiveness published in any language from January 1990 to August 2023. RESULTS No published randomized controlled trial was found on the effectiveness of the high CVD risk strategy for primary stroke/CVD prevention. Targeting high CVD risk individuals excludes a large proportion of the population from effective blood-pressure-lowering and lipid-lowering treatment and effective CVD prevention. There is also evidence that blood pressure lowering and lipid lowering are beneficial irrespective of blood pressure and cholesterol levels and irrespective of absolute CVD risk and that risk-stratified pharmacological management of blood pressure and lipids to only high CVD risk individuals leads to significant underuse of blood-pressure-lowering and lipid-lowering medications in individuals otherwise eligible for such treatment. CONCLUSIONS Primary stroke and CVD prevention needs to be done in all individuals with increased risk of CVD/stroke. Pharmacological management of blood pressure and blood cholesterol should not be solely based on the high CVD risk treatment thresholds. International guidelines and global strategies for primary CVD/stroke prevention need to be revised.
Collapse
Affiliation(s)
- Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Institute for Health Metrics Evaluation, University of Washington, Seattle, Washington, USA
| | - Sheila C Martins
- Hospital de Clínicas de Porto Alegre, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Michael Brainin
- Department of Neuroscience and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Bo Norrving
- Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Saltanat Kamenova
- Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
| | - Azhar Giniyat
- Minister of Healthcare of the Republic of Kazakhstan, Astana, Republic of Kazakhstan
| | - Aida Kondybayeva
- Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
| | - Daulet K Aldyngurov
- Department of Science and Human Resource, Ministry of Healthcare of the Republic of Kazakhstan, Astana, Republic of Kazakhstan
| | - Magripa Bapayeva
- Department of Internal Medicine, Kazakhstan Medical University «KSPH», Almaty, Republic of Kazakhstan
| | - Murat Zhanuzakov
- Higher School of Medicine, al-Farabi Kazakh National University, Almaty, Republic of Kazakhstan
| | - Graeme J Hankey
- Perron Institute Chair in Stroke Research, Medical School, University of Western Australia, Perth, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Perth, Western Australia, Australia
| |
Collapse
|
10
|
Majert J, Nazarzadeh M, Ramakrishnan R, Bidel Z, Hedgecott D, Perez-Crespillo A, Turpie W, Akhtar N, Allison M, Rao S, Gudgin B, McAuley M, A'Court C, Billot L, Kotecha D, Potter J, Rahimi K. Efficacy of decentralised home-based antihypertensive treatment in older adults with multimorbidity and polypharmacy (ATEMPT): an open-label randomised controlled pilot trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e172-e181. [PMID: 38342123 DOI: 10.1016/s2666-7568(23)00259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Older patients with multimorbidity and polypharmacy have been under-represented in clinical trials. We aimed to assess the effect of different intensities of antihypertensive treatment on changes in blood pressure, major safety outcomes, and patient-reported outcomes in this population. METHODS ATEMPT was a decentralised, two-armed, parallel-group, open-label randomised controlled pilot trial conducted in the Thames Valley area, South East England. Individuals aged 65 years or older with multimorbidity (three or more chronic conditions) or polypharmacy (five or more types of medications) and a systolic blood pressure of 115-165 mm Hg were eligible for inclusion. Participants were identified through a search of national hospital discharge databases, identification of patients registered with an online pharmacy, and via targeted advertising on social media platforms. Participants were randomly assigned to receive up to two more classes versus up to two fewer classes of antihypertensive medications. Apart from routine home visits for conducting the baseline assessment, all communication, monitoring, and management of participants by the trial team was conducted remotely. The primary outcome was change in home-measured blood pressure. FINDINGS Between Dec 15, 2020, and Aug 31, 2022, 230 participants were randomly assigned (n=126 to more vs n=104 to fewer antihypertensive medications). The frequency of serious adverse events was similar across both groups; no cardiovascular events occurred in the more antihypertensive drugs group, compared with six in the fewer antihypertensive drugs group, of which two were fatal. Over a 13-month follow-up period, the mean systolic blood pressure in the group allocated to receive more antihypertensive medications decreased from 134·5 mm Hg (SD 10·7) at baseline to 122·1 mm Hg (10·5). By contrast, in the group allocated to receive fewer antihypertensive medications, it remained relatively unchanged, moving from 134·8 mm Hg (SD 11·2) at baseline to 132·9 mm Hg (15·3); this corresponded to a mean difference of -10·7 mm Hg (95% CI -17·5 to -4·0). INTERPRETATION Remotely delivered antihypertensive treatment substantially reduced systolic blood pressure in older adults who are often less represented in trials, with no increase in the risk of serious adverse events. The results of this trial will inform a larger clinical trial focusing on assessing major cardiovascular events, safety, physical functioning, and cognitive function that is currently in the planning stages. These results also underscore the efficiency of decentralised trial designs, which might be of broader interest in other settings. FUNDING National Institute for Health Research Oxford Biomedical Research Centre and the Oxford Martin School.
Collapse
Affiliation(s)
- Jeannette Majert
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Deborah Hedgecott
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | | | - Wendy Turpie
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Naseem Akhtar
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Moira Allison
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Shishir Rao
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | | | | | - Christine A'Court
- Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre & NHS West Midlands Secure Data Environment, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Potter
- Department of Medicine, University of East Anglia, Norwich, UK
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK.
| |
Collapse
|
11
|
Greenstein AS, Reusch JEB, Heagerty AM. Is it time to recommend cardiovascular protection for all? J Hypertens 2024; 42:224-226. [PMID: 38165051 DOI: 10.1097/hjh.0000000000003501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Adam S Greenstein
- Division of Cardiovascular Sciences, University of Manchester, Core Technology Facility, Manchester, UK
| | - Jane E B Reusch
- University of Colorado, Division of Endocrinology, CU Anschutz Medical Center and Rocky Mountain Regional VAMC Research I South, Aurora, Colorado, USA
| | - Anthony M Heagerty
- Division of Cardiovascular Sciences, University of Manchester, Core Technology Facility, Manchester, UK
| |
Collapse
|
12
|
Tran KC, Mak M, Kuyper LM, Bittman J, Mangat B, Lindsay H, Kim Sing C, Xu L, Wong H, Dawes M, Khan N, Ho K. Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study. JMIR Form Res 2024; 8:e49592. [PMID: 38111177 PMCID: PMC10865197 DOI: 10.2196/49592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. OBJECTIVE Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. METHODS Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. RESULTS A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. CONCLUSIONS HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.
Collapse
Affiliation(s)
- Karen C Tran
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Meagan Mak
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Laura M Kuyper
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jesse Bittman
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Birinder Mangat
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Heather Lindsay
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chad Kim Sing
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Liang Xu
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Hubert Wong
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Martin Dawes
- Division of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadia Khan
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Kendall Ho
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
13
|
Tsabedze N, Naicker RD, Mrabeti S. Efficacy of beta-blockers on blood pressure control and morbidity and mortality endpoints in hypertensives of African ancestry: an individual patient data meta-analysis. Front Cardiovasc Med 2024; 10:1280953. [PMID: 38322274 PMCID: PMC10844441 DOI: 10.3389/fcvm.2023.1280953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/11/2023] [Indexed: 02/08/2024] Open
Abstract
Introduction Compared with first-line antihypertensives, beta-blockers (BB) have been reported to lower the central aortic blood pressure suboptimally and are associated with increased stroke risk. This observation has not been investigated in hypertensives of African ancestry. We hypothesised that an individual patient data meta-analysis (IPD-MA) on the efficacy of second- or third-generation beta-blockers (STGBBs) in hypertensives of African descent may provide new insights. Methods A single-stage IPD-MA analysed the efficacy of STGBB in lowering the mean arterial blood pressure and reducing the composite outcomes: cardiovascular death, stroke, and myocardial infarction. Results A total of 11,860 participants from four randomised control trials were included in the analysis. Second- or third-generation beta-blockers reduced the mean arterial pressure by 1.75 mmHg [95% confidence interval (CI):1.16-2.33; P < 0.001] in all participants included in the analysis, and by 1.93 mmHg (95% CI: 0.86-3.00; P < 0.001) in hypertensive Africans. In patients with established cardiovascular disease, where the benefits of BB therapy are well established, STGBBs were associated with an adjusted odds ratio of 1.33 (95% CI: 1.06-1.65; P = 0.015) of the composite outcome, most likely due to confounding. Similarly, the risk of total myocardial infarction was 1.76 times higher (95% CI: 1.15-2.68; P = 0.008) in hypertensives of African ancestry on STGBBs. Conclusion The STGBBs reduced the mean arterial pressure comparably to other antihypertensives, and they were not associated with an increased risk of stroke.
Collapse
Affiliation(s)
- Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R. Darshni Naicker
- Medical Department, Healthcare Division, Merck Pty Ltd, Modderfontein, South Africa
| | - Sanaa Mrabeti
- Medical Affairs EMEA, Merck Serono Middle East FZ-LLC, Dubai, United Arab Emirates
| |
Collapse
|
14
|
Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
15
|
Jung H. Sex differences in cardiovascular risk factors and quality of life among individuals with hypertension in Korea from 2013 to 2018: A cross-sectional cohort study. PLoS One 2024; 19:e0296326. [PMID: 38165950 PMCID: PMC10760734 DOI: 10.1371/journal.pone.0296326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 12/11/2023] [Indexed: 01/04/2024] Open
Abstract
As its prevalence increases and its association with cardiovascular disease and mortality is established, there is a need to improve prevention and management strategies for hypertension. Therefore, we aimed to compare differences in cardiovascular health status between men and women with hypertension defined by systolic blood pressure ≥140 mmHg and diastolic blood pressure ≥90 mmHg, and/or treatment with antihypertensive drugs. The association between cardiovascular health status and health-related quality of life was also evaluated. Additionally, a secondary analysis was performed on the cross-sectional data from 7306 adults with hypertension, ≥40 years of age between 2013 and 2018. Of this sample, 51.2% of patients were women from the Korean National Health and Nutrition Examination Survey. The seven Cardiovascular Health Metrics were used to quantify cardiovascular health status and the 5-dimensional European Quality of Life Questionnaire (EQ-5D) was used to evaluate health-related quality of life. A higher proportion of men than that of women was observed in the poor cardiovascular health score group [total score 0-7], with a higher proportion of women in the intermediate group [total score 8-10] and ideal group [total 11-14] (p<0.0001). The proportion of women in the EQ-5D index was higher than that of men in the poor and intermediate groups (p<0.0001), with no difference in the proportion of men and women in the ideal group (p = 0.1452). Furthermore, specific cardiovascular risk factors were different between men and women: women had lower physical activity level and higher prevalence of high cholesterol (≥200 mg/dl), and men had higher body mass indices and worse diet management. These findings indicate that prevention and management strategies for hypertension and cardiovascular health might need to differ for men and women to improve outcomes.
Collapse
Affiliation(s)
- Hyejin Jung
- Department of Meridian & Acupoint, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| |
Collapse
|
16
|
ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Das SR, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Kosiborod MN, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S179-S218. [PMID: 38078592 PMCID: PMC10725811 DOI: 10.2337/dc24-s010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
17
|
Ding J, Chen J, Zhou J, Jiang Z, Xiang D, Xing W. Association between renal surface nodularity and increased adverse vascular event risk in patients with arterial hypertension. Clin Exp Hypertens 2023; 45:2228518. [PMID: 37366048 DOI: 10.1080/10641963.2023.2228518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/16/2023] [Accepted: 06/17/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE To explore the association of renal surface nodularity (RSN) with the increased adverse vascular event (AVE) risk in patients with arterial hypertension. METHODS This cross-sectional study included patients with arterial hypertension aged 18-60 years who underwent contrasted computed tomography (CT) of kidney from January 2012 to December 2020. The subjects were classified into AVE or not (non-AVE) matched with age (≤5 years) and sex. Their CT images were analyzed using both qualitative (semiRSN) and quantitative RSN (qRSN) methods, respectively. Their clinical characteristics included age, sex, systolic blood pressure (SBP), diastolic blood pressure, hypertension course, diabetes history, hyperlipidemia, and estimated glomerular filtration rate (eGFR). RESULTS Compared with non-AVE group (n = 91), AVE (n = 91) was at lower age, higher SBP, and fewer rate of diabetes and hyperlipidemia history (all P < .01). Rate of positive semiRSN was higher in AVE than non-AVE (49.45% vs 14.29%, P < .001). qRSN was larger in AVE than non-AVE [1.03 (0.85, 1.33) vs 0.86 (0.75,1.03), P < .001]. The increased AVE was associated with semiRSN (odds ratio = 7.04, P < .001) and qRSN (odds ratio = 5.09, P = .003), respectively. For distinguishing AVE from non-AVE, the area under receiver operating characteristic was bigger in the models combining the clinical characteristics with either semiRSN or qRSN than that of semiRSN or qRSN alone (P ≤.01). CONCLUSION Among the patients with arterial hypertension aged 18-60 years, CT imaging-based RSN was associated with increased AVE risk.
Collapse
Affiliation(s)
- Jiule Ding
- Department of Radiology, The Third Affiliated Hospital of Soochow Univesity, Changzhou, Jiangsu, China
| | - Jie Chen
- Department of Radiology, The Third Affiliated Hospital of Soochow Univesity, Changzhou, Jiangsu, China
| | - Jun Zhou
- Department of Radiology, The Third Affiliated Hospital of Soochow Univesity, Changzhou, Jiangsu, China
| | - Zhenxing Jiang
- Department of Radiology, The Third Affiliated Hospital of Soochow Univesity, Changzhou, Jiangsu, China
| | - Dehui Xiang
- School of Electronics and Information Engineering, Soochow University, Suzhou, Jiangsu, China
| | - Wei Xing
- Department of Radiology, The Third Affiliated Hospital of Soochow Univesity, Changzhou, Jiangsu, China
| |
Collapse
|
18
|
Kotta PA, Nambi V, Bozkurt B. Biomarkers for Heart Failure Prediction and Prevention. J Cardiovasc Dev Dis 2023; 10:488. [PMID: 38132656 PMCID: PMC10744096 DOI: 10.3390/jcdd10120488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/13/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
Heart failure (HF) is a global pandemic affecting over 64 million people worldwide. Its prevalence is on an upward trajectory, with associated increasing healthcare expenditure. Organizations including the American College of Cardiology (ACC) and the American Heart Association (AHA) have identified HF prevention as an important focus. Recently, the ACC/AHA/Heart Failure Society of America (HFSA) Guidelines on heart failure were updated with a new Class IIa, Level of Evidence B recommendation for biomarker-based screening in patients at risk of developing heart failure. In this review, we evaluate the studies that have assessed the various roles and contributions of biomarkers in the prediction and prevention of heart failure. We examined studies that have utilized biomarkers to detect cardiac dysfunction or abnormality for HF risk prediction and screening before patients develop clinical signs and symptoms of HF. We also included studies with biomarkers on prognostication and risk prediction over and above existing HF risk prediction models and studies that address the utility of changes in biomarkers over time for HF risk. We discuss studies of biomarkers to guide management and assess the efficacy of prevention strategies and multi-biomarker and multimodality approaches to improve risk prediction.
Collapse
Affiliation(s)
| | - Vijay Nambi
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
| | - Biykem Bozkurt
- Department of Medicine, Cardiology Section, Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA;
| |
Collapse
|
19
|
Saeed D, Reza T, Shahzad MW, Karim Mandokhail A, Bakht D, Qizilbash FH, Silloca-Cabana EO, Ramadhan A, Bokhari SFH. Navigating the Crossroads: Understanding the Link Between Chronic Kidney Disease and Cardiovascular Health. Cureus 2023; 15:e51362. [PMID: 38292979 PMCID: PMC10825078 DOI: 10.7759/cureus.51362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 02/01/2024] Open
Abstract
Chronic Kidney Disease (CKD) has emerged as a global healthcare challenge affecting a significant portion of the world's population. This comprehensive narrative review delves into the intricate relationship between CKD and cardiovascular disease (CVD). CKD is characterized by kidney damage persisting for at least three months, often with or without a decline in glomerular filtration rate (GFR). It is closely linked with CVD, as individuals with CKD face a high risk of cardiovascular events, making cardiovascular-associated mortality a significant concern in advanced CKD stages. The review emphasizes the importance of precise risk assessment using biomarkers, advanced imaging, and tailored medication strategies to mitigate cardiovascular risks in CKD patients. Lifestyle modifications, early intervention, and patient-centered care are crucial in managing both conditions. Challenges in awareness and recognition of CKD and the need for comprehensive interdisciplinary care are highlighted. Recent advances in research offer promising therapies, such as SGLT2 inhibitors, MRAs, GLP-1R agonists, and selective endothelin receptor antagonists. Stem cell-based therapies, gene editing, and regenerative approaches are under investigation. Patient-physician "risk discussions" and tailored risk assessments are essential for improving patient outcomes. In conclusion, the review underscores the complexity of the interconnected CKD and cardiovascular health domains. Ongoing research, innovative therapies, and personalized healthcare will be instrumental in addressing the challenges, reducing the disease burden, and enhancing well-being for individuals facing CKD and cardiovascular issues. Recognizing the intricate connections between these conditions is imperative for healthcare providers, policymakers, and researchers as they seek to improve the quality of care and outcomes for affected individuals.
Collapse
Affiliation(s)
- Danish Saeed
- Internal Medicine, Shaikh Zayed Medical Complex, Lahore, PAK
| | - Taufiqa Reza
- Internal Medicine, Avalon University School of Medicine, Youngstown, USA
| | | | | | - Danyal Bakht
- Medicine and Surgery, Mayo Hospital, Lahore, PAK
| | | | | | - Afif Ramadhan
- General Practice, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, IDN
| | | |
Collapse
|
20
|
Kerr AJ, Choi Y, Williams MJ, Stewart RA, White HD, Devlin G, Selak V, Lee MAW, El-Jack S, Adamson PD, Fairley S, Jackson RT, Poppe K. Paired risk scores to predict ischaemic and bleeding risk twenty-eight days to one year after an acute coronary syndrome. Heart 2023; 109:1827-1836. [PMID: 37558394 DOI: 10.1136/heartjnl-2023-322830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE The recommended duration of dual anti-platelet therapy (DAPT) following acute coronary syndrome (ACS) varies from 1 month to 1 year depending on the balance of risks of ischaemia and major bleeding. We designed paired ischaemic and major bleeding risk scores to inform this decision. METHODS New Zealand (NZ) patients with ACS investigated with coronary angiography are recorded in the All NZ ACS Quality Improvement registry and linked to national health datasets. Patients were aged 18-84 years (2012-2020), event free at 28 days postdischarge and without atrial fibrillation. Two 28-day to 1-year postdischarge multivariable risk prediction scores were developed: (1) cardiovascular mortality/rehospitalisation with myocardial infarction or ischaemic stroke (ischaemic score) and (2) bleeding mortality/rehospitalisation with bleeding (bleeding score). FINDINGS In 27 755 patients, there were 1200 (4.3%) ischaemic and 548 (2.0%) major bleeding events. Both scores were well calibrated with moderate discrimination performance (Harrell's c-statistic 0.75 (95% CI, 0.74 to 0.77) and 0.69 (95% CI, 0.67 to 0 .71), respectively). Applying these scores to the 2020 European Society of Cardiology ACS antithrombotic treatment algorithm, the 31% of the cohort at elevated (>2%) bleeding and ischaemic risk would be considered for an abbreviated DAPT duration. For those at low bleeding risk, but elevated ischaemic risk (37% of the cohort), prolonged DAPT may be appropriate, and for those with low bleeding and ischaemic risk (29% of the cohort) short duration DAPT may be justified. CONCLUSION We present a pair of ischaemic and bleeding risk scores specifically to assist clinicians and their patients in deciding on DAPT duration beyond the first month post-ACS.
Collapse
Affiliation(s)
- Andrew J Kerr
- Department of Medicine, The University of Auckland, Auckland, New Zealand
- Cardiology Department, Middlemore Hospital, Auckland, New Zealand
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Yeunhyang Choi
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | | | - Ralph Ah Stewart
- Cardiology Department, Greenlane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Harvey D White
- Cardiology Department, Greenlane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Vanessa Selak
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | | | | | - Philip D Adamson
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Sarah Fairley
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Rodney T Jackson
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Katrina Poppe
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
21
|
Poorthuis MHF, Sherliker P, de Borst GJ, Clack R, Lewington S, Clarke R, Bulbulia R, Halliday A. Detection rates of asymptomatic carotid artery stenosis and atrial fibrillation by selective screening of patients without cardiovascular disease. Int J Cardiol 2023; 391:131262. [PMID: 37574023 DOI: 10.1016/j.ijcard.2023.131262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Individuals with significant asymptomatic carotid artery stenosis (ACAS) and atrial fibrillation (AF) could benefit from specific interventions to prevent heart attack and stroke, but are often clinically 'silent'. We aimed to determine detection rate of ACAS and AF by screening, targeting a population at increased cardiovascular risk. METHODS Data on adults who attended voluntary and self-funded commercial screening clinics in the United States or the United Kingdom between 2008 and 2013 were used. The Atherosclerotic Cardiovascular Disease (ASCVD) risk equation was applied to each participants and detection rates of targeted screening for ≥50% ACAS and AF to those at highest risk of CVD was assessed. RESULTS Among 0.4 million individuals between 40 and 80 years, without CVD, 6191 (1.6%) had ACAS and 1026 (0.3%) had AF. Selective screening of participants with a predicted 10-year CVD risk of ≥20% identified 40% of ACAS cases, a prevalence of 3.7%, leading to a number needed to screen (NNS) of 27, as well as 39% of AF cases, a prevalence of 0.6%, with a NNS of 170. Selective screening of those with a predicted 10-year CVD risk of ≥15% identified 54% of ACAS cases, a prevalence of 3.3%, and an NNS of 31, as well as 51% of AF cases, a prevalence of 0.5%, with an NNS of 195. CONCLUSIONS Selective screening for ACAS and AF implemented in ASCVD risk assessment greatly reduces the NNS when compared with population-level screening with detection rates of ACAS and AF substantially greater in people at higher predicted CVD risk.
Collapse
Affiliation(s)
- Michiel H F Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Alison Halliday
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
22
|
Jackson R, Rodgers A. The ESH guidelines and missed prevention opportunities. Lancet 2023; 402:1729-1730. [PMID: 37844587 DOI: 10.1016/s0140-6736(23)01925-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Rod Jackson
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand.
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
23
|
Divison-Garrote JA, Carbayo-Herencia JA, Simarro-Rueda M, Molina-Escribano F, Escobar-Cervantes C, Artigao-Rodenas LM, Gil-Guillén V, Banegas JR. Prognosis of Systolic Pressure 130 to 139 According to Risk. A Prospective Cohort Study Between 1992 and 2019. Hypertension 2023; 80:2485-2493. [PMID: 37694400 DOI: 10.1161/hypertensionaha.123.21732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Guidelines recommend pharmacological treatment for systolic blood pressure (SBP) of 130 to 139 mm Hg in secondary prevention. However, uncertainty persists in primary prevention in low cardiovascular risk patients (CVR). METHODS Cohort study representative of the general population of Albacete/Southeast Spain. We examined 1029 participants with untreated blood pressure and free of cardiovascular disease, followed-up during 1992 to 2019. Cox regression modeled the association of SBP with cardiovascular morbidity and mortality (outcome-1) and cardiovascular morbidity and all-cause mortality (outcome-2). RESULTS Participants' mean age was 44.8 years (53.8%, women; 77.1% at low-CVR); 20.3% had SBP 120 to 129; 13.0% 130 to 139 at low-CVR and 3.4% at high-CVR; and 27.4% ≥140 mm Hg. After a 25.7-year median follow-up, 218 outcome-1 and 302 outcome-2 cases occurred. Unadjusted hazard ratios of outcome-1 for these increasing SBP categories (versus <120) were 2.72, 2.27, 11.54, and 7.52, respectively; and 2.69, 2.32, 10.55, and 7.34 for outcome-2 (all P<0.01). After adjustment for other risk factors, hazard ratio (95% CI) of outcome-1 were 1.49 (0.91-2.44), 1.65 (0.94-2.91, P=0.08), 1.36 (0.72-2.57), and 1.82 (1.15-2.88), respectively, and 1.39 (0.91-2.11), 1.69 (1.05-2.73), 1.09 (0.63-1.88), and 1.64 (1.11-2.41) for outcome-2. Compared with 130 to 139 at low-CVR, hazard ratio for 130 to 139 at high-CVR was 4.85 for outcome-1 (P<0.001) and 4.43 for outcome-2 (P<0.001). CONCLUSIONS In this primary prevention population of relatively young average age, untreated SBP of 130 to 139 mm Hg at low-CVR had long-term prognostic value and might benefit from stricter SBP targets. High-CVR patients had nonsignificant higher risk (limited sample size) but 4-fold greater risk when compared with low-CVR. Overall, results indicate the importance of risk stratification, supporting risk-based decision-making.
Collapse
Affiliation(s)
- Juan A Divison-Garrote
- Casas Ibáñez Primary Care Center (J.A.D.-G., F.M.-E.), Atención Primaria Albacete, Spain
- Department of Medicine, Universidad Católica de Murcia (UCAM), Spain (J.A.D.-G.)
- GEVA (Grupo Enfermedades Vasculares Albacete), Spain (J.A.D.-G., J.A.C.-H., M.S.-R., F.M.-E., L.M.A.-R., V.G.-G., J.R.B.)
| | - Julio A Carbayo-Herencia
- GEVA (Grupo Enfermedades Vasculares Albacete), Spain (J.A.D.-G., J.A.C.-H., M.S.-R., F.M.-E., L.M.A.-R., V.G.-G., J.R.B.)
- Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Alicante, Spain (J.A.C.-H., V.G.-G.)
| | - Marta Simarro-Rueda
- Villamalea Primary Care Center (M.S.-R.), Atención Primaria Albacete, Spain
- GEVA (Grupo Enfermedades Vasculares Albacete), Spain (J.A.D.-G., J.A.C.-H., M.S.-R., F.M.-E., L.M.A.-R., V.G.-G., J.R.B.)
| | - Francisca Molina-Escribano
- Casas Ibáñez Primary Care Center (J.A.D.-G., F.M.-E.), Atención Primaria Albacete, Spain
- GEVA (Grupo Enfermedades Vasculares Albacete), Spain (J.A.D.-G., J.A.C.-H., M.S.-R., F.M.-E., L.M.A.-R., V.G.-G., J.R.B.)
| | | | - Luis M Artigao-Rodenas
- GEVA (Grupo Enfermedades Vasculares Albacete), Spain (J.A.D.-G., J.A.C.-H., M.S.-R., F.M.-E., L.M.A.-R., V.G.-G., J.R.B.)
| | - Vicente Gil-Guillén
- Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Alicante, Spain (J.A.C.-H., V.G.-G.)
- Institute of Health and Biomedical Research of Alicante, Hospital General Universitario de Alicante, Spain (V.G.-G.)
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain (V.G.-G.)
| | - José R Banegas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPaz and CIBERESP, Madrid, Spain (J.R.B.)
| |
Collapse
|
24
|
Christoffersen NB, Nilou FE, Thilsing T, Larsen LB, Østergaard JN, Broholm-Jørgensen M. Exploring targeted preventive health check interventions - a realist synthesis. BMC Public Health 2023; 23:1928. [PMID: 37798691 PMCID: PMC10557298 DOI: 10.1186/s12889-023-16861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Preventive health checks are assumed to reduce the risk of the development of cardio-metabolic disease in the long term. Although no solid evidence of effect is shown on health checks targeting the general population, studies suggest positive effects if health checks target people or groups identified at risk of disease. The aim of this study is to explore why and how targeted preventive health checks work, for whom they work, and under which circumstances they can be expected to work. METHODS The study is designed as a realist synthesis that consists of four phases, each including collection and analysis of empirical data: 1) Literature search of systematic reviews and meta-analysis, 2) Interviews with key-stakeholders, 3) Literature search of qualitative studies and grey literature, and 4) Workshops with key stakeholders and end-users. Through the iterative analysis we identified the interrelationship between contexts, mechanisms, and outcomes to develop a program theory encompassing hypotheses about targeted preventive health checks. RESULTS Based on an iterative analysis of the data material, we developed a final program theory consisting of seven themes; Target group; Recruitment and participation; The encounter between professional and participants; Follow-up activities; Implementation and operation; Shared understanding of the intervention; and Unintended side effects. Overall, the data material showed that targeted preventive health checks need to be accessible, recognizable, and relevant for the participants' everyday lives as well as meaningful to the professionals involved. The results showed that identifying a target group, that both benefit from attending and have the resources to participate pose a challenge for targeted preventive health check interventions. This challenge illustrates the importance of designing the recruitment and intervention activities according to the target groups particular life situation. CONCLUSION The results indicate that a one-size-fits-all model of targeted preventive health checks should be abandoned, and that intervention activities and implementation depend on for whom and under which circumstances the intervention is initiated. Based on the results we suggest that future initiatives conduct thorough needs assessment as the basis for decisions about where and how the preventive health checks are implemented.
Collapse
Affiliation(s)
- Nanna Bjørnbak Christoffersen
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Freja Ekstrøm Nilou
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Trine Thilsing
- Research Unit of General Practice, University of Southern, Odense, Denmark
| | - Lars Bruun Larsen
- Research Unit of General Practice, University of Southern, Odense, Denmark
- Steno Diabetes Center Zealand, Holbæk, Denmark
| | | | - Marie Broholm-Jørgensen
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| |
Collapse
|
25
|
Muíño-Domínguez D, Gómez-Sánchez L, Gallego-Fernández V, Seoane-Pillado T, López-Álvarez XL. [Twenty-year experience in strict versus non-strict control of arterial hypertension in a health center in Spain]. Semergen 2023; 49:101999. [PMID: 37302207 DOI: 10.1016/j.semerg.2023.101999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/20/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION AND AIMS During clinical trials effective reduction of blood pressure (BP) leads to a reduction in the incidence of cardiovascular (CV) morbimortality. Our main aim is to ascertain whether, under actual conditions of clinical practice, BP monitoring leads to a long-term reduction in CV events. PATIENTS AND METHODS The study was performed on 164 patients with hypertension (HT) selected among patients who came to family medicine consultations because of HT. An analysis was performed between patients who presented clinical BP lower than 140/90mmHg and those that had higher levels. When patients entered the study, they were followed up until a CV event occurred or up to a maximum of 20 years, at which time follow up ended. RESULTS Of the total of 164 patients, good control of BP was attained by 93 (56.7%), and 71 did not attain good control (42.2%). In the multivariate analysis, the only predictive variable for CV events was the lack of strict control of BP (HR: 2.93; 95% CI: 1.45-5.89; p=0.003), and the female sex was protective for CV events (HR: 0.37; 95% CI: 0.18-0.74; p=0.005). CONCLUSIONS The fundamental predictor variable of CV morbimortality in patients with HT is the lack of HT strict control; the women also had fewer CV complications.
Collapse
Affiliation(s)
- D Muíño-Domínguez
- Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | | | | | - T Seoane-Pillado
- Área de Medicina Preventiva y Salud Pública, Departamento de Ciencias de la Salud, Universidad de A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, España
| | | |
Collapse
|
26
|
Montano D. Public health impact of antihypertensive medication use on arterial blood pressure: A pooled cross-sectional analysis of population health surveys. PLoS One 2023; 18:e0290344. [PMID: 37603547 PMCID: PMC10441779 DOI: 10.1371/journal.pone.0290344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/05/2023] [Indexed: 08/23/2023] Open
Abstract
The early initiation of antihypertensive drug therapy is conceived as one of the most important public health interventions addressing cardiovascular risk in the population. However, the actual contribution of this public health intervention to reduce blood pressure (BP) at the population level is largely unknown. Hence, the aim of the present investigation is to estimate the potential public health effects of the use of antihypertensive medication on BP in the population aged 16 and older. Data from three population health surveys periodically conducted in the United States, England, and Scotland are analysed (N = 362,275). The secular trends of BP measurements and the potential public health impact of the use of antihypertensive medications on BP over time are analysed in a series of linear mixed models. Between 1992 and 2019, a secular trend of decreasing systolic and diastolic BP occurred (-16.24 99% CI [-16.80; -15.68] and -3.08 99% CI [-3.36; -2.80] mmHg, respectively). The potential public health impact of the use of antihypertensive medications in the period 1992-2019 on systolic BP was estimated to lie between -8.56 99% CI [-8.34; -8.77] and -8.68 99% CI [-8.33; -9.03] mmHg. Average reduction of diastolic BP was in the range of -5.56 99% CI [-5.71; -5.42] and -6.55 99% CI [-6.78; -6.32] mmHg. The observed changes in the distribution of BP measurements over time were found to be more strongly related to secular trends affecting the whole populations, rather than to increases in the proportion of individuals taking antihypertensive medications.
Collapse
Affiliation(s)
- Diego Montano
- Department of Population-Based Medicine, University of Tübingen, Tübingen, Germany
| |
Collapse
|
27
|
Rao S, Nazarzadeh M, Li Y, Canoy D, Mamouei M, Salimi-Khorshidi G, Rahimi K. Systolic blood pressure, chronic obstructive pulmonary disease and cardiovascular risk. Heart 2023; 109:1216-1222. [PMID: 37080767 PMCID: PMC10423512 DOI: 10.1136/heartjnl-2023-322431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/04/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE In individuals with complex underlying health problems, the association between systolic blood pressure (SBP) and cardiovascular disease is less well recognised. The association between SBP and risk of cardiovascular events in patients with chronic obstructive pulmonary disease (COPD) was investigated. METHODS AND ANALYSIS In this cohort study, 39 602 individuals with a diagnosis of COPD aged 55-90 years between 1990 and 2009 were identified from validated electronic health records (EHR) in the UK. The association between SBP and risk of cardiovascular end points (composite of ischaemic heart disease, heart failure, stroke and cardiovascular death) was analysed using a deep learning approach. RESULTS In the selected cohort (46.5% women, median age 69 years), 10 987 cardiovascular events were observed over a median follow-up period of 3.9 years. The association between SBP and risk of cardiovascular end points was found to be monotonic; the lowest SBP exposure group of <120 mm Hg presented nadir of risk. With respect to reference SBP (between 120 and 129 mm Hg), adjusted risk ratios for the primary outcome were 0.99 (95% CI 0.93 to 1.05) for SBP of <120 mm Hg, 1.02 (0.97 to 1.07) for SBP between 130 and 139 mm Hg, 1.07 (1.01 to 1.12) for SBP between 140 and 149 mm Hg, 1.11 (1.05 to 1.17) for SBP between 150 and 159 mm Hg and 1.16 (1.10 to 1.22) for SBP ≥160 mm Hg. CONCLUSION Using deep learning for modelling EHR, we identified a monotonic association between SBP and risk of cardiovascular events in patients with COPD.
Collapse
Affiliation(s)
- Shishir Rao
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Milad Nazarzadeh
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Yikuan Li
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Dexter Canoy
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mohammad Mamouei
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Gholamreza Salimi-Khorshidi
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Kazem Rahimi
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
28
|
Sheridan SL. From guidelines to decision aids and adherence supports: Insights from the process of evidence translation. PATIENT EDUCATION AND COUNSELING 2023; 113:107806. [PMID: 37229931 DOI: 10.1016/j.pec.2023.107806] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To explore the evidence-translator's experience of the expert-recommended process of translating guidelines into tools for decision making, action, and adherence with the goal of improvement. METHODS A single reviewer dual reviewed the content, quality, certainty, and applicability of primary atherosclerotic cardiovascular prevention guidelines from the U.S. Preventive Services Task Force at the time of this work and used targeted searches of Medline to define the ideal structure and outcomes of tools; fill in gaps in guidelines; identify end-user needs; and choose and optimize existing tools in preparation for testing. RESULTS Guidelines addressed screening, treatments, and/or supports, but never the combination of all three. None provided all of the information needed for evidence translation. Searches in Medline filled in some evidence gaps and provided key insights into end-user needs and effective tools. However, evidence translators are left with complicated decisions about how to use and align evidence. CONCLUSION Guidelines provide some, but not all, of the evidence needed for evidence translation, requiring additional intensive work. Evidence gaps result in complicated decisions about how to use and align evidence and balance feasibility and rigor. PRACTICE IMPLICATIONS Guidelines, standards groups, and researchers should work to better support the process of evidence translation.
Collapse
|
29
|
Li X, Zhang J, Xing Z, Liu Q, Zhou S, Xiao Y. Intensive blood pressure control for patients aged over 60: A meta-analysis of the SPRINT, STEP, and ACCORD BP randomized controlled trials. Maturitas 2023; 172:52-59. [PMID: 37099984 DOI: 10.1016/j.maturitas.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/10/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES To evaluate the effects of intensive treatment to lower blood pressure (BP) on the risk of cardiovascular disease (CVD) among patients aged over 60 years. STUDY DESIGN We extracted individual-level data of participants aged over 60 years from the SPRINT study and ACCORD study first, and then conducted a meta-analysis of major adverse cardiovascular events (MACEs) and other adverse events (hypotension and syncope) and renal outcomes across the SPRINT, STEP, ACCORD BP trials, which included 18,806 participants over 60 years of age. Participants were randomized to receive standard BP treatment or intensive BP treatment. MAIN OUTCOME MEASURES Hazard ratios (HRs) were used to calculate summary statistics. RESULTS In this meta-analysis, intensive treatment did not decrease either the all-cause mortality rate (HR: 0.98; 95 % confidence interval [CI]: 0.76-1.26; p = 0.87) or the cardiovascular mortality rate (HR: 0.77; 95 % CI: 0.54-1.08; p = 0.13). The incidence of MACEs (HR: 0.83; 95 % CI: 0.74-0.94; p = 0.003) and stroke (HR: 0.70; 95 % CI: 0.56-0.88; p = 0.002) was reduced, however. Intensive treatment had no effect on acute coronary syndrome (HR: 0.87; 95 % CI: 0.69-1.10; p = 0.24) or heart failure (HR: 0.70; 95 % CI: 0.40-1.22; p = 0.21). Intensive treatment increased the risk of hypotension (HR: 1.46; 95 % CI: 1.12-1.91; p = 0.006) and syncope (HR: 1.43; 95 % CI: 1.06-1.93; p = 0.02). Intensive treatment did not increase the risk of impaired kidney function among patients with chronic kidney disease (HR: 0.98; 95 % CI: 0.41-2.34; p = 0.96) or without chronic kidney disease (HR: 1.77; 95 % CI: 0.48-6.56; p = 0.40) at baseline. CONCLUSIONS Intensive BP goals reduced the incidence of MACEs and increased the risk of other adverse events without significant changes in mortality or renal outcome.
Collapse
Affiliation(s)
- Xiaoting Li
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China; Xiangya School of Medicine, Central South University, Changsha 410013, China.
| | - Jiejun Zhang
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China; Xiangya School of Medicine, Central South University, Changsha 410013, China.
| | - Zhenhua Xing
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China.
| | - Shenghua Zhou
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China.
| | - Yichao Xiao
- Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China.
| |
Collapse
|
30
|
Virani SS, Aspry K, Dixon DL, Ferdinand KC, Heidenreich PA, Jackson EJ, Jacobson TA, McAlister JL, Neff DR, Gulati M, Ballantyne CM. The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint Clinical Perspective from the National Lipid Association and the American Society for Preventive Cardiology. J Clin Lipidol 2023; 17:208-218. [PMID: 36965958 DOI: 10.1016/j.jacl.2023.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 03/03/2023]
Abstract
Despite the established role of low-density lipoprotein cholesterol (LDL-C) as a major risk factor for cardiovascular disease (CVD), and the persistence of CVD as the leading cause of morbidity and mortality in the United States, national quality assurance metrics no longer include LDL-C measurement as a required performance metric. This clinical perspective reviews the history of LDL-C as a quality and performance metric and the events that led to its replacement. It also presents patient, healthcare provider, and health system rationales for re-establishing LDL-C measurement as a performance measure to improve cholesterol control in high-risk groups and to stem the rising tide of CVD morbidity and mortality, cardiovascular care disparities, and related healthcare costs.
Collapse
Affiliation(s)
- Salim S Virani
- Baylor College of Medicine, Houston, Texas, USA (Drs Virani, Ballantyne); Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA (Dr Virani); The Aga Khan University, Karachi, Pakistan (Dr Virani)
| | - Karen Aspry
- Lifespan Cardiovascular Institute, and Alpert Medical School, Brown University, Providence, Rhode Island, USA (Dr Aspry)
| | - Dave L Dixon
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA (Dr Dixon)
| | - Keith C Ferdinand
- Tulane University School of Medicine, New Orleans, Louisiana, USA (Dr Ferdinand)
| | | | | | - Terry A Jacobson
- Emory University School of Medicine, Atlanta, Georgia, USA (Dr Jacobson)
| | | | - David R Neff
- Michigan State University, College of Osteopathic Medicine, Department of Family and Community Medicine, East Lansing, Michigan, USA (Dr Neff)
| | - Martha Gulati
- Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA (Dr Gulati)
| | | |
Collapse
|
31
|
Flack JM, Cheema A. Therapeutic Nihilism in Older Hypertensives: A Resounding Call to Action. Hypertension 2023; 80:563-565. [PMID: 36791221 DOI: 10.1161/hypertensionaha.122.20091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- John M Flack
- Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University
| | - Asad Cheema
- Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University
| |
Collapse
|
32
|
Clinical outcomes by atherosclerotic cardiovascular disease risk score and blood pressure level in high risk individuals with type 2 diabetes. J Hum Hypertens 2023; 37:181-188. [PMID: 35184142 DOI: 10.1038/s41371-022-00661-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/17/2022] [Accepted: 02/04/2022] [Indexed: 11/09/2022]
Abstract
Clinical practice guidelines for patients with diabetes recommend using blood pressure (BP) and atherosclerotic cardiovascular disease (ASCVD) risk to guide antihypertensive treatment. While this approach directs treatment to patients who should receive a large ASCVD risk reduction, its effect on other outcomes is uncertain. The aim of this study was to assess the contributions of systolic blood pressure level (SBP) and predicted 10-year ASCVD risk using Pooled Cohort risk equations to the prediction of major macrovascular disease, death and major microvascular disease in patients with diabetes. Data came from 7426 individuals with type 2 diabetes (T2D) without macrovascular disease at baseline in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. The risk for major macrovascular events and death increased progressively across ASCVD risk categories. Compared to participants with 10-year predicted ASCVD risk <20% and SBP <130 mmHg, the hazard ratios (HRs) (95% confidence intervals (CIs)) associated with SBP ≥150 mmHg and 10-year predicted ASCVD risk <20%, 20-34% and ≥35% were 1.01 (0.58, 1.77), 1.90 (1.28, 2.84) and 2.82 (1.98, 4.01) for major macrovascular disease, respectively, and 0.83 (0.42, 1.62), 1.79 (1.13, 2.82) and 3.29 (2.22, 4.88) for death, respectively. The risk for major microvascular disease increased with BP regardless of ASCVD risk; HRs for SBP ≥150 mmHg and 10-year predicted ASCVD risk <20%, 20-34% and ≥35% vs. ASCVD risk <20% and SBP <130 mmHg were 1.52 (1.08,2.13), 1.47 (1.10, 1.96) and 1.23 (0.94, 1.60), respectively. ASCVD risk in addition to SBP improved the estimation of major macrovascular events and death but not major microvascular events among individuals with T2D.
Collapse
|
33
|
Taler SJ. Lowering the Norms for Blood Pressure. Mayo Clin Proc 2023; 98:363-365. [PMID: 36868742 DOI: 10.1016/j.mayocp.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Sandra J Taler
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| |
Collapse
|
34
|
Virani SS, Aspry K, Dixon DL, Ferdinand KC, Heidenreich PA, Jackson EJ, Jacobson TA, McAlister JL, Neff DR, Gulati M, Ballantyne CM. The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint clinical perspective from the National Lipid Association and the American Society for Preventive Cardiology. Am J Prev Cardiol 2023; 13:100472. [PMID: 36970638 PMCID: PMC10037190 DOI: 10.1016/j.ajpc.2023.100472] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/11/2023] [Indexed: 03/02/2023] Open
Abstract
Despite the established role of low-density lipoprotein cholesterol (LDL-C) as a major risk factor for cardiovascular disease (CVD), and the persistence of CVD as the leading cause of morbidity and mortality in the United States, national quality assurance metrics no longer include LDL-C measurement as a required performance metric. This clinical perspective reviews the history of LDL-C as a quality and performance metric and the events that led to its replacement. It also presents patient, healthcare provider, and health system rationales for re-establishing LDL-C measurement as a performance measure to improve cholesterol control in high-risk groups and to stem the rising tide of CVD morbidity and mortality, cardiovascular care disparities, and related healthcare costs.
Collapse
|
35
|
Kandzari DE, Weber MA, Poulos C, Coulter J, Cohen SA, DeBruin V, Jones D, Pathak A. Patient Preferences for Pharmaceutical and Device-Based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment. Circ Cardiovasc Qual Outcomes 2023; 16:e008997. [PMID: 36484251 PMCID: PMC9848220 DOI: 10.1161/circoutcomes.122.008997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation. METHODS Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute. RESULTS Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP. CONCLUSIONS Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.
Collapse
Affiliation(s)
| | | | | | - Joshua Coulter
- RTI Health Solutions, Research Triangle Park, NC, (J.C.)
| | | | | | - Denise Jones
- Medtronic, Santa Rosa, CA (S.A.C., V.D.B., D.J.)
| | - Atul Pathak
- Department of Cardiovascular Medicine, Centre Hospitalier Princese Grace, Monaco (A.P.).,UMR UT CNRS 88 Hypertension and Heart Failure: molecular and clinical investigations. Toulouse, France, INI-CRCT F-CRIN, GREAT Networks (A.P.)
| |
Collapse
|
36
|
ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Das SR, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Kosiborod M, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S158-S190. [PMID: 36507632 PMCID: PMC9810475 DOI: 10.2337/dc23-s010] [Citation(s) in RCA: 185] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
37
|
Parkkila K, Kiviniemi A, Tulppo M, Perkiömäki J, Kesäniemi YA, Ukkola O. Carotid and femoral bruits as cardiovascular risk indicators in a middle-aged Finnish population: A 20-year prospective study. PLoS One 2022; 17:e0278901. [PMID: 36490299 PMCID: PMC9733881 DOI: 10.1371/journal.pone.0278901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Effective treatment and prevention of cardiovascular (CV) diseases requires reliable methods of assessing individual CV event risk. Although standardized risk calculators like Systematic Coronary Risk Evaluation (SCORE) are sufficient in most instances, sometimes more specific clinical examination is needed to determine the most optimal intervention and its intensity. AIM To study whether carotid and femoral bruits provide prognostic information on CV events, CV mortality and all-cause mortality beyond traditional CV risk factors. METHODS 1045 subjects (49.8% men), aged 51.3 ± 5.97 years were clinically examined in the beginning of 1990's. The subjects were followed for over 20 years and data on CV events and causes of deaths was collected. RESULTS During the follow-up period, 241 (23.1%) of the subjects died and 82 (34.6%) of the deaths were of CV origin. Carotid bruits were a significant risk factor for CV deaths only if subjects with previous CV events were included. After adjusting for age, sex, systolic blood pressure, smoking, diabetes, LDL cholesterol, coronary artery disease and stroke, carotid bruits posed a hazard ratio (HR) (95% confidence interval) of 4.15 (2.39-8.52) p<0.001 for CV deaths. After excluding subjects with previous CV events (after which n = 941) neither carotid nor femoral bruits were statistically associated with CV events or all-cause mortality. Adding carotid or femoral bruits in the baseline risk model with traditional CV risk factors did not improve C-statistic, reclassification, or discrimination of the subjects. CONCLUSIONS Carotid and femoral bruits do not provide clinically useful information in a pure primary prevention setting. Carotid bruits might be useful in evaluating the overall CV risk in a population where recurrent CV events may occur.
Collapse
Affiliation(s)
- Karri Parkkila
- Medical Research Center Oulu, Research Unit of Internal Medicine, Oulu University Hospital, University of Oulu, Oulu, Finland
- * E-mail:
| | - Antti Kiviniemi
- Medical Research Center Oulu, Research Unit of Internal Medicine, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mikko Tulppo
- Department of Physiology, Research Unit of Biomedicine, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Juha Perkiömäki
- Medical Research Center Oulu, Research Unit of Internal Medicine, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Y. Antero Kesäniemi
- Medical Research Center Oulu, Research Unit of Internal Medicine, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Olavi Ukkola
- Medical Research Center Oulu, Research Unit of Internal Medicine, Oulu University Hospital, University of Oulu, Oulu, Finland
| |
Collapse
|
38
|
Schlaich MP, Bellet M, Weber MA, Danaietash P, Bakris GL, Flack JM, Dreier RF, Sassi-Sayadi M, Haskell LP, Narkiewicz K, Wang JG. Dual endothelin antagonist aprocitentan for resistant hypertension (PRECISION): a multicentre, blinded, randomised, parallel-group, phase 3 trial. Lancet 2022; 400:1927-1937. [PMID: 36356632 DOI: 10.1016/s0140-6736(22)02034-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Resistant hypertension is associated with increased cardiovascular risk. The endothelin pathway has been implicated in the pathogenesis of hypertension, but it is currently not targeted therapeutically, thereby leaving this relevant pathophysiological pathway unopposed with currently available drugs. The aim of the study was to assess the blood pressure lowering efficacy of the dual endothelin antagonist aprocitentan in patients with resistant hypertension. METHODS PRECISION was a multicentre, blinded, randomised, parallel-group, phase 3 study, which was done in hospitals or research centres in Europe, North America, Asia, and Australia. Patients were eligible for randomisation if their sitting systolic blood pressure was 140 mm Hg or higher despite taking standardised background therapy consisting of three antihypertensive drugs, including a diuretic. The study consisted of three sequential parts: part 1 was the 4-week double-blind, randomised, and placebo-controlled part, in which patients received aprocitentan 12·5 mg, aprocitentan 25 mg, or placebo in a 1:1:1 ratio; part 2 was a 32-week single (patient)-blind part, in which all patients received aprocitentan 25 mg; and part 3 was a 12-week double-blind, randomised, and placebo-controlled withdrawal part, in which patients were re-randomised to aprocitentan 25 mg or placebo in a 1:1 ratio. The primary and key secondary endpoints were changes in unattended office systolic blood pressure from baseline to week 4 and from withdrawal baseline to week 40, respectively. Secondary endpoints included 24-h ambulatory blood pressure changes. The study is registered on ClinicalTrials.gov, NCT03541174. FINDINGS The PRECISION study was done from June 18, 2018, to April 25, 2022. 1965 individuals were screened and 730 were randomly assigned. Of these 730 patients, 704 (96%) completed part 1 of the study; of these, 613 (87%) completed part 2 and, of these, 577 (94%) completed part 3 of the study. The least square mean (SE) change in office systolic blood pressure at 4 weeks was -15·3 (SE 0·9) mm Hg for aprocitentan 12·5 mg, -15·2 (0·9) mm Hg for aprocitentan 25 mg, and -11·5 (0·9) mm Hg for placebo, for a difference versus placebo of -3·8 (1·3) mm Hg (97·5% CI -6·8 to -0·8, p=0·0042) and -3·7 (1·3) mm Hg (-6·7 to -0·8; p=0·0046), respectively. The respective difference for 24 h ambulatory systolic blood pressure was -4·2 mm Hg (95% CI -6·2 to -2·1) and -5·9 mm Hg (-7·9 to -3·8). After 4 weeks of withdrawal, office systolic blood pressure significantly increased with placebo versus aprocitentan (5·8 mm Hg, 95% CI 3·7 to 7·9, p<0·0001). The most frequent adverse event was mild-to-moderate oedema or fluid retention, occurring in 9%, 18%, and 2% for patients receiving aprocitentan 12·5 mg, 25 mg, and placebo, during the 4-week double-blind part, respectively. This event led to discontinuation in seven patients treated with aprocitentan. During the trial, a total of 11 treatment-emergent deaths occurred, none of which were regarded by the investigators to be related to study treatment. INTERPRETATION In patients with resistant hypertension, aprocitentan was well tolerated and superior to placebo in lowering blood pressure at week 4 with a sustained effect at week 40. FUNDING Idorsia Pharmaceuticals and Janssen Biotech.
Collapse
Affiliation(s)
- Markus P Schlaich
- Dobney Hypertension Centre, Royal Perth Hospital Research Foundation, Medical School, The University of Western Australia, Perth, WA, Australia; Department of Cardiology and Department of Nephrology, Royal Perth Hospital, Perth, WA, Australia.
| | - Marc Bellet
- Global Clinical Development, Idorsia Pharmaceuticals, Allschwil, Switzerland
| | - Michael A Weber
- Downstate College of Medicine, State University of New York, Brooklyn, NY, USA
| | - Parisa Danaietash
- Global Clinical Development, Idorsia Pharmaceuticals, Allschwil, Switzerland
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA
| | - John M Flack
- Division of General Internal Medicine, Hypertension Section, Department of Medicine, Hypertension Section, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Roland F Dreier
- Global Clinical Development, Idorsia Pharmaceuticals, Allschwil, Switzerland
| | | | - Lloyd P Haskell
- The Janssen Pharmaceutical Companies of Johnson & Johnson, Raritan, NJ, USA
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ji-Guang Wang
- Department of Hypertension, The Shanghai Institute of Hypertension, Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
39
|
Esler M, Kjeldsen SE, Pathak A, Grassi G, Kreutz R, Mancia G. Diverse pharmacological properties, trial results, comorbidity prescribing and neural pathophysiology suggest European hypertension guideline downgrading of beta-blockers is not justified. Blood Press 2022; 31:210-224. [PMID: 36029011 DOI: 10.1080/08037051.2022.2110858] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Beta-blockers have solid documentation in preventing cardiovascular complications in the treatment of hypertension; atenolol, metoprolol, oxprenolol and propranolol demonstrate proven cardiovascular prevention in hypertension mega-trials. Hypertension is characterised by activation of the sympathetic nervous system from early to late phases, which makes beta-blockers an appropriate treatment seen from a pathophysiological viewpoint, especially in patients with an elevated heart rate. Beta-blockers represent a heterogenous class of drugs with regard to both pharmacodynamic and pharmacokinetic properties. This position is manifest by reference to another clinical context, beta-blocker treatment of heart failure, where unequivocally there is no class effect (no similar benefit from all beta-blockers); there are good and less good beta-blockers for heart failure. Analogous differences in beta-blocker efficacy is also likely in hypertension. Beta-blockers are widely used for the treatment of diseases comorbid with hypertension, in approximately 50 different concomitant medical conditions that are frequent in patients with hypertension, leading to many de facto beta-blocker first choices in clinical practice. Thus, beta-blockers should be regarded as relevant first choices for hypertension in clinical practice, particularly if characterised by a long half-life, highly selective beta-1 blocking activity and no intrinsic agonist properties.SUMMARYBeta-blockers have solid documentation in preventing cardiovascular complications in the treatment of hypertension; atenolol, metoprolol, oxprenolol and propranolol demonstrate proven cardiovascular prevention in hypertension mega-trialsHypertension is characterised by activation of the sympathetic nervous system from early to late phases, which makes beta-blockers an appropriate treatment seen from a pathophysiological viewpoint, especially in patients with an elevated heart rateBeta-blockers represent a heterogenous class of drugs with regard to both pharmacodynamic and pharmacokinetic propertiesThis position is manifest by reference to another clinical context, beta-blocker treatment of heart failure, where unequivocally there is no class effect (no similar benefit from all beta-blockers); there are good and less good beta-blockers for heart failureAnalogous differences in beta-blocker efficacy is also likely in hypertensionBeta-blockers are widely used for the treatment of diseases comorbid with hypertension, in approximately 50 different concomitant medical conditions that are frequent in patients with hypertension, leading to many de facto beta-blockers first choices in clinical practiceThese observations, in totality, inform our opinion that beta-blockers are relevant first choices for hypertension in clinical practice and this fact needs highlightingFurther, these arguments suggest European hypertension guideline downgrading of beta-blockers is not justified.
Collapse
Affiliation(s)
- Murray Esler
- Baker Heart and Diabetes Institute, Human Neurotransmitters Laboratory and Monash University, Melbourne, Australia
| | - Sverre E Kjeldsen
- Department of Cardiology, Ullevaal Hospital, University of Oslo, Oslo, Norway
| | - Atul Pathak
- Department of Cardiology, and UMR UT3 CNRS 5288 Hypertension and heart failure: molecular and clinical investigations, INI-CRCT F-CRIN, GREAT Networks, Centre Hospitalier Princesse Grace, Monte Carlo, Monaco
| | | | - Reinhold Kreutz
- Charité - Medical University of Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | | |
Collapse
|
40
|
Ferrario CM, Saha A, VonCannon JL, Meredith WJ, Ahmad S. Does the Naked Emperor Parable Apply to Current Perceptions of the Contribution of Renin Angiotensin System Inhibition in Hypertension? Curr Hypertens Rep 2022; 24:709-721. [PMID: 36272015 DOI: 10.1007/s11906-022-01229-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To address contemporary hypertension challenges, a critical reexamination of therapeutic accomplishments using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, and a greater appreciation of evidence-based shortcomings from randomized clinical trials are fundamental in accelerating future progress. RECENT FINDINGS Medications targeting angiotensin II mechanism of action are essential for managing primary hypertension, type 2 diabetes, heart failure, and chronic kidney disease. While the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to control blood pressure is undisputed, practitioners, hypertension specialists, and researchers hold low awareness of these drugs' limitations in preventing or reducing the risk of cardiovascular events. Biases in interpreting gained knowledge from data obtained in randomized clinical trials include a pervasive emphasis on using relative risk reduction over absolute risk reduction. Furthermore, recommendations for clinical practice in international hypertension guidelines fail to address the significance of a residual risk several orders of magnitude greater than the benefits. We analyze the limitations of the clinical trials that have led to current recommended treatment guidelines. We define and quantify the magnitude of the residual risk in published hypertension trials and explore how activation of alternate compensatory bioprocessing components within the renin angiotensin system bypass the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to achieve a significant reduction in total and cardiovascular deaths. We complete this presentation by outlining the current incipient but promising potential of immunotherapy to block angiotensin II pathology alone or possibly in combination with other antihypertensive drugs. A full appreciation of the magnitude of the residual risk associated with current renin angiotensin system-based therapies constitutes a vital underpinning for seeking new molecular approaches to halt or even reverse the cardiovascular complications of primary hypertension and encourage investigating a new generation of ACE inhibitors and ARBs with increased capacity to reach the intracellular compartments at which Ang II can be generated.
Collapse
Affiliation(s)
- Carlos M Ferrario
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA.
| | - Amit Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Jessica L VonCannon
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Wayne J Meredith
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Sarfaraz Ahmad
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| |
Collapse
|
41
|
Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2022; 11:CD010315. [PMID: 36398903 PMCID: PMC9673465 DOI: 10.1002/14651858.cd010315.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND This is the third update of the review first published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown. OBJECTIVES To determine if lower blood pressure targets (systolic/diastolic 135/85 mmHg or less) are associated with reduction in mortality and morbidity compared with standard blood pressure targets (140 mmHg to 160mmHg/90 mmHg to 100 mmHg or less) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease). SEARCH METHODS For this updated review, we used standard, extensive Cochrane search methods. The latest search date was January 2022. We applied no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) with more than 50 participants per group that provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (135/85 mmHg or less) compared with standard targets for blood pressure (140 mmHg to 160 mmHg/90 mmHg to 100 mmHg or less). Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included seven RCTs that involved 9595 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). Six of seven RCTs provided individual participant data. None of the included studies was blinded to participants or clinicians because of the need to titrate antihypertensive drugs to reach a specific blood pressure goal. However, an independent committee blinded to group allocation assessed clinical events in all trials. Hence, we assessed all trials at high risk of performance bias and low risk of detection bias. We also considered other issues, such as early termination of studies and subgroups of participants not predefined, to downgrade the certainty of the evidence. We found there is probably little to no difference in total mortality (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.91 to 1.23; 7 studies, 9595 participants; moderate-certainty evidence) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; 6 studies, 9484 participants; moderate-certainty evidence). Similarly, we found there may be little to no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; 7 studies, 9595 participants; low-certainty evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure (CHF)) (RR 0.89, 95% CI 0.80 to 1.00; 7 studies, 9595 participants; low-certainty evidence). The evidence was very uncertain about withdrawals due to adverse effects. However, studies suggest more participants may withdraw due to adverse effects in the lower target group (RR 8.16, 95% CI 2.06 to 32.28; 3 studies, 801 participants; very low-certainty evidence). Systolic and diastolic blood pressure readings were lower in the lower target group (systolic: mean difference (MD) -8.77 mmHg, 95% CI -12.82 to -4.73; 7 studies, 8657 participants; diastolic: MD -4.50 mmHg, 95% CI -6.35 to -2.65; 6 studies, 8546 participants). More drugs were needed in the lower target group (MD 0.56, 95% CI 0.16 to 0.96; 5 studies, 7910 participants), but blood pressure targets at one year were achieved more frequently in the standard target group (RR 1.20, 95% CI 1.17 to 1.23; 7 studies, 8699 participants). AUTHORS' CONCLUSIONS We found there is probably little to no difference in total mortality and cardiovascular mortality between people with hypertension and cardiovascular disease treated to a lower compared to a standard blood pressure target. There may also be little to no difference in serious adverse events or total cardiovascular events. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on withdrawals due to adverse effects, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (135/85 mmHg or less) in people with hypertension and established cardiovascular disease. Several trials are still ongoing, which may provide an important input to this topic in the near future.
Collapse
Affiliation(s)
- Luis Carlos Saiz
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Javier Gorricho
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
- Healthcare Business Intelligence Service, Navarre Health Service, Pamplona, Spain
| | - Javier Garjón
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
- Medicines Advice and Information Service, Navarre Health Service, Pamplona, Spain
| | - Mª Concepción Celaya
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
- Drug Prescribing Service, Navarre Health Service, Pamplona, Spain
| | - Juan Erviti
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| |
Collapse
|
42
|
Abstract
IMPORTANCE Hypertension, defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affects approximately 116 million adults in the US and more than 1 billion adults worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (coronary heart disease, heart failure, and stroke) and death. OBSERVATIONS First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption. The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy. The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk. First-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic such as hydrochlorothiazide or chlorthalidone, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker such as enalapril or candesartan, and a calcium channel blocker such as amlodipine and should be titrated according to office and home SBP/DBP levels to achieve in most people an SBP/DBP target (<130/80 mm Hg for adults <65 years and SBP <130 mm Hg in adults ≥65 years). Randomized clinical trials have established the efficacy of BP lowering to reduce the risk of CVD morbidity and mortality. An SBP reduction of 10 mm Hg decreases risk of CVD events by approximately 20% to 30%. Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg. CONCLUSIONS AND RELEVANCE Hypertension affects approximately 116 million adults in the US and more than 1 billion adults worldwide and is a leading cause of CVD morbidity and mortality. First-line therapy for hypertension is lifestyle modification, consisting of weight loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, physical activity, and limited alcohol consumption. When drug therapy is required, first-line therapies are thiazide or thiazidelike diuretics, angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, and calcium channel blockers.
Collapse
Affiliation(s)
- Robert M Carey
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Andrew E Moran
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Paul K Whelton
- Departments of Epidemiology and Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
| |
Collapse
|
43
|
Beall RF, Leung AA, Quinn AE, Salmon C, Scory TD, Bresee LC, Ronksley PE. Laboratory testing and antihypertensive medication adherence following initial treatment of incident, uncomplicated hypertension: A real-world data analysis. J Clin Hypertens (Greenwich) 2022; 24:1316-1326. [PMID: 36125169 DOI: 10.1111/jch.14567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
In this study on medication adherence among newly diagnosed patients with uncomplicated, incident hypertension, we conducted a retrospective cohort study using available administrative and laboratory data from April 1, 2012 to March 31, 2017 in Alberta, Canada to understand the extent to which baseline laboratory assessment and/or subsequent follow-up was associated with persistence with antihypertensive therapy. We determined the frequency of baseline and follow-up testing and compared the rates of medication persistence by patient-, neighbourhood-, and treatment-related factors. Of 103 232 patients with newly diagnosed, uncomplicated hypertension who filled their first prescription within our study timeframe, 52.5% were non-persistent within 6 months. Persistent patients were more often female and residing in neighbourhoods with higher social status (with exception to rurality). Aside from older age, the strongest predictor of persistence was performance of laboratory testing related to hypertension with an apparent effect in which higher levels of medication persistence were seen with more frequent laboratory testing. We concluded that medication persistence was far from optimal, dropping off considerably after 6 months for more than half of patients. Medication persistence is a substantial barrier to realizing the full societal benefits of antihypertensive treatment. Ongoing follow up with patients, including laboratory testing, may be a critical component of better long term treatment persistence.
Collapse
Affiliation(s)
- Reed F Beall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amity E Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charleen Salmon
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D Scory
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lauren C Bresee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
44
|
Zheng H, Li H, Wang Y, Li Z, Hu B, Li X, Fu L, Hu H, Nie Z, Zhao B, Wei D, Karlson BW, Bots ML, Meng X, Chen Y, Wang Y. Rosuvastatin Slows Progression of Carotid Intima-Media Thickness: The METEOR-China Randomized Controlled Study. Stroke 2022; 53:3004-3013. [PMID: 36017704 PMCID: PMC9508961 DOI: 10.1161/strokeaha.120.031877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atherosclerosis is the leading cause of cardiovascular disease worldwide, including in China. Primary prevention, through lipid-lowering, could avert development of atherosclerosis. Carotid intima-media thickness (CIMT) is a well-validated measure of atherosclerosis used in intervention studies as the primary outcome and alternative end point for cardiovascular disease events. METHODS This randomized, double-blind, placebo-controlled, multicenter, parallel-group study assessed the effects of rosuvastatin 20 mg/d compared with placebo on progression of CIMT over 104 weeks in Chinese people with subclinical atherosclerosis. The primary end point was the annualized rate of change in mean of the maximum CIMT measurements taken 7× over the study period from each of 12 carotid artery sites (near and far walls of the right and left common carotid artery, carotid bulb, and internal carotid artery). Secondary end points included CIMT changes at different artery sites and lipid-parameter changes. Safety was also assessed. RESULTS Participants were randomized (1:1) to receive rosuvastatin (n=272) or placebo (n=271). Baseline characteristics were well balanced between groups. The change in mean of the maximum CIMT of the 12 carotid sites was 0.0038 mm/y (95% CI, -0.0023-0.0100) for the rosuvastatin group versus 0.0142 mm/y (95% CI, 0.0080-0.0204) for the placebo group, with a difference of -0.0103 mm/y (95% CI, -0.0191 to -0.0016; P=0.020). For the CIMT secondary end points, the results were generally consistent with the primary end point. There were clinically relevant improvements in lipid parameters with rosuvastatin. We observed an adverse-event profile consistent with the known safety profile of rosuvastatin. CONCLUSIONS Rosuvastatin 20 mg/d significantly reduced the progression of CIMT over 2 years in Chinese adults with subclinical atherosclerosis and was well tolerated. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02546323.
Collapse
Affiliation(s)
- Huaguang Zheng
- Beijing Tiantan Hospital, Capital Medical University, China (H.Z., Yilong Wang, Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China (H.Z., Yilong Wang, Yongjun Wang)
| | - Hongwei Li
- Department of Cardiology, Beijing Friendship Hospital affiliated to Capital Medical University, China (H.L.)
| | - Yilong Wang
- Beijing Tiantan Hospital, Capital Medical University, China (H.Z., Yilong Wang, Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China (H.Z., Yilong Wang, Yongjun Wang)
| | - Zhanquan Li
- The People's Hospital of Liaoning Province, Shenyang, China (Z.L.)
| | - Bo Hu
- Department of Neurology, Union Hospital of Huazhong University of Science and Technology, Wuhan, China (B.H.)
| | - Xiaogang Li
- Department of Neurology, Peking University Third Hospital, Beijing, China (X.L.)
| | - Lu Fu
- The First Affiliated Hospital of Harbin Medical University, China (L.F.)
| | - Hongtao Hu
- Beijing Ji Shui Tan Hospital, China (H.H.)
| | - Zhiyu Nie
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China (Z.N.)
| | - Bilian Zhao
- AstraZeneca R&D, Shanghai, China (B.Z., D.W. [at the time the work was conducted], X.W.M.)
| | - Di Wei
- AstraZeneca R&D, Shanghai, China (B.Z., D.W. [at the time the work was conducted], X.W.M.).,Bayer Healthcare Co Ltd, Beijing, China (D.W.)
| | - Björn W Karlson
- AstraZeneca R&D Gothenburg, Mölndal, and Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (B.W.K.)
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands (M.L.B.)
| | - XiangWen Meng
- AstraZeneca R&D, Shanghai, China (B.Z., D.W. [at the time the work was conducted], X.W.M.)
| | - Yundai Chen
- Department of Cardiology, China PLA General Hospital, Beijing, China (Y.C.)
| | - Yongjun Wang
- Beijing Tiantan Hospital, Capital Medical University, China (H.Z., Yilong Wang, Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China (H.Z., Yilong Wang, Yongjun Wang)
| | | |
Collapse
|
45
|
Javadivala Z, Ranjbarkhah A, Mohammadpoorasl A, Shekari F, Bhalla D, Gilani N. Psycho-behavioral predictors of uncontrolled blood pressure: A case-control study. Health Promot Perspect 2022; 12:218-225. [PMID: 36276412 PMCID: PMC9508388 DOI: 10.34172/hpp.2022.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022] Open
Abstract
Background: We aimed to determine the role of demographic, lifestyle, and personality trait factors in predicting control of blood pressure (BP) among patients with hypertension (HTN) in West Azerbaijan, Iran. Methods: In this case control study we recruited participants from all primary health centers of Salmas city; who were at least 18 years of age, had a HTN diagnosis during the previous six months, and had a mandatory household record. Of 490 random subjects approached, 441 (84.2%) fulfilled our inclusion criteria (case: 221; control: 220). The age-matched controls were recruited from the same source population and were required to have controlled HTN. Data were collected through demographic Checklist, Ten-Item Personality Inventory (TIPI) and International Physical Activity Questionnaire (IPAQ). Results: Upon multivariate analyses, factors related to personality traits subdomains including extraversion personality (odd ratio [OR]: 0.85; CI: 0.73, 0.97) was effective in control of BP. Factors related to uncontrolled BP were agreement and consciences subdomains (OR 1.26 [CI: 1.07, 1.48] and OR 1.21 [CI: 1. 02, 1.44]), rare fruit consumption (OR 5.95 [CI: 1.24, 12.1]), Grade 1 and 2 obesities (OR 2.29 [CI: 1.28, 4.09] and OR 7.11 [CI: 2.21, 12.52]) and smoking (OR 3.27 [CI: 1.56, 6.89]). Conclusion: In addition to regular physical activity and fruit consumption and quitting smoking; personality traits such as Agreement and conscience personality traits were predictive of HTN control. We believe our work provides the required knowledge to design comprehensive HTN prevention programs by taking into account the multi-level causality approach.
Collapse
Affiliation(s)
- Zeinab Javadivala
- Department of Health Education & Promotion, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Akbar Ranjbarkhah
- Member of the Student Research Committee, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Asghar Mohammadpoorasl
- Department of Statistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farhad Shekari
- Department of Statistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Devender Bhalla
- Ple Universitaire Euclide Intergovernmental UN Treaty 49006/49007, Bangui, Central African Republic
| | - Neda Gilani
- Department of Statistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran
- Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
46
|
Canoy D, Nazarzadeh M, Copland E, Bidel Z, Rao S, Li Y, Rahimi K. How Much Lowering of Blood Pressure Is Required to Prevent Cardiovascular Disease in Patients With and Without Previous Cardiovascular Disease? Curr Cardiol Rep 2022; 24:851-860. [PMID: 35524880 PMCID: PMC9288358 DOI: 10.1007/s11886-022-01706-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE OF REVIEW To review the recent large-scale randomised evidence on pharmacologic reduction in blood pressure for the primary and secondary prevention of cardiovascular disease. RECENT FINDINGS Based on findings of the meta-analysis of individual participant-level data from 48 randomised clinical trials and involving 344,716 participants with mean age of 65 years, the relative reduction in the risk of developing major cardiovascular events was proportional to the magnitude of achieved reduction in blood pressure. For each 5-mmHg reduction in systolic blood pressure, the risk of developing cardiovascular events fell by 10% (hazard ratio [HR] (95% confidence interval [CI], 0.90 [0.88 to 0.92]). When participants were stratified by their history of cardiovascular disease, the HRs (95% CI) in those with and without previous cardiovascular disease were 0.89 (0.86 to 0.92) and 0.91 (0.89 to 0.94), respectively, with no significant heterogeneity in these effects (adjusted P for interaction = 1.0). When these patient groups were further stratified by their baseline systolic blood pressure in increments of 10 mmHg from < 120 to ≥ 170 mmHg, there was no significant heterogeneity in the relative risk reduction across these categories in people with or without previous cardiovascular disease (adjusted P for interaction were 1.00 and 0.28, respectively). Pharmacologic lowering of blood pressure was effective in preventing major cardiovascular disease events both in people with or without previous cardiovascular disease, which was not modified by their baseline blood pressure level. Treatment effects were shown to be proportional to the intensity of blood pressure reduction, but even modest blood pressure reduction, on average, can lead to meaningful gains in the prevention of incident or recurrent cardiovascular disease.
Collapse
Affiliation(s)
- Dexter Canoy
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
- National Institutes of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
| | - Emma Copland
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
- National Institutes of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
- National Institutes of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shihir Rao
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
| | - Yikuan Li
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Hayes House 1F, 75 George St, Oxford, OX1 2BQ UK
- National Institutes of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
47
|
Pandit R, Pandit T, Goyal L, Ajmera K. A Review of National Level Guidelines for Risk Management of Cardiovascular and Diabetic Disease. Cureus 2022; 14:e26458. [PMID: 35800190 PMCID: PMC9246244 DOI: 10.7759/cureus.26458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 12/04/2022] Open
Abstract
Cardiovascular diseases and diabetes are among the leading preventable causes of morbidity and mortality. Cardiovascular disease risk reduction aimed to address the significant modifiable risk factors, including lifestyle-related risk factors, hypertension, hyperlipidemia, and diabetes. Given the severity and disease burden, many insurances, including Medicare, cover the annual counseling for risk reduction of cardiovascular disease. Although numerous national-level guidelines are available for managing these conditions, most of them focus on disease management. Given the broad areas covered in these recommendations, a concise review summarizing the measures addressing the preventive approach in these conditions is not readily available. Herewith, we review and outline the currently available guidelines from national-level publications with principal attention to the primary prevention measures to provide a broad overview and assist providers with the risk reduction counseling.
Collapse
|
48
|
Martin KE, Thomas BS, Greenberg KI. The expanding role of primary care providers in care of individuals with kidney disease. J Natl Med Assoc 2022; 114:S10-S19. [DOI: 10.1016/j.jnma.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
49
|
Wang J, Wang Y, Li Y, Hu Y, Jin L, Wang W, Gao Z, Tang X, Yan L, Wan Q, Luo Z, Qin G, Chen L, Gu W, Lyv Z, Mu Y. High Normal Urinary Albumin-Creatinine Ratio Is Associated With Hypertension, Type 2 Diabetes Mellitus, HTN With T2DM, Dyslipidemia, and Cardiovascular Diseases in the Chinese Population: A Report From the REACTION Study. Front Endocrinol (Lausanne) 2022; 13:864562. [PMID: 35669685 PMCID: PMC9165688 DOI: 10.3389/fendo.2022.864562] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Albuminuria has been widely considered a risk factor for cardiovascular diseases (CVDs), which is associated with hypertension (HTN), type 2 diabetes mellitus (T2DM), HTN with T2DM, and dyslipidemia. However, the associations between albuminuria and HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs are still unclear. Thus, this study aimed to explore the association of albuminuria thoroughly, especially within the normal range, with the abovementioned diseases in the Chinese population. Methods This study included 40,188 participants aged over 40 years from seven centers across China. Urinary albumin-creatinine ratio (UACR) was firstly divided into the ≥30-mg/g group, indicating kidney damage, and <30-mg/g group. Furthermore, UACR was divided into five groups: the <20%, 20%-39%, 40%-59%, 60%-79%, and ≥80% groups, according to the quintile division of participants within the normal range. Propensity score matching was used to reduce bias, and multiple logistic regression models were conducted to examine the association between UACR and HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs. Results Multivariable regression analysis revealed that UACR, even within the normal range, is significantly associated with HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs, and the association between UACR and HTN with T2DM was the most significant in model 3 even after adjusting for confounding factors (HTN: OR = 1.56 (95% CI = 1.45-1.68), p < 0.0001; T2DM: OR = 1.78 (95% CI = 1.60-1.97), p < 0.0001; HTN with T2DM: OR = 1.76 (95% CI = 1.59-1.95), p < 0.0001; dyslipidemia: OR = 1.08 (95% CI = 1.01-1.14), p = 0.0146; CVDs: OR = 1.12 (95% CI = 1.00-1.25), p = 0.0475). In the stratified analysis, high normal UACR was significantly associated with HTN, T2DM, HTN with T2DM, and dyslipidemia in subgroups. Conclusions In summary, we observe a higher prevalence of HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs in abnormal UACR and reveal a significant association of UACR, even within the normal range, with HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs.
Collapse
Affiliation(s)
- Jie Wang
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yun Wang
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
- Graduate School, Chinese General Hospital, Beijing, China
| | - Yijun Li
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Ying Hu
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Lingzi Jin
- Department of International Medical Services, Peking Union Medical College Hospital, Beijing, China
| | - Weiqing Wang
- Department of Endocrinology, Shanghai National Research Centre for Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhengnan Gao
- Department of Endocrinology, Dalian Central Hospital, Dalian, China
| | - Xulei Tang
- First Hospital of Lanzhou University, Lanzhou, China
| | - Li Yan
- Department of Endocrinology, Sun Yat-Sen Memorial Hospital, Zhongshan University, Guangzhou, China
| | - Qin Wan
- Department of Endocrinology, Southwest Medical University Affiliated Hospital, Luzhou, China
| | - Zuojie Luo
- Department of Endocrinology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Guijun Qin
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lulu Chen
- Wuhan Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Weijun Gu
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
- Graduate School, Chinese General Hospital, Beijing, China
| | - Zhaohui Lyv
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
- Graduate School, Chinese General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, The First Medical Center of PLA General Hospital, Beijing, China
- Graduate School, Chinese General Hospital, Beijing, China
| |
Collapse
|
50
|
Barroso WKS, Brandão AA, Vitorino PVDO, Feitosa ADDM, Barbosa ECD, Miranda RD, Redon J, Camafort-Babkowski M, Coca A, Gomes MAM. Angiotensin Receptor Blockers Evaluated by Office and Home Blood Pressure Measurements. TeleHBPM Study. Arq Bras Cardiol 2022; 118:S0066-782X2022005005204. [PMID: 35544853 PMCID: PMC9345159 DOI: 10.36660/abc.20210504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/08/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adequate treatment of arterial hypertension and achieving arterial hypertension goals in are important in reducing cardiovascular outcomes. OBJECTIVES To describe angiotensin receptor blockers in monotherapy or double combination therapy and the rate of arterial hypertension control. METHODS This cross-sectional study evaluated patients who were using angiotensin receptor blockers between 2017 and 2020. Those using three or more antihypertensive drugs were excluded. The analyzed variables included sex, age, body mass index, valid home blood pressure monitoring (HBPM) measurements, casual and HBPM systolic and diastolic blood pressure measurements, blood pressure variability, and antihypertensive and angiotensin receptor blocker class. Paired t, chi-square, and Fisher's exact tests were used, as well as overlapping 95% confidence intervals and a significance level of 5% (p < 0.05). RESULTS Of 17,013 patients, 12,813 met the inclusion criteria, 62.1% of whom were female. The mean number of valid measurements was 23.3 (SD, 2.0). The mean HBPM and casual measurements for systolic blood pressure were 126.8 (SD, 15.8) mmHg and 133.5 (SD, 20.1) mmHg (p <0.001), respectively, while those for diastolic blood pressure were 79.1 (SD, 9.7 mmHg) and 83.6 (SD, 11.9) mmHg (p <0.001), respectively. Losartan was the most common angiotensin receptor blocker and resulted in the highest blood pressure values. Combinations of angiotensin receptor blockers with diuretics or calcium channel antagonists resulted in lower blood pressure values. CONCLUSIONS More than half of the patients used losartan, although it was the least efficient drug for reducing and controlling blood pressure.
Collapse
Affiliation(s)
- Weimar Kunz Sebba Barroso
- Universidade Federal de GoiásLiga de Hipertensão ArterialGoiâniaGOBrasilUniversidade Federal de Goiás - Liga de Hipertensão Arterial, Goiânia, GO – Brasil
| | - Andréa Araujo Brandão
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro – Cardiologia, Rio de Janeiro, RJ – Brasil
| | - Priscila Valverde de Oliveira Vitorino
- Pontifícia Universidade Católica de GoiásEscola de Ciências Sociais e da SaúdeGoiâniaGOBrasilPontifícia Universidade Católica de Goiás - Escola de Ciências Sociais e da Saúde,Goiânia, GO – Brasil
| | - Audes Diógenes de Magalhães Feitosa
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco, Recife, PE – Brasil
- Universidade Católica de PernambucoRecifePEBrasilUniversidade Católica de Pernambuco, Recife, PE – Brasil
| | - Eduardo Costa Duarte Barbosa
- Complexo Hospitalar Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrasilComplexo Hospitalar Santa Casa de Misericórdia de Porto Alegre – Cardiologia, Porto Alegre, RS - Brasil
| | - Roberto Dischinger Miranda
- Universidade Federal de São PauloEscola Paulista de MedicinaSão PauloSPBrasilUniversidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, SP – Brasil
| | - Josep Redon
- University of ValenciaValenciaEspanhaUniversity of Valencia – Hypertension, Valencia, Comunitat Valenciana – Espanha
| | - Miguel Camafort-Babkowski
- University of BarcelonaHospital ClínicHypertension UnitBarcelonaCatalunyaEspanhaUniversity of Barcelona - Hospital Clínic. Hypertension Unit, Barcelona, Catalunya – Espanha
| | - Antonio Coca
- Hypertension and Vascular Risk UnitHospital ClinicUniversity of BarcelonaBarcelonaEspanhaHypertension and Vascular Risk Unit. Hospital Clinic. University of Barcelona,Barcelona – Espanha
| | - Marco Antônio Mota Gomes
- Centro Universitário CESMACHospital do CoraçãoMaceióALBrasilCentro Universitário CESMAC - Hospital do Coração, Maceió, AL – Brasil
| |
Collapse
|