Hypertension therapy in the older adults—do we know the answers to all the questions? The status after publication of the ACCF/AHA 2011 expert consensus document on hypertension in the elderly

The effect of a low versus high sodium diet on blood pressure in diabetic patients: A systematic review and meta‐analysis of clinical trials

There have been numerous clinical trials that have investigated the effect of sodium intake on blood pressure in diabetic patients. The purpose of this systematic review and meta-analysis was to evaluate the clinical trial studies performed on the effect of low sodium diet (LSD) versus high sodium diet (HSD) on blood pressure in diabetic patients. PubMed, Scopus, and Web of Science were systematically searched from database inception to July 10, 2021. Both type 1 and 2 diabetes was considered. Overall, there were 15 studies included in this meta-analysis. The weighted (WMD) mean difference with 95% confidence interval (CI) was calculated using a random-effects model. Risk of bias in the studies was assessed based on the Cochrane collaboration tool and the quality of all the studies was considered as good. Overall, LSD significantly reduced SBP (systolic blood pressure) (WMD: -3.79 mmHg, 95% CI: -6.02, -1.56) and DBP (diastolic blood pressure) (WMD: -1.62 mmHg, 95% CI: -2.84, -0.40), in comparison with HSD, in diabetics. However, LSD had no significant effect on MAP (mean arterial pressure) in comparison with HSD (WMD: -1.81, 95%CI: -5.49, 1.87). Although subgroup analysis could not attenuate heterogeneity in SBP, subgroup analysis in DBP based on duration (≤1 week: WMD: -2.35, 95%CI: -3.69, -1.00, I ²  = 48.9%, p = 0.081, >1 week: WMD: -1.04, 95% CI: -2.83, 0.76, I ²  = 74.7%, p = 0.003) and study design (cross-over: WMD: -1.94, 95% CI: -2.71, -1.17, I ²  = 32.1%, p = 0.183, parallel: WMD: -2.17, 95% CI: -6.48, 2.13, I ²  = 82.4%, p = 0.001) successfully detected sources of heterogeneity. LSD significantly reduced SBP and DBP, however, had no effect on MAP, in comparison with HSD.

Associations between the lipid profile and the development of hypertension in young individuals - the preliminary study

INTRODUCTION

Hypertension is the leading direct cause of death in the world and one of the most important risk factors for cardiovascular disease (CVD). Elevated blood pressure (BP) often coexists with lipid disorders and is an additional factor that increases CV risk. Nowadays, we are able to distinguish low density lipoproteins (LDL) and high density lipoproteins (HDL) subfractions. Except LDL also HDL small subfractions can increase the risk of CV events. Therefore, we aimed to investigate the associations between changes of lipoprotein subfractions and the risk of hypertension development.

MATERIAL AND METHODS

In 2-year long study 200 volunteers with normal blood pressure at the age of 19-32 years were included. Each volunteer underwent detailed medical examination, 12-lead electrocardiogram was taken at rest, echocardiogram, lipid subfraction assessment (using Lipoprint^®) and two 24-hour BP measurements.

RESULTS

Mean total cholesterol concentration was 189 mg/dl (4.89 mmol/l), with mean LDL concentration of 107 mg/dl (2.77 mmol/l), HDL of 63 mg/dl (1.63 mmo/l), very low-density lipoprotein (VLDL) of 40 mg/dl (1.04 mmol/l) and triglycerides (TG) of 89 mg/dl (1.00 mmol/l). Subfractions LDL 1-3 were most abundant, LDL 4-5 making up a marginal portion and LDL 6-7 were not observed. Whereas, subfractions HDL 4-6 were most abundant, in lower concentration was present HDL 1-3 and HDL 8-10. We showed that increased systolic blood pressure coreclated significantly with HDL cholesterol concentrations (p = 0.0078), HDL intermediate subgractions (p = 0.0451), with HDL-3 subfraction (p = 0.0229), and intermediate density lipoprotein-A (IDL-A) (p = 0.038). A significant correlation between increased diastolic blood pressure and HDL lipoprotein levels (p = 0.0454) was only observed.

CONCLUSIONS

Obtained results indicating correlation between total HDL levels and HDL-3 subfraction concentration (for systolic BP) and the tendency to develop hypertension.

Hypertension and Comorbidities in Rural and Urban Chinese Older People: An Epidemiological Subanalysis From the SAGE Study

BACKGROUND

There is a lack of studies comparing hypertension and comorbidities in rural and urban older people in China. This study aimed to investigate the prevalence of hypertension and comorbidities in older people and to describe differences between patients from rural and urban areas in China.

METHODS

A cross-sectional study on global AGEing and adult health (SAGE) was conducted from 2007 to 2010 across 8 provinces in China. The current study included a nationally representative subsample of 7,403 respondents aged 60 years and above. Hypertension was either self-reported diagnosed hypertension or 1 elevated measured blood pressure measurement (≥140/90 mm Hg). Comorbidities were self-reported and included angina, arthritis, asthma, stroke, diabetes, depression, and chronic lung disease.

RESULTS

The prevalence of hypertension was 66.1%. Hypertension associated with 1 comorbidity was recorded in 35.9% of all participants. A large majority (73.6%) of participants with hypertension reported "good" or "very good" general health status. The prevalence of hypertension and the number of comorbidities increased with age. The prevalence rates of multiple comorbidities were higher for urban participants than their rural counterparts (27.8 vs. 42.4% for 1 morbidity; 7.7 vs. 16.4% for 2 comorbidities; 1.4 vs. 4.7% for 3 comorbidities; 0.4 vs. 1.2% for ≥4 comorbidities) after adjustment for sociodemographic factors. However, urban participants reported better general health status, irrespective of the number of comorbidities.

CONCLUSIONS

Our study implies that health promotion policies targeting older people should be developed. Rural areas should be a priority, and investment in the quality of health care in rural areas is urgently needed.

Buckwheat and CVD Risk Markers: A Systematic Review and Meta-Analysis

The effects of buckwheat intake on cardiovascular diseases (CVDs) have not been systematically investigated. The aim of the present study was to comprehensively summarize studies in humans and animals, evaluating the impact of buckwheat consumption on CVD risk markers and to conduct a meta-analysis of relevant data. Thirteen randomized, controlled human studies, two cross-sectional human studies and twenty-one animal studies were identified. Using random-effects models, the weighted mean difference of post-intervention concentrations of blood glucose, total cholesterol and triglycerides were significantly decreased following buckwheat intervention compared with controls [differences in blood glucose: -0.85 mmol/L (95% CI: -1.31, -0.39), total cholesterol: 0.50 mmol/L (95% CI: -0.80, -0.20) and triglycerides: 0.25 mmol/L (95% CI: -0.49, -0.02)]. Responses of a similar magnitude were seen in two cross-sectional studies. For animal studies, nineteen of twenty-one studies showed a significant reduction in total cholesterol of between 12% and 54%, and fourteen of twenty studies showed a significant reduction in triglycerides of between 2% and 74%. All exhibited high unexplained heterogeneity. There was inconsistency in HDL cholesterol outcomes in both human and animal studies. It remains unclear whether increased buckwheat intake significantly benefits other markers of CVD risk, such as weight, blood pressure, insulin, and LDL-cholesterol, and underlying mechanisms responsible for any effects are unclear.

Quantifying the effects of spirulina supplementation on plasma lipid and glucose concentrations, body weight, and blood pressure

PURPOSE

Spirulina is generally used as a nutraceutical food supplement due to its nutrient profile, lack of toxicity, and therapeutic effects. Clinical trials have investigated the influence of spirulina on metabolic-related risk factors but have yielded conflicting results in humans. Here, we summarize the evidence of the effects of spirulina on serum lipid profile, glucose management, BP, and body weight by conducting a meta-analysis.

MATERIALS AND METHODS

Relevant studies were retrieved by systematic search of MEDLINE, EMBASE, Scopus databases, and reference lists of relevant original studies from inception to July 2018. Data were extracted following a standardized protocol. Two investigators independently extracted study characteristics, outcomes measures, and appraised methodological quality. Effect sizes were performed using a random-effects model, with weighted mean differences (WMDs) and 95% CIs between the means for the spirulina intervention and control arms. Subgroup analyses were conducted to explore the possible influences of study characteristics. Publication bias and sensitivity analysis were also performed.

RESULTS

A total of 1,868 records were identified of which 12 trials with 14 arms were eligible. The amount of spirulina ranged from 1 to 19 g/d, and intervention durations ranged from 2 to 48 weeks. Overall, data synthesis showed that spirulina supplements significantly lowered total cholesterol (WMD = -36.60 mg/dL; 95% CI: -51.87 to -21.33; P=0.0001), low-density lipoprotein cholesterol (WMD = -33.16 mg/dL; 95% CI: -50.52 to -15.75; P=0.0002), triglycerides (WMD = -39.20 mg/dL; 95% CI: -52.71 to -25.69; P=0.0001), very-low-density lipoprotein cholesterol (WMD = -8.02 mg/dL; 95% CI: -8.77 to -7.26; P=0.0001), fasting blood glucose (WMD = -5.01 mg/dL; 95% CI: -9.78 to -0.24; P=0.04), and DBP (WMD = -7.17 mmHg; 95% CI: -8.57 to -5.78; P=0.001). These findings remained stable in the sensitivity analysis, and no obvious publication bias was detected.

CONCLUSION

Our findings provide substantial evidence that spirulina supplementation has favorable effect on select cardiovascular and metabolic biomarkers in humans, including lipid, glucose, and DBP management.

Optimal Blood Pressure Goals in Patients With Hypertension at High Risk for Cardiovascular Events

Existing epidemiologic and clinical trial data suggest that the blood pressure in patients with hypertension at high risk for cardiovascular events because of coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, or heart failure should be reduced to <140/90 mm Hg in patients younger than 80 years and the systolic blood pressure be reduced to 140-145 mm Hg if tolerated in patients aged 80 years and older. Studies from patients with coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, and heart failure will be discussed that support a blood pressure goal of <140/90 mm Hg in patients younger than 80 years at high risk for cardiovascular events.

Polypills for the prevention of Cardiovascular diseases

INTRODUCTION

Cardiovascular diseases (CVD) remain the leading cause of death worldwide with an estimated 17.5 million deaths per year. Since its initial conception over a decade ago, the use of cardiovascular polypills has gained increasing momentum as a strategy to lower risk factor levels and prevent CVD. Several new data have emerged including the recent publication of the first outcomes trial using polypills. Areas covered: In this review, the authors summarize the current literature on the safety, efficacy, and cost-effectiveness of polypills for primary and secondary prevention of CVD, describe the current controversies in this field, and identify important areas for future research. The authors searched PubMed, CENTRAL, and ClinicalTrials.gov from inception till 25 June 2016 using the search term 'polypill.' Expert opinion: Cardiovascular polypills containing aspirin, statin, and one or more anti-hypertensive medications, along with lifestyle interventions, represent an attractive, safe, and cost-effective strategy for primary and secondary prevention of CVD. Future research efforts should focus on identifying patients who will benefit the most from the use of polypills, marketing several polypills with different components and doses, and developing novel regulatory strategies for making polypills more readily available in all countries worldwide.

Effects of Berries Consumption on Cardiovascular Risk Factors: A Meta-analysis with Trial Sequential Analysis of Randomized Controlled Trials

The effects of berries consumption on cardiovascular disease (CVD) risk factors have not been systematically examined. Here, we aimed to conduct a meta-analysis with trial sequential analysis to estimate the effect of berries consumption on CVD risk factors. PubMed, Embase, and CENTRAL were searched for randomized controlled trials (RCTs) that regarding the effects of berries consumption in either healthy participants or patients with CVD. Twenty-two eligible RCTs representing 1,251 subjects were enrolled. The pooled result showed that berries consumption significantly lowered the low density lipoprotein (LDL)-cholesterol [weighted mean difference (WMD), −0.21 mmol/L; 95% confidence interval (CI), −0.34 to −0.07; P = 0.003], systolic blood pressure (SBP) (WMD, −2.72 mmHg; 95% CI, −5.32 to −0.12; P = 0.04), fasting glucose (WMD, −0.10 mmol/L; 95% CI, −0.17 to −0.03; P = 0.004), body mass index (BMI) (WMD, −0.36 kg/m²; 95% CI, −0.54 to −0.18, P < 0.00001), Hemoglobin A1c (HbA1c) (WMD, −0.20%; 95% CI, −0.39 to −0.01; P = 0.04) and tumor necrosis factor-α (TNF-α) (WMD, −0.99 ρg/mL; 95% CI, −1.96 to −0.02; P = 0.04). However, no significant changes were seen in other markers. The current evidence suggests that berries consumption might be utilized as a possible new effective and safe supplementary option to better prevent and control CVD in humans.

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

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

Lipids, blood pressure and kidney update 2014

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

Effects of salt substitutes on blood pressure: a meta-analysis of randomized controlled trials

BACKGROUND

Clinical trials assessing the effects of salt substitutes on blood pressure (BP) have reported mixed results.

OBJECTIVES

A meta-analysis of randomized controlled trials was conducted to evaluate the effect of salt substitutes on BP, including systolic BP (SBP) and diastolic BP (DBP).

DESIGN

Studies were identified via systematic searches of the PubMed, Embase, Cochrane Library, Wanfang Data, and the China National Knowledge Infrastructure databases through December 2013. Random-effects models were used to estimate pooled mean differences in SBP and DBP.

RESULTS

Six cohorts from 5 articles (1 trial enrolled 2 cohorts for independent intervention) consisting of 1974 participants were included. Pooled results showed that salt substitutes had a significant effect on SBP (mean difference: -4.9 mm Hg; 95% CI: -7.3, -2.5 mm Hg; P < 0.001) and DBP (mean difference: -1.5 mm Hg; 95% CI: -2.7, -0.3 mm Hg; P = 0.013). Significant heterogeneity was found for both SBP (I(2) = 76.7%) and DBP (I(2) = 65.8%). The sensitivity analysis indicated that the pooled effects of salt substitutes on SBP and DBP were robust to systematically dropping each trial. Furthermore, no evidence of significant publication bias from funnel plots or Egger's tests (P = 0.17 and 0.22 for SBP and DBP, respectively) was found.

CONCLUSION

This meta-analysis showed that salt-substitution strategies are effective at lowering SBP and DBP, which supports a nutritional approach to preventing hypertension.

Prognostic power of lower pulse pressure on long-term all-cause mortality in octogenarians with acute coronary syndrome: a propensity-score-matched cohort study

OBJECTIVE

The impact of lower pulse pressure (PP) on long-term all-cause mortality in the octogenarian patients with acute coronary syndrome (ACS) remains unknown. This study sought to reveal the prognostic power of lower PP in long-term all-cause mortality in the octogenarian ACS patients.

METHODS

The current study included a total of 353 consecutive ACS patients aged at least 80 years during the period of 5-year follow-up. Association between PP and long-term mortality was confirmed by sensitivity analyses such as propensity score matching and multivariate Cox analyses. The matched cohort was developed by one-to-one, nearest-neighbor propensity score matching analyses.

RESULTS

Among patients with ACS, 113 (32.1%) admissions were alive, 240 (67.9%) were dead. There was a U-shaped association of mortality rate with PP, and the mortality rate increased in patients with PP equal to or less than 50  mmHg and greater than 70  mmHg. PP equal to or less than 50  mmHg was a predictor of the mortality rate in the overall cohort [hazard ratio: 1.92, 95% confidence interval (CI): 1.08-3.43, P = 0.027] and in the matched cohort (hazard ratio: 2.67, 95% CI: 1.16-6.14, P = 0.020). Moreover, PP equal to or less than 50  mmHg was independently related to mortality rate in the subgroup with hypertension in the overall cohort (hazard ratio: 2.04, 95% CI: 1.04-4.00, P = 0.039) and in the matched cohort (hazard ratio: 2.63, 95% CI: 1.01-6.83, P = 0.048).

CONCLUSION

This study reveals a U-shaped association of mortality rate with PP in the octogenarians with ACS and demonstrates that PP equal to or less than 50  mmHg has an independent prognostic power in long-term all-cause mortality in the octogenarians with ACS as well as the subgroup with hypertension.

Blood pressure levels and stroke: J-curve phenomenon?

The blood pressure J-curve discussion has been ongoing for more than 30 years, yet there are still questions in need of definitive answers. On one hand, existing antihypertensive therapy studies provide strong evidence for J-curve-shaped relationships between both diastolic and systolic blood pressure and primary outcomes in the general hypertensive patient population, as well as in high-risk populations, including subjects with coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and the elderly. On the other hand, we have very limited data on the relationship between systolic and diastolic blood pressure and stroke prevention. Moreover, it seems that this outcome is more a case of “the lower the better.” Further large, well-designed studies are necessary in order to clarify this issue, especially as existing available studies are observational, and randomized trials either did not have or lost statistical power and were thus inconclusive.

Hypertension, brain damage and cognitive decline

Loss of cognitive function is one the most devastating manifestations of ageing and vascular disease. Cognitive decline is rapidly becoming an important cause of disability worldwide and contributes significantly to increased mortality. There is growing evidence that hypertension is the most important modifiable vascular risk factor for development and progression of both cognitive decline and dementia. High blood pressure contributes to cerebral small and large vessel disease resulting in brain damage and dementia. A decline in cerebrovascular reserve capacity and emerging degenerative vascular wall changes underlie complete and incomplete brain infarcts, haemorrhages and white matter hyperintensities. This review discusses the complexity of factors linking hypertension to brain functional and structural changes, and to cognitive decline and dementia. The evidence for possible clinical markers useful for prevention of decreased cognitive ability, as well as recent data on vascular mechanism in the pathogenesis of cognitive decline, and the role of antihypertensive therapies in long-term prevention of late-life cognitive decline will be reviewed.

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

INTRODUCTION

The aim of the study was to identify the association of systolic blood pressure (SBP) levels with cardiovascular events, all-cause mortality, and falls among elderly persons taking antihypertensive medication.

METHODS

US adults ≥ 45 years of age taking antihypertensive medication enrolled in the REGARDS study were categorized into 3 age groups: 55-64, 65-74 and ≥ 75 years old and baseline on-treatment SBP levels. Our primary analyses focused on incident cardiovascular disease (CVD) (n=9787) and all-cause mortality (n=13,948).

RESULTS

During follow-up, 530 (5.4%) participants had CVD events and 2095 (15%) participants died. After multivariable adjustment among participants ≥ 75, the incidence of CVD per 1000 person-years (95% confidence interval) was 16.9 (11.1-25.7), 13.4 (9.2-19.7), 11.6 (7.6-17.7), 17.8 (11.2-27.5) and 36.7 (26.6-50.8) at SBP levels of <120, 120-129, 130-139, 140-149, and ≥ 150 mmHg, respectively. For the same SBP categories, the adjusted CVD incidence rates were 9.3 (7.2-12.0), 10.0 (8.1-12.3), 9.4 (7.5-11.8), 14.0 (11.0-17.8), and 16.4 (12.5-21.4), respectively, among participants 55-64 years, and 16.5 (13.6-21.5), 17.4 (14.8-20.6), 19.2 (16.4-22.5), 22.3 (18.6-26.9), and 27.6 (22.7-33.4), respectively, for participants 65-74 years. Among participants aged 55-64 and 65-74 years, a linear association was present between higher SBP categories and all-cause mortality risk (each p-trend<0.001). In contrast, for participants ≥ 75 years no association was present between SBP and all-cause mortality (p-trend=0.319). No association was observed between SBP and falls among participants in all age groups.

CONCLUSIONS

Among adults aged ≥ 55 taking antihypertensive medication, SBP between 120 and 139 mmHg was significantly associated with a reduced risk for cardiovascular and all-cause mortality outcomes.

Lipid, blood pressure and kidney update 2013

The year 2013 proved to be very exciting as far as landmark trials and new guidelines in the field of lipid disorders, blood pressure and kidney diseases. Among these are the International Atherosclerosis Society Global Recommendations for the Management of Dyslipidemia, European Society of Cardiology (ESC)/European Society of Hypertension Guidelines for the Management of Arterial Hypertension, American Diabetes Association Clinical Practice Recommendations, the Kidney Disease: Improving Global Outcomes Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease (CKD) Patients, the American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, the Joint National Committee Expert Panel (JNC 8) Evidence-Based Guideline for the Management of High Blood Pressure in Adults, the American Society of Hypertension/International Society of Hypertension Clinical Practice Guidelines for the Management of Hypertension in the Community, the American College of Physicians Clinical Practice Guideline on Screening, Monitoring, and Treatment of Stage 1-3 CKD and many important trials presented among others during the ESC Annual Congress in Amsterdam and the American Society of Nephrology Annual Meeting--Kidney Week in Atlanta, GA. The paper is an attempt to summarize the most important events and reports in the mentioned areas in the passing year.

Increasing complexity: which drug class to choose for treatment of hypertension in the elderly?

Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.

During ablation for atrial fibrillation, is simultaneous renal artery ablation appropriate?

Over the past few decades, the mainstay of hypertension management has been pharmacological therapy; however, there is now a growing body of evidence that drug-resistant hypertension can be managed effectively by renal artery ablation. Several studies have documented the feasibility and safety of this treatment, although data regarding long-term outcomes are still emerging. Atrial fibrillation (AF) and hypertension commonly coexist, and recent work has demonstrated improved outcomes from catheter ablation of AF with concomitant renal artery denervation at little extra cost in terms of time and resource. The aim of this review is to explore the link between hypertension and AF, the synergistic effect of renal artery ablation on AF ablation, explain how this may work and address unanswered questions.

Current perspectives on treatment of hypertensive patients with chronic obstructive pulmonary disease

Systemic hypertension and chronic obstructive pulmonary disease (COPD) frequently coexist in the same patient, especially in the elderly. Today, a wide variety of antihypertensive drugs with different mechanisms of action are available to the prescribing physician. In addition, combination drugs for hypertension are becoming increasingly popular. Certain antihypertensive drugs can affect pulmonary function. Therefore the management of such patients can present therapeutic challenges. We have examined the literature pertaining to the use of antihypertensive drugs in patients with systemic hypertension and coexisting COPD. Although data are often limited or of poor quality, we have attempted to review and then provide recommendations regarding the use of all the specific classes of antihypertensive drug therapies including combination drugs in patients with COPD. The antihypertensive agents reviewed include diuretics, aldosterone receptor blockers, beta blockers, combined alpha and beta blockers, angiotensin-converting enzyme inhibitors, angiotensin II antagonists, calcium channel blockers, alpha-1 blockers, centrally acting drugs, direct vasodilators, and combinations of these drugs. Of these classes, calcium channel blockers and angiotensin II antagonists appear to be the best initial choices if hypertension is the only indication for treatment. However, the limited data available on many of these drugs suggest that additional studies are needed to more precisely determine the best treatment choices in this widely prevalent patient group.

Health-related behaviours and hypertension prevention in Poland. An environmental study

INTRODUCTION

Primary and secondary prevention of hypertension is difficult and if the condition is not treated it may cause a number of dangerous complications. The objective of this study was to collect and systematize data on the health-related behaviours of Poles aiming at the prevention of hypertension in order to determine potential areas where primary health care could be improved.

MATERIAL AND METHODS

A group of 1018 participated in the study (60% women and 40% men). The study was conducted in Poland in 2009 by means of an anonymous research questionnaire developed for survey use. The study involved people aged 30-50 years, who had not been diagnosed with hypertension, and who were under the care of a primary care physician.

RESULTS

Over 35% of respondents in the potential risk group do not measure blood pressure at all, and just over 10% perform cholesterol and blood glucose level tests more often than once a year. Individuals who pay most attention to prevention in the form of physical activity are women, more often young (67% of people under 35), unmarried (52%), mostly with secondary or higher education. Moreover, one third of the women surveyed (32.4%) and almost half of men (48.4%) stated that they smoke cigarettes, and in most men (66.3%) the amount of alcohol taken in one serving exceeded the pressor threshold (> 20 g).

CONCLUSIONS

Desirable health-promoting actions such as stress reduction are effective but actions such as consuming alcohol and eating fats are unsatisfactory and require intensive public education.

Blood pressure at hospital admission and outcome after primary intracerebral hemorrhage

INTRODUCTION

The importance of the admission blood pressure (BP) for intracerebral hemorrhage (ICH) outcome is not completely clear. Our objective was to analyze the clinical impact of BP at hospital arrival in patients with primary ICH.

MATERIAL AND METHODS

We studied 316 patients (50% women, mean age: 64 years, 75% with hypertension history) with acute primary ICH. The first BP reading at admission was evaluated for its association with neuroimaging findings and outcome. A Cox proportional hazards model and Kaplan-Meier analyses were constructed to evaluate factors associated with in-hospital mortality.

RESULTS

Intraventricular irruption occurred in 52% of cases. A high frequency of third ventricle extension was observed in patients with BP readings in the upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure). Blood pressure readings did not correlate with hematoma volumes. In-hospital case fatality rate was 46% (63% among those with ventricular irruption). Systolic BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval: 1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for known strong predictors (age, ICH volume, Glasgow coma scale and ventricular extension). Blood pressure was not significantly associated with ventricular extension or outcome in patients with infratentorial ICH.

CONCLUSIONS

A high BP on admission is associated with an increased risk of intraventricular extension and early mortality in patients with supratentorial ICH. However, a significant proportion of patients with high BP readings without ventricular irruption still have an increased risk of death.

Blood pressure j-curve: current concepts

The blood pressure (BP) J-curve debate started in 1979, and we still cannot definitively answer all the questions. However, available studies of antihypertensive treatment provide strong evidence for J-shaped relationships between both diastolic and systolic BP and main outcomes in the general population of hypertensive patients, as well as in high-risk populations, including subjects with coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and elderly patients. However, further studies are still necessary in order to clarify this issue. This is connected to the fact that most available studies were observational, and randomized trials did not have or lost their statistical power and were inconclusive. Perhaps only the Systolic Blood Pressure Intervention Trial (SPRINT) and Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives (ESH-CHL-SHOT) will be able to finally answer all the questions. According to the current state of knowledge, it seems reasonable to suggest lowering BP to values within the 130-139/80-85 mmHg range, possibly close to the lower values in this range, in all hypertensive patients and to be very careful with further BP level reductions, especially in high-risk hypertensive patients.

What should the blood pressure goal be in patients with hypertension who are at high risk for cardiovascular disease?

Epidemiologic and clinical trial data suggest that blood pressure in patients with hypertension who are at high risk for cardiovascular events because of coronary artery disease, diabetes, chronic kidney disease, stroke, or heart failure should be reduced to < 140/90 mm Hg in patients aged < 80 years, and that systolic blood pressure should be reduced to 140 to 145 mm Hg, if tolerated, in patients aged ≥ 80 years. Studies on patients with coronary artery disease, diabetes, chronic kidney disease, stroke, and heart failure are discussed, supporting a blood pressure goal of < 140/90 mm Hg in patients aged < 80 years who are at high risk for cardiovascular events.