Time to Reassess Blood-Pressure Goals

Benefits of more intensive versus less intensive blood pressure control. Updated trial sequential analysis

Outcome data from randomized trials which compared different blood pressure (BP) targets grew impressively after publication of recent trials. We conducted a cumulative updated trial sequential analysis of studies which compared a more versus less intensive BP control strategy, for a total of 60,870 randomized patients. The compared BP targets differed across the trials. Outcome measures were stroke, heart failure, myocardial infarction and cardiovascular death. The average duration of follow-up was 3.95 years and achieved systolic BP was 7.69 mmHg lower with the more intensive than the less intensive BP control strategy. The more intensive BP control strategy significantly reduced the risk of stroke (OR 0.79; 95% CI 0.67-0.93), heart failure (OR 0.73; 95% CI 0.55-0.96), myocardial infarction (OR 0.81; 95% CI 0.73-0.91) and cardiovascular death (OR 0.81; 95% CI 0.68-0.98) as compared to the less intensive strategy. In a trial sequential analysis, the more intensive BP control strategy provided conclusive benefits over the less intensive strategy on the risk of stroke, heart failure and myocardial infarction by definitely crossing the efficacy monitoring boundary. For cardiovascular death, the cumulative Z-curve of the sequential analysis touched the efficacy monitoring boundary, but did not cross it. In conclusion, data accrued from randomized trials conclusively demonstrate the superiority of a more intensive over a less intensive BP control strategy for the prevention of stroke, heart failure and myocardial infarction. Results also suggest a significant benefit, albeit not yet conclusive, of a more intensive over a less intensive strategy for prevention of cardiovascular death.

Effect of Melissa officinalis on systolic and diastolic blood pressures in essential hypertension: A double-blind crossover clinical trial

For a long time, Melissa officinalis (M. officinalis) has been used to treat cardiovascular diseases. Therefore, this study aimed at evaluating the effects of M. officinalis on systolic and diastolic blood pressures in hypertensive patients. We conducted a double-blind, controlled, randomized crossover clinical trial on 49 patients who received either M. officinalis capsules (400 mg/d; n = 23) or the placebo (n = 26) three times per day for a 4-week period. After a 2-week washout period, the M. officinalis group received placebo and the other group received M. officinalis for another 4-week period. The systolic and diastolic blood pressures were measured once at baseline and then every 2 weeks for 10 weeks. The statistical analysis of the obtained data revealed that the chronology of the consumption of M. officinalis and placebo had no effect on the systolic and diastolic blood pressures in these two studied groups. Moreover, it was found that systolic and diastolic blood pressures significantly decreased after the consumption of M. officinalis, compared to placebo. Systolic and diastolic blood pressures in group A at the beginning of the study were 152.30 ± 5.312 mmHg and 95.52 ± 1.988 mmHg, respectively, and, after the first phase (drug use), reached 129.88 ± 9.009 mmHg and 80.13 ± 5.488 mmHg, respectively. Systolic and diastolic blood pressures in group B at the beginning of the study was 152.26 ± 5.640 mmHg and 94.44 ± 2.607 mmHg, respectively, and after the second phase (drug use), reached 131.77 ± 8.091 mmHg and 81.46 ± 7.426 mmHg, (p = .005), respectively. Also, no significant side effects were observed during the study. According to the results, M. officinalis can reduce systolic and diastolic blood pressures of the patients with essential hypertension.

Effect of differential music tempo on post-exercise cardiovascular recovery parameters in hypertensive individuals: a randomised control trial

Hypertensive individuals tend to have autonomic dysfunction indicated by sympathetic dominance or delayed parasympathetic reactivation. A complimentary therapy such as music following exercise is considered to be beneficial in improving autonomic recovery. The purpose of this study was to assess the effect of differential music tempo on post-exercise cardiovascular recovery parameters in hypertensive individuals. Thirty hypertensive individuals were recruited for the present study which were randomly allocated to no music (n=10), slow music (n=10) and fast music (n=10) group. Participants in all three groups were subjected to submaximal exercise bout by Harvard step test. The cardiovascular recovery parameters i.e. heart rate recovery (HRR), blood pressure recovery (BPR) and rating of perceived exertion recovery (RPER) were assessed in all three groups after 1 min, 2 min and 3 min following termination of exercise. A significant decline was observed in HRR (P=0.002) and RPER (P=0.008) following exercise in slow music group as compared to fast and no music while no significant differences were observed in BPR between the three groups. The study concluded that music accelerates post-exercise recovery and slow music has greater effect as compared to fast or no music. These findings may have potential implications in the cardiovascular recovery dynamics in hypertensive individuals participating in submaximal exercise.

Impact of the SPRINT Trial on Hypertension Management

The Systolic Blood Pressure Intervention Trial is the first large prospective randomized controlled trial to demonstrate the benefit of an intensive systolic blood pressure (SBP) treatment target (<120 mm Hg) compared to a standard target (<140 mm Hg) in reducing cardiovascular morbidity and mortality and all-cause mortality in high-risk hypertensive patients. The impact of SPRINT on hypertension treatment has been large, but major questions remain about the feasibility of achieving the SPRINT intensive SBP target in routine practice, the generalizability of the SPRINT findings to hypertensive populations that were excluded from the trial, and the cost effectiveness of adopting the SPRINT intensive treatment goal. In this review, we discuss the generalizability of SPRINT data to the general population of adults with hypertension and with various comorbidities, the cost effectiveness of intensive SBP-lowering therapy, and the implications of SPRINT for future hypertension guideline development and clinical practice.

Effect of intensive lowering of systolic blood pressure treatment on heart failure events: a meta-analysis of randomized controlled studies

We performed this meta-analysis to assess the association between intensive systolic blood pressure (SBP)-lowering strategies and heart failure (HF). A comprehensive literature review was conducted using English and Chinese databases from their origination through April 2018. Random-effects models were used to calculate pooled relative risks and 95% confidence intervals. Nine randomized controlled trials including a total of 39,936 hypertensive patients were ultimately included in our meta-analysis. Pooled analysis of these nine trials showed that a treatment target of SBP ≤140 mmHg was associated with a significant reduction in HF risk (RR: 0.73, 95%CI: 0.62-0.87). Furthermore, the pooled analysis of prospective randomized controlled trials indicated a significant association between intensive lowering of SBP and HF risk (RR: 0.75, 95%CI: 0.62-0.90) and showed that intensive lowering of SBP could decrease risk of HF in patients without diabetes mellitus (RR: 0.69, 95%CI: 0.52-0.91) and in those ≥65 years old (RR: 0.72, 95%CI: 0.56-0.93), but this finding was not shown for patients with diabetes mellitus (RR: 0.81, 95%CI: 0.56-1.19) or in those <65 years old (RR: 0.81, 95%CI: 0.56-1.19). When intensive lowering of SBP achieved an SBP ≤ 120 mmHg, a pooled analysis indicated a positive association between SBP and HF risk (RR: 0.75, 95%CI: 0.63-0.89), and a pooled analyses showed that intensive lowering of SBP could decrease risk of HF in patients without diabetes mellitus (RR: 0.71, 95%CI: 0.51-0.98) and in those ≥65 years old (RR: 0.76, 95%CI: 0.58-0.98); however, this result was not found for patients with diabetes mellitus (RR: 0.81, 95%CI: 0.56-1.19) or those <65 years old (RR: 0.81, 95%CI: 0.56-1.19). The existing data support the results of a positive association between intensive SBP-lowering treatment and HF risk, especially for those patients without diabetes and those older than 65 years. However, additional prospective studies are still needed to confirm these associations.

Hypertension Guidelines: Effect of Blood Pressure Targets

There has been an abundance of hypertension guidelines over the years. Their purpose is to convey evidence-based findings from clinical trials to clinicians so that best medical choices can be made for the diagnosis and treatment of patients with hypertension. Over the past 3 years new hypertension guidelines have been published in the United States, Canada, Europe, and elsewhere with new or refined recommendations made regarding diagnosis, therapy, and intensity of treatment. Previous national guidelines were generally well aligned. However, there are major differences in the current North American and European recommendations in terms of the classification of hypertension and treatment goals, with the diagnosis of hypertension starting at 140/90 mm Hg for the European guidelines and 130/80 mm Hg for the American and Canadian guidelines. An important controversial aspect in the updated guidelines relates to a lowered threshold (130/80 mm Hg) at which hypertension is diagnosed and treated, because growing evidence indicates that individuals at low cardiovascular risk might be exposed to incremental harm because of overtreatment with antihypertensive drugs. However, these concerns need to be weighed against the robust evidence from the landmark Systolic Blood Pressure Intervention Trial (SPRINT) study and numerous meta-analyses, which clearly showed that intensive blood pressure-lowering aimed at a systolic blood pressure of 120-130 mm Hg causes ̴a significant, > 25% reduction in cardiovascular morbidity and mortality. This review highlights some of the important discrepancies between the major current guidelines, with a focus on definitions and treatment goals of hypertension. The effect of lower blood pressure targets and intensive antihypertensive treatment on cardiovascular benefit and risk is also discussed.

Antihypertensive Treatment Patterns and Blood Pressure Control in Older Adults: Results from the Berlin Aging Study II

BACKGROUND

Hypertension is highly prevalent in older adults and represents a major public health issue since recognition, awareness, treatment and control are insufficient. Analyses of prescription patterns in conjunction with clinical parameters can provide novel insights into the current practice of hypertension management and help to identify barriers to sufficient hypertension control.

METHODS

A cross-sectional analysis was conducted. Prevalence of hypertension, patterns of antihypertensive therapy, and determinants of blood pressure (BP) control were examined in the Berlin Aging Study II cohort, including 1654 community-dwelling older adults (60-85 years of age).

RESULTS

Of the participants, 75.9% had hypertension; 40.6% of these were not prescribed BP medications. Lack of hypertension awareness, younger age, absence of comorbidities, not being on a statin, and not having visited a physician in the past 3 months were associated with lack of treatment. Forty-two percent of treated hypertensive individuals received monotherapy and 58.0% received combination therapy. Renin-angiotensin-aldosterone system (RAAS) inhibitors, and β-blockers were most commonly prescribed, while calcium channel blockers were least prescribed. Only 38.5% of treated hypertensive individuals had their BP controlled to < 140/90 mmHg. Number and choice of BP medications were not predictive of BP control; neither were age, glycated hemoglobin (HbA_1c), kidney function, or number of healthcare visits. However, female sex, lower low-density lipoprotein cholesterol (LDL-C) levels and current smoking, amongst others, were positively associated with BP control. There was evidence of significant effect modification by statins in the association of LDL-C and BP.

CONCLUSION

The majority of older adults do not reach BP goals. Antihypertensive prescription patterns do not conform to current guidelines. Using more BP medications was not associated with higher odds of BP control. Lowering LDL-C might be favorable in terms of BP control.

Lowering systolic blood pressure does not increase stroke risk: an analysis of the SPRINT and ACCORD trial data

Objective

Traditional neurology teaching states that when mean arterial pressure dips below a 60 mm Hg threshold, there is an increase in stroke risk due to cerebral hypoperfusion. The aim of this study was to determine whether intensive lowering of systolic blood pressure increases adverse cardiovascular outcomes by examining the association between achieved blood pressure values, specifically mean arterial pressure and pulse pressure, and risk of stroke.

Methods

Data from participants in the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure (BP) trial were examined, using survival analysis to model minimal arterial pressure and average pulse pressure during the study period against risk of stroke, hypotension, and syncope, with death as a competing risk.

Results

In both SPRINT and ACCORD participants, there was no increase in stroke risk with achieved mean arterial pressure values below 60 mm Hg. In SPRINT participants, achieved mean arterial pressure values greater than 90 mm Hg were associated with a 247% (HR: 3.47, 95% CI: 2.06–5.85) higher risk of stroke compared with participants in the 80–89 mmHg reference group. No association was found between low achieved pulse pressure values and greater stroke risk in either the SPRINT or ACCORD participants, as well as no association between mean arterial pressure and pulse pressure values and risk of syncope.

Interpretation

Intensive lowering of systolic blood pressure does not increase risk of stroke in hypertensive patients, despite extremely low mean arterial pressure or pulse pressure values.

Value of Assessing Autonomic Nervous Function by Heart Rate Variability and Heart Rate Turbulence in Hypertensive Patients

Purpose

To explore the relationship between blood pressure control and autonomic nervous function assessing by heart rate variability (HRV) and heart rate turbulence (HRT) in hypertensive patients.

Methods

A total of 120 consecutive hypertensive patients and 80 nonhypertensive patients (N-HP group) were enrolled in this study. The hypertensive patients were divided into controlled blood pressure and uncontrolled blood pressure groups according to their blood pressure on admission. All subjects underwent 24-hour Holter monitoring. This study compared HRV and HRT in nonhypertensive and hypertensive patients and hypertensive patients with controlled and uncontrolled blood pressure. HRV parameters include square root of mean of the sum of squares of successive NN interval differences (rMSSD), number of successive NN intervals differing by > 50ms divided by the total number of successive NN intervals (pNN50), very low frequency (VLF) at frequency between 0.0033 and 0.04 Hz, low frequency (LF) at frequency between 0.04 and 0.15 Hz, and high frequency (HF) at frequency between 0.15 and 0.4 Hz. Turbulence slope (TS) belongs to HRT parameters.

Results

TS, rMSSD, pNN50, VLF, LF, and HF values were significantly lower in the HP group than in the N-HP group. Multiple logistic regression analysis showed that reduced TS, rMSSD, pNN50, LF, and HF values were risk factors of hypertension. TS, rMSSD, pNN50, VLF, LF, and HF values were significantly lower in hypertensive patients with uncontrolled blood pressure than in hypertensive patients with controlled blood pressure. Multiple logistic regression analysis showed that reduced TS, rMSSD, pNN50, VLF, LF, and HF values were risk factors for uncontrolled blood pressure.

Conclusions

This study indicates impaired autonomic nervous function in hypertensive patients, especially in hypertensive patients with uncontrolled blood pressure despite guideline recommended antihypertensive medications.

Translational science matters: forging partnerships between biomedical and behavioral science to advance the public's health

The prevention and effective treatment of many chronic diseases such as cardiovascular disease, cancer and diabetes are dependent on behaviors such as not smoking, adopting a physically-active lifestyle, eating a healthy diet, and adhering to prescribed medical and behavioral regimens. Yet adoption and maintenance of these behaviors pose major challenges for individuals, their families and communities, as well as clinicians and health care systems. These challenges can best be met through the integration of the biomedical and behavioral sciences that is achieved by the formation of strategic partnerships between researchers and practitioners in these disciplines to address pressing clinical and public health problems. The National Institutes of Health has supported a number of clinical trials and research initiatives that demonstrate the value of biomedical and behavioral science partnerships in translating fundamental discoveries into significant improvements in health outcomes. We review several such examples of collaborations between biomedical and behavioral researchers, describe key initiatives focused on advancing a transdisciplinary translational perspective, and outline areas which require insights, tools and findings from both the biomedical and behavioral sciences to advance the public's health.

Post-stroke hypertension control and receipt of health care services among veterans

Many ischemic stroke patients do not achieve goal blood pressure (BP < 140/90 mm Hg). To identify barriers to post-stroke hypertension management, we examined healthcare utilization and BP control in the year after index ischemic stroke admission. This retrospective cohort study included patients admitted for acute ischemic stroke to a VA hospital in fiscal year 2011 and who were discharged with a BP ≥ 140/90 mm Hg. One-year post-discharge, BP trajectories, utilization of primary care, specialty and ancillary services were studied. Among 265 patients, 246 (92.8%) were seen by primary care (PC) during the 1-year post-discharge; a median time to the first PC visit was 32 days (interquartile range: 53). Among N = 245 patients with post-discharge BP data, 103 (42.0%) achieved a mean BP < 140/90 mm Hg in the year post-discharge. Provider follow-ups were: neurology (51.7%), cardiology (14.0%), nephrology (7.2%), endocrinology (3.8%), and geriatrics (2.6%) and ancillary services (BP monitor [30.6%], pharmacy [20.0%], nutrition [8.3%], and telehealth [8%]). Non-adherence to medications was documented in 21.9% of patients and was observed more commonly among patients with uncontrolled compared with controlled BP (28.7% vs 15.5%; P = .02). The recurrent stroke rate did not differ among patients with uncontrolled (4.2%) compared with controlled BP (3.8%; P = .89). Few patients achieved goal BP in the year post-stroke. Visits to primary care were not timely. Underuse of specialty as well as ancillary services and provider perception of medication non-adherence were common. Future intervention studies seeking to improve post-stroke hypertension management should address these observed gaps in care.

Experiences, expectations and challenges of an interactive mobile phone-based system to support self-management of hypertension: patients' and professionals' perspectives

BACKGROUND

A well-controlled blood pressure (BP) reduces cardiovascular complications. Patient participation in care using technology may improve the current situation of only 13.8% of adults diagnosed with hypertension worldwide having their BP under control.

OBJECTIVE

The objective of this study was to explore patients' and professionals' experiences of and expectations for an interactive mobile phone-based system to support self-management of hypertension.

METHODS

The self-management system consists of: 1) a mobile phone platform for self-reports, motivational messages and reminders; 2) a device for measuring BP and 3) graphical feedback of self-reports. Patients diagnosed with high BP (n=20) and their treating professionals (n=7) participated in semi-structured interviews, after 8 weeks use of the system in clinical practice. Data were analyzed thematically.

RESULTS

The self-reporting of BP, symptoms, medication use, medication side effects, lifestyle and well-being was perceived to offer insight into how daily life activities influenced BP and helped motivate a healthy lifestyle. Taking increased responsibility as a patient, by understanding factors affecting one's well-being, was reported as an enabling factor for a more effective care. Based on the experiences, some challenges were mentioned: for adoption of the system into clinical practice, professionals' educational role should be extended and there should be a reorganization of care to fully benefit from technology. The patients and professionals gave examples of further improvements to the system, for example, related to the visualization of graphs from self-reports and an integration of the system into the general technical infrastructure. These challenges are important on the path to accomplishing adoption.

CONCLUSION

The potential of a more autonomous, knowledgeable and active patient, through use of the interactive mobile system would improve outcomes of hypertension treatment, which has been desired for decades. Documentation and visualization of patients' self-reports and the possibilities to communicate these with professionals may be a significant resource for person-centered care.

Personalized medicine-a modern approach for the diagnosis and management of hypertension

The main goal of treating hypertension is to reduce blood pressure to physiological levels and thereby prevent risk of cardiovascular disease and hypertension-associated target organ damage. Despite reductions in major risk factors and the availability of a plethora of effective antihypertensive drugs, the control of blood pressure to target values is still poor due to multiple factors including apparent drug resistance and lack of adherence. An explanation for this problem is related to the current reductionist and ‘trial-and-error’ approach in the management of hypertension, as we may oversimplify the complex nature of the disease and not pay enough attention to the heterogeneity of the pathophysiology and clinical presentation of the disorder. Taking into account specific risk factors, genetic phenotype, pharmacokinetic characteristics, and other particular features unique to each patient, would allow a personalized approach to managing the disease. Personalized medicine therefore represents the tailoring of medical approach and treatment to the individual characteristics of each patient and is expected to become the paradigm of future healthcare. The advancement of systems biology research and the rapid development of high-throughput technologies, as well as the characterization of different –omics, have contributed to a shift in modern biological and medical research from traditional hypothesis-driven designs toward data-driven studies and have facilitated the evolution of personalized or precision medicine for chronic diseases such as hypertension.

Effect of Intensive Blood-Pressure Treatment on Patient-Reported Outcomes

BACKGROUND

The previously published results of the Systolic Blood Pressure Intervention Trial showed that among participants with hypertension and an increased cardiovascular risk, but without diabetes, the rates of cardiovascular events were lower among those who were assigned to a target systolic blood pressure of less than 120 mm Hg (intensive treatment) than among those who were assigned to a target of less than 140 mm Hg (standard treatment). Whether such intensive treatment affected patient-reported outcomes was uncertain; those results from the trial are reported here.

METHODS

We randomly assigned 9361 participants with hypertension to a systolic blood-pressure target of less than 120 mm Hg or a target of less than 140 mm Hg. Patient-reported outcome measures included the scores on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Veterans RAND 12-Item Health Survey, the Patient Health Questionnaire 9-item depression scale (PHQ-9), patient-reported satisfaction with their blood-pressure care and blood-pressure medications, and adherence to blood-pressure medications. We compared the scores in the intensive-treatment group with those in the standard-treatment group among all participants and among participants stratified according to physical and cognitive function.

RESULTS

Participants who received intensive treatment received an average of one additional antihypertensive medication, and the systolic blood pressure was 14.8 mm Hg (95% confidence interval, 14.3 to 15.4) lower in the group that received intensive treatment than in the group that received standard treatment. Mean PCS, MCS, and PHQ-9 scores were relatively stable over a median of 3 years of follow-up, with no significant differences between the two treatment groups. No significant differences between the treatment groups were noted when participants were stratified according to baseline measures of physical or cognitive function. Satisfaction with blood-pressure care was high in both treatment groups, and we found no significant difference in adherence to blood-pressure medications.

CONCLUSIONS

Patient-reported outcomes among participants who received intensive treatment, which targeted a systolic blood pressure of less than 120 mm Hg, were similar to those among participants who received standard treatment, including among participants with decreased physical or cognitive function. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062 .).

Ethnic and racial disparities in hypertension management among women

Hypertension is a major independent risk factor for cardiovascular disease for all ethnic and racial groups. Compared with other lifestyle and metabolic risk factors, hypertension is the leading cause of death in women. Women with preeclampsia are three times more likely to develop chronic hypertension and have an elevated risk of future cardiovascular disease. The objective of this article is to provide a review of the factors related to racial and ethnic disparities in blood pressure control. This is followed by a summary of contemporary clinical practice guidelines for the prevention, through lifestyle behavioral modification, and treatment of hypertension with pharmacotherapy.

A Network Meta-Analysis of Clinical Management Strategies for Treatment-Resistant Hypertension: Making Optimal Use of the Evidence

BACKGROUND

With the addition of surgical interventions to current medicinal treatments, it is increasingly challenging for clinicians to rationally choose among the various options for treating patients with apparent treatment-resistant hypertension (ATRHTN). This study aims to establish the comparative effectiveness of mineralocorticoid receptor antagonists (MRA), renal denervation (RDN), darusentan and central arteriovenous anastomosis (CAA) for patients with ATRHTN by performing a network meta-analysis.

METHODS

Data Sources: Studies from recent meta-analyses for RDN and placebo effect were supplemented with a systematic search for MRAs in ATRHTN in the Pubmed, EMBASE, CINAHL and Cochrane databases through November 2016.

STUDY SELECTION

Randomized controlled trials comparing treatment options for patients with ATRHTN.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using predefined data extraction forms, including the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. A Bayesian random effects model was used to conduct a network meta-analysis. Spironolactone was used as the main comparator. Main Outcomes and Measures: Reduction in 24-h ambulatory blood pressure measurement (ABPM).

RESULTS

Twenty articles met our inclusion criteria, and seven treatment alternatives were compared. Compared to MRA, CAA had the highest probability of being more effective, further reducing 24-h SBP (-4.8 mmHg [-13.0, 3.7]) and 24-h DBP (-9.7 mmHg [-18, -0.63]). This difference is likely to be clinically meaningful, with a probability of 78 and 96% at a threshold of a 2-mmHg reduction in blood pressure.

CONCLUSIONS

When compared to MRA as anchor, darusentan, CAA and RDN are not more effective in achieving a clinically significant reduction in ambulatory blood pressure in individuals with apparent treatment-resistant hypertension.

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

BACKGROUND

Blood pressure (BP) targets from the SPRINT (Systolic Blood Pressure Intervention Trial) differ from targets of the 2014 hypertension (HTN) recommendations of the Eighth Joint National Committee.

OBJECTIVES

The goal of this study was to estimate the proportion of hypertensive adults with who would meet BP goals under the SPRINT criteria and under the 2014 recommendations, and to determine related effects on cardiovascular morbidity and mortality.

METHODS

We used data from the Korean National Health and Nutrition Examination Survey of 2008 to 2013 (n = 13,346), as well as the Korean National Health Insurance Service health examinee cohort of 2007 (n = 67,965), to estimate the proportion of subjects meeting BP goals of each of the criteria. Using data from the Korean National Health Insurance Service health examinee cohort of 2007 (n = 67,965), we compared risks of major cardiovascular events (composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes) associated with different BP control goals.

RESULTS

A substantially lower proportion of hypertensive adults met BP goals of the SPRINT criteria compared with the 2014 recommendations (11.9% vs. 70.8%, respectively). Ten-year predicted cardiovascular risks were lowest in the intensive control group (below SPRINT BP goals), intermediate in the less-intensive group (above SPRINT goals but below 2014 recommendation goals), and highest in the uncontrolled group (above 2014 recommendations) (6.15%, 7.65%, and 9.39%, respectively; p < 0.001). After multivariable adjustment, the less-intensive and uncontrolled groups had a greater risk of major cardiovascular events (hazard ratios 1.17 and 1.62, respectively; p value for trend, <0.001) than the intensive group.

CONCLUSIONS

Substantially fewer hypertensive adults would meet SPRINT BP goals than would meet 2014 recommendation goals. Stricter BP control is associated with a decreased risk of major cardiovascular events.

Characteristics and Incidence of Chronic Illness in Community-Dwelling Predominantly Male U.S. Veteran Centenarians

OBJECTIVES

To assess the incidence of chronic illness and its effect on veteran centenarians.

DESIGN

Retrospective longitudinal cohort study.

SETTING

United States Veterans Affairs Corporate Data Warehouse (CDW).

PARTICIPANTS

Community-dwelling veterans born between 1910 and 1915 who survived to at least age 80 (N = 86,892; 31,121 octogenarians, 52,420 nonagenarians, 3,351 centenarians).

MEASUREMENTS

The Kaplan-Meier method was used to estimate cumulative incidence of chronic conditions according to age group. Incidence rates were compared using the log-rank test. Cox proportional hazards models were used to estimate unadjusted hazard ratios.

RESULTS

Ninety-seven percent of Centenarians were male, 88.0% were white, 31.8% were widowed, 87.5% served in World War II, and 63.9% did not have a service-related disability. The incidence rates of chronic illnesses were higher in octogenarians than centenarians (atrial fibrillation, 15.0% vs 0.6%, P < .001; heart failure, 19.3% vs 0.4%, P < .001; chronic obstructive pulmonary disease, 17.9% vs 0.6%, P < .001; hypertension, 29.6% vs 3.0%, P < .001; end-stage renal disease, 7.2% vs 0.1%, P < .001; malignancy, 14.1% vs 0.6%, P < .001; diabetes mellitus, 11.1% vs 0.4%, P < .001; stroke, 4.6% vs 0.4%, P < .001) and in nonagenarians than centenarians (atrial fibrillation, 13.2% vs 3.5%, P < .001; heart failure, 15.8% vs 3.3%, P < .001; chronic obstructive pulmonary disease, 11.8% vs 3.5%, P < .001; hypertension, 27.2% vs 12.8%, P < .001; end-stage renal disease, 11.9% vs 4.5%, P < .001; malignancy, 8.6% vs 2.3%, P < .001; diabetes mellitus, 7.5% vs 2.2%, P < .001; and stroke, 3.5% vs 1.3%, P < .001).

CONCLUSION

In a large cohort of predominantly male community-dwelling elderly veterans, centenarians had a lower incidence of chronic illness than those in their 80s and 90s, demonstrating similar compression of morbidity and extension of health span observed in other studies.

Proportion and Characteristics of US Adults Who May Be Eligible From Additional Blood Pressure Lowering Based on Absolute Risk

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) and the Heart Outcomes Prevention Evaluation 3 (HOPE-3) trial demonstrated the merits of blood pressure (BP) lowering to reduce cardiovascular events in intermediate to high cardiovascular risk adults. However, the population impact of an absolute risk-based strategy for BP lowering remains unclear.

METHODS

We examined 3 treatment thresholds using the National Health and Nutrition Examination Survey. First, the JNC8 guideline was used to determine treatment goals. Second, adults with a systolic BP (SBP) of 130 mm Hg and high cardiovascular risk (based on eligibility for SPRINT) were considered eligible for additional BP lowering. Finally, we combined the treatment threshold for high-risk adults with an SBP treatment threshold of 140 mm Hg for intermediate-risk adults that met the eligibility criteria for HOPE-3.

RESULTS

Under the JNC8 guideline, 78.0% of adults ≥50 years were at target while 22.0% were eligible for additional BP lowering. If an SBP treatment threshold of 130 mm Hg was used for adults at high cardiovascular risk, 31.1% would be eligible for additional BP lowering (an increase of 8.1 million). If an SBP threshold of 140 mm Hg was additionally used for adults at intermediate risk, 31.4% of adults would be eligible for BP lowering (an increase of 8.3 million). The proportion of adults eligible for BP lowering with established coronary artery disease decreased with the risk-based strategies.

CONCLUSION

An absolute risk treatment strategy would modestly increase the proportion of adults eligible for BP lowering.

Heart rate recovery in hypertensive patients: relationship with blood pressure control

Delayed heart rate recovery (HRR) post treadmill exercise testing reflects autonomic dysfunction and is related to worse cardiovascular outcome. The present study compared HRR in normotensive subjects and hypertensive patients taking anti-hypertensive medications with controlled blood pressure (BP) and uncontrolled BP. A total of 279 consecutive patients with (n=140, HP) and without (n=139, N-HP) essential hypertension who were hospitalized in our department during May 2012 to March 2016 were included in this study. All subjects underwent treadmill exercise testing. Hypertensive patients were divided into controlled BP (n=88) and uncontrolled BP (n=52) groups according to their BP prior to treadmill exercise testing. Body mass index, triglyceride level and incidence of diabetes mellitus (DM) were significantly higher in the HP group than in the N-HP group, and HDL-c and HRR were significantly lower. Male gender, higher creatinine value and lower cholesterol and HDL-c were associated with lower HRR in the N-HP group, and higher triglyceride, lower LDL-c, and HDL-c were associated with lower HRR in the HP group. More frequent, ⩾3, antihypertensive drug use, less monotherapy use and high incidence of smokers and lower HRR were found in hypertensive patients with uncontrolled BP compared to hypertensive patients with controlled BP. The present results demonstrate that uncontrolled BP following antihypertensive medication is associated with lower HRR in hypertensive patients.

[Towards new targets in the treatment of hypertension?]

Blood pressure is a major determinant of cardiovascular risk. Blood pressure target to reach with antihypertensive therapy, and the population to whom it should apply, remain debatted. Blood pressure goals established by scientific societies may be revised after the publication of the US multicenter SPRINT study results (Systolic Blood Pressure Intervention Trial) obtained in 2015. Analysis of the generalizability of the SPRINT results shows that they may not be directly applied to the french population which is at lower risk than the US population and would have major medical and economic implications.

Potential Clinical Impact of Abdominal Aortic Calcification on Bone Density Lateral Spine Images

Abdominal aortic calcification (AAC) predicts incident atherosclerotic cardiovascular disease (ASCVD) events and can be accurately identified on densitometric lateral spine images obtained at the time of bone densitometry. Our objective was to estimate the proportion of patients referred for bone densitometry who have a high level of AAC and are not already known to have ASCVD or to be at high risk for ASCVD. AAC was scored on densitometric lateral spine images of 2168 individuals blinded to clinical diagnoses or risk factors using the 24-point Framingham scale. We ascertained preexisting ASCVD diagnoses and risk factors using electronic health record data. We used the risk calculator of the American Heart Association (AHA) and the American College of Cardiology (ACC) to estimate the 10-yr risk of hard ASCVD outcomes (myocardial infarction, death caused by coronary heart disease, or nonfatal or fatal stroke). A high level of AAC (AAC score ≥5) was present in 41 (6.1%, 95% confidence interval [CI]: 4.4%-8.2%) of those aged less than 65 yr, in 253 (23.1%, 95% CI: 20.7%-25.7%) of those aged 65-74 yr, and in 153 (37.8%, 95% CI: 33.0%-42.7%) of those aged 75-80 yr. Among those aged 65-74 yr, 16.9% (95% CI: 14.7%-19.3%) had a high level of AAC and no prior clinical diagnosis of ASCVD, but only 2.4% had a high level of AAC and a predicted 10-yr risk of hard ASCVD outcomes <7.5%. AAC is common among those aged 65 yr and older who were referred for bone densitometry and had no known ASCVD, although these individuals can also be recognized as being at intermediate to high risk using the AHA-ACC ASCVD risk calculator. Further studies regarding the impact of identification of AAC on provider and patient cardiovascular disease risk management choices are warranted.

A cholinergic-sympathetic pathway primes immunity in hypertension and mediates brain-to-spleen communication

The crucial role of the immune system in hypertension is now widely recognized. We previously reported that hypertensive challenges couple the nervous drive with immune system activation, but the physiological and molecular mechanisms of this connection are unknown. Here, we show that hypertensive challenges activate splenic sympathetic nerve discharge to prime immune response. More specifically, a vagus-splenic nerve drive, mediated by nicotinic cholinergic receptors, links the brain and spleen. The sympathetic discharge induced by hypertensive stimuli was absent in both coeliac vagotomized mice and in mice lacking α7nAChR, a receptor typically expressed by peripheral ganglionic neurons. This cholinergic-sympathetic pathway is necessary for T cell activation and egression on hypertensive challenges. In addition, we show that selectively thermoablating the splenic nerve prevents T cell egression and protects against hypertension. This novel experimental procedure for selective splenic denervation suggests new clinical strategies for resistant hypertension.

Immune system participates in the development of high blood pressure. Here the authors show that cholinergic-sympathetic pathway mediated by the α7nAChR receptor and the activation of splenic T cells prime immunity during hypertension and that selective splenic denervation protects against the onset of hypertension in mice.

More Versus Less Intensive Blood Pressure-Lowering Strategy: Cumulative Evidence and Trial Sequential Analysis

Several randomized trials compared a more versus less intensive blood pressure-lowering strategy on the risk of major cardiovascular events and death. Cumulative meta-analyses and trial sequential analyses can establish whether and when firm evidence favoring a specific intervention has been reached from accrued literature. Therefore, we conducted a cumulative trial sequential analysis of 18 trials that randomly allocated 53 405 patients to a more or less intensive blood pressure-lowering strategy. We sought to ascertain the extent to which trial evidence added to previously accrued data. Outcome measures were stroke, myocardial infarction, heart failure, cardiovascular death, and all-cause death. Achieved blood pressure was 7.6/4.5 mm Hg lower with the more intensive than the less intensive blood pressure-lowering strategy. For stroke and myocardial infarction, the cumulative Z curve crossed the efficacy monitoring boundary solely after the SPRINT (Systolic Blood Pressure Intervention Trial) study, thereby providing firm evidence of superiority of a more intensive over a less intensive blood pressure-lowering strategy. For cardiovascular death and heart failure, the cumulative Z curve crossed the conventional significance boundary, but not the sequential monitoring boundary, after SPRINT. For all-cause death, the SPRINT trial pushed the cumulative Z curve away from the futility area, without reaching the conventional significance boundary. We conclude that evidence accrued to date strongly supports the superiority of a more intensive versus a less intensive blood pressure-lowering strategy for prevention of stroke and myocardial infarction. Cardiovascular death and heart failure are likely to be reduced by a more intensive blood pressure-lowering strategy, but evidence is not yet conclusive.