Association of Blood Pressure Trajectory With Mortality, Incident Cardiovascular Disease, and Heart Failure in the Cardiovascular Health Study

Association of Cardiovascular Health in Young Adulthood With Long-Term Blood Pressure Trajectories

BACKGROUND

Cardiovascular health (CVH) in young adulthood (YA) has been associated with cardiovascular outcomes in older age. However, little is known about the relationship between YA CVH and mid-life blood pressure (BP) trajectories.

METHODS

Baseline CVH (defined by 7 of the American Heart Association's [AHA] Life's Essential 8 [LE8] metrics, excluding BP) was measured in YA with individual metrics scored and averaged as a composite LE8 score. Categorical CVH status was defined as high, moderate, and low. Latent class analysis was used to identify trajectories of mid-BP (mean of systolic blood pressure [SBP] and diastolic blood pressure [DBP]) from average ages 35 to 55 years. Multinomial logistic regression was used to estimate the association of YA CVH status (continuously and categorically) with mid-life BP trajectory group membership.

RESULTS

There were 3,688 participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study in YA with follow-up data for mid-life BP trajectories. We observed 3 BP trajectory groups, labeled as Persistently-Low, Middle, and High-Increasing. On average, each 10-points higher baseline LE8 score (mean [SD] of 73.5 [13.1]) in YA was associated with adjusted odds ratios of 0.78 (95% CI, 0.72-0.84) for membership in the Middle and 0.65 (0.57-0.73) for membership in the High-Increasing trajectory groups. Compared with categorical low CVH status at baseline, those with high CVH were significantly less likely to be in the Middle and High-Increasing BP trajectory groups.

CONCLUSIONS

Moderate or low CVH status in YA is associated with elevated mid-life BP trajectory. These data suggest that young adult CVH promotion may be important for the primordial prevention of hypertension.

Association between blood pressure multi-trajectory and cardiovascular disease among a Chinese elderly medical examination population

Objective

This study aimed to characterize multivariate trajectories of blood pressure [systolic blood pressure (SBP) and diastolic blood pressure (DBP)] jointly and examine their impact on incident cardiovascular disease (CVD) among a Chinese elderly medical examination population.

Methods

A total of 13,504 individuals without CVD during 2018-2020 were included from the Chinese geriatric physical examination cohort study. The group-based trajectory model was used to construct multi-trajectories of systolic blood pressure and diastolic blood pressure. The primary outcome was the incidence of the first CVD events, consisting of stroke and coronary heart diseases, in 2021. The Cox proportional hazards model was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between BP multi-trajectories and incident CVD events.

Results

We identified four blood pressure (BP) subclasses, summarized by their SBP and DBP levels from low to high as class 1 (7.16%), class 2 (55.17%), class 3 (32.26%), and class 4 (5.41%). In 2021, we documented 890 incident CVD events. Compared with participants in class 1, adjusted HRs were 1.56 (95% CI: 1.12-2.19) for class 2, 1.75 (95% CI: 1.24-2.47) for class 3, and 1.88 (95% CI: 1.24-2.85) for class 4 after adjustment for demographics, health behaviors, and metabolic index. Individuals aged 65 years and above with higher levels of BP trajectories had higher risks of CVD events in China.

Conclusions

Individuals with higher levels of both SBP and DBP trajectories over time were associated with an increased risk of incident CVD in the Chinese elderly population.

Remission to normal blood pressure in older adults with hypertension who did not receive antihypertensive medication: analysis of data from two longitudinal cohorts

Background

How often hypertensive patients could achieve remission to normal blood pressure (BP) (i.e., <140/90 mmHg) in the absence of antihypertensive drugs, which is important for the management of hypertension, remains largely unknown. This observational study aimed to investigate the change of BP in older adults with hypertension who did not take antihypertensive drugs and preliminarily examine whether the remission from hypertension to normal BP observed in this setting was associated with lower risk of cardiovascular disease (CVD).

Methods

2760 participants aged 33-99 years (median 60 years, interquartile 54-68 years) from the Health and Retirement Study (wave 2006 to wave 2018) and the English Longitudinal Study of Ageing (wave 1998 to wave 2016), who had no major CVD, were hypertensive, and were not on antihypertensive drugs at the time of baseline BP measurement, and had at least one follow-up BP measurement before which no antihypertensive drugs were taken, were included for analysis. The main outcome was the proportion of patients who achieved remission of hypertension at the last wave of measurement.

Findings

During a median follow-up of six years, 52% of the participants showed a reduction of ≥6 mmHg in systolic BP and 60% a reduction of ≥3 mmHg in diastolic BP. 1171 participants (42%, 95% CI: 41-44%) achieved remission at the last measurement, and by that time 67%, 43%, and 29% of them had maintained the normotensive state for around 4, 8, and 12 years, respectively. Various supplementary analyses that aimed to examine the impact of chance and bias yielded similar results. Preliminary analyses showed that being non-smokers at baseline, achieving a normal body mass index during follow-up, and quitting alcohol drinking during follow-up, among others, were associated with the remission of hypertension. Compared with the participants who remained hypertensive, those who achieved remission had a lower CVD risk (adjusted hazard ratio 0.66, 95% CI: 0.47-0.92).

Interpretation

In many of this study population, hypertension could be reversed without the intervention of drug treatment in the first few years after diagnosis. This finding may have implications for more individualized management of hypertension. Further studies to identify the factors or algorithms predictive of such hypertension remission are warranted.

Funding

The Chinese University of Hong Kong (7106452; 7105959),Shenzhen Science and Technology Program (KQTD20190929172835662), Strategic Priority Research Program of Chinese Academy of Sciences (XDB 38040200), National Institute on Aging (R01AG017644; NIA U01AG009740).

Clusters of longitudinal risk profile trajectories are associated with cardiometabolic diseases: Results from the population-based KORA cohort

BACKGROUND

Multiple risk factors contribute jointly to the development and progression of cardiometabolic diseases. Therefore, joint longitudinal trajectories of multiple risk factors might represent different degrees of cardiometabolic risk.

METHODS

We analyzed population-based data comprising three examinations (Exam 1: 1999-2001, Exam 2: 2006-2008, Exam 3: 2013-2014) of 976 male and 1004 female participants of the KORA cohort (Southern Germany). Participants were followed up for cardiometabolic diseases, including cardiovascular mortality, myocardial infarction and stroke, or a diagnosis of type 2 diabetes, until 2016. Longitudinal multivariate k-means clustering identified sex-specific trajectory clusters based on nine cardiometabolic risk factors (age, systolic and diastolic blood pressure, body-mass-index, waist circumference, Hemoglobin-A1c, total cholesterol, high- and low-density lipoprotein cholesterol). Associations between clusters and cardiometabolic events were assessed by logistic regression models.

RESULTS

We identified three trajectory clusters for men and women, respectively. Trajectory clusters reflected a distinct distribution of cardiometabolic risk burden and were associated with prevalent cardiometabolic disease at Exam 3 (men: odds ratio (OR)ClusterII = 2.0, 95% confidence interval: (0.9-4.5); ORClusterIII = 10.5 (4.8-22.9); women: ORClusterII = 1.7 (0.6-4.7); ORClusterIII = 5.8 (2.6-12.9)). Trajectory clusters were furthermore associated with incident cardiometabolic cases after Exam 3 (men: ORClusterII = 3.5 (1.1-15.6); ORClusterIII = 7.5 (2.4-32.7); women: ORClusterII = 5.0 (1.1-34.1); ORClusterIII = 8.0 (2.2-51.7)). Associations remained significant after adjusting for a single time point cardiovascular risk score (Framingham).

CONCLUSIONS

On a population-based level, distinct longitudinal risk profiles over a 14-year time period are differentially associated with cardiometabolic events. Our results suggest that longitudinal data may provide additional information beyond single time-point measures. Their inclusion in cardiometabolic risk assessment might improve early identification of individuals at risk.

Blood pressure status, trajectories and cardiovascular disease: the CoLaus|PsyCoLaus prospective study

BACKGROUND

High blood pressure (BP) is a major risk factor for cardiovascular disease (CVD). Adequate treatment of high BP should reduce the risk of CVD, but this association has seldom been assessed in a general population setting.

METHODS

Population-based prospective study conducted in Lausanne, Switzerland, with a follow-up between 2003 and 2021. Participants were categorised as normal BP, untreated high BP, treated and uncontrolled BP and treated and controlled BP. Total and CVD mortality as well as any CVD event were assessed.

RESULTS

5341 participants (65% normal, 17.4% untreated, 8.8% treated and uncontrolled and 8.8% treated and controlled) were included. After a median follow-up of 14 years (IQR: 11-15), 575 CVD events occurred. Relative to participants with normal BP, multivariable-adjusted HRs (and 95% CI) for total CVD were 1.38 (1.11 to 1.72) for untreated, 1.35 (1.04 to 1.76) for treated and uncontrolled and 1.50 (1.15 to 1.95) for treated and controlled. The corresponding HRs for CVD mortality (112 events) were 0.94 (0.52 to 1.70), 1.77 (1.00 to 3.12) and 2.52 (1.50 to 4.23), respectively. For total mortality (677 events), the HRs were 1.24 (1.01 to 1.52), 1.26 (0.99 to 1.60) and 1.27 (0.99 to 1.62), respectively. Sensitivity analysis using BP status during a 5-year period and categorising participants as always normal, always treated and uncontrolled, always treated and controlled and other led to similar findings.

CONCLUSION

Over a long follow-up period of 14 years, BP control was not associated with reduction of CVD events, CVD-related or total mortality. This finding should help define further studies on factors affecting CVD and mortality in people treated for hypertension in the general population.

Associations between long-term blood pressure trajectory and all-cause and CVD mortality among old people in China

Background

Optimal blood pressure (BP) management strategy among the elderly remains controversial, with insufficient consideration of long-term BP trajectory. This study aimed to identify BP trajectory patterns as well as terminal BP trajectory among the Chinese elderly and to explore the relationships between BP trajectories and all-cause mortality and cardiovascular disease (CVD) mortality.

Methods

We included 11,181 participants older than 60 at baseline (mean age, 80.98 ± 10.71) with 42,871 routine BP measurements from the Chinese Longitudinal Healthy Longevity Survey. Latent class trajectory analysis and Cox proportional hazard model were conducted to identify trajectory patterns and their associations with mortality. Furthermore, we also applied mixed-effects model to identify terminal BP trajectories among the elderly.

Results

Compared with stable at normal high level trajectory, excess systolic BP (SBP) trajectory with decreasing trend was associated with a 34% (HR = 1.34, 95% CI: 1.23-1.45) higher risk of all-cause mortality. Considering the competing risk of non-CVD death, excess BP trajectory with decreasing trend had a more pronounced effect on CVD mortality, in which HR (95% CI) was 1.67 (1.17, 2.37). Similar results were also found in diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP) trajectories. We further conducted a mixed-effects model and observed that SBP and PP trajectories first increased and began to decline slightly six years before death. In contrast, DBP and MAP showed continuous decline 15 years before death.

Conclusion

Long-term BP trajectory was associated with all-cause mortality, especially CVD mortality. Keeping a stable BP over time may be an important way for CVD prevention among the elderly.

Association of blood pressure trajectories with coronary heart disease among the disabled population in Shanghai, China: a cohort study of 7 years following up

BACKGROUND

Much less is known about the importance of blood pressure (BP) trajectories concerning the incidence of coronary heart disease (CHD) in people with disabilities. Our aim was to evaluate this association.

METHODS

This cohort study surveyed 5711 adults from the Shanghai Disability Health Survey from June 2012 to June 2019. The latent class growth mixture model was used to examine distinct BP trajectories. We evaluated the association of BP trajectories with the risk of CHD by Cox proportional hazard models. The model for CHD risk fitted to BP trajectories was compared with models fitted to other BP-related indicators by goodness-of-fit, discrimination, and calibration.

RESULTS

During a median follow-up of 71.74 months, 686 cases (median age was 49.03 (54.49, 58.55) years, 51.90% female) with CHD were identified, with a cumulative incidence of 12.01%. Systolic BP (SBP) and diastolic BP (DBP) were categorized into three classes, respectively. A statistically significant association was only observed between SBP trajectories and CHD. Compared with the normotensive stable SBP group (n = 1956), the prehypertension-stable group (n = 3268) had a higher risk (adjust hazards ratio (aHR) = 1.266, 95% confidence interval (CI) 1.014-1.581), and the stage 1 hypertension-decreasing group (n = 487) had the highest risk (aHR = 1.609, 95%CI 1.157-2.238). Among the BP-related indicators, the SBP trajectory was the strongest predictor of new-onset CHD. Findings were similar when sensitivity analyses were conducted.

CONCLUSIONS

SBP trajectory was a more important risk factor for CHD than other BP-related indicators and stringent BP control strategies may be effective for primary CHD prevention in the disabled population.

Cardiac Mechanics and Kidney Function Decline in the Cardiovascular Health Study

Key Points

Two-dimensional speckle-tracking echocardiography (2D-STE) can detect early changes in cardiac mechanics and may be able to identify individuals at risk for kidney disease progression. Novel indices of cardiac mechanics on 2D-STE may identify a population that may benefit from early diagnosis, monitoring, and treatment. Novel pharmacologic therapies may be beneficial in patients with subclinical myocardial dysfunction at risk for kidney function decline.

Background

Clinical heart failure frequently coexists with CKD and may precipitate kidney function decline. However, whether earlier-stage myocardial dysfunction assessable by speckle-tracking echocardiography (STE) is a contributor to kidney function decline remains unknown.

Methods

We studied 2135 Cardiovascular Health Study participants who were free of clinical heart failure and had year 2 baseline 2D-STE and two measurements of eGFR (year 2 and year 9). “Archival” speckle tracking of digitized echocardiogram videotapes was used to measure left ventricular longitudinal strain (LVLS), LV early diastolic strain rate (EDSR), left atrial reservoir strain (LARS), right ventricular free wall strain (RVFWS), and mitral annular velocity (e′). Multivariable Poisson regression models that adjusted for demographics and cardiovascular risk factors (RFs) were used to investigate the independent associations of cardiac mechanics indices and decline in kidney function defined as a 30% decline in eGFR over 7 years.

Results

In RF models, LVLS, EDSR, RVFWS, and e′ were all significantly associated with the prevalence of kidney disease. After multivariable adjustment, left atrial dysfunction (relative risk [RR], 1.18; 95% confidence interval [CI], 1.01 to 1.38 per SD lower LARS) and left ventricular diastolic dysfunction (RR, 1.21; 95% CI, 1.04 to 1.41 per SD lower EDSR) were each significantly associated with 30% decline in eGFR.

Conclusions

Subclinical myocardial dysfunction suggesting abnormal diastolic function detected by 2D-STE was independently associated with decline in kidney function over time. Further studies are needed to understand the mechanisms of these associations and to test whether interventions that may improve subclinical myocardial dysfunction can prevent decline of kidney function.

Associations between trajectories of cardiovascular risk factor change and cognitive impairment in Chinese elderly: A nationwide cohort study

Objectives

This study aimed to investigate the relationship between long-term trajectories of changes in cardiovascular risk factors (CVRFs) and the risk of cognitive impairment among Chinese adults over 60 years old.

Methods

Data were obtained from the Chinese Longitudinal Healthy Longevity Survey 2005-2018. Cognitive function was evaluated longitudinally through the Chinese version of the Mini-Mental State Examination (C-MMSE), and cognitive impairment (C-MMSE ≤23) was used as the main outcome variable. The cardiovascular risk factors, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), and body mass index (BMI), were continuously measured in the follow-up duration. The patterns of trajectories of changes in CVRFs were derived from the latent growth mixture model (LGMM). The Cox regression model was used to evaluate the cognitive impairment hazard ratio (HR) across different CVRF trajectories.

Results

A total of 5,164 participants aged ≥60 years with normal cognitive function at baseline were included in the study. After a median follow-up of 8 years, 2,071 participants (40.1%) developed cognitive impairment (C-MMSE ≤ 23). The four-class trajectories of SBP and BMI were obtained by means of LGMM, and the trajectories of DBP, MAP, and PP were grouped into a three-class subgroup. In the final adjusted Cox model, the lowered SBP [adjusted HR (aHR): 1.59; 95% CI: 1.17-2.16], lowered PP (aHR: 2.64; 95% CI: 1.66-4.19), and progressively obese (aHR: 1.28; 95% CI: 1.02-1.62) and stable slim (aHR: 1.13; 95% CI: 1.02-1.25) were associated with the higher risk of cognitive impairment. Low stable DBP (aHR: 0.80; 95% CI: 0.66-0.96) and elevated PP (aHR: 0.76; 95% CI: 0.63-0.92) decreased the risk for cognitive impairment among participants.

Conclusion

Lowered SBP, lowered PP, progressive obesity, and stable slim increased the risk for cognitive impairment in the Chinese elderly. Low stable DBP and elevated PP were protective against cognitive impairment, but more DBP lowering and ≥25 mmHg growth in PP contributed to a higher risk of cognitive impairment. The findings have important implications for preventing cognitive impairment in elder adults based on the long-term trajectories of changes in CVRFs.

Changes in blood pressure and cardiovascular disease in middle-aged to older Chinese: the Guangzhou Biobank Cohort Study

BACKGROUND

Most studies on the associations of blood pressure (BP) with cardiovascular disease (CVD) risk were based on single or average BP levels. Knowledge on the association between BP trajectories and CVD in middle-aged individuals who are not on antihypertensive medication may inform the care of individuals in this group whose BPs are not controlled.

METHODS

Eight thousand nine hundred and sixty-nine participants aged 50-70 years, without CVD at baseline and not taking antihypertensive medication throughout the study, were included. Four time-points data from the Guangzhou Biobank Cohort Study were used to identify BP trajectories using latent class mixed model. Cox regression was used to investigate the association of BP trajectories with fatal and nonfatal CVD till April 2021.

RESULTS

Three SBP trajectories were identified: 'low-slow-increase' characterized by SBP from 110 to 125 mmHg (86.5%); 'low-increase' from 110 to 150 mmHg (8.1%) and 'moderate-increase' from 125 to 155 mmHg (5.4%). Compared with the low-slow-increase group, the moderate-increase had the highest risk of CVD (hazard ratio = 1.76, 95% confidence interval = 1.34-2.29), ischemic heart disease (1.77, 1.01-3.09), myocardial infarction (3.52, 1.58-7.85), all strokes (1.88, 1.37-2.60), ischemic stroke (1.65, 1.10-2.49), haemorrhagic stroke (3.98, 1.30-12.12) and CVD mortality (2.41, 1.55-3.76). Higher risks of CVD (1.27, 1.01-1.61) and ischemic stroke (1.49, 1.07-2.09) in the low-increase group were also found.

CONCLUSION

Most people between 50 and 70 years of age and not taking antihypertensive medication maintained a slow increase SBP trajectory over a follow-up period of approximately 7 years. However, those whose SBPs increased from low and moderate levels were associated with higher CVD risks.

Blood Pressure Trajectories for 16 Years and the Development of Left Ventricular Hypertrophy and Increased Left Atrial Size: The Korean Genome and Epidemiology Study

Background

Elevated single blood pressure (BP) measurement can be associated with the development of hypertension-mediated target organ damage including left ventricular hypertrophy (LVH) and left atrial (LA) enlargement (LAE). However, long-term patterns of BP and their effects on LVH and LAE are poorly understood. We evaluated the association between the BP trajectories and the presence of LVH and LAE.

Methods

We analyzed a total of 2,565 participants (1,267 males, 47.8 ± 6.7 years old) from the first biennial examination (2001-2002) of the Korean Genome and Epidemiology Study. The presence of LVH and LAE was identified by echocardiography performed at the 8^th biennial examination (2015-2016). Latent mixture modeling was used to identify trajectories in mid-BP ((systolic BP + diastolic BP)/2) over time. Linear logistic regression was used for assessing BP trajectories with the outcomes.

Results

We identified 4 distinct mid-BP trajectories: group 1 (lowest, 20.9%, n = 536), group 2 (36.2%, n = 928), group 3 (32.3%, n = 828), and group 4 (highest, 10.6%, n = 273). Compared with the lowest group, trajectories with elevated mid-BP had greater odds ratios having LVH and LAE by multivariable-adjusted regression models. Adjusted odd ratios for LVH were 2.033 (95% CI = 1.462–2.827, P < 0.001) for group 2, 3.446 (95% CI = 2.475–4.797, P < 0.001) for group 3, and 4.940 (95% CI = 3.318–7.356, P < 0.001) for group 4. Adjusted odd ratios for LAE were 1.200 (95% CI = 0.814–1.769, P = 0.358) for group 2, 1.599 (95% CI = 1.084–2.360, P = 0.018) for group 3, and 1.944 (95% CI = 1.212–3.118, P = 0.006) for group 4.

Conclusions

Higher long-term mid-BP was an independent risk factor of cardiac structural changes such as LVH and LAE among middle-aged population.

Blood Pressure Trajectories From Childhood to Youth and Arterial Stiffness in Adulthood: A 30-Year Longitudinal Follow-Up Study

Background

This study aimed to identify the subgroups of individuals sharing similar blood pressure (BP) trajectories from childhood to youth and explore the associations of these trajectories with arterial stiffness in adulthood.

Methods

A group-based trajectory model was used to identify BP trajectories among 2,082 individuals in the Hanzhong adolescent hypertension cohort by using BP values repeatedly measured at four visits from childhood (6–15 years) to youth (14–23 years). The brachial–ankle pulse wave velocity (baPWV) was examined 30 years after the baseline survey. Mixed linear regression models were used to examine the associations of these trajectories with adult baPWV.

Results

Among the 2,082 individuals, three trajectory groups of systolic BP were identified as follows: the low-level group (n = 889), medium-level group (n = 1,021), and high-level group (n = 172). The baPWV in adulthood was higher in medium-level and high-level groups compared with the low-level group (1271.4 ± 224.7 cm/s, 1366.1 ± 249.8 cm/s vs. 1190.1 ± 220.3 cm/s, all p < 0.001). After adjustment for potential confounding factors, the association between baPWV and systolic BP trajectories was statistically significant (adjusted β = 49.4 cm/s; p < 0.001 for the medium-level group and β = 107.6 cm/s; p < 0.001 for the high-level group compared with the low-level group). Similar results were obtained for the association of baPWV with the trajectories of diastolic BP and mean arterial pressure (MAP), except for pulse pressure.

Conclusion

Our investigation demonstrates different BP trajectories from childhood to youth and shows the trajectories of systolic BP, diastolic BP, and MAP are significant predictors of arterial stiffness in adulthood.

Acute-phase heart rate trajectories and functional outcomes in acute ischemic stroke

The heart rate (HR) trajectory is a dynamic metric that shows how HR changes over time. Previous studies have demonstrated that elevated HR is associated with stroke events. However, little research has been done on the influence of shifting HR throughout the acute period on clinical outcomes. This study aims to investigate the effect of HR trajectories on functional outcomes in patients with acute ischemic stroke (AIS). A total of 981 AIS patients were included in the study. A latent mixture model was used to assess HR trends over the first 7 days following disease onset. The patients were divided into four groups based on different HR trajectories: markedly decreasing in 48 h (T1), mildly decreasing in 48 h (T2), sustained moderate in 7 days (T3), and sustained high in 7 days (T4). Poor outcome was defined as a modified Rankin Scale (mRS) score of ≥3 in 3 months. Logistic regression was used to analyze the correlation between different HR trajectories and outcomes. The incidence of poor outcomes was 9.02%, 10.80%, 11.79%, 16.36% in T1 (n = 133), T2 (n = 352), T3 (n = 441), and T4 (n = 55) groups, respectively. Compared with T1 group, T4 group was significantly associated with a higher risk of poor outcome at 3 months (odds ratio = 3.00, 95% confidence interval = 1.06-8.54, p value = .0392). This suggests that in AIS patients, a sustained high HR trajectory is linked to a greater likelihood of poor functional outcome than a markedly decreasing HR trajectory. HR trajectories demonstrate the utility of repeated HR measurements for outcome assessment.

Modelling of longitudinal data to predict cardiovascular disease risk: a methodological review

OBJECTIVE

The identification of methodology for modelling cardiovascular disease (CVD) risk using longitudinal data and risk factor trajectories.

METHODS

We screened MEDLINE-Ovid from inception until 3 June 2020. MeSH and text search terms covered three areas: data type, modelling type and disease area including search terms such as "longitudinal", "trajector*" and "cardiovasc*" respectively. Studies were filtered to meet the following inclusion criteria: longitudinal individual patient data in adult patients with ≥3 time-points and a CVD or mortality outcome. Studies were screened and analyzed by one author. Any queries were discussed with the other authors. Comparisons were made between the methods identified looking at assumptions, flexibility and software availability.

RESULTS

From the initial 2601 studies returned by the searches 80 studies were included. Four statistical approaches were identified for modelling the longitudinal data: 3 (4%) studies compared time points with simple statistical tests, 40 (50%) used single-stage approaches, such as including single time points or summary measures in survival models, 29 (36%) used two-stage approaches including an estimated longitudinal parameter in survival models, and 8 (10%) used joint models which modelled the longitudinal and survival data together. The proportion of CVD risk prediction models created using longitudinal data using two-stage and joint models increased over time.

CONCLUSIONS

Single stage models are still heavily utilized by many CVD risk prediction studies for modelling longitudinal data. Future studies should fully utilize available longitudinal data when analyzing CVD risk by employing two-stage and joint approaches which can often better utilize the available data.

Trajectories of Blood Pressure Control a Year After Randomization and Incident Cardiovascular Outcomes in SPRINT

BACKGROUND

While studies have assessed the association between blood pressure trajectories and cardiovascular disease (CVD) outcomes using observational data, few have assessed these associations using clinical trial data. We sought to identify systolic blood pressure (SBP) trajectories and to determine if these trajectory patterns carry inherent CVD risk, irrespective of baseline blood pressure.

METHODS

SBP trajectories were identified using latent class group-based modeling among a cohort of Systolic Blood Pressure Intervention Trial (SPRINT) participants by incorporating SBP measures during the first 12 months of the trial postrandomization. Cox models were used to evaluate the association between SBP trajectory with CVD and all-cause mortality.

RESULTS

Four distinct SBP trajectories were identified: "low decline" (41%), "high decline" (6%), "low stable" (48%), and "high stable" (5%). Relative to the "low decline" group, the "low stable" group was associated with a 29% increased risk of CVD (hazard ratio [HR]: 1.29, 95% confidence interval [CI]: 1.06-1.57) and the "high stable" group was associated with a 76% increased risk of all-cause mortality (HR: 1.76, 95% CI: 1.15-2.68). Relative to the "low stable" group, the "high stable" group was associated with a 54% increased risk of all-cause mortality (HR: 1.54, 95% CI: 1.05-2.28).

CONCLUSIONS

Our results demonstrate that SBP trajectory patterns are associated with important cardiovascular outcomes, irrespective of baseline blood pressure, which may help better identify individuals at risk and assist with accurate adjudication of antihypertensive therapy to reduce future events.

Three-year trajectories of metabolic risk factors predict subsequent long-term mortality in patients with type 2 diabetes

AIM

This study aims to evaluate the associations between 3-year trajectories of metabolic risk factors and subsequent mortality in patients with type 2 diabetes.

METHODS

A total of 6400 persons aged ≥ 30 years with type 2 diabetes and ≥ 3 years of follow-up period were included. The cluster analysis determined the patterns of 3-year trajectories, and Cox proportional hazards models evaluated the associations between patterns and mortality.

RESULTS

Three trajectory subgroups of metabolic risk factors, namely, cluster 1, normal; cluster 2, high-stable or reducing with high level at baseline; and cluster 3, fluctuation: elevated and decreasing, were generated. The clusters 2 and 3 of body mass index (BMI), fasting plasma glucose (FPG), HbA1c, and triglyceride (TG) trajectories were associated with increased risks of all-cause mortality compared with cluster 1 (hazard ratio = 1.27, 95% confidence interval = 1.06-1.51 and 1.45, 1.19-1.78 for BMI; 1.41, 1.22-1.62 and 1.81, 1.38-2.38 for FPG; 1.42, 1.23-1.64 and 1.47, 1.23-1.75 for HbA1c; 1.34, 1.10-1.63 and 2.40, 1.30-4.37 for TG, respectively). For the systolic blood pressure trajectory, only cluster 3 was associated with an increased mortality risk relative to cluster 1 (1.76, 1.13-2.77).

CONCLUSIONS

Long-term metabolic risk factor trajectories may be associated with subsequent mortality.

Long Term Prognostic Impact of Sex-specific Longitudinal Changes in Blood Pressure. The EPIC-Norfolk Prospective Population Cohort Study

AIMS

We aimed to determine the sex differences in longitudinal systolic and diastolic blood pressure (SBP and DBP) trajectories in mid-life and delineate the associations between these and mortality (all-cause, cardiovascular, and non-cardiovascular) and incident cardiovascular disease (CVD) in old age.

METHODS AND RESULTS

Participants were selected from the European Prospective Investigation into Cancer, Norfolk (EPIC-Norfolk) cohort study. Sex-specific trajectories were determined using group-based trajectory models using three clinic BP measurements acquired between 1993 and 2012 (mean exposure ∼12.9 years). Multivariable Cox regressions determined the associations between trajectories and incident outcomes over the follow-up (median follow-up 9.4 years). A total of 2897 men (M) and 3819 women (F) were included. At baseline, women were younger (F-55.5, M-57.1), had a worse cardiometabolic profile and were less likely to receive primary CVD prevention including antihypertensive treatment (F-36.0%, M-42.0%). Over the exposure period, women had lower SBP trajectories while men exhibited more pronounced SBP decreases over this period. Over the follow-up period, women had lower mortality (F-11.9%, M-20.5%) and CVD incidence (F-19.8%, M-29.6%). Compared to optimal SBP (≤120 mmHg) and DBP (≤70 mmHg) trajectories, hypertensive trajectories were associated with increased mortality and incident CVD in both men and women during follow-up at univariable level. These associations were nevertheless not maintained upon extensive confounder adjustment including antihypertensive therapies.

CONCLUSION

We report sex disparities in CVD prevention which may relate to worse cardiometabolic profiles and less pronounced longitudinal SBP decreases in women. Effective anti-hypertensivetherapy may offset the adverse outcomes associated with prolonged exposure to high blood pressure.

Trajectory patterns of blood pressure change up to six years and the risk of dementia: a nationwide cohort study

The present study aimed to investigate the associations between the trajectory of blood pressure (BP) change and the risk of subsequent dementia and to explore the differences in age, gender, and hypertension subgroups. We included 10,660 participants aged ≥ 60 years from 1998 to 2018 waves of the Chinese Longitudinal Healthy Longevity Survey. Latent growth mixture models were used to estimate BP trajectories. Cox-proportional hazard models were used to analyze the effects of BP trajectories on the risk of dementia. According to the results, stabilized systolic BP (SBP) was found to be associated with a higher risk of dementia compared with normal SBP [adjusted hazard ratio (aHR): 1.62; 95% confidence interval (CI): 1.27-2.07] and elevated SBP (aHR: 2.22; 95% CI: 1.51-3.28) in and only in the subgroups of the oldest-old, women, and subjects without hypertension at baseline. Similarly, stabilized pulse pressure (PP) was associated with a higher risk of dementia compared with normal PP (aHR: 1.52; 95% CI: 1.24-1.88) and elevated PP (aHR: 2.12; 95% CI: 1.48-3.04) in and only in the subgroups of the oldest-old, women, and subjects with hypertension at baseline. These findings suggest that stabilized SBP and PP have predictive significance for the occurrence of dementia in late life, and the factors of age, gender, and late-life hypertension should be considered when estimating the risk of BP decline on dementia.

Longitudinal Measures of Blood Pressure and Subclinical Atrial Arrhythmias: The MESA and the ARIC Study

Background High blood pressure (BP) is a well-known risk factor for atrial fibrillation (AF), but a single BP measurement may provide limited information about AF risk in older adults. Methods and Results This study included 1256 MESA (Multi-Ethnic Study of Atherosclerosis) and 1948 ARIC (Atherosclerosis Risk in Communities) study participants who underwent extended ambulatory electrocardiographic monitoring and who were free of clinically detected cardiovascular disease, including AF. Using BP measurements from 6 examinations (2000-2018 in MESA and 1987-2017 in ARIC study), we calculated individual long-term mean, trend, and detrended visit-to-visit variability in systolic BP and pulse pressure for each participant. Outcomes, assessed at examination 6, included subclinical AF and supraventricular ectopy. Results from each study were combined with inverse variance-weighted meta-analysis. At examination 6, the mean age was 73 years in MESA and 79 years in ARIC study, and 4% had subclinical AF. Higher visit-to-visit detrended variability in systolic BP was associated with a greater prevalence of subclinical AF (odds ratio [OR], 1.20; 95% CI, 1.02-1.38) and with more premature atrial contractions/hour (geometric mean ratio, 1.08; 95% CI, 1.01-1.15). For pulse pressure as well, higher visit-to-visit detrended variability was associated with a greater prevalence of AF (OR, 1.18; 95% CI, 1.00-1.37). In addition, higher long-term mean pulse pressure was associated with a greater prevalence of subclinical AF (OR, 1.36; 95% CI, 1.08-1.70). Conclusions Antecedent visit-to-visit variability in systolic BP and pulse pressure, but not current BP, is associated with a higher prevalence of subclinical atrial arrhythmias. Prior longitudinal BP assessment, rather than current BP, may be more helpful in identifying older adults who are at higher risk of atrial arrhythmias.

Evolution of Cardiovascular Risk Factors in a Worker Cohort: A Cluster Analysis

The identification of the cardiovascular risk factor (CVRF) profile of individual patients is key to the prevention of cardiovascular disease (CVD), and the development of personalized preventive approaches. Using data from annual medical examinations in a cohort of workers, the aim of the study was to characterize the evolution of CVRFs and the CVD risk score (SCORE) over three time points between 2009 and 2017. For descriptive analyses, mean, standard deviation, and quartile values were used for quantitative variables, and percentages for categorical ones. Cluster analysis was performed using the Kml3D package in R software. This algorithm, which creates distinct groups based on similarities in the evolution of variables of interest measured at different time points, divided the cohort into 2 clusters. Cluster 1 comprised younger workers with lower mean body mass index, waist circumference, blood glucose values, and SCORE, and higher mean HDL cholesterol values. Cluster 2 had the opposite characteristics. In conclusion, it was found that, over time, subjects in cluster 1 showed a higher improvement in CVRF control and a lower increase in their SCORE, compared with cluster 2. The identification of subjects included in these profiles could facilitate the development of better personalized medical approaches to CVD preventive measures.

Blood Pressure Trajectories Across the Life Course

High blood pressure (BP) is a strong modifiable risk factor for cardiovascular disease (CVD). Longitudinal BP patterns themselves may reflect the burden of risk and vascular damage due to prolonged cumulative exposure to high BP levels. Current studies have begun to characterize BP patterns as a trajectory over an individual's lifetime. These BP trajectories take into account the absolute BP levels as well as the slope of BP changes throughout the lifetime thus incorporating longitudinal BP patterns into a single metric. Methodologic issues that need to be considered when examining BP trajectories include individual-level vs. population-level group-based modeling, use of distinct but complementary BP metrics (systolic, diastolic, mean arterial, mid, and pulse pressure), and potential for measurement errors related to varied settings, devices, and number of readings utilized. There appear to be very specific developmental periods during which divergent BP trajectories may emerge, specifically adolescence, the pregnancy period, and older adulthood. Lifetime BP trajectories are impacted by both individual-level and community-level factors and have been associated with incident hypertension, multimorbidity (CVD, renal disease, cognitive impairment), and overall life expectancy. Key unanswered questions remain around the additive predictive value of BP trajectories, intergenerational contributions to BP patterns (in utero BP exposure), and potential genetic drivers of BP patterns. The next phase in understanding BP trajectories needs to focus on how best to incorporate this knowledge into clinical care to reduce the burden of hypertensive-related outcomes and improve health equity.

The Association between Blood Pressure Trajectories and Risk of Cardiovascular Diseases among Non-Hypertensive Chinese Population: A Population-Based Cohort Study

Although previous studies have discussed the association between trajectories of blood pressure (BP) and risk of cardiovascular diseases (CVDs), the association among the non-hypertensive general population of youth and middle age has not been elucidated. We used the growth mixture model to explore the trajectories of BP among the non-hypertensive Chinese population and applied Cox regression to evaluate the association between trajectories of BP and the risk of stroke or myocardial infarction (MI). Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were categorized into three classes, respectively. Statistically significant associations were observed between SBP trajectories and stroke (range of adjusted hazard ratios (aHR): 1.369-3.837) or MI (rang of aHR = 6.047-13.017). Association between DBP trajectories and stroke (aHR: 3.685) or MI (range of aHR = 1.312-2.821) were also observed, although they did not reach statistical significance. Trajectories of SBP were more important risk factors than that of DBP in stroke and MI in our study population. BP management is important among pre-hypertensive adults to prevent stroke and MI when they age. Well-designed research with a larger sample size is required to confirm our findings and develop efficient methods to prevent CVDs.

Association between cumulative blood pressure and long-term risk of cardiovascular disease: findings from the 26-year Chinese Multi-provincial Cohort Study-Beijing Project

Background:

Cumulative blood pressure (BP), a measure incorporating the level and duration of BP exposure, is associated with the risk of cardiovascular disease (CVD). However, the level at which cumulative BP could significantly increase the risk remains unclear. This study aimed to investigate the association of 15-year cumulative BP levels with the long-term risk of CVD, and to examine whether the association is independent of BP levels at one examination.

Methods:

Data from a 26-year follow-up of the Chinese Multi-provincial Cohort Study-Beijing Project were analyzed. Cumulative BP levels between 1992 and 2007 were calculated among 2429 participants free of CVD in 2007. Cardiovascular events (including coronary heart disease and stroke) occurring from 2007 to 2018 were registered. Adjusted hazard ratios (HRs) for CVD incidence associated with quartiles of cumulative systolic blood pressure (SBP) and diastolic blood pressure (DBP) were calculated.

Results:

Of the 2429 participants, 42.9% (1042) were men, and the mean age in 2007 was 62.1 ± 7.9 years. Totally, 207 CVD events occurred during the follow-up from 2007 to 2018. Participants with higher levels of cumulative SBP or DBP exhibited a higher incidence rate of CVD (P < 0.001). Compared with the lowest quartile of cumulative SBP, the HR for CVD was 1.03 (95% confidence interval [CI]: 0.59–1.81), 1.69 (95% CI: 0.99–2.87), and 2.20 (95% CI: 1.21–3.98) for the second to the fourth quartile of cumulative SBP, and 1.46 (95% CI: 0.86–2.48), 1.99 (95% CI: 1.18–3.35), and 2.08 (95% CI: 1.17–3.71) for the second to the fourth quartile of cumulative DBP, respectively. In further cross-combined group analyses with BP measurements in 2007, 15-year cumulative BP levels higher than the median, that is, 1970.8/1239.9 mmHg·year for cumulative SBP/DBP, which were equivalent to maintaining SBP/DBP levels of 131/83 mmHg or above on average in 15 years, were associated with higher risk of CVD in subsequent years independent of BP measurements at one-time point.

Conclusion:

Cumulative exposure to moderate elevation of BP is independently associated with increased future cardiovascular risk.

Association of antecedent cardiovascular risk factor levels and trajectories with cardiovascular magnetic resonance-derived cardiac function and structure

BACKGROUND

The association of longitudinal trajectories of cardiovascular risk factors with cardiovascular magnetic resonance (CMR)-measures of cardiac structure and function in the community is not well known. Therefore we aimed to relate risk factor levels from different examination cycles to CMR-measures of the left ventricle (LV) and right ventricle in a population-based cohort.

METHODS

We assessed conventional cardiovascular disease risk factors in 349 participants (143 women; aged 25-59 years) at three examination cycles (Exam 1 [baseline], at Exam 2 [7-years follow-up] and at Exam 3 [14-years follow-up]) of the KORA S4 cohort and related single-point measurements of individual risk factors and longitudinal trajectories of these risk factors to various CMR-measures obtained at Exam 3.

RESULTS

High levels of diastolic blood pressure, waist circumference, and LDL-cholesterol at the individual exams were associated with worse cardiac function and structure. Trajectory clusters representing higher levels of the individual risk factors were associated with worse cardiac function and structure compared to low risk trajectory clusters of individual risk factors. Multivariable (combining different risk factors) trajectory clusters were associated with different cardiac parameters in a graded fashion (e.g. decrease of LV stroke volume for middle risk cluster β = - 4.91 ml/m2, 95% CI - 7.89; - 1.94, p < 0.01 and high risk cluster β = - 7.00 ml/m2, 95% CI - 10.73; - 3.28, p < 0.001 compared to the low risk cluster). The multivariable longitudinal trajectory clusters added significantly to explain variation in CMR traits beyond the multivariable risk profile obtained at Exam 3.

CONCLUSIONS

Cardiovascular disease risk factor levels, measured over a time period of 14 years, were associated with CMR-derived measures of cardiac structure and function. Longitudinal multivariable trajectory clusters explained a greater proportion of the inter-individual variation in cardiac traits than multiple risk factor assessed contemporaneous with the CMR exam.

Life-course blood pressure trajectories and cardiovascular diseases: A population-based cohort study in China

BACKGROUND

The patterns of blood pressure trajectory (i.e., change over time) over life-course remain to be explored. In this study, we aim to determine the trajectories of systolic blood pressure (SBP) from adulthood to late life and to assess its impact on the risk of cardiovascular diseases (CVDs).

METHODS

Based on the China Health and Nutrition Survey, a total of 3566 participants aged 20-50 years at baseline (1989) with at least three SBP measurements during 1989-2011 were included. SBP was measured through physical examination, and socio-demographic factors, lifestyles, medications, and CVDs were based on self-reported questionnaire. Latent class growth modeling was performed to examine SBP trajectory. Odds ratio (OR) and 95% confidence interval (CI) from logistic regression was used to determine the association between SBP trajectory and CVDs.

RESULTS

Five trajectory groups of SBP were identified: Class 1: rapid increase (n = 113, 3.2%); Class 2: slight increase (n = 1958, 54.9%); Class 3: stable (n = 614, 17.2%); Class 4: increase (n = 800, 22.4%); Class 5: fluctuant (n = 81, 2.3%). After adjustment of demographic factors, baseline SBP, and lifestyles, compared with the "slight increase" group, the OR (95% CI) of CVDs was 0.65 (0.32, 1.28) for "stable" group, 2.24 (1.40, 3.58) for "increase" group, 3.95 (1.81, 8.62) for "rapid increase" group, and 4.32 (1.76, 10.57) for "fluctuant" group. After stratified by use of antihypertensive drugs, the association was only significant for "rapid increase" group among those using antihypertensive drugs with OR (95% CI) of 2.81 (1.01, 7.77).

CONCLUSIONS

Having a rapidly increasing SBP over life-course is associated with a higher risk of CVDs. This implies the importance of monitoring lifetime change of blood pressure for the prevention of CVDs.

Trajectories of Waist-to-Hip Ratio and Adverse Outcomes in Heart Failure with Mid-Range Ejection Fraction

BACKGROUND

Waist-to-hip ratio (WHR) is a strong predictor of mortality in patients with heart failure (HF). However, common WHR trajectories are not well established in HF with mid-range ejection fraction (HFmrEF) persons, and their relationship to clinical outcomes remains uncertain.

METHOD

We prospectively enrolled 1,396 participants with HFmrEF (left ventricular ejection fraction 40-49%) from April 2013 through April 2017. The waist and hip circumferences of the subjects were measured at regular intervals, and the WHR was calculated as waist circumference divided by hip circumference. Latent mixture modeling was performed to identify WHR trajectories. We then used Cox proportional-hazard models to examine the association between WHR trajectory patterns and incident HF, incident cardiovascular disease (CVD), and all-cause mortality.

RESULTS

We identified four distinct WHR trajectory patterns: lean-moderate increase (9.2%), medium-stable/increase (32.7%), heavy-stable/increase (48.0%), and heavy-moderate decrease (10.1%). After multivariable adjustment, the heavy-stable/increase and heavy-moderate decrease patterns were associated with an increased all-cause mortality risk (heavy-stable/increase: adjusted hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.75-4.62; heavy-moderate decrease: adjusted HR 2.32, 95% CI 1.71-3.04), incident CVD risk (heavy-stable/increase: adjusted HR 4.03, 95% CI 2.39-4.91; heavy-moderate decrease: adjusted HR 3.05, 95% CI 2.34-4.09), and incident HF risk (heavy-stable/increase: adjusted HR 2.72, 95% CI 2.05-3.28; heavy-moderate decrease: adjusted HR 2.39, 95% CI 1.80-3.03) with reference to the lean-moderate increase pattern.

CONCLUSION

Among patients with HFmrEF, the trajectories of WHR gain are associated with poor outcomes. These findings highlight the importance of abdominal fat accumulation management during the progression of HFmrEF.