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Wang C, Shen J, Charalambous C, Pan J. Modeling biomarker variability in joint analysis of longitudinal and time-to-event data. Biostatistics 2024; 25:577-596. [PMID: 37230468 PMCID: PMC11017116 DOI: 10.1093/biostatistics/kxad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
The role of visit-to-visit variability of a biomarker in predicting related disease has been recognized in medical science. Existing measures of biological variability are criticized for being entangled with random variability resulted from measurement error or being unreliable due to limited measurements per individual. In this article, we propose a new measure to quantify the biological variability of a biomarker by evaluating the fluctuation of each individual-specific trajectory behind longitudinal measurements. Given a mixed-effects model for longitudinal data with the mean function over time specified by cubic splines, our proposed variability measure can be mathematically expressed as a quadratic form of random effects. A Cox model is assumed for time-to-event data by incorporating the defined variability as well as the current level of the underlying longitudinal trajectory as covariates, which, together with the longitudinal model, constitutes the joint modeling framework in this article. Asymptotic properties of maximum likelihood estimators are established for the present joint model. Estimation is implemented via an Expectation-Maximization (EM) algorithm with fully exponential Laplace approximation used in E-step to reduce the computation burden due to the increase of the random effects dimension. Simulation studies are conducted to reveal the advantage of the proposed method over the two-stage method, as well as a simpler joint modeling approach which does not take into account biomarker variability. Finally, we apply our model to investigate the effect of systolic blood pressure variability on cardiovascular events in the Medical Research Council elderly trial, which is also the motivating example for this article.
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Affiliation(s)
- Chunyu Wang
- Department of Mathematics, The University of Manchester, Manchester, M13 9PL, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK
| | - Jiaming Shen
- Department of Mathematics, The University of Manchester, Manchester, M13 9PL, UK
| | | | - Jianxin Pan
- Research Center for Mathematics, Beijing Normal University, Zhuhai, China
- Guangdong Provincial Key Laboratory of Interdisciplinary Research and Application for Data Science, BNU-HKBU United International College, Zhuhai, China
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Saputra PBT, Lamara AD, Saputra ME, Pasahari D, Kurniawan RB, Farabi MJA, Multazam CECZ, Oktaviono YH, Alkaff FF. Long-term systolic blood pressure variability independent of mean blood pressure is associated with mortality and cardiovascular events: A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102343. [PMID: 38103812 DOI: 10.1016/j.cpcardiol.2023.102343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
The association between long-term systolic blood pressure variability (SBPV) and cardiovascular (CV) outcomes after being adjusted with mean blood pressure (BP) is questionable. This systematic review aims to evaluate the associations between mean BP adjusted long-term SBPV and CV outcomes. A systematic search was conducted on PubMed, Scopus, and Science Direct on January 4, 2023. A total of 9,944,254 subjects from 43 studies were included in this meta-analysis. Long-term SBPV increased the risk of all-cause mortality (HR 1.21 [95%CI 1.16-1.25], I2=100%), CV mortality (HR 1.10 [95%CI 1.07-11.4], I2 = 90%), MACE (HR 1.10 [1.07-1.13], I2 = 91%), cerebrovascular stroke (HR 1.22 [1.16-1.29], I2=100%), and myocardial infarction (HR 1.13 [95%CI (1.07-1.19)], I2=91%). European populations generally had higher risk compared to other continents. In conclusion, long-term SBPV is associated with all-cause mortality, CV mortality, MACE, MI, and stroke. Poor outcomes related to long-term SBPV seem more dominated by cerebrovascular than coronary events.
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Affiliation(s)
- Pandit Bagus Tri Saputra
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Cardiovascular Research and Innovation Center, Universitas Airlangga, Surabaya, Indonesia.
| | - Ariikah Dyah Lamara
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Cardiovascular Research and Innovation Center, Universitas Airlangga, Surabaya, Indonesia
| | - Mahendra Eko Saputra
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Cardiovascular Research and Innovation Center, Universitas Airlangga, Surabaya, Indonesia
| | - Diar Pasahari
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Cardiovascular Research and Innovation Center, Universitas Airlangga, Surabaya, Indonesia
| | | | - Makhyan J Al Farabi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Cardiovascular Research and Innovation Center, Universitas Airlangga, Surabaya, Indonesia
| | | | - Yudi Her Oktaviono
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Cardiovascular Research and Innovation Center, Universitas Airlangga, Surabaya, Indonesia.
| | - Firas F Alkaff
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands; Division of Pharmacology and Therapy, Department of Anatomy, Histology, and Pharmacology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.
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Reinhart M, Puil L, Salzwedel DM, Wright JM. First-line diuretics versus other classes of antihypertensive drugs for hypertension. Cochrane Database Syst Rev 2023; 7:CD008161. [PMID: 37439548 PMCID: PMC10339786 DOI: 10.1002/14651858.cd008161.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Different first-line drug classes for patients with hypertension are often assumed to have similar effectiveness with respect to reducing mortality and morbidity outcomes, and lowering blood pressure. First-line low-dose thiazide diuretics have been previously shown to have the best mortality and morbidity evidence when compared with placebo or no treatment. Head-to-head comparisons of thiazides with other blood pressure-lowering drug classes would demonstrate whether there are important differences. OBJECTIVES To compare the effects of first-line diuretic drugs with other individual first-line classes of antihypertensive drugs on mortality, morbidity, and withdrawals due to adverse effects in patients with hypertension. Secondary objectives included assessments of the need for added drugs, drug switching, and blood pressure-lowering. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the Cochrane Hypertension Specialized Register, CENTRAL, MEDLINE, Embase, and trials registers to March 2021. We also checked references and contacted study authors to identify additional studies. A top-up search of the Specialized Register was carried out in June 2022. SELECTION CRITERIA Randomized active comparator trials of at least one year's duration were included. Trials had a clearly defined intervention arm of a first-line diuretic (thiazide, thiazide-like, or loop diuretic) compared to another first-line drug class: beta-blockers, calcium channel blockers, alpha adrenergic blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, direct renin inhibitors, or other antihypertensive drug classes. Studies had to include clearly defined mortality and morbidity outcomes (serious adverse events, total cardiovascular events, stroke, coronary heart disease (CHD), congestive heart failure, and withdrawals due to adverse effects). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We included 20 trials with 26 comparator arms randomizing over 90,000 participants. The findings are relevant to first-line use of drug classes in older male and female hypertensive patients (aged 50 to 75) with multiple co-morbidities, including type 2 diabetes. First-line thiazide and thiazide-like diuretics were compared with beta-blockers (six trials), calcium channel blockers (eight trials), ACE inhibitors (five trials), and alpha-adrenergic blockers (three trials); other comparators included angiotensin II receptor blockers, aliskiren (a direct renin inhibitor), and clonidine (a centrally acting drug). Only three studies reported data for total serious adverse events: two studies compared diuretics with calcium channel blockers and one with a direct renin inhibitor. Compared to first-line beta-blockers, first-line thiazides probably result in little to no difference in total mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.84 to 1.10; 5 trials, 18,241 participants; moderate-certainty), probably reduce total cardiovascular events (5.4% versus 4.8%; RR 0.88, 95% CI 0.78 to 1.00; 4 trials, 18,135 participants; absolute risk reduction (ARR) 0.6%, moderate-certainty), may result in little to no difference in stroke (RR 0.85, 95% CI 0.66 to 1.09; 4 trials, 18,135 participants; low-certainty), CHD (RR 0.91, 95% CI 0.78 to 1.07; 4 trials, 18,135 participants; low-certainty), or heart failure (RR 0.69, 95% CI 0.40 to 1.19; 1 trial, 6569 participants; low-certainty), and probably reduce withdrawals due to adverse effects (10.1% versus 7.9%; RR 0.78, 95% CI 0.71 to 0.85; 5 trials, 18,501 participants; ARR 2.2%; moderate-certainty). Compared to first-line calcium channel blockers, first-line thiazides probably result in little to no difference in total mortality (RR 1.02, 95% CI 0.96 to 1.08; 7 trials, 35,417 participants; moderate-certainty), may result in little to no difference in serious adverse events (RR 1.09, 95% CI 0.97 to 1.24; 2 trials, 7204 participants; low-certainty), probably reduce total cardiovascular events (14.3% versus 13.3%; RR 0.93, 95% CI 0.89 to 0.98; 6 trials, 35,217 participants; ARR 1.0%; moderate-certainty), probably result in little to no difference in stroke (RR 1.06, 95% CI 0.95 to 1.18; 6 trials, 35,217 participants; moderate-certainty) or CHD (RR 1.00, 95% CI 0.93 to 1.08; 6 trials, 35,217 participants; moderate-certainty), probably reduce heart failure (4.4% versus 3.2%; RR 0.74, 95% CI 0.66 to 0.82; 6 trials, 35,217 participants; ARR 1.2%; moderate-certainty), and may reduce withdrawals due to adverse effects (7.6% versus 6.2%; RR 0.81, 95% CI 0.75 to 0.88; 7 trials, 33,908 participants; ARR 1.4%; low-certainty). Compared to first-line ACE inhibitors, first-line thiazides probably result in little to no difference in total mortality (RR 1.00, 95% CI 0.95 to 1.07; 3 trials, 30,961 participants; moderate-certainty), may result in little to no difference in total cardiovascular events (RR 0.97, 95% CI 0.92 to 1.02; 3 trials, 30,900 participants; low-certainty), probably reduce stroke slightly (4.7% versus 4.1%; RR 0.89, 95% CI 0.80 to 0.99; 3 trials, 30,900 participants; ARR 0.6%; moderate-certainty), probably result in little to no difference in CHD (RR 1.03, 95% CI 0.96 to 1.12; 3 trials, 30,900 participants; moderate-certainty) or heart failure (RR 0.94, 95% CI 0.84 to 1.04; 2 trials, 30,392 participants; moderate-certainty), and probably reduce withdrawals due to adverse effects (3.9% versus 2.9%; RR 0.73, 95% CI 0.64 to 0.84; 3 trials, 25,254 participants; ARR 1.0%; moderate-certainty). Compared to first-line alpha-blockers, first-line thiazides probably result in little to no difference in total mortality (RR 0.98, 95% CI 0.88 to 1.09; 1 trial, 24,316 participants; moderate-certainty), probably reduce total cardiovascular events (12.1% versus 9.0%; RR 0.74, 95% CI 0.69 to 0.80; 2 trials, 24,396 participants; ARR 3.1%; moderate-certainty) and stroke (2.7% versus 2.3%; RR 0.86, 95% CI 0.73 to 1.01; 2 trials, 24,396 participants; ARR 0.4%; moderate-certainty), may result in little to no difference in CHD (RR 0.98, 95% CI 0.86 to 1.11; 2 trials, 24,396 participants; low-certainty), probably reduce heart failure (5.4% versus 2.8%; RR 0.51, 95% CI 0.45 to 0.58; 1 trial, 24,316 participants; ARR 2.6%; moderate-certainty), and may reduce withdrawals due to adverse effects (1.3% versus 0.9%; RR 0.70, 95% CI 0.54 to 0.89; 3 trials, 24,772 participants; ARR 0.4%; low-certainty). For the other drug classes, data were insufficient. No antihypertensive drug class demonstrated any clinically important advantages over first-line thiazides. AUTHORS' CONCLUSIONS When used as first-line agents for the treatment of hypertension, thiazides and thiazide-like drugs likely do not change total mortality and likely decrease some morbidity outcomes such as cardiovascular events and withdrawals due to adverse effects, when compared to beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers.
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Affiliation(s)
- Marcia Reinhart
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Lorri Puil
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Douglas M Salzwedel
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - James M Wright
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
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Murad MH, Larrea-Mantilla L, Haddad A, Spencer-Bonilla G, Serrano V, Rodriguez-Gutierrez R, Alvarez-Villalobos N, Benkhadra K, Gionfriddo MR, Prokop LJ, Brito JP, Ponce OJ. Antihypertensive Agents in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Clin Endocrinol Metab 2019; 104:1575-1584. [PMID: 30903690 DOI: 10.1210/jc.2019-00197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/25/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND This systematic review summarizes the benefits of treating blood pressure (BP) in individuals 65 years and older. METHODS We included randomized trials that evaluated BP-lowering medications or BP targets in individuals 65 years and older. Trials were selected and appraised by pairs of independent reviewers. RESULTS We included 19 trials (42,134 patients). In individuals 65 years or older, antihypertensive therapy was associated with a reduction in all-cause mortality [relative risk: 0.88 (95% CI: 0.81 to 0.94); high certainty evidence; mean follow-up 31 months], cardiovascular mortality, myocardial infarction, heart failure, stroke, and chronic kidney disease. Individuals 75 years or older had a significant reduction in the risk of all-cause and cardiovascular mortality, stroke, and heart failure. Strict systolic BP targets (<120 mm Hg and <130 mm Hg) were associated with a significant reduction in the risk of all-cause and cardiovascular mortality and heart failure, whereas more liberal systolic targets (<150 mm Hg and <160 mm Hg) were associated with lower risk of heart failure and stroke. Older adults with type 2 diabetes mellitus (DM) had lower risk of chronic kidney disease without a significant reduction in other outcomes. However, there was no significant difference in estimates (i.e., interaction) between those with and without DM. CONCLUSIONS Individuals aged 65 years and older or 75 years and older who receive antihypertensive therapy have statistically significant reduction in the risk of all-cause and cardiovascular mortality, heart failure, and stroke. There was no statistically significant difference in estimates between those with and without DM.
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Affiliation(s)
| | | | - Abdullah Haddad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Section of Cardiology, Temple University-Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | | | - Valentina Serrano
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Department of Nutrition, Diabetes and Metabolism, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rene Rodriguez-Gutierrez
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Plataforma INVEST Medicina UANL-KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, México
| | - Neri Alvarez-Villalobos
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Plataforma INVEST Medicina UANL-KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, México
| | - Khaled Benkhadra
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Michael R Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, Pennsylvania
| | - Larry J Prokop
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Juan P Brito
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Oscar J Ponce
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Unidad de Conocimiento y Evidencia (CONEVID), Universidad Peruana Cayetano Heredia, Lima, Peru
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Huang CJ, Chiang CE, Williams B, Kario K, Sung SH, Chen CH, Wang TD, Cheng HM. Effect Modification by Age on the Benefit or Harm of Antihypertensive Treatment for Elderly Hypertensives: A Systematic Review and Meta-analysis. Am J Hypertens 2019; 32:163-174. [PMID: 30445419 DOI: 10.1093/ajh/hpy169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 11/08/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The influence of age on balance of benefit vs. potential harm of blood pressure (BP)-lowering therapy for elderly hypertensives is unclear. We evaluated the modifying effects of age on BP lowering for various adverse outcomes in hypertensive patients older than 60 years without specified comorbidities. METHODS All relevant randomized controlled trials (RCTs) were systematically identified. Coronary heart disease, stroke, heart failure (HF), cardiovascular death, major adverse cardiovascular events (MACE), renal failure (RF), and all-cause death were assessed. Meta-regression analysis was used to explore the relationship between achieved systolic BP (SBP) and the risk of adverse events. Random-effects meta-analysis was used to pool the estimates. RESULTS Our study included 18 RCTs (n = 53,993). Meta-regression analysis showed a lower achieved SBP related with a lower risk of stroke and cardiovascular death, but an increased risk of RF. The regression slopes were comparable between populations stratifying by age 75 years. In subgroup analysis, the relative risks of a more aggressive BP lowering strategy were similar between patients aged older or less than 75 years for all outcomes except for RF (P for interaction = 0.02). Compared to treatment with final achieved SBP 140-150 mm Hg, a lower achieved SBP (<140 mm Hg) was significantly associated with decreased risk of stroke (relative risk = 0.68; 95% confidence interval = 0.55-0.85), HF (0.77; 0.60-0.99), cardiovascular death (0.68; 0.52-0.89), and MACE (0.83; 0.69-0.99). CONCLUSIONS To treat hypertension in the elderly, age had trivial effect modification on most outcomes, except for renal failure. Close monitoring of renal function may be warranted in the management of elderly hypertension.
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Affiliation(s)
- Chi-Jung Huang
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London (UCL) and National Institute for Health Research (NIHR) UCL Hospitals Biomedical Research Centre, London, UK
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shih-Hsien Sung
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chen-Huan Chen
- Department of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Faculty Development, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzung-Dau Wang
- Division of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Min Cheng
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Faculty Development, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
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Heo BM, Ryu KH. Prediction of Prehypertenison and Hypertension Based on Anthropometry, Blood Parameters, and Spirometry. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2571. [PMID: 30453592 PMCID: PMC6265931 DOI: 10.3390/ijerph15112571] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/08/2018] [Accepted: 11/14/2018] [Indexed: 01/01/2023]
Abstract
Hypertension and prehypertension are risk factors for cardiovascular diseases. However, the associations of both prehypertension and hypertension with anthropometry, blood parameters, and spirometry have not been investigated. The purpose of this study was to identify the risk factors for prehypertension and hypertension in middle-aged Korean adults and to study prediction models of prehypertension and hypertension combined with anthropometry, blood parameters, and spirometry. Binary logistic regression analysis was performed to assess the statistical significance of prehypertension and hypertension, and prediction models were developed using logistic regression, naïve Bayes, and decision trees. Among all risk factors for prehypertension, body mass index (BMI) was identified as the best indicator in both men [odds ratio (OR) = 1.429, 95% confidence interval (CI) = 1.304⁻1.462)] and women (OR = 1.428, 95% CI = 1.204⁻1.453). In contrast, among all risk factors for hypertension, BMI (OR = 1.993, 95% CI = 1.818⁻2.186) was found to be the best indicator in men, whereas the waist-to-height ratio (OR = 2.071, 95% CI = 1.884⁻2.276) was the best indicator in women. In the prehypertension prediction model, men exhibited an area under the receiver operating characteristic curve (AUC) of 0.635, and women exhibited a predictive power with an AUC of 0.777. In the hypertension prediction model, men exhibited an AUC of 0.700, and women exhibited an AUC of 0.845. This study proposes various risk factors for prehypertension and hypertension, and our findings can be used as a large-scale screening tool for controlling and managing hypertension.
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Affiliation(s)
- Byeong Mun Heo
- Database/Bioinformatics Laboratory, Chungbuk National University, Cheongju 28644, Korea.
| | - Keun Ho Ryu
- Faculty of Information Technology, Ton Duc Thang University, Hochiminh City 700000, Vietnam.
- Department of Computer Science, Chungbuk National University, Cheongju 28644, Korea.
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Mancia G, Schumacher H, Böhm M, Redon J, Schmieder RE, Verdecchia P, Sleight P, Teo K, Yusuf S. Relative and Combined Prognostic Importance of On-Treatment Mean and Visit-to-Visit Blood Pressure Variability in ONTARGET and TRANSCEND Patients. Hypertension 2017; 70:938-948. [DOI: 10.1161/hypertensionaha.117.09714] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/06/2017] [Accepted: 09/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Giuseppe Mancia
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Helmut Schumacher
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Michael Böhm
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Josep Redon
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Roland E. Schmieder
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Paolo Verdecchia
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Peter Sleight
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Koon Teo
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
| | - Salim Yusuf
- From the University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Italy (G.M.); Statistical Consultant, Ingelheim, Germany (H.S.); Klinik für innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (M.B.); Hypertension Clinic, Department of Internal Medicine, Hospital Clinico Universitario de Valencia INCLIVA, University of Valencia and CIBERObn, ISCIII, Madrid, Spain (J.R.); Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany (R.E.S
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8
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Vögele A, Johansson T, Renom-Guiteras A, Reeves D, Rieckert A, Schlender L, Teichmann AL, Sönnichsen A, Martinez YV. Effectiveness and safety of beta blockers in the management of hypertension in older adults: a systematic review to help reduce inappropriate prescribing. BMC Geriatr 2017; 17:224. [PMID: 29047367 PMCID: PMC5647554 DOI: 10.1186/s12877-017-0575-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The benefit from a blood pressure lowering therapy with beta blockers may not outweigh its risks, especially in older populations. The aim of this study was to look for evidence on risks and benefits of beta blockers in older adults and to use this evidence to develop recommendations for the electronic decision support tool of the PRIMA-eDS project. METHODS Systematic review of the literature using a stage approach with searches for systematic reviews and meta-analyses first, and individual studies only if the previous searches are inconclusive. The target population were older adults (≥65 years old) with hypertension. We included studies reporting on the effectiveness and/or safety of beta blockers on clinically relevant endpoints (e.g. mortality, cardiovascular events, and stroke) in the management of hypertension. The recommendations were developed according to the GRADE methodology. RESULTS Fifteen studies were included, comprising one meta-analysis, four randomized controlled trials, six secondary analyses of randomized controlled trials and four observational studies. Seven studies involved only older adults and eight studies reported subgroup analyses by age. With regard to a composite endpoint (death, stroke or myocardial infarction) beta blockers were associated with a higher risk of events then were other antihypertensive agents. Further, beta blockers showed no benefit compared to other antihypertensive agents or placebo regarding mortality. They appear to be less effective than other antihypertensive agents in reducing cardiovascular events. Contradictory results were found regarding the effect of beta blockers on stroke. None of the studies explored the effect on quality of life, hospitalisation, functional impairment/status, safety endpoints or renal failure. CONCLUSION The quality of current evidence to interpret the benefits of beta blockers in hypertension is rather weak. It cannot be recommended to use beta blockers in older adults as first line agent for hypertension.
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Affiliation(s)
- Anna Vögele
- South Tyrolean Academy of General Practice, via dei Vanga, Bolzano, Italy
| | - Tim Johansson
- Institute of General Practice and Family Medicine, Paracelsus Medical University, Strubergasse, Salzburg, Austria
| | - Anna Renom-Guiteras
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
- Department of Geriatrics, University Hospital Parc de Salut Mar, Passeig Marítim, Barcelona, Spain
| | - David Reeves
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Oxford Rd, Manchester, UK
| | - Anja Rieckert
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Lisa Schlender
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Anne-Lisa Teichmann
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Andreas Sönnichsen
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Yolanda V Martinez
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Oxford Rd, Manchester, UK
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9
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Wilhelm M, Winkler A, Rief W, Doering BK. Effect of placebo groups on blood pressure in hypertension: a meta-analysis of beta-blocker trials. ACTA ACUST UNITED AC 2016; 10:917-929. [DOI: 10.1016/j.jash.2016.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/18/2016] [Accepted: 10/27/2016] [Indexed: 01/02/2023]
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10
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Damian DJ, McNamee R, Carr M. Changes in selected metabolic parameters in patients over 65 receiving hydrochlorothiazide plus amiloride, atenolol or placebo in the MRC elderly trial. BMC Cardiovasc Disord 2016; 16:188. [PMID: 27716064 PMCID: PMC5050956 DOI: 10.1186/s12872-016-0368-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/28/2016] [Indexed: 11/25/2022] Open
Abstract
Background Treatment of hypertension reduces incidence of stroke, myocardial infarction and heart failure perhaps partly by controlling different metabolic parameters. There is limited information regarding the changes in potassium, sodium, weight, cholesterol and glucose levels in patients using anti-hypertensives. This study aimed to determine changes in potassium, sodium, glucose, cholesterol, weight, urea and urate levels in patients using anti-hypertensives. Furthermore, to describe these changes and differences between the atenolol, hydrochlorothiazide plus amiloride and placebo arms of the Medical Research Council (MRC) elderly randomised controlled trial. Methods Patients were randomly allocated to one of the three treatment arms. Measurements were taken at baseline, end of year one and end of year two in 4396 subjects. Linear Mixed Models (LMM) were used to determine the longitudinal profiles of sodium, potassium, weight, cholesterol, glucose, urea and urate. Estimates of changes within groups and difference between groups were obtained. Results Patients randomised to receive hydrochlorothiazide + amiloride experienced a significantly greater mean reduction in potassium, sodium and weight compared to placebo at end of year one - mean differences in change −0.18 mmol/L, (95 % CI: −0.21, −0.15); −1.45 mmol/L, (95 % CI: −1.62, −1.29) and −0.46 kgs (95 % CI: −0.73, −0.20) respectively, and greater increases in cholesterol, urea and urate - mean differences in change 0.16 mmol/L, (95 % CI: 0.10,0.22); 0.77 mmol/L, (95 % CI: 0.68, 0.87) and 53.10 μmol/L, (95 % CI: 49.35, 56.85) respectively. Changes were in the same direction but smaller in the atenololarm except for potassium and weight (increases). No group differences in glucose were found. Conclusion Results were in line with expectation except for lack of change in glucose in the hydrochlorothiazide + amiloride arms. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0368-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Damian J Damian
- Community Health Department, Kilimanjaro Christian Medical Centre, P. O. Box 3010, Moshi, Tanzania. .,Biostatistics, Institute for Population Health, University of Manchester, Manchester, UK.
| | - Roseanne McNamee
- Biostatistics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Matthew Carr
- Biostatistics, Institute for Population Health, University of Manchester, Manchester, UK
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11
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Stevens SL, Wood S, Koshiaris C, Law K, Glasziou P, Stevens RJ, McManus RJ. Blood pressure variability and cardiovascular disease: systematic review and meta-analysis. BMJ 2016; 354:i4098. [PMID: 27511067 PMCID: PMC4979357 DOI: 10.1136/bmj.i4098] [Citation(s) in RCA: 497] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality. DATA SOURCES Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English. ELIGIBILITY CRITERIA FOR STUDY SELECTION Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation. RESULTS 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively). CONCLUSIONS Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014015695.
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Affiliation(s)
- Sarah L Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Sally Wood
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Kathryn Law
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Paul Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Richard J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
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Parsons C, Murad MH, Andersen S, Mookadam F, Labonte H. The effect of antihypertensive treatment on the incidence of stroke and cognitive decline in the elderly: a meta-analysis. Future Cardiol 2016; 12:237-48. [PMID: 26919226 DOI: 10.2217/fca.15.90] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To evaluate the effectiveness of antihypertensives in reducing neurocognitive outcomes in elderly patients. PATIENTS & METHODS We conducted a systematic literature search of randomized trials in which hypertensive patients with a mean age ≥65 years received antihypertensive or control treatment. Outcomes were stroke, transient ischemic attack, cognitive decline and dementia. We included 14 trials for meta-analysis. RESULTS Compared to placebo, antihypertensive treatment reduced the risk of stroke (RR: 0.67 [95% CI: 0.57-0.79]). Reduced risk was significant for transient ischemic attack, fatal stroke, nonfatal stroke and total stroke. There were insufficient data to compare individual agents. CONCLUSION Antihypertensive treatment is associated with a significant reduction in stroke in elderly individuals. Reductions in dementia and cognitive decline were not significant; however, there was short follow-up. Comparative effectiveness evidence is limited.
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Affiliation(s)
- Christine Parsons
- Deptartment of Internal Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Mohammad Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Stuart Andersen
- Deptartment of Internal Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Farouk Mookadam
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Helene Labonte
- Deptartment of Internal Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
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Muntner P, Whittle J, Lynch AI, Colantonio LD, Simpson LM, Einhorn PT, Levitan EB, Whelton PK, Cushman WC, Louis GT, Davis BR, Oparil S. Visit-to-Visit Variability of Blood Pressure and Coronary Heart Disease, Stroke, Heart Failure, and Mortality: A Cohort Study. Ann Intern Med 2015; 163. [PMID: 26215765 PMCID: PMC5021508 DOI: 10.7326/m14-2803] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Variability of blood pressure (BP) across outpatient visits is frequently dismissed as random fluctuation around a patient's underlying BP. OBJECTIVE To examine the association of visit-to-visit variability (VVV) of systolic BP (SBP) and diastolic BP with cardiovascular disease (CVD) and mortality outcomes. DESIGN Prospective cohort study. SETTING Post hoc analysis of ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). PARTICIPANTS 25 814 ALLHAT participants. MEASUREMENTS The VVV of SBP was defined as the SD across SBP measurements obtained at 7 visits conducted from 6 to 28 months after ALLHAT enrollment. Participants without CVD events during the first 28 months of follow-up were followed from the 28-month visit through the end of active ALLHAT follow-up. Outcomes included fatal coronary heart disease (CHD) or nonfatal myocardial infarction, all-cause mortality, stroke, and heart failure. RESULTS During follow-up, 1194 fatal CHD or nonfatal MI events, 1948 deaths, 606 strokes, and 921 heart failure events occurred. After multivariable adjustment, including for mean SBP, the hazard ratio comparing participants in the highest versus lowest quintile of SD of SBP (≥14.4 mm Hg vs. <6.5 mm Hg) was 1.30 (95% CI, 1.06 to 1.59) for fatal CHD or nonfatal MI, 1.58 (CI, 1.32 to 1.90) for all-cause mortality, 1.46 (CI, 1.06 to 2.01) for stroke, and 1.25 (CI, 0.97 to 1.61) for heart failure. Higher VVV of diastolic BP was also associated with CVD events and mortality. LIMITATION Long-term outcomes were not available. CONCLUSION Higher VVV of SBP is associated with an increased risk for CVD and mortality. Future studies should examine whether reducing VVV of BP lowers this risk. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Paul Muntner
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Jeff Whittle
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Amy I. Lynch
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Lisandro D. Colantonio
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Lara M. Simpson
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Paula T. Einhorn
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Emily B. Levitan
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Paul K. Whelton
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - William C. Cushman
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Gail T. Louis
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Barry R. Davis
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
| | - Suzanne Oparil
- From University of Alabama at Birmingham, Birmingham, Alabama; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; University of Texas School of Public Health, Houston, Texas; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Tulane University, New Orleans, Louisiana; and Veterans Affairs Medical Center, Memphis, Tennessee
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14
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Diaz KM, Tanner RM, Falzon L, Levitan EB, Reynolds K, Shimbo D, Muntner P. Visit-to-visit variability of blood pressure and cardiovascular disease and all-cause mortality: a systematic review and meta-analysis. Hypertension 2014; 64:965-82. [PMID: 25069669 DOI: 10.1161/hypertensionaha.114.03903] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Visit-to-visit variability of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between visit-to-visit variability of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014, for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease, stroke, or mortality outcomes; events confirmed via database, death certificate, or event ascertainment committee; and adjustment for confounders. Data were extracted by 2 reviewers and pooled using a random-effects model. Overall, 8870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, visit-to-visit variability of systolic BP and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mm Hg higher SD of systolic BP, the pooled hazard ratio for stroke across 7 cohorts was 1.17 (95% confidence interval [CI], 1.07-1.28), for coronary heart disease across 4 cohorts was 1.27 (95% CI, 1.07-1.51), for CVD across 5 cohorts was 1.12 (95% CI, 0.98-1.28), for CVD mortality across 5 cohorts was 1.22 (95% CI, 1.09-1.35), and for all-cause mortality across 4 cohorts was 1.20 (95% CI, 1.05-1.36). In summary, modest associations between visit-to-visit variability of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.
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Affiliation(s)
- Keith M Diaz
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.).
| | - Rikki M Tanner
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Louise Falzon
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Emily B Levitan
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Kristi Reynolds
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Daichi Shimbo
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Paul Muntner
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
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